Sample Policy and Procedures: Dehydration, Heat- and Cold-Related Illnesses

An athletics department must demonstrate an unwavering commitment to protect the health of, and provide a safe environment for, each of its participating student-athletes. The safety and health of our student-athletes, staff, and event personnel are paramount.  Thus, policies and procedures with regard to dehydration as well as heat and cold related illnesses of student-athletes must be implemented in the training of sports medicine personnel, event personnel, coaches, and the education of student-athletes themselves. Additionally, public postings that outline instructions and procedures for responding to these health issues must be displayed to keep the message at the forefront of the minds of all those associated with athletics department and its student-athletes.

These recommendations do not guarantee full protection from dehydration, heat and cold related illnesses, but should decrease the risk of such occurrences during athletic participation.   It should recognized that all student-athletes and the athletics staff working with them are at risk for dehydration as well as exertional heat and cold related illnesses in some capacity. The cooperation of sports medicine staff in conjunction with the continuous education of administrators, coaches, staff, and student-athletes will serve to improve prevention strategies and ensure proper treatment.
 
The following policy and procedures is a sample and should not be used verbatim.  Always submit policy drafts to your legal counsel for review to be sure all provisions conform to both institutional policy and applicable local, state and federal laws.

Policy and Procedures Related to Dehydration, Heat- and Cold- Related Illnesses

1.0    General.  All coaches and student-athletes shall receive a copy of the current NCAA Sports Medicine Handbook guidelines on (a) weight loss and hydration, (b) prevention of heat illness, and (c) cold stress and cold exposure upon which this policy is partially based (NCAA Sports Medicine Handbook, 2011).  These NCAA guidelines and this policy shall be reviewed with each team by a member of the athletics training staff prior to the start of the sport season.

2.0    Dehydration

2.1    General Policy. Dehydration can compromise athletic performance and increase the risk of exertional heat injury. Various studies have shown that (a) athletes do not voluntarily drink sufficient water to prevent dehydration during physical activity, (b) education, increasing accessibility, and optimizing palatability can modify drinking behavior, and (c) excessive overdrinking should be avoided because it can also compromise physical performance and health (Armstrong et al, 1995; Casa & Hillman, 2000; Joy, 2002; Sadler, 2006). The athletics department has adopted practical recommendations from nationally certified associations (Inter-Agency Task Force, 2003) which were derived from research regarding fluid replacement for student-athletes to lessen the risk and prevent the likelihood of dehydration. These policies and procedures for risk prevention require a cooperative effort of educated student-athletes, coaches, and athletic training staff to ensure the safety of student-athletes.  The prevention procedures presented herein are non-negotiable and the disregard for the prevention of dehydration may result in termination of employment.

2.2    Description & Symptoms. All athletics department staff members working with student-athletes are responsible for knowing the symptoms of dehydration:  thirst, irritability, and general discomfort followed by headache, weakness, dizziness, cramps, chills, vomiting, nausea, head or neck heat sensations, and/or decreased performance.

2.3    Risk Factors.  All athletics department staff members working with student-athletes are responsible for recognizing the following risk factors for heat illnesses:  extreme heat and/or humidity, excessive perspiration, inadequate fluid intake, bouts of vomiting or diarrhea prior to exercise, dark-colored urine, use of medications that are dehydrating, alcohol consumption, and caffeine use.  Particular attention should be given to barriers to evaporation: when certain types of athletic equipment do not allow water vapor to pass through and inhibit evaporative, convective, and radiant heat loss or when athletic apparel is dark-colored, causing greater absorption of heat from the environment.   Student- athletes also at increased risk are those who are currently or were recently ill, have a history of heat illness, have high body mass, are muscle-bound, are untrained or overzealous and are not yet acclimated to hot conditions.

