1. AHSAA Medical Advisory Committee Update 2018
James B. Robinson, M. D.
Head Team Physician- University of Alabama
Co-Chairman- AHSAA Medical Advisory Committee

2. Important Updates Concussion Heat Illness PPE EAP AEDs Lightning
Telemedicine

3. Concussion
Make sure all of your coaches have taken the on-line training course
Know the signs and symptoms of a concussion
Never let an athlete return to practice or game on the same day as injury occurred
“When in doubt, sit them out”
Only a licensed MD or DO can clear an athlete for return to play

4. AHSAA Concussion Resources
Mandatory Training for ALL coaches
Links to NFHS on-line learning via web-site
Instructional presentations on web-site

5. Heat Illness

6. Heat Related Deaths Heat related deaths are declining
3 deaths in 2017 (2 High School)
3rd most common cause of death in High School athletes
Usually occurs in first 4 days of practice (90%)
Death from Exertional Heat Stroke is completely preventable!

7. EXERTIONAL HEAT STROKE
Elevated core temperature ( >104 degrees) associated with signs of organ system failure due to hyperthermia.
Total body collapse due to thermoregulatory failure
Life threatening!
Mortality rates are directly related to time before cooling and length of time core temperature elevated.

8. EXERTIONAL HEAT STROKE Signs and Symptoms
Coma ~ 70%
Acute renal failure
Mortality ~ 80%
Temperature >104 rectal
Fast heart rate
Low blood pressure
Sweating
Rapid breathing
Altered mental status
Vomiting
Diarrhea
Seizures

9. EXERTIONAL HEAT STROKE Treatment
Measure rectal temperature
Lower temperature as rapidly as possible!!
Place in a tub of ice water, remove when temp <102°F
(0 fatalities if cooled within 10 minutes)
If no ice tubs, place iced towels over entire body and replace every 2-3 minutes
Ice chest with 6 towels, water, and ice
911- to Emergency Room only after cooled!

10. Cool First – Transport Second!!
“…no one should die if proper, prompt, and aggressive care begins within 10 minutes of collapse.”
Alamama is the first state to enact a state-wide
policy of “cool first, transport second

11. when cooling initiated within 10 minutes
Survival Time
100% survival rate
when cooling initiated
within 10 minutes

12. HEAT ILLNESS Prevention
Emergency Plan
Nearest Emergency facility,
transportation, communications, cool tub,
rectal thermometer
Pre-participation physical exam - identify
previous heat related problems
Adequate acclimatization = days
Educate - athletes, coaches, parents
Well balanced diet, adequate sleep, avoiding drugs and alcohol

13. ACCLIMATIZATION
Physiologic process by which an individual becomes able to tolerate work in a hot environment.
Becoming “Thermal efficient”
Usually takes days - maximum acclimatization takes 3 months.
Fluid and salt increase heat acclimatization.
Exposure to hot environment for minutes/day

14. AHSAA Acclimatization Rule Section 18
The first day of Fall practice is Monday, August 6, The first three days of fall football practice must be in shorts. These three days are designed for coaches to determine if the students are conditioned physically for football practice. During the first three days of practice, teams are allowed to use hand-held blocking pads. Helmets may be worn from the first day of practice, full pads from the fifth practice day. The earliest date full pads may be worn is August 10.
No matter when a student begins fall football practice, that student must practice for three days in shorts before practicing in pads.
During two-a-day practices, only one practice per day may be in full pads. The other practice that day can be only in helmets and shoulder pads.
No consecutive days of two-a-days practices
4 Hour break between two-a-days practices

15. HEAT ILLNESS Prevention
Weigh athletes before and after practice.
“a pint’s a pound…”
Replace fluid lost during activity.
Monitor urine color and volume.
Have ice bags available
Adequate cold fluids available.
Rest periods- adjust for temperature and place in shade if possible. “Cool Zone”
Remove clothing at rest periods, change shirts

16. Heat Illness Prevention
Heat Index Monitoring
Newspaper
Television
Airport
Phone Apps
Not the best indicator of heat stress, but best we got

21. Prevention Adjust practice times Adjust practice intensity
Adjust practice equipment
Monitor your athletes
Identify at-risk athletes especially those with sickle cell trait
Get an Athletic Trainer

