PAs and the Mass Athlete Event: What to Expect and How to Plan for It.Dennis Rivenburgh, MS, ATC, PA-C Physician AssistantComprehensive Sports Concussion Program The Sandra and Malcolm Berman Brain & Spine Institute Sinai Hospital Baltimore
DisclosuresI have no financial interest or affiliation with themanufacturer or distributor of any medicalproducts, devices, or services.I will not be discussing investigational orunlabeled uses of products and/or devices.
ObjectivesAt the end of this session, participants will be able to: List common injuries and illnesses involved with athletes in mass events Describe how to work to prevent injuries Describe how to set up and provide appropriate medical care and coverage. Requirements for medical and non-medical personnel.
Scope of ServicesCritical CareFirst Aid and General Medical ProblemsSpecial Problems
Medical Tent SetupCots for athletes to lieonReadily accessiblesuppliesMinor injury areaRegistration area
Clear Area outsideMedical TentNo family member’sin tent areaSecurity at theentrance
StaffingMedical Director Staff MD, DO MD, DO, PA-C, NP, DPMMedical Coordinator RN MD, DO, PA-C, ATC, RN ATC Paramedics/EMT Non-medical 5-10 medically trained and 4-6 non-medical per 1000 runners Volunteers
Medical Aid Stations/SitesFinish Line Site Similar to Hospital EROn Course Aid Station Physician, PA, ARNP, RN, ParamedicRoving Medical Vehicles Physicians, PA, ARNP, RN, ParamedicBike Medics Paramedics, ER PA/ARNP/Physician
Finish Line SiteTriage OfficerTeam Care Physician/PA/ARNP RN Scribe Nursing Students, PA Students, EMT
Volunteer EducationImportant to educate medical team Weather conditions Site Supplies Transport criteriaLocal ED’s
Temperature and Humidity Temperature and humidity can affect the performance andsafety of runners. Warm temperatures and high humidity increase the incidence of heat related injuries. Back Flag: Extreme risk. WBGT in excess of 82-degreesF. Event may be cancelled Red Flag: High risk. WBGT between 73 – 82 degrees F.Runners who are sensitive to heat or humidity shouldconsider not participating. Yellow: Moderate risk. WBGT between 63 – 72 degreesF.Green: Low risk. WBGT below 63 degrees F. This is a medical decision, not a race director decision
VolunteersLiability Insurance State DependentShould be provided by the race
Injury Management0.1% to 20% ofrunners seekattentionCardiovasculardeaths occur at anydistance Maybe greater at shorter distance
2011 US Largest RacePeachtree Road Race 10K, 55,077Lilac Bloomsday Run 12K, 51,303BolderBOULDER 10K, 49,213ING New York City Marathon, 47,133Bay to Breakers 12K, 43,954Chicago Marathon, 35,755Cooper River Bridge Run 10K, 34,789Race for the Cure: DC 5K, 34,751 EUkrops Monument Avenue 10K, 33,365Rock n Roll Las Vegas HMAR, 33,257
Runner EducationWeb Site InstructionsRace Packet InstructionsPre-Race athlete meeting Mandatory at all Ironman EventsWhat to Include Fluid demands Identification/medical history Weather Precautions Aid stations sites/types
Incidence of Nontraumatic Sudden Death in AthletesPopulation Group Age distribution IncidenceOrganized High High school/college aged 7.47:1,000,000/year Mschool/college athletes 1.33:1,000,000/year FUS Air Force Recruits 17 to 28 years of age 1:735,000 per yearRhode Island Joggers < 30 year of age 1:280,000 per yearRhode Island Joggers 30 to 65 years of age 1:7,620 joggers per yearMarathon Runners Mean age 37 1:50,000 race finishersw
Diagnosis of HypothermiaRequires 1) High index of suspicion 2) Low-reading thermometer (down to 25°C) At least 10cm into rectum • Check for fecal cache – Impaction will give a falsely elevated reading
Definition• Core temperature <35º C (95º F)• Mild: 32.1º C-35º C• Moderate: 28º C-32º C• Severe: <28º C
HypothermiaStages of Hypothermia Core Body Temperature Symptoms98 – 96 Shivering95 – 91 Intense Shivering, difficulty Speaking90 – 86 Shivering decreases and is replaced by strongmuscular rigidity. Muscle coordination is affected and erratic orjerky movements are produced. Thinking is less clear, generalcomprehension is dulled, possible total amnesia. Generally ableto maintain the appearance of psychological contact withsurroundings.85 – 81 Becomes irrational, loses contact withenvironment, drifts into stuporous state. Muscular rigiditycontinues. pulse and respirations are slow and cardiacdysrhythmias may develop.80 – 78 Loses consciousness and does not respond tospoken words. Most reflexes cease to function. Heartbeat slowsfurther before cardiac arrest occurs.
Frequency• 700 die annually from accidental primary hypothermia• Majority – Urban setting due to environmental exposure – Aggravated by homelessness, illicit drug use, alcoholism, mental illness• Minority – Outdoor setting: hunters, swimmers, hikers, etc.
