PREDISPOSING RISK FACTORS FOR HEAT ILLNESS AND HEAT STROKE

“How hot is hot enough to cause heat illness is a moving target because Predisposing Factors contribute to Death from heat illness and abnormal body heat balance,” says Dr. William O. Roberts.

There are reports of death from heat illness with temperatures in the 70″s. because of Predisposing Risk Factors.

Temperature alone from dehydration from insufficient water consumption might not be the sole cause of heat illness. An athlete patient can be diagnosed with heat illness if one of the following is associated with body heat imbalance and increased lethal body temperature while working or exercising in the heat.

Water consumption errors do not always account for all heat illness death. Predisposing Factors for heat imbalance and increased body heat and death from heat illness will only be definitively ruled in or out after autopsy. However, clinical diagnoses are all that can be relied on in lieu of an autopsy.

There are Primary and Secondary Risk Factors for Heat Stroke.

I. PRIMARY RISK FACTORS FOR HEAT STROKE AFFECT THE AIRWAY, BREATHING AND CIRCULATION, CARDIOVASCULAR SYSTEMS DIRECTLY.
A. Inadequate Oxygen an/ or Inadequate Airway
B. Breathing Difficulty. Can’t Breathe on their own.
C. Circulation Compromise and Cardiovascular Pathology
D. Poor Air Quality. Increased Ground Level Ozone and other Air Polution. See Publication Heat + Ozone + Synergism + Exercise http://www.cappaa.com/heat-ozone-synergism-exercise-to-exhaustion

In addition the ABC’s of Resuscitation are a mnemonic used in the care of the unconscious or unresponsive patient. It is used as a reminder of the priorities for assessment and treatment of patients in many acute medical and trauma situations. Airway, breathing, and circulation are vital for life, and each is required, in that order, for the next to be effective. The Heat Stroke Patient must have the ABC’s attended and stabilized first in that order.

II. SECONDARY RISK FACTORS
MEDICATIONS
A. Sympathomimetics (alpha adrenergic agonists)
Amphetamines
Epinephrine
Ephedrine
Cocaine
Norepinephrine
B. Anticholinergics
Atropine
Scopolamine
Benztropine mesylate
Antihistamines
C. Diuretics
Caffeine
Alcohol
Furosemide (Lasix)
Hydrochlorothiazide
Bumetanide (Bumex)
D. Phenothiazines
Prochlorperazine
Chlorpromazine hydrochloride
Promethazine hydrochloride
E. Butyrophenones
Haloperidol (Haldol)
F. Tricyclic Antidepressant
Amitriptyline (Elavil)
Imipramine
Nortriptyline
Protriptyline
G. Monoamine Oxidase Inhibitors
Phenelzine
Tranylcypromine
H. Recreational and Illicit Drugs
Alcohol
Lysergic Acid diethylamide (LSD)
Other Medications
Beta Blockers
Calcium Channel Blockers
Lithium
Heat Illness Prevention
Pathophysiology Predisposing conditions alter heat balance
1. Increased endogenous heat load : Vigorous Exercise or overexertion
2. Increased Exogenous Heat load -Sun Exposure -Increased Heat Index
3. Decreased Heat Dissipation
a. Exogenous cause -Humidity
Occlusive or excessive clothing
b. Endogenous cause –
Dehydration
Lack of acclimatization
Healed burns
Sunburn
Dermatitis
Sweat Gland Dysfunction
4. Other predisposing factors for abnormal heat balance
a. Prior Heat Stroke
b. Concurrent infection
Upper Respiratory Infection
Gastroenteritis
c. Elderly
Myocardial dysfunction
Decreased muscle mass
Decreased skin blood supply
Renal insufficiency
Chronic illness
d. Comorbid medical condition
Anorexia
Cystic Fibrosis
Diabetes Insipidus
Poorly controlled Diabetes Mellitus
Obesity
Hypokalemia

