Influence of Race Performance and Environmental Conditions on Exertional Heat Stroke Prevalence Among Runners Participating in a Warm Weather Road Race

Context:Evidence-based best practices for the recognition and treatment of exertional heat stroke (EHS) indicate that rectal thermometry and immediate, aggressive cooling via cold-water immersion ensure survival from this medical condition. However, little is known about the recovery, medical follow-up, and return to activity after an athlete has suffered EHS.Objective:To highlight the transfer of evidenced-based research into clinical practice by chronicling the treatment, recovery, and return to activity of a runner who suffered an EHS during a warm-weather road race.Design:Case study.Setting:Warm-weather road race.Participant:53-y-old recreationally active man.Intervention:A runner’s treatment, recovery, and return to activity from EHS and 2014 Falmouth Road Race performance.Main Outcomes:Runner’s perceptions and experiences with EHS, body temperature, heart rate, hydration status, exercise intensity.Results:The runner successfully completed the 2014 Falmouth Road Race without incident of EHS. Four dominant themes emerged from the data: predisposing factors, ideal treatment, lack of medical follow-up, and patient education. The first theme identified 3 predisposing factors that contributed to the runner’s EHS: hydration, sleep loss, and lack of heat acclimatization. The runner received ideal treatment using evidence-based best practices. A lack of long-term medical care following the EHS with no guidance on the runner’s return to full activity was observed. The runner knew very little about EHS before the 2013 race, which drove him to seek knowledge as to why he suffered EHS. Using this newly learned information, he successfully completed the 2014 Falmouth Road Race without incident.Conclusions:This case supports prior literature examining the factors that predispose individuals to EHS. Although evidence-based best practices regarding prompt recognition and treatment of EHS ensure survival, this case highlights the lack of medical follow-up and physician-guided return to activity after EHS.

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Environmental Conditions and the Occurrence of Exertional Heat Illnesses and Exertional Heat Stroke at the Falmouth Road Race

Journal of Athletic Training ◽

10.4085/1062-6050-49.3.26 ◽

2014 ◽

Vol 49 (4) ◽

pp. 478-485 ◽

Cited By ~ 34

Author(s):

Julie K. DeMartini ◽

Douglas J. Casa ◽

Luke N. Belval ◽

Arthur Crago ◽

Rob J. Davis ◽

...

Keyword(s):

Relative Humidity ◽

Environmental Conditions ◽

Heat Stroke ◽

Epidemiologic Study ◽

Treatment Strategies ◽

Heat Index ◽

Exertional Heat Stroke ◽

Road Race ◽

Relationship Of ◽

Environmental Temperatures

Context: The Falmouth Road Race is unique because of the environmental conditions and relatively short distance, which allow runners to maintain a high intensity for the duration of the event. Therefore, the occurrence of exertional heat illnesses (EHIs), especially exertional heat stroke (EHS), is 10 times higher than in other races. Objective: To summarize the occurrence and relationship of EHI and environmental conditions at the Falmouth Road Race. Design: Descriptive epidemiologic study. Setting: An 11.3-km (7-mile) road race in Falmouth, Massachusetts. Patients or Other Participants: Runners who sustained an EHI while participating in the Falmouth Road Race. Main Outcome Measure(s): We obtained 18 years of medical records and environmental conditions from the Falmouth Road Race and documented the incidence of EHI, specifically EHS, as related to ambient temperature (Tamb), relative humidity, and heat index (HI). Results: Average Tamb, relative humidity, and HI were 23.3 ± 2.5°C, 70 ± 16%, and 24 ± 3.5°C, respectively. Of the 393 total EHI cases observed, EHS accounted for 274 (70%). An average of 15.2 ± 13.0 EHS cases occurred each year; the incidence was 2.13 ± 1.62 cases per 1000 runners. Regression analysis revealed a relationship between the occurrence of both EHI and EHS and Tamb (R2 = 0.71, P = .001, and R2 = 0.65, P = .001, respectively) and HI (R2 = 0.76, P < .001, and R2 = 0.74, P < .001, respectively). Occurrences of EHS (24.2 ± 15.5 cases versus 9.3 ± 4.3 cases) and EHI (32.3 ± 16.3 versus 13.0 ± 4.9 cases) were higher when Tamb and HI were high compared with when Tamb and HI were low. Conclusions: Because of the environmental conditions and race duration, the Falmouth Road Race provides a unique setting for a high incidence of EHS. A clear relationship exists between environmental stress, especially as measured by Tamb and HI, and the occurrence of EHS or other EHI. Proper prevention and treatment strategies should be used during periods of high environmental temperatures as the likelihood of runners experiencing EHS is exacerbated in these harsh conditions.

