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UNIVERSAL TRAINING PRECAUTIONS TO REDUCE THE RISK OF EXERCISE- RELATED COLLAPSE AND DEATH

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Tony

UNCLASSIFIED//
ROUTINE
R 101338Z MAY 19
FM CNO WASHINGTON DC
TO NAVADMIN
INFO CNO WASHINGTON DC
BT
UNCLAS

NAVADMIN 108/19

PASS TO OFFICE CODES:
FM CNO WASHINGTON DC//N1//
INFO CNO WASHINGTON DC//N1//
MSGID/GENADMIN/CNO WASHINGTON DC/N1/MAY//

SUBJ/UNIVERSAL TRAINING PRECAUTIONS TO REDUCE THE RISK OF EXERCISE- RELATED 
COLLAPSE AND DEATH//

REF/A/DOC/OPNAV/11JUL11//
NARR/REF A IS OPNAVINST 6110.1J, PHYSICAL READINESS PROGRAM.//

RMKS/1.  This NAVADMIN alerts all personnel of the importance of universal 
training precautions (UTP) to reduce the risk of exercise- related collapse 
and death and directs modifications to reference (a), the procedures for 
conducting the Navy Physical Readiness Test (PRT).  Tragically, in the past 
year, four Sailors have passed away during seemingly normal physical fitness 
exercise.  One loss is too many and it is critical that every Sailor 
understands the risk factors for exercise-related death and the strategies to 
minimize those risks.  Commanders and key leadership personnel, including 
Command Fitness Leaders (CFL), must foster an exercise culture that promotes 
these UTPs, recognizes the early signs of distress and permits prompt 
termination of exertional activity when clear signs of distress are present.

2.  Risk factors associated with exercise-related collapse and death can be 
personal, environmental or external.  Personal risk factors include lack of 
appropriate environmental or exercise acclimatization, dehydration, recent or 
current illness, accumulated fatigue, poor baseline conditioning, a 
predisposing or underlying cardiac condition, exercise-induced asthma, sickle 
cell trait (SCT), excess body fat (BMI > 30) and prior poor PRT performance.
Excessive motivation, is equally important to recognize as a risk factor, as 
an individual can push to work hard, while ignoring the onset of physical 
signs and symptoms of distress.  Environmental or external risk factors 
include:  exercise at altitude, high ambient temperature and humidity and 
dietary supplements containing stimulants to include thermogenic and energy 
shots or drinks.

3.  It is critically important to recognize an emergency during training 
evolutions, with a timely and accurate response.  Some syndromes can result 
in rapid collapse while others may slowly evolve to an initial conscious 
collapse.  Understanding the syndromes that can lead to exercise-related 
collapse can assist in guiding treatment.
    a.  Sudden Cardiac Arrest (SCA).  SCA from cardiovascular collapse is 
generally abrupt with an immediate loss of consciousness, sometimes with 
brief seizure-like movements.  After confirming a lack of responsiveness and 
absence of a pulse, it is critical to begin high-quality cardiopulmonary 
resuscitation (CPR), deploy an Automated Electronic Defibrillator (AED) and 
activate Emergency Medical Services (EMS).
    b.  Exertional Collapse Associated with SCT (ECAST).  An ECAST victim may 
have been a front runner, or off to a strong start, but will be noted 
somewhere before the collapse as slowing down, falling behind and struggling.  
They begin to lose smooth coordination, they evolve into an awkward running 
posture and gait, with legs that may look wooden or wobbly.  The victim may 
complain of progressive weakness, pain, cramping or shortness of breath.  
Distinct from the cramping of exercise associated muscle cramping, in ECAST, 
there is generally no visible muscle twitching and the muscles do not "lock 
up."  The pain of muscle cramping is generally excruciating, whereas the 
predominate symptom of ECAST is weakness over pain.  The ECAST victim will 
initially be mentally clear, before the onset of confusion and loss of 
consciousness.
    c.  Exertional Heat Stroke.  Heat stroke can have a similar progression 
to ECAST, but the hallmark that defines heat stroke is not only an elevated 
temperature, but an altered mental status.
    d.  Continued exertional effort in both ECAST and heat stroke will 
eventually lead to collapse, that in the absence of prompt intervention can 
be life threatening.

