Collapse During a Double Session: Cool First or Wait for EMS?
It is 2:15 pm in mid-August with a WBGT of 32°C (90°F) during the second session of a double-day football practice. A 17-year-old lineman in full pads collapses during a conditioning drill. He is confused and combative, cannot answer simple questions, and was lucid 10 minutes ago. Rectal temperature on the field is 41.1°C (106°F). HR 150, BP 100/60, skin hot and dry, and he has vomited once. EMS was called 4 minutes ago and is 8 minutes out. A cold-water immersion tub, ice, the team physician, and the athletic trainer are on site. The athletic trainer asks whether to start immersion now or wait for EMS to arrive.
1. State the diagnosis and the immediate priority, and justify the sequence of actions.
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Exertional heat stroke - core temperature above 40.5°C with central nervous system dysfunction in a setting of exertion. The CNS change is what separates this from heat exhaustion, and it is present.
Priority: cool first, transport second. Start cold-water immersion immediately; do not wait eight minutes for EMS.
Reasoning: survival and organ injury track the magnitude and duration of hyperthermia, not the speed of arrival at the hospital. Cooling rate with cold-water immersion is several times faster than with ice packs, fans, or cold IV fluids, and the target is to bring core temperature below roughly 39°C within about 30 minutes. Waiting for EMS converts a survivable emergency into a potentially fatal one.
Sequence: move to shade, remove pads and equipment, immerse in ice water with the head controlled, and assign one person to continuous rectal temperature. Brief EMS on arrival, have them continue cooling in the ambulance, and transport with cooling ongoing. Do not give antipyretics - this is not a hypothalamic set-point fever - and dantrolene is not indicated. Stop active cooling at about 38.5–39°C to avoid overshoot.
2. What complications do you anticipate, and what must be done before and during transport?
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Anticipated complications: rhabdomyolysis with acute kidney injury, hepatic injury, disseminated intravascular coagulation, ARDS, seizures, altered mental status, hypotension and arrhythmia, hypoglycemia, and electrolyte derangement including hyponatremia, hypernatremia, and hypocalcemia. Myocardial injury occurs and can be masked by the athlete's age and fitness.
Before transport: airway and aspiration precautions given the vomiting, supplemental oxygen, IV access with isotonic fluid for hypotension, point-of-care glucose, cardiac monitoring, and continuous rectal temperature. Ensure the cooling continues during transfer - do not stop for packaging or procedures, and do not stop cooling just because the ambulance arrives.
Information to hand over: time of collapse, time immersion began, temperature trajectory with times, treatments given, and the fact that this is exertional heat stroke with suspected rhabdomyolysis.
On arrival the ED should be told explicitly to check CK, renal function, coagulation studies, and liver enzymes, and to monitor urine output once the patient is stabilized.
3. He is discharged after three days with normal labs. When can he return to play, and what programmatic changes should follow?
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Return to play: no exercise for at least two to four weeks, longer if any organ dysfunction persists, and a graded return over two to four weeks in a cool environment before any return to heat. He needs a formal heat-acclimatization period of 10–14 days before full pads in heat, and he should be reassessed for predisposing factors: sickle cell trait, medications (stimulants, ADHD medications, diuretics), recent illness, sleep debt, dehydration, high BMI, and prior heat illness.
Programmatic changes are the real intervention:
- Move August practices earlier or later; WBGT-based modification and cancellation thresholds.
- Acclimatize over two weeks before full equipment; progressive equipment introduction.
- Mandatory water breaks and unrestricted fluid access; individual hydration monitoring with pre- and post-practice weights.
- A cold-water immersion tub on site at every hot-weather session, with rehearsed emergency action plan and designated cooling roles.
- Educate coaches and athletes about early signs and the 'cool first' principle, and review whether the conditioning drill itself was appropriate at that WBGT.
Document the event so next season's staff inherits the plan rather than the same conditions.