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CYCLING ILLNESS & INJURY

Mark Greve MD FACEP Clinical Asst Prof Emergency Medicine Warren Alpert School of Medicine Brown University Division of Sports Medicine Team MD Team Novonordisk 2

Medical Emergencies in Cycling Course

• Field Management of Competitive Cycling Injuries and Illness • Demographics • Mechanisms • Injury Patterns • Interventions • Collapsed Athlete 3

Event Injury Factors

Criterium Road Race Time Trial

Trigger

Other rider Obstacle Pedestrian Animal Motor Vehicle Other 4

Mechanism of Injury 5

Injury Location

Back/Neck+6%+ ! Neck!1.9%! Upper!Back!1.1%! Cranio'facial+5.7%+ Lower!Back!3.0%! Head!1.9%! Face!3.8%! Torso+5.6%+ ! Chest!5.2%! Upper+Extremity+31.6+%+ Abdomen!0.4%! Shoulder!13.6%! Upper!Arm!0.7%! Elbow!6.3%! Lower+Extremity+ Forearm!3.5%! 42.8%+ Hand/Wrist!7.5%! Pelvis/Hip!15.5%! Thigh!7.9%! ! Knee!14.8%! Lower!Leg!2.4%! Ankle!1.7%! Foot!0.5%!

! ! 6

Injury Type

Freq

Other

Concussion

Abrasion or laceration

Penetrating Trauma Freq

Ligament inj

Dislocation

Fracture

0 50 100 150 200 250 300 350 7

Traumatic Cycling Injuries

• Chest Trauma • Pneumo(hemo)thorax • Cardiac Tamponade • Tracheobronchial disruption • Traumatic Brain Inj • Maxillo-facial • Abdominal Injury • Soft Tissue Injury 8

Chest Trauma

• Penetrating vs. Blunt… • Aortic injury • Tension pneumothorax • Hemothorax with active bleeding • Pericardial tamponade • Tracheobronchial disruption 9

Pneumothorax

• Simple Pneumothorax • Tension Pneumothorax • Hemothorax 10

Cardiac Tamponade

• External forces on heart preventing filling. • Becks Triad 1. Low arterial pressure 2. Distended neck veins 3. Muffled heart sounds • Mediastinal Shift 11

Tracheobronchial disruption

• Blunt or Penetrating • Blunt- Most common near carina • - Think Upper Neck • Respiratory distress • Hemopytsis 12

CNS Trauma

• Mild TBI (13-15) • Moderate (9-12) • Severe (3-8) • Brain injury is a dynamic process • Questions? 1. Do they have a neurosurgical injury? 2. Can they safely continue? 13 Severe TBI

§ Severe TBI GCS < 8 § Primary Injury after resuscitation ú Damage from direct § Protocol driven mgmt trauma including blunt, penetrating, ú Early intubation acceleration, ú Rapid ACLS transport deceleration and ú Early CT scan rotational forces. ú Immediate evacuation of § Secondary Injury mass lesions ú Bimolecular and ú Meticulous ICU mgmt physiological cascade ú ú Hypotension

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Maxillo-facial Trauma

• Suction = Airway • Traumatized upper airway. • Potential CNS/C Spine Trauma 15 16 17

Abdominal Trauma

• Blunt • Spleen • Liver • Doudenal Hematoma • Pelvic • Penetrating • Fast Scan? • When is it an emergency? 18

Skin/Tissue

• Road Rash • Early and aggressive cleaning/ debridement • Topical Antibacterial • Dressing to race • During events • Joints? • Massive Hemorrhage • Vascular Injury 19

Staple a face? 20

Adapted from Malik S et al. Sports Collapsed Athlete Cardiology Essentials, part 2: The Collapsed Athlete. 2011, pages 141–161. Immobilize C-Spine

Absent/Unstable Stable Pulse and Pulse and Respirations Respirations

AED Normal Abnormal Shockable Mental Status Mental Status Rhythm? Collapse Collapse Test Blood Sugar, Temp, Sodium -in -post Yes No Exercise Exercise Trauma Hypo- Heat Hypo- Hypo- Seizure Trauma glycemia Stroke natremia thermia Cardiac Exercise- Tox Vfib/ Cardiac Resp. Associated CVA VTach Cause Collapse Cardiac Heat- Exhaustion Exhaustion

Illness- Fluid Passive CPR D50 Rapid Illness- Oral fluids Specific Restrict External Glucagon Cooling Transport Specific Elevate Treatment 3% Warming Treatment Legs 21

Cardiac Collapse in Athletes Etiology • Hypertrophic Cardiomyopathy 36%-46% • Coronary Artery Abnormalities 19% • Cardiac contusion • Arrhythmia inducing drugs, supplements etc… • Long QT Syndrome Intervention 1. EMS Activation, get electricity! (survival drops 5-10% every minute) 2. BLS Responder early CPR. Hands only, “Staying Alive” 3. Defibrillation 95% survival if within first minute Ø ACLS and Rapid Transport 22

Heat Related Illness

• Cramps-Fluids, Na+, Pickle Juice? • Heat -LOC with regained MS. • Heat Exhaustion-Cognitive changes but responsive. • Exertional § >40oC (104oF), Persisting Altered MS. Possible Sz, Dry? Tour of California 2013 Palm § Rapid Cooling Springs- 107OF § ABC § IV 23 /Anaphylaxis • Minor reaction • Rash • Swelling • Upper respiratory • Lower respiratory Ø Treat symptomatically (MDI, Anti- histamine, consider steroids) • Severe reaction • Not looking good- wheezing and swelling, tiring out, rash is extensive… Ø Steroids, anti-histamines, consider EMS • Anaphylaxis vs. Anaphylactic Shock

Ø Epi IM 0.4ml 1/1000, IV 0.4ml 1/10000 Ø High Dose Rapid Steroids

Ø Diphenhydramine (H2Blocker, glucagon)

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Exercise induced anaphylaxis

• Exercise Induced Anaphylaxis (EIA) and Food Dependant Exercise Induced Anaphylaxis (FDEIA) • Common triggers- Wheat, NSAIDS, Shellfish • 5% to 15% of all anaphylactic cases 25

Exercise induced bronchospasm

• An increase in airway osmolarity secondary to hyperventilation • Cold air exposure. 37.4% XC skiers -20% FEV1 • Symptoms- seasonal allergies • Poor Perceivers • Testing • Treatment • WADA Limit Albuterol 26

Hypoglycemia

• Glucose < 20 - Expect depression • Interventions in level consciousness with 1. Oral Sugar possible seizures. Death can occur 2. Glucagon without intervention 3. IV therapy • Glucose 20-40 – Typically will feel weak, nauseous. Often will have a 4. Epinephrine? headache, rapid heart rate and profuse sweating. Generally will have depressed level of consciousness • Glucose 40-60 –Typically will be conscious with milder symptoms. 27

Hyponatremia

• Exercise Associated Hyponatremia o Nausea and vomiting. Hyponatremia o Headache. o . • Over drinking, high Na o Loss of energy and loss, decreased kidney fatigue. output. o Restlessness and irritability. o Muscle weakness, spasms or cramps. • ? o Seizures. o . 28

Performance Enhancing Drugs

• Amphetamines • Epo • Insulin • Anabolics • Diuretics • Caffeine 29

Final Thoughts