Exertional Heat Illness

John W. Gardner, MD, DrPH COL(ret), MC, FS, US Army

Uniformed Services University of the Health Sciences Bethesda, MD

Less than 20% of energy expended during exercise is converted to mechanical energy The remainder is released as HEAT

Heat Dissipation
Heat must be dissipated or the body temperature rises
Rise in body temperature stimulates thermoregulatory mechanisms (in proportion to amount of rise) Heat is dissipated primarily at the SKIN (and some through respiration)

Body Cooling Mechanisms

Conduction
Convection

Radiation Evaporation

Body Cooling Mechanisms

Efficiency of body cooling depends upon the differential between skin and environmental temperatures When there is no gradient between skin and environmental temperatures, the only mechanism for heat dissipation is through evaporation In high humidity, evaporation is also ineffective (dripping sweat does not cool, but simply induces further dehydration)

Hydration Requirements
Maximal sweating is 2-3 liters/hour
GI water absorption during exercise is limited to about 1.5 liters/hour Maximal sweat rates cannot be maintained indefinitely, as dehydration always progresses even when drinking maximally

Estimated Distribution of Cardiac Output

25

Liters per Minute

20 15 10 5 0
n es tio tR er er tio n t

Skin Muscle Viscera

Ex

C oo

ax

tM

la

oo

ot

at

ax

Ex

la

Exertional Heat Illness

The combination of dehydration, circulatory demands, and metabolic processes induce tissue injury & organ dysfunction The heart must work harder to meet circulatory demands Redistribution of blood flow may compromise vital organs:
bloody diarrhea in marathoners? acute renal failure? encephalopathy?

Acidosis and electrolyte imbalance may disrupt other metabolic processes or induce organ dysfunction High temperature may alter metabolic rates and induce organ dysfunction Inflammatory processes initiated? (release of endotoxin through gut compromise?)

THE SPECTRUM OF EXERTIONAL HEAT ILLNESS

Hyperthermia Dehydration Nephropathy Cell Lysis

Heat Exhaustion Heat Injury

Shock Renal Failure Heatstroke

Rhabdomyolysis
Moderate Severe

Encephalopathy

Key Points
Severe exertional heat illness:
can occur in cool weather can occur without high body temperature may reflect severe illness must be closely monitored early rapid cooling essential early & aggressive IV therapy

Mental status change

Vital signs & Laboratory values

Dehydration & Acidosis

Sickle Cell Trait Patients

have higher risk of death

Wet-Bulb Globe Temperature Index

The WBGT Index takes into account air temperature, humidity, radiant heat, and air movement. W = Aspirated Wet-Bulb Temperature G = Matte Black Globe Temperature D = Dry-Bulb Temperature

WBGT Index = 0.7*W + 0.2*G + 0.1*D

PARRIS ISLAND MARINE CORPS RECRUIT TRAINING DEPOT, SC

Percent of Days in each Maximum WBGT Group by Year 100% 80% 60% 40% 20% 0%
`82 `83 `84 `85 `86 `87 `88 `89 `90 `91

<70 70-<75 75-<80 80-<85 85-<88 88-<90 90+

PARRIS ISLAND MARINE CORPS RECRUIT TRAINING DEPOT, SC

Percent of Days in each Maximum WBGT Group by Month 100% 80% 60% 40% 20%
Sep Feb Jun Jul Jan Aug Mar Apr May Oct

<70 70-<75 75-<80 80-<85 85-<88 88-<90 90+

0%

PARRIS ISLAND MARINE CORPS RECRUIT TRAINING DEPOT, SC

1982-91 Recruit Heat Illness Rates by Gender and Month

Rate per 1000 person-months

8 6 4 2 0
Aug Nov Apr Sep Jan Feb Jun Oct Jul May Dec Mar

Male Female

Acclimatization
Thermoregulatory mechanisms initiate at lower levels of elevated temperature
Sweating begins sooner and in higher volume

