marathon medicine - sept 2012 copy5d780c98a7d97708865b-7575b66d6af6e3d4b728b20ce2c6dc96.r98… ·...
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Marathon Medicine: Exercise Associated Collapse in
Endurance Sports !
Mark A. Harrast, MDMedical Director, Seattle Marathon
Medical Director, Sports Medicine Center at Husky Stadium
Director, Sports Medicine Fellowship Clinical Professor
University of Washington
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Overview
Epidemiology / Demographics of Runners Emergency Preparedness Exercise Associated Collapse
Exercise Associated Hyponatremia Cardiac Arrest Heat-related Illness
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0
150
300
450
600
1980 1990 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
x1000
US Marathon Finishers
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Exercise Associated CollapseExtensive Differential:
EAC
Heat related illness
Hypothermia
Hypoglycemia
Hyponatremia
Muscle cramps
Cardiac arrest
Other medical / neurologic conditions
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Exercise Associated CollapseExtensive Differential:
EAC
Heat related illness
Hypothermia
Hypoglycemia
Hyponatremia
Muscle cramps
Cardiac arrest
Other medical / neurologic conditions
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“Benign” Exercise Associated Collapse
!
AFTER the finish line
“postural hypotension”
Not simply the result of dehydration (Holzhausen 1994, Med Sci Sports Exer)
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“Benign” Exercise Associated Collapse
!
leg muscles venous pump venous pooling collapse
As temperature increases, blood flow is shunted from core to skin
Pathophysiology:
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Exercise Associated CollapseAssessment:
Level of responsiveness ABC’s
When? -during the race vs. after finish
Blood glucose, Na, Rectal temp, cardiac rhythm, orthostatics
Treatment: Treat the underlying cause Elevate legs and pelvis Oral rehydration Not clearing within 15-30 minutes: IVF
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Exercise Associated CollapseAssessment:
Level of responsiveness ABC’s
When? -during the race vs. after finish
Blood glucose, Na, Rectal temp, cardiac rhythm, orthostatics
Treatment: Treat the underlying cause Elevate legs and pelvis Oral rehydration Not clearing within 15-30 minutes: IVF
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Exercise Associated CollapseExtensive Differential:
EAC
Heat related illness
Hypothermia
Hypoglycemia
Hyponatremia
Muscle cramps
Cardiac arrest
Other medical / neurologic conditions
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Exercise Associated Hyponatremia
Hypervolemic hyponatremia
First reported in the 1981 Comrades Run (90km) in South Africa
International media attention after a 28yo female runner died after the 2002 Boston Marathon
The Boston Globe: “MARATHON RUNNER'S DEATH LINKED TO EXCESSIVE FLUID INTAKE”
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Hyponatremia among runners in the Boston Marathon (2002)
Almond CS, et al: NEng J Med 2005; 352:1530-6.
488 runners had a usable blood sample at the finish
Risk Factors after Multivariate Analysis
13% (63) Na < 135 0.6% (3) Na <120
Weight gain Race time > 4 hours
BMI extremes
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Hyponatremia among runners in the Boston Marathon (2002)
Almond CS, et al: NEng J Med 2005; 352:1530-6.
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Pathophysiology: (similar to SIADH)
Sources of AVP during exercise:
Plasma volume contraction Muscle breakdown (rhabdo) Nausea/vomiting Hypoglycemia Stress Hyperthermia
Overconsumption of fluids
exacerbated by AVP secretion
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Exercise Associated Hyponatremia
Signs and Symptoms:
Early: Lightheaded, dizzy, nauseated
Late: Ashen, obtundation, seizures
Middle: Severe and progressive HA, vomiting,
puffiness, cramps, confusion, “impending doom”
Cerebral Edema and
Pulmonary Edema
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TreatmentNa < 135, fluid overloaded,
symptomatic with progressive encephalopathy
allow natural diuresis
close observation ? hospitalization fluid restriction
Na < 135, fluid overloaded, minimal symptoms
Na < 135, dehydrated
high flow O2 100cc of 3% NaCl over
10 min x 2 (+/- 50-70cc/hour)
(+/- diuretic) Transfer to E.D.
Start Rx of hyponatremia before head CT
rehydrate with NS if encephalopathic: use 3%NS check lytes after each liter consider transfer to E.D.
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TreatmentNa < 135, fluid overloaded,
symptomatic with progressive encephalopathy
allow natural diuresis
close observation ? hospitalization fluid restriction
Na < 135, fluid overloaded, minimal symptoms
Na < 135, dehydrated
high flow O2 100cc of 3% NaCl over
10 min x 2 (+/- 50-70cc/hour)
(+/- diuretic) Transfer to E.D.