References:
William O. Roberts, MD, sports medicine MinnHealth in White Bear Lake, Minn Czerkawski (1996) Your Patient Fitness 10(4): 13-20
Sandor (1997) Physician SportsMed, 25(6):35-40
Barrow (1998) Am Fam Physician 58(3):749
Hett (1998) Postgrad Med 103(6):107
Wexler (2002) Am Fam Physician 65(11):2307

Heat Stroke References

1. Vertuno Jim, The Associated Press, Longhorns Tackling the Heat: Pill Helping Texas Survive Rising Temperatures, published by the Victoria Advocate, August 15, 2007.
2. Hyperthermia, Wikipedia Encylopedia, October 2006, Retrieved from “http://en.wikipedia.org/wiki/Hyperthermia”
3. Heat Illness, Heat Exhaustion, Heat Stroke. The Nemours Foundation/Kids Health at www.revolutionhealth.com January 3, 2007.
4. Joseph Rampulla, MS,APRN,BC (June 2004). Hyperthermia & Heat Stroke: Heat-Related Conditions (pdf). The Health Care of Homeless Persons pp.199-204. Boston Health Care for the Homeless Program. Retrieved on 2007-02-22 at: http://www.bhchp.org/BHCHP%20manual/pdf_files/part2_PDF/Hyperthermia.pdf .
5. “Are you ready for extreme heat?” Courtesy: Federal Emergency Management Agency, Department of Homeland Security. Available from FEMA at: www.fema.gov/areyouready/heat.shtm. Updated August 20, 2007. This information may have changed or been updated since it was accessed. For the most current information, contact FEMA at http://www.fema.gov/.
6. Scott Anderson “Preventing Muscle Cramping in Football”. Coach and Athletic Director. May 2001. At www.FindArticles.com, 15 September 2007. http://findarticles.com/p/articles/mi_m0FIH/is_10_70/ai_n18611880 E.
7. Randy Eichner “Muscle cramps: the right ways for the dog days”. Coach and Athletic Director. August 2002. FindArticles.com. 15 Sep. 2007. http://findarticles.com/p/articles/mi_m0FIH/is_1_72/ai_n18613963.
8. Maddali Sirish, Rodeo Scott, Barnes Ronnie, Warren Russell, Murrell George: Post-exercise Increase in Nitric Oxide in Football Players with Muscle Cramps. The American Journal of Sports Medicine 26: 820-824, 1998.
9. Ruiz E J, Mitchell I D, Eberman L E, Cleary M A. Severe dehydration with cramping resulting in exertional rhabdomyolysis in a high school quarterback. In Cleary M A, Eberman LE, Odai ML eds. Proceedings of the Fifth Annual College of Education Research Conference: Section on Allied Health Professions. April 2006; 1: 31-35. Miami: Florida International Univeristy. http://coeweb.fiu.edu/research_conference/.
10. Cleveland Minot. Musle Cramp. University of Illinois Medical Center at Chicago: Health Library, at www.uimc.discoveryhospital.com, March 13, 2000; reviewed January 4, 2007. “Salt tablets are not useful and should be avoided.”
11. Texas Children’s Hospital. Preventing Heat Illness. Texas Children’s Hospital: Caring for Your Child’s Health at www.texaschildrenshospital.org, 2005. “Salt pills are unnecessary and possibly dangerous.”
12. Centers for Disease Control and Prevention. Frequently Asked Questions about Extreme Heat. Emergency Preparedness and Response Website at www.bt.cdc.gov/disasters/extremeheat/faq.asp. August 15, 2006. “Do not take salt tablets unless directed by your doctor.”
13. Gillis Rick (reviewer). Heat-Related Illness Can Quickly Become Serious. Healthlink: Medical College of Wisconsin at:
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www.healthlink.mcw.edu/article/1031002770.html, June 28, 2007. “Salt pills should not be used without first asking your health care provider.”
14. Taylor-Oring Leslie. Is it Heat Exhaustion or Heat Stroke? Tae Park Tae Kwon Do at: www.eod.gvsu.edu/tkd/newpage22.htm. March 14, 1999. “Give them cool liquids—NO SALT PILLS.”
