1.
Baker To Vegas
Medical Team
Troy W. Pennington DO, MS, FAAEM
Medical Director- B2V 2017

2.
Limited Resources
 Limited diagnostic or therapeutic tools to
manage the patient appropriately on site
 The main role of the Medical Team is to
minimize risk to the athlete by identifying
those who can be treated on site and allowed
to continue and dispatching more serious cases
to hospital.

3.
Medical Team Goals
GOALS OFTHE MEDICALTEAM
 To provide immediate minor treatment and discharge
patients back to the race when it is appropriate to do so,
in order to allow them to achieve their goal on the day!
 To commence treatment and provide guidance or onward
referral to medical specialties for care after the event at a
location appropriate for the patient and their clinical
condition.

4.
Medical Team Goals
GOALS OFTHE MEDICALTEAM
 To counsel athletes towards race termination when it is in
the interests of their own health and wellbeing.
 To assist those unable to complete the race due to medical
reasons in reaching the finish area to collect their
belongings, and aid (to a reasonable extent) in their return
home.
 To provide life saving interventions and transportation to
definitive medical care.

5.
Introduction
This course is designed to introduce you to
the most common conditions seen
in endurance events.
 These issues include:
 Heat-Related Illness
 Rhabdomylosis
 Exercise Associated Collapse
 Exertional Hyponatremia
 Cardiac Arrest
 Stress Fracture

6.
Critical Thermal Maximum
Is the temperature for a given species above
which most individuals respond with
unorganized locomotion, subjecting
the animal to likely death…
Evaluating infant core temperature response in a hot car
using a heat balance model.
Grundstein AJ1, Duzinski SV, Dolinak D, Null J, Iyer SS
Abstract
PURPOSE:
Using a 1-year old male infant as the model subject, the objectives of this study were to measure increased
body temperature of an infant inside an enclosed vehicle during the work day (8:00 am-4:00 pm) during
four seasons and model the time to un-compensable heating, heat stroke [>40 °C (>104 °F)], and critical
thermal maximum [>42 °C (>107.6 °F)].

7.
Critical Thermal Maximum
 38 °C (100.4 °F)
 39 °C (102.2 °F)
 40 °C (104.0 °F)
 41 °C (105.8 °F)
 42 °C (107.6 °F)
 43 °C (109.4 °F)
 44 °C (111.2 °F)
Feeling hot, sweating, feeling thirsty, feeling very
uncomfortable, slightly hungry
Severe sweating, flushed and red. Tachycardia, SOB
Fainting, dehydration, weakness, vomiting, headache,
SOB, and dizziness may occur as well as profuse sweating
Fainting, vomiting, severe headache, dizziness,
confusion, hallucinations, delirium and drowsiness
May turn pale or remain flushed and red.They may become
comatose, delirium, vomiting, seizures, fluctuating BP
Death possible, or brain injury, Seizures and shock,
Circulatory collapse
Likely death if prolonged; however, survival up to 46.5 °C
(115.7 °F), has been documented

8.
Heat Illness
Pathophysiology
 Heat production occurs via three
mechanisms
1. Basal metabolic rate
2. Muscle use
3. Insulation/radiation
 Heat loss occurs via four
mechanisms:
1. Conduction (if gradient exists)
2. Convection (if gradient exists)
3. Radiation
4. Evaporation of moisture.
Remember that
acclimatization
can be very
effective in
preventing heat
illness
The body will re-
adjust to increase
sweating with
less salt loss and
up regulate heat
shock proteins.

9.
Heat Emergencies
Heat Cramps Painful Muscle Cramps
and Spasms
Usually Leg Muscles & Abdomen
Heat Exhaustion Heavy sweating, cool, pale skin,
tachycardia, muscle cramps,
nausea, vomiting, dizziness
Heat Stroke Altered Mental Status
Possible- headache,
confusion, nausea,
dizziness, high core
temperature likely greater
than 105.8 F or 41C
tachycardia, hot, dry skin

10.
Musculoskeletal
Cramps & Pain…
 Musculoskeletal cramps are grouped into three
categories. The least significant, but probably
most common, is a single muscle cramp or muscle
group, such as a right calf muscle.
 These patients should be treated with assisted
walking or independent walking. Highly
competitive athletes will not want any assistance.
These patients do not require transport for
evaluation.

