Transcript
Welcome everyone to the 12 o'clock midday on Wednesday.
I'm central time.
Ray Castle, the moderator for today's session.
I'm excited to have doctor David Heath on board for our next our our second presentation of the day on heat illness management and pediatrics and ad dogs.
Welcome to the presentation, Doctor Heath.
Thank you, sir.
Appreciate that.
Great.
So I wanna do a couple of quick half several I see some familiar faces.
If you would, just in the chat and tag everyone.
Let us know where you're from in your setting.
Helps us to kinda connect everybody together a little better.
And then also when asking the question, Liz, it gives us the opportunity to better understand and answer questions related to your your specific setting as well.
Great to see.
Hillary up in Lancaster, PA, Quentin over in Texas, Eric in Kentucky, Aliyah Aliyah oh, I'm sorry.
Aliyah, and Dallas.
Right.
Welcome to the in different settings, college, and high school.
Got some professional sports on here as well throughout this session as well.
Couple quick housekeeping items.
1, definitely.
Hey, Kim.
How are you doing?
Great to good to savvy on board.
For the chat chat area, we'll do this as some general chat areas.
We have q and a session.
So if you have a question anytime during the presentation, just hit that q and a button You can also upload it so it has a thumbs thumbs up if you like the question.
So the more people get a question, definitely want to address it.
We even have Mir, who's from Dubai.
So welcome, Mir.
Great to have you on board here today.
So that We'll do that.
At the end of the session, we'll field all those questions.
If for some reason, we run out of time and we have a lot of questions, we will come back and get those to you after the facts.
So just know that your questions will be answered.
Also, during the question, if you feel if you'd like to actually ask Doctor Heath the question, not just on typing, but in but over audio, let me know in the chat, and we can I can give you audio access and borrow away your question to the audience?
So let's go ahead and get started.
Wanna talk give a quick introduction, and we'll get moving forward.
So doctor Heath brings it's a phenomenal amount of experience and expertise, not only as an like training, but also a he's a board certified, a Mercy Medicine physician.
He's EMS medical director, and also adjunct clinical professor, Merchant Medicine, for the Lincoln Memorial University, the Bus College of Osteopathic Medicine.
He's currently he currently he's also a hospital he was a hospital administrator and serving as department chairman of Mercy Medicine and and facility medical director.
He's residency trained in emergency medicine.
A number of different accolades.
He's been there as well.
He's worked at Memorial at Lincoln Memorial University.
He had dual athletic training.
I have a degree there.
He's also he returned working with the medical school, a member of their inaugural class, of their of of DECOMM.
And then as as he has done phenomenal work in leadership and emergency medicine and other things.
So He is you know, I'm I'm excited to have you on board, Doctor Heath.
We're talking earlier and even before then.
His his reputation is renowned in in Mercy Medicine excited to have you here today.
So without further ado, Doctor Heath, the the floor, the screen is all yours the next hour.
Oh, wow.
Well, I appreciate that, Doctor Castle.
Thank you for having me.
Can I get a thumbs up?
Can you hear me alright?
Yep.
Super.
Alright.
Well, welcome to everybody.
I know this is probably the only lectures standing between you and lunch.
So, again, I appreciate you coming on board with me here.
So as Doctor Castle mentioned, I kinda have a unique perspective in that I was both an athletic trainer for 20 years as well as an emergency physician.
So I do see a lot of heat illnesses both in pediatrics and adults, which hopefully we can kind of go through some things and maybe get some perspectives today.
So, again, I have no disclosures.
There will be some discussion about some specific like, trademark type items at the end of lecture today, and I have no financial disclosures or interest in those organizations or products.
So I know you probably are, you know, again, thinking about lunch right now, but kinda just bear with me.
And we'll get through this here.
I have made every opportunity to give you information that you need in clinical practice.
I underline it, and I put it in red.
And what I really hope to do in really all my presentations is to give something that you can use clinically, immediately.
So that's my goal here.
I will make a note that I've had a few questions about the wet bulb globe temperature And I really am not going to address that at all today, so that's gonna be a separate type of issue.
But there's gonna be a big push In this presentation, as there is in real life, on heat stroke, exertional heat stroke.
And also throughout the lecture, you're gonna see a little pearls, pitfalls, and little chicken nuggets that you can hopefully snack on, and it'll give you some information.
So as you folks have been provided, educational objectives are there for you.
I will not read them to you.
We will proceed.
So up front here, I wanna tell you that the most important thing when I speak to people is education about exertional heat on us.
You're gonna have to be able to recognize this.
And that is probably the most important thing bar none out of any of this information I'm going to give you.
So if you could take anything out of these slides, please take that.
Now, just as a matter of course, we will have to get on the same page of terminology, and I'm going to go over 4 separate things here for you.
So one of which is gonna be exercise associated muscle cramps.
And as a lot of you probably know, it's a little bit controversial.
There's a growing body of literature now that says they're not actual muscle cramps.
But the mechanism is still just a little bit questionable.
