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Marathon Medicine
Medical Volunteer Training Course
Ben Nelson MD
Essentia Health Sports Medicine
Grandma’s Marathon
Introduction
• Thank you very much for volunteering to provide
medical coverage at Grandma’s Marathon.
• This course is designed to introduce you to the
most common and most important conditions
you’ll be treating in the medical tent.
• These issues include:
– Exercise Associated Collapse
– Heat-Related Illness
– Exertional Hyponatremia
– Cardiac Arrest
– Stress Fracture
Exercise Associated Collapse
• This is the most common medical problem
encountered after marathons
• 59-85% of all post-marathon medical visits
– Br J Sports Med. 2011 Nov;45(14):1157-62.
• EAC is caused by a postural drop in systolic
blood pressure
– Inactivation of the calf muscle pump upon cessation
of prolonged exercise
– Results in lower extremity venous blood pooling,
reduced atrial filling pressure, and subsequent
syncope
Exercise Associated Collapse
Presentation
• Runners with EAC will be exhausted,
lightheaded, unsteady on their feet or
unable to stand
Exercise Associated Collapse
Treatment
• Evaluate in supine position with legs elevated
• Oral rehydration
• Cooling
• Rest
• Most patients will recover in 30 min
• Monitor for MENTAL STATUS CHANGES or
failure to progress – which might suggest
– Exertional Hyponatremia
– Hyperthermia
– Cardiac Arrest
– Hypothermia
– Hypoglycemia
True or False?
• A patient with suspected exercise
associated collapse is not improving
despite 30 minutes of rest with her legs
elevated, gentle cooling and oral fluids.
You should give her a liter of IV normal
saline.
False
• It would be appropriate to check her core
temperature (rectal thermometer) and
serum electrolytes.
• IV fluids are rarely necessary. Oral
rehydration is safer and less expensive.
• If the patient is too nauseated to tolerate
oral fluids antiemetic medications are
available.
Exertional Hyponatremia
• Dilutional decrease in serum sodium
concentration during physical activity caused by:
– Over hydration
– Salt losses in sweat
– Fluid retention enhanced by increased ADH secretion
during running
• Incidence
– 12.5% of marathon runners.
• London Marathon
• Br J Sports Med. 2011 Jan;45(1):14-9. Epub 2009 Jul 20.
Exertional Hyponatremia
• Risk factors
– Finishing time over 4 hours
– Marathon running inexperience
– Small stature
– Female gender
– NSAID use
– Unusually hot conditions
Exertional Hyponatremia
• Mild EH
• Defined by Na+ less
than 135mmol/L with
headache,
paresthesias,
nausea,
bloated/swollen
sensation
• Severe EH
• Defined by Na+ less
than 135mmol/L with
decreased mental
status, confusion,
disorientation,
agitation, delirium,
seizures, respiratory
distress
Exertional Hyponatremia
Treatment
• Mild EH
• No IV fluids
• Consider oral fluid restriction
• Pt may drink salty oral fluids
like V8, Coke, or chicken broth
(4 bouillon cubes in 4oz
water).
• Monitor until urination.
• Discharge home with
instructions to monitor for EH
symptoms and to seek urgent
medical attention if any
symptoms develop
• Severe EH
• Check core temp – treat
hyperthermia if present
• 100mL 3%
hypertonic saline
bolus
• Up to two additional 100ml 3%
hypertonic saline boluses may
be given at 10 min intervals
with Na+ recheck and no
improvement in symptoms
• Transfer to ER for ongoing
treatment/monitoring/recovery
True or False?
• A runner with headache, nausea, and
tingling feet has a Na+ 125. She has no
confusion. She could receive 1L of IV
normal saline.
False
• No exercise-associated hyponatremic
patient should receive IV normal saline.
– Mild hyponatremics (those without mental
status changes) can use saltly oral fluids until
they urinate.
– Severe hyponatremics (those with mental
status changes) should receive the hypertonic
saline boluses.
– Please involve Dr. Nelson or Dr. Pipho in the
care of any hyponatremic patients.
Heat-Related Illness
• On a cool, dry day we’ll care for around
200 ill runners. On a hot, humid day the
race could generate over 600 patients in
the medical tent.
• Heat-Related Illness can cause a mass-
casualty event in hot or humid marathons
• Heat-Related Illness can be life-
threatening and must be identified and
treated promptly
Heat-Related Illness
Definitions – Continuum of disease
– Hyperthermia – core temp > 40°C or 104°F
– Heat Cramps – cramping assoc with
dehydration, muscle fatigue, and electrolyte
depletion.
