Medical Support for Endurance Races

1
Medical Support for Endurance Races
Military Sports Medicine Fellowship
Every Warrior an Athlete

• Kevin deWeber, MD, FAAFP
• Director,
• Primary Care Sports Medicine Fellowship

2
Objectives

• List common injuries encountered at endurance
  races
• Describe basic treatment for those injuries
• List medical equipment needed at endurance races
• Apply principles with case studies

3
Developing a Medical Plan

• Overall Goals
• Provide safe environment for athletes and support
  staff
• Adequately prepare all support staff and
  logistics
• Provide medical coverage to prevent, identify and
  treat injuries and medical problems

4
References

• Mass Participation Event Management for the Team
  Physician A Consensus Statement. MSSE 2003.
• ACSM Position Stand Heat and cold illnesses
  during distance running. MSSE 1996.
• Noakes T. Medical Coverage of Endurance Events.
  In Brukner and Khan, Clinical Sports Medicine 3d
  Ed, McGraw-Hill Australia, 2006.

5
Medical Team Planning

• Basic capabilities needed
• CPR and first aid
• Medical and MSk care
• Early defibrillation
• Hyper- and hypo-thermia initial care
• Desirable capabilities
• ACLS
• IV fluids
• Laboratory

6
Heat and Cold Illnesses During Distance
RunningAmerican College of Sports Medicine
Position Stand
Medicine and Science in Sports and Exercise. Vol
28(12) December 1996.
7
Medical Staffing per 1000 competitors

• 1-2 Physicians
• 4-6 Podiatrists
• 1-4 EMTs
• 2-4 Nurses
• 3-6 Physical Therapists
• 3-6 Athletic Trainers
• 1-3 Assistants

8
Secondary Medical Aid Stations

• 3-5 km apart
• Sites with good access for EMS
• Capabilities
• First aid (plasters, bandaids)
• Stretch and massage
• Identification of at-risk competitors (MS
  changes, etc)
• One Ambulance per 3000 Runners
• Medical Documentation needed
• Staffing
• Medical student, EMT, nurse, ATC, etc.
• One physician per several stations

ACSM Position Stand
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Fluid Stations

• Fluids at the Start
• Fluid Stations 2-3 km apart
• At least 50m from aid stations to avoid crowding
  at aid station
• Water (events lt1 hour)
• Carbohydrate-Electrolyte Beverage (gt1 hour)
• Fluids at the Finish

ACSM Position Stand
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Roving Medical Assets

• One ambulance per 3000 competitors
• Physician covering several aid stations
• Personnel on bike to watch competitors

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Finish Line Medical Tent
AMBULANCE
Cooling pools
Serious
EXIT
MED HOLD
MEDICAL
Non-Serious
ENTER
ORTHO
TRIAGE
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Main Medical Tent Staff

• 60-75 of total physicians
• Emergency trained personnel
• Ortho masseurs, PT, ATC, Podiatry
• Medical Sports Med, FP, IM
• Nurses, medics, assistants
• Admin personnel for records

13
Medical Tent Equipment

• Chairs, tables, computer, paperwork
• Stretchers, litter stands, blankets
• Plastic pools w/ ice water
• Refrigerator with fluids
• Lab lytes, glucose
• Toilets

14
Medical supplies

• Stethos, sphygmos
• Rectal thermos
• Otos, Ophthos
• Peak flows
• Defibos
• Os, nebs, masks
• Oral airways
• Intubation equipment
• ACLS
• Bandages, ACE wraps

• Tape, gauze, gloves
• Needles, sutures, drivers
• Skin disinfectant, saline
• IV bags, needles, tubing
• Splints, slings
• Water, ice, cups, drinks
• Plastic bags for ice
• Petro jelly

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Medications

• Lidocaine
• Albuterol MDI/neb
• Tylenol, ibuprofen
• Epinephrine SQ inj
• Steroids (po, inj)
• Aspirin, NTG, morphine
• ACLS drugs

• Imodium
• Phenergan
• Magnesium sulfate
• Valium inj
• Dextrose amp and jel
• Glucagon
• Diphenhydramine po and inj

