Exertional heat stroke (EHS) is a life-threatening medical condition that affects student-athletes every year, especially during the first few weeks of practice and conditioning each season. Fortunately, prevention is possible to reduce incidents of exertional heat stroke and preparation helps improve outcomes.
If staff know how to spot the warning signs, have a plan to respond, and can act without hesitation, EHS is highly survivable.
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3 Ways Schools Can Improve Heat Safety to Prevent EHS
Responding to and preventing exertional heat stroke starts with implementing appropriate heat safety measures across school athletics and extracurricular programs. There are three main areas schools should focus on:
- prevention
- preparation
- practice
Strengthening each of these areas can help schools prepare for student-athlete emergencies like EHS with protocols and procedures that keep student-athletes safer.
1. Prevent Exertional Heat Stroke With Safer Play
Stopping exertional heat stroke before it starts is always preferrable. Consistently implementing heat safety measures to create better training and play conditions can help prevent milder exertional heat illnesses before they progress to EHS.
The following strategies can be used for effective exertional heat illness and exertional heat stroke prevention.
Start With Heat Acclimatization
The risk of heat illness is highest during the first week of practice. Heat acclimatization allows students to adjust to heat exposure slowly. “When done appropriately, not only does [acclimatization] keep athletes safe, but it actually helps them perform better in the heat,” says Dr. Christianne Eason, President of Sport Safety and Education at the Korey Stringer Institute.
She recommends a 14-day heat acclimatization period with
- shorter, less intense practices
- only one practice per day
- gradually introducing uniform/gear
- frequent, shaded recovery breaks
- on-site athletic trainer
Provide Appropriate Hydration
Student-athletes should have access to adequate hydration—either water or electrolyte-replenishing drinks for longer or more intense sessions—before, during, and after practices. When possible, hydration breaks should be taken in the shade.
Avoid Using Exercise as Punishment
“The majority of heat-related illnesses happen in practices,” says Eason. “And this is because there is someone pushing these kids beyond their limits.”
When a student-athlete is given extra laps or drills as punishment, it can push them past safe exertion levels. Moving away from exercise as punishment often requires a cultural shift, prioritizing wellbeing over “toughing it out.”
Adjust for Environmental Conditions
Schools should monitor conditions and plan to adjust or postpone practices and games to prevent overexertion. Using a Wet Bulb Globe Temperature (WBGT) monitoring device provides a more accurate picture of conditions than a standard thermometer or heat index reading.
Many of these strategies are either free or low-cost to implement but make a real impact. For example, when Georgia adopted a state-wide policy mandating a five-day acclimatization period and WBGT-based practice modifications, heat illness rates among high school football players dropped between 35% and 100% depending on conditions.
2. Prepare Staff and Develop a Plan
Even with appropriate prevention measures in place, athletic staff still need to be properly prepared to recognize and respond to heat-related illnesses in students.
Recognizing the Signs of Exertional Heat Stroke
Some symptoms of mild and moderate heat illness are
- lightheadedness or dizziness
- nausea and vomiting
- muscle cramping
Particularly at the beginning of the season or on a very hot day, it’s important to treat these symptoms as early warning signs of exertional heat illness rather than pushing students to continue past safe exertion levels. Affected students should rest and hydrate in the shade, giving their bodies time to cool down until the symptoms pass.
The signs for exertional heat stroke are different from basic heat stroke. There are two criteria to look for when diagnosing EHS: extremely high body temperature (105°F/40.5°C or higher) and central nervous system dysfunction (CNS).
“If you’re not a healthcare professional, don’t take [a core temperature reading],” says Dr. Samantha Scarneo-Miller, Primary Investigator for the Ready EAP Project. “Use CNS as a way to identify that somebody might be in trouble.”
The symptoms of CNS include
- confusion
- disorientation
- stumbling, tripping, or slurred speech
- sudden, drastic mood change
Staff may also notice that a student with CNS symptoms seems to be sweating profusely. “That’s probably a good indication that this is an exertional heat stroke, because they worked so hard that now they’re just sweating like crazy,” says Dr. Christianne Eason. “It’s not like traditional heat stroke, which causes the skin to appear hot and dry.”
Responding to Exertional Heat Stroke
What happens in the critical first few minutes shapes the outcome for students experiencing exertional heat stroke. As soon as staff recognize the signs of EHS, they should take the following steps:
- Cool the student immediately with ice and cold water.
- Call 911 while the student is being cooled.
“Cold-water immersion is the gold standard for this,” says Dr. Samantha Scarneo-Miller. She clarifies that the cold-water immersion tank doesn’t have to be a piece of fancy or expensive equipment. “It can be a trash can that you’re filling halfway with water; it can be a baby pool or even horse troughs.”
The student should not be removed from the cold-water immersion tank until their core body temperature is below 102° F/38.9° C. If there is a medical professional on the scene, they can take that temperature reading, otherwise, staff should keep the student in the cold-water immersion until emergency services arrives and can assess the student.
Writing a Plan
There are two key documents that schools need on hand to help prepare staff to manage heat-related illnesses, including EHS:
- Exertional Heat Illness Policies and Procedures. This documents heat safety policies, protocols, and procedures for the entire school, across all sports and extracurricular activities, including guidance around heat acclimatization periods, recognizing signs and symptoms of heat illnesses, and when and how to adjust practice and games for unsafe conditions. It should also specifically outline how to respond to EHS, as covered above.
