1. PAs and the Mass
Athlete Event: What to
Expect and How to Plan
for It.
Dennis Rivenburgh, MS, ATC, PA-C
Physician Assistant
Comprehensive Sports Concussion Program
The Sandra and Malcolm Berman
Brain & Spine Institute
Sinai Hospital Baltimore

2. Disclosures
I have no financial interest or affiliation with the
manufacturer or distributor of any medical
products, devices, or services.
I will not be discussing investigational or
unlabeled uses of products and/or devices.

3. Objectives
At the end of this session, participants will be able to:
List common injuries and illnesses involved with athletes
in mass events
Describe how to work to prevent injuries
Describe how to set up and provide appropriate medical
care and coverage.
Requirements for medical and non-medical personnel.

4. Scope of Services
Critical Care
First Aid and General Medical Problems
Special Problems

5. Medical Tent Location

6. Medical Tent Location

7. Medical Tent Setup
Cots for athletes to lie
on
Readily accessible
supplies
Minor injury area
Registration area

9. Clear Area outside
Medical Tent
No family member’s
in tent area
Security at the
entrance

10. Staffing
Medical Director Staff
MD, DO MD, DO, PA-C, NP,
DPM
Medical Coordinator
RN
MD, DO, PA-C, ATC,
RN ATC
Paramedics/EMT
Non-medical
5-10 medically trained and 4-6 non-medical per
1000 runners
Volunteers

11. Medical Aid Stations/Sites
Finish Line Site
Similar to Hospital ER
On Course Aid Station
Physician, PA, ARNP, RN,
Paramedic
Roving Medical Vehicles
Physicians, PA, ARNP, RN,
Paramedic
Bike Medics
Paramedics, ER
PA/ARNP/Physician

12. Finish Line Site
Triage Officer
Team Care
Physician/PA/ARNP
RN
Scribe
Nursing Students, PA Students, EMT

13. Volunteer Education
Important to educate medical team
Weather conditions
Site Supplies
Transport criteria
Local ED’s

14. Temperature and Humidity
Temperature and humidity can affect the performance and
safety of runners.
Warm temperatures and high humidity increase the
incidence of heat related injuries.
Back Flag: Extreme risk. WBGT in excess of 82-degrees
F. Event may be cancelled
Red Flag: High risk. WBGT between 73 – 82 degrees F.
Runners who are sensitive to heat or humidity should
consider not participating.
Yellow: Moderate risk. WBGT between 63 – 72 degrees
F.
Green: Low risk. WBGT below 63 degrees F.
This is a medical decision, not a race director decision

15. Volunteers
Liability Insurance
State Dependent
Should be provided by the race

16. Injury Management
0.1% to 20% of
runners seek
attention
Cardiovascular
deaths occur at any
distance
Maybe greater at
shorter distance

17. 2011 US Largest Race
Peachtree Road Race 10K, 55,077
Lilac Bloomsday Run 12K, 51,303
BolderBOULDER 10K, 49,213
ING New York City Marathon, 47,133
Bay to Breakers 12K, 43,954
Chicago Marathon, 35,755
Cooper River Bridge Run 10K, 34,789
Race for the Cure: DC 5K, 34,751 E
Ukrop's Monument Avenue 10K, 33,365
Rock 'n' Roll Las Vegas HMAR, 33,257

18. Runner Education
Web Site Instructions
Race Packet Instructions
Pre-Race athlete meeting
Mandatory at all Ironman Events
What to Include
Fluid demands
Identification/medical history
Weather Precautions
Aid stations sites/types

19. Incidence of Nontraumatic
Sudden Death in Athletes
Population Group Age distribution Incidence
Organized High High school/college aged 7.47:1,000,000/year M
school/college athletes 1.33:1,000,000/year F
US Air Force Recruits 17 to 28 years of age 1:735,000 per year
Rhode Island Joggers < 30 year of age 1:280,000 per year
Rhode Island Joggers 30 to 65 years of age 1:7,620 joggers per year
Marathon Runners Mean age 37 1:50,000 race finishersw

20. Cold, Hot, Salt
3 Critical Race Issues

21. Diagnosis of Hypothermia
Requires
1) High index of suspicion
2) Low-reading thermometer (down to 25°C)
At least 10cm into rectum
• Check for fecal cache
– Impaction will give a falsely elevated reading

