Appendix 1

Olympic Movement Medical CodeIn force as from 1 January 2006
PREAMBLE“Fundamental Principles of Olympism
1 Olympism is a philosophy of life, exalting and combining in a balanced whole thequalities of body, will and mind. Blending sport with culture and education, Olympism
seeks to create a way of life based on the joy of effort, the educational value of good
example and respect for universal fundamental ethical principles.
2 The goal of Olympism is to place sport at the service of the harmonious developmentof man, with a view to promoting a peaceful society concerned with the preservation ofhuman dignity.”
Olympic Charter, September 2004

1.

2.

3.

4.

The Olympic Movement, in accomplishing its mission, should take care thatsport is practised without danger to the health of the athletes and with respect
for fair play and sports ethics. To that end, it takes the measures necessary toprotect the health of participants and to minimise the risks of physical injury
and psychological harm. It also protects the athletes in their relationships withphysicians and other health care providers.
This objective can be achieved only through an ongoing education based on the
ethical values of sport and on each individual’s responsibility in protecting his
or her health and the health of others.
The present Code recalls the basic rules regarding best medical practices in thedomain of sport and the safeguarding of the rights and health of the athletes.
It supports and encourages the adoption of speciﬁc measures to achieve that
objective. It complements and reinforces the World Anti-Doping Code andreﬂects the general principles recognised in the international codes of medical
ethics.
The Olympic Movement Medical Code is intended to apply to the Olympic
Games, the various championships of the International Federations and allcompetitions to which the International Olympic Committee (IOC) grants
its patronage or support, and to all sport practised within the context of the
Olympic Movement, either during training or during competition.

1. General Principles
1.1. Athletes are entitled to the same fundamental rights as all patients in theirrelationships with physicians and health care providers, in particular the right torespect for:a. their human dignity;b. their physical and mental integrityc. the protection of their health and safety;

APPENDICES

d. their self-determination; ande. their privacy and conﬁdentiality.
1.2. The relationship between athletes, their personal physician, the team physician
and other health care providers must be protected and subject to mutual respect. The
health and the welfare of athletes must prevail over the sole interest of competitionand other economic, legal or political considerations.
2. Information
Athletes have the right to be informed in a clear and appropriate way about
their health status and their diagnosis; preventive measures; proposed medical
interventions, together with the risks and beneﬁts of each intervention; alternatives
to proposed interventions, including the consequences of non-treatment for theirhealth and for their return to sports practice; and the prognosis and progress oftreatment and rehabilitation measures.
3. Consent
3.1. The voluntary and informed consent of the athletes is required for any medical
intervention.
3.2. Particular care should be taken to avoid pressures from the entourage (e.g.
coach, management, family, etc.) and other athletes, so that athletes can make fully
informed decisions, taking into account the risks associated with practising a sportwith a diagnosed injury or disease.
3.3. Athletes have the right to refuse or to interrupt a medical intervention. The
consequences of such a decision must be carefully explained to them.
3.4. Athletes are encouraged to designate a person who can act on their behalf in theevent of incapacity. They can also deﬁne in writing the way they wish to be treatedand give any other instruction they deem necessary.
3.5. With the exception of emergency situations, when athletes are unable to consent
personally to a medical intervention, the authorisation of their legal representative orof the person designated by the athletes for this purpose is required, after they havereceived the necessary information.
When the legal representative has to give authorisation, athletes, whether minors
or adults, must nevertheless assent to the medical intervention to the fullest extent of
their capacity.
3.6. The consent of the athletes is required for the collection, preservation, analysis
and use of any biological sample.
4. Conﬁdentiality and Privacy
4.1. All information about an athlete’s health status, diagnosis, prognosis, treatment,
rehabilitation measures and all other personal information must be kept conﬁdential,
even after the death of the athlete.
4.2. Conﬁdential information may be disclosed only if the athlete gives explicit
consent thereto, or if the law expressly provides for this. Consent may be presumed

APPENDICES

when, to the extent necessary for the athlete’s treatment, information is disclosed toother health care providers directly involved in his or her health care.
4.3. All identiﬁable medical data on athletes must be protected. The protection of
the data must be appropriate to the manner of their storage. Likewise, biologicalsamples from which identiﬁable data can be derived must be protected.
4.4. Athletes have the right of access to, and a copy of, their complete medical
record. Such access excludes data concerning or provided by third parties.
4.5. Athletes have the right to demand the rectiﬁcation of erroneous medical data.
4.6. An intrusion into the private life of an athlete is permissible only if it isnecessary for diagnosis, treatment and care, and the athlete consents to it, or if it islegally required. Such intrusion is also permissible pursuant to the provisions of theWorld Anti-Doping Code.
4.7. Any medical intervention must respect privacy. This means that a given
intervention may be carried out in the presence of only those persons who arenecessary for the intervention, unless the athlete expressly consents or requests
otherwise.
5. Care and Treatment
5.1. Athletes have the right to receive such health care as is appropriate to their needs,
including preventive care, activities aimed at health promotion and rehabilitation
measures. Services should be continuously available and accessible to all equitably,
without discrimination and according to the ﬁnancial, human and material resources
available for such purpose.
5.2. Athletes have the right to a quality of care marked both by high technicalstandards and by the professional and respectful attitude of health care providers.
They have the right to continuity of care, including cooperation between all healthcare providers and establishments which are involved in their diagnosis, treatment
and care.
5.3. During training and competition abroad, athletes have the right to the necessary
health care, which if possible should be provided by their personal physician or theteam physician. They also have the right to receive emergency care prior to returninghome.
5.4. Athletes have the right to choose and change their own physician, health careprovider or health care establishment, provided that this is compatible with thefunctioning of the health care system. They have the right to request a second
medical opinion.
5.5. Athletes have the right to be treated with dignity in relation to their diagnosis,
treatment, care and rehabilitation, in accordance with their culture, tradition andvalues. They have the right to enjoy support from family, relatives and friends during
the course of care and treatment, and to receive spiritual support and guidance.
5.6. Athletes have the right to relief of their suffering according to the latest recognised
medical knowledge. Treatments with an analgesic effect, which allow an athlete

APPENDICES

to practise a sport with an injury or illness, should be carried out only after carefulconsideration and consultation with the athlete and other health care providers. If
there is a long-term risk to the athlete’s health, such treatment should not be given.
Procedures that are solely for the purpose of masking pain or other protective
symptoms in order to enable the athlete to practise a sport with an injury or illness
should not be administered if, in the absence of such procedures, his or her participation
would be medically inadvisable or impossible.
6. Rights and Duties of Health Care Providers
6.1. The same ethical principles that apply to the current practice of medicine apply to sports medicine. The principal duties of the physicians and other health careproviders include:
a. making the health of the athletes a priority;b. doing no harm.
6.2. Health care providers who care for athletes must have the necessary education,
training and experience in sports medicine, and must keep their knowledge up to
date. They have a duty to understand the physical and emotional demands placed
upon athletes during training and competition, as well as the commitment andnecessary capacity to support the extraordinary physical and emotional endurance
that sport requires.
6.3. Athletes’ health care providers must act in accordance with the latest recognised
medical knowledge and, when available, evidence-based medicine. They mustrefrain from performing any intervention that is not medically indicated, even at
the request of the athletes, their entourage or another health care provider. Healthcare providers must also refuse to provide a false medical certiﬁcate concerning theﬁtness of an athlete to participate in training or competition.
6.4. When the health of athletes is at risk, health care providers must strongly
discourage them from continuing training or competition and inform them of therisks. In the case of serious danger to the athlete, or when there is a risk to third
parties (players of the same team, opponents, family, the public, etc.), health careproviders may also inform the competent persons or authorities, even against thewill of the athletes, about their unﬁtness to participate in training or competition.
6.5. Health care providers must oppose any sports or physical activity that is not
appropriate to the stage of growth, development, general condition of health, andlevel of training of children. They must act in the best interest of the health of thechildren or adolescents, without regard to any other interests or pressures from theentourage (e.g. coach, management, family, etc.) or other athletes.
6.6. Health care providers must disclose when they are acting on behalf of third
parties (e.g. club, federation, organiser, NOC, etc.). They must personally explain to
the athletes the reasons for the examination and its outcome, as well as the nature of
the information provided to third parties. In principle, the athlete’s physician should
be informed.

APPENDICES

6.7. When acting on behalf of third parties, health care providers must limit thetransfer of information to what is essential. In principle, they may indicate only
the athlete’s ﬁtness or unﬁtness to participate in training or competition. With
the athlete’s consent, the health care providers may provide other information
concerning the athlete’s participation in sport in a way compatible with his or her
health status.
6.8. At sports venues, it is the responsibility of the team or competition physician
to determine whether an injured athlete may continue in or return to the competition.
This decision may not be delegated to other professionals or personnel. In theabsence of the competent physician, these individuals must adhere strictly tothe instructions that he or she has provided. At all times, the priority must be tosafeguard the health and safety of athletes. The outcome of the competition mustnever inﬂuence such decisions.
6.9. When necessary, the team or competition physician must ensure that injured
athletes have access to specialised care, by organising medical follow-up byrecognised specialists.
Chapter II: Protection and Promotion of the Athlete’s Health during Training andCompetition

7. General Principles
7.1. No practice constituting any form of physical injury or psychological harm
to athletes is permissible. The members of the Olympic Movement ensure thatthe athletes’ conditions of safety, well-being and medical care are favourable totheir physical and mental equilibrium. They must adopt the necessary measures toachieve this end and to minimise the risk of injuries and illness. The participation ofsports physicians is desirable in the drafting of such measures.
7.2. In each sports discipline, minimal safety requirements must be deﬁned andapplied with a view to protecting the health of the participants and the public during
training and competition. Depending on the sport and the level of competition,
speciﬁc rules are adopted regarding the sports venues, the safe environmental
conditions, the sports equipment authorised or prohibited, and the training andcompetition programmes. The speciﬁc needs of each athlete category must be
respected.
7.3. For the beneﬁt of all concerned, measures to safeguard the health of the athletes
and to minimise the risks of physical injury and psychological harm must be
publicised in order to beneﬁt all those concerned.
7.4. The measures for the protection and the promotion of the athletes’ health must
be based on the latest recognised medical knowledge.
7.5. Research in sports medicine and sports sciences is encouraged. It must be
conducted in accordance with the recognised principles of research ethics, inparticular the Helsinki Declaration adopted by the World Medical Association(Edinburgh, 2000), and the applicable law. It must never be conducted in a mannerAPPENDICES

which could harm an athlete’s health or jeopardise his or her performance. The
voluntary and informed consent of the athletes to participate in such research is
required.
7.6. Advances in sports medicine and sports science must not be withheld, and mustbe published and widely disseminated.
8. Fitness to Practise a Sport
8.1. Except when there are symptoms or a signiﬁcant family medical history, thepractice of sport for all does not require undergoing a ﬁtness test. The choice toundergo such a test is the responsibility of the personal physician.
8.2. For competitive sport, athletes may be required to present a medical certiﬁcate
conﬁrming that there are no apparent contraindications. The ﬁtness test should bebased on the latest recognised medical knowledge and performed by a speciallytrained physician.
8.3. A pre-participation medical test is recommended for high level athletes. It
should be performed under the responsibility of a specially trained physician.
8.4. Any genetic test that attempts to gauge a particular capacity to practise a sport
constitutes a medical evaluation to be performed solely under the responsibility of a
specially trained physician.
9. Medical Support
9.1. In each sports discipline, guidelines must be established regarding the necessary
medical support depending on the nature of the sports activities and the level ofcompetition.
These guidelines must deﬁne, but not be limited to, the following points:- the medical coverage of training and competition venues and how this isorganised;- the necessary resources (supplies, premises, vehicles, etc.);- the procedures in case of emergencies;- the system of communication between the medical support services, theorganisers and the competent health authorities.
9.2. In the case of a serious incident occurring during training or competition, there
must be procedures to provide the necessary support to those injured, by evacuatingthem to the competent medical services when needed. The athletes, coaches andpersons associated with the sports activity must be informed of those procedures andreceive the necessary training for their implementation.
9.3. To reinforce safety in the practice of sports, a mechanism must exist to allow
for data collection with regard to injuries sustained during training or competition.
When identiﬁable, such data must be collected with the consent of those concerned,
and be treated conﬁdentially and in accordance with the recognised ethical principles
of research.

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Chapter III: Adoption, Compliance and Monitoring

10. Adoption
10.1. The Code is intended to apply to all the members of the Olympic Movement,in particular the IOC, the International Sports Federations and the National Olympic
Committees (hereafter the Signatories). Each Signatory adopts the Code according
to its own procedural rules.
10.2. The Code is ﬁrst adopted by the IOC. It is not mandatory but desirable that theother members of the Olympic Movement adopt it.
10.3. A list of all Signatories will be made public by the IOC.
11. Compliance11.1. The Signatories implement the applicable Code provisions through policies,
statutes, rules or regulations according to their authority and within their respective
spheres of responsibility. They undertake to make the principles and provisionsof the Code widely known, by active and appropriate means. For that purpose,
they collaborate closely with the relevant physicians’ and health care providers’associations and the competent authorities.
11.2. The Signatories ensure that the physicians and other health care providers caring
for athletes within their spheres of responsibility act in accordance with this Code.
11.3. Physicians and other health care providers remain bound to respect their own
ethical and professional rules in addition to the applicable Code provisions. In thecase of any discrepancy, the most favourable rule that protects the health, the rights
and the interests of the athletes shall prevail.
12. Complaints Procedure
12.1. Each Signatory designates a competent body to deal with complaints concerning
alleged violations of the applicable Code provisions and with all other situations
brought to its attention concerning the implementation of the Code. This body musthave the power to take sanctions against the person or organisation at fault or to
propose sanctions or the necessary measures to other authorised bodies.
12.2. The IOC Medical Commission designates a committee (hereafter: Complaints
Committee), composed of three of its members, to deal with all cases of alleged
violations of the applicable Code provisions occurring during the Games. This
Committee also acts as a body to review decisions taken by the competent bodies of
the Signatories pursuant to the Code. A request for a review may be submitted to thisCommittee by the person or organisation sanctioned, as well as by the claimant.
12.3. Decisions taken by the Complaints Committee in the ﬁrst instance may
be submitted to the IOC Executive Board for review. Decisions taken by theComplaints Committee as a review body and those taken by the IOC Executive
Board are ﬁnal.
12.4. The Signatories establish the necessary procedural rules, including theapplicable sanctions in the event of a violation of the applicable Code provisions.