2.4    Required Preventive Measures

2.4.1    Hydration Protocols. The team physician will communicate and coordinate with the department’s certified athletic training staff frequently and closely to implement a hydration protocol of risk prevention for dehydration that includes the following considerations:

  • the student-athlete’s sweat rate
  • sport dynamics (i.e. rest breaks, fluid access)
  • environmental factors
  • acclimatization state of participants
  • exercise duration
  • exercise intensity
  • individual preferences

A proper hydration protocol considers each sport’s unique features.  If rehydration opportunities are frequent (i.e. baseball, football, track and field), the student-athlete can consume smaller volumes at a convenient pace based on sweat rate and environmental conditions. If rehydration must occur at specific times (i.e. soccer, lacrosse, distance running), the student-athlete must consume fluids to maximize hydration within the sport’s rules.

2.4.2    Approval Each Season. Team hydration protocols shall be submitted by coordinating coaches and certified athletic training staff to the team physician for approval each season based on practice and event schedule.

2.4.3    Individual Protocols for High Risk Athletes. Individual hydration protocols shall be submitted to the team physician each season for student-athletes who have a history of heat related illness or other illness that could exacerbate dehydration, taking medications that exacerbate dehydration, those who need further acclimatization, and those who may be in poor physical condition compared to the majority of the team. These student-athletes are to be monitored closely during all practices and competitions by coaches and training staff.

2.4.4    Athlete Education. The athletics department shall educate student-athletes on the effects of dehydration and the factors for risk in seasonally conducted health and awareness sessions implemented by coaches and training staff.

2.4.5    Information Posters. The athletics training staff shall display informational posters at practice facilities and in training rooms to enhance awareness.

2.4.6    Basic Responsibilities. Coaches and athletics training staff shall implement the approved hydration protocol during all practices and games, and adapt it as needed depending on environmental conditions and training or competitive intensity. Further, the athletics department, its coaches, and certified athletic training staff shall inform student-athletes on how to monitor hydration status and assist in hydration efforts by:

  • Providing a scale to assist student-athletes in self-monitoring weight before, during, and after activity.
  • Informing student-athletes that two pound weight loss represents approximately one quart of fluid loss and for activity up to two hours in duration, most weight loss represents water loss, and that fluid loss should be replaced as soon as possible
  • Encouraging student-athletes to drink as much and as frequently as comfort allows
  • Requiring student-athletes to drink one to two eight ounce glasses of water in the hour before practice or competition, and continue drinking during activity at intervals of every fifteen to twenty minutes
  • Ensuring that after activity, the student-athlete will rehydrate with a volume that exceeds the amount lost during the activity
  • Fluids for the hydration of student-athletes must be provided using the optimal oral rehydration solution (water, CHOs, electrolytes) before, during, and after exercise.
  • Fluids must be readily available, easily accessible, and the consumption promoted
  • When extreme temperatures are present, promotion of fluid intake for student- athletes assumes the highest priority for certified athletic training staff and coaches.  The impact of such weather conditions and the importance of fluid intake shall be communicated by the coaches and athletics training staff to student-athletes prior to the start of practices and competitions in such environments.

2.4.7    Practice and Competition Scheduling. The athletics department, coaches and certified athletic training staff will encourage event scheduling and rule modifications to minimize the risks associated with exercise in the heat. Practice times, frequency, and duration of practices should reflect acknowledgement of extreme heat or cold to reduce the risk of dehydration.

2.4.8    Equipment and Apparel Considerations. Clothing to be worn at practice and competition in extreme heat conditions shall be provided by the athletics department and meet the following criteria: (a)  the color and fabric of that clothing will be lighter, (b) lighter apparel use shall be required by coaches and athletics training staff to mitigate the risk of dehydration, and (c) sports equipment normally worn at practice (i.e., pads, long trousers, etc.) shall not be worn and the scope of practice sessions adjusted accordingly.