And kind of the bottom line with that is when these occur, then static stretching is probably the most effective method to treat those on the sidelines.
Pretty much everybody here is probably seeing those.
Moving forward to heat associated collapse, as a as a lot of you also know, it's probably more known by heat syncope, but they're kinda moving away from that.
And a lot of times, it's from volume depletion or if they're unaccustomed to the heated exposure, like during preseason, those type of things.
So that that's a pretty straightforward type of type of explanation for this issue.
But just as you know, it's really not called syncope anymore.
So that's probably an FYI for those folks out there.
Now moving forward to probably the 2 most common ones that we see, you know, in the emergency department is gonna be heat exhaustion.
And by definition, by the big difference between heat exhaustion and heat stroke is gonna be your temperature, and we'll talk about that just a a little bit later.
And also the central nervous system aspect of confusion.
So heat stroke is gonna be a CNS affecting type of syndrome with a temperature typically greater than a 104 degrees.
And as contrast heat exhaustion, it really doesn't have that CNS component, and the temperature is going to be a little bit lower.
Less than 104 degrees.
So those are gonna be your explanations.
Now we as athletic trainers have to care for everybody.
I see a lot of these folks even in the emergency department.
But on the field, you're gonna have to take care of grandma, grandpa, the coach, the other athletic trainers, the players, you're there for everybody.
Even, interestingly, the people in the stands, so you have to take care of them.
Now when we talk about heat stroke, which again is gonna be a little bit more focused on this presentation.
There are 2 different types.
You're gonna have exertional heat stroke.
And then non exertional heat stroke.
We typically see a lot of the exertional heatstrokes on the sidelines and also in the emergency departments.
You know, the players exerting themselves, that type of thing, but as I mentioned, you have to be aware of the people in the stands, the nonexertional heat stroke people.
The more extremes of age, the young folks, the the elderly people sitting there watching their grandkids at the game, You can't forget about those people on the sidelines.
So I wanna go through just a few epidemiological topics with you.
So I will mention As we stated there in the beginning of the presentation, when you talk about exertional heat illness, it's kind of a spectrum.
It kinda kinda goes from minor to major with exertional heat stroke being the most major, of course.
And interestingly, over 9000 annual cases occur in high school athletes.
Now that's interesting because that's reported.
Now you you guys probably know as well as I do.
That it's very likely a lot more than that.
Now that's actually old data that was from 05 to 09.
And if we look a little bit further looking into more my realm now, hospitalizations for exertional heat on us for about a 10 year period was about 28,000.
And 75% of those were heat ex heat exhaustion.
So not exactly not exactly heat stroke.
Okay?
So moving forward further, about 65,000 of emergency department cases.
Okay?
About 65,000 of those were exertional heat illnesses coming to emergency department, and that was about a 9 year period from 97 to 6.
And this is our realm as well.
Because out of those 65,000, three quarters of those are sports related.
K?
So that's where we're so important in this whole chain of treating the illness.
Over 8000 of the emergency department cases were heat stroke.
And as you guys noticed there, The ages are important here.
This is our wheelhouse as athletic trainers.
We see folks, you know, on the broad spectrum of ages, but we see primarily, you know, the younger folks, the twenty to fifty nine year olds, depending on what venue you're in.
54% of those came to the ER with heat stroke were within that age group.
K?
And this is kind of the dark side of exertional heat stroke.
About 700 people die every single year from this disease.
Now Boden did some research in both 2013 2020 did 22 separate studies here.
And he found out that heat illnesses were about 16% of the football fatalities at that time.
And that was back in 13.
So you fast forward to about 7 years later, and that's actually increased by almost 8%.
For whatever reason.
So it is becoming more of an issue here.
And, you know, also interestingly, it's all put up there in the nugget.
There was about a 13 month period there from June 20 to June of 21 worth 13 people, like one person a month, died from exertional heat stroke.
So it is very, very much a fatal type of disease if it's not recognized.
Now I figured this would be important to put on there, primarily just to focus on the severity of exertional heat on this.
On the top left hand corner, as a lot of you know, one of the big high profile cases was Corey Stringer.
Now, Corey Stringer, he was a Minnesota Vikings player that collapsed on the field back in.
I think July of 2001.
And, you know, subsequently, you know, you've obviously had some people die in the meantime.
But one of our more famous colleagues, Doug Casa, he's out of University of Connecticut.
He is the chief operating officer of the Corey Springer Institute.
So a lot of you on this presentation have probably read some of his research But as you know there, a lot of people and a lot of young kids and especially football players, as we'll note here in a little while, have died from 8 stroke.
And it's a very litigious type of thing.
If you'll see in the bottom right hand corner, there was a sixteen year old Georgia high school basketball player that died And it ended up being a $10,000,000 lawsuits.
And the athletic trainer was involved, bunch of people were involved.
So so further, we're kinda tidying up the epidemiological data here, but the actual incidents, the incidents itself.
So in other words, like, for example, exertional heat on its 1.5.
That essentially means there are about 1.5 new cases.
Of exertional heat on us for every 100,000 people or players.