Sweat has much lower sodium content

Blood volume and cardiac capacity expand, with more efficient redistribution of blood flow In well-conditioned individuals most of acclimatization is accomplished in 3-5 days

PARRIS ISLAND MARINE CORPS RECRUIT TRAINING DEPOT, SC

100 90 80 70 10 9 8 7

WBGT F

60 50 40 30 20 10 0 0 2 4

June 3, 1991

6 5 4 3 2 1 0

6 8 10 12 14 16 18 20 22 Hour of Day Case Count

WBGT

Number of Cases

PARRIS ISLAND MARINE CORPS RECRUIT TRAINING DEPOT, SC

1982-91 Recruit Heat Illness Cases by Gender and Time of Day

500
Number of Cases

400 300 200 100 0

Male Female

8 10

12

14

16

18

20

22

PARRIS ISLAND MARINE CORPS RECRUIT TRAINING DEPOT, SC

Recruit Heat Illness by WBGT Category at Time of Illness, 7-9 am Cases 6

Cases per 100,000 person-hours

Case Rates Case Counts

5 4 3 2 1
60-<65 65-<70 70-<75 75-<80 80-<85 85-<88 88-<90 90+ <60

450 400 350 300 250 200 150 100 50 0

WBGT Category (F)

Number of Cases

PARRIS ISLAND MARINE CORPS RECRUIT TRAINING DEPOT, SC

Recruit Heat Illness by WBGT Category of Prior Day Maximum, 7-9 am Cases 12
Cases per 100,000 person-days

Case Rates Case Counts

300 250 200 150 100 50

Number of Cases

10 8 6 4 2
60-<65 65-<70 70-<75 75-<80 80-<85 85-<88 88-<90 90+ <60

WBGT Category (F)

Military and ACSM Flag Conditions

100 90

Black Flag: Red Flag: Yellow Flag: Green Flag:

Military ACSM

Very High Risk High Risk

No Outdoor Training Restricted for All Restricted for Unacclimatized Caution

WBGT F

80 70 60 50 40

Moderate Risk Some Risk

No Flag:

Low Risk

Unrestricted

Body Mass Index (BMI)

on Arrival by Case and Control Status, Male Marine Recruits, MCRD-PI, 1988-1992
BMI CATEGORY
CASES CONTROLS

OR (95% CI)
1.0

<22 kg/m2 22-<26 kg/m2 26+ kg/m2 Total

62

449

156
172 390

659
340 1448

1.7
3.6

(1.3-2.4)
(2.5-5.0)

1.5 mile PFT1 Run Time by Case and Control Status, Male Marine Recruits, MCRD-PI, 1988-1992
Run Time CATEGORY

CASES

CONTROLS

OR (95% CI)

<10 minutes 10-<12 minutes 12+ minutes Total

28 156 193 377

204 884 329 1417

1.0
1.5 5.6
(0.9-2.4) (3.4-9.1)

Odds Ratios Combining PFT1 Run Time and BMI Category for Exertional Heat Illness, Male Marine Recruits, MCRD-PI, 1988-1992 1.5 Mile PFT1 Run Time BMI CATEGORY <10 minutes 10-<12 minutes 12+ minutes
<22 kg/m2

1.0
1.6

1.5
2.0

3.5
8.5

22-<26 kg/m2

26+ kg/m2

3.7

3.3

8.8

PARRIS ISLAND MARINE CORPS RECRUIT TRAINING DEPOT, SC

Percent of Population Producing Heat Illness Cases

100% 90%

% of population

80% 70% 60% 50% 40% 30% 20% 10% 0% Population

35%

65%

18% 47%

Low Risk Med. Risk High Risk

17% 18%

Cases

PARRIS ISLAND MARINE CORPS RECRUIT TRAINING DEPOT, SC

Percent of Cases with Neurologic Heat Stroke

100 90 80 70 60 50 40 30 20 10 0 98 100 102 104 106 108+
M aximum Re ctal Te mpe r ature ( F)

Percent of Cases

Does Rectal Temperature 106F Predict Heat Stroke (Delirious or worse)?

