17
DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM “We have won.” AND THEN HE DIED! Pheidippides: 490 BC

DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

  • Upload
    teige

  • View
    36

  • Download
    0

Embed Size (px)

DESCRIPTION

DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM. “We have won.”. Pheidippides: 490 BC. AND THEN HE DIED!. EXERTIONAL DISORDERS FOR DISCUSSION TONIGHT. CARDIAC ARREST/SUDDEN DEATH. Rare. Usually (but not exclusively) cardiac. - PowerPoint PPT Presentation

Citation preview

Page 1: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

DISORDERS OF PROLONGED EXERTION.Dr Chris Ellis M Sc, MRCGP, MFSEM

“We have

won.”

AND THEN HE DIED!

Pheidippides:490 BC

Page 2: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

SYSTEMIC LOCALISED SUDDEN DEATH

Cardiac arrest > 35yrs (post heart attack). Cardiac arrest < 35yrs (hereditary heart defect). Other medical disorders.

PHYSIOLOGICAL (Extreme variations of normal).

Exercise associated postural hypotension (EAPH). Exertional rise in temperature. Rhabdomyolysis (uncomplicated). Moderate weight loss (2-4%). Exertional low blood sugar/hypoglycaemia.

PATHOLOGICAL (Abnormal/disease states).

Exercise associated low sodium/hyponatraemia (EAH). Dehydration/raised sodium. Rhabdomyolysis with complications (ARF). Heatstroke.

Compartment syndrome. Stress fracture.

EXERTIONAL DISORDERS FOR DISCUSSION TONIGHT.

Page 3: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

CARDIAC ARREST/SUDDEN DEATH.

• Rare. • Usually (but not exclusively) cardiac.• When cardiac, cause usually governed by age:

Under 35 years-Inherited cardiac defect.

Marc-Vivien Foe (Deceased)

Over 35 years-Diseased arteries

Jimmy Fixx (Deceased)

Page 4: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

EXERCISE ASSOCIATED POSTURAL HYPOTENSION (EAPH). Commonest cause of post-exertional collapse, often over-treated and not recognised for what it is.

COLLAPSE: RULE OF THUMB

•Collapse shortly after finishing the race or a stage is usually EAPH if the runner finished symptom free.

•Collapse while running, or considerably after, is usually serious and needs medical assessment

Features:•Immediately on stopping activity•No prior symptoms•Rapid spontaneous recovery•No active treatment needed, just let lie and observe.

Page 5: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

EXERTIONAL RISE IN CORE TEMPERATURE IS COMMON, UN-NOTICED & USUALLY INNOCENT.

THIS IS NOT HEATSTROKE, THIS IS A NORMAL, BUT NOT UNIVERSAL, RESPONSE TO HEAT LOAD.

Byrne et al (2006). Data from Singapore 1/2M.

Page 6: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

RACE NO. CK(<200).

RACE NO. CK(<200).

RACE NO. CK(<200).

63 12,174 124 8,429 67 7,36542 4,756 135 30,243 126 29,837

145 7,528 49 17,097 80 14,6037 8,357 48 9,276 78 14,952

99 8,735 50 2,584 26 3,20954 5,536 44 3,897 37 9,90911 19,487 121 26,723 6 1,124

108 11,485 27 14,773 71 50,3475 19,790 132 7,147 127 13,547

56 3,902 40 13,169 84 3,501141 12,553 86 3,565 120 65,724

22 10,066 34 17,695 103 68,852150 26,345 31 4,925 122 14,738

90 6,346 75 15,029 55 13,86462 6,582 148 17,697 113 42,67094 7,711 130 2,354 21 27,277

144 3,644 29 25,671 20 1,499118 7,648 128 6,371 1 6,624101 2,924 38 6,765 109 8,060

41 9,171 2 2,800 81 132,64519 2,793 70 10,530 134 29,490

111 5,257 67 7,365 79 19,31052 13,309

RHABDOMYOLYSIS IS UNIVERSAL AND USUALLY INNOCENT.

Creatinine Kinase levels in 67 healthy WHWR 2009 finishers. Cuthill, Ellis & Panarelli.

Page 7: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

% WEIGHT CHANGE IN 66 HEALTHY 2009 WHWR FINISHERS.Cuthill, Ellis & Panarelli.

% Wt.change.

WEIGHT LOSS (2-4%): Normal and ? desirable.

Page 8: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

WHWR, 2009. SA Ironman Triathlon, 2001 & 2.