Heat stroke is about the same.
But if you look for heat illness, it's a little bit higher.
It's about 30.
K?
30 new cases per 100,000.
And this further emphasizes the age range there.
Right?
So we talked about this before that you know, between that 18, 59, 15, 34 type of age range is a high risk for us.
So that's gonna be your your low hanging fruit to treat those type of people.
And age range in the emergency department is pretty much right at 40.
That's about what it averages out at.
And, anecdotally, I see a lot of thirty five year olds and a lot of eighteen year olds, those two age ranges.
You know, they're running marathons, they're doing high school sports.
Almost all all my cases are are right in that that type of age range.
And finally, I'll mention this.
Geographically, I know we have people probably all over the country and the world here talking, you know, in this presentation.
But August, Preseason in the South, dangerous times, especially with the heat.
So those are gonna be your most red flag type of issues, which you got geography.
Now when you're talking about exertional heat on this, American football, American style football, girls field hockey, Cross country are gonna be your highest risk.
In practice, during the first roughly 2 weeks of your preseason.
Very important.
And I'll also note there on the slide that it's the 3rd leading cause of death in high school athletes.
Now why?
Why?
It's very important.
So this is where we're gonna kinda get into the kind of the meat and potatoes of the presentation.
It's really super tough.
To get rid of heat whenever you have a lot of these clothes on.
And as you'll see there, radiation is very important to dissipate heat.
65% of your heat is supposed to be dissipated.
And whenever you have on clothes, whenever you're on a hot field, all these type of issues are kind of cumulative whenever we're talking about increasing temperature for exertional heat illness.
And let's just kinda reiterate some of the research by Curran yard.
That American football and girls feel hockey are super high with their incidence rate.
Information here also reiterates American Football being high, but Cross country also being high.
This is in the the collegiate setting.
So you think yourself risk factors.
Who do I need to actually look at?
To pick them out saying they're high risk?
And that's a great question.
As I mentioned before, extremes of age are super, super important.
Individuals that are deconditioned, player type of sports that are where you have excessive clothing like football, rugby, those type of things.
And as we mentioned, lack of a climateization, which will talk a little bit more with pediatrics during a little while, It's actually pretty interesting data.
Those are probably the most important things.
And I don't know if you noticed, but on the previous slides where it had individuals that had that had died from this, there there were a number of them who were offensive linemen, defensive tackles.
Right?
Defensive linemen are pretty notorious for being a little bit on the obese side.
So that also puts them at high risk.
So US athletic trainers also have to be aware of pre existing conditions.
I'd say, you know, majority of you go through pre participation in physicals with people.
You know your athletes.
You know the people you work with, and you know if they are predisposed.
Given some of these risk factors.
And even some of the medications they're on is important, as you see, they're on the left.
So I won't deliver the slide, but it is very, very important to know this.
One other note, keeping folks hydrated.
That's what athletic trainers do.
We try to do that, and sometimes coaches are reluctant to do that.
This is where you're gonna have to be an advocate for your athletes.
So really try to push that.
One last scary type of statistic here.
You can flip a coin.
50% of those people with exertional heat elements don't have any risk factors.
It just happens.
So it's good news and bad news, but you need to kind of know these things to be able to diagnose this effectively.
So earning questions with this type of presentation.
Do pediatrics have any type of different physiological things that make them different?
That is a great question.
You have some pediatric folks, like pediatricians, say, you know, kids are not little adults.
Well, they kind of are, but they're kinda not.
So what do I mean by that?
We'll move on here and talk about some specific things.
What I kinda mean by that is that their thermal regulation is immature.
So it's not like they grew up to be hippopotamuses or elephants or any thing.
I mean, they are little adult, but they're just not mature enough to get rid of heat like adults do, and we'll talk about that here in a moment.
So, Doctor.
Cassel mentioned, this is a presentation to talk at least kinda moderately about the difference between adults and pediatrics.
So here we go.
Acclimatization is very, very important, and it's not exactly practical to acclimatize 10 to 14 days, like, when you're traveling, of course.
But in preseason, it's very appropriate.
That's why you have preseason practice.
But physiologic changes that result in increased heat tolerance in kids, so they can tolerate the heat better, are gonna be an increased rate of sweating a lower temperature threshold for sweating, reduced electrolyte losses and sweat, lower heart rate, and they even have an increased aldosterone production, which is that mineralocorticoid from the Adrenablend.
It helps you keep sodium in your body.
So all these things keep kids from really releasing heat.
They keep heat more so than adults do.
So that right there also I mean, that puts them at a significant risk for exertional heat almost.
We'll make a note there from the Pearl that there is some literature out there that says pediatric patients may be a little bit more high risk.
For heat illnesses.
And it's not exactly true.
What I mean is that they don't have all these risk factors like older folks do.
No com not not enough comorbidities to really increase their risk, but they'd be compensate so much faster.
And anybody who's worked with adolescents and pediatrics know this, Like, when kids, they're okay till they're not.
And then they get really ill, really fast.
Keep production.