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Incidence of Recurrent Exertional Heat Stroke in a Warm-Weather Road Race

Medicina ◽

10.3390/medicina56120720 ◽

2020 ◽

Vol 56 (12) ◽

pp. 720

Author(s):

Rebecca L. Stearns ◽

Yuri Hosokawa ◽

William M. Adams ◽

Luke N. Belval ◽

Robert A. Huggins ◽

...

Keyword(s):

Relative Risk ◽

Risk Ratio ◽

Heat Stroke ◽

Case Series ◽

Relative Risk Ratio ◽

Future Research ◽

Exertional Heat Stroke ◽

Warm Weather ◽

Before And After ◽

Road Race

Background and Objectives: Exertional heat stroke (EHS) survivors may be more susceptible to subsequent EHS; however, the occurrence of survivors with subsequent EHS episodes is limited. Therefore, the purpose of this study was to evaluate the incidence of participants with repeated EHS (EHS-2+) cases in a warm-weather road race across participation years compared to those who experienced 1 EHS (EHS-1). Materials and Methods: A retrospective observational case series design was utilized. Medical record data from 17-years at the Falmouth Road Race between 2003–2019 were examined for EHS cases. Incidence of EHS-2+ cases per race and average EHS cases per EHS-2+ participant were calculated (mean ± SD) and descriptive factors (rectal temperature (TRE), finish time (FT), Wet Bulb Globe Temperature (WBGT), age, race year) for each EHS was collected. Results: A total of 333 EHS patients from 174,853 finishers were identified. Sixteen EHS-2+ participants (11 males, 5 females, age = 39 ± 16 year) accounted for 11% of the total EHS cases (n = 37/333). EHS-2+ participants had an average of 2.3 EHS cases per person (range = 2–4) and had an incidence rate of 2.6 EHS per 10 races. EHS-2+ participants finished 93 races following initial EHS, with 72 of the races (77%) completed without EHS incident. Initial EHS TRE was not statistically different than subsequent EHS initial TRE (+0.3 ± 0.9 °C, p > 0.050). Initial EHS-2+ participant FT was not statistically different than subsequent EHS FT (−4.2 ± 7.0 min, p > 0.050). The years between first and second EHS was 3.6 ± 3.5 year (Mode: 1, Range: 1–12). Relative risk ratios revealed that EHS patients were at a significantly elevated risk for subsequent EHS episodes 2 years following their initial EHS (relative risk ratio = 3.32, p = 0.050); however, the risk from 3–5 years post initial EHS was not statistically elevated, though the relative risk ratio values remained above 1.26. Conclusions: These results demonstrate that 11% of all EHS cases at the Falmouth Road Race are EHS-2+ cases and that future risk for a second EHS episode at this race is most likely to occur within the first 2 years following the initial EHS incident. After this initial 2-year period, risk for another EHS episode is not significantly elevated. Future research should examine factors to explain individuals who are susceptible to multiple EHS cases, incidence at other races and corresponding prevention strategies both before and after initial EHS.

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Effectiveness of Cold Water Immersion in the Treatment of Exertional Heat Stroke at the Falmouth Road Race

Medicine & Science in Sports & Exercise ◽

10.1249/mss.0000000000000409 ◽

2015 ◽

Vol 47 (2) ◽

pp. 240-245 ◽

Cited By ~ 81

Author(s):

JULIE K. DEMARTINI ◽

DOUGLAS J. CASA ◽

REBECCA STEARNS ◽

LUKE BELVAL ◽

ARTHUR CRAGO ◽

...

