Athletic Trainers' Attitudes and Perceptions Regarding Exertional Heat Stroke Before and After an Educational Intervention

Context: Death from exertional heat stroke (EHS) is preventable when evidence-based guidelines are followed. The assessment of core body temperature using rectal thermometry and the treatment of cold-water immersion for EHS has been established as the standard of care; however, rectal thermometry is still controversial. Athletic trainers (ATs) may lack knowledge and comfort with this skill, which could impact implementation. Objective: Examine ATs' current practices, attitudes, and perceptions regarding EHS before and after an educational intervention. Design: Prequantitative/postquantitative experimental. Setting: Classroom. Patients or Other Participants: Twenty-five ATs in various athletic training settings. Intervention(s): Educational intervention designed to increase knowledge and address negative attitudes and perceptions regarding EHS evaluation and treatment. Main Outcome Measure(s): Attitude and perception scores. Results: Prior to the educational intervention, most ATs (86.9%, 20/23) reported that they use methods other than rectal thermometry to evaluate EHS. Of those who did not use rectal thermometry, their reasons included: lack of equipment/budget, concerns about liability/lack of consent (especially when dealing with minors), lack of training, and/or concerns about the privacy, embarrassment, compliance of the athlete. Cold-water immersion was chosen as the definitive method of cooling an athlete by only 41.7% (n = 10) of participants. Following the educational intervention, attitudes toward the use of rectal temperature to assess core body temperature (t[24] = 8.663, P < .001) and cold-water immersion treatment for EHS (t[24] = 4.187, P < .001) were significantly improved. However, while attitudes toward the use of other “cold” methods to treat EHS were not significantly changed (t[24] = 1.684, P = .105), perceptions regarding nonexertional influences on EHS were significantly improved (t[24] = 1.684, P = .105). Conclusions: This study demonstrated that a 3-hour educational intervention can improve attitudes and perceptions regarding the assessment and treatment of EHS in the short term. It is important that educational interventions use best-practice continuing education methods and include special attention to the barriers to evidence-based practice.

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Should Cooling Vests Be Used to Treat Exertional Heatstroke? A Critically Appraised Topic

Journal of Sport Rehabilitation ◽

10.1123/jsr.2015-0082 ◽

2017 ◽

Vol 26 (3) ◽

pp. 286-289

Author(s):

Megan L. Keen ◽

Kevin C. Miller

Keyword(s):

Cold Water ◽

Core Body Temperature ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

Clinical Scenario ◽

Clinical Question ◽

Bottom Line ◽

Cooling Rates ◽

Central Nervous System Dysfunction

Clinical Scenario:Exercise performed in hot and humid environments increases core body temperature (TC). If TC exceeds 40.5°C for prolonged periods of time, exertional heat stroke (EHS) may occur. EHS is a leading cause of sudden death in athletes. Mortality and morbidity increase the longer the patient’s TC remains above 40.5°C; thus, it is imperative to initiate cooling as quickly as possible. Acceptable cooling rates in EHS situations are 0.08–0.15°C/min, while ideal cooling rates are above 0.16°C/min. Cooling vests are popular alternatives for cooling hyperthermic adults. Most vests cover the anterior and posterior torso and have varying numbers of pouches for phase-change materials (eg, gel packs); some vests only use circulating water to cool. While cooling vests offer several advantages (eg, portability), studies demonstrating their effectiveness at rapidly reducing TC in EHS scenarios are limited.Clinical Question:Are TC cooling rates acceptable (ie, >0.08°C/min) when hyperthermic humans are treated with cooling vests postexercise?Summary of Findings:No significant differences in TC cooling rates occurred between cooling vests and no cooling vests. Cooling rates across all studies were ≤0.053°C/min.Clinical Bottom Line:Cooling vests do not provide acceptable cooling rates of hyperthermic humans postexercise and should not be used to treat EHS. Instead, EHS patients should be treated with cold-water immersion within 30 min of collapse to avoid central nervous system dysfunction and organ failure.Strength of Recommendation:Strong evidence (eg, level 2 studies with PEDro scores ≥5) suggests that cooling vests do not reduce TC quickly and thus should not be used in EHS scenarios.

