Preseason Football Collapse at 38°C

The immediate priority is recognizing exertional heat stroke and starting aggressive cooling before transport: cool first, transport second. The combination of rectal temperature above 40.5°C and CNS dysfunction (confusion, combativeness, incoherence) in a hot, humid environment meets the EHS definition. Move him to shade, remove pads and uniform, and place him in the cold-water tub with ice; maintain the airway and monitor breathing. Do not give oral fluids because he is altered and at aspiration risk. Do not rely on antipyretics or fan-only cooling; they are ineffective and delay definitive treatment. Assign one person to continuous rectal temperature and stop immersion at about 38.5-39°C to avoid overshoot. Check glucose if possible, provide oxygen if hypoxic, and have an AED ready. EMS should be called immediately, and cooling should continue during handoff. The locker-room-and-fan plan is dangerous because it delays cooling and increases the risk of multiorgan failure. The two earlier cramping cases should prompt a review of acclimatization and hydration practices, but they do not change this athlete's emergency management.

Heat exhaustion typically has a core temperature below 40°C, no persistent CNS dysfunction, and improvement with rest and oral fluids. EHS has core temperature above 40.5°C plus altered mental status; sweating may be present or absent, so dry skin is not required. Exercise-associated hyponatremia can mimic EHS with confusion, headache, nausea, seizures, or coma, but core temperature is usually normal or only mildly elevated, and there may be a history of excessive fluid intake, weight gain, or prolonged endurance exercise. Rectal temperature is essential; oral, tympanic, and axillary readings are unreliable in this setting. Point-of-care sodium would help if available, but treatment for suspected EHS should not wait. Do not assume hyponatremia and give fluids to an altered athlete with hyperthermia; that could worsen cerebral edema. Document serial vital signs and mental status. If temperature is above 40.5°C with CNS dysfunction, treat as EHS.

After discharge, there should be no same-day or next-day return. This athlete had a severe exertional heat illness; guidelines generally recommend no exercise for at least 2-4 weeks and physician clearance before training, with normalization of renal, hepatic, and coagulation labs and resolution of symptoms. Return should be graded over 2-4 weeks with heat acclimatization: short, low-intensity sessions in cooler parts of the day, progressive increases in duration and intensity, and close monitoring of weight, symptoms, and temperature. Avoid full pads and intense conditioning until fit. Screen for risk factors such as sickle cell trait, medications, sleep, hydration, prior heat illness, body composition, and motivation to push through symptoms. Education should cover pre-hydration, avoidance of overhydration, scheduled breaks, cooling resources, and an emergency action plan. The two earlier cramping cases suggest inadequate acclimatization; staff should review the camp heat policy and WBGT monitoring. Clearance should be written and shared with the team physician, not decided by the coach.