Rectal Temperature 106 F < 106 F Total Delirious + Yes No 35 34 69 36 363 399 Total 71 397 468

Sensitivity = 35 / 69 = 51%
Specificity = 363 / 399 = 91% Predictive Value (+) = 35 / 71 = 49%

Risk of Exercise-Related Threatened or Completed Sudden Cardiac Death

Recruits, Parris Island, SC 1979-90 [95% confidence limits]

Recruits/Cadre w/ Heat Stroke w/ Other EHI w/o EHI

Cases (deaths)

Population

Incidence

7 (2)

137
1,800 267,500

5.1 %
[2.5-10%]

0
4(4)

0.0015%
[0-0.004%]

Types of Exercise-related Recruit Deaths (96 military recruit deaths, 1979-90)

w/ SCT w/o SCT
HS & Rhab

10

10

Unexpl Card

18

Expl Card

43

Expl Non-card0

6 10 20 30 40 50

Number of Recruit Deaths

Percent of Exercise-related Recruit Deaths Exposed to Environmental Heat Stress*

Total Deaths

(N = 96)

HS & Rhab

(N = 20)
Unexpl Card

(N = 25)
Expl Card

(N = 45)
Expl Non-card

(N = 6)
0 10 20 30 40 50 60 70 80 90 100 % Recruit Deaths * Same or Prior Day WBGT > 75F

Clinical Assessment of Heat Illness

Non-Specific Symptoms:
weakness, thirst, headache, cramps, poor concentration

Progressive Orthostatic Symptoms:

faintness, dizziness, wobbly, visual symptoms, collapse

Clinical Assessment of Heat Illness

Exertional Syncope:
brief loss of consciousness

Orthostatic Hypotension:
positive tilt tests sustained hypotension

Shock/Cardiac Arrhythmia

Metabolic Complications

Scale of Encephalopathy in Heat Illness

8 7 6 5 4 3 2 1
Normal - alert, oriented, cooperative Drowsy - lethargic, slow mentation Confused & Appropriate - cooperative

Confused & Inappropriate - disoriented

Delirious - disoriented, agitated Obtunded - minimal mental response Light coma - reflex responses Deep coma - no reflex responses

RECOMMENDED LABORATORY TESTS IN EXERTIONAL HEAT ILLNESS

CBC: Hgb, Hct, WBC, Platelet Count Urinalysis: S.G., pH, evidence of myoglobin

Chemistries: Na, K, Cl, HCO3, Glu, BUN, Creatinine,

CK[CPK], AST[SGOT], Uric Acid, LDH, ALT[SGPT]

If severe:

ABG; Ca, Phos; PT, PTT, FSP, Fibrinogen

Immediate Management of Heat Illness Casualties

Get a Rectal Temperature Assess Mental Status Immediate Cooling with Ice Water Rapid Rehydration Monitor Vital Signs and Serum Chemistries Limit Duty after Treatment

Predictors of Hospitalization Parris Island Recruits, 1988-92

Clinical Variable
Maximum body temperature Min systolic blood pressure Disorientation duration Minimum serum potassium Maximum serum creatinine Maximum serum LDH 106+ F <100 mmHg 1-29 minutes 30+ minutes < 3.7 mEq/L 1.8+ mg/dL 400+ U/mL

Score
1 1 1 2 1 1 1

A score of 2 or more may require hospitalization.

Prevention of Exertional Heat Illness

Schedule Training / Exercises During Cool Hours
Consider Accumulative Effects of Heat Exposure Minimize Heavy or Retentive Clothing Minimize Unnecessary Strenuous Exercise (Running ) Tailor exercise to physical and medical condition of participants

Prevention of Exertional Heat Illness Maintain Good Hydration

Provide Shade, Water and Rest Periods

Have Medical Personnel On-Site During Strenuous Exercise

Prevention of Exertional Heat Illness Forget : NO PAIN, NO GAIN Remember :

TRAIN, NOT PAIN

The notion that courage and esprit de corps can somehow defeat the principles of physiology is not only wrong but dangerously wrong.
Sir Roger Bannister (1989)

