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A Case of Running in Circles: Heat Stroke and Rhabdomyolysis in a Female Division I Track Athlete

Brian Babka, MD FACSMNorthwestern Medicine Orthopaedics

Catherine Brown, M.S.Ed, LAT, ATCNothern Illinois University

Relevant Disclosures

• Neither Catherine Brown nor I have any conflicts of interest to disclose

Objectives

• 1. Recognize the signs and symptoms of exertional rhabdomyolysis and describe medical follow up with appropriate healthcare providers and professionals.

• 2. Explain return to play protocols after exertional rhabdomyolysis

Present History and Initial Presentation

• 80 degrees and sunny with slight humidity

• Ins and Outs 400m workout; oyo rest pace

• Presentation during practice:

Deconditioned / winded

Extremely fatigued after workout

Staggering / unable to walk straight

• Symptoms

Dizziness

Confusion

Loss in motor function

Hyperventilation

Hypotension relative to the athlete

Past Medical History

• Sickle cell trait positive

• History of heart murmur

• Elevated blood pressures – followed by cardiology

• Renal insufficiency – followed by nephrology

• ADD

• Current medications:

Methylphenidate

Amlodipine

• 48 hours prior

Allergic Reaction to insect bite• OTC Benadryl

Non-specified eye infection• Prescribed amoxicillin

Initial Physical Exam

• Lethargic, unable to open eyes fully and focus

• Inability to support herself sitting up and unable to ambulate unassisted

• Skin was hot to touch and wet

• Excessively fatigued compared to workout intensity

• Vitals

BP: 120/50

HR: 180

Differential Diagnoses

• Heat exhaustion

• Heat stroke

• Sickle cell crisis

• Exertional hyponatremia

• Hypoglycemia

ATR Treatment Course

• Athlete placed on treatment table with feet elevated

• Supplemental oxygen

• Vital signs monitored

Every 5-10 minutes

• Ice bags placed on groin and axilla

• Rectal temp taken

104.7

• Athlete placed in cold whirlpool to begin rapid cooling while simultaneously activating EMS

ED Course

• Initial treatment

IV fluids

Monitor rectal temp until normal

Initial lab work• CK 371, troponin 2.83, creat 1.6, NA 141, (+) proteinuria

• Cardiac evaluation

ECG

Echocardiogram

• Admitted due to severe dehydration, repeat blood work, and follow CK levels

• Diagnosed with heat stroke resulting in rhabdomyolysis

Hospital Course

• Continued to improve with observation and IV fluids

• Repeat lab work

Next day: CK 2996, troponin 2.85, creat 1.38, NA 140

Hospital day 2: CK 1815, troponin 0.71, creat 0.94, NA 139

Discharge: CK 640, creat 0.88, NA 135, no proteinuria

Follow Up

• Care Team

Team Physician

Specialists• Cardiology

• cardiac stress test

• Nephrology

• Update nephrologist

• Assess kidney function

Athletic Trainer• Daily check-in

• Routine lab work at 2 months

CK levels 143

Creatinine 1.04

Urinalysis normal without proteinuria

Exertional Heat Related Illness

• Most often occur at temperatures >86° F, but can occur at any temperature with exertion

• 1.6 cases per 100,000 athletic exposures or 9000 cases annually in the US with highest rates occurring during football

Kerr ZY, Casa DJ, Marshall SW, Comstock RD. Epidemiology of exertional heat illness among US high school

athletes. Am J Prev Med. 2013; 14(4):8-14.

• Third leading causes of death in high school athletes Jardine DS. Heat illness and heat stroke. Pediatr Rev.2007; 28(7):249-258.)

Epidemiology

Epidemiology

• US Armed Forces 2017: 2163 cases of heat related illnesses and 464 cases of heat stroke

Incidence of 1.41 and 0.38 per 1000 person-years

Armed Forces Health Surveillance Bureau. Update: heat illness, active component, US Armed Forces, 2018. MSMR. 2018;25(4):6-10

• Rate of ED visits for heat related illnesses was 5 per 10,000 visits from 2006-2010 (n = 326,497)

75% heat exhaustion

5.4% heat stroke

12% admitted

0.7% mortality rate

Hess, et al. Summertime acute heat illness in US emergency departments from 2006-2010: analysis of a nationally representative sample. Environ Health Perspect. 2014;122(11):1209-1215.