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Current Knowledge, Attitudes, and Practices of Certified Athletic Trainers Regarding Recognition and Treatment of Exertional Heat Stroke

Journal of Athletic Training ◽

10.4085/1062-6050-45.2.170 ◽

2010 ◽

Vol 45 (2) ◽

pp. 170-180 ◽

Cited By ~ 33

Author(s):

Stephanie M. Mazerolle ◽

Ian C. Scruggs ◽

Douglas J. Casa ◽

Laura J. Burton ◽

Brendon P. McDermott ◽

...

Keyword(s):

Cold Water ◽

Current Knowledge ◽

Athletic Trainers ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

Exertional Heat Stroke ◽

Certified Athletic Trainers ◽

Attitudes And Practices ◽

Knowledge Attitudes And Practices

Abstract Context: Previous research has indicated that despite awareness of the current literature on the recommended prevention and care of exertional heat stroke (EHS), certified athletic trainers (ATs) acknowledge failure to follow those recommendations. Objective: To investigate the current knowledge, attitudes, and practices of ATs regarding the recognition and treatment of EHS. Design: Cross-sectional study. Setting: Online survey. Patients or Other Participants: We obtained a random sample of e-mail addresses for 1000 high school and collegiate ATs and contacted these individuals with invitations to participate. A total of 498 usable responses were received, for a 25% response rate. Main Outcome Measure(s): The survey instrument evaluated ATs' knowledge and actual practice regarding EHS and included 29 closed-ended Likert scale questions (1 = strongly disagree, 7 = strongly agree), 2 closed-ended questions rated on a Likert scale (1 = lowest value, 9 = greatest value), 8 open-ended questions, and 7 demographic questions. We focused on the open-ended and demographic questions. Results: Although most ATs (77.1%) have read the current National Athletic Trainers' Association position statement on heat illness, only 18.6% used rectal thermometers to assess core body temperature to recognize EHS, and 49.7% used cold-water immersion to treat EHS. Athletic trainers perceived rectal thermometers as the most valid temperature assessment device when compared with other assessment devices (P ≤ .05), but they used oral thermometers as the primary assessment tool (49.1%). They identified cold-water immersion as the best cooling method (P ≤ .05), even though they used other means to cool a majority of the time (50.3%). Conclusions: The ATs surveyed have sound knowledge of the correct means of EHS recognition and treatment. However, a significant portion of these ATs reported using temperature assessment devices that are invalid with athletes exercising in the heat. Furthermore, they reported using cooling treatment methods that have inferior cooling rates.

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Safety and efficacy of cold‐water immersion in the treatment of older patients with heat stroke: a case series

Acute Medicine & Surgery ◽

10.1002/ams2.635 ◽

2021 ◽

Vol 8 (1) ◽

Author(s):

Chikao Ito ◽

Isao Takahashi ◽

Miyuki Kasuya ◽

Kyoji Oe ◽

Masahito Uchino ◽

...

Keyword(s):

Older Patients ◽

Cold Water ◽

Water Immersion ◽

Heat Stroke ◽

Case Series ◽

Cold Water Immersion ◽

Safety And Efficacy

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EFEKTIVITAS COLD WATER IMMERSION SUHU 15° C DAN 25° C TERHADAP PERBAIKAN DAYA TAHAN DAN PERSEPSI NYERI OTOT TUNGKAI PADA PEMAIN SEPAK BOLA USIA DINI

MEDIKORA ◽

10.21831/medikora.v18i1.29191 ◽

2019 ◽

Vol 18 (1) ◽

pp. 12-16

Author(s):

Muhammad Rifqi Fatoni ◽

Sigit Nugroho

Keyword(s):