Example: Combat Confidence Course

Modifications to Reduce Risk for Exertional Heat Illness

Location with Access to Shade and Water

Showers for Wet-Down During Run/Between Events Clothing: T-shirts vs. Full Combat Gear

Cover: None vs. Helmet

Run: Formation vs. Individual (non-competitive ) Hydration Status Checked by Urine Color

Exertional Heat Illness Outbreaks, Ft. Bragg, 2000-2001

9/22/00 11/4/00 EFMB March (12 miles) 6 hospitalizations

Perimeter Challenge (60 miles) 5 hospitalizations

4/12/01
6/14/01 7/20/01

EFMB March (12 miles)

Army Birthday Run (10 miles) EIB March (12 miles)

9 hospitalizations
6 hospitalizations 19 hospitalizations

8/9/01

Corps Birthday Run (4 miles)

4 hospitalizations

Exertional Heat Illness Ft. Bragg, 2000-2001

STUPIDITY:

Death related to 6 mile run in new transfer at pace faster than his 2-mile PFT run (coronary heart disease)
Three heat stroke cases related to 8 mile run in new transfers on their first day of arrival Heat stroke related to chemical gear at Black Flag conditions Permanent mental disability related to recurrent heat injury when on medical restriction after release from hospital for heat stroke - commander insisted on 100% field participation Numerous heat casualties related to use of ephedra-containing nutritional supplements

Career Implications of Heat Stroke Diagnosis

Mandatory MEB with 3-month P3 medical restriction, followed by 6-12 month P2 medical restriction Airborne operations restricted Pilots grounded for a minimum of 3 months, then can request waiver; recurrent episode - waiver not to be recommended Single episode of heat stroke may preclude flight school entry Medical restrictions usually make soldiers non-deployable for a prolonged period of time

Diagnosis of Heat Stroke

Recommendations:
In the setting of heat exposure or exertion, any of the following (elevated body temperature not required): persistent (at least 10-20 minutes) disorientation, confusion, or combativeness delirium or obtundation beyond 3-5 minutes coma beyond the three minutes of a simple faint amnesia beyond 10-15 minutes surrounding the event elevated CK>700, AST>60, ALT>60, or LDH>400 at 24 hours post-event (particularly if rising after initial values, or if associated with myoglobinuria)

Diagnosis of Heat Exhaustion

Recommendations:
In the setting of heat exposure or exertion, all patients not meeting heat stroke criteria who experience exercise-related collapse/illness and require medical intervention (e.g., more than two liters of IV fluids) and/or more than one hour to recover (unable to return to work at light-duty within one hour) Includes exertional dehydration, cramps, syncope These patients should all be evaluated by an experienced clinician, preferably in an Emergency Room setting and with laboratory workup

Field Management of Exertional Heat Illness

Mild patients - Alert with appropriate behavior, near normal and rapidly stabilizing vital signs, and able to drink fluids Care in the field for up to one hour with up to 2 liters of fluids (NS if IV) Rest in the shade, cooling, rehydration, frequent vital signs and mental status assessment (every 5-10 min) Upon realization that recovery will require more than this, or if the patient is not improving, then evacuation to an Emergency Room should be quickly arranged No patient leaves medical care until providing urine

Field Management of Exertional Heat Illness

Moderate/Severe patients - Mental status changes,
amnesia, syncope, seizure, unable to drink fluids, unstable vital signs, or temp >104 Care in the field includes rest in the shade, cooling, rehydration, frequent vital signs and mental status assessment (every 5-10 min), while quickly arranging evacuation to an Emergency Room These patients require immediate evaluation by an experienced clinician, and laboratory tests (CBC, electrolytes, creatinine, liver enzymes, CK, urinalysis) No patient leaves medical care until providing urine

