Exercise-associated Collapse Research Articles

Assessment and initial management of the collapsed endurance athlete

Participation in endurance events such as marathons is increasingly popular. Those taking part in these events may collapse and require medical attention for a range of reasons, some of which are well known and recognised by prehospital providers. However, there are conditions that are specific to endurance exercise which may be less well known so potentially less likely to be recognised and managed appropriately. The most common cause of collapse in the endurance athlete is exercise-associated collapse. However, practitioners should be vigilant regarding life-threatening differentials such as exertional heatstroke and exercise-associated hyponatraemia, which are not uncommon. Identifying the cause of collapse in the endurance athlete is difficult as clinical presentations are often similar. The causes, symptoms and management of these conditions are discussed and a management algorithm proposed.

Longer distance races and slower running pace are associated with Exercise associated collapse: SAFER XXV study in 153,208 distance runners.

Exercise associated collapse (EAC) is a common medical encounter at distance running events. Risk factors associated with EAC are not well documented. The objective is to determine the overall incidence of EAC and identify risk factors associated with EAC in 21.1-km and 56-km runners. A cross-sectional analysis of 153,208 race starters from the Two Oceans Marathon races (2008-2015). All EACs on race day were documented by medical staff. Risk factors associated with EAC investigated included demographics, race distance (21.1 km vs. 56-km), running speed, race experience and race day environmental data (wet-bulb globe temperature [WBGT], humidity, wind speed). Incidence (per 1000 starters; 95% CIs) and incidence ratios (95%CIs) were calculated. The overall incidence of EAC was 1.50 (95% CI: 1.31-1.71). Longer race distance (IR: 2.1; 1.6-2.7; P<0.0001) and slower running speed (IR: 1.3; 1.1-1.5; P=0.0017) were significant risk factors associated with EAC. The incidence of EAC was higher in female vs. male 21.1-km race starters (IR=2.25; 1.47-3.46; P=0.0229). Age and environmental conditions were not associated with EAC (P>0.05) in a cool and temperate environment. About 1 in 667 race starters (21.1 km and 56-km) develop EAC. Longer race distance, slower running speed and female sex (in 21.1-km starters) are significant risk factors associated with EAC. Race medical directors can identify race entrants that may be at risk of developing EAC, develop prevention strategies and better prepare medical care at these events.

Medical emergencies during running events

HintergrundDie Anzahl an kurz- und langstreckigen Laufveranstaltungen in Deutschland nimmt zu. Laufen als Breitensport wird von einer Vielzahl an Personen unterschiedlicher Altersklassen, Risikogruppen und Professionalisierungsgrade betrieben, woraus ein breites Spektrum medizinischer Notfälle resultiert.Ziel der ArbeitDer vorliegende Beitrag erläutert die Inzidenz, Pathophysiologie und Therapie relevanter Notfallbilder bei Laufveranstaltungen. Ziel ist die Optimierung der Arbeitsabläufe des Rettungsdienstpersonals.Material und MethodenEs erfolgte eine Literaturrecherche in PubMed.ErgebnisseAnstrengungsassoziierte Muskelkrämpfe, gastrointestinale Symptome, Kollaps, Kompartmentsyndrom und Tendinopathien sind häufige Erscheinungsbilder und resultieren meist aus akuter oder chronischer Überanstrengung. Der Kreislaufstillstand bzw. plötzliche Herztod ist ein seltenes Ereignis bei Laufveranstaltungen. Bewusstseinsstörungen und generalisierte Krampfanfälle sind schwerwiegende Komplikationen. Disseminierte intravasale Koagulopathie, belastungsinduzierte Hyponatriämie, Hitzschlag, Rhabdomyolyse und thromboembolische Ereignisse sind mit hoher Morbidität und Mortalität verbunden. Substanzen zur Erhöhung der Schmerzschwelle und leistungssteigernde Substanzen sind unter Läufern stark verbreitet und gehen mit einer hohen Rate an Nebenwirkungen einher.DiskussionUnspezifische Symptome wie Erbrechen, Fieber, Kollaps, Muskelschmerzen, Übelkeit, und Schwäche sind die führenden Symptome bei Laufveranstaltungen. Eine sorgfältige Anamnese ist wegweisend für eine zielgerichtete klinische Therapie. Präklinisch steht eine Symptomkontrolle im Mittelpunkt. Das Flüssigkeitsmanagement stellt eine besondere Herausforderung dar.