Interestingly, children They produce more metabolic heat per kilogram of body weight.
Primarily because they have a higher basal metabolic rate.
So they like, I see this in the emergency department all the time.
Like, you'll give it a child of medication to sedate them, and they burn through it so fast because their metabolism is so high.
And what happens is whenever, you know, you're an exercise, that's gonna produce an exothermic reaction.
And guess what?
Produces heat.
And that heat, if they don't have a cooling mechanism, increases your heat by about a degree per Fahrenheit every hour.
So it puts them at a pretty high risk.
And so far, these are pretty interesting findings, you know, for pediatrics compared to adults.
But further, Their body surface area is also different.
So their mass isn't quite as dense as adults.
So they can absorb more heat from the sun.
Like, from actually cold and heat environments.
But particularly, we're talking about cold.
So it's just like having a little baby out, you know, when you're in the stroller, you know, out in the sun, they're gonna get a lot of heat from the radiation or from the absorption rather of the sun.
And the same thing with pediatrics, you know, when they're out there and doing football, that type of thing.
We're going to absorb a lot of heat.
But, again, if these pediatric folks are maybe higher BMI, a little bit more obese, they're not as fit.
They're gonna be higher risk.
What circulation is also important?
So children, their absolute blood volume is decreased compared to an adult.
And, essentially, what that does is it limits the potential of, like, blood borne Key transfer from the body core, okay, to the surface where it can be released in the skin, where it can be dissipated.
And in addition, their cardiac output is lower.
And That also limits their heat dissipation.
So if they can't release all this heat, where is it gonna go?
It's gonna be kept inside their bodies.
So all those things are gonna affect things.
So two more things to talk about.
They have a decrease a decrease sweat rate.
So it takes them a higher temperature for them to sweat.
So the threshold is lower or, excuse me, the threshold is higher.
And when they do start to sweat, they don't sweat as much because their sweat glands aren't quite as sensitive.
Okay?
So all these differences are kind of cumulative.
And this is the final thing I'll talk about with the physiology part.
Least aren't kids just don't drink.
It's really tough to get kiddos to do much of anything.
I know a lot of a few folks out there have children, and kiddos just don't like to drink.
So, you know, as the athletic trainer, you have to be the advocate to get them to hydrate.
So try to replenish their fluid loss as best as possible.
So all those things are going to be the thermal regulatory part of the adolescent and pediatric aspect of exertional heat illness.
Now, Now that we understand some of that, what do we do about it?
I'm glad you asked.
Because here we go.
Prehospital management is the crux of treatment here.
Because like I said, I was an athlete to train for 20 years.
You need to treat these things even before you transfer them to the hospital.
And like I mentioned, you have to identify it and then treat it.
So how do you do that?
You have to be aware.
As we mentioned before, August is a really high risk month.
May to September, you know, those are pretty also high risk months.
But August is gonna be your number 1 probably.
And if you suspect it, like, if you have those individuals that you know on your medical screening exams, like pre participation exams.
If you know those folks that are at high risk anyway, Just keep an eye on them.
They're having a tough time.
Then you can identify those individuals with those risk factors.
And the preexisting conditions.
So you know they may not quite be acting right.
Right?
So those are gonna be individuals or gonna be on your radar, so to speak.
Now I will note that there are some pitfalls here after you recognize exertional heat on this.
Probably the biggest one is delayed, or absent treatment.
Meaning, oh, it's probably not what this is.
You know?
Oh, they'll be fine.
Or yeah.
You know, they're kinda sluggish today.
They'll be fine.
That's what's going to get you in trouble.
And inadequate cooling.
If you do recognize it, cool them immediately.
Now talking about temperature, when and if you do recognize this, you always have to think, you know, is this something else?
You know, that's being a clinician.
You know, that's what us as athletic trainers are.
We make clinical decisions.
Right?
We diagnosing.
So is this something is this a diabetic that has now hypoglycemia?
Is there sugar 21.
You know?
Are they having some sort of other issue that they fall and hit their head?
You know?
Do they have a brain bleed?
What are other causes of their illness?
Why are they altered?
So that's important for you to recognize.
If you are evaluating a patient, go back to the basics.
Airway breathing circulation.
That's important and find out for sure if they are altered.
I've actually had folks on the sidelines, you know, have seizures going to comas.
But most commonly, you know, as you folks that have treated, exertional heat on this before, specifically heat stroke.
They're just altered.
You know?
Lilujani is not right.
Little rachel is not acting right.
K?
Those are gonna be your most common ways they're gonna say, you know, you need to check out this athlete here.
K?
And finally, when you do measure the temperature, do it right.
It's I mean, you gotta do it.
K?
The oral axillary tympanic.
Not gonna cut the mustard with this.
Litigious wise, if if it's found out that you did not Measure this correctly, rectally, you are toast, medical, legally.
You and the sports medicine team are toast.
You might as well write a check for as much money as there is in the universe.
You know?
Than your toast.
K?
Besides, it's doing the right thing for the patient.