APPENDICESThe competent bodies of the Signatories and the Complaints Committee have thepower to act upon the ﬁling of a complaint or under their own authority.
13. Monitoring
13.1. The IOC Medical Commission oversees the implementation of the Code andreceives feedback relating to it. It is also responsible for monitoring changes in theﬁeld of ethics and best medical practice and for proposing adaptations to the Code.
13.2. The IOC Medical Commission may issue recommendations and models of bestpractice with a view to facilitating the implementation of the Code.
Chapter IV: Scope, Entry into Force and Amendments

14. Scope
14.1. The Code applies to all participants in the sports activities governed by each
Signatory, in competition as well as out of competition.
14.2. The Signatories are free to grant wider protection to their athletes.
14.3. The Code applies without prejudice to the national and international ethical,
legal and regulatory requirements that are more favourable to the protection of thehealth, rights and interests of the athletes.
15. Entry into Force
15.1. The Code enters into force for the IOC on 1 January 2006. It applies to all
Olympic Games, starting with the 2006 Games in Turin.
15.2. The Code may be adopted by the other members of the Olympic Movement
after this date. Each Signatory determines when such adoption will take effect.
15.3. The Signatories may withdraw acceptance of the Code after providing the IOC
with written notice of their intent to withdraw.
16. Amendments
16.1. Athletes, Signatories and other members of the Olympic Movement are invited
to participate in improving and modifying the Code. They may propose amendments.
16.2. Upon the recommendation of its Medical Commission, the IOC initiates
proposed amendments to the Code and ensures a consultative process, both to receiveand respond to recommendations, and to facilitate review and feedback from athletes,
Signatories and members of the Olympic Movement on proposed amendments.
16.3. After appropriate consultation, amendments to the Code are approved by the
IOC Executive Board. Unless provided otherwise, they become effective threemonths after such approval.
16.4. Each Signatory must adopt the amendments approved by the IOC Executive
Board within one year after notiﬁcation of such amendments. Failing this, a Signatory
may no longer claim that it complies with the Olympic Movement Medical Code.
Adopted by the IOC Executive Board in Lausanne on 27 October 2005

Appendix 2

Planning International Travel
A. Before Departure

1. Travel schedule. Work with the Federation administration to arrange a
travel schedule that minimises the effects of jet lag.
2. Facilities. Work with the administration to ensure that adequate medicalcare spaces (including sports psychology) are included in the team housing
allocation.
3. Licensure. Determine whether temporary medical licensure is requiredby the host country, and comply if necessary.
4. Drug importation. Determine whether the host country requires permission
for the importation of medications, and complete applications if necessary.
5. Environmental health. Review international health information resources
to determine whether any unusual health situations or infectious disease
outbreaks exist in the host country, and take appropriate preventive
measures (immunisations, medications, etc.).
6. Supplies and Equipment. Work with the medical staff to ensure that
adequate medical supplies and equipment are on hand to support the
number of athletes and other team members.
7. Athlete Healtha. Fitness. Review athlete medical records, and, if possible, conduct
examinations to ensure that athletes are ﬁt and able to compete at thehighest levels.
b. Immunisations. Ensure that all athletes have up-to-date immunisations,
i.e., tetanus, hepatitis, inﬂuenza, etc., and any others that may berequired for health in the host country.
c. Medications. Review all athlete medications, including over-the-counter,
supplements, etc., which the athlete may be taking to be sure that nonecontain banned substances.
If restricted substances are being used, be sure that an appropriate
Therapeutic Use Exemption has been ﬁled and approved. If not, complete
the required application and submit to IAAF.
d. Hygiene and Jet Lag. Educate athletes and staff concerning measuresfor personal hygiene, including food selection, hand washing, potablewater and hydration, sexually transmitted diseases (STDs), and measures
to ameliorate jet lag during and after travel. (See Appendix 10, Recommendations for Minimising Jet Lag, and Appendix 11, General Healthand Hygiene Recommendations for Athletes).

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B. During Travel

1. Medical Supplies. Carry a small kit with medications for emergency use,such as analgesics, anti-histamines, anti-nauseas, and anti-diarrheals.
2. Jet Lag. Remind athletes and staff to follow guidelines to minimise jet lag:frequent hydration (but avoid caffeine and alcohol), exercise and stretch
often, re-set watches to arrival time zone and try to adapt to the new time.
C. Upon Arrival

1. Establish the Team Medical Care Systema. Allocation of work spaces.
b. Hours of operation.
c. Stafﬁng assignments, including various training and competition venues.
Present this information to the team at the initial team meeting. Reinforce
the need to maintain personal hygiene and to report illnesses promptly.
2. Establish contact with the Local Organising Committee (LOC) Medical
Committee to determine the details of the medical care system. Determine
how to access ancillary medical facilities: emergency room, ambulance,
hospital, pharmacy, X-ray, supplies, etc.
Arrange for an orientation tour of the LOC medical care system andfacilities, including spaces allocated for the team.
3. Environmental Health and Sanitation
a. Review the food preparation system.
b. Ensure the availability of potable water at all venues.
c. Determine the contaminated waste disposal system.
d. Determine the procedures for isolation of ill patients in case of
infectious diseases.
4. Record-Keeping.
a. Maintain treatment logs at all venues.
b. Maintain medical record forms for all treatments of illnesses andinjuries.
D. During Training and Competition

1. Establish the medical care operation at team headquarters, and at all
training and warm-up venues.
2. Establish a medical stafﬁng rotation system for each venue; be sure toallow time off for recovery for the staff.

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E. After-Action Responsibilities

1. Trip report. File a trip report to the Director of Athlete Services concerning
the medical staff experiences and any unusual occurrences, such as major
health problems, hospital admissions, etc. Make recommendations for
improving the medical care system for future teams.
2. Staff evaluations. File a report to the Chief Medical Ofﬁcer that includes
the above, plus evaluations of medical staff members as to suitability for
future teams, work ethic, professionalism, etc.
3. Records. Send all medical records to the Chief Medical Ofﬁcer or designee.
This may be needed for insurance purposes, and for future travel planningand other statistics of injury/illness incidence .

Appendix 3

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Reprinted from the Preparticipation Physical Evaluation (monograph) Third Edition. Leawood, Kansas:
American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports
Medicine (ACSM), American Medical Society for Sports Medicine, American Orthopaedic Society forSports Medicine, American Osteopathic Academy of Sports Medicine, Phys Sportsmed © 2005 The
McGraw-Hill Companies.

Appendix 4
American College of Sports Medicine Position StandHeat and Cold Illnesses During Distance RunningThis pronouncement was written for the American College of Sports Medicine
by: Lawrence E. Armstrong, Ph.D., FACSM, (Chair), Yoram Epstein, Ph.D., John E.
Greenleaf, Ph.D., FACSM, Emily M. Haymes, Ph.D., FACSM Roger W. Hubbard,
Ph.D., William O. Roberts, M.D., FACSM, and Paul D. Thompson, M.D., FACSM.
Summary

Many recreational and elite runners participate in distance races each year. Whenthese events are conducted in hot or cold conditions, the risk of environmental
illness increases. However, exertional hyperthermia, hypothermia, dehydration,and other related problems may be minimized with pre-event education andpreparation. This position stand provides recommendations for the medical director
and other race ofﬁcials in the following areas: scheduling; organizing personnel,
facilities, supplies, equipment, and communication; providing competitor education;measuring environmental stress; providing ﬂuids; and avoiding potential legal
liabilities. This document also describes the predisposing conditions, recognition,and treatment of the four most common environmental illnesses: heat exhaustion,
heatstroke, hypothermia, and frostbite. The objectives of this position stand are:1) to educate distance running event ofﬁcials and participants about the mostcommon forms of environmental illness including predisposing conditions, warning
signs, susceptibility, and incidence reduction. 2) To advise race ofﬁcials of theirlegal responsibilities and potential liability with regards to event safety and injury
prevention. 3) To recommend that race ofﬁcials consult local weather archives andplan events at times likely to be of low environmental stress to minimize detrimental
effects on participants. 4) To encourage race ofﬁcials to warn participants about
environmental stress on race day and its implications for heat and cold illness.
5) To inform race ofﬁcials of preventive actions that may reduce debilitation andenvironmental illness. 6) To describe the personnel, equipment, and supplies
necessary to reduce and treat cases of collapse and environmental illness.
Introduction

This document replaces the position stand titled The Prevention of Thermal
Injuries During Distance Running (4). It considers problems that may affect theextensive community of recreational joggers and elite athletes who participate indistance running events. It has been expanded to include heat exhaustion, heatstroke,
hypothermia, and frostbite—the most common environmental illnesses during races.
Because physiological responses to exercise in stressful environments mayvary among participants, and because the health status of participants varies fromday to day, compliance with these recommendations will not guarantee protection
from environmentally induced illnesses. Nevertheless, these recommendations
should minimize the risk of exertional hyperthermia, hypothermia, dehydration,

APPENDICES

and resulting problems in distance running and other forms of continuous athletic
activity such as bicycle, soccer, and triathlon competition.
Managing a large road race is a complex task that requires ﬁnancial resources, acommunication network, trained volunteers, and teamwork. Environmental extremes
impose additional burdens on the organizational and medical systems. Therefore,
it is the position of the American College of Sports Medicine that the following
RECOMMENDATIONS be employed by race managers and medical directors ofcommunity events that involve prolonged or intense exercise in mild and stressfulenvironments.
1. Race Organization
a. Distance races should be scheduled to avoid extremely hot and humid andvery cold months. The local weather history should be consulted when schedulingan event. Organizers should be cautious of unseasonably hot or cold days in early
spring and late fall because entrants may not be sufﬁciently acclimatized. The windchill index should be used to reschedule races on cold, windy days because ﬂesh
may freeze rapidly and cold injuries may result.
b. Summer events should be scheduled in the early morning or the evening tominimize solar radiation and air temperature. Winter events should be scheduled at
midday to minimize the risk of cold injury.
c. The heat stress index should be measured at the site of the race because
meteorological data from a distant weather station may vary considerably fromlocal conditions (66). The wet bulb globe temperature (WBGT) index is widelyused in athletic and industrial settings [see Appendix I;(87)]. If the WBGT index
is above 28ºC (82ºF), or if the ambient dry bulb temperature is below -20ºC (-4ºF),
consideration should be given to canceling the race or rescheduling it until lessstressful conditions prevail. If the WBGT index is below 28ºC, participants shouldbe alerted to the risk of heat illness by using signs posted at the start of the race andat key positions along the race course [see Appendix I;(61)]. Also, race organizers
should monitor changes in weather conditions. WBGT monitors can be purchasedcommercially, or Figure 1 may be used to approximate the risk of racing in hot
environments based on air temperature and relative humidity. These two measures
are available from local meteorological stations and media weather reports, or canbe measured with a sling psychrometer.
d. An adequate supply of ﬂuid must be available before the start of the race,
along the race course, and at the end of the event. Runners should be encouraged
to replace their sweat losses or consume 150—300 ml (5.3–10.5 ounces) every
15 min (3). Sweat loss can be derived calculating the difference between pre- andpostexercise body weight.
e. Cool or cold (ice) water immersion is the most effective means of coolinga collapsed hyperthermic runner (25,48,49,59,88). Wetting runners externally by
spraying or sponging during exercise in a hot environment is pleasurable but does
not fully attenuate the rise in body core temperature (14,88). Wetting the skin can
result in effective cooling once exercise ceases.

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Figure 1. Risk of heat exhaustion or heat stroke
while racing in hot environments. Figure drawn
from data presented in American College ofSports Medicine Position stand: the preventionof thermal injuries during distance running.
Med. Sci. Sports Exercise 19: 529-533, 1987.

f. Race ofﬁcials should be aware of the warning signs of an impending collapse
in both hot and cold environments and should warn runners to slow down or stop if
they appear to be in difﬁculty.
g. Adequate trafﬁc and crowd control must be maintained along the course at all
times.
h. Radio communications or cellular telephones should connect various points
on the course with an information processing center to coordinate emergency
responses.
2. Medical Director
A sports medicine physician should work closely with the race director
to enhance the safety and provide adequate medical care for all participants.
The medical director should understand exercise physiology, interpretation of
meteorological data, heat and cold illness-prevention strategies, potential liability,
and the treatment of medical problems associated with endurance events conductedin stressful environments.
3. Medical Support
a. Medical organization and responsibility: The medical director should alert
local hospitals and ambulance services and make prior arrangements to care forcasualties, including those with heat or cold injury. Medical personnel should havethe authority to evaluate, examine, and stop runners who display signs of impending
illness or collapse. Runners should be advised of this procedure prior to the event.
b. Medical facilities: Medical support staff and facilities must be available atthe race site. The facilities should be staffed with personnel capable of instituting
immediate and appropriate resuscitation measures. The equipment necessary to
institute both cooling therapy (ice packs, child’s wading pools ﬁlled with tap wateror ice water, fans) and warming therapy (heaters, blankets, hot beverages) may benecessary at the same event. For example, medical personnel treated 12 cases ofhyperthermia and 13 cases of hypothermia at an endurance triathlon involving 2300
competitors; air temperature was 85ºF, water temperature was 58ºF.

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4. Competitor Education
The physical training and knowledge of competitive runners and joggers has
increased greatly, but race organizers must not assume that all participants are
well-prepared or informed about safety. Distributing this position stand before
registration, publicizing the event in the media, and conducting clinics or seminars
before events are valuable educational procedures.
a. All participants should be advised that the following conditions may exacerbate
heat illness: obesity (13,39,89), low degree of physical ﬁtness (30,63,79,83),
dehydration (23,34,69,83,84,95), lack of heat acclimatization (31,51,89), a previous
history of heat stroke (82,89), sleep deprivation (5), certain medications, including
diuretics and antidepressants (31), and sweat gland dysfunction or sunburn (31).
Illness 1 wk prior to an event should preclude participation (32,96), especially those
involving fever, respiratory tract infections, or diarrhea (41,46).
b. Prepubescent children sweat less than adults and have lower heat tolerance(11,12).
c. Adequate training and ﬁtness are important for full enjoyment of the event andwill reduce the risk of heat illness and hypothermia (22,64,67,85).
d. Prior training in the heat will promote heat acclimatization (6) and thereby
reduce the risk of heat illness, especially if the training environment is warmer thanthat expected during a race (5,51). Artiﬁcial heat acclimatization can be induced incold conditions (6).
e. Adequate ﬂuid consumption before and during the race can reduce the risk ofheat illness, including disorientation and irrational behavior, particularly in longer
events such as a marathon (23,34,95).
f. Excessive consumption of pure water or dilute ﬂuid (i.e., up to 10 liters
per 4 hours) during prolonged endurance events may lead to a harmful dilutional
hyponatremia (60), which may involve disorientation, confusion, and seizure or
coma. The possibility of hyponatremia may be the best rationale for inclusion of
sodium chloride in ﬂuid replacement beverages (3).
g. Participants should be advised of the early symptoms of heat illness, which
may include clumsiness, stumbling, headache, nausea, dizziness, apathy, confusion,and impairment of consciousness (41,86).
h. Participants should be advised of the early symptoms of hypothermia (slurredspeech, ataxia, stumbling gait) and frostbite (numbness, burning, pain, paresthesia)
on exposed skin (36). Wet clothing, especially cotton, increases heat loss and the riskof hypothermia (68).
i. Participants should be advised to choose a comfortable running speed and not
to run faster than environmental conditions or their cardiorespiratory ﬁtness warrant(43,71,91).
j. It is helpful if novice runners exercise with a partner, each being responsible
for the other’s well-being (71).

APPENDICES

5. Responsibilities and Potential Liability
The sponsors and directors of an endurance event are reasonably safe fromliability due to injury if they avoid gross negligence and willful misconduct, carefully inform the participants of the hazards, and have them sign waivers before the race(78). However, a waive signed by a participant does not totally absolve race organizers
of moral and/or legal responsibility. It is recommended that race sponsors anddirectors: 1) minimize hazards and make safety the ﬁrst concern; 2) describe inherent
hazards (i.e., potential course hazards, trafﬁc control, weather conditions) in the race
application; 3) require all entrants to sign a waiver; 4) retain waivers and records for
3 yrs; 5) warn runners of the predisposing factors and symptoms of environmental
illness; 6) provide all advertised support services; 7) legally incorporate the race ororganizations involved; 8) purchase liability insurance (18,78,80).
Race directors should investigate local laws regarding Good Samaritan action.
In some states physicians who do not accept remuneration may be classiﬁed as Good
Samaritans. Race liability insurance may not cover physicians (78), therefore themalpractice insurance policy of each participating physician should be evaluated todetermine if it covers services rendered at the race.
Medical and race directors should postpone, reschedule, or cancel a race if
environmental conditions warrant, even though runners and trained volunteers
arrive at the site and ﬁnancial sponsorship has been provided. Runners may nothave adequate experience to make the decision not to compete; their safety must be
considered. Downgrading the race to a “fun run” does not absolve race supervisorsfrom their responsibility or decrease the risk to participants (15,66).
Background for this Position Stand

Dehydration is common during prolonged endurance events in both hot andcold environmental conditions because the average participant loses 0.5–1.5 quarts(0.47–1.42 liters) of sweat/hr, and ﬂuid replacement is usually insufﬁcient (2,42,69).
Runners may experience hyperthermia [body core temperature above 39ºC
(102.2ºF)] or hypothermia [body core temperature below 35ºC (95ºF)], depending on
the environmental conditions, caloric intake, ﬂuid consumption, and clothing worn.
Hyperthermia is a potential problem in warm and hot weather race when the body’srate of heat production is greater than its heat dissipation (2). Indeed, on extremely
hot days, it is possible that up to 50% of the participants may require treatment forheat-related illnesses such as heat exhaustion and heatstroke (1,66). Hypothermia ismore likely to occur in cold or cool-windy conditions. Scanty clothing may provide
inadequate protection from such environments, particularly near the end of a longrace when running speed and heat production are reduced. Frostbite can occur in
low air temperature and especially when combined with high wind speed. The raceand medical directors should anticipate the above medical problems and be capableof responding to a large number of patients with adequate facilities, supplies, andsupport staff. The four most common heat and cold illnesses during distance runningare heat exhaustion, heatstroke, hypothermia, and frostbite.