Keyword(s):

Cold Water ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

Exertional Heat Stroke ◽

Road Race

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Age- and Sex-Based Differences in Exertional Heat Stroke Incidence in a 7-Mile Road Race

Journal of Athletic Training ◽

10.4085/1062-6050-539-19 ◽

2020 ◽

Vol 55 (12) ◽

pp. 1224-1229

Author(s):

Luke N. Belval ◽

Gabrielle E.W. Giersch ◽

William M. Adams ◽

Yuri Hosokawa ◽

John F. Jardine ◽

...

Keyword(s):

Heat Stroke ◽

Age Groups ◽

Medical Personnel ◽

Reference Population ◽

Exertional Heat Stroke ◽

Stroke Incidence ◽

Relative Contribution ◽

Epidemiologic Evidence ◽

Road Race ◽

Globe Temperature

Context Sex, age, and wet-bulb globe temperature (WBGT) have been proposed risk factors for exertional heat stroke (EHS) despite conflicting laboratory and epidemiologic evidence. Objective To examine differences in EHS incidence while accounting for sex, age, and environmental conditions. Design Observational study. Setting Falmouth Road Race, a warm-weather 7-mi (11.26-km) running road race. Patients or Other Participants We reviewed records from patients treated for EHS at medical tents. Main Outcome Measure(s) The relative risk (RR) of EHS between sexes and across ages was assessed with males as the reference population. Multivariate linear regression analyses were calculated to determine the relative contribution of sex, age, and WBGT to the incidence of EHS. Results Among 343 EHS cases, the female risk of EHS was lower overall (RR = 0.71; 95% confidence interval [CI] = 0.58, 0.89; P = .002) and for age groups 40 to 49 years (RR = 0.43; 95% CI = 0.24, 0.77; P = .005) and 50 to 59 years (RR = 0.31; 95% CI = 0.13, 0.72; P = .005). The incidence of EHS did not differ between sexes in relation to WBGT (P > .05). When sex, age, and WBGT were considered in combination, only age groups <14 years (β = 2.41, P = .008), 15 to 18 years (β = 3.83, P < .001), and 19 to 39 years (β = 2.24, P = .014) significantly accounted for the variance in the incidence of EHS (R2 = .10, P = .006). Conclusions In this unique investigation of EHS incidence in a road race, we found a 29% decreased EHS risk in females compared with males. However, when sex was considered with age and WBGT, only younger age accounted for an increased incidence of EHS. These results suggest that road race medical organizers should consider participant demographics when organizing the personnel and resources needed to treat patients with EHS. Specifically, organizers of events with greater numbers of young runners (aged 19 to 39 years) and males should prioritize ensuring that medical personnel are adequately prepared to handle patients with EHS.

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A Case of Exertional Heat Stroke Complicated by Hypoxic Hepatitis

Case Reports in Emergency Medicine ◽

10.1155/2020/8724285 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Bertram K. Woitok ◽

Shawki Bahmad ◽

Gregor Lindner

Keyword(s):

Supportive Care ◽

Liver Failure ◽

Acute Liver Failure ◽

Multiorgan Failure ◽

Heat Stroke ◽

Exertional Heat Stroke ◽

Hypoxic Hepatitis ◽

Threatening Condition ◽

Life Threatening ◽

Delayed Referral

Background.Exertional heat stroke is a life-threatening condition often complicated by multiorgan failure. We hereby present a case of a 25-year-old male presenting with syncope after a 10 km run in 28°C outside temperature who developed acute liver failure. Case Presentation. Initial temperature was found to be 41.1°C, and cooling measures were rapidly applied. He suffered from acute renal failure and rhabdomyolysis and proceeded to acute liver failure (ASAT 6100 U/l and ALAT 6561 U/l) due to hypoxic hepatitis on day 3. He did not meet criteria for emergency liver transplantation and recovered on supportive care. Conclusions. Acute liver failure due to heat stroke is a life-threatening condition with often delayed onset, which nevertheless resolves on supportive care in the majority of cases; thus, a delayed referral to transplant seems to be reasonable.