Changes in gastrointestinal cell integrity after marathon running and exercise-associated collapse.

Endurance exercise and hyperthermia are associated with compromised intestinal permeability and endotoxaemia. The presence of intestinal fatty acid-binding protein (I-FABP) in the systemic circulation suggests intestinal wall damage, but this marker has not previously been used to investigate intestinal integrity after marathon running. Twenty-four runners were recruited as controls prior to completing a standard marathon and had sequential I-FABP measurements before and on completion of the marathon, then at four and 24h later. Eight runners incapacitated with exercise-associated collapse (EAC) with hyperthermia had I-FABP measured at the time of collapse and 1hour later. I-FABP was increased immediately on completing the marathon (T0; 2593 ± 1373ng·l-1) compared with baseline (1129 ± 493ng·l-1; p < 0.01) in the controls, but there was no significant difference between baseline and the levels at four hours (1419 ± 1124ng·l-1; p = 0.7), or at 24h (1086 ± 302ng·l-1; p = 0.5). At T0, EAC cases had a significantly higher I-FABP concentration (15,389 ± 8547ng.l-1) compared with controls at T0 (p < 0.01), and remained higher at 1hour after collapse (13,951 ± 10,476ng.l-1) than the pre-race control baseline (p < 0.05). I-FABP is a recently described biomarker whose presence in the circulation is associated with intestinal wall damage. I-FABP levels increase after marathon running and increase further if the endurance exercise is associated with EAC and hyperthermia. After EAC, I-FABP remains high in the circulation for an extended period, suggesting ongoing intestinal wall stress.

Preventing Exercise-Associated Collapse Using Online Runner Education: A Randomized, Controlled Trial.

To determine whether online exercise-associated collapse (EAC) prevention education decreases medical tent EAC visits among first-time marathoners. A prospective controlled study, with age- and sex-stratified randomization, evaluated rates of medical tent diagnosed EAC among runners randomized to the intervention group and intervention participants, compared with a control group. Grandma's Marathon Medical Tent in Duluth, MN, June 2016. Runners in the 2016 Grandma's Marathon who never previously ran a marathon (n = 2943), randomized into control (n = 1482) and intervention (n = 1461) groups. Intervention participants opened the EAC prevention video (n = 590). Online EAC education included an introductory webpage and 5-minute professional video describing EAC and prevention. Medical tent visit with EAC diagnosis. Intervention participants had no decreased likelihood of EAC, compared with controls [odds ratio (OR), 0.88, 95% confidence interval (CI), 0.46-1.69]. Exercise-associated collapse occurred less frequently in those with longer race times (OR, 0.58, 95% CI, 0.43-0.79). Intervention participation was associated with longer race times (OR, 1.12, 95% CI, 1.10-1.23). Those opening the EAC prevention video and controls had similar EAC rates. Slower running speed was associated with lower EAC rates. Video viewing was a predictor of slower running pace.

Burden of Injury and Illness in the Road Race Medical Tent: A Narrative Review.

