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Prevention of Heat Illness and Heat Cramps

Prevention of Heat Illness and Heat Cramps. Joel S. Brenner, M.D., M.P.H., F.A.A.P. Medical Director, Sports Medicine and Adolescent Medicine Programs Associate Professor of Pediatrics Children’s Hospital of The King’s Daughters Eastern Virginia Medical School Norfolk, Virginia.

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Prevention of Heat Illness and Heat Cramps

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  1. Prevention of Heat Illness and Heat Cramps Joel S. Brenner, M.D., M.P.H., F.A.A.P. Medical Director, Sports Medicine and Adolescent Medicine Programs Associate Professor of Pediatrics Children’s Hospital of The King’s Daughters Eastern Virginia Medical School Norfolk, Virginia

  2. Faculty Disclosure Information Author for UpToDate Speakers’ Bureau for Merck & Co, Inc. I do not intend to discuss an unapproved/ investigative use of a commercial product/ device in our presentation.

  3. Objective The learner will be able to: Understand and implement prevention strategies for heat illness and heat cramps in young athletes

  4. Patient A.J. • 16 y.o AA male football player finishing up 2nd day of two-a-day practices in July • Became combative and dizzy • Helped to field house and put in cold shower • Shirt removed and 911 called • Transferred to local ED where rectal temp 26 min later was 107° F

  5. Patient A.J. • Cooled with ice bags, 1 liter NS bolus • Versed and bicarbonate given • Bicarb 24, BUN 18, Cr 2.9, AST 233, ALT 105 CPK 2615

  6. Patient A.J. • Transferred to ICU for 4 days • CPK peak 35,000 • IVF, allopurinol, bicarbonate, CaCarbonate • Urine kept alkalinized at pH 7 or > • Prevent uric acid crystallization • Discharged on HD #7 with CPK 7417

  7. Patient A.J. • PMH: No heat illness or sickle cell dz or trait • Meds: no supplements or herbs • SH: During practice drinks every 20-30 minutes • Cramps after games

  8. Dog Days and SiriasisHow to Kill a Football PlayerKnochel, JP (1975)JAMA, 233(6):513-5 • Practice 2:30-6:00 PM • No Water • Lots of Salt Tablets • Rapid Weight Loss • Diuretics • Sauna • Plastic Suits • Wear All Gear All the Time • Continue with wind sprints until most players vomit, cramp, or collapse • Amphetamines

  9. Exertional Heat Illness Korey Stringer 1974-2001 Steve Belcher 1979-2003

  10. Chicago Marathon 2003 • High temperature 61°F • 3 cases of heatstroke (107°, 108°, 108.8°) • All survived due to rapid cooling

  11. Autopsy shows LR football player died of heat stroke, had enlarged heart (Columbia) Aug. 7, 2004 - Officials say the autopsy for a Lower Richland High School football player showed that the 15-year-old died of a heat stroke. The autopsy also revealed that the student had an enlarged heart. SPORTS 8/4/2004 Dallas football player dies after practice, cause unknown. Didn't have physical exam before first practice. Two other players hospitalized after first practice of season Senior Eric Brown, 17, was Carter's 5-foot-11, 275-pound center. He finished practice around noon and went home, where he fell ill.

  12. Effects of hydration status and BMI on core body temperature during pre-season high school football practice M.F. Bergeron, V.D. Valentine, J.S. Brenner, E.L. Hall, and D.A. Ludwig Medical College of Georgia Augusta, Georgia Pediatrics, (In Review)

  13. Environmental Conditions • Day 1 • 90.5 °F • 58.0 % rh • Day 2 • 93 °F • 53.8 % rh • Hazy, sunny, slight breeze

  14. Core Body Temperature

  15. Effects of Fluid Intake on Core Body Temperature During Exercise in the Heat

  16. ACSM Roundtable • Practice Modification • Acclimatization • Environment • Intensity • Uniform/Protective Gear • Hydration • Buddy system • Scheduling • Standardized PPE • Sickle Trait

  17. VHSL Fall Practice Policy (1) During their first six days of tryouts: • No practice session, full or walk-thru, may exceed three hours. • Total practice time per day is limited to five hours. • Only one full practice session will be permitted per day; it may be broken into two sessions. • One walk-thru session is permitted on the day of a full practice. • Two walk-thru practices may be substituted for a full and a walk thru session(s). • A one-hour minimum recovery period is required between sessions. (2) For week two and three the following regulations exist in addition to (a) through (f) above: • Two full practices are permissible per day provided they do not exceed five total hours, or three hours in a single session • No more that three full practices may be conducted in two consecutive calendar days Football Only restrictions: • Day 1-3 helmets only • Day 4-5 helmet and shoulder pads • Day 6+ full pads

  18. Patient A.J. • Could this have been prevented? • Would the new recommendations have helped A.J.? • Close monitoring during practice • Gradual introduction of equipment • Easy access to fluids • Gradual acclimatization • No consecutive two-a-days

  19. Exercise-Associated Muscle Cramps- Who is the Culprit? • Calcium? • Magnesium? • Potassium? • Enzyme Deficiency? • Lack of Conditioning? • Muscle Fatigue?

