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Team Physician

see Team Physician: Consensus Statement.

Acute Mountain Sickness  
Anaphylaxis Hypothermia
Athlete's Heart Infectious mononucleosis
Bleeding  
Cardiac Eligibility Recommendations Marfan's Syndrome
Commotio Cordis MRSA
Concussion Pre Participation Exam
Diabetes Mellitis  
Down's Syndrome Sideline Preparedness
Emergency Bag (sideline bag) Sudden Cardiac Death
Exercise Induced Asthma / Bronchospasm  
Female Athlete  
Heat Stroke Tooth Avulsion
High-Altitude Cerebral Edema (HACE)  
Hypertrophic Cardiomyopathy  

Read: Griffin LY, JBJS 2005;87A:894

Acute Mountain Sickness (AMS)

  • Determinates: rate of ascent, absolute altitude, time at altitude, level of exertion, sleeping altitude.
  • Heights: generally occurs above 8000 ft, but can occur at lower altitudes especially in patients with comorbidities.
  • Symptoms: similar to hangover, headache, fatigue, weakness, dizziness, lightheaded, anorexia, nausea, vomiting, insomnia, difficulty sleeping. Generally developing with 6-10 hours of recent arrival to unacclimated altitude.
  • Severe AMS may demonstrate: ataxia, extreme lassitude, irritability, confusion, impaired judgement, disorientation.
  • End Stage = High-Altitude Cerebral Edema (HACE)generally occurs 12-72 hours at heights >12,000ft. Ataxia and altered consciousness.
  • Prevention: slow ascent, 2-3nights at 8,000 ft before higher ascent, limit change in sleeping altitude to <2,000ft once above 8,000ft, avoid overexertion, no alcohol, adequate hydration, avoid carbon monoxide from cooking in tents etc, carbohydrate rich diet, Ginko biloba 80-120mg po bid
  • Treatment: stop ascent and descend 500m, acetazolamide 250mg PO BID or 500mg SR QD(speeds acclimization), NSAIDs(headache), Promethazine(nausea), low-flow oxygen, Prochloperazine(augments hypoxic response). If symptoms do not improve within 12hours or worsen descent is mandatory.

High-Altitude Cerebral Edema (HACE)

  • Generally occurs after 12-72hours at heights above 12,000 ft.
  • Symptoms: ataxia and/or altered consciousness, severe lassitude, severe headache, nausea, vomiting, cognitive dysfunction, hallucinations, stupor, coma. May have hemiplegia, hemiparesis, CN palsy, SZ or other focal deficits.
  • Physical Exam: hypoxia, retinal hemorrhages, pallor, cyanosis, focal neuro deficits.
  • Prevention: slow ascent, 2-3nights at 8,000 ft before higher ascent, limit change in sleeping altitude to <2,000ft once above 8,000ft, avoid overexertion, no alcohol, adequate hydration, avoid carbon monoxide from cooking in tents etc, carbohydrate rich diet, Ginko biloba 80-120mg po bid
  • Treatment: immediate descent. Consider acetazolamide 250mg PO BID or 500mg SR QD. Dexamethasone 8mg po/im/iv

High-Altitude Pulmonary Edema (HAPE)

  • Generally occurs 24-72 hours at heights above 10,000 ft.
  • Symptoms: dry cough, decreased activity tolerance, fatuge, dyspnea, weakness, may develop blood-tinged cough.
  • Physical exam: tachycardia, tachypnea, hypoxia, cyanosis(lips, nails), audible rales, fever.
  • Xray: CXR demonstrates pulmonary edema.
  • Prevention: slow ascent, 2-3nights at 8,000 ft before higher ascent, limit change in sleeping altitude to <2,000ft once above 8,000ft, avoid overexertion, no alcohol, adequate hydration, avoid carbon monoxide from cooking in tents etc, carbohydrate rich diet,
  • Teatment: high-flow oxygen, immediate descent. Consider acetazolamide 250mg PO BID or 500mg SR QD,

Infectious mononucleosis

  • Most commonly college and high school age.
  • Febrile illness with pharyngitis, swollen glands, malaise, fatigue and splenomegally. Splenomegally predisposes patients to splenic rupture.
  • Athletes with mono may return to sports 4 weeks after the onset of symptoms provided the spleen (ultrasound) has returned to normal size. (Waninger KN, Clin J Sports Med 2005;15:410)

Bleeding

  • Athletes are responsible for reporting any active bleeding to the appropriate medical personnel.
  • Athletes may not participate until all active bleeding has stopped and been appropriately dressed.
  • Blood soaked clothing/equipement must be changed.

