Annex C - TRADOC Heat Illness Prevention For Leaders - 2021

U.
S Army Training and Doctrine Command
Heat Illness Prevention for Leaders

2021
Victory Starts Here!

CUI 1
Objective
OBJECTIVE
Commanders and supervisors at all levels are

responsible for protecting Soldiers and civilian
personnel from the adverse effects of heat, and
for ensuring subordinate leaders are trained in
recognition and treatment of heat illness.

CUI 2
Senior
Senior Leaders
Leaders
• Ensure medical support and evacuation plans are tested at

least annually per TRADOC Regulation (TR) 350-6, para 3-9.c.
• Establish coordination between the military medical treatment

facility and training organizations for assistance.
• Report heat injuries IAW TR 1-8, Operations and Reporting.
• Ensure appropriate hot weather protective items (sunscreen,

arm immersion cooling systems) are available to Soldiers.

CUI 3
Unit
Unit Leaders
Leaders
• Continue precautionary measures to prevent or reduce the

spread of coronavirus disease (COVID-19) infection.
• Employ field sanitation measures to monitor conditions of heat

and advise on risk factors.
• Modify uniforms based on senior leader guidance and local

conditions.
• Ensure potable water, ice, and supplemental snacks and

beverages are available to Soldiers.
• Identify and mark prior hot weather injury and high-risk

Soldiers (e.g., “550” cords).
CUI 4
Unit Leaders
Unit Leaders (cont.)
(cont.)
• Monitor conditions of heat on • Ensure Soldiers drink

the training site. sufficient but not excessive
• Recommend modifications for amounts of fluids and eat
scheduling, location, and adequate calories.
uniform to senior leadership. • Ensure Soldiers maintain their
• Plan for alternate activities supply of sunscreen and
and locations for conditions of apply it daily.
extreme heat. • Develop and enforce
• Be prepared to apply iced work/rest cycles and sleep
sheets in case of heat illness. plans during extended training
• Be prepared to treat and hours.
evacuate Soldiers with signs • Remind Soldiers to observe
of heat illness. their buddies for signs of heat
illness.

CUI 5
Unit
UnitLeaders (cont.)
Leaders (cont.)
Marking Soldiers with Prior Heat Illnesses
Remember – Heat stress is

cumulative. Soldiers who have been
subjected to category (CAT) 4 and/or
CAT 5 conditions for 2-3
consecutive days are at increased
risk for a heat illness on the
subsequent day.
“550” Cord
Boot lace
Prior heat illness
Prior heat illness

CUI 6
Unit
UnitLeaders (cont.)
Leaders (cont.)
• Plan for no more than 12 quarts of water per day per Soldier just for
drinking.
• Certain conditions justify the use of a carbohydrate-electrolyte

beverage. These conditions include:
- Continuous physical activity for periods beyond 3 hours

- Poor nutritional intake or calories deficit of 1,000 or more
per day
- High sweat loss and inadequate electrolyte replacement
- CDR discretion based upon anticipated high-intensity activity
• Reevaluate the training mission if two or more heat illnesses occur at

a given training site on the same day.

CUI 7
Basics
BasicsofofHeat
Heat Illness Risk
Illness Risk
The Hazard
Exposure to high environmental temperature produces heat

stress in the body. As the body attempts to compensate,
physiological strain, or heat load results.
This strain, usually in combination with other strains caused

by work, dehydration, and fatigue may lead to heat illness.
Temperature, humidity, and wind conditions affect the body
and its ability to adjust to heat.

CUI 8
Basics
Basics
of of
Heat
HeatIllness
Illness Risk
Risk (cont.)
(cont.)
The Defense
The body normal rids itself of heat through the skin and by
exhaled breath, constituting heat relief. Some heat radiates
from the skin, but the body relies mostly on evaporation of
sweat from the skin to cool.
The adverse impact of high environmental temperature can

be reduced by drinking enough water, wearing clothing
properly, maintaining a high level of fitness, and resting after
exposure to heat. These measures contribute to the body’s
normal mechanisms for relieving its heat load.

CUI 9
Basics
Basics
ofof
Heat
HeatIllness
Illness Risk
Risk(cont.)
(cont.)
Acclimatization
Most Soldiers’ physiological responses to heat stress

improve in 10-14 days of exposure to heat and regular
strenuous exercise. Factors to consider in acclimatizing
Soldiers are the wet bulb globe temperature (WBGT) index,
work/rest ratio, uniform and equipment, and Soldiers’
physical and mental conditions.

