General Medical Emergencies ( Things that tighten my schinter !)

1. General Medical Emergencies (Things that tighten my schinter!) John C. Hill, DO, FACSM Director of Primary Care Sports Medicine Fellowship University of Colorado Team Physician, University of Denver

2. Primary Goal • At the conclusion of this talk: • Everyone of you will be more comfortable handling life threatening situations on the playing field • How? • By knowing your athletes history • Preparing for emergencies • Reacting quickly

3. Objectives • Review case based examples of serious medical emergencies • Discuss on field management of life threatening emergencies • Evaluate your own preparation for such emergencies

4. Case 1, Soccer • 19 y/o male D1 starting forward • Has allergic rhinitis and known allergy to bee stings • During a game, late in the first half while sitting on the bench he is stung by a wasp on the neck • He jumps and attempts to swat the bee, who stings him again • Team mates, trainer and physician all observe this activity

5. Case 1, Soccer • He has a frightened look of impending doom on his face and reminds the trainer he is allergic to bee stings • The trainer starts digging though her bag looking for the epinephrine syringe – which is not there • The patient is now audibly wheezing and straining to breath • Signs of urticaria and angioedema are becoming noticeable

6. Case 1, Soccer • Assistant trainer has run to training room where she thinks the bee sting kit is located • Player is now on his knees and begins to vomit • Physician is looking for laryngoscope and endotrachial tube to intubate the patient • In less than 5 minutes from the first bee sting, the players breathing has become labored and he is now laying on the ground near the bench and appears dusky blue

7. Anaphylaxis • Signs and symptoms • Begins within seconds to minutes after contact with offending antigen • Respiratory: Bronchospasm and laryngeal edema • CV: Hypotension, dysrhythmia • GI: Nausea, vomiting and diarrhea • Cutaneous: Urticaria, angioedema • Neurological: Sense of impending doom, seizures • Hematological: Activation of intrinsic coagulation pathway leading to DIC • Death

8. Anaphylaxis • Mechanism/Description • Acute widely distributed form of shock occurs within minutes after exposure to antigen • Causes approximately 400-800 deaths in the US each year • Rapid release of bioactive molecules such as histamine, leukotrienes and prostaglandins from inflammatory cells producing: • Increased vascular permeability, vasodilatation, smooth muscle contractions • Manifested in a decrease of total vascular resistance and reduced cardiac output

9. Anaphylaxis • Etiology • IgE-mediated • Antibiotics (especially penicillin family) • Venom • Latex • Vaccines • Food (shellfish, peanuts, eggs, liver) • Non-IgE-mediated • Iodine contrast media • Opiates • Vancomycin

10. Anaphylaxis • Acute Treatment • ABC’s • Assure adequate ventilation • Endotrachial intubation is paramount, but is difficult due to laryngeal edema • Transtrachial jet insufflation and cricothyrotomy may be necessary • Epinephrine IV/IM/SQ/ET • Direct injection into the venous plexus at the base of the tongue may be necessary • Volume resuscitation with Crystalloids (NS, LR)

11. Anaphylaxis • Key Medications • Epinephrine:0.3-0.5 mg (1:1,000 dilution) SQ, administered immediately (Epipen 0.3mg 1:1000) • Peds dosing • <30 kg, 0.15mg 1:1000 (EpipenJr) • >30 kg, 0.3 mg 1:1000 (Epipen) • Diphenhydramine(Benadryl): 50 mg IV in adults, 1-2 mg/kg in Peds • Methylprednisolone(Solumedrol): 125mg IV in adults, 1-2 mg/kg in Peds

12. Anaphylaxis • Transport • Call 911 if condition worsens to the point of airway compromise • Hospital admission is required for significant generalized reactions and these patients are observed for 24 hours • Follow-up • They need follow-up appointment with allergist • Patients must carry Epipen in the future • They need to avoid known triggers

13. So What happened? • As physician was attempting to intubate the patient, he began having a generalized seizure • Assistant trainer arrived with the Epinephrine • IM injection of 0.3 mg (1:1,000 dilution given) • As IV was being attempted, seizure stopped and he began breathing • Ambulance arrived and he was transported to the hospital where he was observed in the ICU for 24 hours, then discharged to home

14. Case 2, Swimmer • 20 y/o female D1 Junior, 3rd year on team • During practice trainer notices that she is holding on to the side of the pool and seems to be short of breath • She is coughing and looks anxious • Trainer helps her out of the pool asks if she is OK • Swimmer is unable to speak, has a look of impending doom, and is now gasping for air • Trainer knows that this athlete has asthma