Down's Syndrome

  • Trisomy 21 chormosomal abnormality. Defective collagen, generalized laxity, poor muscle tone.
  • Flexible flat feet, joint subluxations, patellar instability, hip laxity, metatarsus primus varus, hallux valgus, scoliosis, poor muscle tone, Congenital heart disease(ventricular septal defect, mitral valve regurg, aortic regurg).
  • Risk of paralysis due to C1-C2 subluxation (annular ligament laxity).
  • Requires spine clearance with xrays before sports participation. Sports are contraindicated for: odontoid agenesis, odontoid hypoplasia, os odontoideum, >4.5mm odontoid/C1 arch.
  • Swimmers with atlantoaxial instability are restricted from starting on the blocks.

Diabetes Mellitis

  • Hypoglycemia: Glucose 50mL or 50% solution orally or glucagon 1mg IM/SQ
  • Diabetic ketoacidosis: glucose >250mg/dL; ketosis, hyperosmolar coma, possible death. Emergent transfer to ER for IV fluids and insulin IV drip with frequent potassium monitoring etc.
  • Contraindicated sports: rock climbing, scuba diving, hang gliding.

Sideline Preparedness

Sudden Cardiac Death

  • Risk factors: sudden death of family member <50y/o, family history of heart disease, exertional dyspnea/chest pain, unexplained syncope, excessive fatiguability, heart murmur, HTN (AHA, Circulation 1996;94:850).
  • Etiology: hypertrophic cariomyopathy 38%, coronary anomalies 19%, increased cardiac mass 10%,, ruptured aorta 5%, tunneled LAD 5%, aortic stenosis 4%, otheres (myocarditis, dilated C-M, ARVD, MVP, CAD, etc) (AHA, Circulation 1996;94:850).
  • Routine use of 12-lead EKG, echocardiography, or graded exercise testing not recommened for large populations of young or older athletes / PPE. (AHA, Circulation 1996;94:850).

Hypertrophic Cardiomyopathy

  • Autosommal dominant; affects 1/500
  • Ventricular septal wall symmetrically thickened.
  • PE: any diastolic murmur or late systolic murmur require cardiology consultation. Generally produces systolic murmur the decreases in supine position and increases with standing or valsalva.
  • Diagnosed with EKG or echo. EKG may be normal
  • Treatment: refer to cardiologist. No strenous sports.

Athlete's Heart

  • Abnormal but benign EKG changes affecting @40% of trained athletes.
  • EKG findings: sinus bradycardia, sinus pauses, sinus arrythmia, atrial or ventricular premature beats(AV block, 1st degree block, 2nd degree Wenckebach block, advanced AV block), Right/left ventricular hypertrophy by voltage criteria, St elevations, T wave changes.
  • Pelliccia A, Ciculation 2000:102:278.

Hypothermia

  • Core temp <95° F or 35° C. (91-95°F = mild; 88-90° F=moderate; <88° F=severe)
  • Best determined with rectal temperature.
  • Symptoms: shivering, metabolic acidosis, atrial/ventricular arrhymias, pathognomic J wave
  • Treatment: controlled rewarming (blankets, warm water, hot packs), consider internal active rewarming if in hospital, monitored setting.

Anaphylaxis

  • Etiololgy: idiopathic, isect sting, medications, food allergy, exercise, latex allergy
  • Symptoms: labored breathing, urticaria, hives, may have vascular collapse
  • Treatment:
    -Epinephrine 0.5ml of 1:1000 solution SQ/IM or 0.5ml of 1:10,000 solution IV
    -Diphenhydramine 10-50mg IM/IV
    -Immediate transfer to hospital

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