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 BermanBrain & Spine Institute

Sinai Hospital Baltimore

Disclosures

I have no financial interest or affiliation with the manufacturer or distributor of any medical products, devices, or services.

I will not be discussing investigational or unlabeled uses of products and/or devices.

Objectives

At 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 Services

Critical Care

First Aid and General Medical Problems

Special Problems

Medical Tent Location

Medical Tent Location

Medical Tent Setup

Cots for athletes to lie on

Readily accessible supplies

Minor injury area

Registration area

Clear Area outside Medical Tent

No family member’s in tent area

Security at the entrance

Staffing

Medical Director

MD, DO

Medical Coordinator

MD, DO, PA-C, ATC, RN

Staff

MD, DO, PA-C, NP, DPM

RN

ATC

Paramedics/EMT

Non-medical

5-10 medically trained and 4-6 non-medical per 1000 runners

Volunteers

Medical Aid Stations/Sites

Finish Line Site

Similar to Hospital ER

On Course Aid Station

Physician, PA, ARNP, RN, Paramedic

Roving Medical Vehicles

Physicians, PA, ARNP, RN, Paramedic

Bike Medics

Paramedics, ER PA/ARNP/Physician

Finish Line Site

Triage Officer

Team Care

Physician/PA/ARNP

RN

Scribe

Nursing Students, PA Students, EMT

Volunteer Education

Important to educate medical team

Weather conditions

Site Supplies

Transport criteria

Local ED’s

Temperature and Humidity

Temperature and humidity can affect the performance and safety of runners.

Warm temperatures and high humidity increase the incidence of heat related injuries.

Back Flag: Extreme risk. WBGT in excess of 82-degrees F. Event may be cancelled

Red Flag: High risk. WBGT between 73 – 82 degrees F. Runners who are sensitive to heat or humidity should consider not participating.

Yellow: Moderate risk. WBGT between 63 – 72 degrees F.

Green: Low risk. WBGT below 63 degrees F. 

This is a medical decision, not a race director decision

Volunteers

Liability Insurance

State Dependent

Should be provided by the race

Injury Management

0.1% to 20% of runners seek attention

Cardiovascular deaths occur at any distance

Maybe greater at shorter distance

2011 US Largest Race

Peachtree Road Race 10K, 55,077

Lilac Bloomsday Run 12K, 51,303

BolderBOULDER 10K, 49,213

ING New York City Marathon, 47,133

Bay to Breakers 12K, 43,954

Chicago Marathon, 35,755

Cooper River Bridge Run 10K, 34,789

Race for the Cure: DC 5K, 34,751 E

Ukrop's Monument Avenue 10K, 33,365

Rock 'n' Roll Las Vegas HMAR, 33,257

Runner Education

Web Site Instructions

Race Packet Instructions

Pre-Race athlete meeting

Mandatory at all Ironman Events

What to Include

Fluid demands

Identification/medical history

Weather Precautions

Aid stations sites/types

Incidence of Nontraumatic Sudden Death in Athletes

Population Group Age distribution Incidence

Organized High school/college athletes

High school/college aged 7.47:1,000,000/year M1.33:1,000,000/year F

US Air Force Recruits 17 to 28 years of age 1:735,000 per year

Rhode Island Joggers < 30 year of age 1:280,000 per year

Rhode Island Joggers 30 to 65 years of age 1:7,620 joggers per year

Marathon Runners Mean age 37 1:50,000 race finishersw

Cold, Hot, Salt

3 Critical Race Issues

Diagnosis of Hypothermia

Requires

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

Hypothermia

Stages of Hypothermia Core Body Temperature Symptoms

98 – 96 Shivering 95 – 91 Intense Shivering, difficulty Speaking 90 – 86 Shivering decreases and is replaced by strong muscular rigidity. Muscle coordination is affected and erratic or jerky movements are produced. Thinking is less clear, general comprehension is dulled, possible total amnesia. Generally able to maintain the appearance of psychological contact with surroundings. 85 – 81 Becomes irrational, loses contact with environment, drifts into stuporous state. Muscular rigidity continues. pulse and respirations are slow and cardiac dysrhythmias may develop. 80 – 78 Loses consciousness and does not respond to spoken words. Most reflexes cease to function. Heartbeat slows further 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

Hypothermic Predisposing Factors

• Impede circulation– Dehydration, DM, Peripheral vascular disease, tight

clothes, tobacco

• Increase heat loss– Burns, skin diseases, environment, alcohol/drugs,

infancy,

• Decrease heat production– Endocrine failure, hypoadrenalism, hypoglycemia,

hypopituitarism, hypothyroidism, infancy, old age, malnutrition

• Impair thermoregulation– DM, Parkinson’s, spinal cord injuries, stroke

Answer

Answer

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 – Especially with cold-water

immersion• Supine to avoid postural

hypotension• O2• Monitors• CPR and intubation should not be

withheld if needed• Trauma immobilization as needed• Intense vasoconstriction at <30 °C

may make IV meds ineffective• Lidocaine/atropine: ineffective• by 30-33ºC)

• Prophylactic (<30 °C) and therapeutic bretylium

– Treat life-threatening arrhythmias only; the remainder will self-correct with re-warming

– Attempt defibrillation up to 3 times and no re-attempts until core temp reaches 30ºC

– Magnesium sulfate: Helpful in spontaneous resolution of v fib

• Reduce further heat loss• Begin re-warming

– Heat packs in axillae, groin, belly

• Intubate as needed; pre-oxygenate first

• Resuscitate cold and dead to warm and dead (at least by 30-33ºC)

Hyperthermia

Hyperthermia

Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability 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 body's temperature set-point.

HYPOTHERMIA

• Every year in the U.S. between 600 and 700 people die of hypothermiahypothermia.

• Every year in Arizona an average of 23 people die of hypothermia.hypothermia.

Signs and symptoms

Hot, dry skin is a typical sign of hyperthermia.[8] The skin may become red and hot as blood vessels dilate in an attempt to increase heat dissipation, sometimes leading to swollen lips. An inability to cool the body through perspiration causes 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

Diagnosis

Hyperthermia is generally diagnosed in the presence of an unexpectedly high body temperature and a history that suggests hyperthermia instead of a fever. Most commonly this means that the elevated temperature has appeared in a person who was working in a hot, humid environment (heat stroke) or who was taking a drug for which hyperthermia is a known side effect (drug-induced hyperthermia). The presence of other signs and symptoms related to hyperthermia syndromes, such as the extrapyramidal symptoms that are characteristic of neuroleptic malignant syndrome, and the absence of signs and symptoms more commonly related to infection-related fevers, are also considered in making the diagnosis.

Prevention

Exposure limits to heat stress are usually set by indices based on the wet bulb globe 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.

Hyponatremia

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/L

Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8)

Elevate the Feet and Pelvis

Mayers 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 oral rehydration 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

exercise

Casa 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– Discomfort– Tissue injury– Bleeding– Infection– Embolization– Worsening electrolyte imbalances– Utilize resources

• Benefits– Treat identifiable

conditions– Lessen the strain on

emergency and hospital services

– Training

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.