APPENDICES

1. Heat Exhaustion
Body sweat loss can be signiﬁcant in summer endurance races and may result ina body water deﬁcit of 6–10% of body weight (41,95). Such dehydration will reduce
the ability to exercise in the heat because decreases in circulating blood volume,
blood pressure, sweat production, and skin blood ﬂow all inhibit heat loss (41,81)
and predispose the runner to heat exhaustion or the more dangerous hyperthermia
and exertional heatstroke (41,66).
Heat exhaustion, typically the most common heat illness among athletes, isdeﬁned as the inability to continue exercise in the heat (7). It represents a failureof the cardiovascular responses to workload, high external temperature, anddehydration (16,41,42). Heat exhaustion has no known chronic, harmful effects.
Symptoms may include headache, extreme weakness, dizziness, vertigo, “heatsensations” on the head or neck, heat cramps, chills, “goose ﬂesh” (“goose bumps”),
vomiting, nausea, and irritability (41,42). Hyperventilation, muscular incoordination,
agitation, impaired judgment, and confusion also may be seen. Heat syncope(fainting) may or may not accompany heat exhaustion (41). The onset of heatexhaustion symptoms is usually sudden and the duration of collapse brief. During
the acute stage of heat exhaustion, the patient looks ashen-gray, the blood pressure islow, and the pulse rate is elevated. Hyperthermia may add to the symptoms of heatexhaustion, even on relatively cool days (20,22,30,37,38,43,62,90).
Although it is improbable that all heat exhaustion cases can be avoided, themost susceptible individuals are those who either exert themselves at or near
their maximal capacities, are dehydrated, not physically ﬁt, and not acclimatized
to exercise in the heat. It is imperative that runners be adequately rested, fed,
hydrated, and acclimatized (7); they should drink ample ﬂuids before, during, andafter exercise (3). Also, repeated bouts of exercise in the heat (heat acclimatization)
reduce the incidence of both heat exhaustion and heat syncope. Heat acclimatization
can best be accomplished by gradually increasing the duration and intensity of
exercise training during the initial 10–14 days of heat exposure (6).
Oral rehydration is preferred for heat exhaustion patients who are conscious,
coherent, and without vomiting or diarrhea. Intravenous (IV) ﬂuid administration
facilitates rapid recovery (42,57). Although a variety of IV solutions have beenused at races (42), a 5% dextrose sugar in either 0.45% saline (NaCl) or 0.9% NaCl
are the most common (1). Runners may require up to 4 l of IV ﬂuid if severely
dehydrated (57).
2. Exertional Heatstroke
Heat production, mainly from muscles, during intense exercise is 15–20 times
greater than at rest, and is sufﬁcient to raise body core temperature by 1ºC (1.8ºF)
each 5 min without thermoregulatory (heat loss) adjustments (56). When the rateof heat production exceeds that of heat loss for a sufﬁcient period of time, severe
hyperthermia occurs.
Heatstroke is the most serious of the syndromes associated with excess body
heat. It is deﬁned as a condition in which body temperature is elevated to a level

APPENDICES

that causes damage to the body’s tissues, giving rise to a characteristic clinical andpathological syndrome affecting multiple organs (32,83). After races, adult core(rectal) temperatures above 40.6º (105.1ºF) have been reported in conscious runners
924,52,69,74,77), and 42-43ºC (107.6–109.4ºF) in collapsed runners (72–74,86,90).
Sweating is usually present in runners who experience exertional heatstroke.
Strenuous physical exercise in a hot environment has been notorious as the causeof heatstroke, but heatstroke also has been observed in cool-to-moderate [13–28ºC(55–82ºF)] environments (5,32,74), suggesting variations in individual susceptibility
95,31,32). Skin disease, sunburn, dehydration, alcohol or drug use/abuse, obesity,
sleep loss, poor physical ﬁtness, lack of heat acclimatization, advanced age, and aprevious heat injury all have been theoretically linked to increased risk of heatstroke(5,31,51,84). The risk of heatstroke is reduced if runners are well-hydrated, wellfed, rested, and acclimatized. Runners should not exercise if they have a concurrent
illness, respiratory infection, diarrhea, vomiting, or fever (5,7,46). For example,
a study of 179 heat casualties at a 14-km race showed that 23% reported a recent
gastrointestinal or respiratory illness (70), whereas a study of 10 military heatstroke
patients reported that three had a fever or disease and six recalled at least one
warning sign of impending illness at the time of their heatstroke (5).
Appropriate ﬂuid ingestion before and during prolonged running can minimize
dehydration and reduce the rate of increase in body core temperature (23,34).
However, excessive hyperthermia may occur in the absence of signiﬁcantdehydration, especially in races of less than 10 km, because the fast pace generates
greater metabolic heat (90).
The mortality rate and organ damage due to heatstroke are proportional to thelength of time between core temperature elevation and initiation of cooling therapy(5,26). Therefore, prompt recognition and cooling are essential (1,5,22,42,48,51,62,7
4,83). A measurement of deep body temperature is vital to the diagnosis, and a rectal
temperature should be measured in any casualty suspected of having heat illness
or hypothermia. Ear (tympanic), oral, or axillary measurements are spuriously
affected by peripheral (skin) and environmental temperatures and should not be used
after exercise (8,75,76). When cooling is initiated rapidly, most heatstroke patients
recover fully with normal psychological status (79), muscle energy metabolism(65), heat acclimatization, temperature regulation, electrolyte balance, sweat gland
function, and blood constituents (5).
Many whole-body cooling techniques have been used to treat exertional heatstroke, including water immersion, application of wet towels or sheets, warm air
spray, helicopter downdraft, and ice packs to the neck, underarm, and groin areas.
There is disagreement as to which modality provides the most efﬁcient cooling(7,47,97), because several methods have been used successfully. However, the fastest whole-body cooling rates 925,48,49,59,88) and the lowest mortality rates (25)have been observed during cool and cold water immersion. Whichever modality isutilized it should be simple and safe, provide great cooling power, and should not
restrict other forms of therapy (i.e., cardiopulmonary resuscitation, deﬁbrillation, IV

APPENDICES

cannulation). The advantages and disadvantages of various cooling techniques havebeen discussed (47,75,97).
Heatstroke is regarded as a medical emergency that might be fatal if not
immediately diagnosed and properly treated. Early diagnosis is of utmost importanceand time-consuming investigation should be postponed until body temperature iscorrected and the patient is evacuated to a nearby medical facility that is aware ofsuch conditions.
3. Hypothermia
Hypothermia [body core temperature below 35ºC (95ºF)] occurs when heatloss is greater than metabolic heat production (94). Early signs and symptomsof hypothermia include shivering, euphoria, confusion, and behavior similar
to intoxication. Lethargy, muscular weakness, disorientation, hallucinations,depression, or combative behavior may occur as core temperature continues to fall.
If body core temperature falls below 31.1ºC (88ºF), shivering may stop and thepatient will become progressively delirious, uncoordinated, and eventually comatose
if treatment is not provided (10).
During cool or cold weather marathons, the most common illnesses are hypothermia, exhaustion, and dehydration. The most common medical complaints are
weakness, shivering, lethargy, slurred speech, dizziness, diarrhea, and thirst (1,45).
Runner complaints of feeling hot or cold do not always agree with changes in rectal
temperature (74). Dehydration is common in cool weather (1,45). Runners shouldattempt to replace ﬂuids at a rate that matches their sweat and urine losses. Cases ofhypothermia also occur in spring and fall because weather conditions change rapidly
and runners wear inappropriate clothing that becomes sweat-soaked during trainingor competition (19).
Hypothermia may occur during races, for example when distance runnercomplete the second half of the event more slowly than the ﬁrst half (54).
Evaporative and radiative cooling increase because wet skin (from sweat, rain, orsnow) and clothing are exposed to higher wind speed at a time when metabolic heatproduction decreases. Hypothermia also occurs after a race, when the temperature
gradient between the body surface and the environment is high. Subfreezing ambient
temperatures need not be present and hypothermia may develop even when the
air temperature is 10–18ºC (50–65ºF) (19,36,74). A WBGT meter can be used toevaluate the risk of hypothermia (see Appendix I). Cold wind increases heat loss inproportion to wind speed; i.e., wind chill factor. The relative degree of danger can beassessed [note: see Table 11-2 in Chapter 11, Part 1, Heat and Cold of this volume](55). Wind speed can be estimated; if you feel the wind in your face the speed is atleast 16 km/h (kph) [10 miles/h (mph)]; if small tree branches move or if snow anddust are raised, approximately 32 kph (20 mph); if large tree branches move, 48 kph(30 mph); if an entire tree bends, about 64 kph (40 mph) (9).
To reduce heat loss, runners should protect themselves from moisture, wind, andcold air by wearing several layers of light, loose clothing that insulate the skin withtrapped air (17). An outer garment that is windproof, allows moisture to escape, andAPPENDICES

provides rain protection is useful. Lightweight nylon parkas may not offer thermal
insulation but offer signiﬁcant protection against severe wind chill, especially if ahood is provided. Wool and polyester fabrics retains some protective value whenwet; cotton and goose down do not (10). Areas of the body that lose large amount ofheat (head, neck, legs, hands) should be covered (17).
Mild [34–36º (93–97ºF)] or moderate [30–34ºC (86–93ºF)] hypothermia shouldbe treated before it progresses. Wet clothing should be replaced with dry material(sweatsuit, blanket) that is insulated from the ground and wind. Warm ﬂuids
should be consumed if patients are conscious, able to talk, and thinking clearly.
Patients with moderate and severe [<30ºC (86ºF)] hypothermia should be insulated
in a blanket and evacuated to a hospital immediately (19,58). Although severe
hypothermia should be treated in the ﬁeld (27), it is widely recognized that lifethreatening ventricular ﬁbrillation is common in this state and may be initiated byphysical manipulation, chest compression, or intubation (10,27,58,93). However,with conclusive evidence of cardiac standstill and breathlessness, emergency
procedures (i.e., Basic Life Support, Advanced Cardiac Life Support) should beinitiated. Life-support procedures (27) and commonly observed laboratory (i.e.,electrolyte, acid-base) values (10,58) have been described by others.
4. Frostbite
Frostbite involves crystallization of ﬂuids in the skin or subcutaneous tissue
after exposure to subfreezing temperatures [-0.6ºC (31ºF)]. With low skintemperature and dehydration, cutaneous blood vessels constrict and circulation
is attenuated because the viscosity of blood increases (55). Frostbite may occur
within seconds or hours of exposure, depending upon air temperature, wind speed,
and body insulation. Frostbitten skin can appear white, yellow-white, or purple,
and is hard, cold, and insensitive to touch (55). Rewarming results in intense pain,
skin reddening, and swelling. Blister formation is common and loss of extremities(ﬁngers, toes, ears, hands, feet) is possible (36,55). The degree of tissue damage
depends on duration and severity of the freezing and effectiveness of treatment.
No data have been published regarding the incidence of frostbite among athletes
during training or competition. Since winter running races are rarely postponed
when environmental conditions are harsh, and frostbite is the most common cold
injury in military settings (35), it is imperative that runners be aware of the dangers.
Cross-country ski races are postponed if the temperature at the coldest point of thecourse is less than -20ºC (-4ºF), due to the severe wind chill generated at race pace.
Runners risk frozen ﬂesh within minutes if the air temperature and wind speed
combine to present a severe wind chill. Because runners prefer to have unrestrictedmovement during races, and because they know that exercise results in body heating,they may not wear sufﬁcient clothing. Runners can avoid frostbite and hypothermia
in cold and windy conditions by protecting themselves by dressing adequately: wetskin or clothing will increase the risk of frostbite (21,29).
When tissue freezes [skin temperature -2º–0ºC, (28–32ºF)], water is drawn outof the cells and ice crystals cause mechanical destruction of skin and subcutaneous

APPENDICES

tissue (36). However, initial ice crystal formation is not as damaging to tissues as
partial rethawing and refreezing (40). Therefore, the decision to treat severe frostbite
in the ﬁeld (versus transport to a hospital) should consider the possibility of refreezing.
If there is no likelihood of refreezing, the tissue should be rapidly rewarmed (36,40)
in circulating warm water (40–43.3ºC, 104–110ºF), insulated, and the patienttransported to a medical facility. Research on animals suggests that topical aloevera and systemic ibuprofen may reduce tissue damage and speed rehabilitation inhumans (9). Other aspects of hospital treatment protocols are detailed elsewhere(9,36,40).
Race Organization

The following suggestions constitute the ideal race medical team. They are
offered for consideration, but are not intended as absolute requirements. Staff andequipment needs are unique to each race and may be revised after 1–2 yr, in light ofthe distinctive features of each race. Depending on the weather conditions, 2–12% of
all entrants will typically enter a medical aid station (1,45,50,74).
1. Medical Personnel
a. Provide medical assistance if the rae is 10 km (6.2 miles) or longer.
b. Provide the following medical personnel per 1,000 runners: 1–2 physicians,
46 podiatrists, 1–4 emergency medical technicians, 2–4 nurses, 3–6 physical therapists,
3–6 athletic trainers, and 1–3 assistants. Approximately 75% of these personnel
should be stationed at the ﬁnish area. Recruit one nurse (per 1,000 runners) trainedin IV therapy.
c. Recruit emergency personnel from existing organizations (police, ﬁre-rescue,
emergency medical service).
d. One physician and 10–15 medical assistants serve as the triage team in the ﬁnish
chute. Runners unable to walk are transported to the medical tent via wheelchair,litter, or two-person carry.
e. Consider one or two physicians and two to four nurses trained in the
rehabilitative medical care of wheelchair athletes.
f. Medical volunteers should attend a brieﬁng prior to the event to meettheir supervisor and receive identiﬁcation tags, weather forecast, instructions, andschedules. Supervisors from the following groups should be introduced: medical
director; podiatry, nursing, physical therapy, athletic training, medical records,
triage, wheelchair, athlete care, and medical security (optional: chiropractic, massage
therapy). Medical volunteers should be distinguished from other race volunteers;luminous/distinctive vests, coats, or hats work well.
2. Medical Aid Stations
a. Provide a primary medical aid station (250–1,500 ft2 [23–139m2] for each
1,000 runners; see Table 1) at the ﬁnish area, with no public access. Place security
guards at all entrances with instructions regarding who can enter.

APPENDICES

Table 1: Suggested equipment and supplies per 1,000 runners.
Item
Stretchers (at 10 km and beyond)
Cots
Wheelchairs
Wool blankets (at 10 km and beyond)
Bath towels
High and low temperature rectal
thermometers (37–43ºC; 99–110ºF)
and (22–37ºC; 72–99ºF)dElastic bandages (2, 4, and 6 inch)
Gauze pads (4 x 4 inch)
Adhesive tape (1.5 inch)
Skin disinfectant
Surgical soap
Band-aids
Moleskin
Petroleum jelly, ointments
Disposable latex gloves
Stethoscopes
Blood pressure cuffs
Intravenous (IV) stationsd
IV ﬂuids (D5:1/2 NS; o.5 or 1 l)dSharps and biohazard disposal containersd
Alcohol wipes
Small instrument kits
Athletic trainer’s kit
Podiatrist’s kit
Inﬂatable arm and leg splints
Tables for medical supplies
Hose with spray nozzle, running watere
Wading pool for water immersionse
Fans for cooling
Oxygen tanks with regulators and masks
Crushed ice in plastic bags
Rehydration ﬂuids
Cups (≥0.3 l, 10 oz)
Eye drops
Urine dipsticksd
Glucose blood monitoring kitd
Inhalation therapy for asthmaticsd
EMS ambulance or ACLS station
Injectable and oral drugsd

Secondary
Aid Stationb

Primary
Aid Stationc

2–5
10
0
6–10
5–10
5

4–10
30
1
12–20
10–20
10

3 each1/2 case
1/2 case
1l
1/2 case
110
1/2 case
1/2 case
80 pairs
1
1
1
15e
1
50
1
1
1–2
2 each
1
1
1
1
0
7 kg
50 le
1250
1
10
1
1
1

6 each1 case1 case2l
1 case220
1 case1 case175 pairs
2
2
2
30e
2
100
1
1
2–4
2 each
2
2
2
2–4
2
14 kg
100 le
2250
1
20
2
1
1

a
Revised from Adner, M. M., J. J. Scarlet, J. Casey, W. Robison, and B. H. Jones. The Boston Marathon medicalcare team: ten years of experience. Physician Sportsmed. 16:99-106, 1988; and Noble, H. B. and D. Bachman.
Medical aspects of distance race planning. Physician Sportsmed. 7:78-84, 1979.
b
Increase supplies and equipment if race is out and back. cAt ﬁnish area. dSupervised by a physician.
eDepends on environmental conditions.