4.  All personnel present during a training evolution or PRT can encourage 
good performance, but should also be on guard for signs that a participant is 
struggling and be ready to terminate the evolution.  The Navys PRT portion of 
the Physical Fitness Assessment (PFA) is intended as a measure of long-term 
health and wellness  not of individual athletic prowess.  No one should risk 
their life by pushing through life-threatening conditions during a PRT.  At 
the first sign of distress, conduct an initial evaluation on the participant 
and determine whether to call EMS for rapid transport to a capable medical 
facility.  Service Members who report signs of distress described above shall 
seek immediate medical attention and must be evaluated by a medical provider 
prior to returning to exercise.

5.  Effective immediately, commanding officers (CO) and officers-in- charge 
(OIC) are encouraged to exercise a liberal Bad Day makeup PRT policy for 
those impacted by any signs of distress, and allow the individual to 
prioritize health safety over a score by authorizing a Bad Day makeup PRT 
prior to failing or completing the event.  In line with reference (a) 
enclosure (2), the following guidelines pertain to Sailors who:
    a.  Do not complete any portion of the PRT, fail or demonstrate any early 
signs of exercise distress.  These Sailors are authorized, at CO or OIC 
discretion, a Bad Day makeup PRT and are required to be screened by medical.  
Sailors must be cleared by medical to participate in the Bad Day makeup PRT.
    b.  Are medically cleared. They must conduct the Bad Day makeup PRT 
within 7 days from medical clearance, within 45 days of the BCA date and 
within the current Navy PFA cycle.
    c.  Participate, but do not complete the Bad Day makeup PRT.
They must be screened by medical again, and if medically cleared (no medical 
waiver), the Sailor will receive a failure for the PRT and will be enrolled 
in Fitness Enhancement Program (FEP).
    d.  Participate in the Bad Day makeup PRT.  They will have only their 
final PRT scores entered in PRIMS.  CFLs are no longer required to enter 
initial PRT scores in PRIMS (e.g., 59:59) for Bad Day makeup PRT 
participation.

6.  The following UTP must be applied to all fitness tests or other training 
evolutions that are expected to require at least moderate exertion (heavy 
breathing but able to talk in full sentences, sweating within a few minutes 
of start):
    a.  Allow acclimatization, outside of the new accession training 
environment, giving 2 to 4 weeks, to adapt to a warmer environment or higher 
altitude.  The wet bulb globe temperature (WGBT) is the gold standard to 
measure environmental heat stress at
https://www.hprc-online.org/articles/wet-bulb-globe-temperature-
devices-measure-heat-stress.  Commands may rely on heat stress meters to 
provide WBGT information when available.
    b.  Ensure progressive and graduated increases in exercise duration and 
intensity to the greatest extent possible in the training environment.
    c.  Adhere to current guidelines for hydration, promote water consumption 
when thirsty and to maintain clear or light-yellow urine color as described 
at https://www.hprc- online.org/articles/hydration-basics.
    d.  Follow DoD guidelines for rest-work cycles as described at
https://home.army.mil/lee/application/files/3615/3808/9560/H20-
Consumption-Table.pdf.
    e.  Prior to and during exercise, avoid stimulants, alcohol, energy shots 
or drinks, antihistamines, diuretics, pre-workout products, weight loss and 
performance enhancing supplements.
    f.  After PFA testing, participants should be observed for no less than 
10 minutes post exertion, during an active cool down period.
    g.  At the early signs of distress, provide prompt medical attention, and 
when deemed necessary, transfer to an appropriate level of medical care.