To summarize the literature relating to prehospital care at 5 km through marathon distance road races and present the epidemiology of common medical encounters, significant medical complications, and medical outcomes. We searched PubMed and Google Scholar for the published literature pertaining to road race medical tent encounters at 5 km through marathon distance road races from 2000 to 2018. We included English-language, original articles reporting on injury and illness incidence. Standard medical encounter definitions have recently been formulated in response to the previous lack of uniform definitions. The incidence of medical complications at road races may be influenced by environmental conditions and race distance. Minor and moderate medical encounters, such as dermatologic injuries, musculoskeletal injuries, and exercise-associated collapse, are common. Serious and life-threatening medical complications, including exertional heat stroke, exercise-associated hyponatremia, and cardiac arrest, are less frequent. Fatalities are also rare, with rates of 0.3 to 5 per 100 000 participants reported at marathons. The ratio of hospital transports to medical encounters is low. On-site medical services play a key role in the safety of both runners and the community. Future research and care initiatives in this field should focus on optimizing treatment protocols, promoting injury prevention efforts and reducing host community costs.

Profiling Collapsing Half Marathon Runners-Emerging Risk Factors: Results from Gothenburg Half Marathon.

Among several serious medical conditions, arrhythmia and heat stroke are two important causes of death during endurance races. Clinically, collapsing might be the first sign of these serious conditions and may mimic the more common and benign exercise-associated collapse. Several risk factors have been reported in the literature. We aimed to conduct a qualitative study to find a perceived risk profile among runners who collapsed and who were transported by ambulances to the nearest hospital during Gothenburg’s half marathon (2010–2017). Collapsing runners seem to lack the ability to make a decision to withdraw from the contest despite being exhausted. They feel the pain, but are unable to put meaning to their feeling, to adjust their pacing, and to handle other influences. Consequently, they do not overcome the problem or assess the situation. These individual mental characteristics may indicate a unique profile for collapsing runners. Pre-race health control and educational initiatives aiming at mental preparedness and information before endurance races might be a necessary step to avoid life-threatening complications.

Heat-related illness in the African wilderness

Wilderness heat-related illnesses span a variety of conditions caused by excessive or prolonged heat exposure, and/or the inability to compensate adequately for increased endogenous production during strenuous outdoor activities. Despite management of well-known risk factors, such as lack of fitness or acclimatisation, dehydration, underlying illness and certain medications, even highly trained individuals may exceed their physiological capability to dissipate increased core temperature. Heat illnesses range from benign cramps to the more concerning heat syncope and exercise-associated collapse (with or without hyperthermia), and culminate in life-threatening heat stroke. The differential diagnosis in the wilderness is broad and should include exercise-associated hyponatraemia with or without encephalopathy. Clinical guidelines for wilderness and hospital management of these conditions are available. Field management and evacuation are based on severity, and include cooling, rehydration and assessment of core temperature and serum sodium, if possible. Hyponatraemia should be corrected with the use of oral or intravenous hypertonic saline, depending on whether the patient can safely take oral fluids. Hospital management may include aggressive and potentially invasive cooling, careful assessment for organ dysfunction, and intensive multi-organ support, if required. Paracetamol, non-steroidal anti-inflammatory drugs and dantrolene should not be used.

Heat-related illness in sports and exercise.

Exertional heat-related illness (EHRI) is comprised of several states that afflict physically active persons when exercising during conditions of high environmental heat stress. Certain forms of EHRI may become life threatening if not treated. Exertional heat stroke (EHS), characterized by a core body temperature of >40° C and mental status changes, is the most severe form of EHRI. EHS must be treated immediately with rapid body cooling to reduce morbidity and mortality. Many EHRI cases are preventable by following heat acclimatization guidelines, modifying sports and exercise sessions during conditions of high environmental heat stress, maintaining adequate hydration, avoiding exertion in the heat when ill, and by educating sports medicine personnel, coaches, parents, and athletes on the early recognition and prevention of EHRI. Heat exhaustion, exercise-associated collapse, exercise-associated muscle cramps, exercise-associated hyponatremia, and exertional rhabdomyolysis are also described.

Medical complications and deaths in 21 and 56 km road race runners: a 4-year prospective study in 65 865 runners—SAFER study I

BackgroundCardiac arrest and sudden death during distance-running events have been reported but other medical complications, including serious life-threatening complications have not been well described.ObjectiveTo document the incidence and nature of...