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Marine Corps Marathon Medical Support Plan
CDR Scott W. Pyne, M.D. Past Medical Director
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Marine Corps MarathonPast Experience
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Common Medical Conditions

• Blisters/Abrasions
• Strains/Sprains
• Exercise-Induced Cramps
• Heat injuries
• Asthma Exacerbation
• Suspected Stress Fractures
• Hypoglycemia
• Anaphylaxis

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Triage and Treatment Guidelines

• Rapidly assess and appropriately distribute
  runners requiring care
• Separate serious from non-serious
• Separate medical from musculoskeletal

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Determining Severity of a Collapsed Athlete

• Non-severe
• Conscious
• Alert
• Temp lt40C
• SBP gt100
• HR lt100

• Serious
• Unconscious, altered mental state
• Confused, disoriented, aggressive
• Temp gt40C
• SBP lt100

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Treatment for MusculoSkeletal Conditions
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Hot Spots, Abrasions Blisters

• Hot spot future blister site where friction is
  occurring
• Abrasions skin worn through from friction
• Blister inner skin layers separated from
  friction
• Protect from further irritation
• Plaster patch over area, bandaid, etc.
• Petroleum jelly/neosporin ointment if open skin
• Rapid treatment

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Hot-spot and Small Blister Treatment

• Blisters lt 5mm and hot spots
• Do not unroof
• Protect with doughnut shaped pad or
  hydrocolloidal dressing

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Larger Blister Treatment

• Blisters gt 5 mm in size
• Drain with sterile technique
• Do not unroof unless torn most of the way
• Clean and cover
• Advise re-check in 24-48 hrs

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Sprains Strains

• Sprain injury to a ligament/joint capsule
• Strain injury to a muscle or its tendinous jxn
• Treatment
• Evaluation of severity (complete tear?)
• Able to continue race?
• PRICEM (protection, rest, ice, compression,
  elevation, med)

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Indications for Ankle Radiographs

• Ottawa Ankle Rules
• Age 55 years or older OR

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Exercise Muscle Cramps

• Immediate treatment
• Rest, get vital signs
• Passive stretching
• Gentle massage to cramping area
• Oral hydration
• Secondary treatment
• Check serum sodium
• Start IV normal saline
• Tertiary Treatment
• Consider MgSO4/Valium/Transport

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Treatment Guidelines for Common Medical Conditions

• Dehydration
• Exercise Associated Collapse
• Post-Exercise Positional Hypotension
• Hyperthermia
• Hypothermia
• Hyponatremia
• Cardiac Arrest

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Dehydration

• Over-diagnosed and over-treated
• Runners can tolerate 2 -8 dehydration
• Rapid response to oral hydration
• Potential complications of IV hydration
• infection, bleeding, syncope
• cost, manpower
• overhydration

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Indications for Intravenous Fluids

• Physical exam consistent with dehydration
• Dry mouth and lips
• Increased skin turgor
• Persistent symptomatic hypotension and
  tachycardia
• Persistent emesis
• Suspected heatstroke, hyponatremia, hypoglycemia
• As part of stabilization

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Exercise Associated Collapse
Mental Status Conscious/oriented
Unconscious/disoriented Positional
Hypotension Rectal
Temperature Supine head down position lt95F
95F-103F gt103F
Hypothermia Hyperthermia

EAC
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Severity Determination Noakes 2002

• Severe
• Unconscious
• Confused, disoriented, combative
• Temp gt 103 F/39.5C
• SBP lt 100 mm Hg
• HR gt 100 BPM

• Nonsevere
• Conscious
• Alert
• Temp lt 103 F/39.5C
• SBP gt 100 mm Hg
• HR lt 100 BPM

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Cardiac Arrest

• ABCs
• CPR if needed
• Defibrillate if indicated
• ACLS protocols
• Call 911, transport!

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Case One

• 38 y.o. male collapses as he crosses the
  finish-line. He is arousable but disoriented.
• PMH neg.
• Questions?