•

Risk Factors

• Environmental exposure

strenuous exercise, exposure to high temperatures and/or humidity, lack of acclimatization, poor physical fitness, excessive clothing

• Metabolic demands

• Impaired cooling mechanism

Young and old, certain medications

• Medical conditions

Cardiac, congenital, sickle cell trait, recent or acute illness, previous heat injury, skin abnormalities

Exertional Heat Related Illnesses

• Mild:

heat edema

exercise associated muscle cramps

heat rash

• Moderate:

exercise associated collapse

heat exhaustion

• Severe:

heat stroke

Types

Rhabdomyolosis

• A syndrome characterized by muscle necrosis and the release of muscle constituents into the circulation

• Creatine kinase (CK) levels are typically markedly elevated

• Muscle pain and myoglobinuria often present

• Severity ranges from asymptomatic elevations in serum muscle enzymes to life threatening disease with acute enzyme elevations, electrolyte abnormalities, and acute kidney injury

Definition

Recognition

Early:

• Weakness

• Fatigue

• Headache

• Nausea

• Dizziness

Late:

• Imbalance

• Altered Mentation

• Confusion

• Irritability/aggression that is out of character

• Loss of consciousness

Signs and Symptoms

TreatmentAcute Algorithm

Treatment

• Immersion tub or kiddie pool

• Ice

• Bags for ice

• Cold towels and cooler

• Hydration: water, hoses, cooler, sports drink

• Tent or other shady area

• Rectal thermometer (continuous if possible)

• Glucometer

• Point of care electrolyte monitor (if not in a facility with lab capabilities)

Acute Setting

Rapid Cooling

• Should have a high degree of suspicion when environmental conditions and high risk patient/athlete

• Morbidity and mortality are directly related to the length of time required to cool the patient/athlete under 40oC/104oF Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO. American College of Sports Medicine

position stand: exertionalheat illness during training and competition.Med Sci Sports Exerc. 2007;39:556–572.

• Cooling should ideally be completed on site prior to transport

Best achieved with submersion ice bath • Belval L, et al. Consensus Statement- Prehospital Care of ExertionalHeat Stroke. PrehospitalEmergency Care.

2018; 22:3, 392-397.

Submersion ice bath cools .15-.24oC/minute compared to .04-.08oC/minute ice bags• Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO. American College of Sports

Medicine position stand: exertionalheat illness during training and competition. Med Sci Sports Exerc. 2007;39:556–572.

• If a patient arrives at a medical facility and hyperthermic, ice bath is still the most ideal way to achieve rapid cooling

• The patient/athlete can be removed from the ice bath once rectal temp

Sideline to Hospital/ED

Treatment

• Continue to hydrate orally

• Follow lab work until normalize

• No increased exposure to heat or exercise for minimum 7 days

• Utilize subspecialists when needed

Follow up

Return to Play After Exertional Rhabomyolysis

Schleich, et al/Univ. of Iowa proposed template to safely return athletes to play after exertional rhabdomyolysis

In Jan 2011, 10 members of an NCAA Div 1 football team were diagnosed and treated for exertional rhabdomyolysis- Smoot MK, et al. A cluster of exertional rhabdomyolysis affecting a Division I football team. Clin J Sport Med. 2013; 23 5: 365-372.

Successfully returned 10 Div I football players to play within 9 weeks of experiencing exertional rhabdomyolysis without recurrence of symptoms

Scleich et al. Return to Play After ExertionalRhabdomyolysis. J Athl Train. 2016 May; 51(5): 406-408.

University of Iowa RTP after Rhabdomyolysis

• 4 phase progressive return to play

Step 1:• Return to daily living activities for 2 wks.