APPENDICES

b. Position secondary medical aid stations along the route at 2- to 3-km (1.2- to
1.9-mile) intervals for races over 10 km, and at the halfway point for shorter races(see Table 1). Some race directors have successfully secured equipment and medical
volunteers from military reserve or national guard medical units, the American Red
Cross, and the National Ski Patrol.
c. Station one ambulance per 3,000 runners at the ﬁnish area and one or moremobile emergency response vehicles on the course. Staff each vehicle with a nurse
and radio person or cellular telephone. Stock each vehicle with a medical kit, automatic deﬁbrillator, IV apparatus, blankets, towels, crushed ice, blood pressure cuffs,
rehydration ﬂuid, and cups.
d. Signs should be posted at the starting line and at each medical station toannounce the risk of heat illness or cold injury (see Appendix I).
e. A medical record card should be completed for each runner who receives
treatment (1,74). This card provides details that can be used to plan the medical
coverage of future events.
f. Provide personal protective equipment (gloves, gowns, face shields, eyeprotection) and hand washing facilities.
g. Provide portable latrines and containers for patients with vomiting anddiarrhea.
h. Initial medical assessment must include rectal (not oral, aural, or axillarytemperature; see ref. 8,76), central nervous system function, and cardiovascularfunction. Rehydration and cooling or warming are the cornerstones of treatment(32,41,42,50,74,94).
3. Universal Precautions
All medical personnel may encounter blood-borne pathogens or other potentially
infectious materials, and should observe the following precautions (53,63):
a. Receive immunization against hepatitis B prior to the event.
b. Recognize that blood and infectious body ﬂuids may be encountered fromneedle sticks, cuts, abrasions, blisters, and clothing.
c. Reduce the likelihood of exposure by planning tasks carefully (i.e., prohibiting recapping of needles by a two-handed technique, minimizing splashing andspraying).
d. Wear personal protective equipment such as gloves, gowns, face shields andeye protection. Remove this equipment and dispose/decontaminate it prior to leaving
the work area.
e. Wash hands after removing gloves or other personal protective equipment.
f. Dispose of protective coverings, needles, scalpels, and other sharp objects inapproved, labeled biohazard containers.
g. Do not eat, drink, smoke, handle contact lenses, or apply cosmetics/lip balmin the medical treatment area.
h. Decontaminate work surfaces, bins, pails, and cans [1/10 solution of household bleach (sodium hypochlorite) in water] after completion of procedures.

APPENDICES

4. Fluid Stations
a. At the start and ﬁnish areas provide 0.34–0.45 l (12–16 oz) of ﬂuid per runner.
At each ﬂuid station on the race course (2–3 km apart), provide 0.28–0.34 l (10–12oz) of ﬂuid per runner. Provide both water and a carbohydrate-electrolyte beveragein equal volumes.
b. In cool or cold weather [≤10ºC (50ºF)], an equivalent amount of warm ﬂuid
should be available.
c. Number of cups (≥ 0.3 l, 10 oz) per ﬂuid station on the course = number ofentrants + 25% for spillage and double use. Double this total if the course is out and back.
d. Number of cups at start and ﬁnish area = (2 x number of entrants) + 25% additional.
e. Cups should be ﬁlled prior to the race and placed on tables to allow easy
access. Runners drink larger volumes if volunteers hand them cups ﬁlled with ﬂuid.
5. Communications/Surveillancea. Provide two-way radio or telephone communication between the medical
director, medical aid stations, mobile vans, and pick-up vehicles.
b. Arrange for radio-equipped vehicles to drive the race course (ahead andbehind participants) and provide communication with the director and his/her staff.
These vehicles should be stationed at regular intervals along the course to search thecourse for competitors who require emergency care and encourage compromised
runners to stop.
c. Place radio-equipped observers along the course.
d. Notify local hospitals, police, and ﬁre-rescue departments of the time of theevent, number of participants, location of aid stations, extent of medical coverage,
and the race course.
e. Use the emergency response system (telephone number 911 [in U.S.] or 112[international]) in urban areas.
6. Instructions to Runners
a. Advise each race participant to print name, address, telephone number, andmedical problems on the back of the race number (pinned to the body). This permits
emergency personnel to quickly identify unconscious runners. Inform emergency
personnel that this information exists.
b. Inform race participants of potential medical problems at pre-race conferences
and at the starting line. Signed registration forms should clearly state the types ofheat or cold injuries that may arise from participation in this event.
c. Provide pre-event recommendations regarding training, ﬂuid consumption,
clothing selection, self-care, heat acclimatization, and signs or symptoms of heat/cold illness (88).
d. The race director should announce the following information to all participantsby loudspeaker immediately prior to the race:– Current and predicted maximum (or minimum) temperature, humidity, windspeed, and cloud cover;APPENDICES

–
–
–
–
–
–
–
–
–

The WBGT category and risks for hyperthermia or hypothermia (seeAppendix I);
Location of aid stations, types of assistance, and ﬂuid availability;
Signs and symptoms of heat or cold illness;
Recommended clothing;
The need for ﬂuid replacement before, during, and after the race;
The policy of race monitors to stop runners who are ill;
A request that runners seek help for impaired competitors who appear ill,
who are not coherent, who run in the wrong direction, or who exhibit upperbody swaying and poor competitive posture;
A warning to novice runners entering their ﬁrst race that they should run at a
comfortable pace and run with a partner;
Warnings to runners who are taking medications or who have chronic
illnesses (asthma, hypertension, diabetes, cardiovascular problems).

Acknowledgment

This position stand replaces the 1987 ACSM position paper, “The Prevention of
Thermal Injuries During Distance Running.”
The pronouncement was reviewed for the American College of Sports Medicine
by members-at-large, the Pronouncement Committee, and by: Arthur E. Crago,
M.D., Stafford W. Dobbin, M.D., Mary L. O’Toole, Ph.D., FACSM, LTC Katy L.
Reynolds, M.D., and John W. Robertson, M.D., FACSM.
References

See http://www.acsm-msse.org/pt/re/msse/positionstandards.htm for list ofreferences (scroll to December 1, 1996 for pdf).

Appendix I. Measurement of Environmental StressAmbient temperature is only one component of environmental heat or cold
stress; others are humidity, wind speed, and radiant heat. The most widely used heatstress index is the wet bulb globe temperature (WBGT) index (96):
WBGT = (0.7 Twb) + (0.2 Tg) + (0.1 Tdb)
Where Twb is the wet bulb temperature, Tg is the black globe temperature, and
Tdb is the shaded dry bulb temperature (28). Tdb refers to air temperature measured
with a standard dry bulb thermometer not in direct sunlight. Twb is measured with awater-saturated cloth wick over a dry bulb thermometer (not immersed in water). Tg
is measured by inserting a dry bulb thermometer into a standard black metal globe.
Both Twb and Tg are measured in direct sunlight.
A portable monitor that gives the WBGT index in degrees Celsius or degrees
Fahrenheit has proven useful during races and in military training (28,44,87,96). The
measurement of air temperature alone is inadequate. The importance of humidity

APPENDICES

in total heat stress can be readily appreciated because Twb accounts for 70% of theindex whereas Tdb accounts for only 10%.
The risk of heat illness (while wearing shorts, socks, shoes, and a t-shirt) due toenvironmental stress should be communicated to runners in four categories (see Fig.
1):
Very high risk: WBGT above 28ºC (82ºF);
High risk: WBGT 23–28ºC (73–82ºF);
Moderate risk: WBGT 18–23ºC (65–73ºF);
Low risk: WBGT below 18ºC (65ºF).
Large signs should be displayed, at the start of the race and at key points along
the race course, to describe the risk of heat exhaustion and heatstroke (Fig. 1). When
the WBGT index is above 28ºC (82ºF), the risk of heat exhaustion or heatstroke
is very high; it is recommended that the race be postponed or canceled. High risk
[WBGT index = 23–28ºC (73–82ºF)] indicates that runners should be aware thatheat exhaustion or heatstroke may be experienced by any participant; anyone who
is particularly sensitive to heat or humidity probably should not run. Moderate risk
[WBGT index = 18–23ºC (65–73ºF)] reminds runners that heat and humidity during
the course of the race if conducted during the morning or early afternoon. Low risk
[WBGT index = below 18ºC (65ºF)] does not guarantee that heat exhaustion (evenheat stroke, see ref. 5,32) will not occur; it only indicates that the risk is low.
The risk of hypothermia (while wearing shorts, socks, shoes, and a t-shirt) also
should be communicated to runners. A WBGT index below 10ºC (50ºF) indicatesthat hypothermia may occur in slow runners who run long distances, especiallyin wet and windy conditions. Core body temperatures as low as 92ºF have been
observed in 65ºF conditions (74).

Appendix 5

IAAF Policy on Fluid Replacement
Heat Stress and Heat Illness

Heat stress and heat illness occur when the body’s heat production goes beyond
the many factors responsible for heat loss.
Heat production is determined by the athlete’s metabolic rate (energy expenditure),i.e., race pace, body weight, and running economy. About three-quarters of theenergy produced by exercise is stored as heat. Thus, higher-intensity races such as a
10 kilometre race are more likely to lead to heat injury than longer races, which are
run at a slower pace.
Many factors determine the body’s ability to dissipate heat: environmental
factors such as ambient temperature, relative humidity, and air currents, aswell as the athlete’s level of ﬁtness and his or her degree of heat adaptation.
The environmental factors can be assessed by measuring the Wet Bulb Globe
Temperature (WBGT). It is advised to run distance races below 18 degrees of
WBGT value.
One of the major factors responsible for cooling and maintaining the body’s
temperature in warm weather is the body’s ability to evaporate sweat. Hence,adequate hydration is one of the most important elements in the prevention of heat
injury, and the ability to maintain a high level of performance.
Performance begins to become impaired when the body loses more than 2–3%
of body weight, primarily as ﬂuid losses from sweating. The athlete’s heart rateand core temperature will be increased. Thus, maintaining adequate hydration isimportant, but athletes must realise that hydration alone is not sufﬁcient to prevent
heat injury.
Athletes must learn to recognise thirst as a late indicator of dehydration. They
should consume ﬂuid before they feel thirst. However, drinking excess amounts of
ﬂuid in the absence of thirst may lead to over-hydration and exertional hyponatremia(low blood sodium), especially if the ﬂuids consumed are sodium-free. Exertional
hyponatremia can be a life-threatening condition, and is more likely to occur inslower runners who are exercising for four hours or more. Their metabolic rateand heat production are lower, and due to their slower pace they are more able toconsume more ﬂuids than they need.
Pre-Race Preparation

1. Heat adaptation. Train under similar conditions as those expected during
the race. This ideally may require 7–10 days. If this is not possible, train
with additional clothing in order to raise core temperature. However,
NEVER wear rubber suits or other clothing that inhibits sweat evaporation.
2. Practice drinking during training runs, so that you can drink comfortably
while running. Use the same drinks in the training run and the race run.
Observe weight changes during training sessions to get a feel for typicalsweat rates, then develop a drinking plan that allows you to replace most

APPENDICES

3.
4.

5.
6.

of these losses during the session. (For example, if you ﬁnd that you
sweat at a rate of ~1 litre per hour, drinking at a rate of 400–800 ml
per hour is likely to be a good plan).
Salt food heavily for several days prior to the competition. Restore salt
in the body.
Begin the race well-hydrated. Consume 500–600 ml of water or a sports
drink during the 2–3 hours before the race, and another 300 ml 10–15
minutes before the start (300 ml of water can be absorbed within 15
minutes).
Be aware of WBGT, which will let you know the possibility of heat illness.
Do not use any non-steroidal anti-inﬂammatory drugs (NSAIDs) except
acetaminophen. NSAIDs are thought to increase the possibility ofhyponatremia while running long distances.

During the Race

1. Consume an adequate amount of ﬂuids to prevent dehydration (see point
2 under race preparation).
2. Consume cool liquids that contain 0.2–0.45% sodium and 5% glucose or
glucose polymer. This combination replaces electrolytes lost in sweat,aids in preventing hyponatremia, and provides carbohydrate for energy.
3. As sweat losses and the ability to absorb ﬂuids may vary considerably
among individuals, it is useful to determine one’s individual needs byusing the guidelines found in References 1 and 2 (see below).
4. It may not be possible or necessary to drink at a rate that completely replaces
sweat losses during an event. In most cases, drinking to keep losses lessthan 2% of body mass is suitable. You should not drink at rates greater thansweat losses so that you gain weight over the session.
After the Race

1. Begin to re-hydrate and restore muscle glycogen as soon as possible after
the race. Fluids containing electrolytes (sodium and potassium) andcarbohydrates are needed to replace losses.
2. Optimal replenishment of muscle glycogen is best carried out in the ﬁrst
2–4 hours post-competition.
3. If possible, the athlete should weigh him or herself before and after therace to determine the amount of ﬂuid loss, and replace this loss with
1 1/4–1 1/2 times this amount.
Dehydration and hyponatremia can be prevented in distance running, andperformance should be improved by proper ﬂuid and salt replacement before andduring the races.

APPENDICES

This policy has been written by Dr. Fumihiro Yamasawa, Dr. Harmon Brown,
and Professor Louise Burke on behalf of the IAAF Medical and Anti-Doping
Commission.
References

1.
2.
3.

4.

Hydration Guidelines. www.USATF.org
Nutrition for Athletes. International Consensus Conference. Lausanne: IOC,
June 2003.
Noakes, T., and D. E. Martin. IMMDA-AIMS advisory statement on guidelines
for ﬂuid replacement during marathon running. New Studies in Athletics 17:1524, 2002.
Shapiro, S. A., A. A. Ejaz, M. D. Osborne, and W. C. Taylor. Moderate
exercise-induced hyponatremia. Clin. J. Sport Med. Jan; 16(1):72-73, 2006.

5. Dugas, J. P., and T. D. Noakes. Hyponatraemic encephalopathy despite amodest rate of ﬂuid intake during a 109 km cycle race. Br. J. Sports. Med.
Oct; 39(10):e38, 2005.