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Exertional Heat Stroke Knowledge and Management among Emergency Medical Service Providers

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18095016 ◽

2021 ◽

Vol 18 (9) ◽

pp. 5016

Author(s):

Rebecca Hirschhorn ◽

Oluwagbemiga DadeMatthews ◽

JoEllen Sefton

Keyword(s):

Service Providers ◽

Heat Stroke ◽

The United States ◽

Knowledge Assessment ◽

Years Of Experience ◽

Exertional Heat Stroke ◽

Emergency Medical ◽

Previously Treated ◽

Stroke Knowledge ◽

Cooling Methods

This study evaluated emergency medical services (EMS) providers’ knowledge of exertional heat stroke (EHS) and assessed current EMS capabilities for recognizing and managing EHS. EMS providers currently practicing in the United States were recruited to complete a 25-item questionnaire. There were 216 questionnaire responses (183 complete) representing 28 states. On average, respondents were 42.0 ± 13.0 years old, male (n = 163, 75.5%), and white (n = 176, 81.5%). Most respondents were Paramedics (n = 110, 50.9%) and had ≥16 years of experience (n = 109/214, 50.9%) working in EMS. Fifty-five percent (n = 99/180) of respondents had previously treated a patient with EHS. The average number of correct answers on the knowledge assessment was 2.6 ± 1.2 out of 7 (~37% correct). Temporal (n = 79), tympanic (n = 76), and oral (n = 68) thermometers were the most prevalent methods of temperature assessment available. Chemical cold packs (n = 164) and air conditioning (n = 134) were the most prevalent cooling methods available. Respondents demonstrated poor knowledge regarding EHS despite years of experience, and over half stating they had previously treated EHS in the field. Few EMS providers reported having access to an appropriate method of assessing or cooling a patient with EHS. Updated, evidence-based training needs to be provided and stakeholders should ensure their EMS providers have access to appropriate equipment.

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Prehospital management of exertional heat stroke at sports competitions: International Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020

British Journal of Sports Medicine ◽

10.1136/bjsports-2020-103854 ◽

2021 ◽

pp. bjsports-2020-103854

Author(s):

Yuri Hosokawa ◽

Sebastien Racinais ◽

Takao Akama ◽

David Zideman ◽

Richard Budgett ◽

...

Keyword(s):

Rectal Temperature ◽

Working Group ◽

Olympic Games ◽

Heat Stroke ◽

International Olympic Committee ◽

Exertional Heat Stroke ◽

Weather Impact ◽

Prehospital Management ◽

Adverse Weather ◽

Expert Working Group

ObjectivesThis document aimed to summarise the key components of exertional heat stroke (EHS) prehospital management.MethodsMembers of the International Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020 summarised the current best practice regarding the EHS prehospital management.ResultsSports competitions that are scheduled under high environmental heat stress or those that include events with high metabolic demands should implement and adopt policy and procedures for EHS prehospital management. The basic principles of EHS prehospital care are: early recognition, early diagnosis, rapid, on-site cooling and advanced clinical care. In order to achieve these principles, medical organisers must establish an area called the heat deck within or adjacent to the main medical tent that is optimised for EHS diagnosis, treatment and monitoring. Once admitted to the heat deck, the rectal temperature of the athlete with suspected EHS is assessed to confirm an elevated core body temperature. After EHS is diagnosed, the athlete must be cooled on-site until the rectal temperature is below 39°C. While cooling the athlete, medical providers are recommended to conduct a blood analysis to rule out exercise-associated hyponatraemia or hypoglycaemia, provided that this can be safely performed without interrupting cooling. The athlete is transported to advanced care for a full medical evaluation only after the treatment has been provided on-site.ConclusionsA coordination of care among all medical stakeholders at the sports venue, during transport, and at the hospital is warranted to ensure effective management is provided to the EHS athlete.

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