15. Case 2, Swimmer • Trainer runs to her bag to get the Albuteral inhaler • Swimmer begins taking puffs of inhaler and trainer calls 911 • The rest of the team has noticed the disturbance and is now crowding around to get a better look

16. Asthma and EIA • Definition • Airway bronchoconstriction characterized by wheezing, coughing and/or chest tightness occurring after exposure to trigger or exercise • Incidence /Prevalence • 10-50% of recreational and elite athletes • 70-80% of known asthmatics have EIA • 40% of patients with allergic rhinitis

17. Asthma and EIA • Signs and Symptoms • Coughing • Wheezing • Shortness of Breath • Chest tightness • Stomachache • Headache • Fatigue • Muscle cramps • Feeling out of shape

18. Asthma and EIA • Risk Factors • High asthmogenic sports: • Long-distance running • Cycling • Soccer • Cross-country skiing • Environmental • Tobacco smoke • Pollens and molds • Air pollution • Cold weather, low humidity • Duration and Intensity of exercise

19. Asthma and EIA • History • Personal or family history of allergies or asthma • Positive response to signs and symptoms • Patient has stopped or run out of their medications • Physical Exam • Look for sinusitis or underlying infection • Lung exam is initially normal, then wheezing will be noted • Peak flow will be mildly to severely decreased

20. Asthma and EIA • Acute Management • Short-acting Beta agonist (Albuterol): 2-4 puffs 15-20 minutes before exercise; repeat during exercise as needed (This may need to be continuous if severe bronchoconstriction is noted) • Chronic Management • Salmeterol: 2 puffs twice daily (Advair) • Inhaled Corticosteroids: 2 puffs twice daily • Leukotriene modifiers (Singular, Accolate, Zyflo CR) used once daily • Ensure proper use of inhalers and spacers

21. So What Happened? • Swimmer took about 20 puffs of Albuteral inhaler and was beginning to clear when the ambulance arrived • She was transported to ED where she was stabilized, treated for an underlying sinusitis and discharged home • She had run out of her Advair (Salmeterol/Fluticosone) discus two weeks prior to this asthma attack and had symptoms of a cold for more than a week

22. Case 3, Basketball • 21 y/o male, nationally ranked, stand-out player • Event occurred during televised playoff game • He is playing well in the first quarter when suddenly he stops running • He is looking dizzy and collapses at mid-court • Trainer and sideline physician come to his aid • Player is not responding and seems to have trouble breathing

23. Case 3, Basketball • Trainer runs back to sideline for bag and physician attempts to open his airway • Physician determines he is not breathing and begins mouth to mouth while trainer is looking for Bag-Mask • Soon they determine the player is pulseless and CPR is begun • EMS is activated

24. Case 3, Basketball • CPR is continued, but no AED is available • The TV cameras are moving in for better coverage • Eventually the ambulance arrives and Hank Gathers is transported to the hospital; he does not recover and is declared dead after being coded for more than an hour • The physician and trainer are on the front page of the newspaper the following day

25. Arrhythmias • Definition • Arrhythmias are defined as any deviation from normal sinus rhythm. They are categorized as tachyarrhythmias or bradyarrhythmias • Incidence: Bradyarrhythmias • Common in aerobically trained athletes and are related to increased vagus tone • Sinus pause, 1st degree AV block and 2nd degree Mobitz I blocks are common in athletes

26. Arrhythmias • Incidence: Bradyarrhythmias • 2nd degree, Mobitz II and 3rd degree (complete) blocks are rare in athletes and have ominous prognosis • Junctional rhythms are also rare in athletes • Incidence: Tachyarrhythmias • Premature Ventricular Contractions (PVC’s) occur frequently in athletes and the general population • Intermittent Atrial fibrillation: found more commonly in athletes than general population (0.063% vs (0.004%)

27. Arrhythmias • Incidence: Tachyarrhythmias • Supraventricular tachycardia: Rare in athletes and may be related to WPW (Wolff-Parkinson-White) which is characterized by short PR interval, wide QRS and can spontaneously convert to SVT. • Complex Wide QRS tachycardia (V-Tach) is always abnormal and needs prompt attention • Long Q-T interval, may predispose to V-tach

28. Arrhythmias • Signs and Symptoms: • Arrhythmias present with a broad scope of clinical scenarios, ranging from transient palpitations to sudden death • Most tachyarrhythmia's cause palpitations and may cause chest pain • Lightheadedness or syncope may occur • If syncope occurs DURING exercise, rather than immediately AFTER exercise this is OMINOUS and should scare the hell out of you

29. Arrhythmias • Risk factors: • Structural heart disease: (<30 y/o) • Hypertrophic Cardiomyopathy • Anomalous coronary artery • Marfan’s syndrome • Aortic Stenosis • Myocarditis/Pericarditis • Atherosclerotic coronary artery disease: (>30 y/o) • This should always be a consideration

30. Sudden Death is Natures Way of Telling You to Slow Down Woody Allen

31. Sudden Death • A rare occurrence in the athlete. • 1/200,000? high school athletes over an academic year, 1/70,000? over a three year career. • Receives a disproportionate amount of attention, especially in the media. • The public generally considers young athletes to be the healthiest of the healthy. • When one of these athletes unexpectedly dies, it creates a deep sense of vulnerability and fear in a community. This is especially true with a well known local athlete or a nationally known elite athlete.