– Heat Exhaustion – Inability to exercise due to
heat intolerance
– Heat Stroke – Hyperthermia with central
nervous system changes (Mental Status
Changes) and possibly multiple organ
system failure
Heat-Related Illness
• Symptoms are
Nonspecific
– Headache
– Dizziness
– Profound Fatigue
– Chills
– Nausea
– Vomiting
– Heat Cramps
• Signs
– Core Temp > 39.4
– Tachycardia
– Hyperventilation
– Hypotension
– Syncope
– Disorientation
– Confusion
– Irrational/unusual
behavior
Treatment of Heat-Related Illness
• Early recognition and treatment is key
• Rectal Temp is the only accurate measure
of core temperature
• Emperical treatment if suspicion is high
• Remove excess clothing
• Place in supine position with legs elevated
• Oral fluid replacement
• Cooling therapy
– Must be done on-site prior to transfer
– Time is tissue!!!
Treatment of Heat-Related Illness
On-Site Cooling Methods
• Ice Bags
– Place bags in groin, axilla, and behind neck
– Least efficient but most convenient cooling method
– Appropriate for low-grade cases
• Iced Towels
– Cover exposed skin with iced towels
– Place fan on pt for improved convection
– Proven as a rapid method for core temp reduction
– Less invasive than Ice Water Submersion
• Ice Water Submersion
– Continuous rectal temperature must be monitored
– Pt is lowered into ice water
– Remove pt when temp is below 40C
True or False?
• A hyperthermic runner with delirious
behavior should be emergently transferred
to the hospital for cooling.
False
• Heat stroke needs to be treated
immediately with on-site cooling in the
medical tent.
• Ice water submersion has the fastest core
temp cooling rate, followed by iced towel
rotation.
Cardiac Arrest
• Incidence of SCA
– 1 in 57,000 marathon runners
• Retrospective survey of marathon medical directors
• Med Sci Sports Exerc. 2012 Apr 19.
– 1 per 100,00 full marathon runners
• Race Associated Cardiac Arrest Event Registery
• N Engl J Med. 2012 Jan 12;366(2):130-40
– 1 per 50,000 marathon runners
• TCM and Marine Corp marathons 1976-1994
• J Am Coll Cardiol. 1996 Aug;28(2):428-31
Location of Cardiac Arrest According to Race Quartile.
Cardiac Arrest Can Happen Anywhere on the Course.
Time to defibrillation affects survival
Survival rate decreases by 10% every 3 minutes in VF
Myocardial Infarction
• Most common in middle-aged male runners
• May have vague or atypical presentation
mimicking other conditions like GERD or MSK
pain
• A normal EKG in the medical tent is not
reassuring as ischemic changes may have not
yet developed
• All angina should be considered unstable.
Emergency cardiac meds and rapid hospital
transfer should be initiated.
Stress Fractures
• Atraumatic bone injury caused by
repetitive, excessive stress.
• Continued stress can progress to
complete fractures.
• Stress fractures comprise 5-10% of sports
medicine visits in the US.
• Running is the most common sport
associated with stress fractures.
Stress Fractures
• History: Focal bone pain worsened with
walking, running or weight bearing.
Pain may persist into rest periods.
• Physical exam: Reproducible focal point
tenderness. Pain with ROM if joint
involved (ie femoral neck)
• Urgency of treatment depends on low or
high-risk stratification
High Risk Stress Fractures
• High Risk Stress
Fractures should be
made non-wt bearing
and sent for urgent
imaging
• Increased risk
complications
including:
– Malunion
– Nonunion
– Avascular necrosis
– Arthritic change
– Occult fractures.
• High Risk Locations
– Femoral Neck
– Tibial Diaphysis
– Navicular
– 5th
Metatarsal
True or False
• A runner has severe groin pain. You
suspect a femoral neck stress fracture.
This patient can be placed on crutches
and follow-up with an orthopedists in 2 or
3 days.
False
• Xrays should be done immediately to
evaluate for a completed femoral neck
stress fracture. This is urgent because of
the risk of femoral head avascular
necrosis and developing hip arthritis.
Thank You!