Start Rx of hyponatremia before head CT
rehydrate with NS if encephalopathic: use 3%NS check lytes after each liter consider transfer to E.D.
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PreventionEmphasize Individual Differences
Drink when you are thirsty (very safe for slower and at risk runners)
Replace what you need (sweat losses)
Salty sweaters (or if competition > 6hrs): use Na / electrolyte replacement
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PreventionEmphasize Individual Differences
Drink when you are thirsty (very safe for slower and at risk runners)
Replace what you need (sweat losses)
Average fluid replacement in a marathon: 400-800 cc / hour (14-27 ounces)
Salty sweaters (or if competition > 6hrs): use Na / electrolyte replacement
General Guidelines:
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Diagnosis and Prevention of Hyponatremia at an Ultradistance Triathlon
Speedy DB, et al: Clin J Sport Med 2000; 10:52-8.
Ironman New Zealand
3.8% (25) received care for EAH 14 were hospitalized
2 were admitted to ICU
19981997
0.6% (4) received care for EAH none were critical
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Diagnosis and Prevention of Hyponatremia at an Ultradistance Triathlon
Speedy DB, et al: Clin J Sport Med 2000; 10:52-8.
Ironman New Zealand
Intervention:
3.8% (25) received care for EAH 14 were hospitalized
2 were admitted to ICU
Education on fluid intake (500-1000cc/hour)
Limited the number of aid stations bike: from q 12km to q 20km
run: from q 1.8 km to q 2.5 km
19981997
0.6% (4) received care for EAH none were critical
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Exercise Associated Hyponatremia: Summary
Treatment
Transfer to Emergency Facility
3% NaCl on site
Oxygen
Risk Factors
Smaller runners
Weight gain / high fluid intake
Finish time > 4 hrs
Hot & humid conditions
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Exercise Associated CollapseExtensive Differential:
EAC
Heat related illness
Hypothermia
Hypoglycemia
Hyponatremia
Muscle cramps
Cardiac arrest
Other medical / neurologic conditions
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SCD in MarathonsOften quoted risk of SCD in marathons due to CV disease:
1:50,000
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SCD in MarathonsOften quoted risk of SCD in marathons due to CV disease:
1:50,000
The rate has improved over the last 10-15 years (potentially due to earlier recognition, better preparation, AED use)
!1976-1994 Twin Cities & Marine Corp: 1:55,000 1995-2004 Twin Cities & Marine Corp: 1:220,000
1981-2006 London: 1:130,000 !
Roberts WO, Maron BJ: J Am Coll Cardiology 2005;46(7):1373-7. Tunstall Pedoe DS: Sports Med 2007;37(4-5):448-50.
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Twin Cities & Marine Corp
1976-2004 ~442,000 finishers
9 cardiac arrests 5 died (1:88,000)
4 resuscitated (45%), (75% in last decade): - 3 VFib, 1 asystole
- all had AED within 5 minutes
!!!
London 1981-2006
~650,000 finishers
11 cardiac arrests 5 died
6 resuscitated (55%), (50% in last decade)
!!!!
7/9 (age 32-58): CAD 19yo female: anomolous coronary artery origin
28yo male: mitochondrial myopathy 6/9 completed one prior marathon
!!
8/11: CAD 3/11: HCM
1/3rd presented at finish 2/3rd btwn Miles 6-26
!!!!
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Twin Cities & Marine Corp
1976-2004 ~442,000 finishers
9 cardiac arrests 5 died (1:88,000)
4 resuscitated (45%), (75% in last decade): - 3 VFib, 1 asystole
- all had AED within 5 minutes
!!!
London 1981-2006
~650,000 finishers
11 cardiac arrests 5 died (1:130,000)
6 resuscitated (55%), (50% in last decade)
!!!!
7/9 (age 32-58): CAD 19yo female: anomolous coronary artery origin
28yo male: mitochondrial myopathy 6/9 completed one prior marathon
!!
8/11: CAD 3/11: HCM
1/3rd presented at finish 2/3rd btwn Miles 6-26
!!!!
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Toronto 2001-2008
2,500 - 4,000 entrants / year
4 cardiac deaths !2001: 54yo multi-marathoner in marathon 2004: 42yo male near end of half-marathon 2005: 37yo male after the half-marathon 2006: 41yo male 800m from finish of marathon
!!!!!!
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Berlin September 2008
40,000 entrants
Danny Kassup 25yo Canadian Olympic hopeful
!!
Collapsed at the 5K mark CPR started immediately
AED within 2 minutes V Fib arrest from myocarditis
(had a recent URI) !!!
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Seattle November 2007
~ 11,000 entrants
37yo software engineer !!
