General Medical Emergencies (Things that tighten my schinter!)
John C. Hill, DO, FACSMDirector of Primary Care Sports Medicine FellowshipUniversity of ColoradoTeam Physician, University of Denver
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 historyPreparing for emergenciesReacting quickly
Objectives Review case based examples of
serious medical emergencies Discuss on field management of life
threatening emergencies Evaluate your own preparation for
such emergencies
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
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
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
Anaphylaxis Signs and symptoms
Begins within seconds to minutes after contact with offending antigen
Respiratory: Bronchospasm and laryngeal edemaCV: Hypotension, dysrhythmiaGI: Nausea, vomiting and diarrheaCutaneous: Urticaria, angioedemaNeurological: Sense of impending doom, seizuresHematological: Activation of intrinsic coagulation
pathway leading to DICDeath
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
Anaphylaxis Etiology
IgE-mediated Antibiotics (especially penicillin family) Venom Latex Vaccines Food (shellfish, peanuts, eggs, liver)
Non-IgE-mediated Iodine contrast media Opiates Vancomycin
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 necessaryEpinephrine 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)
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 (Epipen Jr)• >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
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-upThey need follow-up appointment with
allergistPatients must carry Epipen in the futureThey need to avoid known triggers
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
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
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
Asthma and EIA
DefinitionAirway bronchoconstriction
characterized by wheezing, coughing and/or chest tightness occurring after exposure to trigger or exercise
Incidence /Prevalence10-50% of recreational and elite athletes70-80% of known asthmatics have EIA40% of patients with allergic rhinitis
Asthma and EIA
Signs and SymptomsCoughingWheezingShortness of BreathChest tightnessStomachacheHeadacheFatigueMuscle crampsFeeling out of shape
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
Asthma and EIA
HistoryPersonal or family history of allergies or
asthmaPositive response to signs and symptomsPatient has stopped or run out of their
medications Physical Exam
Look for sinusitis or underlying infectionLung exam is initially normal, then
wheezing will be notedPeak flow will be mildly to severely decreased
Asthma and EIA
Acute ManagementShort-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 ManagementSalmeterol: 2 puffs twice daily (Advair)Inhaled Corticosteroids: 2 puffs twice dailyLeukotriene modifiers (Singular, Accolate,
Zyflo CR) used once dailyEnsure proper use of inhalers and spacers
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
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
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
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
Arrhythmias
DefinitionArrhythmias 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 toneSinus pause, 1st degree AV block and 2nd
degree Mobitz I blocks are common in athletes
Arrhythmias
Incidence: Bradyarrhythmias2nd 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%)
Arrhythmias
Incidence: TachyarrhythmiasSupraventricular 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
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 occurIf syncope occurs DURING exercise,
rather than immediately AFTER exercise this is OMINOUS and should scare the hell out of you
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
Sudden Death is Natures Way of Telling You to Slow Down
Woody Allen
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.
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
Under 30 years old
Over 40 years old
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
Arrhythmias
Risk Factors:Drugs: Amphetamines, cocaine, ephedrineCommotio cordis: Direct trauma to chest wallMetabolic 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
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
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
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
Diabetes and Diabetic Emergencies
Treatment goalsEuglycemic 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
Diabetes and Diabetic Emergencies
Acute ManagementInsulin 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
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
Skeletal Muscle Glucose Transport in Normal, Active (Exercising) Individuals
Skeletal Muscle Glucose Transport in Normal, Inactive Individuals
Skeletal Muscle Glucose Transport in Inactive Diabetics
(Without any mechanism for removal, blood glucose elevates, leading to
diabetic complications.)
Skeletal Muscle Glucose Transport in Active (Exercising) Diabetics
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
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