11.
Musculoskeletal
Cramps & Pain…
 The second category is repeated cramping. For
example, the left calf muscle cramped at mile 3, 5, and
now 10. Now it is cramping and won’t stop.
 These patients are likely experiencing electrolyte or
dehydration problems. The treatment is oral hydration,
a calorie resource, and either assisted or independent
walking.
 There is no standard for oral rehydration techniques.
Once their cramps have resolved, they can resume the
race.

12.
Musculoskeletal
Cramps & Pain
 If patients are unable to ambulate unassisted, or are
collapsing due to involvement of multiple muscle
groups, they will need IV fluid rehydration and
possibly benzodiazepines.
 Consider giving magnesium intravenously if
available. However, medical staff at most races will
not be able to administer magnesium.

13.
Heat Exhaustion
 Heavy sweating
 Cool, pale skin
 Tachycardia
 Muscle cramps
 Nausea
 Vomiting
 Dizziness

14.
HEAT Stroke
Classic vs. Exertional Heat Stroke
Classic nonexertional heatstroke (NEHS) more commonly affects
sedentary elderly individuals, persons who are chronically ill, and very
young persons. Classic NEHS occurs during environmental heat waves
and is more common in areas that do not typically experience periods of
prolonged hot weather.
Exertional heatstroke (EHS) generally occurs in young individuals
who engage in strenuous physical activity for a prolonged period of
time in a hot environment.
Both types of heatstroke are associated with high morbidity and mortality,
especially when cooling therapy is delayed.

15.
HEAT STROKE PEARLS
About 1 in 10,000 marathon runners
will experience heat stroke.
All sorts of inflammatory mediators such as interleukins, cytokines, will
increase with heat stroke.
In animal and other studies if you overheat the gut, permeability
increases, and you have the movement of bacteria and endotoxins
into the bloodstream and creating a state that looks like sepsis…
You have the same chemical mediators
Increase the metabolic rate and eventually run out of energy

16.
HEAT STROKE PEARLS
Sweat About .1% normal saline
Don’t send anyone who has had heat exhaustion
back to another hot environment
Decreased ability to tolerate heat
on subsequent days

17.
HEAT STROKE PEARLS
The risk of developing heat stroke is actually often
higher in shorter races.
Often in athletes with higher body mass
Higher body mass athletes develop
more heat than lighter ones
Also remember slower runners are very unlikely to develop heat illness, yet
they constitute the majority receiving medical care in most endurance races

18.
Chaffing & Blisters
 Bloody nipples
 Cotton shirts
 Chafing and blisters. Some runners are
prone to this, patients who are new to
running or those who are overweight with
thighs rubbing together. Cotton
t-shirts can chafe nipples.
 The treatment includes putting Vaseline
on the wound or chafed area. The area
can be protected with moleskin or a
Band-Aid. Moleskin can be very helpful
for blisters, especially between the toes,
and allow runners to continue.

19.
What Should You Drink?
The evidence on this is clear. If your event or workout
is longer than 30 minutes you should be drinking a
sports drink.
The added carbohydrate and electrolytes speed
absorption of fluids and have the added benefit of
energy fuel and electrolytes.
There is actually decreased benefit to watering
down or diluting sports drinks or alternating
sports drinks with water.
Recommendations adapted from the IMMDA guidelines

20.
A weight loss of more than 2% or
any weight gain are warning signs
that justify immediate medical
consultation and indicate that
you are drinking improperly.
Recommendations adapted from the IMMDA guidelines

21.
How Much Should You Drink?
 Athletes should drink to THIRST during the
race and not more than 800ml/hr.
 Athletes that collapse During Exercise are
different than those that collapse after
exercise. In almost all cases they need to be
seen in the hospital…
Recommendations adapted from the IMMDA guidelines

22.
How Much Should You Drink?
The reader should understand that there are
individual variations: “one size does not fit all”.
We endorse thirst as the best scientifically supported
method for you to use. These alternate methods may
not take into account changes in ambient conditions,
running speed and terrain which can all change
dynamically which thirst as a method to use does.
Recommendations adapted from the IMMDA guidelines

23.
How Much Should You Drink?
Runners/walkers planning to spend between 4-6
hours or longer on the course are at risk for
developing fluid-overload hyponatremia and usually
do not need to ingest more than one cup
(3-6 oz: 3 oz if you weigh approximately 100 lbs and
6 oz if you weigh approximately 200 lbs)
of fluid per mile. Athletes should avoid weight gain
during an event.
Recommendations adapted from the IMMDA guidelines