Pain Perception ◽

Cold Water ◽

Water Immersion ◽

Cold Water Immersion ◽

Wilcoxon Test ◽

Rank Test ◽

Muscle Endurance ◽

Before And After ◽

Post Test ◽

Signed Rank Test

Akumulasi pertandingan dengan masa pemulihan yang singkat menyebabkan kelelahan, kerusakan dan inflamasi otot yang dapat menurunkan daya tahan otot dan meningkatkan resiko cedera. Pada keadaan cedera akut, penggunaan terapi dingin dapat mencegah kerusakan jaringan yang lebih luas. Penelitian ini bertujuan untuk mengetahui efektivitas Cold Water Immersion (CWI) suhu 15°C dan 25°C terhadap daya tahan dan persepsi nyeri otot tungkai pada pemain sepak bola usia dini. Desain yang digunakan dalam penelitian ini adalah eksperimen semu dengan pola Two Group Pretest-Posttest. Instrumen yang digunakan adalah tes dan pengukuran nyeri dan daya tahan otot tungkai. Subjek penelitian ini adalah atlet sepak bola Sekolah Sepak Bola (SSB) KKK Klajuaran usia 9-11 tahun. Teknik sampel menggunakan quota sampling dengan subyek sebanyak 14 orang. Subyek dibagi menjadi dua kelompok yaitu, perlakuan CWI 15°C (G15) dan CWI suhu 25°C (G25). Data pretest pada kedua perlakuan dan data post test kedua perlakuan diuji dengan uji Mann Whitney. Daya tahan otot dan persepsi nyeri sebelum dan sesudah perlakuan pada masing masing kelompok terkumpul dianalisis secara deskriptif dan diuji dengan analisis Wilcoxon Signed Rank Test. Uji efektivitas dihitung dengan membandingkan selisih data post test dan pretest terhadap data pretest. Tidak ditemukan perbedaan daya tahan otot dan persepsi nyeri sebelum dan sesudah perlakuan antara kedua kelompok perlakuan. Pada kelompok G15 terjadi penurunan persepsi nyeri sebesar 55% dengan uji wilcoxon dengan nilai p = 0,018, akan tetapi tidak ditemukan perubahan daya tahan otot setelah perlakuan. Hasil yang sama ditemukan pada kelompok G25 dimana terdapat penurunan persepsi nyeri sebesar 58% dengan uji wilcoxon dengan p = 0,018 serta tidak ditemukan perubahan daya tahan otot tungkai. Dapat disimpulkan bahwa perlakuan CWI 15°C dan 25°C dapat menurunkan nyeri tapi tidak mempengaruhi daya tahan otot. Tidak terdapat perbedaan efektivitas kedua jenis perlakuan tersebut dalam menurunkan persepsi nyeri dan meningkatkan daya tahan otot. EFFECTIVENESS OF COLD WATER IMMERSION TEMPERATURE OF 15 ° C AND 25° C AGAINST IMPROVEMENT IN ENDURANCE AND PERCEPTION OF LEG MUSCLE PAIN IN EARLY AGE FOOTBALL PLAYERSAbstractAccumulation of matches with a short recovery period causes fatigue, damage and inflammation of the muscles which can reduce muscle endurance and increase the risk of injury. In the case of acute injury, the use of cold therapy can prevent damage to broader tissue. This study aims to determine the effectiveness of Cold Water Immersion (CWI) temperatures of 15 ° C and 25 ° C on the endurance and perception of leg muscle pain in early age soccer players.The design used in this study was quasi-experimental with Two Group Pretest-Posttest patterns. The instrument used was a test and measurement of pain and endurance of leg muscles. The subjects of this study were the soccer athletes of Klajuaran KKK Soccer School (SSB) aged 9-11 years. The sampling technique uses quota sampling with subjects as many as 14 people. The subjects were divided into two groups namely, 15 ° C (G15) CWI treatment and 25 ° C (G25) CWI treatment. Pretest data on both treatments and post-test data on both treatments were tested with the Mann Whitney test. Muscle endurance and pain perception before and after treatment in each group collected were analyzed descriptively and tested with the Wilcoxon Signed Rank Test analysis. The effectiveness test is calculated by comparing the difference between the post test and pretest data against the pretest data. There were no differences in muscle endurance and pain perception before and after treatment between the two treatment groups. In the G15 group there was a decrease in pain perception by 55% with the Wilcoxon test with a value of p = 0.018, but there was no change in muscle endurance after treatment. Similar results were found in the G25 group where there was a decrease in pain perception by 58% with the Wilcoxon test with p = 0.018 and no changes in endurance of leg muscles were found. It can be concluded that the CWI treatment of 15 ° C and 25 ° C can reduce pain but does not affect muscular endurance. There is no difference in the effectiveness of the two types of treatment in reducing pain perception and increasing muscle endurance.