The right thing is to get the temperature and know whether they're a 102 degrees or they're a 109 degrees.
So my record so far is I've had a 112.2 degree Fahrenheit rectal temperature.
112.2.
K.
Sorry to belabor that, but it's very, very important.
K?
So moving on.
Rapid cooling.
Again, maintain a very high index of suspicion.
Now as you noticed there, I mentioned that the core temperature is sometimes and sometimes generally not perform.
Now I get that a lot.
But as I mentioned on the previous slide, if you're gonna do it do it.
K?
If you're gonna take the temperature, take it right.
But if you're just gonna treat them for exertional heat illness because your index of suspicion is so high, go full court press.
Treat them.
You know?
Cool them.
Get them transported, get them to the Mercer department.
So it may not be practical to do that.
Temperature is what I'm saying.
Okay?
But if you're gonna treat them, treat them.
That's what I mean by that.
Hope that makes sense.
Now this is interesting.
When you have people that are pre pubertal, so before puberty, Some of the literature is stating and suggesting that cold water immersion may not be the best treatment for this.
Kind of interesting.
I was taught for many, many years that cold water immersion is good for the gander.
It's good for everybody.
Home care if it's newborn or, you know, an elderly person.
But it's not necessarily the right answer.
Here.
Evaporative cooling is probably the best thing for pre pervertal individuals.
Given the new literature.
So that's where you cool them with a fan, you spray them, you put ice in their armpits, or in their broines.
You know, I think that's probably appropriate.
Okay.
Alright.
How are we doing on time?
I think we're doing okay on time.
So pediatric cooling, this is also another way you can do that if I just mentioned.
Spraying that type of water, as I mentioned, with the high flow fans, very important.
You can use the ice packs.
But there's also a method called a wet towel system method where, you know, at the beginning of practice, you have 12 towels in a tub.
That are rolled up.
And if you have an individual, you place 6 of the towels on the patient, and then 6 of the towels go back in the bin.
And that's how you can alternate.
That's the wet towel system.
I've actually used that, you know, quite often as well.
Now moving into more of the adolescent and adults, rapid cooling measures, this is something probably we're more familiar with.
That first 30 minutes is very, very important.
Just like with the golden hour of trauma, there's the golden 30 minutes of exertional heat illness.
It's very important to cool these folks off.
Aggressive management is key here.
Aggressive management.
And this is something that I 100% agree with doctor Casa and other researchers about and being an ER doc.
I also believe it wholeheartedly that you cool them first and you transport them second.
The more time that they are kept in a hyperthermic state is going to cause more damage to them than good.
So meaning, if you have to cool them for an additional 10 minutes on-site, as long as you're cooling them adequately.
Please do that, and that needs to be in your emergency action plan.
That needs to be communicated with your EMS folks.
And that's important because, you know, as an EMS director, I I know this pretty pretty well.
Ambulances can't accommodate cold water immersion.
I mean, you can't take a big bin of water in the ambulance with you or anything like that.
Now you can take ice and so forth.
But to any significant degree, they cannot accommodate that.
So just as the wilderness medicine society and, you know, most of the literature suggests, cold water immersion is the most effective.
So that is the gold standard for post pubertal individuals.
Alright?
Now, speeding up a little bit here, what are some type of things that you can use?
Cold water immersion, you can buy the 150 gallon tub.
Now again, I have, you know, no disclosures or anything or financial incentive for these, but they work.
And you can go to Tractor Supply, you know, and buy 1 for 200 bucks.
But there are other, you know, more expensive methods, you know, commercial type of methods that you can use.
We'll go over those here in a minute.
But there is a special little device you can buy called a polar protector that goes over your rubbermaid tub, and I've seen those on eBay.
They kinda help keep it cold.
You know?
So you can actually have those at the sidelines and have the polar protector on to keep it from melting all your ice.
Thought that was pretty interesting.
As we mentioned before, at the bottom there, about the evaporative cooling, it's just good to kinda maybe have a high float fan and have some ice packs with some spray bottles there available.
Okay?
So this just kinda mentions about the whole body cooling with ice water massage.
That's just another option that I found in the literature.
So ice water massage, you can do.
And, you know, it's not one of my go to's, but if you can't do anything else, it's probably a decent option.
So here is the literature for that, and I will not belabor that, but it has been shown to to work.
So Now as you'll see in the video here, there's also a method called tarp assisted cooling with oscillation, a taco method.
I love tacos.
And, actually, last night was taco Tuesday.
It was good too.
My wife makes great tacos.
But anyway, tarp assisted cooling oscillation is a little bit a little bit more on the impractical side if you don't have enough hands.
As you'll see from the video there, I mean, it makes total sense.
You're putting water and ice in this tarp, right, and you move them around.
But you need probably 3 or 4 people to move the player around.
And, again, you can't transport this with EMS.
Okay?
There are a few published studies about that.
I'm not gonna go to in-depth about it, but it is an option for you.
There's also the Polar Life pod.
Interestingly, I'm here in Canton, Ohio.
Stow's about 20 miles away.