24.
Exercise Associated Postural
Hypotension aka Collapse
 Exercise-associated Postural Hypotension (EAPH)
commonly occurs after the completion of endurance
running events.
 59-85% of all post-marathon medical visits
 Br J Sports Med. 2011 Nov;45(14):1157-62.
 EAPH is caused by a postural drop in systolic blood
pressure
 Inactivation of the calf muscle pump upon cessation of
prolonged exercise
 Results in lower extremity venous blood pooling, reduced
atrial filling pressure, and subsequent syncope

25.
 EAC is a collapse in conscious athletes who
are unable to stand or walk unaided as a
result of light headedness, faintness and
dizziness or syncope causing a collapse
that occurs after completion
of an exertional event.
Exercise Associated Collapse

26.
 Evaluate in supine position with legs elevated
 Oral rehydration
 Cooling
 Rest
 Most patients will recover in 30 min
 Monitor for MENTAL STATUS CHANGES or failure to
progress – which might suggest
Exertional Hyponatremia
Hyperthermia
Cardiac Arrest
Hypothermia
Hypoglycemia
Exercise Associated Postural
Hypotension
Treatment

27.
Exercise Associated
Postural Hypotension
Most athletes who collapse after exercise have
Exercise Associated Postural Hypotension
and require no treatment
than to recover while lying supine with
the head below the level of the heart
The Best form of treatment is
” Masterful Inactivity”
Dr.Timothy Noakes

28.
True or False?
A patient with suspected exercise associated
collapse is not improving despite 30 minutes of
rest with her legs elevated, gentle cooling and
oral fluids.
You should give her a 2 liter bolus of IV
normal saline.

29.
False
 It would be appropriate to check her core
temperature (rectal thermometer) and
serum electrolytes.
 IV fluids are rarely necessary. Oral
rehydration is safer and less expensive.
 If the patient is too nauseated to tolerate
oral fluids antiemetic medications are
available.

30.
Top Two
Causes of
Exercise Related Collapse
1. Heatstroke
2. Exercise Associated
Hyponatremic Encephalopathy
They are differentiated by measuring a rectal
temperature and a blood sodium concentration

31.
Top Two
Causes of
Exercise Related Collapse
Heatstroke Treatment is rapid cooling!
All cooling must start immediately…
Remember the principal of the
Critical Thermal Maximum
All Altered competitors
must get a
RECTAL TEMPERATURE

32.
There are multiple cooling
techniques available for
hyperthermia.
Evaporative cooling is often
the fastest and most readily
available technique; it reduces
core body temperature by
approximately 0.3°C (0.54°F)
per minute.
After removing all clothing
from the patient, continuously
mist him or her with tepid water
while directing a large fan at
the individual.
Evaporative Cooling

33.
Strategic- Ice Pack Cooling

34.
Treatment of Heat
Emergencies
 Rehydration – oral in mild/moderate cases (sports drinks). Be
cautious with oral rehydration via free water – can lead to
hyponatremia, use the GUT whenever possible…IV rarely needed
 Evaporative cooling – Fan patient with tepid mist/wet sheet.
 Ice water immersion – Logistically difficult, may cause further
problems (arrest), can lead to vasoconstriction and more difficulty
dissipating heat
 Bypass/dialysis – Rarely used
Tylenol – won’t help in true heat illness
Antibiotics ok if sepsis or infection is in the differential (culture first)
Disposition consider discharge when Temperature normalized,
symptoms controlled, able to tolerate PO intake,
and reliable home setting

35.
True or False?
A hyperthermic runner with delirious
behavior should be emergently transferred
to the hospital before cooling.

36.
False
Heat stroke needs to be treated immediately
with on-site cooling starting on scene
Please Start all Cooling Measures
Immediately…
Think Crock Pot
Critical Thermal Maximum
Time and Duration

37.
IV Fluid Therapy must be
“Earned”
Please recognize that there are very few indications
for IV fluids in collapsed Marathon Runners!!

38.
Exertional Hyponatremia
 Dilutional decrease in serum sodium
concentration during physical activity caused by:
 Over hydration
 Salt losses in sweat
 Fluid retention enhanced by increased ADH secretion
during running
 Incidence
 12.5% of marathon runners.
 London Marathon
 Br J Sports Med. 2011 Jan;45(1):14-9. Epub 2009 Jul 20.