3.0     Heat-Related Illness

3.1    General Policy. Heat-related illness risk is inherent to physical activity and its incidence increases with rising ambient temperature and relative humidity. Student-athletes who begin training in the late summer experience exertional heat-related illness more often than student-athletes who begin training during the winter and spring. This athletics department policy is based on NCAA guidelines (NCAA Sports Medicine Handbook, 2011) recommendations from nationally certified associations based on research and recommendations by others regarding identification of symptoms and procedures to lessen the risk and prevent the likelihood of heat-related illness occurring among  student-athletes (Armstrong et al, 1995; Binkley et al, 2002; Casa and Hillman, 2000; Inter-Agency Task Force, 2003; Joy, 2002; Sadler, 2006). These policies and procedures for risk prevention require a cooperative effort of educated student-athletes, coaches, and athletic training staff to ensure the safety of student-athletes.  The prevention procedures presented herein are non-negotiable and the disregard for the prevention of heat-related illness may result in termination of employment.

3.2    Descriptions and Symptoms

3.2.1    Exercise-Associated Muscle (Heat) Cramps. Exercise-associated muscle cramps (i.e., acute, painful, involuntary muscle contractions) occur during or after intense exercise sessions and moderate exercise in conditions of high heat and humidity. Other systems include dehydration, thirst, sweating, and fatigue.  Cramps are caused by fluid deficiencies (dehydration), electrolyte imbalances, neuromuscular fatigue, or any combination of these factors.  Normal hydration status is established by replacing some sodium loss with a sports drink or other sodium source.  Muscles should be lightly stretched and massaged in response to pain.

3.2.2    Heat Syncope. Heat syncope, or orthostatic dizziness, occurs when the student-athlete is exposed to high environmental temperatures. Other symptom include dehydration, fatigue, tunnel vision, pale or sweaty skin, decreased pulse rate, dizziness, lightheadedness, fainting.  This condition results from peripheral vasodilation, postural pooling of blood, diminished venous return, dehydration, reduction in cardiac output, and/or cerebral ischemia.   Heat syncope often occurs during the first five days of preseason training as the student-athlete is acclimatizing to high heat environments.   It often occurs after standing for long periods of time, immediately after cessation of activity, or after rapid assumption of upright posture after resting or being seated.  Clothing should be removed, the student-athlete should be given a tepid sponge bath, allowed to rest in cool/shaded environment, rehydrated orally with fluids, and monitored with regard to cardiac functioning.

3.2.3    Exercise (Heat) Exhaustion. Exercise (heat) exhaustion is the inability to continue exercise in hot and often humid conditions usually resulting from a combination of heavy sweating, dehydration, sodium loss, and energy depletion.   Body core temperature may be normal or elevated but other symptoms may include dehydration, dizziness, lightheadedness, headache, nausea, disinterest in eating, diarrhea, decreased urine output, persistent muscle cramps, pallor, profuse sweating, chills, cool, clammy skin, intestinal cramps, urge to defecate, weakness, and hyperventilation.  It is difficult to distinguish from exertional heat stroke without measuring rectal temperature.  Clothing should be removed and the student-athlete should be given a cool sponge bath or ice bath, directed to rest in cool/shaded environment, rehydrated orally with fluids and monitored with regard to cardiac functioning.  Emergency medical assistance should be summoned if symptoms are severe.

3.2.4    Exertional Heat Stroke. Exertional heat stroke is an elevated core temperature (usually 40C [104F]) with signs of organ system failure due to hyperthermia. Symptoms include high body-core temperature (40C [104F]), central nervous system changes, dizziness, drowsiness, irrational behavior, confusion, irritability, emotional instability, hysteria, apathy, aggressiveness, delirium, disorientation, staggering, seizures, loss of consciousness, coma, dehydration, weakness, hot and wet or dry skin, tachycardia (100 to 120 beats per minute), hypotension, hyperventilation, vomiting, and diarrhea.  The central nervous system neurologic changes (disorientation) are often the first marker of exertional heat stroke.  This condition is life threatening and can be fatal unless promptly recognized and treated.   The risk of morbidity and mortality is significantly reduced if body temperature is lowered rapidly.  The student-athlete should be immediately immersed in an ice bath, placed in cool and shaded environment, and rehydrated orally with fluids.  Emergency transportation should be arranged if symptoms severe but only after rapid cooling efforts.

