NATA Position Statement Review Part 10: Exertional Heat Illness

As temperatures rise and preseason practices begin, athletic trainers are on the front lines of preventing, recognizing, and managing exertional heat illnesses (EHIs). While heat-related emergencies have been studied extensively, exertional heat stroke remains one of the leading causes of sudden death in sport. When recognized quickly and treated appropriately, survival rates can approach 100%.

The National Athletic Trainers’ Association (NATA) Position Statement on Exertional Heat Illnesses provides a comprehensive framework for prevention, emergency management, and return-to-play decision-making. Here are the key clinical takeaways every athletic trainer should know.

Understanding the Spectrum of Exertional Heat Illness

Not all heat illnesses are created equal. The position statement emphasizes the importance of differentiating between the various forms of EHI because treatment strategies differ significantly.

Exercise-Associated Muscle Cramps (EAMCs)

These painful, involuntary muscle contractions often occur during or after exercise. Despite the common term “heat cramps,” they are not directly caused by elevated body temperature.

Common signs include:

• Visible muscle cramping
• Localized pain
• Fatigue
• Heavy sweating
• Dehydration

Treatment typically includes:

• Rest
• Passive stretching
• Sodium-containing fluids or foods when appropriate
• Addressing underlying risk factors

Heat Syncope

Heat syncope is essentially a fainting episode caused by temporary reductions in blood flow to the brain.

Athletes may experience:

• Dizziness
• Tunnel vision
• Pale skin
• Brief loss of consciousness
• Low blood pressure

Management focuses on:

• Moving the athlete to a shaded area
• Elevating the legs
• Monitoring vital signs
• Rehydration

Heat Exhaustion

Heat exhaustion represents a more serious condition characterized by cardiovascular strain and an inability to continue exercising effectively.

Signs and symptoms often include:

• Excessive fatigue
• Weakness
• Dizziness
• Headache
• Nausea or vomiting
• Lightheadedness
• Impaired coordination

A critical point from the position statement is that athletes with heat exhaustion generally have a core temperature below 105°F (40.5°C) and do not exhibit severe central nervous system dysfunction.

Exertional Heat Stroke (EHS)

This is the emergency athletic trainers must be prepared to identify and treat immediately.

According to the NATA statement, two findings define exertional heat stroke:

1. Central nervous system dysfunction
2. Core body temperature greater than 105°F (40.5°C)

Athletes may present with:

• Confusion
• Irritability
• Aggressive behavior
• Loss of consciousness
• Seizures
• Disorientation
• Collapse

The statement repeatedly emphasizes that EHS is a medical emergency requiring immediate action.

The Most Important Clinical Pearl: Cool First, Transport Second

If there is one takeaway every athletic trainer should remember, it is this:

Cool first, transport second.

Research cited in the position statement demonstrates that rapid cooling dramatically reduces morbidity and mortality. The goal is to reduce core body temperature below 102°F (38.9°C) within 30 minutes of collapse.

Cold-water immersion remains the gold standard treatment.

The recommended protocol includes:

• Immediate full-body immersion
• Water temperatures between approximately 35°F and 59°F
• Continuous stirring of the water
• Ongoing temperature monitoring
• Removal from immersion once rectal temperature reaches 102°F

For athletic trainers, this means having a cooling tub, water source, ice, and a practiced emergency action plan readily available before an emergency occurs.

Why Rectal Temperature Matters

One of the strongest recommendations in the position statement is the use of rectal thermometry for suspected exertional heat stroke.

The authors clearly state that rectal temperature is the clinical gold standard for measuring core body temperature in exercising athletes. Oral, tympanic, temporal artery, and forehead devices are not considered valid for diagnosing EHS in the field.

This recommendation remains one of the most important, and sometimes most challenging, practice changes for athletic trainers.

Practical considerations include:

• Educating administrators and coaches before the season
• Discussing procedures with parents and athletes
• Including rectal thermometry in emergency action plans
• Maintaining competency through training and rehearsal

Prevention Starts Long Before the Emergency

While emergency management often receives the most attention, the position statement strongly emphasizes prevention.

Heat Acclimatization

Gradual heat acclimatization over 7 to 14 days is one of the most effective strategies for reducing heat illness risk.

Athletic trainers should advocate for:

• Progressive increases in exercise duration and intensity
• Gradual equipment introduction
• Modified practice schedules during preseason
• Appropriate work-to-rest ratios

Hydration Monitoring

The statement recommends preventing body mass losses greater than 2% during activity. Strategies include:

• Pre- and post-practice weigh-ins
• Monitoring urine color
• Providing unrestricted fluid access
• Encouraging sodium replacement when appropriate

Identifying High-Risk Athletes

Athletic trainers should pay close attention to athletes who have:

• A previous history of heat illness
• Poor physical conditioning
• High body mass index
• Recent illness or fever
• Sleep deprivation
• Certain medication or supplement use
• Inadequate heat acclimatization

These athletes may require additional monitoring during high-risk environmental conditions.

Applying the Position Statement in Clinical Practice

The best athletic trainers don’t simply memorize guidelines—they build systems around them.

Consider evaluating your current program with these questions:

Do We Have the Right Equipment?

You should have:

• A rectal thermometer
• Cold-water immersion tub
• Adequate ice supply
• Emergency communication systems
• Environmental monitoring equipment

Do We Have a Rehearsed Emergency Action Plan?

Every member of the care team should know:

• Who recognizes the emergency
• Who obtains temperature
• Who initiates cooling
• Who activates EMS
• Who documents the incident

Are Coaches Educated?

Coaches should understand:

• Early warning signs
• Heat acclimatization principles
• Environmental modifications
• The importance of reporting symptoms immediately

Are We Monitoring Environmental Conditions?

The position statement supports using Wet-Bulb Globe Temperature (WBGT) measurements to guide activity modifications and scheduling decisions.

The NATA Position Statement on Exertional Heat Illnesses reinforces a simple but powerful message: exertional heat stroke is survivable when athletic trainers are prepared.

The combination of heat acclimatization, hydration monitoring, environmental awareness, rectal thermometry, and rapid cold-water immersion has transformed outcomes for athletes experiencing heat emergencies. Athletic trainers who build these evidence-based practices into their daily operations can dramatically reduce risk while improving athlete safety.

When it comes to exertional heat stroke, preparation before the emergency often determines the outcome during the emergency. The athletic trainer’s ability to recognize, assess, and intervene quickly remains one of the most important factors in protecting athletes from catastrophic heat illness.

Casa DJ, DeMartini JK, Bergeron MF, et al. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. J Athl Train. 2015;50(9):986-1000. doi:10.4085/1062-6050-50.9.07