- Emergency Action Plan (EAP). EAPs run parallel to the Exertional Heat Illness Policies and Procedures documentation. EAPs should outline in detail how to respond to a variety of catastrophic events, including EHS.
The 2024 National Athletic Trainers’ Association (NATA) Position Statement provides more detailed guidance on how to develop effective EAPs for K-12 athletics programs.
3. Practice Responding to Exertional Heat Stroke
“A document on paper is not any good if no one knows how to use it,” says Dr. Christianne Eason, emphasizing the importance of rehearsing and stress testing an emergency action plan. NATA specifically recommends annual review and rehearsal of sports EAPs.
Assigning Emergency Roles
Practicing an EAP helps staff understand their individual roles and responsibilities during an emergency event. In the case of responding to EHS, athletic staff should know explicitly
- who calls 911
- who retrieves or fills the cold-water immersion tank
- who provides direct care to the student
- who manages crowd-control and other student-athletes
- who meets EMS and directs them to the scene
- who manages communication during the incident
These roles need to be assigned with the specific venue and sport in mind and reflected in both documentation and training.
Dr. Samantha Scarneo-Miller gives the example of JV girls’ lacrosse and JV boys’ lacrosse. Both sports may use the same practice fields, but the personnel involved are different. “The JV girls’ lacrosse coach might be a paramedic, and the JV boys’ lacrosse coach might be a math teacher,” she says. “Both are extremely important professions, but when it comes to providing healthcare on the field, I want the JV girls coach giving care with me.”
To practice those roles, Scarneo-Miller recommends regular tabletop exercises or simulations that are condition specific.
Identifying Safety Gaps
Another critical piece of EAP rehearsal is discovering what’s not working. “I can tell you countless stories of situations where there was an EAP…and no one tested to see if the key they had actually opened the lock to access the field,” says Dr. Christianne Eason. “Or they had an AED onsite, but no one knew where it was.”
Tabletop scenarios and drills help uncover these kinds of issues and allow schools to update plans, target staff training, and close safety gaps.
Building Muscle Memory
Finally, one of the most important reasons to practice sports EAPs is to help staff build crucial muscle memory. Particularly in the case of medical emergencies like EHS, staff’s ability to act quickly has a significant impact on the affected student’s outcome.
“Once you identify a heat-related emergency, you’re on the clock,” says Eason.
Knowing what to do and having practiced it before helps muscle memory kick in, so staff aren’t wondering what to do or where to go to get critical equipment. This allows them to act quickly and efficiently and begin cooling the student down as soon as possible.
A Better Playbook for Student-Athlete Safety
For schools that want to improve heat safety in their athletics and extracurricular programs, there are some practical next steps to take:
- Update policies to reflect heat safety priorities, including heat acclimatization periods and accommodations, no exercise as punishment, and guidance for monitoring and adjusting for unsafe environmental conditions.
- Audit your current sports EAPs with NATA’s Position Statement, following their 25 best practices for developing specific EAPs.
- Schedule annual reviews and rehearsals. Tabletop exercises and EAP reviews can help identify gaps that may not be obvious in a written plan.
- Improve staff training. Role-based safety training can help improve your staff’s ability to recognize the warning signs of heat-related illnesses and respond to emergencies like EHS.
When schools take an intentional, proactive approach to heat safety, staff are better prepared to prevent emergencies before they happen and respond quickly for better outcomes for student-athletes.
FAQs
What Is Exertional Heat Stroke?
Exertional heat stroke is a life-threatening medical emergency that occurs due to extreme overexertion, typically seen more often in athletes. Core temperature rises to dangerous levels (105° F/40.5° C or higher), and the body loses its ability to cool itself. This condition is different from traditional heat stroke because it is brought on by intense physical activity, causing the patient to appear extremely sweaty, rather than hot and dry.
How Do You Treat Exertional Heat Stroke?
Exertional heat stroke should be treated through cold-water immersion, submerging the patient in a tub filled with cold water and ice as quickly as possible. Patients should be cooled on site before being moved and should never be left alone. A core body temperature reading is the most reliable way to confirm the diagnosis and determine when the patient can be removed from the cold water, but if no medical professional is on site, patients should be kept in the cold water until EMS arrives and can assess them.
If a cold-water immersion tank is not available, ice-cold wet towels can be applied across the patient’s torso, neck, and limbs or their body can be packed in ice.
What Is an Emergency Action Plan?
An emergency action plan (EAP) is a written document that outlines exactly how an organization or school will respond to a catastrophic event, injury, or medical emergency.
How To Write an Emergency Action Plan for Sports?
The National Athletic Trainers’ Association (NATA) provides official guidance for how to develop an EAP for sports. Their positioning statement gives schools a list of 25 best practices to follow, including
- sport and venue specificity
- annual reviews and rehearsals
- coordination with local emergency responders
- pre-event medical meetings
- defining specific roles for efficient response
Their guidelines also recommend involving a medical professional in the EAP development process, if possible.
Related Resources
Learn how to prevent, prepare for, and respond to other common student-athlete emergencies with our free Guide to K-12 Sports Safety.
