Team Physician

see Team Physician: Consensus Statement.

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

• AOSSM concensus statement.
• www.ncaa.org
• Equipement: spine board, stretcher, equipement for helmet removal and the initiation and maintenance of cardiopulmonary resuscitation, telephone
• Sideline Medical Bag list.
• Griffen LY, JBJS 2005;87A;894

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