39.
Exertional Hyponatremia
 Risk factors
 Finishing time over 4 hours
 Marathon running inexperience
 Small stature
 Female gender
 NSAID use
 Unusually hot conditions

40.
Exertional Hyponatremia
Mild EH
Defined by Na+ less than
135mmol/L
With
headache,
paresthesias, nausea,
bloated/swollen
sensation
Severe EH
Defined by Na+ less than
120 mmol/L
With
decreased mental status,
confusion,disorientation,
agitation, delirium,
seizures, respiratory
distress

41.
Exertional Hyponatremia
Treatment
 Mild EH
 No IV fluids
 Consider oral fluid restriction
 Pt may drink salty oral fluids
like V8, Coke, or chicken broth
(4 bouillon cubes in 4oz
water).
 Monitor until urination.
 Discharge home with
instructions to monitor for EH
symptoms and to seek urgent
medical attention if any
symptoms develop
 Severe EH
 Check core temp – treat
hyperthermia if present
 100mL 3%
hypertonic saline
bolus
 Up to two additional 100ml 3%
hypertonic saline boluses may
be given at 10 min intervals
with Na+ recheck and no
improvement in symptoms
 Transfer to ER for ongoing
treatment/monitoring/recovery

42.
True or False?
A runner with headache, nausea, and tingling
feet has a Na+ 125.
She has no confusion. She should receive
2L of IV normal saline.

43.
False
No exercise-associated hyponatremic patient should
receive IV normal saline.
 Mild hyponatremics (those without mental status
changes) can use salty oral fluids until they urinate.
 Severe hyponatremics (those with mental status
changes) should receive the hypertonic saline
boluses.
Please involve one of our physicians in the care

44.
Stress Fractures
 Atraumatic bone injury caused by
repetitive, excessive stress.
 Continued stress can progress to
complete fractures.
 Stress fractures comprise 5-10% of sports
medicine visits in the US.
 Running is the most common sport
associated with stress fractures.

45.
Stress Fractures
 History: Focal bone pain worsened with
walking, running or weight bearing. Pain may
persist into rest periods.
 Physical exam: Reproducible focal point
tenderness. Pain with ROM if joint involved (ie.
femoral neck)
 Urgency of treatment depends on low or high-
risk stratification

46.
High Risk Stress Fractures
 High Risk Stress
Fractures should be made
non-wt bearing and sent
for urgent imaging
 Increased risk
complications including:
 Malunion
 Nonunion
 Avascular necrosis
 Arthritic change
 Occult fractures.
 High Risk Locations
 Femoral Neck
 Tibial Diaphysis
 Navicular
 5th Metatarsal

47.
True or False
 A runner has severe groin pain. You suspect
a femoral neck stress fracture.
 This patient can be placed on crutches and
follow-up with an orthopedists in 2 or 3 days.

48.
False
Xrays should be done immediately to
evaluate for a completed femoral neck
stress fracture. This is urgent because of
the risk of femoral head avascular necrosis
and developing hip arthritis.

49.
Exertional Rhabdomyolysis
&
Acute renal failure in Marathon Runners
Strenuous exercise, including marathon running, can result in damage to
skeletal muscle cells, a process known as exertional rhabdomyolysis.
In most cases, this damage is resolved without consequence. However,
when the damage is profound, there is a release of muscle proteins into
the blood; one of these proteins, myoglobin, in high concentrations and
under certain conditions (such as dehydration and heat stress) can
precipitate in the kidneys, thereby resulting in acute renal failure.

50.
Although the marathon is a grueling physiological challenge, with
races sometimes run in hot and humid weather, acute renal failure
is relatively infrequent. From case reports, a high proportion of
marathon runners who developed acute renal failure had taken
analgesics, had a viral or bacterial infection, or a pre-existing
condition.
The rare cases of acute renal failure in marathon runners may be
a situation of the 'perfect storm' where there are several factors
(heat stress, dehydration, latent myopathy, non-steroidal anti-
inflammatory or other drug/analgesic use, and viral/bacterial
infection) that, in some combination, come together to result in
acute renal failure.
Exertional Rhabdomyolysis
&
Acute renal failure in Marathon Runners

51.
Rhabdo- Coca Cola Urine

52.
Rhabdo- Treatment Algorithm
Isotonic Saline
-Initial Resuscitation: 1-2 L/hr
-100-200 ml/hr (if hemolysis induced injury)
-Correct electrolyte abnormalities
-Avoid lactate and potassium containing
solutions
Titrate IVF UOP goal: 200-300ml/hr
Serial CK measurements
CK>5000
CK<5000 StopTreatment
Consideration For:
Forced alkaline diuresis
(e.g. lasix, mannitol)
Increases tubular flow and
increases pH to
prevent precipitation of myoglobin
in tubules
Hyperkalemia
calcium gluconate/ chloride,
insulin-dextrose, B2 agonists,
NaHCO3
if > 5,000 -> 50% chance of AKI

