2015 Significant Hypothermia in an Ultrarunner Case Study

© 2015 The Paramedic Foundation, All Rights Reserved
SEVERE HYPOTHERMIA IN A
50 MILE ULTRAMARATHON
NICK NUDELL, MS, NRP
EXECUTIVE DIRECTOR
ULTRAMEDICAL TEAM

2015 LOST BOYS 50 MILE TRAIL RUN
Point-to-point trail ultramarathon in San Diego County
Potential entrants must have completed at a MINIMUM an official
trail 50k race (within the race's qualifying time)
2015 Race is stopped at final aid station at hour 12 due to severe
inclement weather & concerns for runner safety
15 hour limit
Neil Feerick 8:23:46 & Tracy Dimino 9:44:14
56 finishers (78%)

4 miles (6.4km) of
desert washes without
roads or trails, 18
(29km) miles of jeep
roads, and 28 miles
(45km) of trails

9000’ up (2740m)
6100’ down (1860m)
Range of 1200'
(365m) to 6200’
(1890m)

NICE DESERT

WIND? WHAT WIND?

WHAT WEATHER?

FINISH LINE SOAKING

2015 WEATHER

WIND CHILL CHART

WIND CHILL
Australia Apparent Temperature
The formula is:
AT = Ta + 0.33e - 0.70ws - 4.00
Where:
Ta = Dry bulb temperature (°C)
e = Water vapor pressure (hPa)
ws = Wind speed (m/s) at an elevation of 10 meters
The vapor pressure can be calculated from the temperature and relative humidity
using the equation:
e = (rh/100} * 6.105 * exp ((17.27 * Ta)/{237.7 + Ta))
Where:
Ta = Dry bulb temperature (°C)
rh = Relative humidity [%]
exp represents the exponential function
40F = 7C
40mph = 17m/s
100% humidity
-7C = 19F
http://planetcalc.com/2089/

STEVE: 54 YEAR OLD
• 2013 Boston 3:12, 4.5hr 50k, 8hr 50M
(80km), 12hr 100K, 27hr 100M (161km)
• Sponsored triathelete & ultrarunner
• No pertinent medical history, great
physical condition
• Wore 4 layers: running tank, two long
sleeve tech tees, long sleeve synthetic
material warmup pullover. Besides shorts
also had calf sleeves, a thin skull cap, and
cotton gloves.
• After 10 bonus miles Steve finds a friend
off course – they buddy up and become
the last two runners on course

GOING DOWNHILL
5pm: Buddy reports Steve was stumbling a lot and having
difficulty moving forward
6pm: Buddy pulled Steve up last climb, mile 48 forward progress
stopped
6:05pm: Buddy called 911 while running down to finish
6:15pm: Ultra Medical Team ED & safety sweep headed up
6:40pm: Steve was found in center of trail in the water runoff
Awake, slow/minimal verbal response, not shivering,
completely soaked, cold to touch, can’t swallow gel
6:45pm: UMT began rewarming & requesting stokes basket

SAN DIEGO
BURRITO
TrailDirection
UMT
Legs
Steve’s Feet
UMT Responder sits on
mylar blanket with Steve
Perpendicular in lap.
UMT Responder wraps
Own jacket around his
head and is wrapped in
several more mylar
blankets – face to face
with Steve for an hour

GOING DOWNHILL
30 minutes before fire department arrive, Steve starts to
make slow rhythmic myoclonic movements
10 minutes before fire department arrives, Steve starts
some on/off shivering of upper extremities in addition to
myoclonus
7:45pm: Fire dept arrives with wheeled stokes basket

60+ MINUTE TRANSPORT

CORE TEMP
• 82 F (28 C)
• ~2 hours after he was found
• After passive 2 hours of rewarming
• Core temp upon discovery possible ~78 F (25 C)
• Significant hypothermia, near cardiac arrest

HYPOTHERMIA
Hypothermia is classified as core temperatures rated as:
• Mild: 35C to 32C (90F to 95F)
• Moderate: 32C to 28C (82F to 90F)
• Severe: <28C (<82F)
Some experts have advocated a further category, profound
hypothermia, <24C or <20C. The chance of survival seems to be
much lower in this range, probably because of a high likelihood of
cardiac arrest.
Although it is helpful to use core temperature to classify
hypothermia, there is great variation among individuals in
response to core temperature, as with any other physiologic
parameter
Zafren, et al. WILDERNESS & ENVIRONMENTAL MEDICINE, 25, 425–445 (2014)