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Marathon medicine volunteer training course

  • 1. Marathon Medicine Medical Volunteer Training Course Ben Nelson MD Essentia Health Sports Medicine Grandma’s Marathon
  • 2. Introduction • Thank you very much for volunteering to provide medical coverage at Grandma’s Marathon. • This course is designed to introduce you to the most common and most important conditions you’ll be treating in the medical tent. • These issues include: – Exercise Associated Collapse – Heat-Related Illness – Exertional Hyponatremia – Cardiac Arrest – Stress Fracture
  • 3. Exercise Associated Collapse • This is the most common medical problem encountered after marathons • 59-85% of all post-marathon medical visits – Br J Sports Med. 2011 Nov;45(14):1157-62. • EAC is caused by a postural drop in systolic blood pressure – Inactivation of the calf muscle pump upon cessation of prolonged exercise – Results in lower extremity venous blood pooling, reduced atrial filling pressure, and subsequent syncope
  • 4. Exercise Associated Collapse Presentation • Runners with EAC will be exhausted, lightheaded, unsteady on their feet or unable to stand
  • 5. Exercise Associated Collapse Treatment • Evaluate in supine position with legs elevated • Oral rehydration • Cooling • Rest • Most patients will recover in 30 min • Monitor for MENTAL STATUS CHANGES or failure to progress – which might suggest – Exertional Hyponatremia – Hyperthermia – Cardiac Arrest – Hypothermia – Hypoglycemia
  • 6. True or False? • A patient with suspected exercise associated collapse is not improving despite 30 minutes of rest with her legs elevated, gentle cooling and oral fluids. You should give her a liter of IV normal saline.
  • 7. False • It would be appropriate to check her core temperature (rectal thermometer) and serum electrolytes. • IV fluids are rarely necessary. Oral rehydration is safer and less expensive. • If the patient is too nauseated to tolerate oral fluids antiemetic medications are available.
  • 8. Exertional Hyponatremia • Dilutional decrease in serum sodium concentration during physical activity caused by: – Over hydration – Salt losses in sweat – Fluid retention enhanced by increased ADH secretion during running • Incidence – 12.5% of marathon runners. • London Marathon • Br J Sports Med. 2011 Jan;45(1):14-9. Epub 2009 Jul 20.
  • 9. Exertional Hyponatremia • Risk factors – Finishing time over 4 hours – Marathon running inexperience – Small stature – Female gender – NSAID use – Unusually hot conditions
  • 10. Exertional Hyponatremia • Mild EH • Defined by Na+ less than 135mmol/L with headache, paresthesias, nausea, bloated/swollen sensation • Severe EH • Defined by Na+ less than 135mmol/L with decreased mental status, confusion, disorientation, agitation, delirium, seizures, respiratory distress
  • 11. Exertional Hyponatremia Treatment • Mild EH • No IV fluids • Consider oral fluid restriction • Pt may drink salty oral fluids like V8, Coke, or chicken broth (4 bouillon cubes in 4oz water). • Monitor until urination. • Discharge home with instructions to monitor for EH symptoms and to seek urgent medical attention if any symptoms develop • Severe EH • Check core temp – treat hyperthermia if present • 100mL 3% hypertonic saline bolus • Up to two additional 100ml 3% hypertonic saline boluses may be given at 10 min intervals with Na+ recheck and no improvement in symptoms • Transfer to ER for ongoing treatment/monitoring/recovery
  • 12. True or False? • A runner with headache, nausea, and tingling feet has a Na+ 125. She has no confusion. She could receive 1L of IV normal saline.
  • 13. False • No exercise-associated hyponatremic patient should receive IV normal saline. – Mild hyponatremics (those without mental status changes) can use saltly oral fluids until they urinate. – Severe hyponatremics (those with mental status changes) should receive the hypertonic saline boluses. – Please involve Dr. Nelson or Dr. Pipho in the care of any hyponatremic patients.
  • 14. Heat-Related Illness • On a cool, dry day we’ll care for around 200 ill runners. On a hot, humid day the race could generate over 600 patients in the medical tent. • Heat-Related Illness can cause a mass- casualty event in hot or humid marathons • Heat-Related Illness can be life- threatening and must be identified and treated promptly
  • 15. Heat-Related Illness Definitions – Continuum of disease – Hyperthermia – core temp > 40°C or 104°F – Heat Cramps – cramping assoc with dehydration, muscle fatigue, and electrolyte depletion. – Heat Exhaustion – Inability to exercise due to heat intolerance – Heat Stroke – Hyperthermia with central nervous system changes (Mental Status Changes) and possibly multiple organ system failure
  • 16. Heat-Related Illness • Symptoms are Nonspecific – Headache – Dizziness – Profound Fatigue – Chills – Nausea – Vomiting – Heat Cramps • Signs – Core Temp > 39.4 – Tachycardia – Hyperventilation – Hypotension – Syncope – Disorientation – Confusion – Irrational/unusual behavior
  • 17. Treatment of Heat-Related Illness • Early recognition and treatment is key • Rectal Temp is the only accurate measure of core temperature • Emperical treatment if suspicion is high • Remove excess clothing • Place in supine position with legs elevated • Oral fluid replacement • Cooling therapy – Must be done on-site prior to transfer – Time is tissue!!!