So I just thought that was interesting.
But, anyway, the Polar Life pod is actually a decent option.
And, you know, actually, this is transportable, but it costs a lot of money.
So if you can get that at your facilities or high schools or college is super, you know, that's something that, you know, at least my EMS can accommodate.
Because it's basically waterproof.
So that is actually kinda nice.
But as an alternative, we have elected to use body bags.
So, interestingly, a body bag can save a life.
Oddly enough.
So here at our local EMS where where I work, some of the local schools we've giving out some body bags to use to transport some patients in because you can put water and ice in them.
And EMS, they're aware.
We basically put them on a spine board and kinda wrapped them up, kinda like a burrito, and transport them to the ER.
So in a way we can accommodate cold water immersion.
But whenever they do get to the emergency department, we do this.
If I get a call, they are gonna be put into a body bag with ice and water when they arrive if they don't arrive in it.
If that makes sense.
And there is some literature out there about it.
If you look at the number 50, on your your references, you could take a look at that article.
But I I actually use that method.
In my practice.
So kinda wrapping up with the whole presentation here.
I will give you doctor Tasas kinda outline for algorithm here, for completeness, and I really like the way he does things.
Very smart gentleman.
Given a lots of profession, does a lot of research on heat illness, So if Doctor Casa is listening, sir, you get my respect, this is very, very applicable.
So please look at that.
I will not go into it in detail.
Few more slides and more finish up here.
As I mentioned, you treat, and then you're going to transport.
Very important.
But ABCs are so important, especially when you immerse people, I will wholeheartedly concede to you that immersion may not be practical as they're so altered.
They you don't want them to drown in their water.
So maybe ice is the only practical way of doing it.
So monitor their mental status during this whole thing.
And treat, treat, treat, treat.
Okay?
That is so important.
And, you know, as doctor Castle mentioned in his heat on this presentation, the emergency action plan is so important.
You you need to get your physician involved, your sports medicine team, your EMS, they need to know what you're doing, and and also the parents.
You know, they also need to know too.
They'll they're gonna maybe look at you and go, why aren't you getting this kid out of here?
Well, you wanna decrease your temperature before they leave.
That's why.
Everybody needs to be on board.
So finally, last two or three slides here.
I cannot emphasize enough the importance of an emergency action plan at whatever venue you're at.
All across the world here.
Every venue.
Athletic trainers do it, and we do it right.
And it starts with us.
We have to educate people.
As I mentioned, know the ways to treat the adult and pediatric patients for exertional heat illness.
And please, if you're going to do a temperature, do the rectal one.
Please do that.
Entry before you transport, maybe invest in a body bag.
It could save a life interestingly.
And finally, although kiddos are little adults, they're kinda not thermoregulatory wise, So just be aware of the differences in their thermal regulation compared to the post pubertal.
People.
That was a mouthful, close people to people.
Alright.
So finishing up here, this is my medical school email address.
I am available for all of you.
Please drop me a line.
If you have any questions, comments, anything like that.
And I think the references are listed here at the very end, you know, for for your information.
So that is all I have, Doctor Castle.
I appreciate you letting me speak.
Fantastic, Doctor Heath.
Let me go right here for a second, kinda get here squared away.
So we've got a couple of questions sitting out there.
Some are gonna probably go through audio, some will go through some other ones.
So I'm a go with I'm a try to check on the first one right here.
It's Hillary.
I'm a Hillary, I'm a turn on your audio, so feel free to fire away with Doctor Heath.
You can turn your audio on Hillary and ask your question.
Here we
go.
So I work at a catholic school, and they are very weird about rectal temperatures.
How would you recommend someone at a private Catholic school go about, you know, educating them into why we need to do that.
Yeah.
That's a great question.
I appreciate the question.
So again, I do run into that with some facilities that I, you know, advise at.
And what I've recommended is include in your emergency action plan and or statements that say, like, or if I have a high clinical index of suspicion to treat.
So if you think about it, treat it.
That is definitely one of those options.
Mhmm.
And, also, you can provide maybe some literature to your school board about this because that's kinda where we had to go.
We had to go over the heads of everybody, and I kinda hate to say that.
But we really had to get a top people to concede that this is the right thing to do for the patient.
To get that done.
Does that make sense?
It does.
Thank you very much.
Of course.
And please look at the literature there.
I think it's 35 to 37 in the complete references.
Thank you.
You're welcome.
Great.
That was fantastic question.
Something we also have, Hillary, I know that we did a week or 2 weeks ago, did a mock trial on exertional heat stroke in pediatric So that's a free CPU course, not not promoting it, but it's really it hit on some questions that a lot of people had about laws and other things as well.
Tomorrow is kind of as a as a moving forward, we're having a one of the I have an attorney coming on board talking about the role that organizations have in establishing scope of practice for athletic for health care providers, for coaches, I think that may help you to answer some of those questions as well.
So there's a very difficult one.
So next question is from Chris is What is the rationale for why cold water immersion should not be used for pediatric patients?
Is there an age or body mass cutoff for using CWI?
