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Urban Adventure for a Young Ultra-marathoner

Urban Adventure for a Young Ultra-marathoner. February 5, 2011. Rachel Biber Brewer, MD Primary Care Sports Medicine Fellow Vanderbilt University Medical Center Nashville, Tennessee. Case Presentation, History.

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Urban Adventure for a Young Ultra-marathoner

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  1. Urban Adventure for a Young Ultra-marathoner February 5, 2011 Rachel Biber Brewer, MD Primary Care Sports Medicine Fellow Vanderbilt University Medical Center Nashville, Tennessee

  2. 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.

  3. 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.

  4. History, continued • He has not run in the interim and returns because of excessive weakness, increasing headaches, nausea, vomiting, intermittent vertigo and blurred vision.

  5. 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

  6. 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.

  7. 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

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

  9. Questions?

  10. Imaging

  11. Footer

  12. Labs • BMP: Na119, 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

  13. 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

  14. 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.

  15. 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. Footer

  16. 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. Footer

  17. 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.

  18. 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. Footer

  19. 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. Footer

  20. Questions?

  21. SIADH Footer

  22. 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 Footer

  23. EAH Consensus Development Conference, 2007, Cin J Sport Med, 2008. Footer

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