EMERGENCY LABS
Glucose Level 91 mg/dL CKMB Index 2.3
Sodium 139 mmol/L Troponin 0.2 ng/mL
Potassium 3.8 mmol/L WBC 25.2 x103/mm2 HI
Chloride 105 mmol/L RBC 4.30 x 106/mm3 LOW
CO2 20 mmol/L LOW Hgb 13.8 g/dL
BUN 37 mg/dL HI Hct 39.1%
Creatinine 0.96 mg/dL MCV 91 fL
Calcium 8.2 mg/dL LOW MCH 32.1 pg HI
Phosphorus 5.0 mg/dL HI MCHC 35.3 g/dL
Mag Level 2.9 mg/dL HI Platelet 390 c103/mm3
CK 3,177 U/L HI RDW 12.4%
CKMB 71.7 ng/mL HI MPV 7.0 fL
ALT HBA1C

ATRIAL FIBRILLATION
W/OSBORNE WAVES



http://www.ncbi.nlm.nih.gov/
pmc/articles/PMC1501063/
ATRIAL FIBRILLATION
W/OSBORNE WAVES

EMERGENCY PHYSICIAN
Impression and Plan - Diagnosis
Acute hypothermia
Acute dysrhythmia
Acute rhabdomyolysis
Acute exertional syncope
Discharge plan: Condition: Stable. Disposition: AMA.
Patient was given the following educational materials: Hypothermia-
SportsMed. Rhabdomyolysis (Muscle Fiber Breakdown). Atrial Fibrillation.
Follow up with: Follow up with primary care physician In 1 day. Please
return for any worsening.
The patient was instructed not to engage in potentially dangerous activity.
The patient had no further questions.

FOLLOW UP LABS – 4 DAYS POST
Glucose Level 77 mg/dL
Sodium 136 mEq/L
Potassium 3.8 mEq/L
Chloride 103 mEq/L
CO2 25 mEq/L
Creatinine 0.79 mg/dL
Calcium 9.0 mg/dL
Phosphorus 3.4 mg/dL
Mag Level 2.1 mg/dL
CK 196 U/L
ALT 65 U/L HBA1C 5.6%

LESSONS LEARNED
• Runner status/experience should not be a factor
• Wet bulb calculations should be used with guidance for RDs
and participants
• ED practices defensive medicine, unfamiliar with UR norms
• Have a GoBag ready at every race for emergency rescue
supplies
• Myoclonic activity is associated with anoxic brain injury in
therapeutic hypothermia but not in acute hypothermia
• Have an extrication/rescue plan for each event
• Educate local EMS providers about ultramarathon specific
medical conditions

STEVE’S COMMENTS
• At the end of a long race, it’s hard to tell the difference
between cognitive deficit (fogginess, slow speech, etc.) due to
Hypothermia versus that we normally feel at the end of a long,
tough race.
• I experienced some onset symptoms not always reported as
typical of Hypothermia; namely, ringing in the ears and slow,
jerky, visual tracking. Again, attributed to normal physical and
mental fatigue.
• Body temperature was sapped at a slow, insidious rate. I did
not at any time feel distressingly cold, nor shiver.
• The self-confidence of veteran runners may work against them,
as they will tend to push through discomfort and symptoms that
would probably alarm less experienced runners.

THANK YOU!

ULTRAMEDICAL TEAM
• Provides medical direction, planning, training, equipment &
advice for ~20 ultras a year from 25-215 miles (40-346km)
• Provides medical malpractice, equipment, organizational
support, and tax deduction for medical volunteers
• All distances but value is more clear >=50mi (80km)
• Expanding worldwide
Nick Nudell (760) 405-6869
nick@ultramedicalteam.org
www.ultramedicalteam.org
https://www.facebook.com/ultramedicalteam

2015 Significant Hypothermia in an Ultrarunner Case Study

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2015 Significant Hypothermia in an Ultrarunner Case Study