CUI 10
Identify
Identifythe
theHazards
Hazards
• Not acclimated • Minor illness (cold) or injured

• Previous heat injury • Medications (prescribed or over-
• Poor fitness the-counter)
• Overweight • Skin disorder such as rash or
• Alcohol or nicotine use sunburn
• Lack of quality sleep • Age (above 40)

CUI 11
FOUO
Identify thethe
Identify Hazards
Hazards(cont.)
(cont.)
Medications that Interfere with Heat Regulation

 Antihistamines (Benadryl, Zyrtec, Claritin)
 Decongestants (Sudafed)
 High blood pressure medications (diuretics, beta blockers)
 Psychiatric medications (tricyclic antidepressants, antipsychotics)

CUI 12
Assess the
Assess theHazards (cont.)
Hazards (cont.)

CUI 13
Assess thethe
Assess Hazards
Hazards(cont.)
(cont.)

CUI 14
Assess the the
Assess Hazards (cont.)
Hazards
Heat illnesses can occur under green flag temperature conditions
due to previous days’ conditions and/or dehydration.
Frequency of Heat Illness Cases
Heat illnesses are a year-round problem, with varying severity depending on the
installation; approximately 17% of all heat illnesses occur outside of the heat season.
CUI 15
Assess
Assess the the Hazards
Hazards (cont.)
High heat category, especially on several sequential days

(measure WBGT when ambient temperature is over 75 ºF.)
Exertional level of training, especially on several sequential

days (last 72 hours must be considered.)
Acclimatization
Time (length of heat exposure and recovery time)

CUI 16
Supervise
Supervise and
and Evaluate
Evaluate
Proper Nutrition Measures

• A proper nutrition plan is essential for eating and hydrating before, during,
and after physical training to assist in mitigating and/or reducing heat
illnesses.
• Pre-activity: Always eat prior to any physical activity.
- Eat snacks or small meals 2-4 hours before exercise.
- Drink water (32-48 ounces) approximately 2-3 hours prior to exercise.
Drink another 4 to 8 ounces of water right before starting activity.
- For early morning exercise workouts: drink 8-16 ounces of sports
beverage; eat fruit, toast, or other light snacks.

• During activity:
- Drink water, as needed, for physical activity less than an hour.
- Consume 10-20 grams of carbohydrates (e.g., fruit, gel, energy bars) at
the 20-minute mark for physical activity 60 minutes or more.
CUI 17
Develop
DevelopControls
Controls
Deliberate Risk Assessment

Worksheet
Heat Illness Prevention
• Department of Defense (DD) Form 2977
• Should be filled out completely prior to
each training event.
• Should be developed specifically for
each training site.
• Should not be a template document use
to “check” the block”.
• Include factors from the example as an
additional objective measure of risk.
Risk Management is never complete. It is a continuing cycle.

CUI 18
FOUO
Develop Controls (cont.)
Arm Immersion Cooling System (AICS)

Extremity immersion in cold water is an effective body cooling method
Water Temperature (Degrees) Immersion Time (Minutes)
o Replace Water
>80 F
o 12-15
71-80 F
o 8-12
55-70 F
o 5-8
45-54 F
o 3-5
35-44 F

CUI 19
FOUO

(AICS) Heat Mitigation in COVID-19 Environment
• Sustain use of AICS for high-risk trainees & students during physically
demanding events
• Ensure all remove uniform top before submerging forearms
• Limit number to one (1) trainee/student per AICS & maintain social
distancing (6 ft) while waiting to use the AICS
• Fill AICS container with 10 gallons of fresh potable water, cubed ice, & one
(1) capful of household bleach (skin-safe concentration) daily/prior to
training
• Maintain safe water temperature & minimum/maximum use times
• Refill AICS with 10 gallons of fresh potable water, ice, & one (1) capful of
household bleach every three (3) hours during the training day
• ENVIRONMENTAL SAFETY NOTE: Do not discharge used water in storm

drains or ditches

CUI 20
FOUO
Develop Controls
(cont.)
Sports Drink
Water Coolers
Buffalo Shade
Cover
COOL ZONE
AICS
Misting Fan

CUI 21
Develop Controls
Types of (cont.)
Heat Injuries
• Heat Exhaustion
• Heat Stroke *
• Hyponatremia *
• Rhabdomyolysis
• Exertional Collapse Associated with Sickle Cell Trait *
* Medical Emergency

CUI 22
Heat Exhaustion
Cause First Aid

• Loss of body fluids through sweating • Loosen uniform and remove head gear.
without adequate fluid replacement.
• Can occur in fit Soldiers involved in • Place in the shade and have casualty
physical exertion in any hot drink no more than 1-1/2 quarts of water
environment. per hour.
Symptoms • Evacuate if symptoms worsen or do not

• Excessive sweating with pale, improve after rest and
moist, cool skin; headache; rehydration.
• Weakness; dizziness; loss of
appetite; cramping; • All heat casualties require constant
• Nausea (with or without vomiting). monitoring.

