Abstract
Objective: Exertional heat stroke (EHS) is a significant cause of morbidity and mortality in athletes and active individuals. In the field, initial management of exertional heat illness is based on rapid whole-body cooling. Cold-water immersion (CWI) is considered the superior cooling modality for EHS treatment. However, there often is a disconnect between the sports medicine community and the emergency medical service (EMS) community. Well-written emergency action plans may fail if EMS protocols do not allow for CWI in initial management. This is the first study to look at the current national EMS protocols regarding prehospital management of EHS. The purpose of our study was to assess the status of heat illness protocols regarding CWI for EHS in all 50 states plus Washington, DC. Methods: An internet search was performed to find EHS protocols. Statewide protocols were preferred. Several parameters were recorded for each protocol including whether: 1) CWI was the recommended cooling treatment for EHS and 2) CWI was explicitly permitted to be completed prior to transportation.Results: We found nine of the 51 protocols, or 17.6%, explicitly recommended CWI and 11 of the 51, or 21.6%, specifically instructed EMS personnel to complete CWI or cooling methods prior to transport. However, six protocols, or 11.8%, provided the recommendation instructing some variation of the phrase “do not delay transport to cool the patient.”Conclusion: Despite the medical literature endorsing CWI as the most effective treatment modality in a prehospital setting for exertional heat illness, EMS protocols largely fail to reflect this which leads to mismanagement and inadequate care of EHS patients. While CWI is not always available, all EMS protocols should include a systematic practical guideline for a heat illness patient when employing cooling treatment with an emphasis on CWI when available as the preferred treatment technique for EHS and the concept of “cool first, transport second.”
Highlights
Exertional heat stroke (EHS) is a unique form of heat illness which is life-threatening and may occur in any individual who undergoes exertion beyond their physical limits or in an unfavorable environment
The purpose of our study was to assess the status of heat illness protocols regarding Cold-water immersion (CWI) for EHS in all 50 states plus Washington, DC
We suggest that every emergency medical service (EMS) protocol should address CWI to both recommend it and explicitly permit it if already begun
Summary
Exertional heat stroke (EHS) is a unique form of heat illness which is life-threatening and may occur in any individual who undergoes exertion beyond their physical limits or in an unfavorable environment. The risk of heat illness exists at any level of physical activity and environmental condition, typically during strenuous or prolonged exercise in hot or humid conditions but can occur in a cool environment [2,5,6]. Immediate recognition and rapid cooling of EHS patients is critical for patient survival [7,8,9]. This requires a core body temperature measurement as soon as possible after the EHS presents, and it must not be impacted by external factors (e.g. sweat, fluid, wind, clothing, etc.). According to the National Athletic Trainers’ Association (NATA) current position statement on exertional heat illnesses, it is
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