Exercise-associated Collapse In A Collegiate Volleyball Athlete

Exercise-associated Collapse In A Collegiate Volleyball Athlete

Sports and Performing Arts Medicine: 4. Events Coverage

This self-directed learning module highlights medical coverage of sports events and artistic performances. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on performance anxiety, exercise-associated collapse, exercise-induced asthma, transient quadriparesis, stingers/burners and anterior glenohumeral joint dislocations. The goal of this article is to improve the learner's ability to formulate and implement an appropriate evaluation and treatment algorithm for certain conditions associated with sports and performing arts events.

Clinical Significance of Cardiac Damage and Changes in Function after Exercise

Acute bouts of ultraendurance exercise may result in the appearance of biomarkers of cardiac cell damage and a transient reduction in left ventricular function. The clinical significance of these changes is not fully understood. There seems to be two competing issues to be resolved. First, could prolonged endurance exercise produce a degree of cardiac stress and/or damage that results, during the short or long term, in deleterious consequences for cardiac health. Second, there is a clear need to educate those responsible for the medical care of endurance athletes about the possibility of a transient reduction in cardiac function and the appearance of cTnT/cTnI after an exercise. Minor elevations in cardiac troponins are commonplace after an endurance exercise in elite and recreational athletes and may occur alongside exercise-associated collapse. Misdiagnosis of myocardial injury and subsequent mismanagement can be unnecessarily expensive and psychologically damaging to the athlete. Diagnosis of myocardial injury after prolonged exercise should be made on the basis of all available information and not blood tests alone. The clinical significance of chronic exposure to endurance exercise is unknown. The development of myocardial fibrosis has been suggested as a long-term outcome to chronic exposure to repetitive bouts of endurance exercise and has been linked to an exercise-induced inflammatory process observed in an animal model. This hypothesis is supported by a limited number of studies reporting postmortem studies in athletes and an increased prevalence of complex arrhythmia in veteran athletes. Care is warranted in promoting this hypothesis without further detailed work, given the unequivocal link between exercise and mortality and morbidity. It would seem erroneous, however, to assume that a linear relationship exists between exercise volume and cardiac health.

Syncope in a Collegiate Rower

HISTROTY: A 21 yr collegiate female rower was referred for evaluation of syncope. During freshman year, a screening ECG for evaluation of a heart murmur revealed an abnormal QT interval: notched & prolonged in the chest leads, not lead II. Initial work-up: normal cardiac function & QT shortening. No provocable arrhythmias during a Bruce protocol exercise test. Multiple long QT experts disagreed on interpretation of her ECG. After signing a waiver, she competed her freshman and sophomore year without incident. During jr year, when returning the boat to the boathouse after an intense competition, she developed acute onset of lightheadedness, diminished vision and fell to the floor. She regained consciousness immediately and did not seize or become incontinent. After this event, she was disqualified from participation in competitive sports. PHYSICAL EXAMINATION: BP seated 126/76 mmHg. Pulse 76 bpm and regular. Lungs clear. Cardiac exam: carotids 2+ without bruits. S1 normal, S2 physiologically split. No S3 or S4. Grade I/VI systolic flow murmur unchanged with Valsalva. DIFFERENTIAL DIAGNOSIS: Long QT with Torsades de Pointes Other cardiac arrhythmia causing syncope Orthostatic hypotension with exercise associated collapse (EAC) TESTS AND RESULTS: Rowing ergometer exercise test: Resting HR 78 bpm, QT interval range 443 - 459 msec, no notching. Submax exercise: QTc interval 383 msec.a. Post warm up; bursts of rapid narrow complex tachycardia followed by periods of trigeminy with multi-form couplets which gradually resolved.Max effort: heart rate 183 bpm, QTc interval 389 msec. Post-exercise: One minute post-exercise; narrow complex tachycardia returned, HR 203 bpm. BP normal. upon standing HRT, BP 80/50 mmHg and became symptomatic. when supine, BP and symptoms improved. Arrhythmia persisted. QT interval returned to 440 msec. Arrhythmia broke spontaneously FINAL/WORKING DIAGNOSIS: Possible long QT syndrome Post-exercise syncope precipitated by PAT with orthostatic hypotension TREATMENT AND OUTCOMES: β-blockade therapy and resume dry land training. RevealR heart rate monitor implantation to determine clinical arrhythmia if it recurs. Risk of next syncope being fatal if truly LQTS approx. 5% Genetic scan for known QT channelopathy. Immediate access to AED on training site.