ER Management of Exertional Heat Illness

ACLS procedures as needed, to include aggressive cooling and rehydration Stop aggressive cooling at 102 to avoid hypothermia Repeat vital signs and mental status assessments every 5-10 minutes until stable and temp <100 Lab assessment is usually required, with follow-up the next day in all but very mild patients All ER and hospitalized patients to be followed-up in the Preventive Medicine clinic for reporting, medical restrictions, MEB referral, and review of need for further medical management or follow-up

Disposition of Exertional Heat Illness Cases

Mildly ill patients who appear to be fully recovered in the ER and have no laboratory abnormalities may return to light duty the next day; maximal exercise should be avoided for several days Patients not fully recovered or who have laboratory abnormalities require next day follow-up by an experienced clinician, with laboratory evaluation All patients remain on quarters, convalescent leave, or P4 medical restriction until all symptoms have completely resolved and laboratory tests are normal When fully recovered, the patient may begin exercise at own pace, building slowly up to maximal efforts

MEB for Heat Stroke Cases

All heat stroke or rhabdomyolysis cases require MEB If no complications, MEB will provide P3 restriction for 3 months which limits vigorous exercise to periods no longer than 15 minutes, no maximal efforts, no PFT, and no chemical gear or significant heat exposure If after 3 months there has been no indication of heat intolerance, the restriction is changed to P2 through the next hot season, which allows normal work but restricts significant heat exposure and maximal exertion If no heat intolerance, return to full duty after the hot season; if signs of heat intolerance, refer to PEB

Surveillance and Reporting of Exertional Heat Illness

Report all cases from the Emergency Room, and none from the field Cases admitted to the hospital are interviewed there by Preventive Medicine, and case summaries developed for discussion with commanders All ER and hospital cases are followed-up in the Preventive Medicine clinic for reporting purposes, as well as to assure that the soldier is properly restricted and referred to MEB, if appropriate If we take the soldiers away from their commanders through the mandatory restriction and MEB process, it will emphasize the seriousness of inducing heat stroke

EFMB Safety
Prevention of Exertional Heat Illness

PROBLEM:
2 deaths from heat stroke during 12-mile march in EFMB testing (9/98 & 6/99) Numerous episodes of exertional heat illness during 12-mile march in EFMB testing (Ft. Bragg examples)

CHALLENGES:
Unlike EIB, EFMB candidates are generally medical personnel who do not march for a living Use of ergogenic aids as nutritional supplements

EFMB Safety
Prevention of Exertional Heat Illness

PROBLEM:
EFMB candidates often arrive physically unprepared for the 3-hour 12-mile road march requirement

SOLUTION:
Require prerequisite physical conditioning per FM 21-18, section 5-11 Certified by individuals unit, and Perhaps tested at beginning of course with 12-mile march in 3-hours without pack

EFMB Safety
Prevention of Exertional Heat Illness

PROBLEM:
EFMB candidates often often use ergogenic nutritional supplements or are taking other medications

SOLUTION:
Prohibit use of ergogenic nutritional supplements within 30-days of EFMB testing Require medical clearance of all candidates to determine medication and supplement hazards

EFMB Safety
Prevention of Exertional Heat Illness

PROBLEM:
Inadequate hydration during the road march

SOLUTION:
It is important to begin the march fully-hydrated Prior day should have minimal physical activity and heat stress exposure Hydration early in the march is important Staff should ensure that candidates actually drink

EFMB Safety
Prevention of Exertional Heat Illness

PROBLEM:
Overzealous candidates and staff put themselves and others at risk

SOLUTION:
Staff should do periodic mental status checks Staff must be authorized to immediately disqualify candidates when medical risks warrant Staff should not be overzealous in enforcing detailed course requirements to the detriment of candidates

EFMB Safety
Prevention of Exertional Heat Illness

PROBLEM:
Medical care at the event is often inadequate

SOLUTION:
Plan for mass casualties and evacuation procedures Every candidate should be medically evaluated before being released from the event Maintain complete records Report all injuries / illness Accurate weights before and after the march are helpful

PM TEAM FORT BRAGG

ALL THE WAY, AIRBORNE

STRATEGIC FORCE... DECISIVE VICTORY