CUI 23
Heat Stroke
Heat Stroke
Cause First Aid
• Exposure to high temperatures or
dressed in protective over garments, • COOL and CALL!!
causing the body temperature to rise.
-Strip (if possible, ensure a
• Failure of the body’s cooling same-gender helper is present)
mechanism, including a decrease in -Rapid cool (iced sheets)
the body’s ability to produce sweat. -Call for evacuation
• Continue cooling during transport.

Symptoms
• Confusion, weakness, dizziness, • Maintain same person to observe for
headaches, seizures, nausea, mental status changes or for worsening
stomach pains or cramps. condition.
• Respiration and pulse may be rapid
and weak.
• Unconsciousness and collapse may
Medical Emergency
occur suddenly. The casualty may Evacuate Immediately
stop sweating.

CUI 24
Heat Stroke
Heat Stroke(cont.)
(cont.)
Assessment
Perform Mental Status Check
- What is your name?

- What month is it? What year is it?
- Where are you?
- What were you doing before you became ill?
Anyone who experiences changes in mental status, including

loss of consciousness, as a result of exertion during warm
weather will be assumed to be a heat stroke victim until
determined otherwise by medical authority.
Mental status changes are more important than the Soldier’s temperature when
deciding on the treatment of heat illnesses.
CUI 25
Hyponatremia
Cause First Aid
• Occurs when the level of sodium (salt) in • Don’t give more water. If awake, allow casualty
blood is abnormally low. to consume salty food/snacks.
• Too much water during exertional • Evacuate immediately.
activities causes sodium in the body to • EMS personnel can perform testing for
become diluted. hyponatremia using point-of-care blood analyzer
• Exceeding more than (1 quart per hour • All heat casualties require constant monitoring.
water during work-rest, or 1-1/2 quarts
per hour water during continuous work,
or maximum 12 quarts of water per day).
• This condition can be mistaken for heat
stroke.
Symptoms
• Headache
• Mental status change
•
Medical Emergency
Repeated vomiting
• Abdomen distended/bloated Evacuate Immediately
• Rings and watches “too tight”

CUI 26
Hyponatremia (cont.)
Recognize Hyponatremia
Important questions to ask Soldiers displaying signs of heat illness:
1 - How much did you drink today?

2 - How often are you urinating?
3 - What color is your urine?
4 - What/how much did you eat today?
Risk factors for hyponatremia include:
• Excessive amount of fluid intake (compared to guidelines)

• Urinating more than every 1-2 hours
• Clear colored urine
• Poor eating/decreased consumption of meals
Hyponatremia is a medical emergency.

Evacuate immediately if you suspect a Soldier has hyponatremia.

CUI 27
Rhabdomyolysis
Rhabdomyolysis
Cause First Aid
• Exercise-induced muscle pain • Have casualty rest, and continue to drink
• Overexertion where there is a water (no more than 1-1/2 quarts per
breakdown of muscle fibers resulting hour).
in the release of muscle fiber • Seek medical attention.
contents into the bloodstream.
Symptoms Prolonged or severe muscle pain

• Severe or prolonged muscle pain in that does not rapidly improve,
during and after exertion especially coupled with dark urine,
• Muscle weakness, stiffness, or requires medical attention and
abnormal firmness laboratory testing to diagnose.
• Abnormal urine color (red, dark
brown, or tea-colored) Rhabdomyolysis can lead to kidney
damage.

