Editorial

Br J Sports Med: first published as 10.1136/bjsports-2020-102153 on 27 March 2020. Downloaded from http://bjsm.bmj.com/ on March 28, 2020 at Uni of Massachusetts NERL Consortia.
Translating evidence-­based practice to Determining when to stop
cooling

clinical practice in Tokyo 2020: how to In most literature and recommendations,

cooling rate is reported linearly, such as the
recommended minimum cooling rate of
diagnose and manage exertional 0.15°C min–1 for EHS treatment.2 However,
in real-­
life observations of patients with
heat stroke EHS during cooling, it is evident that
changes in TREC are non-­ linear and that
1 2 3 there are variabilities in patient response.
Yuri Hosokawa  ‍ ‍, Douglas J Casa, Sebastien Racinais  ‍ ‍ Figure 1 summarises TREC data of patients
with EHS (n=14) treated at the 2016 New
Balance Falmouth Road Race. The average
Elite athletes competing at high-­intensity on-­site, during transport and at cooling duration and rate were 13.5 min
in the hot and humid ambient conditions hospital. and 0.16°C min–1; however, the rate of
of the upcoming Games of the XXXII cooling became faster in the latter 2/3 of
Olympiad (Tokyo 2020) are likely to reach Be able to assess the cooling (figure 1A), which is a trend
elevated core temperature (‍≈‍41.5°C) as The first step of EHS management is that is commonly observed. In addition,
previously reported in elite competitions assessment of internal body tempera- the SD of cooling duration was 4.7 min,
in the heat and the risk of exertional heat ture.2 3 Currently, the only valid internal which shows a large variability in patient
stroke (EHS) is heightened.1 EHS is a body temperature assessment method that response (figure 1). Therefore, medical
medical condition defined as an internal can accurately diagnose EHS and practical providers must use direct measurement
body temperature exceeding 40.5°C with in prehospital setting is rectal temperature of TREC to confirm reduction of internal
central nervous system dysfunction (eg, (T ).2 3 Other methods of temperature body temperature below 39°C. Contrarily,
REC
disorientation, aggressiveness, hysteria, assessment (eg, tympanic, oral, axillary, there may be times when the patient pres-
delirium, altered consciousness, irrational temporal temperatures) have shown to be ents with unreasonably fast cooling rate
behaviour).2 3 (figure 1B), which would require medical
less reliable when used during or immedi-
Survival and sequela from EHS depend ately after exercise and in outdoor condi- providers to question the value and reassess

Protected by copyright.
on the duration of hyperthermia.4 In 2020, tion.7 The ability to accurately assess body the temperature. In such circumstances,
evidence-­based consensus suggests whole-­ temperature is also important in deter- it is important for medical providers to
body cooling until 39°C within the first mining the end point of EHS treatment acknowledge the average cooling curve and
30 min of collapse as the critical require- (ie, cooling). While an aggressive whole-­ time as a reference to make comprehensive
ment to maximise patient outcome.2 3 5 body cooling is warranted at the venue evaluation of the patient.
Whole-­body cold water immersion (CWI)
medical tent, medical providers must also Managing patient after cooling
was associated with 100% survival rate
take precautions to prevent patients from Once the cooling is completed, the patient
in 274 runners diagnosed with EHS over
experiencing hypothermia—afterdrop. in Tokyo should be removed from the ice
the 18 years of patients treated at the
New Balance Falmouth Road Race, with
average cooling rate of 0.22°C min–1.5 In
a different study, CWI using circulated
water controlled at 2°C demonstrated an
average cooling rate of 0.35°C min–1.6
To achieve the clinical target, medical
providers at Tokyo 2020 must:
1. provide on-­ site assessment of inter-
nal body temperature using rectal
thermometer,
2. provide whole-­body CWI at the venue
medical tent if it is needed,
3. be able to reduce internal body tem-
perature below 39°C prior to hospital
transport and
4. coordinate care by medical providers
who are involved in EHS management