Oh, good question.
So as you guys kinda saw here, you know, in the presentation, there are about 3 references I think let me kinda go back here right in there.
So 35 to 37.
They meaning they, the 3 the 3 articles that we were mentioning here, mostly what they were pretty much documenting is the subjective side effects.
So it's the it's uncomfortable.
The child's shivering They're outwardly agitated.
They're combative.
Now the question is, does this cause physiological harm?
And I think that's what Chris' question is.
The answer is no.
It doesn't.
It's more a subjective type of issue with this with this type of cooling method.
Now if you notice there, cold water immersion is suggested if evaporative cooling isn't.
So the answer is it's safe.
Absolutely.
K.
Excellent.
I'm a give I'm a give this over.
The next one is for I guess it's maybe Jamie.
I'm giving you that you should have gotten the louder talk.
You'll see your line.
Go ahead and please go ahead and turn your audio on and go ahead and provide the question to doctor Heath.
And as we're jumping waiting for Jamie, to jump on board with her question, quick question is, what is the optimal water temperature range for immersion?
Yeah.
That's a great question.
So typically, 32 is the number that that's pretty magic.
And that's that's ice.
You know?
That's about as cold as you can get, honestly.
So 32 to 36 is about electa optimal range that you'd want to decrease their temperature.
But if you're immersing an ice that is you're gonna be ranging between 32 to 36.
I think the one thing is hard to do that in the field, keep it that temperature.
So I know I'm seeing a good bit where you're, you know, if you're around 5055, you're still sitting in you're still got it's water ice will be in the in the in the tub.
With water as well.
So that's kind of a good at least you're trying to get that in the field without, you know, obviously, the colder, the better.
But that does that as well.
It's not below freezing, which you wouldn't have any
cooling, you
know, with that.
Okay.
So I'll move on next question.
I was hoping to see if had Jamie to ask if she want here's I'm wanting to answer that question.
I'll move ahead.
So is if you jump online and with audio, please go ahead and just ask a question, the next one starting up.
Here's one anonymous is The research for cold water immersion in all patients, pre preoperative and post preoperative suggest whole body cold water immersion This is also supportive of any of these physician statements and other best practice documents.
Can you please tell us a specific study where you're saying this is not true for prepubescent's patients?
Again, good question.
So as I kinda go back to, you know, Chris's question, there are the 3 studies there.
That subjectively talk about how it makes kids combative, agitated, and it's uncomfortable to them.
So again, I will emphasize that it is not going to hurt the individual, but it can cause a little bit of subjective issues with them.
K?
Subjective discomfort.
So I I wholeheartedly can concede that it's a a very safe way of treating coal treating the exertional heat elements.
So as far as what I do in the field, I have been, like, a team meetings and things, team team type of running marathon type of thing.
I tend to try to use the spray first.
With the fans.
But nine times out of 10, everybody's scrubbing ice.
K?
So I I wholeheartedly can see that.
Okay.
Great.
Great question.
I'm a throw in.
Jeff, go ahead and ask a question if you would.
You can unmute yourself.
Hey.
Thank you for a great presentation.
I live here in I live here in Arkansas, and And you intrigued my mind a little bit about the pre the post pubescent.
What is there a Hallmark study in your in your mind that really compared all the different techniques with pre pubescent subjects or post pubescent subjects.
Oh, yes.
Absolutely.
And my apologies for not knowing that study by name.
But what I will mention to you here is when I go back here to the big one, it's gonna be 23 to 27 on my on my presentation here.
So Okay.
We had I can get that later.
Okay.
I was just I hadn't seen that study come out yet, and I was just wondering.
Yep.
So if I remember right, it's gonna be by Tomski, and that was in the I'm trying to go by memory here.
My apologies.
I think it was in 2003.
It's actually, I remember it's Bikomski and Squire.
Okay.
So it was in my
Yeah.
It's in 2003.
Also, if I can add a comment to the girl call from the Catholic school.
We also do We have the retro thermometer on the on the ambulance.
So when they get there, they actually insert it because you got 20 to 30 minute window.
While they're in the pool or not till you put them in the pool.
We the ambulance actually inserts it.
That way, you know, there's really we're out of it, but they have them on their ambulance.
So that always helped us out.
So Anyway, hope that helps, sir.
Excellent.
Thank you.
Alright.
Thank you.
Bye bye.
Alright.
Next up is Hillary.
Go ahead and if you would.
If you wanna ask a question, please.
Welcome to the
No.
I'm good.
Thank you.
I already asked my question.
Thank you.
Okay.
I'm sorry.
I'm sorry.
I thought you
had it.
It's
getting getting too crazy here on this call.
That's alright.
And my
new buttons.
Great.
Great to help you on board.
Yep.
Folks, these are great questions.
I really appreciate everything.
This is great.
Let's see here.
Jessica, Go ahead.
I've got I think Jessica from Florida, I believe.
We'll go ahead and allow a couple of people to jump on it.
We're running low one time.
So if you if you've asked a question, raise your hand, go ahead and do that.
