Transcript General Medical Emergencies or - University of Colorado Denver

John C. Hill, DO, FACSM
Director of Primary Care Sports Medicine Fellowship
University of Colorado
Team Physician, University of Denver
 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

 Review case based examples of serious
medical emergencies
 Discuss on field management of life
threatening emergencies
 Evaluate your own preparation for such
emergencies
 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
 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
 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
 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
 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
 Etiology
 IgE-mediated
 Antibiotics
(especially penicillin family)
 Venom
 Latex
 Vaccines
 Food (shellfish,

peanuts, eggs, liver)
Non-IgE-mediated
 Iodine
contrast media
 Opiates
 Vancomycin
 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)
 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

 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

 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
 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
 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
 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

 Signs and Symptoms
 Coughing
 Wheezing
 Shortness of Breath
 Chest tightness
 Stomachache
 Headache
 Fatigue
 Muscle cramps
 Feeling out of shape
 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
 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

 Acute Management
 Short-acting Beta agonist (Albuterol): 2-4 puffs 1520 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
 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
 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
 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
 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
 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

 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%)
 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

 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

 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
Woody Allen
 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.
 Rare:
 0.2-0.5 per 100,000
adolescents /year
 Usually Cardiac:
 < 30 years, Structural
heart defect
 > 30 years, Coronary
artery disease
 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
 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

 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
 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
 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
 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
 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
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
 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
 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