Collapsed Athlete

1. Womack Army Medical Center Family Medicine - Sports Medicine Chris Pappas, MD Attending Lisa M. Harris, DO PGY-3 Michael Rossi, MD PGY-3 Chase Grames, DO PGY-2 Collapsed Athlete

2. Marine Corps MarathonOctober 25, 2009Washington, D.C. “THE PEOPLE’S MARATHON”

3. Marathon – 26.2 miles • 30,000 registered  21,000 completed • Minimum 14:00 min/mile pace • 10 K – 6.2 miles • 10 Aid Stations – 8 throughout course and 2 at the finish line. • DOD Level 1 (BLS-level) care—no ACLS meds. Marine Corps MarathonVital Statistics

4. Aid station

5. Aid station

6. Francis G. O’Connor, MD, FACSM Medical Director, Consortium for Health And Military Performance (CHAMP) Associate Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bruce Adams, MD Medical Director, Marine Corps Marathon Director, Sports Medicine Naval Medical Clinic, Quantico, VA  Scott Pyne, MD Former Medical Director, Marine Corps Marathon Director, Sports Medicine US Naval Academy, MD Fred Brennan, DO Director, Sports Medicine Clinic Seacoast Orthopedics and Sports Medicine Durham, New Hampshire Marine Corp Marathon Symposium Algorithm (last updated 2007)

7. The Collapsed Athlete Algorithm Athlete collapses during or after event1 Assess Responsiveness Exit to ECC Algorithm N Y Brief History and Physical Vital Signs Initiate Immediate and Appropriate Action Athlete with Identifiable Medical Emergency N Rectal Temp >40o Y Exit to Hyperthermia Algorithm N Y Rectal Temp 36o to 40o Exit to EAC Algorithm N Rectal Temp <36o Y Exit to Hypothermia Algorithm

8. Patient with Probable Exercise-Associated Collapse Exercise Associated Collapse Algorithm • Obvious Signs of Dehydration • Marked alteration of Consciousness IV NS 1 Liter Leg/pelvis elevation Labs: Sodium, Glucoses, Lytes Treat/triage Identified electrolyte Abnormalities 15-30 Minute Reassessment Supine HR, BP Rectal Temp Mental Status Y N Oral Rehydration Supine with Pelvis and Legs Elevated 6 to 12 inches T>104 BPs<110 HR>100 No Change in Mental Status • Prepare for Transfer to Hospital • Initiate cooling measures as appropriate Y 15-30 Minute Reassessment Supine HR, BP Rectal Temp Mental Status N Observe and Manage as Appropriate T>102 BPs<110 HR>100 No Change in Mental Status IV D5NS Leg/pelvis elevation Labs: Sodium, Glucoses, Lytes Initiate cooling measures as appropriate Y N Observe and Manage as Appropriate

9. Heat Illness Algorithm Rectal Temp > 40 • IV NS 1 Liter • Pool Immersion • Rectal Thermistor • Continuous V/S Reassessment • Continuous Cooling thru 15 to 20 Min • minutes Remove from Ice Immersion Manage as Appropriate T < 102 Prepare for Transport with Cooling as Appropriate

10. 40 y/o Female that finished the race, stumbles and falls on to your cot and says: “My husband is a physician, I need an IV!” What do you do? MCM: Case 1

12. Exercise Associated Collapse • Obvious Signs of dehydration • No salt stains on shirt • 2 sec cap refill • Mucous membranes are moist • Marked Alteration of Consciousness • Answers all questions appropriately Mcm case 1

13. Oral rehydration • H20, Gatorade, Broth, Crackers, Banana • Elevation • Patient supine with pelvis and legs elevated 12-24 inches above the heart/chest • Reassess in 15-20 minutes • stable MCM Case 1: Exercise Associated Collapse

14. 26 yo Female brought in by stretcher and dropped at your station. What do you do? MCM: Case 2

15. He’s a stud!

16. Assess Responsiveness • Knows her name, where she is • She finished the 10K run • Brief History and Physical • No medical problems – However…. “This happened to me during my last race” • Mental Status • Laying on the cot, her eyes keep closing as if she is tired, and opens them when you ask her questions • When asked how old she was, she couldn’t remember • Vitals MCM case 2: Collapsed Athlete Algorithm

18. Rapid CoolingIce water Immersion

19. Rapid CoolingIce water Immersion

20. Continuous rectal temp via rectal probe • Start IV • Temp below 102 after 15 minutes • Remove patient from ice bath to prevent overshooting and secondary risk of hypothermia MCM Case 2: Hyperthermia

22. 54 y/o male comes in to the tent after finishing the race in 5hrs 10 min, complaining of chest pain. What do you do? MCM Case 3

23. History and Physical • Medical History • MI with stent placement 3 years ago “This chest pain feels just like when I had my heart attack” • 12 lead EKG • Oxygen • ASA • SL Nitroglycerin • IV Access MCM Case 3: Chest pain

24. 12 Lead EKG Intern- please read What do you do?

25. Emergency room Transport!

26. 23 y/o Female finished the marathon in under 5 hours, brought in by stretcher and had passed out at the finish line. What do you do? MCM Case 4

27. Assess Responsiveness • Answers questions appropriately, but she wants to leave, doesn’t want to be assessed. • Brief History and Physical • No medical problems • “Boyfriend” is in law school, he won’t leave her side • Policeman had to restrain him! • Vitals • When vitals are taken and rectal temp Patient becomes COMBATIVE !! MCM Case 4: Collapsed Athlete

28. Rapid CoolingIce Water Immersion

29. Rapid CoolingIce Water Immersion “The Great White Hunter” Dr. deWeber Primary Care Sports Medicine Fellowship Director

30. Once core temp was below 106 she calmed down

31. 22 y/o Female that walks in covered in bloody stool. What do you do? MCM: Case 5

32. Bloody stool

33. Assess Responsiveness • Answers questions appropriately • Trying to qualify for Boston Marathon (she did) • Naval Academy Sophomore • Brief History and Physical • Recent PRK surgery 3 weeks ago. • Medications: Motrin 800 mg TID since the surgery. • Vitals • Stable MCM: Case 5

34. MCM: Case 5 What do you think?

35. Ischemic colitis ?

36. Marine Corps MarathonOctober 25, 2009Washington, D.C.