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Collapsed Athlete
Airway/Breathing/Circulation
Yes
No
Brief Hx/PE
Y
Indentifiable Emergency?
Treat
N
Emergency Cardiac Care
Core Temperature
gt103F/39.5C
103-95F
lt95F/35C
Hyperthermia
Hypothermia
EAC
37
Case One (cont)

• VS-standing HR94, BP124/80
• VS-supine HR88, BP132/80
• Temp100.2ºF/37.9C
• BG 78
• PE
• L CTAB
• H RRR w/o m
• Pt confused and disoriented

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Collapsed Athlete
Airway/Breathing/Circulation
Yes
No
Brief Hx/PE
Y
Indentifiable Emergency?
Treat
N
Emergency Cardiac Care
Core Temperature
gt103F/39.5C
103-95F
lt95F/35C
Hyperthermia
Hypothermia
EAC
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Exercise Associated Collapse
Y
Dehydration/MS Abnormalities
Position/1L NS/Na Glucose/Treat
N
Position, Oral Hydration
Reassess 10-15min Improvement
N
Reassess 10-15min Improvement
Y
Transport or Change Treatment
Y
N
Continue Management
Treat Identifiable Etiology/Transport
40
Case One (cont)

• Pt was given oral re-hydration, legs were
  elevated and pt rested for 15 minutes
• VS HR70, BP120/60, Temp99.4ºF/37.4C
• MS Ox4, Alert, NAD
• Pt. released

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Case Two

• 27 y/o healthy female
• Presents to main medical tent with intractable
  cramping in calves, hamstrings, and quads

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Case Two (cont)

• Finished race in new PR time of 330
• Felt a little tight at the finish but did well
  until she was in the concession area
• VS 105/65, 55, 12
• Exam
• Tense muscle cramping most notable in calves

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Muscle Cramps
VS/Rest/Massage/Stretch/Ice 10-15 Minutes
Re-eval
IV NS/Serum Na/2 liters of fluids 10-15 Minute
Re-eval
Transport
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Case Two (cont)

• Initial treatment
• Rest
• Ice
• Stretch/massage
• Oral hydration (hyperosmolar)
• Not improved 15-20 min
• Check serum Na
• IV NS
• Continue to monitor
• If not responding
• Consider transport

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Case Three

• 25 yo male finished at 245

• Passed out at the Finish Line

• Disoriented and Confused
• Unable to get to his feet
• Dropped over fence onto stretcher

• Carried to medical tent by two Marines

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Case Three (cont)

• History from friends/race card
• Swerving through finish area before passing out
• PMH neg, no meds
• Initial examination
• Sweating
• Disoriented, decreased LOC

• BP 100/64, P 120, R 26, T 107.9 F/42.2C

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Collapsed Athlete
Airway/Breathing/Circulation
Yes
No
Brief Hx/PE
Y
Indentifiable Emergency?
Treat
N
Emergency Cardiac Care
Core Temperature
gt103F
103-95F
lt95F
Hyperthermia
EAC
Hypothermia
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Hyperthermia
Tgt103F
Rectal Thermistor Ice Water Immersion IV NS 1L
Continuous VS/Cooling
Y
Continue Cooling
N
Tlt102F 38.9C
Remove from Water Manage as Appropriate
15-20min
Tlt102F
Y
N
Continue Cooling and Transport
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Case Three (cont)

• Ice water immersion

-Continuous vital signs monitoring
-IV access

• Cooling to 102 F/38.9C over 15 minutes
• Improved level of consciousness
• Improved vital signs

• Transport via EMS

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Case Four

• 30 y/o healthy male
• Brought in by running partner 15 minutes
  post-finish
• Not acting like himself confused
• Had been doing well other than
• Mild headache
• Leg and stomach cramps
• Questions??

52
Case Four (cont)

• Finished marathon in 4 hours 30 minutes
• Religiously drank 2 cups of water at every water
  stop
• VS 138/64, 90, 20
• Disoriented
• Combative

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Case Four (cont)

• Evaluation
• Rectal temp 102F/38.9C
• Labs
• Glucose 90
• Na 112
• Interventions
• IV Line
• Normal Saline
• Transport
• Questions??