• Monitor CK levels and serum creatinine via team physician

• Daily check in with ATC

• Sleep patterns, urine color, hydration, class attendance

Step 2:• Initiation of physical activity

• Foam rolling, dynamic warm-up, aquatic jogging, stretching



Step 3:• Daily check in with ATC


• Progression of physical activity

• Body weight resistance movements, resistance training w/ bands, core training, stationary bike

Step 4:• Initiation of resistance training 20%-25% 1RM



University of Iowa RTP after Rhabdomyolysis

NCAA Safety Summit

• The Second Safety in College Football Summit 2016

• 4th document recently published - Interassociation Recommendations: Preventing Catastrophic Injury and Death in Collegiate Athletes

Football has highest number of both traumatic and nontraumaticcatastrophic injuries of any collegiate sport• Since 1931 (first year of collected data), 94 traumatic fatalities and 127 nontraumatic fatalities

• Since 1960, 51 traumatic fatalities and 99 nontraumatic fatalities

• Since 1970 traumatic deaths undergone steep and steady decline

• Most fatalities in high school and college football continue to be from nontraumatic causes

Kucera KL et al. Annual survey of football injury research: 1931-2017. NCAA; Feb 16 2018.

NCAA Injury Prevention Recommendations

• Intense sustained non sport specific exertion that does not include appropriate work-to-rest ratios and without modifications for individual risk and precautions is too often the mechanism for exertion-related nontraumatic fatality

• Recommendation 3: Acclimatization and Conditioning

Training and conditioning should be introduced intentionally, gradually, and progressively• Especially important in the first 7 days of a new conditioning cycle

Collegiate athletes are especially vulnerable to exertional injuries during the first 4 days of transition periods• Data support modifications during this period can greatly reduce risk of catastrophic events

Eichner ER. Preventing exertional sickling deaths and probing team rhabdomyolysis outbreaks. Curr Sports Med Rep 2016; 15(3): 122-123.

All training and conditioning should be documented

Disciplinary system should be developed to coaches who fail to follow recommendations


• Recommendation 4: Emergency Action Plan for the following nontraumaticcatastrophic events

Cardiac arrest

Exertional heat stroke

Asthma

Exertional collapse associated with sickle cell trait

Any exertional or nonexertional collapse

Mental health emergency


• Recommendation 5: Responsibilities of Athletics Personnel

Physical activity should never be used for punitive purposes

All training and conditioning should be administered by personnel with demonstrated competency in the safe and effective development and implementation

• Necessary training to respond to emergency situations

NCAA bylaws in all three divisions require strength and conditioning coaches to have a strength and conditioning certification

Sports medicine staff have unchallengeable authority to cancel or modify workouts for health and safety reasons


• Recommendation 6: Education and Training

Institutions should adopt education and training requirements for athletics personnel

Education and training should occur annually

Including:• Foundational information regarding EAPs

• Head and neck injuries

• Cardiac events

• Environmental monitoring (heat, humidity, lightening)

• Exertional heat illnesses and heat stroke

• Exertional collapse associated with sickle cell trait

• Asthma

• Rhabdomyolysis

• Diabetic emergency

• Any exertional or nonexertional collapse

• Proper training principles and principles of periodization

Prevention

• Can be avoided or minimized

• Wet bulb globe device or mobile app (e.g. Weather FX) to estimate risk of heat related illness

• Strategies:

Acclimatization

Adequate hydration, frequent water breaks

Loose fitting light colored clothing

Avoid extreme environmental conditions

Scheduled rest and recovery

No punitive workouts

Education and preparation• Supervisory staff

• EAPs

• Practice

Wet Globe Awareness

Athlete Update

• She is doing well

• Back to competing without restrictions

• Scheduled follow up and compliance with her coexisting medical issues

Resources

• 1. Recognize to Recover: Environmental Conditions. USA Soccer Heat Guidelines. http://www.recognizetorecover.org/environmental/#environmental-conditions.

• 2. Korey Stringer Institute. Emergency Conditions: Heat Illness.

• 3. Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO. American College of Sports Medicine position stand: exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39:556–572.

• 4. Binkly HM, Beckett J, Casa DJ, Kleiner DM, Plummer PE. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training, 2002;37(3):329-343

http://www.recognizetorecover.org/environmental/#environmental-conditions

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