Exercising heat-related illness (EHRI) consists of several states that affect physically active individuals exercising under conditions of high environmental heat stress. EHRI can be life-threatening in extreme cases if left untreated. Exertional heat stroke (i.e. core body temperature >40°C and altered mental status) is the most severe form of EHRI and requires immediate treatment (rapid cooling) to reduce morbidity and mortality.
EHRI includes a range of conditions from mild (thermorrhoids) to life-threatening (heat stroke). Deaths from heatstroke related to sports, such as high-risk football players, appear to be on the rise. 
Types of Heat Illness
There are two types of heat stroke:
- Typical heat illnesses are directly related to the environment and the way it affects the body’s ability to dissipate heat. These factors include increased temperature and humidity, strong direct sunlight and still air. 
- Exertional heat stroke (EHI) is primarily caused by an individual’s own heat production and can occur in all types of weather.
It should be noted that the treatment and recognition of these two types of heat illness has not changed, but illustrates the fact that athletes should be aware of the signs of heat illness even in cooler and lower humidity climates. 
Levels of Heat Illness
Patients are sprayed with cold water in 1943.
Heat-related illnesses start as mild discomfort and can become life-threatening. Conditions are listed from least to most severe: heat swelling, heat rash, heat syncope, heat cramps, heat exhaustion, and heat stroke. 
- Pyretic edema and heat rash: Pyretic edema and heat rash are the mildest forms of fever. Heat swelling can occur when the body tries to dissipate heat by dilating blood vessels and diverting blood flow to the skin. This occurs mainly in the lower extremities, as the fluid can cause inflammation in the feet, ankle. Prickly heat (also known as prickly heat or red prickly heat) is a pin-shaped red rash that develops on skin covered by clothing. This usually occurs in areas with dense heat glands, such as the torso and groin, and is caused by increased sweating Sweat ducts are clogged on clothing and the surface of the skin. 
- Heat fainting: Heat fainting, or heat fainting, may result from excessive heat exposure as blood is shunted to the skin and extremities.  Rapid changes in body position (common from sitting to standing or stooping to standing) may result in temporary changes Blood pressure that causes a person to faint. Most athletes recover quickly after lying flat, allowing blood flow to return to normal. It is said that a fall due to a rapid loss of consciousness may result in a concussion, and athletes who faint from the heat should be evaluated before being treated Allowed to continue training or competition. 
# Heat Cramps
- Heat Cramps: It has been known for years that heat cramps, or muscle cramps, are associated with dehydration and electrolyte imbalances. However, exercise-related muscle cramps are often related to broader variables, such as fatigue and muscle imbalances. While detrimental to performance Exercise-related muscle cramps are usually harmless to our health and occur most often on one side of the body. If bilateral or bilateral cramps or generalized cramps occur, this is usually related to a more serious condition, such as extreme dehydration or hyponatremia (depleted electrolytes from excess fluid intake) and should be addressed by a physician or medical team immediately during an activity. 
- Heat Exhaustion: Heat exhaustion should be taken seriously and managed promptly, as it can progress to serious and potentially life-threatening conditions such as heat stroke. Heat exhaustion is usually manifested by fatigue, dizziness, excessive sweating, nausea, vomiting, headache, fainting, weakness, and Cold clammy skin. Athletes who are exhausted often still have normal cognitive and neurological function. They should be able to answer questions about their condition, who they are, etc. 
- Heat stroke: Heat stroke is characterized by a core body temperature >104°F (40°C) with changes in central nervous system function such as irritability, confusion, aggression, or more severe loss of consciousness. Hot, dry skin is a sign of heat stroke, but it’s important to understand Athletes can sweat and still suffer from heat stroke. Altered central nervous system function is the hallmark difference between heat exhaustion and heat stroke, but if in doubt, treat the condition as if you were an athlete with heat stroke. Athletes showing signs of heatstroke must be treated by a medical professional ASAP. It is important to emphasize that heatstroke is very serious and can lead to death if left untreated. 