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Collapsed Athlete
Airway/Breathing/Circulation
Yes
No
Brief Hx/PE
Y
Indentifiable Emergency
Treat
N
Emergency Cardiac Care
Core Temperature
gt103F
103-95F
lt95F
Hyperthermia
Hypothermia
EAC
55
Exercise Associated Collapse
Y
Dehydration/MS Abnormalities
Position/1L NS/Na Glucose/Treat
N
Position/Oral Hydration
Reassess 10-15min Improvement
N
Reassess 10-15min Improvement
Y
Transport or Change Treatment
Y
N
Continue Management
Treat Identifiable Etiology/Transport
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Case Five

• 36 yo female runner presents to the medical tent
  at 20 miles
• Appears confused
• Stumbles as she walks
• Speech is slurred
• States she was incontinent of urine

Questions?
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Case Five (cont)

• Local Temp 47F/Winds 15 mph
• No Meds
• No PMHx
• First Marathon
• Vital Signs
• BP 120/60
• HR 80
• RR 24
• Temp 93.5F/34.2C

Questions?
58
Collapsed Athlete
Airway/Breathing/Circulation
Yes
No
Brief Hx/PE
Y
Indentifiable Emergency
Treat
N
Emergency Cardiac Care
Core Temperature
gt103F
103-95F
lt95F
Hyperthermia
EAC
Hypothermia
59
HypothermiaTlt95F/35C
Remove wet clothes/ Warm blankets/ Avoid rough
movements
Pulse present
N
Y
Core Temperature
Emergency Cardiac Care/Airway/Warm
95-93F
lt93
Transport
Reassess 10-15min
N
Passive Rewarming
Improving
Continue Rewarming
Y
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Case Five (cont)

• Treatment
• Wet clothes removed
• Wrapped in a blanket
• Placed by heater
• Given hot cocoa
• Monitored closely
• Repeat temp after 1 hr. 94F/34.4C and still
  symptomatic
• Transferred to hospital for further warming

Questions?
61
Case Six

• 28 yo male brought to the medical tent via finish
  line spotter crew, seen staggering, and confused
  to place, time, date, and event
• Butterflies in my stomach
• HR 180
• Questions?

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Case Six (cont)

• VS HR160, BP132/76, RR18, T100ºF/37.8C
• PMH non-contrib.
• Meds none
• Supp none
• Last Meal 1800hrs
• Finger-stick glucose37
• Treatment?

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Collapsed Athlete
Airway/Breathing/Circulation
Yes
No
Brief Hx/PE
Y
Indentifiable Emergency
Treat
N
Emergency Cardiac Care
Core Temperature
gt103F
103-95F
lt95F
Hyperthermia
EAC
Hypothermia
64
Case Six (cont)

• Pt given oral re-hydration with fruit juice,
  orange slices, bananas, and glucose gel
• Rechecking every 10 minutes
• VS and mental status stabilize after 30 min and
  pt released, instructed to follow with PCM

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Case Seven

• 25 yo male runner comes to Mile 3 Aid Station
  asking for a puff of bronchodilator
• Asthma for 12 years
• Rx Serevent, Flovent, Tilade, Singulair
• 20 ER visits, 2 intubations in past 5 yrs.

Questions?
66
Case Seven (cont)

• Says hes ok, refuses bronchodilator and returns
  to race
• Re-presents at Mile 8 Aid Station
• Blue lips
• Prolonged expiratory phase
• Wheezes Poor Air Movement

Questions?
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Asthma Exacerbation
Requesting Bronchodilator
Moderate/Severe Sx
Mild Sx
Offer Bronchodilator Remove from Race Discharged
to Home
Offer Bronchodilator Arrange Transport
O2 as required
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Case Seven (cont)

• Treatment
• Given 4 puffs of Bronchodilator
• Called ambulance for nebs O2
• Disposition ambulance transport to ER

Questions?
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Case Eight
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Questions?