I've got You see your name on there, go ahead and just unmute yourself, and go ahead and start firing away your question.
Think oh, I actually got words as well.
So if you see your name up there, go ahead and unmute yourself if you would, please, and we can well, take the first one.
Okay.
It's the one who's answering your question.
So So I'll go ahead and just if we're trying to close this off, if you do, go ahead and I'm gonna unmute the get these dump off here for a second.
One question I do have, Doctor Heath, if you would just kinda talk about the the intersection of where, you know, you had obviously, you have your perspective in EMS, but also I was, like, trying to know what you see, you know, trying to that transfer of care from a patient standpoint, what that looks like, how we what are some strategies to improve that communication, especially for exertional heat stroke and any, I guess, nugget or pearls that you've seen that work well in addition to the medical time out, other aspects of how to how to utilize, like, the previous call the one the call or the presentation had about getting with EMS to if you're there, can they do an exception request to the medical director to to have a change in protocol, but that would occur?
Yes.
So good question.
During every emergency action plan, practice at our local high schools, our EMS are required to be there.
So that's one thing that is very important that to me is still for the local high schools and great schools to have BMS involved.
So that's the first thing.
And their EMS director because I'm the medical director, and then you have a director that works with her every day.
They are also gonna be on-site for every one of these practice sessions.
So that's the first thing.
With regard to I think hand off, what's your question?
Yes.
This is how to extract.
I know that it comes that we've had several commerce discussions throughout the week already about issues with, I guess, hit when to hand off, when not to hand off, there's been, you know, that that conflict resolution that typically that not typically, but can occur with in when in recognizing that the athletic trainer is the unless at a medical authority, they're they are the definitive care point and not automatically just assuming giving control over to EMS unit.
But I'm ensuring that the body temperature is maintained or do the things to cool first, then transport.
Yes.
So in our emergency action plan, it's understood and written that a cooling method is applied prior to their departure from whatever venue they're at and when feasible that is transported with the athlete.
So typically, it's gonna be ice ice packs.
That's the most common one.
And most commonly, they're gonna get CWI on-site before ambulance arrives to the scene in their body bags, and then they're gonna have ice packs transported with EMS crew.
So almost always the at our venues anyway, the the athletes are gonna be taken almost immediately.
Since probably all the high schools and great schools in Guernsey County were on that in Ohio or less than ten miles from the hospital.
You know?
So it may not be feasible to treat them for 30 minutes there.
Does that make sense?
Yeah.
It does.
I think the I think the what the audience is recognizing that, also, and I think, you know, you Sunday, you've seen this as well is this important to the core trending vitals.
Have that information, make a rapid transfer if you're, you know, articulating that and get that because they're gonna present pretty unless, you know, they're if they're stable, they're gonna present very well.
They're gonna have normal, you know, conversation with them.
And they're gonna be normally.
They're not gonna be combative.
They're not gonna have these altered mental status you know, aberration, so to speak, those things are really, really crucial that you recognize how long you've been treating what the intervention is of ice how long it's in what you're seeing from in those data, those those vital signs will trend positive pretty you know, may take 25, 30 minutes.
If they're into heat heat stroke at the late at least.
But, you know, it just depends.
You gotta make sure you have that good transfer.
The good.
Well, I know we're past an hour of what we've been here before.
Appreciate your time as well.
If you have other questions, we'll be more about We can answer those as well down the line.
I think this is definitely you know, we had we had the heat stroke failure, the the fail points that doctor Walters gave on Monday, This is a great turnaround, gives a different perspective from what EMS encounters as well.
And the main thing is just do the wrap do rapid treatment.
One last parting thing, you mentioned this, you all have as a protocol, is I know that when Louisiana, you know, the number states a smart heart coalition they've done with NFL came out with the cardiac arrest.
Their number of policies that are being implemented related to exertional heat stroke in various states.
In Louisiana, we did that several years ago.
And once we did that, then we had it as a recommendation that we could go we actually went to at the time I was working with them, one of the largest EMS companies in the country, is I went to them and said, look, this is what the it's law now.
You you have schools have to have a cold water immersion process in place, EAP, etcetera.
And once they did that, then they went back in within their protocol changes.
It was typically about 2 years.
They went into protocols and made it as a recommendation And it is simply if you go if they come on-site and they're cooling, they're they're recommended as part of their protocol, not required, but recommended that they allow the patient to be cool and stabilized first before transporting.
So that's just an opportunity that those audience have to reach out to the medical directors various eco and look at standard care and how you can help mitigate that or help improve that communication.
So, again, Doctor Heath, it was a pleasure having you here.
Everyone in the audience, thank you so much as well.
And we look forward to seeing you all again tomorrow.
Don't forget to fill the evaluation part out.
And after when the email is you receive, again, Doctor Heath, thank you so much.
Thank you for being a part of our program.
Thank you.
It was great.
Great.
Have a good one.
Thank you.
Heat-Related Illnesses: Pediatric vs. Adult Patient Management
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Updated Jan 22, 2024
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