3.2.5    Exertional Hyponatremia. Exertional hyponatremia is a relatively rare low serum-sodium condition that usually occurs when activity exceeds four hours, a student-athlete ingests water or low-solute beverages well beyond sweat losses (also known as water intoxication), and/or a student-athlete’s sweat sodium losses are not adequately replaced.   The resulting intracellular swelling can cause potentially fatal neurologic and physiologic dysfunction.  Other symptiom may include body-core temperature, 40C (104F), nausea, vomiting, extremity (hands and feet) swelling, low blood-sodium level, progressive headache, confusion, significant mental compromise, lethargy, altered consciousness, apathy, pulmonary edema, cerebral edema, seizures, and coma.  This condition can be prevented by matching fluid intake with sweat and urine losses and by rehydrating with fluids that contain sufficient sodium.   Athletics training staff in consultation with team physician arranges for intravenous rehydration with fluids containing sufficient sodium and emergency care if necessary.

3.3    Risk Factors.   All athletics department staff members working with student-athletes are responsible for recognizing the following risk factors for heat illnesses:  extreme heat and/or humidity, excessive perspiration, inadequate fluid intake, bouts of vomiting or diarrhea prior to exercise, dark-colored urine, use of medications that are dehydrating, alcohol consumption, and caffeine use.  Particular attention should be given to barriers to evaporation: when certain types of athletic equipment do not allow water vapor to pass through and inhibit evaporative, convective, and radiant heat loss or when athletic apparel is dark-colored, causing greater absorption of heat from the environment.   Student- athletes also at increased risk are those who are currently or were recently ill, have a history of heat illness, have high body mass, are muscle-bound, are untrained or overzealous and are not yet acclimated to hot conditions. 

3.4    Preventive Measures

3.4.1    Hydration Protocol. The team physician shall communicate and coordinate with the athletics training staff and coaches frequently and closely to implement a hydration protocol of risk prevention for dehydration as outlined in sections 2.4 above.  

3.4.2    Preparation for Medical Care. The team physician and head athletics trainer shall ensure that appropriate medical care is available and that rescue personnel are familiar with exertional heat illness prevention, recognition, and treatment.

3.4.3    Evaluation by Health Care Providers.  Coaches shall ensure that athletic trainers and other health care providers attending practices or events are allowed to evaluate and examine any student-athlete who displays signs or symptoms of heat illness and have the authority to restrict the student-athlete from participating if heat illness is present.

3.4.4    Pre-Participation Screening Requirement. The athletics department  physician-supervised pre-participation medical screening before the season starts shall include a review of athletics training room injury/illness records, medical history, and physical examination queries that identify student-athletes predisposed to heat illness on the basis of risk factors and those who have a history of exertional heat illness.

3.4.5    Heat Adaptation. Coaches, athletics training staff, and strength and conditioning staff shall ensure the adoption of a conditioning programs that permits student-athletes to gradually adapt to exercise in the heat (acclimatization) over ten to fourteen days. 

3.4.6    Education. The athletics department, athletics trainers, and strength and conditioning staff shall educate student- athletes and coaches on an ongoing basis regarding the prevention, recognition, and treatment of heat illnesses and the risks associated with exercising in hot, humid environmental conditions.

3.4.7    Guidelines. The athletics department, coaches, and certified athletic training staff shall develop event and practice guidelines for hot, humid weather that anticipate potential problems encountered.

3.4.8    Rest Breaks. Coaches and certified athletic training staff shall plan rest breaks to match the environmental conditions and the intensity of the activity.

3.4.9    High Risk Student-Athletes. Athletics training staff will weigh high-risk student-athletes, and in high-risk conditions all student-athletes, before and after practice to estimate the amount of body water lost during practice and to ensure a return to pre-practice weight before the next practice.

3.4.10    Clothing Adjustments. The athletics department, coaches, and certified athletic training staff will minimize the amount of equipment and clothing worn by the athlete in hot or humid (or both) conditions.

3.4.11    Warm-Up Considerations. Coaches will minimize warm-up time when feasible, and conduct warm-up sessions in the shade when possible to minimize the radiant heat exposure for student-athletes.