CUI 28
Exertional Collapse Associated with
SickleRhabdomyolysis
Cell Trait (ECAST)
Cause First Aid
• Sickle Cell Trait is an inherited blood • COOL and CALL!!
disorder
• Associated exertion risk with people -Strip (if possible, ensure a same-gender
who have SCT helper is present)
-Rapid cool (iced sheets)
-Call for evacuation
Symptoms -Give oxygen if available
• Severe or prolonged muscle pain in
during and after exertion • Continue cooling during transport.
• Loss of coordination, evolving in
awkward running, posture and gait • Maintain same person to observe for
• Legs may look wooden or wobbly mental status changes or for worsening
• Complaints of weakness, pain, and condition.
cramping
• Shortness of breath
• Progression to mental confusion and Medical Emergency
unconsciousness Evacuate Immediately
• Conscious collapse

CUI 29
Summary of Heat Casualty Treatment
Heat Exhaustion versus Heat Stroke Management
HEAT EXHAUSTION HEAT STROKE
• Rest Soldier in shade • If Soldier’s brain isn’t working

correctly then COOL and CALL!!
• Loosen uniform and remove head
gear
- Strip (modesty)
• Have Soldier drink no more than
- Rapid cool (ice sheets)
1.5-1/2 quarts of water over 1 hour
- Call for evacuation
• Evacuate if no improvement or if
Soldier’s condition worsens
• Continue cooling during transport
• Maintain same person to observe
for mental status changes or for • Maintain same person to observe
worsening conditions for mental status changes or for
worsening conditions

CUI 30
Heat IllnessTreatment
Heat Illness Treatment
Remember "M.A.D.E.ininthe
Remember "M.A.D.E. the Shade”
Shade”
• MOVE victim to cool location (i.e., shade, air conditioning in vehicle, building)
• ASSESS victim to determine type of heat illness

- Signs/symptoms
- Method (e.g., 550 cord) to check for hyponatremia/over hydration
- Identify risk level (e.g., colored beads for risk factors)
- Mental status (for heat stroke)
- Designate single person to continue monitoring. It is critical that a specific
person is assigned to STAY with victim and continuously monitor all changes
including mental status. Even the slightest changes that can occur in minutes
may not be noticed if different personnel are checking victim. These slight
changes can be critical in ensuring the best outcome for the victim.
• DECIDE and take proper management approach

- Heat Stroke: begin rapid cooling, evacuate immediately
- Hyponatremia: evacuate immediately, discontinue fluid intake
- Heat Exhaustion: rest in shade, rehydrate
- ECAST: begin rapid cooling, evacuate immediately, give oxygen if available
• EVALUATE other Soldiers and adjust training as necessary

CUI 31
FOUO
Heat Stroke Treatment
Iced Sheets
• Medical treatment for a life-threatening condition.
• Provide iced sheets in accordance with risk assessment and local guidance.
• Optimum use of iced sheets involves covering as much exposed skin as
possible.
• Maintain privacy:
• Move uninvolved personnel away from treatment site
• Use same gender cadre and gender medics when available
• Have the same gender battle buddy serve as a “chaperone”
• If there are privacy concerns, not removing the undershirt is acceptable
• Discontinue iced sheets if the casualty is shivering.
• Evacuate any Soldier who requires cooling with iced sheets to the nearest
emergency room via Emergency Medical Service (EMS).
• Appropriately document response and care in Serious Incident Report (SIR).

CUI 32
Heat Stroke
Heat StrokeTreatment (Cont.)
Treatment (Cont.)
• Prepare iced sheets by placing ordinary bed sheets in iced water.
- Keep iced water ready in cooler-type ice chests.
- Have sheet readily available, either soaking in iced water or in re-sealable
plastic bags.
- Cover as much exposed skin as possible with the ice cold sheets.
- Also cover the top of the head.
- Replace sheets every 3 minutes. Put back into cooler and then reapply.
- When needed, immerse sheet in iced water and ensure it is saturated;
this should be done as Soldier's outer clothing is being removed.
Placement of
Mental status changes are more
Iced Sheets important than the Soldier’s
temperature when deciding on the
treatment of heat illnesses

CUI 33
Heat
HeatStroke
Stroke Treatment (Cont.)
Treatment (Cont.)

CUI 34
FOUO
Heat
HeatStroke
StrokeTreatment
Treatment(Cont.)
(Cont.)
Commercial Ice Packs and Ice Sheets
 Treats individuals suffering from suspected heat-related injury/illness such

as heat stroke or heat exhaustion.
 Combines widely used conduction and evaporative cooling protocols into a

single, self-contained, cost effective,
and easy to use system.
 Eliminates maintenance and replacement costs

associated with mold, mildew, or environmental
contamination of regular sheets.
 Lightweight characteristics allows for easy

transport in remote locations.