  • 18. Treatment of Heat-Related Illness On-Site Cooling Methods • Ice Bags – Place bags in groin, axilla, and behind neck – Least efficient but most convenient cooling method – Appropriate for low-grade cases • Iced Towels – Cover exposed skin with iced towels – Place fan on pt for improved convection – Proven as a rapid method for core temp reduction – Less invasive than Ice Water Submersion • Ice Water Submersion – Continuous rectal temperature must be monitored – Pt is lowered into ice water – Remove pt when temp is below 40C
  • 19. True or False? • A hyperthermic runner with delirious behavior should be emergently transferred to the hospital for cooling.
  • 20. False • Heat stroke needs to be treated immediately with on-site cooling in the medical tent. • Ice water submersion has the fastest core temp cooling rate, followed by iced towel rotation.
  • 21. Cardiac Arrest • Incidence of SCA – 1 in 57,000 marathon runners • Retrospective survey of marathon medical directors • Med Sci Sports Exerc. 2012 Apr 19. – 1 per 100,00 full marathon runners • Race Associated Cardiac Arrest Event Registery • N Engl J Med. 2012 Jan 12;366(2):130-40 – 1 per 50,000 marathon runners • TCM and Marine Corp marathons 1976-1994 • J Am Coll Cardiol. 1996 Aug;28(2):428-31
  • 22. Location of Cardiac Arrest According to Race Quartile. Cardiac Arrest Can Happen Anywhere on the Course.
  • 23. Time to defibrillation affects survival Survival rate decreases by 10% every 3 minutes in VF
  • 24. Myocardial Infarction • Most common in middle-aged male runners • May have vague or atypical presentation mimicking other conditions like GERD or MSK pain • A normal EKG in the medical tent is not reassuring as ischemic changes may have not yet developed • All angina should be considered unstable. Emergency cardiac meds and rapid hospital transfer should be initiated.
  • 25. Stress Fractures • Atraumatic bone injury caused by repetitive, excessive stress. • Continued stress can progress to complete fractures. • Stress fractures comprise 5-10% of sports medicine visits in the US. • Running is the most common sport associated with stress fractures.
  • 26. Stress Fractures • History: Focal bone pain worsened with walking, running or weight bearing. Pain may persist into rest periods. • Physical exam: Reproducible focal point tenderness. Pain with ROM if joint involved (ie femoral neck) • Urgency of treatment depends on low or high-risk stratification
  • 27. High Risk Stress Fractures • High Risk Stress Fractures should be made non-wt bearing and sent for urgent imaging • Increased risk complications including: – Malunion – Nonunion – Avascular necrosis – Arthritic change – Occult fractures. • High Risk Locations – Femoral Neck – Tibial Diaphysis – Navicular – 5th Metatarsal
  • 28. True or False • A runner has severe groin pain. You suspect a femoral neck stress fracture. This patient can be placed on crutches and follow-up with an orthopedists in 2 or 3 days.
  • 29. False • Xrays should be done immediately to evaluate for a completed femoral neck stress fracture. This is urgent because of the risk of femoral head avascular necrosis and developing hip arthritis.

Editor's Notes

  1. Figure 1. Location of Cardiac Arrest According to Race Quartile. To account for differences in race distance between the marathon (26.2 mi) and half-marathon (13.1 mi), the point in the race course where the cardiac arrest occurred was examined as a function of the total race-distance quartile. Q1 denotes 0 to 6.5 mi (marathon) and 0 to 3.3 mi (half-marathon), Q2 6.5 to 13.1 mi (marathon) and 3.3 to 6.5 mi (half-marathon), Q3 13.1 to 20 mi (marathon) and 6.5 to 10 mi (half-marathon), and Q4 20 mi to finish (marathon) and 10 mi to finish (half-marathon).
  2. Shows that time to defibrillation affects survival. No different in athletes. Survival rate decreases by 10% every 3 minutes in VF. Avg 1st response unit 3.5 min, Avg paramedic response 6.5 min Recommend early recognition of SCA, immediate CPR, and Defibrillation in less than 3-5 min.