Appendix 6

Supplies for Injury Prevention/First Aid
On-Site Medical Supplies

Following are lists of medical bag items and medical supplies for contact/
collision and high-risk sports.
General• Alcohol swabs and povidone iodine swabs• Bandage scissors• Bandages, sterile/nonsterile, Band-Aids• Disinfectant• Gloves, sterile/nonsterile• Local anesthetic/syringes/needles• Paper/ Pen• Plastic bags
• Sharps box and biohazard bag• Sling• Suture set/Steri-Strips• Wound irrigation materials (e.g. , sterile normal saline, 10- to 50-cc syringe)
Cardiopulmonary• Oropharyngeal airway• Blood pressure cuff
• Epinephrine 1:1000 in a prepackaged unit
• Mouth-to-mouth mask
• Short-acting beta2 agonist inhaler• Stethoscope
Head and Neck/Neurologic• Dental kit ( e.g., cyanoacrylate, Hank’s solution)• Eye kit ( e.g., blue light, ﬂuorescein stain strips, eye patch pads,
cotton tip applicators, ocular anesthetic and antibiotics, contact remover,mirror)• Semirigid cervical collar• Spine board and attachments• Flashlight• Pin or other sharp object for sensory testing• Reﬂex hammer

APPENDICES

General• Access to a telephone• Crutches• Extremity splints• Ice• List of emergency phone numbers• Injury and illness care instruction sheets for the athlete• Benzoin• Blister care materials• Contact lens case and solution• Ferric subsulfate solution (e.g., Munsell’s for cauterizing abrasions and cuts)• Nail clippers• Nasal packing material• Oral ﬂuid replacement• Oto-ophthalmoscope• Razor and shaving cream• Scalpel• Skin lubricant• Skin staple applicator• Small mirror• Tape cutter• Tongue depressors• Topical antibiotics• Massage lotion
Cardiopulmonary• Advanced Cardiac Life Support (ACLS) drugs and equipment• IV ﬂuids and administration set• Tourniquet• Automated external deﬁbrillator (AED)
In addition, sideline medical supplies should include the following:• Blanket/Crutches• Sling psychrometer and temperature/humidity activity risk chart

Appendix 7

Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) Guidelines
Adult Basic Life Support
Adapted from the 2005 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care, Circulation. 2005; 112:IV-19–IV-34.

Basic life support (BLS) includes recognition of signs of sudden cardiac
arrest (SCA), heart attack, stroke, and foreign-body airway obstruction (FBAO);
cardiopulmonary resuscitation (CPR); and deﬁbrillation with an automated externaldeﬁbrillator (AED). This section summarizes BLS guidelines for lay rescuers andhealthcare providers.
Introduction

Sudden cardiac arrest is a leading cause of death in the United States andCanada.1–3 At the ﬁrst analysis of heart rhythm, about 40% of victims of out-ofhospital SCA demonstrate ventricular ﬁbrillation (VF).3–5 VF is characterized bychaotic rapid depolarizations and repolarizations that cause the heart to quiver sothat it is unable to pump blood effectively.6 It is likely that an even larger number of
SCA victims have VF or rapid ventricular tachycardia (VT) at the time of collapse,
but by the time of ﬁrst rhythm analysis the rhythm has deteriorated to asystole.7
Many SCA victims can survive if bystanders act immediately while VF is stillpresent, but successful resuscitation is unlikely once the rhythm deteriorates toasystole.8 Treatment for VF SCA is immediate bystander CPR plus delivery of ashock with a deﬁbrillator. The mechanism of cardiac arrest in victims of trauma,
drug overdose, drowning, and in many children is asphyxia. CPR with bothcompressions and rescue breaths is critical for resuscitation of these victims.
The American Heart Association uses 4 links in a chain (the “Chain of Survival”)
to illustrate the important time-sensitive actions for victims of VF SCA. Three andpossibly all 4 of these links are also relevant for victims of asphyxial arrest.9• Early recognition of the emergency and activation of the emergency medical
services (EMS) or local emergency response system: “phone 911.”10,11• Early bystander CPR: immediate CPR can double or triple the victim’s chanceof survival from VF SCA.8, 12–14• Early delivery of a shock with a deﬁbrillator: CPR plus deﬁbrillation within 3
to 5 minutes of collapse can produce survival rates as high as 49% to 75%.15, 16• Early advanced life support followed by postresuscitation care delivered byhealthcare providers.
Bystanders can perform 3 of the 4 links in the Chain of Survival. When
bystanders recognize the emergency and activate the EMS system, they ensurethat basic and advanced life support providers are dispatched to the site of theemergency. In many communities the time interval from EMS call to EMS arrivalis 7 to 8 minutes or longer.17 This means that in the ﬁrst minutes after collapse thevictim’s chance of survival is in the hands of bystanders.

APPENDICES

Shortening the EMS response interval increases survival from SCA, but theeffect is minimal once the EMS response interval (from the time of EMS call until
arrival) exceeds 5 to 6 minutes.18, 19 EMS systems should evaluate their protocols for
cardiac arrest patients and try to shorten response intervals when improvements arefeasible and re- sources are available. Each EMS system should measure the rate ofsurvival to hospital discharge for victims of VF SCA and use these measurements to
document the impact of changes in procedures.21
Victims of cardiac arrest need immediate CPR, which provides a small but
critical amount of blood ﬂow to the heart and brain. CPR prolongs the time VF ispresent and increases the likelihood that a shock will terminate VF (deﬁbrillate theheart) and allow the heart to resume an effective rhythm and effective systemic
perfusion. CPR is especially important if a shock is not delivered for 4 or more
minutes after collapse.22 Deﬁbrillation does not “restart” the heart; deﬁbrillation“stuns” the heart, brieﬂy stopping VF and other cardiac electrical activity. If theheart is still viable, its normal pacemakers may then resume ﬁring and produce aneffective ECG rhythm that may ultimately produce adequate blood ﬂow.
Adult BLS Sequence

The steps of BLS consist of a series of sequential assessments and actions,which are illustrated in the BLS algorithm (Figure 1). The intent of the algorithm
is to present the steps in a logical and concise manner that will be easy to learn,
remember, and perform.
Before approaching the victim, the rescuer must ensure that the scene is safe.
Lay rescuers should move trauma victims only if absolutely necessary (e.g., thevictim is in a dangerous location, such as a burning building).
Check for Response
Once the rescuer has ensured that the scene is safe, the rescuer should check for
response. To check for response, tap the victim on the shoulder and ask, “Are you
all right?” If the victim responds but is injured or needs medical assistance, leave
the victim to phone 911. Then return as quickly as possible and recheck the victim’s
condition frequently.
Activate the EMS System
If a lone rescuer ﬁnds an unresponsive adult (i.e., no movement or responseto stimulation), the rescuer should activate the EMS system (phone 911), get an
AED (if available), and return to the victim to provide CPR and deﬁbrillation if
needed. When 2 or more rescuers are present, one rescuer should begin the stepsof CPR while a second rescuer activates the EMS system and gets the AED. If theemergency occurs in a facility with an established medical response system, notifythat system instead of the EMS system.
Healthcare providers may tailor the sequence of rescue actions to the most likely
cause of arrest.23, 24 If a lone healthcare provider sees an adult or child suddenly
collapse, the collapse is likely to be cardiac in origin, and the provider should phone

APPENDICES

No movement or response

Phone 911 or emergency number
Get AEDor send second rescuer(if available) to do thisOpen AIRWAY, check BREATHING

If not breathing, give 2 BREATHS that make chest riseDeﬁnite pulse
If no response, check pulse.
Do you DEFINITELY feel pulse
within 10 seconds?

Give 1 breath every
5 to 6 seconds.
Recheck pulse every
2 minutes.

No pulse
Give cycles of 30 COMPRESSIONS and 2 BREATHS
until AED/deﬁbrillator arrives, ALS providers take over,or victim starts to move.
Push hard and fast (100/min) and release completely.
Minimize interruptions in compressions.

AED/deﬁbrillator ARRIVESCheck rhythm
Shockable rhythm?
Shockable
Give 1 shock
Resume CPR immediately
for 5 cycles

Not shockable
Resume CPR immediately
for 5 cycles.
Check rhythm every
5 cycles; continue until ALS
providers take over or
victim starts to move.

Figure 1. Adult BLS Healthcare Provider Algorithm. Boxes bordered with dotted lines indicate
actions or steps performed by the healthcare provider but not the lay rescuer.

APPENDICES

911, get an AED, and return to the victim to provide CPR and use the AED. If alone healthcare provider aids a drowning victim or other victim of likely asphyxial(primary respiratory) arrest of any age, the healthcare provider should give 5 cycles(about 2 minutes) of CPR before leaving the victim to activate the EMS system.
When phoning 911 for help, the rescuer should be prepared to answer the
dispatcher’s questions about location, what happened, number and condition of
victims, and type of aid provided. The caller should hang up only when instructed
to do so by the dispatcher and should then return to the victim to provide CPR anddeﬁbrillation if needed.
Open the Airway and Check Breathing
To prepare for CPR, place the victim on a hard surface in a face up (supine)
position. If an unresponsive victim is face down (prone), roll the victim to asupine (face up) position. If a hospitalized patient with an advanced airway (e.g.,
endotracheal tube, laryngeal mask airway [LMA], or esophageal- tracheal combitube[Combitube]) cannot be placed in the supine position (e.g., during spinal surgery),the healthcare provider may attempt CPR with the patient in a prone position.
Open the Airway: Lay Rescuer
The lay rescuer should open the airway using a head tilt– chin lift maneuver forboth injured and noninjured victims. The jaw thrust is no longer recommended forlay rescuers because it is difﬁcult for lay rescuers to learn and perform, is often not
an effective way to open the airway, and may cause spinal movement.
Open the Airway: Healthcare Provider
A healthcare provider should use the head tilt– chin lift maneuver to open the
airway of a victim without evidence of head or neck trauma. Although the headtilt– chin lift technique was developed using unconscious, paralyzed adult volunteers
and has not been studied in victims with cardiac arrest, clinical25 and radiographic
evidence.26, 27 have shown it to be effective. Approximately 2% of victims with blunttrauma have a spinal injury, and this risk is tripled if the victim has a craniofacial
injury, a Glasgow Coma Scale score of 8 or both.28 If a healthcare provider suspects
a cervical spine injury, open the airway using a jaw thrust without head extension.29
Because maintaining a patent airway and providing adequate ventilation is a priority
in CPR, use a head tilt– chin lift maneuver if the jaw thrust does not open the airway.
Check Breathing
While maintaining an open airway, look, listen, and feel for breathing. If you area lay rescuer and do not conﬁdently detect normal breathing or if you are a healthcare provider and do not detect adequate breathing within 10 seconds, give 2 breaths(see below). If you are a lay rescuer and you are unwilling or unable to give rescue
breaths, begin chest compressions.
Professional as well as lay rescuers may be unable to accurately determine thepresence or absence of adequate or normal breathing in unresponsive victims30
because the airway is not open31 or the victim has occasional gasps, which canAPPENDICES

occur in the ﬁrst minutes after SCA and may be confused with adequate breathing.
Occasional gasps are not effective breaths. Treat the victim who has occasional
gasps as if he or she is not breathing and give rescue breaths. CPR training shouldemphasize how to recognize occasional gasps and should instruct rescuers to give
rescue breaths and proceed with the steps of CPR when the unresponsive victim
demonstrates occasional gasps.
Give Rescue Breaths
Give 2 rescue breathes, each over 1 second, with enough volume to produce
visible chest rise. This recommended 1-second duration to make the chest riseapplies to all forms of ventilation during CPR, including mouth-to-mouth and bagmask ventilation and ventilation through an advanced airway, with and without
supplementary oxygen.
During CPR the purpose of ventilation is to maintain adequate oxygenation,
but the optimal tidal volume, respiratory rate, and inspired oxygen concentration toachieve this are not known. The following general recommendations can be made:1. During the ﬁrst minutes of VF SCA, rescue breaths are probably not asimportant as chest compressions32 because the oxygen level in the blood remains
high for the ﬁrst several minutes after cardiac arrest. In early cardiac arrest,
myocardial and cerebral oxygen delivery is limited more by the diminished blood
ﬂow (cardiac output) than a lack of oxygen in the blood. During CPR blood ﬂow isprovided by chest compressions. Rescuers must be sure to provide effective chest
compressions (see below) and minimize any interruption of chest compressions.
2. Both ventilations and compressions are important for victims of prolonged
VF SCA, when oxygen in the blood is utilized. Ventilations and compressions arealso important for victims of asphyxial arrest, such as children and drowning victims
who are hypoxemic at the time of cardiac arrest.
3. During CPR blood ﬂow to the lungs is substantially reduced, so an
adequate ventilation-perfusion ratio can be maintained with lower tidal volumes andrespiratory rates than normal.33 Rescuers should not provide hyperventilation (toomany breaths or too large a volume). Excessive ventilation is unnecessary and isharmful because it increases intrathoracic pressure, decreases venous return to theheart, and diminishes cardiac output and survival.34
4. Avoid delivering breaths that are too large or too forceful. Such breaths are
not needed and may cause gastric inﬂation and its resultant complications.35
The ECC Guidelines 200036 recommended a variety of tidal volumes, respiratory
rates, and breath delivery intervals. But it is unrealistic to expect the rescuer todistinguish half-second differences in inspiratory times or to judge tidal volumes
delivered by mouth-to-mouth or bag-mask ventilation. So these guidelines provide
simple recommendations for delivery of rescue breaths during cardiac arrest:• Deliver each rescue breath over 1 second.
• Give a sufﬁcient tidal volume (by mouth-to-mouth/mask or bag mask withor without supplementary oxygen) to produce visible chest rise.
• Avoid rapid or forceful breaths.

APPENDICES• When an advanced airway (i.e., endotracheal tube, Combi-tube, or LMA)
is in place during 2-person CPR, ventilate at a rate of 8 to 10 breaths per minutewithout attempting to synchronize breaths between compressions. There should be
no pause in chest compressions for delivery of ventilations.
If you are delivering ventilation with a bag and mask, use an adult ventilatingbag (volume of 1 to 2 L); a pediatric bag delivers inadequate tidal volume for an
adult.37, 38 When giving rescue breaths, give sufﬁcient volume to cause visible chest
rise. In 1 observational study trained BLS providers were able to detect “adequate”
chest rise in anesthetized, intubated, and paralyzed adult patients when a tidal
volume of approximately 400 mL was delivered.33 It is likely, however, that a larger
volume is required to produce chest rise in a victim with no advanced airway (e.g.,
endotracheal tube, Combitube, LMA) in place. We therefore recommend a tidal
volume of 500 to 600 mL but emphasize that the volume delivered should produce
visible chest rise. It is reasonable to use the same tidal volume in patients with asphyxial and arrhythmic cardiac arrest.
Mouth-to-Mouth Rescue Breathing
Mouth-to-mouth rescue breathing provides oxygen and ventilation to the victim.39
To provide mouth-to-mouth rescue breaths, open the victim’s airway, pinch thevictim’s nose, and create an airtight mouth-to-mouth seal. Give 1 breath over 1
second, take a “regular” (not a deep) breath, and give second rescues breathe over 1
second. Taking a regular rather than a deep breath prevents you from getting dizzyor lightheaded. The most common cause of ventilation difﬁculty is an improperly
opened airway, so if the victim’s chest does not rise with the ﬁrst rescue breath,
perform the head tilt– chin lift and give the second rescue breath.
Mouth-to–Barrier Device Breathing
Despite its safety, some healthcare providers and lay rescuers may hesitate togive mouth-to-mouth rescue breathing and prefer to use a barrier device. Barrier
devices may not reduce the risk of infection transmission,40 and some may increase
resistance to airﬂow.41 If you use a barrier device, do not delay rescue breathing.
Barrier devices are available in 2 types: face shields and face masks. Face shields
are clear plastic or silicone sheets that reduce direct contact between the victim andrescuer but do not prevent contamination of the rescuer’s side of the shield.42
A rescuer with a duty to respond should use a face shield only as a substitute formouth-to-mouth breathing. These responders should switch to face mask or bagmask ventilation as soon as possible.42 Masks used for mouth-to-mask breathingshould contain a 1-way valve that directs the rescuer’s breath into the patient while
diverting the patient’s exhaled air away from the rescuer.42 Some masks include anoxygen inlet for administration of supplementary oxygen. When oxygen is available,
healthcare providers should provide it at a minimum ﬂow rate of 10 to 12 L/min.