Mortality• Mild (32-35° C): No significant morbidity/mortality• Moderate (29° C-32° C): 21% mortality• Severe (<28° C): Even higher mortality rate
CNS in Hypothermia• All organ systems affected• <33°C: Abnormal brain activity• 19°-20°C: EEG consistent with brain death
General Care• Remove wet clothes• Insulate victim from environment• Don’t delay urgent procedures (e.g. intubation, IVs)• Remember: Because of rigidity of jaw and chest wall, it may be next to impossible to intubate orotracheally as well as to ventilate a patient.
Rewarming Techniques• Passive external• Active external• Active internal (core)
Passive External Rewarming• Usually adequate for mild hypothermia• Place in warm environment• Remove wet clothing• Cover with blankets• Rewarming rate: 0.5°C-1°C/hour
Pre-hospital Care• Avoid needless sudden movements • Prophylactic (<30 °C) and therapeutic bretylium – Especially with cold-water immersion – Treat life-threatening arrhythmias only; the remainder• Supine to avoid postural will self-correct with re-warming hypotension – Attempt defibrillation up to 3• O2 times and no re-attempts until• Monitors core temp reaches 30ºC• CPR and intubation should not be – Magnesium sulfate: Helpful in withheld if needed spontaneous resolution of v fib• Trauma immobilization as needed • Reduce further heat loss• Intense vasoconstriction at <30 °C • Begin re-warming may make IV meds ineffective – Heat packs in axillae, groin, belly• Lidocaine/atropine: ineffective • Intubate as needed; pre-oxygenate• by 30-33ºC) first • Resuscitate cold and dead to warm and dead (at least by 30-33ºC)
HyperthermiaHyperthermia is an elevated body temperaturedue to failed thermoregulation. Hyperthermiaoccurs when the body produces or absorbsmore heat than it can dissipate. When theelevated body temperatures are sufficiently high,hyperthermia is a medical emergency andrequires immediate treatment to preventdisability or death.
Classification• Temperature Classification• Core (rectal, esophageal, etc.)• Normal• 36.5–37.5 °C (97.7–99.5 °F)• Hypothermia• <35.0 °C (95.0 °F)• Fever• >37.5–38.3 °C (99.5–100.9 °F)• Hyperthermia• >37.5–38.3 °C (99.5–100.9 °F)• Hyperpyrexia• >40.0–41.5 °C (104–106.7 °F)• Note: The difference between fever and hyperthermia is the mechanism.• Hyperthermia is defined as a temperature greater than 37.5–38.3 °C (100–101 °F), depending on the reference, that occurs without a change in the bodys temperature set-point.
HYPOTHERMIA• Every year in the U.S. between 600 and 700 people die of hypothermia. hypothermia• Every year in Arizona an average of 23 people die of hypothermia.
Signs and symptomsHot, dry skin is a typical sign of hyperthermia. The skin may become red and hot as bloodvessels dilate in an attempt to increase heatdissipation, sometimes leading to swollen lips.An inability to cool the body through perspirationcauses the skin to feel dry.
Signs and symptoms• Nausea• Headaches• Low Blood Pressure• Fainting/Dizziness• Confused or hostile• tachycardia & tachypnea• Seizures• Unconscious and Death
Causes Heat stroke• environmental exposure to heat – abnormally high body temperature.• Non-exertional (classic)• Exertional
Causes• Other factors,• drinking too little water,• drinking alcohol• Non-exertional – young and the elderly. • medications reduce vasodilation, sweating • anticholinergic drugs, • antihistamines, • diuretics
DiagnosisHyperthermia is generally diagnosed in thepresence of an unexpectedly high body temperatureand a history that suggests hyperthermia instead ofa fever. Most commonly this means that theelevated temperature has appeared in a person whowas working in a hot, humid environment (heatstroke) or who was taking a drug for whichhyperthermia is a known side effect (drug-inducedhyperthermia). The presence of other signs andsymptoms related to hyperthermia syndromes, suchas the extrapyramidal symptoms that arecharacteristic of neuroleptic malignant syndrome,and the absence of signs and symptoms morecommonly related to infection-related fevers, arealso considered in making the diagnosis.
PreventionExposure limits toheat stress areusually set by indicesbased on the wet bulbglobe temperature.
Treatment• Treatment for hyperthermia depends on its cause – Mild hyperthemia • drinking water and resting in a cool place – body temperature is significantly elevated • mechanical methods of cooling are used to remove heat from the body • bathtub of tepid or cool water (immersion method)
Treatment – exertional heat stroke • cool water immersion is the most effective cooling technique• body temperature reaches about 40°C – MEDICAL EMERGENCY • May Need intravenous hydration, gastric lavage with iced saline, and even hemodialysis to cool the blood.