3.4.12    Adaptation Considerations. Coaches will allow student-athletes to practice in shaded areas and use electric or cooling fans to circulate air whenever feasible.

3.4.13    Emergency Preparedness. The athletics department and athletics training staff will have available for use the following supplies on the field, in the locker room, and at various other stations:

  • A supply of cool water or sports drinks or both to meet the needs of student-athletes
  • Ice for active cooling (ice bags, tub cooling) and to keep beverages cool during exercise
  • Rectal thermometer to assess body-core temperature
  • Telephone or two-way radio to communicate with medical personnel and to summon emergency medical transportation if necessary
  • Tub, wading pool, kiddy pool, or whirlpool to cool the trunk and extremities for immersion cooling therapy

3.4.14    Notification of Health Centers. The athletics training staff shall notify local hospital and emergency personnel before mass participation events (charity running or walking events, cross country meets, high attendance outdoor events) conducted in high heat or humidity conditions to inform them of the event and the increased possibility of heat-related illnesses.

4.0    Cold-Related Illnesses

4.1    General. Cold-related illness is inherent to physical activity outdoors and its incidence increases with dropping temperatures and in environments with wet or windy conditions (or a combination of these).  All of these factors increase the risk of cold-related injury for student-athletes. Sports like football, baseball, softball, soccer, lacrosse and track and field that have seasons extending into late fall or early winter or begin in early spring, when weather holds the potential for the aforementioned conditions increase student-athletes’ susceptibility to cold injury.  This athletics department policy is based on NCAA guidelines recommendations from nationally certified associations,  research and recommendations by others regarding identification of symptoms and procedures to lessen the risk and prevent the likelihood of cold-related illness occurring among its student-athletes (Armstrong et al, 1995;  DeFranco et al, 2008;  NCAA Sports Medicine Handbook, 2011; UIL, 1999).  These policies and procedures for risk prevention require a cooperative effort of coaches and athletics training staff working together to enhance the safety of student-athletes. The prevention factors discussed herein are non-negotiable and disregard for the prevention of heat-related illness may result in termination of employment.

4.2    Descriptions & Symptoms

4.2.1    Hypothermia. The signs and symptoms of mild hypothermia include vigorous shivering, increased blood pressure, core body temperature less than 98.6F(37.6C) but greater than 95.6F (35.6C), fine motor skill impairment, lethargy, apathy and mild amnesia. Signs of moderate and severe hypothermia include cessation of shivering, very cold skin, depressed vital signs, core body temperature between 90.6F (32.6C) and 95.6F (35.6C) for moderate hypothermia or below 90.6F (32.6C) for severe hypothermia, impaired mental function, slurred speech, unconsciousness and gross motor skill impairment.

4.2.2    Frostbite. The signs and symptoms of superficial frostbite include swelling, redness or mottled gray skin appearance, stiffness and transient tingling or burning. Deep frostbite includes edema, mottled or gray skin appearance, tissue that feels hard and does not rebound, blisters, and numbness or loss of sensation.

4.2.3    Chilblain. Occurs with exposure to cold, wet conditions for more than sixty minutes at temperatures less than 50.6F (16.6C). It can be identified by the presence of small red bumps, swelling, tenderness, itching and pain.

4.2.4    Immersion Foot. Immersion (Trench) Foot: Occurs with exposure to cold, wet environments for twelve hours to three or four days. Symptoms include burning, tingling or itching, loss of sensation, bluish or blotchy skin, swelling, pain or sensitivity, blisters and skin fissures or maceration.