Exercise-Associated Collapse Care Matrix in the Marathon

Exercise-associated collapse (EAC) was developed as a marathon collapse classification matrix to speed clinical decision making and improve care. The definition was simply stated as the need for assistance during or immediately after endurance activity that specifically excluded cardiac arrest, insulin shock, anaphylaxis, trauma, skin conditions and orthopedic injuries. The presenting symptoms were neither specific nor sensitive and the initial classification, based on presenting rectal temperature, neurological status and ability to walk, was intended to shape the on-site medical intervention. The treatment of EAC centres on fluid redistribution and replacement to improve cerebral and core organ circulation and body temperature correction if needed. Most runners are discharged from the medical area in the company of another person.

Recommendations for treatment of hyponatraemia at endurance events.

This review focuses on possible pathophysiology of exercise-associated hyponatraemia and its implication on evaluation and treatment of collapsed athletes during endurance events. Rehydration guidelines and field care have traditionally been based on the belief that endurance events create a state of significant fluid deficit in athletes, which must be corrected by liberal hydration. Beliefs in the necessity of liberal hydration may have contributed to cases of hyponatraemia. Assumptions that fluid loss accounts for the entire weight loss during exercise and that fluid ingestion is the only source of water gain during exercise may lead to an overestimation of the degree of volume depletion and the amount of fluid needed for replacement. Increasing evidence suggests that hyponatraemic athletes are fluid overloaded; ingestion of large amount of hypotonic fluid in combination with inappropriate or inadequate physiological responses leads to excessive retention of free fluid. Risk factors include hot weather, female sex, slower finishing time, and possibly the use of nonsteroidal anti-inflammatory medications. Symptoms of hyponatraemia can be subtle and can mimic those of other exercise-related illnesses, thereby complicating its diagnosis and leading to possible inappropriate treatment. Most athletes who collapse at the finish line experience exercise-associated collapse, a benign and transient form of postural hypotension that can be treated simply by continued ambulation after finishing or elevation of legs while in a supine position for those who cannot walk. Care providers should consider the use of intravenous hydration with normal saline carefully since it is not needed by most collapsed athletes and may worsen the condition of patients with unsuspected hyponatraemia. Historic information and clinical signs of volume depletion should be elicited prior to its use. Most hyponatraemic athletes will recover uneventfully with careful observation while awaiting spontaneous diuresis. Use of hypertonic saline should be reserved for patients with severe symptoms. Moderate consumption of carbohydrate-electrolyte solution during exercise may allow the maintenance of adequate hydration and the prevention of hyponatraemia.

Managing triathlon competition.

Medical coverage of endurance events requires knowledge of conditions that are specific to, or present differently in, endurance athletes. Serious conditions such as hyponatremia and rhabdomyolysis, and heat illnesses such as hypo- and hyperthermia, need to be accurately and quickly separated from more benign conditions such as exercise-associated collapse.