22. Definition
• Core temperature <35º C (95º F)
• Mild: 32.1º C-35º C
• Moderate: 28º C-32º C
• Severe: <28º C

23. Hypothermia
Stages of Hypothermia Core Body Temperature Symptoms
98 – 96 Shivering
95 – 91 Intense Shivering, difficulty Speaking
90 – 86 Shivering decreases and is replaced by strong
muscular rigidity. Muscle coordination is affected and erratic or
jerky movements are produced. Thinking is less clear, general
comprehension is dulled, possible total amnesia. Generally able
to maintain the appearance of psychological contact with
surroundings.
85 – 81 Becomes irrational, loses contact with
environment, drifts into stuporous state. Muscular rigidity
continues. pulse and respirations are slow and cardiac
dysrhythmias may develop.
80 – 78 Loses consciousness and does not respond to
spoken words. Most reflexes cease to function. Heartbeat slows
further before cardiac arrest occurs.

24. Frequency
• 700 die annually from accidental primary
hypothermia
• Majority
– Urban setting due to environmental exposure
– Aggravated by homelessness, illicit drug use,
alcoholism, mental illness
• Minority
– Outdoor setting: hunters, swimmers, hikers,
etc.

25. Mortality
• Mild (32-35° C): No significant
morbidity/mortality
• Moderate (29° C-32° C): 21% mortality
• Severe (<28° C): Even higher mortality rate

26. Hypothermic Predisposing
Factors
• Impede circulation
– Dehydration, DM, Peripheral vascular disease,
tight clothes, tobacco
• Increase heat loss
– Burns, skin diseases, environment, alcohol/drugs,
infancy,
• Decrease heat production
– Endocrine failure, hypoadrenalism, hypoglycemia,
hypopituitarism, hypothyroidism, infancy, old age,
malnutrition
• Impair thermoregulation
– DM, Parkinson’s, spinal cord injuries, stroke

28. Answer

30. Answer

31. CNS in Hypothermia
• All organ systems affected
• <33°C: Abnormal brain activity
• 19°-20°C: EEG consistent with brain death

32. General Care
• Remove wet clothes
• Insulate victim from environment
• Don’t delay urgent procedures (e.g. intubation,
IVs)
• Remember: Because of rigidity of jaw and chest
wall, it may be next to impossible to intubate
orotracheally as well as to ventilate a patient.

33. Rewarming Techniques
• Passive external
• Active external
• Active internal (core)

34. Passive External Rewarming
• Usually adequate for mild hypothermia
• Place in warm environment
• Remove wet clothing
• Cover with blankets
• Rewarming rate: 0.5°C-1°C/hour

35. Pre-hospital Care
• Avoid needless sudden movements • Prophylactic (<30 °C) and
therapeutic bretylium
– Especially with cold-water
immersion – Treat life-threatening
arrhythmias only; the remainder
• Supine to avoid postural will self-correct with re-warming
hypotension
– Attempt defibrillation up to 3
• O2 times and no re-attempts until
• Monitors core temp reaches 30ºC
• CPR and intubation should not be – Magnesium sulfate: Helpful in
withheld if needed spontaneous resolution of v fib
• Trauma immobilization as needed • Reduce further heat loss
• Intense vasoconstriction at <30 °C • Begin re-warming
may make IV meds ineffective – Heat packs in axillae, groin, belly
• Lidocaine/atropine: ineffective • Intubate as needed; pre-oxygenate
• by 30-33ºC) first
• Resuscitate cold and dead to warm
and dead (at least by 30-33ºC)

36. Hyperthermia

37. Hyperthermia
Hyperthermia is an elevated body temperature
due to failed thermoregulation. Hyperthermia
occurs when the body produces or absorbs
more heat than it can dissipate. When the
elevated body temperatures are sufficiently high,
hyperthermia is a medical emergency and
requires immediate treatment to prevent
disability or death.

