Urban Adventure for a Young Ultra-marathoner

Vanderbilt Sports Medicine

Urban Adventure for a Young Ultra-marathoner

Rachel Biber Brewer, MDPrimary Care Sports Medicine FellowVanderbilt University Medical Center

Nashville, Tennessee

February 5, 2011


Case Presentation, History• JS is 19 year-old runner and college freshman

presenting to the ED via EMS due to a chief complaint of generalized weakness, vomiting, and headache.

• He stated he felt like his “head was going to explode.”

• He recently moved into the dorm while starting college 4 days earlier.


History, continued• In his hometown 7 days prior to presentation,

he was running on the road and was struck by a car.

• He was thrown 25 feet and briefly lost consciousness.

• He was evaluated at an outside ED and released.


History, continued• He has not run in the interim and returns

because of excessive weakness, increasing headaches, nausea, vomiting, intermittent vertigo and blurred vision.


Past Medical History• Medical History

– Healthy

• Social History– College freshman – Ran cross-country in HS and progressed to marathons

and ultras

• Medications/EtOH/Drug Use– None


Training/Nutrition History• Training for his second 50k. • He reports drinking 5-10 liters of water per

day. • He has not run over the past week (after initial

injury) but continues to maintain the same hydration habits.


Physical Exam• Vitals: normal with exception of BP elevated, 138/82• General: AAOx3, appears fatigued, NAD• HEENT: small posterior scalp wound; PERRLA; left scleral

hemorrhage, no nystagmus, normal visual acuity• CV/Resp: normal• GI: normal• Musculoskeletal: left ankle lateral abrasion; bilateral hand edema• Neuro: CN 2-12 intact; 5/5 motor strength upper/lower

extremities; sensory intact to light touch


Differential Diagnosis• Traumatic brain injury• Hyponatremia• Drug overdose• Alcohol intoxication• Adrenal insufficiency


Questions?


Imaging


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Labs• BMP: Na 119, K 3.1, Cl 88, CO2 26, BUN 7, Cr 0.53,

Gluc 88• CPK: 186• Serum Osmolality: 241 mosm/kgH20• Urine: Osmolality 330 mosm/kgH20, K 10, Na 117• Drug Screen: Negative• Thyroid studies: normal• Cortisol stim test: normal


Diagnosis• Syndrome of inappropriate antidiuretic

hormone secretion (SIADH) due to head trauma exacerbated by excessive free water replacement

• Left zygomatic arch fracture, left anterior and lateral maxillary sinus fracture


Treatment• The patient’s Na gradually corrected while

inpatient. – He was hospitalized for approximately 36 hours.

His free water intake was initially restricted at 500cc per day and then gradually liberalized to 1.5L at discharge.


Time Elapsed Fluid Resuscitation

Sodium (mEq/L)

Free H2O Restriction

-- -- 119 --

2 hrs 2L NS 119 500cc

7 hrs NS 100cc/hr 121 500cc

13 hrs NS 100cc/hr 119 500cc

19 hrs NS 100 cc/hr 119 500cc

23 hrs NS 100 cc/hr 125 500cc

30 hrs NS 100 cc/hr 128 500cc

34 hrs NS 100 cc/hr 129 500cc

38 hrs IVF d/c 130 1.5L

4 days (f/u) -- 141 2L

1 week -- 141 2.5L

2 weeks -- 143 d/c H20 restriction


Treatment Principles• Fluid restriction is the mainstay of

treatment in this case normal mental status.

• Rapid correction can lead to osmotic demyelination.

• When hyponatremia is hyperacute (as in exercise-associated hyponatremia), 3% NaCl can be used more liberally.

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Treatment• His Na was 130 at discharge and 141 forty-eight

hours later. His headache, nausea/vomiting, vertigo, blurred vision, and weakness completely resolved.

• His fluid intake was further liberalized after discharge while continuing to monitor sodium levels (which remained normal).

• Facial fractures managed non-operatively.

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Outcome/Follow-up• The patient’s free water was gradually

liberalized and restriction was discontinued at approximately 2 weeks.

• He returned to training one week after discharge and successfully completed his second 50k five weeks later.

• Education regarding proper hydration and nutrition for ultra-running training and racing.


Key Points• There is a wide variability in sweat rates and renal water

excretory capacity during exercise.– Absolute drinking/sodium intake guidelines are difficult

to attain.• No data to support that Na supplementation or

consumption of electrolyte containing fluids can prevent exercise associated hyponatremia in those drinking to excess.

• Education of race directors as well as endurance athletes, especially those at risk.

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Key Points• Hyponatremia comes in different forms in

athletes and it is crucial to recognize it clinically, as well as understand treatment and prevention.

• Nutrition education and strategy is an integral part of race preparation and training in all endurance athletes.

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Questions?


SIADH

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ETIOLOGYCNS disturbances: stroke, hemorrhage, infection, trauma, pyschosis

Malignancies: most often due to small cell carcinoma of the lung

Drugs: chlorpropamide, carbamazepine, oxcarbazepine, high dose IV cyclophosphamide, selective SSRI’s

Major surgery: abdominal or thoracic surgery

Pulmonary disease: pneumonia

Hormone deficiency: adrenal insufficiency, hypothyroidism

Idiopathic


Exercise Associated Hyponatremia• The occurrence of hyponatremia during or up to 24

hours after prolonged physical activity.• Has emerged as an important cause of race-related

death and life-threatening illness among endurance athletes.

• Presentation edema, N/V, headache, weakness, progressing to AMS seizures, etc

• Pathogenesis increased fluid intake +/- persistent secretion of ADH

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Risk Factors for EAHATHLETE-RELATED EVENT-RELATED

Excessive drinking behavior High availability of drinking fluids

Weight gain during exercise >4 hours of exercise duration

Low body weight Unusually hot or cold environmental conditions

Female sex

Slow running/performance pace

Event inexperience

NSAID use (association vs. cause)

MEDICAL RISK FACTORS

Altered renal excretory capacity potentially impaired by drugs (e.g. thiazide diuretics), intrinsic renal disease, low solute diet, SIADHEAH Consensus Development Conference, 2007, Cin J Sport Med, 2008.

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Urban Adventure for a Young Ultra-marathoner