15. Eichner Randy. Curbing Muscle Cramps: More than Oranges and Bananas. Hot Topics in Sports Nutrition. Gatorade Sports Science Institute, at: www.gssiweb.com/ShowArticle.aspx?articled=619. July 25, 2003.
16. Coyle Edward. Fluid and Carbohydrate Replacement During Exercise: How Much and Why? Gatorade Sports Science Institute, Sports Science Exhange #50, Volume7 (1994), Number 3, at: www.gssiweb.com/Article_Detail.aspx/articleid=23&level=2&topic=2.
17. Eichner Randy. Heat Stroke in Sports: Causes, Prevention, and Treatment. Gatorade Sports Science Institute, Sports Science Exchange #86, Volume 15 (2002), Number 3, at: www.gssiweb.com/Article_Detail.aspx?articleid=597&level=2&topic=7.
18. Eichner Randy. Heat Stroke in Sports: How to Protect Yourself and Help Your Teammates. Gatorade Sports Science Institute, Sports Science Exchange #86, Volume 15 (2002), Number 3 Supplement, at: www.gssiweb.com/Article_Detail.aspx?articleid=597&level=2&topic=7.
19. Murray Robert, Eichner Randy. Preventing Heat Illness: Keeping Athletes from Falling into Danger Zones. Gatorade Sports Science Institute, Sports Science Library at: http://gssiweb.com/Article_Detail.aspx?articleid=570&level=2&topic=7.
20. Casa Douglas, Murray Robert. Sports Science News: Preventing Exertional Heat Illness: A Consensus Statement. Gatorade Sports Science Institute, Sports Science Library, 2007, at: http://gssiweb.com/Article_Detail.aspx?articleid=625&level=2&topic=7.
21. Conrad Mark. Mark’s View: Heat Stroke and Football Practice (A comment on the heat stroke death of Minnesota Viking Korey Stringer). Mark’s Sportslaw News, 2001, at: www.sportslawnews.com.
22. CNN News. Vikings football player dies of heat stroke, at: www.CNN.com./U.S., August 1, 2001. This is a CNN news story about Korey Stringer.
23. Associated Press, Mankato, Minnesota. Vikings tackle Stringer dies from heatstroke, August 2001.
24. The Associated Press, Gainesville, Florida: Florida player Autin dies six days after heat stroke. Volume 101, No. 187, Thursday, July 26, 2001. This article discusses the heat stroke death of 18 year old freshman Eraste Autin who collapsed during a work out in 88 degrees, 72% humidity, heat index of 100.
25. Smith Michael. Football Practice Heat Stroke Deaths Preventable (An article about the heat stroke death of 18 year old Chris Stewart). MedPage Today, Daily Headlines, Oklahoma City, August 18, 2005.
26. Sparks Tara. Death has parents concerned. Victoria Advocate, page 1, August 15, 2003 at: www.nl.newsbank.com/nl-search/we/Archives?p_product=VA&P_t.
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This article describes a parents’ safety meeting following the death of 14 year-old Matthew Thomas.
27. Victoria Advocate staff writer. Autopsy not yet released. Victoria Advocate, page 1, August 15, 2003, at: www.nl.newsbank.com/nl-search/we/Archives?p_product=VA&P_t.
28. deLench Brook. To Nineteen Youth Athletes Dying Young. MomsTeam, A Parents Trusted Youth Sports Source, at www.momsteam.com. August 25, 2007.
29. Reddy Vinay. Heat Cramps, Heat Exhaustion, and Heat Stroke. Dr. Reddy’s Pediatric Office on the Web at http://www.drreddy.com, 1/12/07.
30. Williamson David. UNC Warns of Possible Heat Strokes for High School Atheletes, at www.unc.edu//depts/nccsi, 2004.
31. Roberts William. Death in the Heat: Can Football Heat Stroke be Prevented? Current Sports Medicine Reports. (3), 2004.
32. Roberts William. Common Threads in a Random Tapestry: Another Viewpoint on Exertional Heatstroke, The Physician and Sports Medicine. 33(10) 2-5, October 2005.
33. Roberts William. Exertional Heat Stroke during a Cool Weather Marathon: A Case Study. Medicine & Science in Sports & Exercise, Official Journal of the American College of Sports Medicine, pages 1197-1203, January 2006 at http://www.acsm-msse.org.