38. Classification
• Temperature Classification
• Core (rectal, esophageal, etc.)
• Normal
• 36.5–37.5 °C (97.7–99.5 °F)
• Hypothermia
• <35.0 °C (95.0 °F)
• Fever
• >37.5–38.3 °C (99.5–100.9 °F)
• Hyperthermia
• >37.5–38.3 °C (99.5–100.9 °F)
• Hyperpyrexia
• >40.0–41.5 °C (104–106.7 °F)
• Note: The difference between fever and hyperthermia is the mechanism.
• Hyperthermia is defined as a temperature greater than 37.5–38.3 °C (100–101
°F), depending on the reference, that occurs without a change in the body's
temperature set-point.

39. HYPOTHERMIA
• Every year in the U.S. between 600 and 700
people die of hypothermia.
hypothermia
• Every year in Arizona an average of 23 people
die of hypothermia.

40. Signs and symptoms
Hot, dry skin is a typical sign of hyperthermia. [8]
The skin may become red and hot as blood
vessels dilate in an attempt to increase heat
dissipation, sometimes leading to swollen lips.
An inability to cool the body through perspiration
causes the skin to feel dry.

41. Signs and symptoms
• Nausea
• Headaches
• Low Blood Pressure
• Fainting/Dizziness
• Confused or hostile
• tachycardia &
tachypnea
• Seizures
• Unconscious and
Death

42. Causes
Heat stroke
• environmental exposure to heat
– abnormally high body temperature.
• Non-exertional (classic)
• Exertional

43. Causes
• Other factors,
• drinking too little water,
• drinking alcohol
• Non-exertional
– young and the elderly.
• medications reduce vasodilation, sweating
• anticholinergic drugs,
• antihistamines,
• diuretics

44. Diagnosis
Hyperthermia is generally diagnosed in the
presence of an unexpectedly high body temperature
and a history that suggests hyperthermia instead of
a fever. Most commonly this means that the
elevated temperature has appeared in a person who
was working in a hot, humid environment (heat
stroke) or who was taking a drug for which
hyperthermia is a known side effect (drug-induced
hyperthermia). The presence of other signs and
symptoms related to hyperthermia syndromes, such
as the extrapyramidal symptoms that are
characteristic of neuroleptic malignant syndrome,
and the absence of signs and symptoms more
commonly related to infection-related fevers, are
also considered in making the diagnosis.

45. Prevention
Exposure limits to
heat stress are
usually set by indices
based on the wet bulb
globe temperature.

46. Treatment
• Treatment for hyperthermia depends on its
cause
– Mild hyperthemia
• drinking water and resting in a cool place
– body temperature is significantly elevated
• mechanical methods of cooling are used to remove
heat from the body
• bathtub of tepid or cool water (immersion method)

47. Treatment
– exertional heat stroke
• cool water immersion is the most effective cooling
technique
• body temperature reaches about 40°C
– MEDICAL EMERGENCY
• May Need intravenous hydration, gastric lavage
with iced saline, and even hemodialysis to cool the
blood.

48. Hyponatremia

49. Background information
• Most common electrolyte disorder.
• Frequency is higher in females, the elderly,
and in patients that are hospitalized.
•30% of depressed patients on SSRI
•

50. Medical and Physiological
Considerations in Triathlons
• US triathlons 1982-
1986 (>6000 athletes)
• Dehydration is most
frequent medical
encounter
• 27% hyponatremic
• IV Fluid
recommendations
Hiller DW, et al: The American Journal of Sports Medicine Vol 15 (2) 1987.

51. Intravenous Fluid Effect on
Recovery After Running a
Marathon
• 2.5 l of 2.5%
glucose/0.45% NaCl
solution
• 100 ml 0.9% NaCl
Solution
• No significant influence
on:
– Rate of total recovery
– Number of days with pain,
stiffness, appetite, sleep or
fatigue
Polak AA, et al: British Journal of Sports Medicine 1993; 27(3):205-8.
1991 Rotterdam Marathon

52. A Guide to Treating Ironman
Triathletes at the Finish Line
• Treatment by
necessity is most
often initiated in the
absence of a
diagnosis.
• All persons who
collapse after
exercise do not have
dehydration-induced
hyperthermia
Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8).