7.  Our Sailors are expected to maintain a high level of fitness, as part of 
military readiness.  Failure to do so puts the individual and unit at risk.  
We must all embrace this culture of fitness while still safely applying UTP.  
To minimize the risk of injury, we should all limit our activity to light 
exercise the day before a graded event.  If a Sailor reports poor 
conditioning before an event with high exertion, efforts should be made to 
provide time to acclimate to an appropriate level of exercise before the 
evolution.
A meaningful FEP, as outlined in reference (a), using the recommended spot 
checks, is intended to do this.

8.  All personnel with SCT should review the video in para 13 below.
SCT is common, present in 1 per 10-12 African Americans, 1 per 183 
Hispanic/Latinos and 1 per 625 Caucasians.  Because SCT disproportionately 
affects African Americans, any African American who does not know their 
sickle cell status should engage with medical to determine their status and 
understand the risk.

9.  To ensure safe conduct of physical training:
    a.  All CFLs, first responders, corpsmen, recruit division commanders and 
supervisors should watch the first responder videos listed in para 13 below.  
CFLs must understand the predisposing conditions that are risk factors for 
exercise-related injuries.
    b.  All medical treatment facility providers should watch the provider 
video listed in para 13 below.
    c.  All PRT evolutions shall be monitored by personnel trained in CPR.
    d.  All training evolutions (e.g., command physical training, FEP, Sailor 
360, etc) involving at least moderate exercise shall occur within the 
Emergency Medical Service (base or 911) response area of an ambulance 
equipped with a defibrillator, oxygen and hydration.
    e.  Activities conducting high-risk training involving physical exertion 
shall incorporate SCA, ECAST and heat stroke signs, symptoms, prevention and 
response protocol, including UTP, into Core Unique Instructor Training and 
instructor sustainment programs.

10.  ECAST Treatment.  Though formal treatment guidelines have not been 
developed, National Collegiate Athletic Association (NCAA) and National 
Athletic Training Association (NATA) recommend the
following:
    a.  Removal from activity upon demonstration of distress
    b.  Administer high flow oxygen
    c.  Transport to an emergency department in an EMS vehicle (ideally 
Advanced Life Support capable) with emergency communication to alert 
providers about the potential of a profound metabolic collapse event.

11.  Return to training.  Medical providers should follow evidence- based 
guidelines that exist for rhabdomyolysis and exertional heat injury.  
Currently, there are no guidelines for SCT-related injury.
Generally, the following criteria must be met:  the individual should have no 
symptoms (muscle ache, fatigue, etc) normal organ function as measured by 
laboratory markers, and a review by a medical professional to include 
counseling on progressive return to exercise and application of the UTP.

12.  Reference (a) and CFL training will be updated to incorporate these risk 
factors and outline procedures for preparation, intervention and return to 
exercise.  In the interim, and until the Physical Activity Risk Factor 
Questionnaire can also be updated, CFLs must add SCT as a risk factor to ask 
PRT participants about prior to beginning each PRT.

13.  Videos and other training resources are available on the Uniformed 
Services Universitys Consortium for Health and Military Performance (CHAMP) 
website.
    a.  Videos for the warfighter with SCT, first responders, and sickle cell 
awareness for medical personnel can be found at https://www.hprc-
online.org/articles/sickle-cell-trait-awareness.
    b.  Guidance on heat injury prevention and treatment can be found at 
https://www.hprc-online.org/articles/heat-illness-
prevention-treatment-and-recovery.
    c.  Guidance on supplements are available through the Department of 
Defense Dietary Supplement Resource https://www.opss.org.

14.  Points of contact:
    a.  OPNAV N17 Policy:  AMCS Eric Anderson, (901)874-2210 or via e-mail at 
eric.anderson(at)navy.mil.
    b.  BUMED:  CAPT Marc Franzos, (703) 681-9085 or via email at 
marc.a.franzos.mil(at)mail.mil

15.  This message was developed in coordination with the Surgeon General of 
the Navy, Vice Admiral F. Faison and Bureau of Medicine and Surgery Staff.

16.  Released by Vice Admiral R. P. Burke, N1.//

BT
#0001
NNNN
UNCLASSIFIED//
 

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