APPENDICES

Ventilation With Bag and Mask
Rescuers can provide bag-mask ventilation with room air or oxygen. A bagmask device provides positive-pressure ventilation without an advanced airway andtherefore may produce gastric inﬂation and its complications (see above). Whenusing a bag-mask device, deliver each breath over a period of 1 second and provide
sufﬁcient tidal volume to cause visible chest rise.
The Bag-Mask Device
A bag-mask device should have the following43, 44: a non jam inlet valve; either
no pressure relief valve or a pressure relief valve that can be bypassed; standard 15mm/22-mm ﬁttings; an oxygen reservoir to allow delivery of high oxygen concentrations; a nonrebreathing outlet valve that cannot be obstructed by foreign material
and will not jam with an oxygen ﬂow of 30 L/min; and the capability to function
satisfactorily under common environmental conditions and extremes of temperature.
Masks should be made of transparent material to allow detection of regurgitation.
They should be capable of creating a tight seal on the face, covering both mouth andnose. Masks should be ﬁtted with an oxygen (insufﬂation) inlet, have a standard 15mm/22-mm connector,45 and should be available in one adult and several pediatricsizes.
Bag-Mask Ventilation
Bag-mask ventilation is a challenging skill that requires considerable practicefor competency.46, 47 The lone rescuer using a bag-mask device should be able tosimultaneously open the airway with a jaw lift, hold the mask tightly against thepatient’s face, and squeeze the bag. The rescuer must also watch to be sure the chest
rises with each breath. Bag-mask ventilation is most effective when provided by 2
trained and experienced rescuers. One rescuer opens the airway and seals the mask
to the face while the other squeezes the bag. Both rescuers watch for visible chest
rise. 46, 47 The rescuer should use an adult (1 to 2 L) bag to deliver a tidal volume
sufﬁcient to achieve visible chest rise. If the airway is open and there are no leaks(i.e., there is a good seal between face and mask), this volume can be delivered bysqueezing a 1-L adult bag about one half to two thirds of its volume or a 2-L adultbag about one-third its volume. As long as the patient does not have an advanced
airway in place, the rescuer(s) should deliver cycles of 30 compressions and 2
breaths. The rescuer delivers the breaths during pauses in compressions and delivers
each breathe over 1 second.
The healthcare provider should use supplementary oxygen (O2 40%, a minimum
ﬂow rate of 10 to 12 L/min) when available. Ideally the bag should be attached toan oxygen reservoir to enable delivery of 100% oxygen. Advanced airway devices
such as the LMA145 and the esophageal-tracheal Combitube are currently within
the scope of BLS practice in a number of regions (with speciﬁc authorization frommedical control).48 These devices may provide acceptable alternatives to bag-mask
devices for healthcare providers who are well trained and have sufﬁcient experience
to use them. It is not clear that these devices are any more or less complicated to use

APPENDICES

than a bag and mask; training is needed for safe and effective use of both the bagmask device and each of the advanced airways.
Ventilation With an Advanced Airway
When the victim has an advanced airway in place during CPR, 2 rescuers nolonger deliver cycles of CPR (i.e., compressions interrupted by pauses for ventilation).
Instead, the compressing rescuer should give continuous chest compressions at a rateof 100 per minute without pauses for ventilation. The rescuer delivering ventilation
provides 8 to 10 breaths per minute. The 2 rescuers should change compressor andventilator roles approximately every 2 minutes to prevent compressor fatigue anddeterioration in quality and rate of chest compressions. When multiple rescuers arepresent, they should rotate the compressor role about every 2 minutes.
Rescuers should avoid excessive ventilation by giving the recommended
breaths per minute and limiting tidal volume to achieve chest rise.34 A translational
research study showed that delivery of 12 breaths per minute during CPR leads
to increased intrathoracic pressure, impeding venous return to the heart during
chest compressions.34 Reduced venous return leads to diminished cardiac output
during chest compressions and decreased coronary and cerebral perfusion.49, 50 It is
critically important that rescuers maintain a ventilation rate of 8 to 10 breaths per
minute during CPR and avoid excessive ventilation.34, 50
Cricoid Pressure
Pressure applied to the victim’s cricoid cartilage pushes the trachea posteriorly,
compresses the esophagus against the cervical vertebrae, and can prevent gastricinﬂation and reduce the risk of regurgitation and aspiration.51, 52 Application ofcricoid pressure usually requires a third rescuer, one who is not responsible for chest
compressions or ventilations. Cricoid pressure should be used only if the victim is
deeply unconscious (i.e., has no cough or gag reﬂex).
Pulse Check (for Healthcare Providers)

Lay rescuers fail to recognize the absence of a pulse in 10% of pulseless victims(poor sensitivity for cardiac arrest) and fail to detect a pulse in 40% of victims
with a pulse (poor speciﬁcity). In the ECC Guidelines 200036 the pulse check wasdeleted from training for lay rescuers and de-emphasized in training for healthcare
providers. There is no evidence, however, that checking for breathing, coughing,or movement is superior for detection of circulation.53 For ease of training, the lay
rescuer will be taught to assume that cardiac arrest is present if the unresponsive
victim is not breathing. Healthcare providers also may take too long to check for apulse, and have difﬁculty determining if a pulse is present or absent. The healthcare
provider should take no more than 10 seconds to check for a pulse. If a pulse is not
deﬁnitely felt within 10 seconds, proceed with chest compressions.

APPENDICES

Rescue Breathing Without Chest Compressions

If an adult victim with spontaneous circulation (i.e., palpable pulses) requires
support of ventilation, give rescue breaths at a rate of 10 to 12 breaths per minute, orabout 1 breath every 5 to 6 seconds. Each breath should be given over 1 second
regardless of whether an advanced airway is in place. Each breath should cause
visible chest rise. During delivery of rescue breaths, reassess the pulse approximately every 2 minutes, but spend no more than 10 seconds doing so.
Chest Compressions

Chest compressions consist of rhythmic applications of pressure over the
lower half of the sternum. These compressions create blood ﬂow by increasing
intrathoracic pressure and directly compressing the heart. Although properly
performed chest compressions can produce systolic arterial pressure peaks of 60 to
80 mm Hg, diastolic pressure is low and mean arterial pressure in the carotid artery
seldom exceeds 40 mm Hg.
Blood ﬂow generated by chest compressions delivers a small but critical amountof oxygen and substrate to the brain and myocardium. In victims of VF SCA, chest
compressions increase the likelihood that a shock (i.e., attempted deﬁbrillation)
will be successful. Chest compressions are especially important if the ﬁrst shock isdelivered 4 minutes after collapse.22
Much of the information about the physiology of chest compressions and theeffect of varying compression rates, compression-ventilation ratios, and duty cycles(percent of time the chest is compressed versus time allowed for chest recoil) is
derived from animal models. Researchers at the 2005 Consensus Conference,54
however, reached several conclusions about chest compressions:
1. “Effective” chest compressions are essential for providing blood ﬂow during
CPR.
2. To give “effective” chest compressions, “push hard and push fast.” Compress
the adult chest at a rate of about 100 compressions per minute, with a compression
depth of 11⁄2 to 2 inches (approximately 4 to 5 cm). Allow the chest to recoil
completely after each compression, and allow approximately equal compression andrelaxation times.
3. Minimize interruptions in chest compressions.
4. Further studies are needed to deﬁne the best method for coordinating
ventilations and chest compressions and to identify the best compression-ventilation
ratio in terms of survival and neurologic outcome.
Technique
To maximize the effectiveness of compressions, the victim should lie supine
on a hard surface (e.g., backboard or ﬂoor),58 with the rescuer kneeling beside thevictim’s thorax.56 The safety and efﬁcacy of over-the-head CPR (OTH- CPR) forlone rescuers and 2-person straddle CPR are unknown, but these techniques may be
advantageous in conﬁned spaces.57 “CPR-friendly” deﬂatable mattresses have been

APPENDICES

studied, and they do not provide an adequate surface on which to perform chest
compressions.57
The rescuer should compress the lower half of the victim’s sternum in the center(middle) of the chest, between the nipples.55 The rescuer should place the heel of thehand on the sternum in the center (middle) of the chest between the nipples and thenplace the heel of the second hand on top of the ﬁrst so that the hands are overlappedand parallel.58 Depress the sternum approximately 11⁄2 to 2 inches (approximately
4 to 5 cm) and then allow the chest to return to its normal position. Complete chest
recoil allows venous return to the heart, is necessary for effective CPR, and shouldbe emphasized in training.59 Compression and chest recoil/relaxation times should
be approximately equal.60
Lay rescuers should continue CPR until an AED arrives, the victim begins to
move, or EMS personnel take over CPR. Lay rescuers should no longer interrupt
chest compressions to check for signs of circulation or response. Healthcare providers
should interrupt chest compressions as infrequently as possible and try to limit
interruptions to no longer than 10 seconds except for speciﬁc interventions such as
insertion of an advanced airway or use of a deﬁbrillator. We strongly recommendthat patients not be moved while CPR is in progress unless the patient is in adangerous environment or is a trauma patient in need of surgical intervention. CPR
is better and has fewer interruptions when the resuscitation is conducted where thepatient is found. Allow the chest wall to recoil completely after each compression.
Rescuer fatigue may lead to inadequate compression rates or depth. Signiﬁcant
fatigue and shallow compressions are seen after 1 minute of CPR, although rescuers
may deny that fatigue is present for 5 minutes. When 2 or more rescuers areavailable, it is reasonable to switch the compressor about every 2 minutes (or after
5 cycles of compressions and ventilations at a ratio of 30:2). Every effort should
be made to accomplish this switch in 5 seconds. If the 2 rescuers are positioned
on either side of the patient, one rescuer will be ready and waiting to relieve the“working compressor” every 2 minutes.
Compression-Ventilation Ratio
A compression-ventilation ratio of 30:2 is recommended and further validationof this guideline is needed.49, 50 In infants and children, 2 rescuers should use a ratioof 15:2. This 30:2 ratio is based on a consensus of experts rather than clear evidence.
It is designed to increase the number of compressions, reduce the likelihood of
hyperventilation, minimize interruptions in chest compressions for ventilation,and simplify instruction for teaching and skills retention. Once an advanced
airway is in place, 2 rescuers no longer deliver cycles of CPR (i.e., compressions
interrupted by pauses for ventilation). Instead, the compressing rescuer should
give continuous chest compressions at a rate of 100 per minute without pauses forventilation. The rescuer delivering ventilation provides 8 to 10 breaths per minute.
The 2 rescuers should change compressor and ventilator roles approximately every
2 minutes to prevent compressor fatigue and deterioration in quality and rate of

APPENDICES

chest compressions. When multiple rescuers are present, they should rotate thecompressor role about every 2 minutes.
The compression rate refers to the speed of compressions, not the actual numberof compressions delivered per minute. The actual number of chest compressionsdelivered per minute is determined by the rate of chest compressions and the number
and duration of interruptions to open the airway, deliver rescue breaths, and allow
AED analysis.61 Rescuers must make every effort to minimize these interruptions inchest compressions.
Deﬁbrillation

All BLS providers should be trained to provide deﬁbrillation because VF is themost common rhythm found in adults with witnessed, nontraumatic SCA.7 For thesevictims survival rates are highest when immediate bystander CPR is provided anddeﬁbrillation occurs within 3 to 5 minutes.8, 12–14
Immediate deﬁbrillation is the treatment of choice for VF of short duration, suchas witnessed SCA.
The effect of CPR before deﬁbrillation for prolonged VF SCA has largely been
positive. When EMS arrived more than 436 to 537 minutes after dispatch, a brief
period of CPR (11⁄2 to 3 minutes) before deﬁbrillation improved ROSC and survival
rates for adults with out-of-hospital VF/VT in a before-after study.36 Thus, for adultout-of-hospital cardiac arrest that is not witnessed by the EMS provider, rescuers
may give a period of CPR (e.g., about 5 cycles or about 2 minutes) before checking
the rhythm and attempting deﬁbrillation. In settings with lay rescuer AED programs(AED on-site and available) and for in-hospital environments or if the EMS rescuer
witnesses the collapse, the rescuer should use the deﬁbrillator as soon as it isavailable.
Foreign-Body Airway Obstruction (Choking)

Death from FBAO is an uncommon but preventable cause of death.63 Most
reported cases of FBAO in adults are caused by impacted food and occur while thevictim is eating. Most reported episodes of choking in infants and children occur
during eating or play, when parents or childcare providers are present. The choking
event is therefore commonly witnessed, and the rescuer usually intervenes while thevictim is still responsive.
Recognition of Foreign-Body Airway Obstruction
Because recognition of airway obstruction is the key to successful outcome, it isimportant to distinguish this emergency from fainting, heart attack, seizure, or otherconditions that may cause sudden respiratory distress, cyanosis, or loss of consciousness.
Foreign bodies may cause either mild or severe airway obstruction. The rescuer
should intervene if the choking victim has signs of severe airway obstruction. These
include signs of poor air exchange and increased breathing difﬁculty, such as a silent

APPENDICES

cough, cyanosis, or inability to speak or breathe. The victim may clutch the neck,demonstrating the universal choking sign. Quickly ask, “Are you choking?” If thevictim indicates “yes” by nodding his head without speaking, this will verify that thevictim has severe airway obstruction.
Relief of Foreign-Body Airway Obstruction
When FBAO produces signs of severe airway obstruction, rescuers must act
quickly to relieve the obstruction. If mild obstruction is present and the victim
is coughing forcefully, do not interfere with the patient’s spontaneous coughing
and breathing efforts. Attempt to relieve the obstruction only if signs of severe
obstruction develop: the cough becomes silent, respiratory difﬁculty increases andis accompanied by stridor, or the victim becomes unresponsive. Activate the EMS
system quickly if the patient is having difﬁculty breathing. If more than one rescuer ispresent, one rescuer should phone 911 while the other rescuer attends to the choking
victim.
Although chest thrusts, back slaps, and abdominal thrusts are feasible andeffective for relieving severe FBAO in conscious (responsive) adults and children
1 year of age, for simplicity in training we recommend that the abdominal thrust
be applied in rapid sequence until the obstruction is relieved. If abdominal thrusts
are not effective, the rescuer may consider chest thrusts. It is important to note that
abdominal thrusts are not recommended for infants 1 year of age because thrusts
may cause injuries.
Chest thrusts should be used for obese patients if the rescuer is unable to encircle
the victim’s abdomen. If the choking victim is in the late stages of pregnancy, therescuer should use chest thrusts instead of abdominal thrusts. Because abdominal
thrusts can cause injury,64 victims of FBAO who are treated with abdominal
thrusts should be encouraged to undergo an examination by a physician for injury.
Epidemiologic data63 does not distinguish between FBAO fatalities in which thevictims were responsive when ﬁrst encountered and those in which the victims were
unresponsive when initially encountered. However, the likelihood that a cardiac
arrest or unresponsiveness will be caused by an unsuspected FBAO is thought to be
low.63
If the adult victim with FBAO becomes unresponsive, the rescuer shouldcarefully support the patient to the ground, immediately activate EMS, and thenbegin CPR. A randomized trial of maneuvers to open the airway in cadavers andprospective studies in anesthetized volunteers show that higher sustained airway
pressures can be generated using the chest thrust rather than the abdominal thrust.65,
66
Each time the airway is opened during CPR, the rescuer should look for an
object in the victim’s mouth and remove it. Simply looking into the mouth should
not increase the time it takes to attempt the ventilations and proceed to the 30 chest
compressions.
A healthcare provider should use a ﬁnger sweep only when the provider can see
solid material obstructing the airway of an unresponsive patient. No studies haveevaluated the routine use of the ﬁnger sweep to clear an airway in the absence ofAPPENDICES

visible airway obstruction.22 The recommendation to use the ﬁnger sweep in pastguide- lines was based on anecdotal reports that suggested that it was helpful for
relieving an airway obstruction.64
Summary: The Quality of BLS

Methods should be developed to improve the quality of CPR delivered at
the scene of cardiac arrest by healthcare providers and lay rescuers. These may
include education, training, assistance or feedback from biomedical devices,mechanical CPR, and electronic monitoring. Components of CPR known toaffect hemodynamics include ventilation rate and duration, compression depth,
compression rate and number, complete chest recoil, and hands-off time. Systems
that deliver professional CPR should implement processes of continuous quality
improvement that include monitoring the quality of CPR delivered at the scene ofcardiac arrest, other process-of-care measures (e.g., initial rhythm, bystander CPR,
and response intervals), and patient outcome up to hospital discharge. This evidence
should be used to maximize the quality of CPR delivered.
References
1.
2.

3.
4.
5.
6.
7.

8.
9.

10.

11.