CUI 35
Heat Illness
Heat IllnessIncident
Incident Reporting
Reporting
• Report heat illness incidents (i.e., heat exhaustion, stroke, injury, or
hyponatremia). See TRADOC Reg 1-8 (U.S. Army Training and Doctrine
Command Operations Reporting), para 2-2d(3).
• Coordinate with Military Treatment Facility (MTF) and Safety Office (i.e., DA Form
285-AB, Accident Report) to ensure accurate and complete reporting of the case,
if medical intervention is required, or there is a loss of duty time.
• Complete accurately and prompt (within 72 hours) to document the nature,

magnitude, and distribution of health threats. Ensure the WBGT is recorded in the
SIR (see TRADOC Reg 1-8, para B-2, item 26 (Weather Conditions)).
• MTF Preventive Medicine Staff will use the Disease Reportable System Internet
(DRSi) to record heat injury cases that meet medical reporting guidelines (differs
from Safety reporting guidelines). Data collected can assist in assessing trends
over time.

CUI 36
Resources
Resources
Army Regulation 40-25, Nutrition Standards and Education
https://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/AR40-25_WEB_Final.pdf
TRADOC Reg 1-8, U.S. Army Training and Doctrine Command Operations Reporting
http://adminpubs.tradoc.army.mil/regulations/TR1-8.pdf
TRADOC Reg 350-29, Prevention of Heat and Cold Casualties

TRADOC Reg 350-6, Enlisted Initial Entry Training Policies and Administration
TRADOC Reg 350-29, Basic Officer Leader Training Policies and Administration
TRADOC Surgeon’s Office Heat Illness Prevention Training Products

https://www.milsuite.mil/book/groups/tradoc-environmental-health-protection
Army Safety Center https://safety.army.mil/HOME.aspx
Army Techniques Publication (ATP) 5-19, Risk Management

https://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/atp5_19.pdf
Army Public Health Center (APHC) Heat Injury Training Products

https://phc.amedd.army.mil/topics/discond/hipss/Pages/Heat-Related-Illness-Prevention.aspx

CUI 37

Annex C - TRADOC Heat Illness Prevention For Leaders - 2021

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U.

S Army Training and Doctrine Command

Heat Illness Prevention for Leaders

Victory Starts Here!

Commanders and supervisors at all levels are

Victory Starts Here!

• Ensure medical support and evacuation plans are tested at

• Establish coordination between the military medical treatment

• Report heat injuries IAW TR 1-8, Operations and Reporting.

• Ensure appropriate hot weather protective items (sunscreen,

Victory Starts Here!

• Continue precautionary measures to prevent or reduce the

• Employ field sanitation measures to monitor conditions of heat

• Modify uniforms based on senior leader guidance and local

• Ensure potable water, ice, and supplemental snacks and

• Identify and mark prior hot weather injury and high-risk

• Monitor conditions of heat on • Ensure Soldiers drink

Victory Starts Here!

Marking Soldiers with Prior Heat Illnesses

Remember – Heat stress is

Victory Starts Here!

• Certain conditions justify the use of a carbohydrate-electrolyte

- Continuous physical activity for periods beyond 3 hours

• Reevaluate the training mission if two or more heat illnesses occur at

Victory Starts Here!

Exposure to high environmental temperature produces heat

This strain, usually in combination with other strains caused

Victory Starts Here!

The adverse impact of high environmental temperature can

Victory Starts Here!

Most Soldiers’ physiological responses to heat stress

Victory Starts Here!

• Not acclimated • Minor illness (cold) or injured

Victory Starts Here!

Medications that Interfere with Heat Regulation

Victory Starts Here!

Victory Starts Here!

Victory Starts Here!

High heat category, especially on several sequential days

Exertional level of training, especially on several sequential

Time (length of heat exposure and recovery time)

Victory Starts Here!

Proper Nutrition Measures

beverage; eat fruit, toast, or other light snacks.

Deliberate Risk Assessment

Risk Management is never complete. It is a continuing cycle.

Develop Controls (cont.)

Arm Immersion Cooling System (AICS)

Victory Starts Here!

Develop Controls (cont.)

• Ensure all remove uniform top before submerging forearms

• Maintain safe water temperature & minimum/maximum use times

• ENVIRONMENTAL SAFETY NOTE: Do not discharge used water in storm

Victory Starts Here!

Victory Starts Here!

Victory Starts Here!

Cause First Aid

Symptoms • Evacuate if symptoms worsen or do not

Victory Starts Here!

• Continue cooling during transport.

Victory Starts Here!

- What is your name?