Criteria for Diagnosis of Heat Illness
Condition Core Temperature °F (°C) Associated Symptoms Associated Signs Heat Swelling Normal Undependent Areas Mild Edema (Ankles Foot Hands) Heat Rash Normal Itchy Rash Papules Herpes Rash Dressing Area Heat Syncope Normal Dizziness General Weakness Loss of Posture Control Mental status recovers quickly after lying on the back. Heat cramps are normal or elevated but Headache Red, profuse sweating, clammy skin Heatstroke >104°F (40°C)
Risk of Heat Illness
Risk factors for heat stroke can generally be divided into two categories:
- Internal (related to the athlete)
- External (environmental) factors
Groups at high risk for heat stroke include older children and those with comorbidities that inhibit the ability to regulate body temperature. Alcoholics living on upper floors of multi-story buildings and using psychiatric drugs such as tricyclic antidepressants and typical antipsychotics increase the risk of heatstroke. 
- Age (<15 years or >65 years)
- Alcohol Consumption
- Comorbidities – Respiratory Cardiovascular Hematological Disorders
- History of heat-related illness
- Lack of air conditioning
- Lack of appropriate sleep
- Medications or supplements
- Poor acclimatization
- Poor cardiovascular fitness
- Recent febrile illness
- Sickle cell trait
- Skin Conditions – Eczema Psoriasis Burns etc.
- Use of psychiatric medications
External (Environmental) Factors
- Activity level
- Excessive clothing wear
- Lack of water or sufficient shade
- Temperature (ambient)
- Wet bulb globe temperature
Normal Body Temperature
The goal is to reduce core body temperature to a normal acceptable level (less than 38°C or 100.4°F) as quickly as possible. It is important to note that while fever typically presents at a temperature similar to hyperthermia (a temperature above 100.9° F), the underlying mechanism is different. 
The main focus of heat-related illness is to cool the athlete down as quickly as possible to protect the athlete’s brain and vital organs. To do this, a critical first step is to determine if the player is in trouble. This step is often missed, causing fever to develop into severe Level. In addition to taking off gear and clothing, the ABC assessment is also important. Keep players out of direct sunlight and into a cool, cool environment. Apply a cold compress at the end – this can include pouring cold water from a hose or wrapping a shower in a cold towel Apply ice packs or soak in an ice bath and let them ingest cold fluids. 
Specific Strategies are as follows:
- Thermal swelling: Elevation of the affected extremity with relative rest and use of a compression garment may help relieve dependent swelling. It is important to ensure athletes are well hydrated and eat enough salt, as these conditions can delay resolution of problems. Usually this happens between 7 and Acclimatization takes 14 days, which can be even faster if the athlete returns to his or her home climate. 
- Heat rash/heat rash: The main treatment is avoiding tight clothing. Symptoms can be treated with a topical lotion such as calamine or a moderate-acting steroid such as triamcinolone 0.1% cream, which can also help reduce inflammation. 
- Heat cramps: Athletes should stop physical activity and start oral rehydration fluids. Rest and passive stretching of muscle groups have also been shown to be helpful. 
- Heat Exhaustion: Move athlete to a shady or air-conditioned area. Remove excess clothing and gear. Cool players with cold water fans and/or cold towels. Have the athlete lie down with the legs elevated above heart level. Encourage athletes to drink ice water or sports drinks if nausea is not present or throw up. If condition persists, seek medical attention More aggressive cooling measures should be taken, including warm water spray on the skin and forced air conduction to facilitate evaporation, and consideration of parenteral fluids if oral administration is not tolerated by the athlete Give fluids based on symptoms or extent of injury. In addition, correction of electrolyte disturbances and bivalent disturbances may also require treatment. 
- heatstroke. Treatment strategies for heat stroke in athletes vary and require immediate medical attention with the goal of reducing body temperature below 104° F within 30 minutes. 
- Identify athletes with signs or symptoms of heat illness.
- Initiate Cooling Method: Move to a cool area with ice packs and soak groin/armpit/neck in a fan spray.
- Assess mental status changes.
- Assess the need for rectal temperature (and repeat every 3-5 minutes during the cooling period).
- If tolerated, encourage plenty of oral fluids with a cool sports drink or water.
- Check blood sugar and sodium levels (if available).