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Cold water immersion attenuates anabolic signaling and skeletal muscle fiber hypertrophy, but not strength gain, following whole-body resistance training

Journal of Applied Physiology ◽

10.1152/japplphysiol.00127.2019 ◽

2019 ◽

Vol 127 (5) ◽

pp. 1403-1418 ◽

Cited By ~ 7

Author(s):

Jackson J. Fyfe ◽

James R. Broatch ◽

Adam J. Trewin ◽

Erik D. Hanson ◽

Christos K. Argus ◽

...

Keyword(s):

Skeletal Muscle ◽

Resistance Training ◽

Protein Content ◽

Muscle Fiber ◽

Cold Water ◽

Water Immersion ◽

Cold Water Immersion ◽

Post Exercise ◽

Leg Press ◽

Before And After

We determined the effects of cold water immersion (CWI) on long-term adaptations and post-exercise molecular responses in skeletal muscle before and after resistance training. Sixteen men (22.9 ± 4.6 y; 85.1 ± 17.9 kg; mean ± SD) performed resistance training (3 day/wk) for 7 wk, with each session followed by either CWI [15 min at 10°C, CWI (COLD) group, n = 8] or passive recovery (15 min at 23°C, control group, n = 8). Exercise performance [one-repetition maximum (1-RM) leg press and bench press, countermovement jump, squat jump, and ballistic push-up], body composition (dual X-ray absorptiometry), and post-exercise (i.e., +1 and +48 h) molecular responses were assessed before and after training. Improvements in 1-RM leg press were similar between groups [130 ± 69 kg, pooled effect size (ES): 1.53 ± 90% confidence interval (CI) 0.49], whereas increases in type II muscle fiber cross-sectional area were attenuated with CWI (−1,959 ± 1,675 µM2 ; ES: −1.37 ± 0.99). Post-exercise mechanistic target of rapamycin complex 1 signaling (rps6 phosphorylation) was blunted for COLD at post-training (POST) +1 h (−0.4-fold, ES: −0.69 ± 0.86) and POST +48 h (−0.2-fold, ES: −1.33 ± 0.82), whereas basal protein degradation markers (FOX-O1 protein content) were increased (1.3-fold, ES: 2.17 ± 2.22). Training-induced increases in heat shock protein (HSP) 27 protein content were attenuated for COLD (−0.8-fold, ES: −0.94 ± 0.82), which also reduced total HSP72 protein content (−0.7-fold, ES: −0.79 ± 0.57). CWI blunted resistance training-induced muscle fiber hypertrophy, but not maximal strength, potentially via reduced skeletal muscle protein anabolism and increased catabolism. Post-exercise CWI should therefore be avoided if muscle hypertrophy is desired. NEW & NOTEWORTHY This study adds to existing evidence that post-exercise cold water immersion attenuates muscle fiber growth with resistance training, which is potentially mediated by attenuated post-exercise increases in markers of skeletal muscle anabolism coupled with increased catabolism and suggests that blunted muscle fiber growth with cold water immersion does not necessarily translate to impaired strength development.

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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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Physiologic and Perceptual Responses to Cold-Shower Cooling After Exercise-Induced Hyperthermia

Journal of Athletic Training ◽

10.4085/1062-6050-51.4.01 ◽

2016 ◽

Vol 51 (3) ◽

pp. 252-257 ◽

Cited By ~ 11

Author(s):

Cory L. Butts ◽

Brendon P. McDermott ◽

Brian J. Buening ◽

Jeffrey A. Bonacci ◽

Matthew S. Ganio ◽

...