34. Fighting Heat Stress, at http://fighting_heat_stress,asp.htm.
35. Donohue Paul. Exertional Heat Stroke: A Preventable Cause of Death, To Your Good Health. Victoria Advocate, page E-5, Saturday, July 14, 2007.
36. Jung Alan, Bishop Phillip, Al-Nawwas Ali, Dale Barry. Influence of Hydration and Electolyte Supplementation on Incidence and Time to Onset of Exercise-Associated Muscle Cramps. Journal of Athletic Training 40(2): 71-75, April-June 2005.
37. The Zunis Foundation. How Hot is Hot? How Safe if Safe? At www.zunis.org, April 8, 2007.
38. It’s Hot, It’s Humid, It’s Sunny: Information on Heat and Sun-Related Illnesses. Street Medics, www.action-medical.net
39. Hirsch Larissa. Heat Exhaustion and Heat Stroke: A Poster. This is a handy instructional “Heat Sheet” found at www.kidshealth.com
40. Bergeron Michael F, Cannon Joseph G, Hall Elaina L, Kutlar Abdullah. Erythrocyte Sickling During Exercise and Thermal Stress. Clinical Journal of Sport Medicine. 14(6): 354-356, November 2004.
41. Gallais Daniel Le, Bile Alphonse, Mercier Jacques, Paschel Marc, Tonellot Jean Louis, Dauverchain Jean. Exercise-induced death in sickle cell trait: role of aging, training, and deconditioning. Medicine and Science in Sports and Exercise. 28(5): 541-544, May 1996.
42. Kark J A, Posey D M, Schumacher H R, Ruehle C J. Sickle-cell trait as a risk factor for sudden death in physical training. New England Journal of Medicine. (317): 781-787, September 1987.
43. Binkley Helen M, Beckett Joseph, Casa Douglas J, Kleiner Douglas M, Plummer Paul E. National Athletic Trainers’ Association Position Statement: Exertional
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Heat Illnesses. Journal of Athletic Training. 37(3): 329-343, July-September 2002.
44. Guyton Arthur C, Hall John E. Circulatory Shock and Physiology of its Treatment, Chapter 24, Textbook of Medical Physiology, Eleventh Edition. W.B. Saunders Company, Philadelphia, June 2005.
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48. Graves, Will. Case of Kentucky Coach puts Football on Trial. The Associated Press. The Victoria Advocate, page C-7, Friday, January 30, 2009.
49. Mahalo.com. Max Gilpin, at http://www.mahalo.com/max-gilpin
50. Louisville News, Homepage. Witness: Teen’s Death was Preventable. August 27, 2008. http://www.wlky.com/news/17315849/detail.html Copyright 2008 by WLKY.com.
51. Konz, Antoinette. 911 Call: PRP player drifted in, out of consiousness. Courier-Journal.com, Louisville, Kentucky at http://www.courier-journal.com/article/20081107/NEWS01/811070437/1008/rss01, November 7, 2008.
52. WLKY.com. PRP Football Player Collapses at Practice, In Critical Condition. http://www.wlky.com/sports/17267086/detail.html. August 22, 2008.
53. WLKY.com. PRP Football Player Dies 3 Days after Collapse in Practice. Louisville, Kentucky. At http://www.wlky.com/health/17280899/detail.html, August 27, 2009.
54. Binkley, Helen; Beckett, Joseph;Casa, Douglas; Kleiner, Douglas; Plummer, Paul. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training. 2002 Jul-Sep; 37(3): 329-343.
55. Parents’ and Coasches’ Guide to Dehydration and other Heat Illnesses in Children. National Safe Kids Campaign. Adapted from: Inter-Association task force on exertional heat illnesses consensus statement: National Athletic Trainers’ Association. June 2003. Available at: www.nata.org/industryresources/heatillnessconsensusstatement.pdf.
Prepared by Stephen T. Hougen, M.D., F.A.C.S., GETAC Injury Prevention Committee, August 19,
2009

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