2014 CORK CITY MARATHON
CIAN O’BRIEN
OVERVIEW
Cork City Marathon Overview
Case Studies
Research
Event Medical Plan
WHAT IS A MARATHON? It is named after the Greek Battle of Marathon
After the Greeks were victorious over the Persians at the Battle of Marathon, they sent a runner to Athens with the news
The runner, ran the entire distance to Athens without stopping, announced the victory, and then dropped dead, due to the physical stress on his body
A marathon is an endurance foot race which covers 26 miles, 385 yards (42.2 kilometers)
CORK CITY MARATHON
Full Marathon
• 26 miles 385 yards/42.195 km• Full Association of International Marathons and Distances
Races
Half Marathon
• 21.1 km
Relay Event
Youth Team Relay
• Open to all 2nd level students who will be aged 16 years or older on 2nd June 2014.
THE PHYSIOLOGY OF MARATHON RUNNING
• Running a marathon has been viewed, and still is by many, as too extreme to be healthy.
• Physical stress of running a marathon played some role in not holding a women's Olympic marathon race until 1984
• It should be respected for the physiological stress inflicted over its 26.2 miles
Running a five-minute-per-mile marathon requires a
15-fold increase in energy production for over two hours
Runners who finish in over four hours maintain a
10-fold increase in their metabolism
Extended energy demands require the cardio, respiratory, endocrine, and neuromuscular systems to operate at an elevated level for an inordinate length of time
DIFFERENTIAL DIAGNOSISABDOMINAL PAIN
CASE STUDY 1John O Sullivan 39 year old
Bib Number 5025 (Full Marathon event)
Mile Marker – 14
Alerted by marathon volunteers
Chief Complaint – Disorientated
Vitals Signs
HR – 145 regular
BR – 34 fast
SP02 – 94%
1 2
3
FINAL DIAGNOSIS IN MEDICAL CENTRE
HYPERTHERMIA
HYPERTHERMIA• The heart helps control body temperature by pumping warm
blood to the skin where body heat is lost through the evaporation of sweat
• During a marathon, heat loss and production can increase over 10-fold
• High humidity and dehydration can make heat loss more difficult
• High humidity levels reduce evaporation, while dehydration impairs the ability to transfer heat from the muscles to the skin
• Either situation will increase body temperature and the risk for heat problems
HYPERTHERMIA• Muscle weakness and disorientation can develop with body
temperatures of 40 degrees Celsius,
• A loss of consciousness can occur with body temperatures near 41.5 degrees Celsius
HYPERTHERMIA• Hyperthermia, during marathon running can be due to
• Climate,• Dehydration, • High metabolic rate from running a faster-than-usual pace
• Marathon runners may overdress or not remove layers or clothing as the air temperature rises over the course of the marathon
HYPERTHERMIA
• The average sweat rate for runners is 1.2 liters per hour
• Most runners either can't tolerate drinking that much or choose not to drink that much liquid
• Typically, runners drink as little as 200 milliliters per hour but rarely more than 1 liter per hour
• Therefore, it is not uncommon for runners to lose 2 to 10 % of their body weight through sweating
HYPERTHERMIA
• Towards the end of a marathon, when the speed and effort of running increase, the body becomes less efficient at using energy, which produces more excess heat, which in turn drives the body temperature even higher
CASE STUDY 2
Ann Aherne 27 years oldMile Marker 10.5Bib Number 1141 (Half Marathon Event)Alerted by marathon volunteersChief Complaint: disoriented, vomiting
Vital SignsHR 168 regularBR: 28 fast & ShallowSP02 – 93%Temp – 37.8
1 2
3
FINAL DIAGNOSIS IN MEDICAL CENTRE
HYPONATREMIA
Exercise-Associated
HYPONATREMIA
• A low sodium concentration in the blood
• <135mmol/L• Sodium is an electrolyte that helps with nerve and muscle
function, and also helps to maintain BP.
HYDRATION STRATEGIES
HYPONATREMIA• The major cause of hyponatremia = is drinking too much
water, which dilutes sodium levels in the blood
• Low sodium levels cause swelling or edema in the brain, which can be fatal
Davis et al. (2001) found 26 cases of hyponatremia in over 34,000 runners from the 1998 and 1999 San Diego Rock 'n' Roll
Marathon
• They found that hyponatremia was
• greater in women• slower runners (those who finish in over four hours)
• NSAIDs
Why women? • Less water can dilute sodium levels in
smaller bodies
• Estrogen can further contribute to brain swelling once it starts
Why slow runners? • Slower runners are at a greater risk simply
because they have more time during a marathon to drink too much water
Why NSAIDs?• NSAIDs increase the effect of ADH
Which increases water retention
• Hyponatremia can develop after completion of a marathon when
• Hormonal changes cause increases in absorption of water• Sodium lost in the urine
DIAGNOSIS & TREATMENT
CASE STUDY 3
Sean Lynch 64 years old Bib Number 18978Mile Marker: Finish Line (Full Marathon)Chief Complaint: Disorientated, Shivering & Generally unwell
Vital Signs HR – 68 regularBR – 24 shallow SP02 – un-recordable
1 2
3
FINAL DIAGNOSIS IN MEDICAL CENTRE
Hypothermia
• Hypothermia can be the main environmental concern for marathon runners
• The risk for hypothermia is greater in cold, windy, or wet weather
• If the second half of the marathon is run slower than the first half, not enough heat may be generated to maintain body temperature
• Any sweat that builds up can saturate clothing, which will draw additional heat away from the body
CASE STUDY 4
Sarah Boylan 21 years old
Bib Number: 705
Mile Marker: 18 (Relay Event Change Over Point)
Chief Complaint: Generally unwell, disorientated, nausea, sweating, combatative
Vital Signs
HR – 102 irregular & weak
BR – 34 shallow & fast
SP02 – 92%
1 2
3
FINAL DIAGNOSIS IN MEDICAL CENTRE
Hypoglycaemia
• A blood sugar level <4.0mmol/L
• The brain prefers glucose as its fuel
• Hypoglycemia impairs brain functions
• May occur in Diabetic, or non diabetic runners when not enough carbohydrates are consumed during the race
GLYCOGEN DEPLETION• Carbohydrates provide energy to the muscles faster than fats
• Inside the body, carbohydrates are found as glycogen in the muscles and liver and as glucose in the blood
• As the amount of glucose in the blood is used up, the liver converts its glycogen into glucose and releases it into the bloodstream to maintain a constant supply of glucose to the muscles
Signs & Symptoms may include,
• Altered mental state,
• Sweating,
• Fatigue,
• Tachycardia,
• Palpitations,
• Hunger,
• Headache
• Slurred speech.