Background information• Most common electrolyte disorder.• Frequency is higher in females, the elderly,and in patients that are hospitalized.•30% of depressed patients on SSRI•
Medical and Physiological Considerations in Triathlons• US triathlons 1982- 1986 (>6000 athletes)• Dehydration is most frequent medical encounter• 27% hyponatremic• IV Fluid recommendations Hiller DW, et al: The American Journal of Sports Medicine Vol 15 (2) 1987.
Intravenous Fluid Effect on Recovery After Running a Marathon• 2.5 l of 2.5% glucose/0.45% NaCl solution• 100 ml 0.9% NaCl Solution• No significant influence on: – Rate of total recovery – Number of days with pain, stiffness, appetite, sleep or fatigue Polak AA, et al: British Journal of Sports Medicine 1993; 27(3):205-8. 1991 Rotterdam Marathon
A Guide to Treating Ironman Triathletes at the Finish Line• Treatment by necessity is most often initiated in the absence of a diagnosis.• All persons who collapse after exercise do not have dehydration-induced hyperthermia Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8).
A Guideline to Treating Ironman Triathletes at the Finish Line• “The administration of IV fluids should not be an automatic first response.”• Indications for IV fluids: – Significant dehydration causing cardiovascular instability – Cannot be effectively orally hydrated – Unconscious with serum sodium >130mmol/LMayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8)
Elevate the Feet and PelvisMayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8).
Hyponatremia in Distance Athletes Pulling the IV on the “Dehydration Myth”• Moderate dehydration is not hazardous• Diagnose, then treat• Too much fluid can hurt – oral and IV Noakes TD: Physician and Sports Medicine 2000;28(9).
Intravenous versus oralrehydration during a brief period: responses to subsequent exercise in heat.• No discernable advantage of IV over oral• Oral hydration: – Lower body temperatures – Improved performance – Decreased thirst – Lower perceived exertion with subsequent exerciseCasa DJ, et al: Med Sci Sports Exerc 2000;32(1):124-133.
IV for Exercise Associated Muscle Cramps• Dramatic improvement with normal saline – American Journal of Sports Medicine 1999;27(5) response to letter to the editor• Severe cramping usually subsides after 2-3 hours and 2-3 L of normal saline. – Eichner RE Curbing muscle cramps: more than oranges and bananas GSSI 2002
Serum electrolytes and hydration status are not associated with exercise associated muscle cramping (EAMC) in distance runners• Small but statistically significant differences in serum sodium and magnesium are too small to be clinically significant.• An alternate hypothesis to explain EAMC must be sought.Schwellnus, et al. Br J Sports Med. 2004;38;488-491.
Evaluation and Treatment of Marathon Associated Hyponatremia• On-site sodium analysis – Exercise Associated Hyponatremia (EAH) Concensus Panel. 2005. Clin J Sports Med. 2005;15:208-213.• 3% NaCl solution utilized in the field treatment symptomatic hyponatremia – Ayus C, Rarieff A, Moritz M. Treatment of marathon associated hyponatremia. N Engl J Med. 2005;353(4):427-428.
What did we learn?• Most collapsed runners do not have dehydration-induced hyperthermia• Diagnosis before treatment• There are indications for IV fluids• Too much fluid can hurt• Exercise associated muscle cramping etiology is unclear – But IV saline appears to help in some situations• Measure sodium and field treatment
Ask for IV Guideline Help• Compared notes with others• American Medical Athletic Association• International Marathon Medical Directors Association• American College of Sports Medicine – Endurance Athlete Medicine and Science• American Medical Society of Sports Medicine• Develop intravenous guideline
Survey of Experts• Do you give IV fluids after marathons?• What do you use to determine if an athlete receives IV fluids?• What types of IV fluid do you use?• Do you measure serum electrolytes?• Is there anything else that might be helpful?
Survey Results (10 responses)• 10/10 are prepared to give IV fluids• 8/10 have IV fluid protocols• 10/10 have 0.9% NaCl solution• 9/10 have 3% NaCl solution• 8/10 always measure Na prior to IV – 1/10 measure depending upon presentation – 1/10 never measured Na
IV Risk and Benefit• Risks • Benefits – Discomfort – Treat identifiable conditions – Tissue injury – Lessen the strain on – Bleeding emergency and hospital services – Infection – Training – Embolization – Worsening electrolyte imbalances – Utilize resources
Medical Tent Expectations • Parallel that of office visits • IV requests • Request everything available • Similar treatment as previous events • Perception that more is better • Badge of honor
Why do we want to give IV?• Treat an appropriate diagnosis• Believe it is the right thing to do• Want to help and do not know how• Show we are doing something
Recommendations for IV Fluids• Significant dehydration causing cardiovascular instability• Cannot be effectively orally hydrated• Unconscious with serum sodium >130mmol/L• Symptomatic Exercise-Associated Hyponatremia with 3% NaCl• Consider for resistant exercise associated muscle cramping• Recommend Sodium assessment prior to IV
Conclusions• “First, do no harm”• Diagnose first, treat second• Have clear indications for interventions that you do and do not perform.