- If an athlete has any of the following conditions, use the Emergency Medical System (EMS) immediately:
- Altered mental status
- Temperature elevated >104°F
- Persistent vomiting (without oral rehydration fluids) 
Treatment consists of replacing fluid loss with oral rehydration fluids instead of parenteral fluids. A supine position with the legs elevated above the level of the heart may help. Measurement of orthostatic signs is often considered an adjunct to monitoring adequacy  In addition to addressing symptoms during repositioning, replacement is required.
The best way to prevent heat-related illness is to heat acclimatize before weight training or competing in hot weather, monitor and manage hydration needs, and employ cooling techniques to help manage core body temperature. These Stuff Will Help Reduce Physiological Stress Train and race in the heat and optimize performance. 
Acclimatize to heat and humidity at least 10-14 days before a race. 
Dehydration is one of the key precursors to developing heat-related illness. Although dehydration is caused by insufficient fluid intake, it can be made worse by sweating that keeps the athlete dehydrated, resulting in additional fluid loss. during strenuous exercise The heat sweat rate can sometimes reach 1.5 liters/hour or higher. The ideal recommendation is to consume 16-24 ounces of fluid per hour, but endurance athletes in hot environments often need to consume 2-3 times that amount. Athletes can calculate approximate sweat rate Weigh in before and after your workout. 
Wear light-colored loose clothes and sun protection
Modifying controllable factors
These precautions are mentioned below:
- Make sure athletes are adequately hydrated before practice or competition.
- Provides convenient fluids for all athletes. There is no benefit to restricting water intake; athletes are not used to dehydration.
- Remove equipment/clothing. As temperatures rise, practices should be modified to eliminate the need for additional insulating equipment, including helmets, shoulder pads, and tights.
- Schedule practices and races during cooler times of the day.
- Supply water and provide shade for watering/wetting clothes during breaks.
- Active monitoring of fluid intake and athlete behavior is encouraged. Talk to them during breaks, assign hydration partners so athletes can monitor and remind each other to stay hydrated.
- Increase frequency of breaks: Guidelines based on wet-bulb temperature are a measure that takes temperature, humidity, sun angle and other factors into account when measuring so-called “heat stress.”
- Perform activity planning or activity adjustment according to the athlete’s injury history and training level, etc.
- Review all medications, including supplements and herbal remedies, with your doctor. 
Acclimatization Guidelines for Football
5-day acclimatization period at the beginning of the season – limited to no more than 1 sustained practice session per day
- Helmet wear only for days 1, 2
- Helmet plus shoulder pads only days 3, 4
- Full equipment on day 5
- After day 5, multiple practice days are allowed and specific guidelines are followed:
- The total practice time per day must be
- No single practice session should exceed 3 hours
- Must rest at least 3 hours between exercises
- Multiple practice days shall not appear consecutively
6-day acclimatization period at the start of the season – lasting no more than 1 practice session
- Days 1, 2: helmet only
- Days 3-5: helmet and shoulder pads only
- Day 6: full equipment
- No-contact training during adaptation period
- Limit consecutive practice days to 6
- Day 8: Multi-practice session with the same restrictions as above. 
Fluid Management During Exercise: Specific Guidelines
NCAA Sports Medicine Drink 8 to 16 ounces of water 1 hour before exercise. Continue to drink every 15-20 minutes during activity. Replenish lost fluids at the end of exercise (1 quart [32 oz] for every 2 lbs lost)  National Athletic Trainers Association (NATA) Replenish 16-20 oz of fluids 2-3 hours before exercise. only Take another 6-10 oz before exercise. Take 6-10 oz. every 15-20 minutes during exercise. Fluids consumed after the event exceeded fluids lost. 
Return to Play
For milder cases of febrile illness, it may be safe for athletes to return within 24 hours of being properly hydrated. Athletes should be evaluated by a physician before returning to competition.
To successfully return to full participation after exertional heat stroke (EHS), specific return to play (RTP) strategies should be implemented. These guidelines are as follows:
- Physician clearance before resuming physical activity – Athlete must be asymptomatic and laboratory tests should be normal.
- Recovery time depends largely on the severity of the disease.
- Athletes should begin a progressive RTP protocol under the direct supervision of an appropriate healthcare professional, such as an athletic trainer or physician.
- In general, they should wait at least 1 week before engaging in light activity in a cool environment, then gradually increase the intensity of heat exposure and the amount of equipment. 
