heatand ickle cell …ehi vs ecast with sct and without sct ... · build up intensity slowly while...
TRANSCRIPT
4/13/2016
1
HEAT AND
SICKLE CELL
…EHI vs
ECAST
HEAT AND
SICKLE CELL
…EHI vs
ECAST
“…Dr Kark found that the risk of mild to
moderate EHI among Marine recruits at
Parris Island…was the same for those with SCT and without SCT…This was
contrary to the expected results.”Grant et al. Public health implications of sickle cell trait: a report of the CDC meeting. Am J Prev Med
2011;41(S64):S435-S439
ECAST & EHI ARE SEPARATE
SYNDROMES
EHI rates for black recruits with SCT not significantly different from black recruits without SCT
Kark JA Ward TW Exercise and Hemoglobin S Sem in Hematol 1994;31(3):181-225
Historic military case reports: sudden death in SCT sans major heat stress
Jones SR, Binder RA, Donowho EM Jr. Sudden death in sickle celltrait. N Engl J Med. 1970;282:323–5
Koppes GM, Daly JJ, Coltman CA, Butkus DE. Exertion-induced rhabdomyolysis with acute renal failure and disseminated intravascular coagulation in sickle cell trait. Am J Med. 1977;63:313–7
12 risk factors for EHS discussed with 20 listed and not a word about SCT as a risk factor of EHS
Armstrong LE, Casa DJ Predisposing factors for exertional heat illness. In Exertional Heat Illnesses, edited by Lawrence E Armstrong, 151-66, Human Kinetics, 2003
Cause of Non-Traumatic Death
NCAA Football 2000-16
0
2
4
6
8
10
12
9
1
6
11
SCD
Asthma
EHS
ECAST
Characteristics of Non-Traumatic Collapse
ECAST
Weakness > pain
Slumps to ground
Responsive,
initially
No palpable
cramp
Temp < 103° F
Can occur early in
workout
SCDGasping, gurgling,
snorting, or
moaning
Unprotected fall
Unresponsive
Limp or seizing
Temp irrelevant
No warning
EHS
Fuzzy thinking
Bizarre behavior
Incoherent
Can be in coma
Temp > 106° F
Usually occurs late
in workout
Asthma
Usually known
asthma
Prior episodes,
poor control
Breathless,
may/not wheeze
Gasping, panicky,
on hands/knees
Auscultate: moving
little air
Usually occurs
after sprinting
0
1
2
3
4
5
6
2000 2002 2004 2006 2008 2010 2012 2014
2
1 1
0
3
1
2
0
3
2
3
5
0 0
1 1
ECAST Deaths in Athletes
#25 – 2000-2015
4/13/2016
2
Too much, too fast, too long, too hard…Especially in the presence of modifiers:
• Environmental heat• Acute illness
• New to altitude• Incessant pace / ‘heroic effort’• Relentless ‘coaching’• Uncontrolled asthma
Modifiers may make the activity too
intense for that athlete on that day
Eichner, ER. Sickle cell trait in sports. Current Sports Medicine Reports 2010;9(6):347-51
An ‘Injury’ whose ‘Insult’ is Intensity
Eichner’s Quintus
1. Asymptomatic Sickle Cell Trait
2. Ischemic events
3. Ischemic events with visceral or muscular infarcts
4. Severe rhabdomyolysis with residuals (kidney disease, splenic disease, MI)
5. Fulminant rhabdomyolysis with death
Eichner’s QuintusLow Oxygen
Tension
Sickling
More SicklingMore Ischemia
Infarcts
Ischemia,↓↓↓↓ 02 Tension
Rhabdomyolysis
ARF / Hyperkalemia
MultipleSystemFailure
DeathDeathDeathDeath
Back or LegCramping Sensation
(Ischemia)
SplenicInfarcts
Muscle Infarcts& Myonecrosis
All deaths in athletes with [sickle cell trait] occurred in black Division
I football athletes during…conditioning
Harmon KG, Drezner JA, Klossner D, Asif IM. Sickle cell trait associated with a RR of death of 37 times in National Collegiate Athletic Association football athletes: a database with 2 million athlete-years as the denominator. Br J Sports Med. 2012;46(5):325-330
Maron BJ, Harris KM, Thompson PD, Eichner ER, Steinberg MH. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 14: sickle cell trait: a scientific statement from the american heart association and american college of cardiology. J Am Coll Cardiol. 2015 Dec 1;66(21)
[lethal…collapse in athletes with SCT] were most common in
college football players during conditioning drills
Signs & SymptomsFatigue
Legs like jell-o
“My chest hurts”
“I can’t catch my breath”
Ischemic pain / ‘cramp’
Low back pain, ‘cramp’, spasm
Leg pain, ‘cramp’, spasm
Hyperventilating
"I'm trying. I'm not weak. I just can't go on." Aaron O’Neal
Do you or someone in your family have sickle
cell trait or disease?