32. Exercise Related Death • Rare: • 0.2-0.5 per 100,000 adolescents /year • Usually Cardiac: • < 30 years, Structural heart defect • > 30 years, Coronary artery disease

33. Under 30 years old

34. Over 40 years old

35. Hypertrophic Cardiomyopathy • Most common cause of sports related sudden death. • An asymmetrically thickened septum that impinges on the anterior leaflet of the mitral valve during systole, causing outflow obstruction leading to V-tach • Autosomal dominant disorder (5 different sarcomere related genes/ 100 different mutations) • Incidence: 1/500 general population

36. Arrhythmias • Risk Factors: • Drugs: Amphetamines, cocaine, ephedrine • Commotio cordis: Direct trauma to chest wall • Metabolic abnormalities: Hyperthyroidism and electrolyte disturbances • Acute Treatment: • Symptomatic athletes should always be stabilized with ABC’s • If you watch an athlete drop to the ground while exercising, suspect the worst and react quickly

37. Arrhythmias • Acute Treatment: • Suspected SVT may respond to valsalva and other vagal maneuvers, these athletes are awake and anxious…but alive • If unresponsive, begin CPR and use the AED as soon as possible, there is life in electricity • Know where the AED is, better yet, have it available • Long-Term Management: • Will require thorough evaluation including: Echo, EP studies, heart cath and possible ablation

38. Case 4, Cross-Country • 18 y/o freshman male, with known type-1 Diabetes since age 9 • He recently was started on an insulin pump by his endocrinologist before coming to the University • Overall he has had good glucose control and ran cross-country and track in high school • During the Wednesday speed work-out on the track, this runner collapses and is very lethargic

39. Case 4, Cross-Country • Coach sends another runner to the training room for help. • Trainer grabs his bag and runs out to the track with the other runner • He finds the whole team gathered around an unresponsive rapidly breathing athlete

40. Diabetes and Diabetic Emergencies • Treatment goals • Euglycemic glucose control • Blood glucose >60 and less than 120 • Hemoglobin A1C less than 6.5 • No severe hypoglycemia • Treat associated problems • Maintain weight • Treat hypertension • Treat hyperlipidemia • Avoid alcohol and smoking

41. Diabetes and Diabetic Emergencies • Acute Management • Insulin pumps are now frequently used and often simplify management of glucose control, but… • Suspect hypoglycemia • Give oral glucose or sugar if possible • Glucogon (IV, SC or IM) should see response within 10 minutes. May repeat this in 25 minutes • Evaluate blood glucose with finger stick • If Hyperglycemia • ABC’s and call 911

42. How does Skeletal Muscle Use and Disuse affect Health • Skeletal muscle accounts for ~42% of body mass and 20-93% of whole-body metabolism • Insulin sensitivity, lipoprotein lipase activity, and protein synthesis fall within first 12-48 hours of skeletal muscle disuse • Physical inactivity is associated with incidence of cardiovascular disease, type 2 diabetes, obesity, sarcopenia, etc. • Physical activity counteracts these negative effects

43. Skeletal Muscle Glucose Transport in Normal, Active (Exercising) Individuals

44. Skeletal Muscle Glucose Transport in Normal, Inactive Individuals

45. Skeletal Muscle Glucose Transport in Inactive Diabetics (Without any mechanism for removal, blood glucose elevates, leading to diabetic complications.)

46. Skeletal Muscle Glucose Transport in Active (Exercising) Diabetics

47. What happened? • Trainer injected runner with 2 mg of IM Glucagon • Within 5 minutes the athlete was waking up • He was transported to hospital by EMS and was stabilized in the ED and discharged home • He improved his ability to adjust his pump, brought snacks to practice and continued on the team

48. Summary • Medical Emergencies will happen, so expect them and be prepared • Know your athletes; who has DM and who has a history of Asthma, Anaphylaxis, etc… • ABC’s are always the first step in emergency management • If an athlete collapses during exercise, suspect the worst and carry your AED to the field…especially if you are on national TV