22. FLUIDS
Pre-hydration extremely important, if begin dehydrated, will finish worse.
Pre-activity weight should be about the
same day to day.
Monitor urine color and volume.
Consume oz 2-3 hours prior to activity
Consume 7-10 oz minutes prior to activity
Consume 7-10 oz every minutes of activity
Post-activity hydration in 2hours
Use a urine color chart to determine hydration status
NATA Position Statement: Fluid Replacement for Athletes; J Athl Train; 2000;35(2):

23. FLUIDS Fluids should: Be cool- 50-59 F⁰
Contain carbohydrate = <8% , no fructose
Contain electrolytes- the more the better
Palatable - increases intake by 15%
Avoid:
Caffeine
Energy Drinks
Alcohol
Carbonated beverages

24. Hydration Status

25. Pre-Participation Physical Exams
Not just a “Sports Physical”
A very important exam that should be taken seriously and done properly.
Mandatory for all school aged athletes:
RULE 1, SECTION 14. PHYSICAL EXAMS. In order for a student to
be eligible for interscholastic athletics, there must be on file in the
Superintendent’s or principal’s office a current physician’s statement
certifying that the student has passed a physical exam, and
that in the opinion of the examining physician (M.D. or D.O.) the
student is fully able to participate in interscholastic athletics (grades
7-12). The AHSAA Physician’s Certificate (Form 5) must be used.
Note: A physical exam will satisfy the requirement for one
calendar year from the date of the exam.

26. Mechanics of the PPE Who?
In the state of Alabama, only a licensed physician (M.D. or D.O.) can perform and sign off on the PPE.
It is felt that only physicians have the clinical training and unrestricted medical license that allows them to deal with the broad range of problems that may be encountered.
Other health care providers ( medical students, residents, nurse practitioners, chiropractors) can help perform the exam, however, a licensed physician must review and sign the form, thus taking responsibility for the exam.

27. EAP Emergency Action Plan
Each school is responsible for having an EAP that is venue specific
EAP must be signed off by principal, athletic director, and medical director if available
EAP should be practiced and updated yearly
Each coach should have a copy available and located at each venue.

28. Sudden Cardiac Death Responsible for 4-5 deaths/year
Numbers are decreasing due to early response, AEDs, and EAPs!!!
Mandatory on-line course for coaches on the recognition of cardiac issues

29. AEDs Sudden Cardiac death is the leading cause of death in athletes
For every minute after collapse, the survival rate decreases by 10%
Have an AED accessible within 1 minute of athletic events

30. AEDs Every school has one All AHSAA staff have one Most ATCs have one
Make sure they are in an accessible location
Make sure batteries are checked monthly
Annual training for all users
CPR and AED training for all coaches

31. Lightning
Most consistent cause of weather related deaths (100 deaths/year, 1000 injuries/year)
Most lightning injuries between 10:00 a.m. and 7:00 p.m. with majority between 2:00 and 6:00 p.m.
Should have a way to monitor weather:
Weather radio
Lightning detectors
National Weather Service
Someone should be appointed to monitor weather
Lightning plan should be a part of EAP

32. Lightning Policy should be in place for every sport and every venue
Should include instructions for spectators as well as participants, including evacuation plan
Designate proper shelter
Fully enclosed building with plumbing, electricity
Vehicle/bus with windows up
Designate warning and all-clear signals
Avoid showers and telephone land lines
Practice

33. “If you hear it, clear it”
Lightning
“If you see it, flee it”
“If you hear it, clear it”

34. Lightning Return to play
30 minutes after last flash or thunder clap
This will be when the storm is miles away
If using a weather app, lightning must be 10 miles away
Clock resets if another flash or bang

35. Telemedicine
Wrestling coaches have the ability to videoconference with a physician to assess whether a skin condition needs to be seen by a physician
This allows for rapid treatment to ensure wrestlers are not removed from competition

36. Telemedicine
Network of physicians in each district willing to see athletes on a moments notice
Utilized only for Sub-State and State Championships last year
Will be available all year this year

37. Telemedicine for Wrestling Coaches
2014 State Championships
6 wrestlers with potentially disqualifying skin conditions
3 wrestlers were disqualified at championship meet
2015 State Championships
0 wrestlers with skin conditions
0 wrestlers disqualified
2016 State Sub-Sectionals
2 wrestlers disqualified

38. Telemedicine

39. Thank You
QUESTIONS?