• (Medical alert tag)
Treatment?
INJURY
30,000 - 50,000
steps to run a marathon
Every time the foot hits the ground, a stress three to four times body weight is absorbed by the ankles, knees, hips, and lower back
INJURY EPIDEMIOLOGY
Most common being knee pain, hamstring problems,
dehydration, blisters
The injury rate from 12 years of the Twin Cities Marathon was 2.1 percent of all runners (21.15 per 1,000 entrants), with the top five injuries being:
Exercise-associated collapse 59.4 %
Blisters - 19.9 %
Muscle strain - 14.3 %
Muscle cramps - 6.1 %
Skin abrasions - 1.9 %
BLISTERS – 19.9%
MUSCLE STRAINS – 14.3%
FACTORS THAT INCREASE RISK OF INJURY• 1st marathon
• Participation in other sports
• Illness 2/52 prior
• Current use of medication
• Training mileage
Runners who train less than 60 kilometers per week were more likely to become injured while running a marathon
Higher levels of training have been shown to decrease the risk for knee injuries but increase the risk of injury to the quadriceps and hamstrings during a marathon
ELITE RUNNERS
ELITE RUNNERS
Copenhagen Marathon found the most common problem in elite runners was:
Gastrointestinal (GI) distress - 26 %
Back or joint pain - 20 %,
Muscle cramps -16 %
Blisters and other skin lesions - 16 %
Elite runners who suffer from GI distress secrete higher levels of GI hormones or consume higher amounts of NSAIDs
CASE STUDY 4• Paul Ahern 37 years old
• Bib Number 234
• Mile Marker 19
• Chief Complaint – Collapse/unresponsive
• Agonal breathing, can’t located pulse
• AMPLE – not available
1 2
3
CARDIAC ARREST
How common is it really?
✖ ✔
EXERCISE-ASSOCIATE COLLAPSE
• A collapse in conscious runners who are unable to stand or walk unaided, as a result of dizziness, faintness or light headedness.
• This collapse usually occurs after a runner stops exercising
EXERCISE ASSOCIATED COLLAPSE• This happens because during exercise the muscles of the
lower limbs require an increased blood flow. These muscles then act like a ‘second heart’ ensuring that this blood is returned to the heart assisted by the contraction of the leg muscles.
• When a runner suddenly stops exercising (e.g. finish line) the body’s ‘second heart’ stops functioning and blood pools in the legs, inducing exercise associated collapse.
EXERCISE ASSOCIATED COLLAPSE• EAC is the most common condition seen at finish line medical
tents
• Signs & Symptoms of EAC include:
• Abnormal body temp• Altered mental state, • Altered LOC, • CNS changes• Ambulation problems• Muscle spasms• Tachycardia• Vomiting/Diarrhoea
• Before treating EAC attention must be focused on ruling out other causes of collapse by performing:
• Vital Signs• BSL • ECG• Blood tests• Rectal Temp • AMPLE history
• Treatment of EAC involves fluid redistribution and replacement in the body to improve cerebral and vital organ perfusion.
• The redistribution of blood in the body is assisted by the positioning of the patient.
• With symptoms improving in 5-30 minutes.
• Trendelenburg Position
DISCHARGE CRITERIA FOR RUNNERS
Normal Mental Status/ GCS 15/15
‘Normal’ Vital Signs
Ability to mobilise
Carry out a ‘sit-test’
Warm dry clothing
Discharged to a responsible adult
Diet and hydration advice and ED/GP follow as required
OTHER RUNNING INJURIES TO CONSIDER
Runners Nipple
Stress Fractures
Sprains & Strains RICE
Lung Injury
Exercise Associated Muscle Cramps
Blisters/Cuts/Grazes
MARATHON FIELD HOSPITAL
WHERE WE’VE COME FROM?
WHERE WE ARE GOING…• Following international best practice we will continue to
develop the service we provide.
• Carrying out Research
• Providing Evidence Based Practice
• Looking outside the box.
• Becoming affiliated with the International Marathon Medical Directors Association.
RESEARCHER – CIAN O’BRIEN
The Epidemiology of Illness and Injury at the 2014 Cork City Marathon (O’Brien et al, 2015)
Questions?
Nothing too hard, please!
MEDICAL EVENT PLAN
QUESTIONS