Bernhardt DT, Roberts WO PPE Preparticipation Physical Evaluation, 4th ed, AAP 2010
4/13/2016
3
https://www.ok.gov/health2/documents/NBS%20English%20Brochure.pdf
Test results are available:
Okla St Department of Health
Newborn Screening Program
(405) 271-6617
• Authorized Release of Information
• Date of Birth
• Birthmother’s name
Ideally, sickle cell trait athletes should set their own pace.
Engage in a slow and gradual preseason conditioning and lifting regimen.
Build up intensity slowly while training, e.g., paced progressions.
Use adequate rest and recovery between repetitions, especially during serial sprints and
intense station or mat drills.
Not to participate in “preseason conditioning tests.”
Be excused from performance tests such as timed serial sprints or miles, especially if these are not normal sports activities.
Not be urged to perform all-out exertion of any kind beyond 2-3 minutes without a breather.
Stop activity immediately upon struggling, i.e., at the earliest onset of any undue symptom, such as cramping, pain, weakness, breathlessness, or fatigue.
Report any symptoms to ATC and coach. Seek prompt medical care for any unusual distress.
Stay well hydrated at all times, especially in hot and/or humid conditions.
Curb activity in very hot or humid conditions.
Curb activity when new at altitude, even a “jump” of only 2,000 ft. Cut training effort, monitor closely, have ready access to supplemental oxygen.
Control asthma to cut risk of exertional sickling [Nina has no reported history of exercise-induced asthma].
Decrease activity sharply during any illness, especially with fever, vomiting, or diarrhea.
Decrease activity after nights of poor sleep.
Sickle Cell Trait Precautions
0
1
2
3
4
5
6
7
8
9
10
2000 2002 2004 2006 2008 2010 2012 2014 2016
1 1
0 0
2
1 1
0
2
1 1
0 0 0
1
0
The Eichner Effect: Ending Death
ECAST DeathSickle Cell Trait & the
Athlete
Task Force Consensus Statement is released
NCAA DI Bylaw: SCT Status in PPE
2000-2016Years With At Least
1 ECAST Death
Years With
No ECAST Death
No SCT screening 8 3
SCT screening 1 5
Fisher exact probability test for this 2 x 2 table: Statistically significant (P = 0.0498)
Preventing Div-1 Football ECASTDeaths
Statistical SignificanceStatistical Significance
*Eichner ER. “A stitch in time” and “if 6 was 9”. preventing exertional sickling deaths; probing team rhabdomyolysis outbreaks. Curr Sports Med Rep. 2016. In press
.Adams WM, Huggins RA, Stearns RL, Anderson SA, Kucera KL, Casa DJ. Policy changes reduce exertional sickling related deaths in Division I collegiate football players [abstract]. J Athl Train. 2016. In press
There is no evidence that any player has ever died an
ECAST death as SCT status is known, athlete and staff are
educated, and precautions are heeded
There is no evidence that any player has ever died an
ECAST death as SCT status is known, athlete and staff are
educated, and precautions are heeded
1963- John Anders, Univ of New Mexico
1970 - Hosie Moss, Ft Scott Community College
1974 - Polie Portier, Univ of Colorado
1980 - Gregory Pratt, Abilene Christian Univ
1982 - Charles Tomahsah, OK Panhandle St Univ
1985 - Charles Mitchell, Henderson St Univ
1986 - Venable, HS
1986 - Eric Sorey, Univ of Southern Mississippi
1987 - Parnell Sylvio, Univ of Indiana
1987 - Carleton Oats Jr, Utah St Univ
1990 - Chris Cooper, Univ of New Mexico
1992 - Thomas Eric Curry, Univ of Georgia
1993 - Damion Smith, Florida HS
1995 - Damon Terrell, Univ of Arizona
1999 - Timothy Harlan, California HS
2000 - Preston Birdsong, Tennessee Tech Univ
2000 - Michah Wimberley, Ohio Jr High
2001 - Devaughn Darling, Florida St Univ
2004 - Aaron Richardson, Bowling Green St Univ
2004 - Ivan Okafor, Texas HS
2004 - David Colston, Prairie View A&M
2005 - Aaron O’Neal, Univ of Missouri
2006 - Bobby Stephens, Florida Jr High
2006 - Dale Lloyd, Rice Univ
2008 - Ereck Plancher, Univ of Central FL
2008 - Chad Wiley, North Carolina A&T
2009 - Ja’Quayvin Smalls, W Carolina Univ
2009 - Edwin 'Dek' Miller, Maryland HS
2010 - Bennie Abram, Univ of Mississippi
2010 - Olivier Louis, Florida HS
2011 - Tyquan Brantley, South Carolina HS
2011 - Al Smith Jr, Texas HS
2011 - Isaiah Laurencin, Florida HS
2014 - Ted Agu, Univ of Cal, Berkeley
2015 - Josh Warren, Texas HS
Roll Call of DeathRoll Call of DeathRoll Call of DeathRoll Call of DeathRoll Call of DeathRoll Call of DeathRoll Call of DeathRoll Call of Death