Fatal exertional heat stroke and American football players: The need for regional heat-safety guidelines

Context: Weather-based activity modification in athletics is an important way to minimize heat illnesses. However, many commonly used heat-safety guidelines include a uniform set of heat-stress thresholds that do not account for geographic differences in acclimatization. Objective: To determine if heat-related fatalities among American football players occurred on days with unusually stressful weather conditions based on the local climate and to assess the need for regional heat-safety guidelines. Design: Cross-sectional study. Setting: Data from incidents of fatal exertional heat stroke (EHS) in American football players were obtained from the National Center for Catastrophic Sport Injury Research and the Korey Stringer Institute. Patients or Other Participants: Sixty-one American football players at all levels of competition with fatal EHSs from 1980 to 2014. Main Outcome Measure(s): We used the wet bulb globe temperature (WBGT) and a z-score WBGT standardized to local climate conditions from 1991 to 2010 to assess the absolute and relative magnitudes of heat stress, respectively. Results: We observed a poleward decrease in exposure WBGTs during fatal EHSs. In milder climates, 80% of cases occurred at above-Average WBGTs, and 50% occurred at WBGTs greater than 1 standard deviation from the long-Term mean; however, in hotter climates, half of the cases occurred at near average or below average WBGTs. Conclusions: The combination of lower exposure WBGTs and frequent extreme climatic values in milder climates during fatal EHSs indicates the need for regional activity-modification guidelines with lower, climatically appropriate weather-based thresholds. Established activity-modification guidelines, such as those from the American College of Sports Medicine, work well in the hotter climates, such as the southern United States, where hot and humid weather conditions are common.