53.
Blood in Da Poo
 Bright red blood per rectum
 Hematochezia- not uncommon within 24 hours
 Marathon runners are frequently guiac positive
While running a race, about 80% of the
normal blood flow leaves the gut.
Many of these patients will be vomiting. Use your clinical
judgment. Are they distended? Do they look obstructed? Are they
persistently vomiting despite your treatments?
You don’t want to miss a cecal volvulus but you also can’t transport
everyone who is vomiting. Up to Eighty percent of marathon
runners will vomit by the end of the race.

54.
Ischemic Bowel
Marathon runners may have blood in da poop
 Shunt blood from your gut
 Bright red blood per rectum. This is common in marathon runners. Sixteen
percent of race participants will have hematochezia, or bloody diarrhea
within 24 to 48 hours of the race. This is normal. Eighty-five percent of
runners will be guaiac positive but it is not clinically significant.
 Unless they look like ischemic colitis with a tender abdomen and ill-
appearing, you don’t need to work it up further. Remember, these
patients are all going to look sick initially: they will be diaphoretic, pale,
dehydrated, etc.
Observe them to see if they continue to look ill.

55.
 This is thought to occur traditionally in the 25 to 35 year old age
range.These are endurance athletes.They will present with
symptoms of obstruction, such as acute abdomen, vomiting,
bloating, and toxic.
 The abdominal x-ray looks like a coffee bean. On x-ray Cecum
moves from RLQ to the LUQ.
This is a surgical emergency.
Cecal Volvulus

56.
Syncope While Running
 After the event is rarely anything serious
 Post Exertional Postural Hypotension
 Brady and vasodilated after event
 Exercise induced syncope is a 4 alarm fire
 Heat Stroke
 Hyponatremia
ion channelopathy
 Hypertrophic Cardiomyopathy
 EKG / EXAM
 Murmur increases with valsalva
 EKG high voltage, septal twave inversions

57.
The Collapsed Runner
If the patient is hyperthermic, you need to cool them. You
can use ice packs to the axilla or groin. Spray bottles with
tepid water can be used to passively cool them. Expose
the patient and remove the wet clothing to allow
evaporative cooling. Shivering can cause heat retention.
Make sure to check the glucose.
Hypothermic patients need to be exposed and dried off.
Wrap them in a towel or blanket. They need to be dry and
out of the wind.
If the patient is normothermic,
consider hyponatremia and hypoglycemia.

58.
Considerations for The
Collapsed Runner
 Arrythmyogenic Right Ventricular Dysplasia
 Long QT Syndrome
 Brugada Syndrome
 Coronary Artery Disease- especially Masters level
athletes over 50
 WPW

59.
The Collapsed Runner
Please Remember these are a 4 Alarm Fire!
Not Something that we can treat well on scene
They need to be transported to the hospital

60.
Myocardial Infarction
 Most common in middle-aged male runners
 May have vague or atypical presentation mimicking
other conditions like GERD or MSK pain
 A normal EKG in the medical tent is not reassuring as
ischemic changes may have not yet developed
 All angina should be considered unstable.
Please make sure they get an Aspirin

61.
Mi’s
 Cardiac biomarkers. Troponin will be elevated in many
of these patients. Look at the EKG and the patient, and
trend troponins if clinically indicated.
 Some of the patients will be having MIs. All of these
patients will have an elevated CK.

62.
Cardiac Arrest
 Incidence of SCA
 1 in 57,000 marathon runners
 Retrospective survey of marathon medical
directors
 Med Sci Sports Exerc. 2012 Apr 19.
 1 per 100,00 full marathon runners
 Race Associated Cardiac Arrest Event
Registry
 N Engl J Med. 2012 Jan 12;366(2):130-40
 1 per 50,000 marathon runners
 TCM and Marine Corp marathons 1976-1994
 J Am Coll Cardiol. 1996 Aug;28(2):428-31

63.
Location of Cardiac Arrest According to Race Quartile.
Cardiac Arrest Can Happen Anywhere on the Course.

64.
Thank You 
Questions?
You can contact me at:
troypenn@mac.com
951-544-5433