  20. Muscle overload/ fatigue- related • Overworked or strained muscle • Isolated • Responsive to stretching, massage, and icing • Does not wander or become widespread • Not related to fluid and electrolyte deficits

  21. Sweat Fluid Losses • Boys and Girls (up to 15y): 0.5 – 1.4 L per hour • Young Women (16 - 24y): 0.8 – 1.6 L per hour • Young Men (16 – 32y): 1.2 – 3.0 L per hour • Highest Female Sweating Rate: 2.8 L per hour • Highest Male Sweating Rate: 4.3 L per hour

  22. Is Water Enough?

  23. Adding the Numbers Over Time • 140 lb (63.5 kg) male • 2.1 L sweat per hour • 3090 mg Na per hour • In 4 hours • 8.4 L fluid loss • 12,360 mg Na loss • 31 grams salt (5 tsp) • Intake • 4.0 L fluid • 3200 mg Na • Deficit • 7% body weight • 9160 mg Na

  24. Etiology of Exertional Heat Cramps • Extensive & repeated water and sodium losses • Contracted interstitial compartment • Hyper-excitable motor nerve terminals • Spontaneous discharge

  25. Signs and Symptoms • Subtle “twitches” or fasciculations in certain voluntary muscles • “Full-blown” cramps in 20-30 minutes • Excruciating/ debilitating • Normal electrolytes • Not a good indicator of whole-body electrolyte status

  26. Individual Recommendations • Increase fluid recovery intake during training & competition • Increase Na intake • Supplemental Drinks (1/2 tsp NaCl/ 32 oz of Sports Drink – AM & PM) • Emergency Drink (1 tsp NaCl/ 0.5 L Sports Drink) Bergeron, M.F. International J. Sports Nutrition, 6:62-68, 1996

  27. Is Water Enough? • Unless water and sodium are replaced, rehydration will be incomplete… Nadel, et al. 1993

  28. Bergeron MF. Exertional heat cramps: recovery and return to play. J Sport Rehabil. 2007;16(3):190-196

  29. Other Treatment Options and Considerations • Intravenous • 0.5 - 1.0 L Normal Saline • Quinine • Varrying efficacy/ no benefit • Negative systemic effects • Return to Play • Often promptly • 1-2 days, if more clinically significant/ severe heat strain

  30. Not all skeletal muscle cramps are the same Exertional Heat Cramps Fatigue Cramps

  31. Heat Cramps: Prevention • Know your sweat rate • Drink 4-8 oz water/ sports drink every 15 minutes • Must consume carbohydrate and salt containing fluid if exercising over 1 hour • ¼ tsp salt (590mg Na) to 32oz Gatorade

  32. Suggested Reading • Bergeron MF. Exertional heat cramps: recovery and return to play. J Sport Rehabil. 2007;16(3):190-196 • Bergeron MF. Heat cramps during tennis: a case report. Int J Sport Nutr. 1996;6(1):62-68 • Bergeron MF. Heat cramps: fluid and electrolyte challenges during tennis in the heat. J Sci Med Sport. 2003;6(1):19-27 • Bergeron MF. Muscle cramps during exercise: is it fatigue or electrolyte deficit? Curr Sports Med Rep. 2008;7(4):S50-S55 • Eichner ER. The role of sodium in 'heat cramping'. Sports Med. 2007;37(4-5):368-370 • Mitchell JB, Phillips MD, Mercer SP, Baylies HL, Pizza FX. Postexercise rehydration: effect of Na+ and volume on restoration of fluid spaces and cardiovascular function. J Appl Physiol. 2000;89:1302-1309 • Schwellnus MP, Derman EW, Noakes TD. Aetiology of skeletal muscle 'cramps' during exercise: a novel hypothesis. J Sport Sci. 1997;15(3):277-285 • Schwellnus MP, Nicol J, Laubscher R, Noakes TD. Serum electrolyte concentrations and hydration status are not associated with exercise associated muscle cramping (EAMC) in distance runners. Br J Sports Med. 2004;38(4):488-492

  33. THANK YOU! Call with any questions 757-668-7850 (work) or 757-353-8493 (cell) Joel.Brenner@chkd.org

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