EXERCISE-ASSOCIATED COLLAPSE ??? 3 CASES IN DIFFERENT SPORTS

HISTORY Three patients presented with histories of collapse whilst exercising. Case 1: 21 year old male, tennis player, collapsed while playing tennis. He was well beforehand, and had played after lunch. He reported 7 previous episodes of exercise-associated collapse, when epinephrine had to be injected to revive him. Case 2: 33 year old female, roadrunner. Patient with history of asthma that was well controlled on inhaled corticosteroids and long-acting beta-agonists. The athlete had a salad one afternoon, prior to going jogging. She collapsed and had to be resuscitated with intravenous fluids and epinephrine. Case 3: a 16-year-old female netball player. Known to have a history of mild asthma, using salbutamol pre-exercise, or on an as necessary basis. Between playing a morning and afternoon match, she dined with her teammates. She collapsed whilst playing the afternoon game, requiring resuscitation, including intravenous fluids, antihistamines and epinephrine. This was her first episode. She recalled her skin itching the day before. PHYSICAL EXAMINATION all three patients were found to have common findings. These included: hypotension, tachycardia, angioedema, respiratory distress with wheezing. They all had intact neurological examinations. Cases 2 and 3 had urticarial rashes, and the first case had rhinitis. DIFFERENTIAL DIAGNOSIS Hypoglycemia Cardiac arrhythmia Postural hypotension Cerebral event Anaphylaxis TEST AND RESULTS Bloods: * Case 1: - Food allergen CAP RAST test positive for: Mixed grains, Wheat, Nut mix, Orange fruit, fish mix - Serum IgE elevated * Case 2 - Positive CAP RAST test for tomato, wheat and celery * Case 3 - CAP RAST positive for celery, tomato, wheat, mixed nuts, rye, soyabean, gluten, peanut, citrus (orange, lemon), mixed cereal FINAL/WORKING DIAGNOSIS Food Dependant Exercise Associated Anaphylaxis TREATMENT AND OUTCOMES Avoiding allergic foods before exercise No exercise for 4 hours after meals Reducing intensity of activity Avoid excess heat and humidity Stop activities at first signs of itching Epinephrine injections available at all times To wear Medical Emergency bracelets Education of teammates and coaches to identify and manage the condition. All patients at 3 years follow-up with no recurrence.

Exercise-Associated Collapse: Postural Hypotension, or Something Deadlier?

Exercise-associated collapse (EAC) is the most common reason that athletes are treated in the medical tent following an endurance event. The pathophysiology of EAC is postural hypotension that results when the loss of muscle pumping action caused by the cessation of exercise is combined with cutaneous vasodilation. EAC usually occurs after an athlete crosses the finish line. If an athlete collapses during a race, then another serious medical cause is more likely. A brief assessment of the collapsed athlete should be carried out to obtain a working diagnosis. Prompt treatment of EAC includes elevating the legs and pelvis of the athlete.

The incidence, risk factors, and clinical manifestations of hyponatremia in marathon runners.

To report on the incidence, identify the risk factors, and clarify the clinical manifestations of acute hyponatremia in marathon runners. An observational and retrospective case-controlled series. The medical care area of the 2000 Houston Marathon. Marathon finishers treated in medical area receiving intravenous fluids (N=55), including a more detailed analysis of 39 runners completing a retrospective questionnaire. Vital signs, serum electrolytes, and finish time were analyzed via ANOVA studies between all non-hyponatremic (NH: N=34)) and hyponatremic (H: N=21)) runners. Fluid intake, training variables, NSAID use, and Symptomatology were further analyzed to delineate all significant differences between groups. There were no significant differences in vital signs, training variables, or NSAID use between H and NH groups, although there was a trend towards the less experienced runners presenting with lower post-race sodium levels. H runners had lower potassium [K] (p=.04), chloride [Cl] (p<.001), and blood urea nitrogen [BUN] (p=.004) levels than NH runners. There was a significant inverse linear relationship between both finish time versus [Na] (r2 =.51) and total amount of fluid ingested versus [Na] (r2 =.39). The total cups of water (p=.004), electrolyte/carbohydrate solution (p=.005) and total amount of fluid ingested (p<.001) were significantly higher in H compared to NH runners and the degree of hyponatremia was related in a dose dependent manner. Vomiting was observed more frequently in H than NH runners (p=.03). 21 runners presented to the medical area of the Houston Marathon with hyponatremia (.31% of entrants). Excessive fluid consumption and longer finishing times were the primary risk factors for developing this condition. Vomiting was the only clinical sign differentiating hyponatremia from other conditions that induce exercise-associated collapse.