1st marathon, multiple half-marathon finishes Collapsed 30 yards before finish
CPR started immediately Successfully resuscitated
!Cath: 70%mid LAD lesion--> stented
!!!
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Sept 2009: Virginia Beach RnR HM, 23 yo male during race, near finish
Oct 2009: San Jose RnR HM, 34yo female, 35yo male within last mile
Oct 2009: Baltimore Marathon, 23yo male 25th mile, heat stroke (temp 107-108 in ED)
Oct 2009: Detroit HM, 26, 36, 65 yo males 26yo: after finish, others btwn 11-12 miles, all cardiac (65yo CAD)
Dec 2009: Memphis HM, 32yo female after finish, h/o AFib s/p ablation
Jan 2010: Mississippi Blues Marathon relay, 40yo male died in the initial mile of the anchor leg
Mar 2010: Dallas RnR HM, 32yo male after finish, myocarditis
May 2010: Orange County HM, 46yo male 100yds before finish, heat stroke, h/o sz disorder,
June 2010: Duluth Grandma’s HM, 64yo male after finish, CAD s/p MI
Sept 2010: Virginia Beach RnR HM, 27yo male at finish
Sept 2010: Nashville Women’s HM, 54yo female after finish, CAD s/p MI
!
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Sept 2009: Virginia Beach RnR HM, 23 yo male during race, near finish
Oct 2009: San Jose RnR HM, 34yo female, 35yo male within last mile
Oct 2009: Baltimore Marathon, 23yo male 25th mile, heat stroke (temp 107-108 in ED)
Oct 2009: Detroit HM, 26, 36, 65 yo males 26yo: after finish, others btwn 11-12 miles, all cardiac (65yo CAD)
Dec 2009: Memphis HM, 32yo female after finish, h/o AFib s/p ablation
Jan 2010: Mississippi Blues Marathon relay, 40yo male died in the initial mile of the anchor leg
Mar 2010: Dallas RnR HM, 32yo male after finish, myocarditis
May 2010: Orange County HM, 46yo male 100yds before finish, heat stroke, h/o sz disorder,
June 2010: Duluth Grandma’s HM, 64yo male after finish, CAD s/p MI
Sept 2010: Virginia Beach RnR HM, 27yo male at finish
Sept 2010: Nashville Women’s HM, 54yo female after finish, CAD s/p MI
!
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14 Race Related Deaths in 2009-10
Marathon: 2 Half Marathon: 12
males: 11 females: 3
7 < 35yo 7 > 35yo
(3 > 50yo)
cardiac: 7 heat stroke: 2 unknown: 5
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Risk of SCD in Marathon Running vs.
Dying in an MVA !
(that might otherwise have taken place if the roads had not been closed) DA Redelmeier, 2009 BMJ
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Risk of SCD in Marathon Running vs.
Dying in an MVA !
(that might otherwise have taken place if the roads had not been closed) DA Redelmeier, 2009 BMJ !
!Retrospectively studied 26 US marathons 1975-2004:
26 SCD Due to road closures, 46 MV fatalities were prevented
(35% risk reduction) 1.8 crash deaths saved for each case of SCD
!!
From a societal perspective, organized marathons decrease the death rate
!!
!
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Exercise Associated CollapseExtensive Differential:
EAC
Heat related illness
Hypothermia
Hypoglycemia
Hyponatremia
Muscle cramps
Cardiac arrest
Other medical / neurologic conditions
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Heat Exhaustion
Inability to continue to exercise in the heat
Represents a failure of the CV responses to workload, high env. temps, and dehydration
No known chronic or harmful effects
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Heat Stroke
Hyperthermia: core temp > 39C/102.2F with CNS dysfunction
Rectal temperature Medical Emergency! Causes multi-organ system failure. Treatment: Immediate cooling!