Keyword(s):

Heart Rate ◽

Cooling Rate ◽

Rectal Temperature ◽

Muscle Pain ◽

Cold Water ◽

Thermal Sensation ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

Exercise Induced

Exercise conducted in hot, humid environments increases the risk for exertional heat stroke (EHS). The current recommended treatment of EHS is cold-water immersion; however, limitations may require the use of alternative resources such as a cold shower (CS) or dousing with a hose to cool EHS patients.Context: To investigate the cooling effectiveness of a CS after exercise-induced hyperthermia.Objective: Randomized, crossover controlled study.Design: Environmental chamber (temperature = 33.4°C ± 2.1°C; relative humidity = 27.1% ± 1.4%).Setting: Seventeen participants (10 male, 7 female; height = 1.75 ± 0.07 m, body mass = 70.4 ± 8.7 kg, body surface area = 1.85 ± 0.13 m2, age range = 19–35 years) volunteered.Patients or Other Participants: On 2 occasions, participants completed matched-intensity volitional exercise on an ergometer or treadmill to elevate rectal temperature to ≥39°C or until participant fatigue prevented continuation (reaching at least 38.5°C). They were then either treated with a CS (20.8°C ± 0.80°C) or seated in the chamber (control [CON] condition) for 15 minutes.Intervention(s): Rectal temperature, calculated cooling rate, heart rate, and perceptual measures (thermal sensation and perceived muscle pain).Main Outcome Measure(s): The rectal temperature (P = .98), heart rate (P = .85), thermal sensation (P = .69), and muscle pain (P = .31) were not different during exercise for the CS and CON trials (P > .05). Overall, the cooling rate was faster during CS (0.07°C/min ± 0.03°C/min) than during CON (0.04°C/min ± 0.03°C/min; t16 = 2.77, P = .01). Heart-rate changes were greater during CS (45 ± 20 beats per minute) compared with CON (27 ± 10 beats per minute; t16 = 3.32, P = .004). Thermal sensation was reduced to a greater extent with CS than with CON (F3,45 = 41.12, P < .001).Results: Although the CS facilitated cooling rates faster than no treatment, clinicians should continue to advocate for accepted cooling modalities and use CS only if no other validated means of cooling are available.Conclusions:

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Thermoregulatory Influence of a Cooling Vest on Hyperthermic Athletes

Journal of Athletic Training ◽

10.4085/1062-6050-43.1.55 ◽

2008 ◽

Vol 43 (1) ◽

pp. 55-61 ◽

Cited By ~ 28

Author(s):

Rebecca M. Lopez ◽

Michelle A. Cleary ◽

Leon C. Jones ◽

Ron E. Zuri

Keyword(s):

Heat Stress ◽

Cooling Rate ◽

Core Body Temperature ◽

Athletic Trainers ◽

Water Immersion ◽

Standard Of Care ◽

Humid Environment ◽

Randomized Control ◽

Ice Water ◽

Core Body

Abstract Context: Athletic trainers must have sound evidence for the best practices in treating and preventing heat-related emergencies and potentially catastrophic events. Objective: To examine the effectiveness of a superficial cooling vest on core body temperature (Tc) and skin temperature (Tsk) in hypohydrated hyperthermic male participants. Design: A randomized control design with 2 experimental groups. Setting: Participants exercised by completing the heat-stress trial in a hot, humid environment (ambient temperature = 33.1 ± 3.1°C, relative humidity = 55.1 ± 8.9%, wind speed = 2.1 ± 1.1 km/hr) until a Tc of 38.7 ± 0.3°C and a body mass loss of 3.27 ± 0.1% were achieved. Patients or Other Participants: Ten healthy males (age = 25.6 ± 1.6 years, mass = 80.3 ± 13.7 kg). Intervention(s): Recovery in a thermoneutral environment wearing a cooling vest or without wearing a cooling vest until Tc returned to baseline. Main Outcome Measure(s): Rectal Tc, arm Tsk, time to return to baseline Tc, and cooling rate. Results: During the heat-stress trial, Tc significantly increased (3.6%) and, at 30 minutes of recovery, Tc had decreased significantly (2.6%) for both groups. Although not significant, the time for return to baseline Tc was 22.6% faster for the vest group (43.8 ± 15.1 minutes) than for the no-vest group (56.6 ± 18.0 minutes), and the cooling rate for the vest group (0.0298 ± 0.0072°C/min) was not significantly different from the cooling rate for the no-vest group (0.0280 ± 0.0074°C/min). The Tsk during recovery was significantly higher (2.1%) in the vest group than in the no-vest group and was significantly lower (7.1%) at 30 minutes than at 0 minutes for both groups. Conclusions: We do not recommend using the cooling vest to rapidly reduce elevated Tc. Ice-water immersion should remain the standard of care for rapidly cooling severely hyperthermic individuals.

