It’s Timeout for Heat-Related Illness in Football, Learn the Warning Signs

Two male doctors welcoming a male patient to a health screening
Dr. Gregory Stewart greeting registrants at a health screening for retired players. 

August – we have a love-hate relationship. It marks the start of America’s favorite sport – football, in case you’re wondering – but it’s also one of the hottest months of the year. And therein lies our dilemma. As football practices begin at all levels – Pop Warner, high school, college and the pros – parents, coaches and athletes themselves must know the heat-related risks on the gridiron and learn when to throw in the flag.

A national expert in sports medicine and player safety, Dr. Gregory Stewart, medical director of the HCA Healthcare-affiliated Tulane Institute of Sports Medicine, said that heat-related illness is one of the top three causes of sudden death in sport.

“There were 39 reported football deaths due to heat from 1990 to 2010, representing approximately 16 percent of all fatalities,” he said. “And, according to the University of North Carolina’s National Center for Catastrophic Injury Research, roughly 27 percent of all athlete deaths can be attributed to heat-related illness this past summer alone.”

Male doctor wearing white lab coatWe caught up with Dr. Stewart, who also serves as the team physician for Tulane University Athletics, to help us raise awareness of the potentially devastating effects of heat-related illnesses in football and discuss the proper recognition, management and education of the condition.

What are the types of heat-related illnesses?

Heat Cramps (mild) are caused by losing a large amount of water and salt from exercise.

Symptoms include: thirst, sweat, cramps and fatigue – usually due to dehydration and or low electrolyte levels.

Management: Hydration with an electrolyte solution, like Gatorade/Powerade, or other sports drinks.

Heat Exhaustion (moderate): This is the inability to continue exercise. It’s associated with dehydration, sodium loss, energy depletion and heavy sweating.

Symptoms include: a pale complexion, persistent muscle cramps, weakness, fainting, dizziness, headache, hyperventilation and a body core temperature less than 104 degrees.

Management:  The person suffering from heat exhaustion should be moved into a cool environment and given cool electrolyte fluids, if conscious. Remove excessive clothing, monitor vitals (pulse, blood pressure, respiration). Call 911 immediately, if conditions don’t improve.

Heat Stroke (severe):  This is a medical emergency marked by organ system failure due to hyperthermia, a body temperature greatly above normal.

Symptoms include: Some of the first indications of heat stroke are confusion and poor balance.  You can also have rapid heartbeat and fast breathing.  This can be followed by a drop in blood pressure, seizures, and even coma.

Management: Dial 911. Move to a cool environment, use ice packs, ice tub emersion and monitor vitals.

Cool the patient first, transport second.

What causes a heat-related illness?

There are several causes to look out for such as:

  • practicing during hot portions of the day or during a high heat index environment (high temperature and high humidity conditions);
  • Equipment – wearing football padding, helmets and heavy clothing;
  • Illness – an illness makes athletes more susceptible to experiencing heat-related issues due to increased metabolic activity;
  • Medications – certain medications can make people more susceptible to the heat; and,
  • Dehydration – This is caused by not drinking enough fluids or the wrong type of fluids like high sugar or caffeinated beverages. Athletes should replace the amount of fluid they lose in sweat and respiration. Monitoring urine color is an easy way to gauge hydration status. Urine should look like lemonade not apple juice.

How often should athletes hydrate? And what should they drink?

Athletes should drink cold water or isotonic beverages, a sports drink used to replace fluids and electrolytes lost during prolonged exercise, and avoid caffeine and sugary beverages. Athletes should hydrate well before, during and after competition. Our advice is to drink:

  • 17-20 fluid ounces two to three hours prior to competition;
  • 6-12 fluid ounces immediately before competition;
  • 6-12 fluid ounces every 15-20 minutes during competition (for competitions lasting longer than an hour use an isotonic solution with carbohydrates such as Powerade/Gatorade) and;
  • 24 fluid ounces per pound of body weight lost during activity after competition.

What action should be taken if a heat-related illness is suspected?  

  • Hydrate, if conscious;
  • Cool the body;
  • Move to shade or air conditioning;
  • Ice pack the athlete, and;
  • The gold standard for cooling the body is ice tub emersion.

What can coaches or players do, if anything, to help acclimate their players to the heat during football practice?

Heat acclimatization involves progressively increasing the intensity and duration of physical activity and phasing in protective equipment. The first two to three weeks of preseason practice typically present the greatest risk of exertional heat illness, particularly in equipment-intensive sports. Athletes should be acclimatized to the heat gradually over seven to 14 days. If heat acclimatization is not maintained, the health benefits provided by this process will decay within three weeks.

When can an athlete return to play following a heat-related illness?

In cases of exercise-associated muscle cramps or heat syncope (fainting), the athletic trainer should monitor the patient’s condition until signs and symptoms are no longer present.

In athletes with heat exhaustion, same-day return to activity is not recommended and should be avoided.

Many patients with exertional heat stroke (EHS) are cooled effectively and sent home the same day.  With a physician’s clearance, they may be able to resume modified activity within one month. However, when treatment is delayed (i.e., not provided within 30 minutes), patients may experience residual complications for months or years after the event. Most guidelines suggest that a patient recovering from EHS be asymptomatic with normal blood-work results (renal and hepatic panels, electrolytes, and muscle enzyme levels) before a gradual return to activity is initiated.  Unfortunately, few evidence-based strategies have been developed to determine recovery of the thermoregulatory system, so the medical professional must use clinical cues such as ongoing signs and symptoms, responses to a standard exercise heat-tolerance test, responses to gradually increasing exercise demands, and ability to acclimatize to the heat to make return-to-play decisions

Are heat-related illnesses or deaths worse today than they were 10 years ago?

The worst five-year period for heat-related deaths since the 1970s was from 2005 to 2009. But that increase could be attributed to the fact that we are better at tracking catastrophic injury data in the high school setting now than we have ever been.

How do we help prevent tragedies like heat-related fatalities from happening on the field?

Three things: proper recognition, management and education. The education of athletes, parents and coaches is the key to preventing deaths related to heat illness.  Everyone can implement easy strategies to avoid heat illness, specifically, by moving activities to cooler parts of the day, making sure cold water or isotonic beverages are readily available and never denied to the athlete, modifying the intensity of practice and removing body equipment when conditions are extreme, avoiding caffeinated or sugary beverages, and hydrating well before, during and after activity.

Heat illness follows a progression. Oftentimes, there are signs that an athlete is having problems with heat and it’s apparent if you educate yourself on what to look for. If appropriate measures are taken quickly the progression to heat exhaustion and stroke can be avoided.

Dr. Gregory Stewart is medical director of the Tulane Institute of Sports Medicine, part of HCA Healthcare’s Tulane Health System. He also is the team physician for Tulane Athletics and leads Tulane’s programs with the NFL Players Association and the NFL Player Care Foundation that provide medical care and health evaluations to retired players. Dr. Stewart is well-known for the treatment of high school, college and professional athletes.  

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