Zheng ZJ, Croft JB, Giles WH, Mensah GA. Sudden cardiac death in the United States,
1989 to 1998. Circulation. 2001; 104:2158 –2163.
Chugh SS, Jui J, Gunson K, Stecker EC, John BT, Thompson B, Ilias N, Vickers C, Dogra
V, Daya M, Kron J, Zheng ZJ, Mensah G, McAnulty J. Current burden of sudden cardiac
death: multiple source surveillance versus retrospective death certiﬁcate-based review in alarge US community. J Am Coll Cardiol. 2004; 44:1268 –1275.
Vaillancourt C, Stiell IG. Cardiac arrest care and emergency medical services in Canada.
Can J Cardiol. 2004; 20:1081–1090.
Cobb LA, Fahrenbruch CE, Olsufka M, Copass MK. Changing incidence of out-of-hospital
ventricular ﬁbrillation, 1980 –2000. JAMA. 2002; 288:3008 –3013.
Rea TD, Eisenberg MS, Sinibaldi G, White RD. Incidence of EMS- treated out-of-hospital
cardiac arrest in the United States. Resuscitation. 2004; 63:17–24.
Cummins RO. CPR and ventricular ﬁbrillation: lasts longer, ends better. Ann Emerg Med.
1995; 25:833– 836.
Bayes de Luna A, Coumel P, Leclercq JF. Ambulatory sudden cardiac death: mechanismsof production of fatal arrhythmia on the basis of data from 157 cases. Am Heart J. 1989;
36:151–159.
Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-ofhospital cardiac arrest: a graphic model. Ann Emerg Med. 1993; 22:1652–1658.
Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac
arrest: the “chain of survival” concept. A statement for health professionals from theAdvanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care
Committee, American Heart Association. Circulation. 1991; 83:1832–1847.
Calle PA, Lagaert L, Vanhaute O, Buylaert WA. Do victims of an out-of-hospital cardiac
arrest beneﬁt from a training program for emergency medical dispatchers? Resuscitation.
1997; 35:213–218.
Curka PA, Pepe PE, Ginger VF, Sherrard RC, Ivy MV, Zachariah BS. Emergency medical
services priority dispatch. Ann Emerg Med. 1993; 22:1688 –1695.

APPENDICES

12.

13.

14.
15.

16.
17.
18.
19.

20.
21.

22.

23.

24.

25.
26.
27.

Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of
cardiac arrest interventions: a logistic regression survival model. Circulation. 1997;
96:3308 –3313.
Holmberg M, Holmberg S, Herlitz J. Factors modifying the effect of bystandercardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in
Sweden. Eur Heart J. 2001;22:511–519.
Holmberg M, Holmberg S, Herlitz J, Gardelov B. Survival after cardiac arrest outside
hospital in Sweden. Swedish Cardiac Arrest Registry. Resuscitation. 1998;36:29 –36.
Weaver WD, Hill D, Fahrenbruch CE, Copass MK, Martin JS, Cobb LA, Hallstrom AP.
Use of the automatic external deﬁbrillator in the management of out-of-hospital cardiac
arrest. N Engl J Med. 1988;319: 661– 666.
Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external deﬁbrillators. N Engl J Med. 2002;347:1242–1247.
Eisenberg MS, Horwood BT, Cummins RO, Reynolds-Haertle R, Hearne TR. Cardiac
arrest and resuscitation: a tale of 29 cities. Ann Emerg Med. 1990;19:179 – 86.
MacDonald RD, Mottley JL, Weinstein C. Impact of prompt deﬁbrillation on cardiac arrest
at a major international airport. Prehosp Emerg Care. 2002;6:1–5.
Nichol G, Stiell IG, Laupacis A, Pham B, De Maio VJ, Wells GA. A cumulative metaanalysis of the effectiveness of deﬁbrillator-capable emergency medical services for victimsof out-of-hospital cardiac arrest. Ann Emerg Med. 1999;34:517–525.
Cummins RO, Chamberlain DA. The Utstein Abbey and survival from cardiac arrest: whatis the connection? Ann Emerg Med. 1991;20:918 –919.
Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, Cassan P, Coovadia A, D’Este
K, Finn J, Halperin H, Handley A, Herlitz J, Hickey R, Idris A, Kloeck W, Larkin GL,
Mancini ME, Mason P, Mears G, Monsieurs K, Montgomery W, Morley P, Nichol G, Nolan
J, Okada K, Perlman J, Shuster M, Steen PA, Sterz F, Tibballs J, Timerman S, Truitt T,
Zideman D. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update andsimpliﬁcation of the Utstein templates for resuscitation registries: a statement for healthcare
professionals from a task force of the International Liaison Committee on Resuscitation.
Circulation. 2004;110:3385–3397.
Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin M, Hallstrom AP.
Inﬂuence of cardiopulmonary resuscitation prior to deﬁbrillation in patients with out-ofhospital ventricular ﬁbrillation. JAMA. 1999;281:1182–1188.
Riopelle RJ, Howse DC, Bolton C, Elson S, Groll DL, Holtom D, Brunet DG, Jackson AC,
Melanson M, Weaver DF. Regional access to acute ischemic stroke intervention. Stroke.
2001;32:652– 655.
Hazinski MF. Is pediatric resuscitation unique? Relative merits of early CPR andventilation versus early deﬁbrillation for young victims of prehospital cardiac arrest. Ann
Emerg Med. 1995;25:540 –543.
Guildner CW. Resuscitation: opening the airway. A comparative study of techniques for
opening an airway obstructed by the tongue. JACEP. 1976;5:588 –590.
Greene DG, Elam JO, Dobkin AB, Studley CL. Cineﬂuorographic study of hyperextensionof the neck and upper airway patency. JAMA. 1961;176: 570 –573.
Ruben HM, Elam JO, Ruben AM, Greene DG. Investigation of upper airway problems inresuscitation, 1: studies of pharyngeal x-rays and performance by laymen. Anesthesiology.
1961;22:271–279.

APPENDICES

28.

29.
30.

31.
32.

33.
34.

35.
36.

37.

38.

39.
40.

41.
42.
43.
44.
45.

Holly LT, Kelly DF, Counelis GJ, Blinman T, McArthur DL, Cryer HG. Cervical spine
trauma associated with moderate and severe head injury: incidence, risk factors, and injury
characteristics. J Neurosurg Spine. 2002;96:285–291.
Elam JO, Greene DG, Schneider MA, Ruben HM, Gordon AS, Hustead RF, Benson DW,
Clements JA, Ruben A. Head-tilt method of oral resuscitation. JAMA. 1960;172:812– 815.
Ruppert M, Reith MW, Widmann JH, Lackner CK, Kerkmann R, Schweiberer L, Peter
K. Checking for breathing: evaluation of the diagnostic capability of emergency medical
services personnel, physicians, medical students, and medical laypersons. Ann Emerg Med.
1999;34:720 –729.
Safar P, Escarraga LA, Chang F. Upper airway obstruction in the unconscious patient. J
Appl Physiol. 1959;14:760 –764.
Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest
compressions during cardiopulmonary resuscitation: improved outcome during a simulated
single lay-rescuer scenario. Circulation. 2002;105:645– 649.
Baskett P, Nolan J, Parr M. Tidal volumes which are perceived to be adequate forresuscitation. Resuscitation. 1996;31:231–234.
Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von Briesen C,
Sparks CW, Conrad CJ, Provo TA, Lurie KG. Hyperventilation-induced hypotension during
cardiopulmonary resuscitation. Circulation. 2004;109:1960 –1965.
Garnett AR, Ornato JP, Gonzalez ER, Johnson EB. End-tidal carbon dioxide monitoring
during cardiopulmonary resuscitation. JAMA. 1987; 257:512–515.
American Heart Association in collaboration with International Liaison Committee on
Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science, Part 3: adult basic life support. Circulation. 2000; 102(suppl I):I-22–I-59.
Dorges V, Ocker H, Hagelberg S, Wenzel V, Idris AH, Schmucker P. Smaller tidal volumes
with room-air are not sufﬁcient to ensure adequate oxygenation during bag-valve-mask
ventilation. Resuscitation. 2000;44:37– 41.
Dorges V, Ocker H, Wenzel V, Sauer C, Schmucker P. Emergency airway management by
non-anaesthesia house ofﬁcers–a comparison of three strategies. Emerg Med J. 2001;18:90–94.
Wenzel V, Idris AH, Banner MJ, Fuerst RS, Tucker KJ. The composition of gas given bymouth-to-mouth ventilation during CPR. Chest. 1994;106:1806 –1810.
Mejicano GC, Maki DG. Infections acquired during cardiopulmonary resuscitation:
estimating the risk and deﬁning strategies for prevention. Ann Intern Med. 1998;129:813–
828.
Hess D, Ness C, Oppel A, Rhoads K. Evaluation of mouth-to-mask ventilation devices.
Respir Care. 1989;34:191–195.
Simmons M, Deao D, Moon L, Peters K, Cavanaugh S. Bench evaluation: three face-shield
CPR barrier devices. Respir Care. 1995;40: 618 – 623.
Ruben H. The immediate treatment of respiratory failure. Br J Anaesth. 1964;36:542–549.
Barnes TA. Emergency ventilation techniques and related equipment. Respir Care.
1992;37:673– 694.
Johannigman JA, Branson RD, Davis K Jr, Hurst JM. Techniques of emergency ventilation:a model to evaluate tidal volume, airway pressure, and gastric insufﬂation. J Trauma.
1991;31:93–98.

APPENDICES

46.

47.
48.

49.

50.

51.
52.
53.
54.

55.
56.
57.
58.
59.

60.
61.
62.
63.

64.

Elam JO. Bag-valve-mask O2 ventilation. In: Safar P, Elam JO, eds. Advances in Cardiopulmonary Resuscitation: The Wolf Creek Conference on Cardiopulmonary Resuscitation.
New York, NY: Springer-Verlag, Inc;1977:73–79.
Dailey RH. The Airway: Emergency Management. St Louis, Mo: Mosby Year Book; 1992.
Frass M, Rodler S, Frenzer R, Ilias W, Leithner C, Lackner F. Esophageal tracheal
combitube, endotracheal airway, and mask: comparison of ventilatory pressure curves. J
Trauma. 1989;29:1476 –1479.
Dorph E, Wik L, Stromme TA, Eriksen M, Steen PA. Oxygen delivery and return ofspontaneous circulation with ventilation: compression ratio 2:30 versus chest compressions
only CPR in pigs. Resuscitation. 2004; 60:309 –318.
Berg RA, Sanders AB, Kern KB, Hilwig RW, Heidenreich JW, Porter ME, Ewy GA.
Adverse hemodynamic effects of interrupting chest compressions for rescue breathing
during cardiopulmonary resuscitation for ventricular ﬁbrillation cardiac arrest. Circulation.
2001;104: 2465–2470.
Sellick BA. Cricoid pressure to control regurgitation of stomach contents during inductionof anaesthesia. Lancet. 1961;2:404 – 406.
Petito SP, Russell WJ. The prevention of gastric inﬂation—a neglected beneﬁt of cricoidpressure. Anaesth Intensive Care. 1988;16:139 –143.
Perkins GD, Stephenson B, Hulme J, Monsieurs KG. Birmingham assessment of breathing
study (BABS). Resuscitation. 2005; 64: 109 –113.
International Liaison Committee on Resuscitation. 2005 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
Treatment Recommendations. Circulation. 2005;112:III-1–III-136.
Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massages. JAMA.
1960;173:1064 –1067.
Perkins GD, Stephenson BT, Smith CM, Gao F. A comparison between over-the-head andstandard cardiopulmonary resuscitation. Resuscitation. 2004;61:155–161.
Tweed M, Tweed C, Perkins GD. The effect of differing support surfaces on the efﬁcacy ofchest compressions using a resuscitation manikin model. Resuscitation. 2001;51:179 –183.
Liberman M, Lavoie A, Mulder D, Sampalis J. Cardiopulmonary resuscitation: errors madeby pre-hospital emergency medical personnel. Resuscitation. 1999;42:47–55.
Yannopoulos D, McKnite S, Aufderheide TP, Sigurdsson G, Pirrallo RG, Benditt D, Lurie
KG. Effects of incomplete chest wall decompression during cardiopulmonary resuscitationon coronary and cerebral perfusion pressures in a porcine model of cardiac arrest.
Resuscitation. 2005;64:363–372.
Handley AJ, Handley JA. The relationship between rate of chest compression andcompression: relaxation ratio. Resuscitation. 1995;30: 237–241. IV-32
Kern KB, Hilwig RW, Berg RA, Ewy GA. Efﬁcacy of chest compression-only BLS CPR in
the presence of an occluded airway. Resuscitation. 1998;39:179 –188.
Criley JM, Blaufuss AH, Kissel GL. Cough-induced cardiac compression: self-administeredfrom of cardiopulmonary resuscitation. JAMA. 1976;236:1246 –1250.
Fingerhut LA, Cox CS, Warner M. International comparative analysis of injury mortality:
ﬁndings from the ICE on injury statistics. International Collaborative Effort on Injury
Statistics. Adv Data. 1998:1–20.
Gallardo A, Rosado R, Ramirez D, Medina P, Mezquita S, Sanchez J. Rupture of the lesser
gastric curvature after a Heimlich maneuver. Surg Endosc. 2003;17:1495.

APPENDICES

65.
66.

Guildner CW, Williams D, Subitch T. Airway obstructed by foreign material: the Heimlich
maneuver. JACEP. 1976;5:675– 677.
Ruben H, Macnaughton FI. The treatment of food-choking. Practitioner. 1978;221:725–
729.

APPENDICES

Summary of BLS ABCD Maneuvers for Infants, Children, and Adults (Newborn Information Not Included)
Adult Lay rescuer: ≥8 years
HCP*: Adolescent and older

ManeuverAirwayChild Lay rescuers: 1–8 years
HCP: 1 year to adolescent

Infant Under
1 year of age

Head tilt–chin lift (HCP: suspected trauma, use jaw thrust)

Breathing Initial

2 breaths at 1 second/breath

2 effective breaths at 1 second/breath

HCP: Rescue
breathing without
chest compressions

10–12 breaths/minute (approx.)

12–20 breaths/minute (approximate)

HCP: Rescue breaths
for CPR with advanced
airway8–10 breaths/minute (approximately)

Foreign-body airway
obstruction

Abdominal thrusts

Circulation
HCP: Pulse check (≤10 sec)

Compression landmarks

Back slaps andchest thrusts
Brachial or
femoralCarotid

Lower half of sternum, between nipples

Just below nippl(lower half of sternum)

Compression method
Push hard and fast;
allow complete recoil

Heel of one hand;
other hand on top

Heel of one hand or
as for adultCompression depth

1 1/2–2 inches

Approximately 1/3 to 1/2 the depth of the chest

Compression rate
Compression-ventilation
ratio
Deﬁbrillation
AED

2 or 3 ﬁngers
HCP (2 rescuers): 2
thumb-encircling hands

Approximately 100/minute
30:2 (one or two
rescuers)

30:2 (single rescuer) HCP: 15:2 (2 rescuers)

Use adult pads
Use AED after 5 cycles
No recommendations
Do not use child pads of CPR (out of hospital)
for infants <1 year of age

Use pediatric systemfor child 1–8 years if
available

HCP: For sudden collapse(out of hospital) or in-hospitalarrest, use AED as soon as available*Note: Maneuvers used by only Healthcare Providers are indicated by HCP.