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Loss of α-actinin-3 during human evolution provides superior cold resilience and muscle heat generation

10.1101/2020.10.03.323964 ◽

2020 ◽

Author(s):

VL Wyckelsma ◽

T Venckunas ◽

PJ Houweling ◽

M Schlittler ◽

VM Lauschke ◽

...

Keyword(s):

Skeletal Muscle ◽

Cold Tolerance ◽

Muscle Activation ◽

Cold Water ◽

Muscle Protein ◽

Core Body Temperature ◽

Water Immersion ◽

Cold Water Immersion ◽

Skeletal Muscle Protein ◽

Brown Adipose

ABSTRACTThe fast skeletal muscle protein α-actinin-3 is absent in 1.5 billion people worldwide due to homozygosity for a nonsense polymorphism in the ACTN3 gene (R577X) 1. The prevalence of the 577X allele increased as modern humans moved to colder climates, suggesting a link between α-actinin-3 deficiency and improved cold tolerance 1,2. Here, we show that humans lacking α-actinin-3 (XX) are superior in maintaining core body temperature during cold-water immersion due to changes in skeletal muscle thermogenesis. Muscles of XX individuals displayed a shift towards more slow-twitch isoforms of myosin heavy chain (MyHC) and sarcoplasmic reticulum (SR) proteins, accompanied by altered neuronal muscle activation resulting in increased tone rather than overt shivering 3,4. Experiments on Actn3 knockout mice showed no alterations in brown adipose tissue (BAT) properties that could explain the improved cold tolerance in XX individuals. Thus, this study provides a clear mechanism for the positive selection of the ACTN3 X-allele in cold climates and supports a key thermogenic role of skeletal muscle during cold exposure in humans.

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Emergency Medical Service Directors’ Protocols for Exertional Heat Stroke

Medicina ◽

10.3390/medicina56100494 ◽

2020 ◽

Vol 56 (10) ◽

pp. 494

Author(s):

Michael R. Szymanski ◽

Samantha E. Scarneo-Miller ◽

M. Seth Smith ◽

Michelle L. Bruner ◽

Douglas J. Casa

Keyword(s):

Best Practices ◽

Emergency Medical Service ◽

Best Practice ◽

Medical Service ◽

Cold Water ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

Athletic Trainer ◽

Chi Squared

Background and Objectives: Emergency Medical Service (EMS) protocols vary widely and may not implement best practices for exertional heat stroke (EHS). EHS is 100% survivable if best practices are implemented within 30 min. The purpose of this study is to compare EMS protocols to best practices for recognizing and treating EHS. Materials and Methods: Individuals (n = 1350) serving as EMS Medical or Physician Director were invited to complete a survey. The questions related to the EHS protocols for their EMS service. 145 individuals completed the survey (response rate = 10.74%). Chi-Squared Tests of Associations (χ2) with 95% confidence intervals (CI) were calculated. Prevalence ratios (PR) with 95% CI were calculated to determine the prevalence of implementing best practices based on location, working with an athletic trainer, number of EHS cases, and years of directing. All PRs whose 95% CIs excluded 1.00 were considered statistically significant; Chi-Squared values with p values < 0.05 were considered statistically significant. Results: A majority of the respondents reported not using rectal thermometry for the diagnosis of EHS (n = 102, 77.93%) and not using cold water immersion for the treatment of EHS (n = 102, 70.34%). If working with an athletic trainer, EMS is more likely to implement best-practice treatment (i.e., cold-water immersion and cool-first transport-second) (69.6% vs. 36.9%, χ2 = 8.480, p < 0.004, PR = 3.15, 95% CI = 1.38, 7.18). Conclusions: These findings demonstrate a lack of implementation of best-practice standards for EHS by EMS. Working with an athletic trainer appears to increase the likelihood of following best practices. Efforts should be made to improve EMS providers’ implementation of best-practice standards for the diagnosis and management of EHS to optimize patient outcomes.

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