4.3    Risk Factors. All coaches and training staff shall be educated to recognize the risk factors of cold-related illness:

  • Extreme cold, precipitation, wind
  • Existing medical conditions
  • Previous cold injuries increases the chance of subsequent cold injuries two to four times, even if prior injuries were not debilitating or resolved with no or minimal medical care
  • Low caloric intake, dehydration, and fatigue
  • Low caloric intake (less than 1200 to 1500 kcal/day) or hypoglycemia (or both) 
  • Fatigue associated with hypoglycemia is linked to impaired peripheral vasoconstriction and shivering responses and can lead to faulty decision making and inadequate preparations, indirectly resulting in cold injuries
  • Black individuals have been shown to be two to four times more likely than individuals from other racial groups to sustain cold injuries. These differences may be due to cold weather experience, but are likely due to anthropometric and body composition differences.
  • Nicotine, alcohol, and drug use
  • Low body fat and muscle mass 
  • Gender. The hypothermia injury rate for females is two times higher than for males. Sex differences in thermoregulatory responses during cold exposure are influenced by interactions among total body fat content, subcutaneous fat thickness, amount of muscle mass, and surface area-to-mass ratio.
  • Insufficient clothing or clothing that does not reduce heat loss.

4.4    Preventive Measures

4.4.1    Availability of Medical Personnel. The head athletics trainer shall ensure that appropriate medical care is available and that rescue personnel are familiar with cold-related illness prevention, recognition, and treatment.

4.4.2    Evaluation by Health Care Provider. Coaches shall ensure that certified athletic trainers and other health care providers attending practices or events are allowed to evaluate and examine any student-athlete who displays signs or symptoms of cold-related illness and have the authority to restrict the student-athlete from participating if cold illness is present.

4.4.3    Pre-Participation Screening. The team physician and head athletics trainer shall ensure that all student-athletes receive a thorough, physician-supervised, pre-participation medical screening before the season starts to identify student-athletes predisposed to cold-related illness on the basis of risk factors and those who have a history of cold-related illness.

4.4.4    Education. The team physician and head athletics trainer shall conduct educational sessions for student-athletes and coaches concerning the prevention, recognition, and treatment of cold injury and the risks associated with activity in cold environments.

4.4.5    Hydration and Nutrition. The athletics department, coaches, and certified athletic training staff will educate and encourage student-athletes to maintain proper hydration and eat a well-balanced diet. These guidelines are especially imperative for activities exceeding two hours. Consistent fluid intake during low-intensity exercise is necessary and tudent-athletes should be encouraged to hydrate even if they are not thirsty, as evidence suggests the normal thirst mechanism is blunted with cold exposure.

4.4.6    Training Guidelines. The team physician and head athletics trainer shall develop event and practice guidelines that include recommendations for managing student-athletes participating in cold, windy, and wet conditions. The influence of air temperature and wind speed conditions shall be taken into account by the use wind-chill guidelines contained in the NCAA Sports Medicine Handbook.

4.4.7    Clothing. Coaches are responsible for purchasing and issuing to student-athletes cold-weather clothing that provides an internal layer that allows evaporation of sweat with minimal absorption, a middle layer that provides insulation, and a removable external layer that is wind and water resistant and allows for evaporation of moisture.

4.4.8    Warm-Up.  Coaches shall provide the opportunity for athletes to warm-up or re-warm, as needed, during and after activity using external heaters, a warm indoor environment, or the addition of clothing.

4.4.9    Emergency Supplies. The athletics department and certified athletic training staff will include the following supplies on the field, in the locker room, or at convenient aid stations for re-warming purposes:

  • A supply of water or sports drinks for rehydration purposes as well as warm fluids for possible re-warming purposes.
  • Heat packs, blankets, additional clothing, and external heaters, if feasible, for active re-warming.
  • Flexible low-reading rectal thermometer probe to assess core body temperature.
  • Telephone or two-way radio to communicate with additional medical personnel and to summon emergency medical transportation.
  • Tub, wading pool, or whirlpool for immersion warming treatments 

4.4.10    Notification of Health Centers.  The athletics training staff shall notify local hospital and emergency personnel before mass participation events (charity running or walking events, cross country meets, high attendance outdoor events) conducted in cold, high precipitation, or high wind/cool conditions to inform them of the event and the increased possibility of cold-related illnesses.

References:

--     Sports Management Resources with thanks to Bob Frederick for his assistance in the development of this policy