1
Faculty of Sport Sciences, Waseda University,
Tokorozawa, Saitama, Japan
2
Korey Stringer Institute, Department of Kinesiology,
University of Connecticut, Storrs, Connecticut, USA
3
Aspetar Orthopaedic and Sports Medicine Hospital, Figure 1  Rectal temperature of patients with exertional heat stroke (n=14) during whole-­body
Doha, Qatar cold water immersion at the New Balance 2016 Falmouth Road Race. (A) Average cooling rate. (B)
Correspondence to Dr Yuri Hosokawa, Faculty of
Example cooling plot of a patient with measurement error (dislodged thermometer) during whole-­
Sport Sciences, Waseda University, Tokorozawa 2-579- body cold water immersion. (C) Example cooling plot of a patient who experienced afterdrop
15, Japan; ​yurihosokawa@​waseda.j​ p postcooling.

Hosokawa Y, et al. Br J Sports Med Month 2020 Vol 0 No 0    1

 Editorial
bath and should have the TREC monitored
for at least another 15 min. This is to ensure
that the patient will regain their ability to
thermoregulate and not experience after-
drop from whole-­body CWI (figure 1C).
Although the frequency of EHS cases with
afterdrop is difficult to estimate, Tokyo
2020 medical providers should anticipate
such cases and have a plan to the coordi-
nate care on-­site, during transport and at
hospital. Venue medical guideline must
explain when to transport the patient
from one section to another and establish
the EHS management sequence: (1) recog-
nise (ie, transporting patient to medical
tent), (2) assess (ie, taking TREC), (3) treat
(ie, whole-­ body CWI and monitor TREC
continuously), (4) monitor recovery (ie,
continuous TREC monitoring), (5) trans-
port (ie, discharging athlete from on-­site
medical tent and transporting to advanced
care) and (6) follow-­up examination (ie,
physical examination at hospital).
Conclusion
While the basic principle of EHS manage-
ment is simple (cool first, transport
second), preparing for real-­ life scenario
during an Olympic event required inten-
sive practice by local medical providers
and this will ensure that the roles of each
2 Hosokawa Y, et al. Br J Sports Med Month 2020 Vol 0 No 0
medical provider are clearly defined.8 We
recommended that medical directors of
athletic events have a written manual to
illustrate current best practice and that
they conduct at least one face-­ to-­
face
hands-­ on training session at assigned
venues to go over the four key elements of
EHS management.
Twitter Sebastien Racinais @ephysiol
Contributors  All authors contributed to the
conception of the work. YH contributed to the
acquisition, analysis and interpretation of data
presented in the manuscript. All authors contributed in
drafting or revising the manuscript and approval of final
version to be published.
Funding  The authors have not declared a specific
grant for this research from any funding agency in the
public, commercial or not-­for-­profit sectors.
Competing interests  YH, DJC and SR have a
potential COI as members of the IOC Adverse Weather
Impact expert working Group for the Olympic Games
Tokyo 2020; not receiving honorarium.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned;
externally peer reviewed.
© Author(s) (or their employer(s)) 2020. No commercial
re-­use. See rights and permissions. Published by BMJ.
To cite Hosokawa Y, Casa DJ, Racinais S.
Br J Sports Med Epub ahead of print: [please include
Day Month Year]. doi:10.1136/bjsports-2020-102153
Br J Sports Med: first published as 10.1136/bjsports-2020-102153 on 27 March 2020. Downloaded from http://bjsm.bmj.com/ on March 28, 2020 at Uni of Massachusetts NERL Consortia.
Accepted 12 March 2020
Br J Sports Med 2020;0:1–2.
doi:10.1136/bjsports-2020-102153
ORCID iDs
Yuri Hosokawa http://​orcid.​org/​0000-​0001-​9138-​5361
Sebastien Racinais http://​orcid.​org/​0000-​0003-​0348-​
4744
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