Appendix 8

Differential Diagnosis and Treatment of Exertional Heatstrokeand Heat Exhaustion on Site
Athlete presents withsuspected heat illness(dizziness, dry mouth, nausea,
weakness, muscle cramps,
unsteady gait)

Vomiting, or
Any unresponsiveness, orMental status changes, orRectal temperature >40.5ºC (105ºF), or
Convulsions, or Involuntary Bowel Movement

No• Loosen clothing• Place patient in shade• Provide ﬂuids by mouth –not to exceed 1 qt (950 ml)/hr• Give snack• Help cool (fan, sponge withwater, wet clothing)
Athlete does not improve in
30 minutes orexperiences general deterioration

Improves• Medical evaluation within 24 hours(sooner if athlete not at baseline)• No further heat stress until medical evaluation
has been completed

Yes

Evacuate to hospital/clinic• Place patient in shade• Loosen and remove clothing• Fan patient• Actively cool by sponging with water
and/or wetting clothing• IV hydration only if emergency
evacuation is delayed (limit to Dex
5% in N saline, 500 ml)• Convulsions–Diazepam 5-10 mg IV• Conﬁrm rectal temperature whenambulance arrives

Appendix 9

Differential Diagnosis and Treatment of Exertional Heatstroke,
Heat Exhaustion, and Hyponatremia in a Clinic Setting
Athlete presents withsuspected heat illness

Vomiting, orLoss of consciousness, orPersistent mental status changes, orConvulsions

Vital Signs
IV Access–Dex 5% in N saline
OxygenHeat injury panel*Core Temp (rectal)
Finger-stick glucose
Chest X-ray
Loosen/remove clothing

Rectal Temp. >40º C (104º F)

Rectal Temp. <40º C (104º F)• Cool using immersion, ice sheets,spray water, and fans
• Consider IV bolus: Dex 5% in N saline, 500 ml• EKG, Cardiac monitoring• Admit• Do not use antipyretics
Repeat heat injury panel every 8 hrs• Nausea• Emesis• Headache• History of overhydration(edema, weight gain)

Diagnosis of Heat Stroke
Conﬁrmed by following:• Coma• Obtundation• Persistent mental statuschanges• Liver associated enzymes>4x normal• Thrombocytopenia• Acute renal failure• Arrhythmia

Probable Heat
Exhaustion:• Rule out othermedical problems• If no rectal temp in ﬁeld–
consider heat stroke
if other diagnostic
criteria present

Sodium <130 mEq/L
Overhydration
hyponatremia• Fluid Restriction• 3% NaCl only for severe
CNS disturbance*Heat injury panel: Liver, CPK, electrolytes, renal, CBC, urinalysis, PT/PTT

Appendix 10

Recommendations for Minimising Jet Lag
Three Days Before Travel• On this day, go to bed at your usual time but avoid any sleep deprivation.
Be sure to get a minimum of 7 1/2 hourse of sleep.
• Begin to utilize a high protein/low carbohydrate breakfast and lunch, and ahigh carbohydrate dinner.
Two Days Before Travel• Continue the pattern of high protein breakfast and lunch (no caffeine),and high carbohydrate dinner, but eat skimpier portions. At tea time,
you can still have caffeine but reduce sweets. Snack during the day should
consist of low calorie, high protein foods (for example, chicken soup withpieces of meat but no noodles). No evening snacks are permitted.
• If you are training, do not reduce your caloric intake too much. If you
usually burn 2500 calories a day, do not fall below this level.
• Again, follow your usual sleep schedule, and avoid any sleep deprivation(get a minimum of 7 1/2 hours sleep).
One Day Before Travel• You will likely be running around making last-minute preparations. This
will stimulate you, so do this early in the day. If you do not have a travel
kit, prepare one early in the day (see below for recommended contents).
You may also want to prepare a high protein “picnic” for the ﬂight. It will
supplement food provided on the plane and may be your ﬁrst meal on yournew time. Remember, travel kit foods must either not need refrigeration or
be eaten before they spoil. These foods are intended “for emergency use”;
the airline will usually try to accommodate your schedule if you ask them.
• On this evening, say your goodbyes to friends and family, since you will
have many other things to keep you busy on the travel day. You may want
to remain awake a bit later than usual—feel free to do this.
• Delaying sleep activity helps adjust your biological clock. However, avoid
any sleep deprivation, and get a minimum of 7 1/2 hours sleep.
Travel Day: West to East
• If your schedule allows it, sleep in. Try to get up to 8–9 hours of sleep.
• If you use caffeine, drink 2–3 cups of a strong caffeinated beverage
immediately upon awakening (before 11 a.m.) but do not take in any
more caffeine, if possible, for the rest of the day. The caffeine “jolt” inthe morning will push your body in the right direction.
• If you can, take a nap after breakfast, and keep your activity to a minimum
throughout the day. Avoid the morning sunlight as much as possible. WhenAPPENDICES

•

•
•

•
•
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•

•
•

•

you depart from your home city, feel free to sleep on the plane, and do notdrink caffeine-containing beverages.
If you train before departing, have a late, low calorie, high protein breakfast of just enough calories to get you through the workout. If possible,
reduce your workout schedule this day and cut back your calories accordingly; be careful, however, not to cut back calories to the point that you
feel weak. If you do not train, remember you are burning calories like a
non-athlete, so consume a very skimpy, high protein, low calorie breakfast.
After breakfast do not eat again until breakfast time in your destinationcity. Physical activity on this day should be kept to a minimum.
It is suggested you put on two watches. Set one to destination time andone to home time. Use the watch for home time until you get on the planeto the destination city, but begin to think about what you would be doing
if you were already on the destination time. Once you get on the plane,
use the watch set to the destination time and take off the watch set to hometime.
Remember to carry your in-ﬂight “travel kit” with you.
Arrive at the airport early to avoid the rush. If sleeping is a normal activity
on destination time, feel free to nap while waiting in the airport.
Continue to fast until breakfast time in the destination city, and then, even
if you are still in ﬂight, break the fast with breakfast eaten on destination
time. This large, high-protein breakfast begins a feast day, and represent
the start of eating all your meals on destination time.
If you arrive during the day, rest as much as possible on the plane. Grab a
blanket and pillow, put on your blindfold, and insert your ear plugs tosimulate night. Loosen restrictive clothing, or change into comfortable
clothing, if possible.
If it is night when you arrive, stay awake as much as possible on the plane.
This helps you to be ready to sleep following your arrival.
When your watch tells you it is time to be awake on destination time, getup and move around; take your travel kit to the toilet and wash your face,brush your teeth, etc.—that is, perform your usual morning rituals as muchas possible. Interact with people to stimulate your body. If possible, walkup and down the aisle, and do simple isometric or stretching exercises.
At breakfast and/or lunch time in the destination city, have high protein,high calorie meals. This helps push your body’s biochemistry into its
new time frame. Eat the high protein picnic you brought with you if theairline doesn’t serve appropriate food at appropriate times. Do not worry
if the foods look more like a dinner or snack; your body sees it as a sourceof protein. If eating the meal supplied by the airline, eat only the protein
portions and ignore starches and sweets. Supplement this meal with yourpicnic. If you arrive in the destination only in time for lunch, you may eat

APPENDICES•

most of your picnic at this time, but keep some food in reserve in case you
are detained by airport security or delayed between ﬂights (if changing
planes). Be sure that, according to the destination city time, you eat a highprotein lunch on this day.
During the ﬂight, drink plenty of ﬂuids, avoiding alcohol and caffeinatedbeverages. Humidity in jet cabins is very low, so liquid intake is important
to avoid dehydration. Alcohol and caffeinated beverages are diuretics thatcause the body to eliminate ﬂuid. Water and fruit juices are the best ﬂuids
to drink.

Recommended Contents of In-Flight Travel Kit

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Essential toiletries: Toothbrush, toothpaste, razor, small hand towel,
lotion, etc.
High-protein snacks: Small package of cheese and crackers, hard boiledegg(s), low-sugar granola bars, peanut butter, nuts
Eye mask or blindfold
Ear plugs
Light-weight slippers
Books, cards, mp3 player, DVD player, or other items to entertain you
during waking hours

Appendix 11

General Health and Hygiene: Recommendations for Athletes
The serious athlete must assume much of the responsibility for maintaining his/her health in order to train and compete well. These guidelines also apply to healthful living in general
A. Healthy Lifestyle Factors

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Rest and sleep adequately between periods of hard training or other intense
physical activity. There is no hard and fast rule about the number of hoursof sleep needed, although in general 6–8 hours of sleep should be sufﬁcient.
It’s the soundness of the sleep, more than the number of hours, that’s
important. Each person has his/her own individual sleep requirements.
Avoid unnecessary loitering (as per shopping trips, etc.) before competition
time.
Don’t smoke. Using tobacco is detrimental to health in general and physical ﬁtness in particular. Immediate acute effects include decrease in oxygen
carrying capacity of the blood, elevation of pulse rate, increased coagulability of the blood, and spasm of the coronary blood vessels. Lung and heartdisease as well as lung cancer are a few of the consequences of long-term
tobacco addiction.
Avoid other than moderate intake of alcohol.
Say no to drugs. Drugs are no substitute for proper training. They arebanned. You can be caught and the consequences to your athletic career
are serious. Even if you are not caught, they have serious short and longterm effects on your health.
Be sensible with respect to your sexual activities. Normal sex with legitimate partners is not detrimental to high level sports performance. However,stress associated with illicit or clandestine sexual encounters can affectperformance. And remember, always practice safe sex (see C. 4).
Eat a balanced diet commensurate with your type and level of activity.
Follow the advice of your nutritionist, dietician, or doctor. Be sensible inyour attitudes towards food fads, and avoid overindulgence. Adhere tostrict timing of your meals prior to training or competition.

B. Basic Personal Hygiene•••

Bathe regularly, use soap and dry your skin thoroughly afterwards. Launderand change your clothes regularly. This will minimise the risk of bacterial
and fungal skin infection.
Choose clothing to suit weather conditions. Clothes should ﬁt properly to
avoid chaﬁng and abrasions.
Abstain from using material/articles that contain substances that cause you
allergic reactions or contact dermatitis.

APPENDICES••

Choose appropriate and good quality footwear that ﬁts properly to avoid
blisters. Break in new shoes gradually, padding them at points of pressureor friction.
Take care of your teeth. Brush and ﬂoss daily. See the dentist regularly toensure early diagnosis of problems.

C. Infections (see also Appendix 12, Respiratory Tract Infections)

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A high level of ﬁtness does not protect you against infections, especiallyviral infections. Avoid deliberate exposure to situations where airborne
infections are facilitated. Minimise contacts with infected/sick people,
animals, and contagious objects.
When you have an infection, especially with a fever, refrain from strenuous
physical activity.
Food and waterborne bacteria, viruses, and protozoa can cause diarrhea.
This is especially likely during travel to foreign countries. Eat only
wholesome food that is freshly cooked under hygienic conditions. Whenthe safety of the water supply is not assured drink only boiled or properly
bottled water or beverages.
Sexually transmitted diseases (STDs), including AIDS, are usually transmitted through sexual activity. Practice safe sex, that is, use latex condoms.
AIDS and Hepatitis B can also be transmitted through contaminated needles
and contaminated blood products. Should you become infected and havesymptoms, seek proper medical attention immediately. Do not self-treat or
share medicine with friends to avoid incomplete treatment or masking ofother concomitant STDs.

D. Bronchial Asthma

It is not uncommon for good athletes to be asthmatic. Asthma by itself is
not a contraindication to physical activity. Control your asthma through proper
medical attention. Remember that some medications for asthma or other respiratory
infections contain substances that are on the list of banned drugs. For this reason, it
is best not to use over-the-counter medications.
E. Immunisations and Other Prophylactic Measures

Most countries have childhood immunisation programs against serious
infectious diseases, such as TB, polio, diphtheria, whooping cough, tetanus, measles,and “German measles” (rubella) for females of childbearing age. In addition there
are efﬁcacious vaccines against hepatitis B, mumps, Japanese B encephalitis, andtyphoid. Additional vaccines may be necessary when travelling to areas where these
diseases may be endemic. Inquire through your local health department concerning
outbreaks and recommended immunisations before you travel. Make sure that you
are up to date with all vaccines needed at home and for travels.

APPENDICES

Chemoprophylaxis, or prevention of disease through medications, should also
be considered when travelling to areas where malarial infection is possible. This
could also be considered for prevention of meningococcal meningitis and traveller’s
diarrhea.

Appendix 12

Respiratory Tract Infections (RTI)
A. Prevention

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Keep your distance from people who are coughing, sneezing or have a“runny nose.”
Wash hands regularly, before meals, and after direct contact with potentiallycontagious people, animals, blood, secretions, public places, bathrooms, etc.
Do not use other people’s drinking bottles, cups, cutlery, etc.
Wear proper outdoor clothing and avoid getting cold and wet after exercise.
Use disposable paper towels and limit hand to mouth/nose contact whensuffering from respiratory tract infection (RTI) symptoms.
Quickly isolate a team member with RTI symptoms and move his/herroommate to other accommodations.
Check air conditioning/ventilation systems for potentially contagious
material.
Protect upper and lower airways from being directly exposed to cold anddry air during strenuous exercise, by using a face mask, etc., at temperatures
below -15ºC.
Practice good recovery routines, including proper nutrition and rehydration.

B. Guidelines for Exercise During Episodes of RTI

First day of illness• Cease strenuous exercise or competitions when experiencing RTI symptoms
such as:• Sore throat or coughing• Runny or congested nose
• Cease all exercise when experiencing additional RTI symptoms such as:• Muscle/joint pain and headache• Fever and generalised feeling of malaise• Drink plenty of ﬂuids, keep from getting wet and cold, and minimise
life-stress.
• Consider use of topical therapy with nasal drainage, decongestants, andanalgesics if fever occurs.
• Report illness to a team physician or health care personnel and keep awayfrom other athletes if you are part of a team training or travelling together.
Second day• If you have a fever (temperature >37.5–38ºC) or increased coughing:
No training!

APPENDICES•

If no fever or malaise and no worsening of “above the collar” symptoms:
Light exercise (pulse <120bpm) for 30–45 minutes by yourself (indoors
during the winter).

Third day• If fever and RTI symptoms persist: Consult your (team) physician byphone or at ofﬁce.
•

If no fever or malaise and no worsening of initial symptoms: Moderate
exercise (pulse < 150bpm) for 45–60 minutes, preferably by yourself
and indoors.

Fourth day• If no symptom relief: Do not try to exercise but make an ofﬁce visit toyour doctor.
•

If ﬁrst day of improved condition: Follow the guidelines for “return toexercise after RTI,” below.

C. Guidelines for Returning to Exercise After RTI•

Make sure that you have one day without fever and with improvementof RTI symptoms before returning to exercise.

•Observe the body’s reaction to your ﬁrst exercise session before startingon a new session.

•

Stop physical exercise and consult your physician if:• A new episode with fever or worsening of initial symptoms occurs.
• Persistent coughing and exercise-induced breathing problem occurs.

•

Use the same number of days to step up to normal training as spent offof regular training because of illness.

•

Observe closely your tolerance to increased exercise intensity and takean extra day off if you do not recover satisfactorily.

•

Use proper outdoor clothing and speciﬁc cold air protection for airways
when exercising in temperatures below -10ºC the ﬁrst week after RTI.

Adapted from: Ronsen, O. Prevention and management of of respiratory tract
infections in athletes. New Studies in Athletics 20:3, 49-56, 2005.

Appendix 13

Process for the Management of Gender-Related Issues
1. Gender-related issues will be managed according to the IAAF Policy for
Gender Veriﬁcation, and the IOC Consensus Statement on Sex Reassignment.
2. Gender issues are likely to arise as a result of:a. A “challenge” by another athlete or team as brought forward to authorities
at an athletics event.
b. “Suspicion” raised as to an athlete’s gender as witnessed during the processof specimen collection during doping control.
c. An approach made to an IAAF/Regional AAA or National Federation
by an athlete or his/her representative requesting advice or clariﬁcation.

3. The matter may be handled at various levels, including:• National Federation• The Medical Delegate of an athletics event• The IAAF Medical/Anti-Doping Commission
4. Proceduresa. The case is brought to the attention of the relevant medical authority at
one of the above levels when it ﬁrst arises.
b. The authority decides whether there is reason to investigate.
c. The authority determines who will investigate the matter, e.g., Special
Panel at an international event.
d. The athlete is referred to the investigating authority in conﬁdence forfurther investigation and advice.
e. The verdict is passed on to the National Federation with advice for further
action, including appropriate advice to the athlete as to the need to “withdraw” from competition until the problem is deﬁnitely resolved throughappropriate medical and surgical measures.
f. Evaluation of the effects of such measures to determine if and when theathlete can return to competition as per IOC Consensus guidelines.
5. The IAAF must establish a resource panel at the Medical/Anti-Doping
Commission level that may be available for consultation if there is a needfor resolution of complex cases.