53. A Guideline to Treating Ironman
Triathletes at the Finish Line
• “The administration of IV fluids should not be an
automatic first response.”
• Indications for IV fluids:
– Significant dehydration causing cardiovascular
instability
– Cannot be effectively orally hydrated
– Unconscious with serum sodium >130mmol/L
Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8)

54. Elevate the Feet and Pelvis
Mayers LB, Noakes TD: The Physician and Sports Medicine 2000;28(8).

55. Hyponatremia in Distance
Athletes
Pulling the IV on the “Dehydration Myth”
• Moderate dehydration is not hazardous
• Diagnose, then treat
• Too much fluid can hurt – oral and IV
Noakes TD: Physician and Sports Medicine 2000;28(9).

56. Intravenous versus oral
rehydration during a brief period:
responses to subsequent
exercise in heat.
• No discernable advantage of IV over oral
• Oral hydration:
– Lower body temperatures
– Improved performance
– Decreased thirst
– Lower perceived exertion with subsequent
exercise
Casa DJ, et al: Med Sci Sports Exerc 2000;32(1):124-133.

57. IV for Exercise Associated
Muscle Cramps
• Dramatic improvement
with normal saline
– American Journal of Sports
Medicine 1999;27(5)
response to letter to the
editor
• Severe cramping usually
subsides after 2-3 hours
and 2-3 L of normal
saline.
– Eichner RE Curbing muscle
cramps: more than oranges
and bananas GSSI 2002

58. Serum electrolytes and hydration
status are not associated with
exercise associated muscle
cramping (EAMC) in distance
runners
• Small but statistically significant differences in
serum sodium and magnesium are too small to
be clinically significant.
• An alternate hypothesis to explain EAMC must
be sought.
Schwellnus, et al. Br J Sports Med. 2004;38;488-491.

59. Evaluation and Treatment of
Marathon Associated
Hyponatremia
• On-site sodium analysis
– Exercise Associated Hyponatremia (EAH)
Concensus Panel. 2005. Clin J Sports Med.
2005;15:208-213.
• 3% NaCl solution utilized in the field treatment
symptomatic hyponatremia
– Ayus C, Rarieff A, Moritz M. Treatment of
marathon associated hyponatremia. N Engl J
Med. 2005;353(4):427-428.

60. What did we learn?
• Most collapsed runners do not have
dehydration-induced hyperthermia
• Diagnosis before treatment
• There are indications for IV fluids
• Too much fluid can hurt
• Exercise associated muscle cramping etiology is
unclear
– But IV saline appears to help in some situations
• Measure sodium and field treatment

61. Ask for IV Guideline Help
• Compared notes with others
• American Medical Athletic
Association
• International Marathon Medical
Directors Association
• American College of Sports
Medicine
– Endurance Athlete Medicine
and Science
• American Medical Society of
Sports Medicine
• Develop intravenous guideline

62. Survey of Experts
• Do you give IV fluids after marathons?
• What do you use to determine if an athlete
receives IV fluids?
• What types of IV fluid do you use?
• Do you measure serum electrolytes?
• Is there anything else that might be helpful?

63. Survey Results (10 responses)
• 10/10 are prepared to give IV fluids
• 8/10 have IV fluid protocols
• 10/10 have 0.9% NaCl solution
• 9/10 have 3% NaCl solution
• 8/10 always measure Na prior to IV
– 1/10 measure depending upon presentation
– 1/10 never measured Na

64. IV Risk and Benefit
• Risks • Benefits
– Discomfort – Treat identifiable
conditions
– Tissue injury – Lessen the strain on
– Bleeding emergency and
hospital services
– Infection
– Training
– Embolization
– Worsening electrolyte imbalances
– Utilize resources

65. Medical Tent Expectations
• Parallel that of office
visits
• IV requests
• Request everything
available
• Similar treatment as
previous events
• Perception that more
is better
• Badge of honor

66. Why do we want to give IV?
• Treat an appropriate
diagnosis
• Believe it is the right
thing to do
• Want to help and do
not know how
• Show we are doing
something

67. Recommendations for IV Fluids
• Significant dehydration causing cardiovascular
instability
• Cannot be effectively orally hydrated
• Unconscious with serum sodium >130mmol/L
• Symptomatic Exercise-Associated Hyponatremia
with 3% NaCl
• Consider for resistant exercise associated
muscle cramping
• Recommend Sodium assessment prior to IV

68. Conclusions
• “First, do no harm”
• Diagnose first, treat
second
• Have clear indications
for interventions that
you do and do not
perform.