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