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Whole Body Cooling
!Methods
Ice bath/cold water immersion
Burrito method with sheets and ice
Ice to head, neck, axilla, and groin
!“Golden half-hour”
cool within 30 minutes
<40C/104F
d/c water immersion when at 101-102F
Fastest: cold water immersion
Whatever method is utilized, it should be:
simple and safe
provide adequate cooling
not restrict other forms of rx (CPR, defibrillation, IV cannulation)
Casa DJ: Curr Sports Med Rep 2005
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Whole Body Cooling
!Methods
Ice bath/cold water immersion
Burrito method with sheets and ice
Ice to head, neck, axilla, and groin
!“Golden half-hour”
cool within 30 minutes
<40C/104F
d/c water immersion when at 101-102F
Fastest: cold water immersion
Whatever method is utilized, it should be:
simple and safe
provide adequate cooling
not restrict other forms of rx (CPR, defibrillation, IV cannulation)
Casa DJ: Curr Sports Med Rep 2005
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Whole Body Cooling
!Methods
Ice bath/cold water immersion
Burrito method with sheets and ice
Ice to head, neck, axilla, and groin
!“Golden half-hour”
cool within 30 minutes
<40C/104F
d/c water immersion when at 101-102F
Fastest: cold water immersion
Whatever method is utilized, it should be:
simple and safe
provide adequate cooling
not restrict other forms of rx (CPR, defibrillation, IV cannulation)
Casa DJ: Curr Sports Med Rep 2005
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Etiology of Heat Stroke
!Metabolic heat production from exercise exceeds heat loss / inadequate heat losing mechanisms
but does occur in slower runners whose metabolic rate is lower and thus heat production is lower
!Excessive endothermy (endogenous heat production)
? form of malignant hyperthermia
excessive sympathetic activation in the presence of a metabolic myopathy
!High ambient temperature
but does occur in cool environments
Rae: Med Sci Sports Exerc 2008
Hopkins: Br J Sports Med 2007
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Etiology of Heat Stroke
!Metabolic heat production from exercise exceeds heat loss / inadequate heat losing mechanisms
but does occur in slower runners whose metabolic rate is lower and thus heat production is lower
!Excessive endothermy (endogenous heat production)
? form of malignant hyperthermia
excessive sympathetic activation in the presence of a metabolic myopathy
!High ambient temperature
but does occur in cool environments
Rae: Med Sci Sports Exerc 2008
Hopkins: Br J Sports Med 2007
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Etiology of Heat Stroke
!Metabolic heat production from exercise exceeds heat loss / inadequate heat losing mechanisms
but does occur in slower runners whose metabolic rate is lower and thus heat production is lower
!Excessive endothermy (endogenous heat production)
? form of malignant hyperthermia
excessive sympathetic activation in the presence of a metabolic myopathy
!High ambient temperature
but does occur in cool environments
Rae: Med Sci Sports Exerc 2008
Hopkins: Br J Sports Med 2007
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Etiology of Heat Stroke
!Metabolic heat production from exercise exceeds heat loss / inadequate heat losing mechanisms
but does occur in slower runners whose metabolic rate is lower and thus heat production is lower
!Excessive endothermy (endogenous heat production)
? form of malignant hyperthermia
excessive sympathetic activation in the presence of a metabolic myopathy
!High ambient temperature
but does occur in cool environments
Rae: Med Sci Sports Exerc 2008
Hopkins: Br J Sports Med 2007
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Pathophysiology of Heat Stroke!
Systemic Inflammatory Response System (SIRS)
a “cytokine storm,” similar to sepsis:
organ hypoperfusion -->gut ischemia --> endotoxin release -->pyrogenic cytokines --> worsening hyperthermia
primed by prior viral exposure (URI?)
!Multi-organ system failure
CNS involvement: cerebellum and BBB breakdown
Associated with rhabdomyolysis, renal failure, liver damage, hyperkalemia, hypercalcemia, and hypoglycemia
Bouchama: NEJM 2002
Sonna: Prog Brain Res 2007
O’Connor: Curr Sports Med Rep 2010
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Summary1. Prevention of benign EAC:
- keep the runner walking after the finish
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Summary1. Prevention of benign EAC:
- keep the runner walking after the finish 2. If a significant collapse occurs:
- check Na, glucose, rectal temp, pulse/cardiac rhythm
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Summary1. Prevention of benign EAC:
- keep the runner walking after the finish 2. If a significant collapse occurs:
- check Na, glucose, rectal temp, pulse/cardiac rhythm
3. Exercise Associated Hyponatremia: - prevention: limit fluid intake on the course - Rx: early Dx, 3%NaCl, quick tx to ED
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Summary1. Prevention of benign EAC:
- keep the runner walking after the finish 2. If a significant collapse occurs:
- check Na, glucose, rectal temp, pulse/cardiac rhythm
3. Exercise Associated Hyponatremia: - prevention: limit fluid intake on the course - Rx: early Dx, 3%NaCl, quick tx to ED
4. Cardiac Arrest: - AED access within 3-5 minutes
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Summary1. Prevention of benign EAC:
- keep the runner walking after the finish 2. If a significant collapse occurs:
- check Na, glucose, rectal temp, pulse/cardiac rhythm
3. Exercise Associated Hyponatremia: - prevention: limit fluid intake on the course - Rx: early Dx, 3%NaCl, quick tx to ED
4. Cardiac Arrest: - AED access within 3-5 minutes
5. Hyperthermia: - check rectal temperature - Rx: immediate whole body cooling