- ↑ Poore S, Grundstein A, Cooper E, Shannon J. Regional differences in exertional heat illness rates among Georgia USA high school football players. International journal of biometeorology. 2020 Apr;64(4):643-50.
- ↑ Jump up to:2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Howe AS, Boden BP. Heat-related illness in athletes. The American Journal of Sports Medicine. 2007 Aug;35(8):1384-95.
- ↑ Jump up to:3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 Leiva DF, Church B. Heat Illness. InStatPearls [Internet] 2020 Jan 16. StatPearls Publishing.
- ↑ Jump up to:4.0 4.1 Giersch GE, Belval LN, Lopez RM. Minor Heat Illnesses. InExertional Heat Illness 2020 (pp. 137-147). Springer, Cham.
- ↑ Miller KC. Exercise-associated muscle cramps. InExertional Heat Illness 2020 (pp. 117-136). Springer, Cham.
- ↑ Jump up to:6.0 6.1 Altman, Joshua MDa; Stern, Evan MDb; Stern, Mori MDc; Prine, Bryan MD, CAQ-SMd; Breuhl Smith, Kristy MDe; Smith, Michael Seth MD, CAQ-SM, PharmDd Current paradigms in the prehospital care of exertional heat illness: A review, Current Orthopaedic Practice: January-February 2020 – Volume 31 – Issue 1 – p 1-7 doi: 10.1097/BCO.0000000000000824
- ↑ Armstrong LE. Heat Exhaustion. InExertional Heat Illness 2020 (pp. 81-115). Springer, Cham.
- ↑ Eichner ER. Updates on Heat Stroke, Carbon Monoxide, and Muscle Cramping. Current Sports Medicine Reports. 2020 Nov 1;19(11):446-7.
- ↑ Agustini NN, Arsani NL. Exertional Heat Stroke. InProceeding ICOPESH (International Conference on Physical Education, Sport, and Health) 2020 May 1 (pp. 63-66).
- ↑ Hew-Butler T, Almond C, Ayus JC, Dugas J, Meeuwisse W, Noakes T, Reid S, Siegel A, Speedy D, Stuempfle K, Verbalis J. Consensus statement of the 1st international exercise-associated hyponatremia consensus development conference, Cape Town, South Africa 2005. Clinical Journal of Sport Medicine. 2005 Jul 1;15(4):208-13.
- ↑ Jump up to:11.0 11.1 Westwood CS, Fallowfield JL, Delves SK, Nunns M, Ogden HB, Layden JD. Individual risk factors associated with exertional heat illness: A systematic review. Experimental Physiology. 2020 Apr 6.
- ↑ Jump up to:12.0 12.1 Pryor JL, Périard JD, Pryor RR. Predisposing Factors for Exertional Heat Illness. InExertional Heat Illness 2020 (pp. 29-57). Springer, Cham.
- ↑ Jump up to:13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 Lipman GS, Gaudio FG, Eifling KP, Ellis MA, Otten EM, Grissom CK. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2019 Update. Wilderness & Environmental Medicine. 2019 Dec 1;30(4):S33-46.
- ↑ Bhatia PK, Biyani G, Mohammed S. Hyperthermia and Heatstroke. chronic illness.;10:11.
- ↑ Heat stroke prevention available from https://www.youtube.com/watch?v=Zg7P7EHgHb8
- ↑ Larsen T, Kumar S, Grimmer K, Potter A, Farquharson T, Sharpe P. A systematic review of guidelines for the prevention of heat illness in community-based sports participants and officials. Journal of science and medicine in sport. 2007 Feb 1;10(1):11-26.
- ↑ Jump up to:17.0 17.1 17.2 https://www.ncaa.org/sport-science-institute/heat-and-hydration
- ↑ https://www.acsm.org/acsm-positions-policy/official-positions/ACSM-position-stands
- ↑ Casa DJ, Csillan D, Inter-Association Task Force Participants, Armstrong LE, Baker LB, Bergeron MF, Buchanan VM, Carroll MJ, Cleary MA, Eichner ER, Ferrara MS. Preseason heat-acclimatization guidelines for secondary school athletics. Journal of Athletic Training. 2009 May;44(3):332-3.
- ↑ Jump up to:20.0 20.1 https://www.nata.org/practice-patient-care/health-issues/heat-illness