Medical Protocols -- Little Rock Marathon

Updated 3/2017-- all links removed as many are no longer active and it's easier than checking each one.

The Little Rock Marathon is in it's 6th year. The event this year takes place on Sunday March 2nd. I participated the first three years, finishing each year in less than 6 hours (as I once told Dr Val, I'm a not fast, more of a plodder). I walked/jogged the first year and then just walked the next two. Since then I have switched over to being part of the medical volunteer crew. My first year, I asked Dr Kent Davidson if there were any articles that I could read that would better prepare me. We both felt I would be okay with the blistered feet, the sprains, etc. So he gave me some information on exercise-associated collapse (see reference below). I kept the article and review it each year.

In addition, he gave me the Medical Protocols for the LR Marathon. These are Dr Davidson's guidelines for us. He has managed to recruit physicians, nurses, physical therapists (who do the muscle stretching and massages), EMT's and lay volunteers (who do some of the clerical work). It is a nice summary for anyone like me who volunteers, but is not in the sports medicine specialty.

EXERCISE-ASSOCIATED COLLAPSE (EAC)

Most common reason for treatment of runners in the medical tent following an endurance event. It is caused by blood pooling in the lower extremities at cessation of exercise with resultant hypotension and syncope. Collapse during the race usually implies some other cause, eg. cardiorespiratory, heat illness, or dehydration. May be exacerbated by dehydration or heat but these are not the primary problems.

Clinical Features:

• Mental status--lightheaded, dizzy, brief loss of consciousness
• Rectal temp--below 102.5 degrees Farenheit
• Blood pressure--Orthostatic hypotension, improving with recumbancy (within 30 minutes)
• Pulse--Tachycardia, improving with leg elevation
• Lab--Normal serum sodium and glucose

Treatment:

• Head down position on stretcher or cot with foot elevated 6 in
• Monitor BP and pulse (check every 15 minutes)
• Oral hydration
• Expect recovery in 15-30 minutes

Prevention:

• Appropriate cool-down -- continue moving (walking) after race
• Encourage those that feel faint to lie down with legs elevated

HEAT-ASSOCIATED ILLNESS:

Ranges from nausea/vomiting to heat stroke. Milder forms can be treated with use of water soaked towels to head and trunk, and oral hydration. Heatstroke represents a medical emergency. It is diagnosed via altered mental status (usually unconsciousness) and a rectal temperature higher than 106.7 degrees F. Requires immediate measures to decrease body temperature (immersion in ice water), IV fluids and transportation to emergency department.

Treatment Protocol:

• Assess rectal temperature on admission and every 15 minutes
• If rectal temp is greater than 104 with alteration of mental status, then cover athlete with towels and water or immerse and begin IV with NS.
• For heat stroke initiate the above measures and prepare to transport when rectal temp less than 104 and vital signs (VS) are stable.
• Offer oral fluids when athlete is able.
• Discontinue passive cooling when rectal temp less than 102.
• May discharge when temp has normalized, taking oral fluids, neurologic exam and cognitive function is normal.
• For residual symptoms, eg. CNS, vascular, renal -- transfer to emergency facility for evaluation.

EXERCISE-ASSOCIATED MUSCLE CRAMPING (EAMC):

EAMC is painful, spasmodic, involuntary contraction of skeletal muscles involved in exercise. Generalized cramping (including non-exercising muscle groups), especially if associated with confusion or unconsciousness is more likely due to a metabolic disturbance and is not EAMC. It should be managed as a medical emergency with transport to an emergency department. EAMC can be managed with oral or IV hydration and passive stretching. Dehydration and electrolyte disturbance may contribute to EAMC but IV fluid management is not necessarily required for resolution.

Treatment:

• Passive stretching
• Oral hydration
• Indications for IV fluid therapy

1. Athlete is unable to drink
2. Persistent cramping despite stretching and oral hydration
3. Signs of severe dehydration, eg. dry mucous membranes, sunken eyes, inability to spit, persistent hypotension and tachycardia

HYPONATREMIA:

More commonly seen in ultra-endurance races than in marathons. Primary cause in these events is overhydration with inadequate replacement of electrolytes lost through sweating. Consider this possibility in an endurance athlete with altered mental status and normal rectal temperature.

Clinical features:

• Alteration of mental status--uncoordination, lightheadedness, seizures, coma
• Edema of hand and fingers -- rings fitting tight, weight gain during race
• Serum sodium less than 130 mmol/L

Treatment:

• If alert and serum sodium is more than 130 mmol/L, moniter and await spontaneous diuresis. Do not give IV fluids.
• If serum sodium is less than 125 mmol/L and /or semi-comatose or comatose, transfer to emergency department. Treatment includes use of low dose diuretics and hypertonic saline.

INFECTION CONTROL MEASURES

• Towel used for cooling or wiping athletes must not be reused.
• Use Universal Precautions -- wear gloves
• Sharps containers and medical waste bags are to be used for contaminated materials
• Hand washing between patients.

Not mentioned in his handout, are the cold-related issues. We saw some of this last year. Several athletes came into the finish-line medical tent shivering uncontrollable and were found to have oral temps of 93-95 degree F. They were all alert and carried on appropriate conversations. We managed to warm them with space blankets and warm oral liquids (coffee, hot tea, etc) but found ourselves wishing we some space heaters. Still watching the weather reports here to try to "guess" what issues we will see this year.

REFERENCES
Exercise-Associated Collapse: Postural Hypertension, or Something Deadlier?; Dale B Speedy MD, Timothy D Noakes MD, Lucy-May Holtzhausen MBChB; The Physician and Sportsmedicine, Vol 31, No 3, March 2003
Marathon Racing & Medical Tips (Hyponatremia and Blister Care); Sports Injury Prevention Newsletter, Issue #2 (click on the PDF file)
Marathon Medicine by Dan Tunstall Pedoe; Royal Society of Medicine Press; 1 edition (2000)