COMPARATIVE DATA FROM WHWR AND SA IRONMAN WEIGHT CHANGE v. PERFORMANCE.

Cuthill, Ellis, Panarelli & Sharwood.

WEIGHT LOSS: Statistically significant association with favourable performance.

Page 9: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

WEIGHT LOSS: Protective against hyponatraemia (EAH).Noakes et al, Pooled results from multiple ultras.

Page 10: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

EXERCISE ASSOCIATEDHYPONATRAEMIA (EAH).

David Rogers (Deceased), London Marathon, 2007

•EAH is low blood sodium.Sodium < 135.Cause is TOO much fluid, NOT lack of sodium.

•EAH symptoms. Mild: (sodium > 130).Severe: (sodium < 130)Confusion, fits, coma, death, others.

•EAH is real. Boston marathon study 13% runners, 0.5% critical. 9 known deaths worldwide. 4 known cases in WHWR since 2005.

•EAH risk factors. Drinking more than need, weight gain, female, slow pace, over 4 hour event, anti-inflammatory medication (NSAIDs).

•EAH is substantially avoidable.Drink by thirst. Avoid NSAIDs. Weight monitor during race.

•EAH has low incidence in NZ and SA.Where “keeping ahead” with fluids and “maintaining weight” are no longer advocated.

Page 11: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

WHWR, 2009.n=66

WSER, 2009.n=47

COMPARATIVE SODIUM LEVELS IN HEALTHY FINISHERS WHWR v. WSER, 2009.Cuthill, Ellis, Panarelli & Hew-Butler.

*

*Pre-race sodium, 131. NOT EAH.

WHWR, 2009.(from 66 finishers tested.)

•Asymptomatic Hyponatraemia (EAH) - Nil.•Asymptomatic Hypernatraemia - 4.

WSER, 2009.(from 47 finishers tested.)

•Asymptomatic Hyponatraemia (EAH) - 19.•Asymptomatic Hypernatraemia - Nil.

Page 12: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

• Generalised muscle breakdown and liberation of contents into body is universal and usually innocent.

• Occasionally becomes pathological (abnormal).

• Rhabdo symptoms.Muscle pain. Dark urine. Lack of urine. Lack of well-being.

• Rhabdo complications.Acute kidney (renal) failure (ARF), others, death.

• Rhabdo is real.Two cases of ARF from WHWR since 2005.

• Rhabdo prevention.Less preventable than EAH. Anti-inflammatories and viral illness are risk factors.Suspect early to minimise complications. Report : chocolate or reduced urine & excessive muscle pains.

Page 13: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

EXERTIONAL HEATSTROKEElevation of CORE temperature above 40 degrees, PLUS brain impairment.

• Exertional Heatstroke is NOT same as “hot”.Exercise can cause the core temperature to rise without symptoms or significance.

• Exertional Heatstroke is rare. Not seen so far in WHWR.

• Exertional Heatstroke symptoms are initially vague.Non-specific confusion/lack of well-being.

Mortality, once established, is high.

• Exertional Heatstroke causes.Abnormal overproduction of heat by muscles with which body can’t deal.

A combination of, exercise, inherited disposition and further unknown trigger.

• Exertional heatstroke prevention.Disposition if previous severe “heat reaction” to Anaesthetic or other prescribed or street drugs.

High suspicion needed. Treat early and aggressively and accept unneccessary treatment.

Page 14: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

ACUTE COMPARTMENT SYNDROME

Localised swelling of muscle group, usually of leg, within enclosed sinew (fascia), following injury or overuse and may be associated with constricting bandage or plaster cast.

This is an emergency and requires urgent surgical decompression.

Page 15: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

SITE % OF TOTAL

TIBIA 55

METATARSALS 23

FIBULA 14

Neck of Femur 4

Shaft of Femur 2

Pubic rami 2

Sacrum 0.1

Navicular

Cuboid

Patella

Sesamoids

Calcaneum

RUNNING INDUCED STRESS FRACTURES.Noakes T. (Lore of Running.)

Page 16: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

CONCLUSIONS

•Read and learn the guidelines (runners & crew).

•Drink by thirst.

•Avoid NSAIDs.

•Monitor weight.

•Heat exhaustion doesn’t exist.

•Diagnose dehydration cautiously.

•Take guidelines (& urine) if need medical help.

•Insist on blood tests.

•No iv fluids without sodium.

Page 17: DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM

THANK YOU & QUESTIONS