References

Almond CS, Shin AY, Fortescue EB Hyponatremia among runners in the Boston Marathon. N Engl J Med. 2005; 352:(15)1550-1556 https://doi.org/10.1056/NEJMoa043901

Anley C, Noakes T, Collins M, Schwellnus MP. A comparison of two treatment protocols in the management of exercise-associated postural hypotension: a randomised clinical trial. Br J Sports Med. 2011; 45:(14)1113-1118 https://doi.org/10.1136/bjsm.2010.071951

Asplund CA, O'Connor FG, Noakes TD. Exercise-associated collapse: an evidence-based review and primer for clinicians. Br J Sports Med. 2011; 45:(14)1157-1162 https://doi.org/10.1136/bjsports-2011-090378

Epstein Y, Yanovich R Heatstroke. N Engl J Med. 2019; 380:(25)2449-2459 https://doi.org/10.1056/NEJMra1810762

Filep EM, Murata Y, Endres BD, Kim G, Stearns RL, Casa DJ. Exertional heat stroke, modality cooling rate, and survival outcomes: a systematic review. Medicina (Kaunas). 2020; 56:(11) https://doi.org/10.3390/medicina56110589

Garcia CK, Renteria LI, Leite-Santos G, Leon LR, Laitano O. Exertional heat stroke: pathophysiology and risk factors. BMJ Med. 2022; 1:(1) https://doi.org/10.1136/bmjmed-2022-000239

Gaudio FG, Grissom CK. Cooling methods in heat stroke. J Emerg Med. 2016; 50:(4)607-616 https://doi.org/10.1016/j.jemermed.2015.09.014

Glace B, Murphy C. Severe hyponatremia develops in a runner following a half-marathon. JAAPA. 2008; 21:(6)27-29 https://doi.org/10.1097/01720610-200806000-00085

Hawes R, McMorran J, Vallis C. Exertional heat illness in half marathon runners: experiences of the Great North Run. Emerg Med J. 2010; 27:(11)866-867 https://doi.org/10.1136/emj.2010.090928

Hew-Butler T, Rosner MH, Fowkes-Godek S Statement of the 3rd International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Br J Sports Med. 2015; 49:(22)1432-1446 https://doi.org/10.1136/bjsports-2015-095004

Hew-Butler T, Loi V, Pani A, Rosner MH. Exercise-associated hyponatremia: 2017 update. Front Med (Lausanne). 2017; 4 https://doi.org/10.3389/fmed.2017.00021

Kerr ZY, Casa DJ, Marshall SW, Comstock RD. Epidemiology of exertional heat illness among US high school athletes. Am J Prev Med. 2013; 44:(1)8-14 https://doi.org/10.1016/j.amepre.2012.09.058

Kipps C, Sharma S, Tunstall Pedoe D. The incidence of exercise-associated hyponatraemia in the London marathon. Br J Sports Med. 2011; 45:(1)14-19 https://doi.org/10.1136/bjsm.2009.059535

Kruijt N, van den Bersselaar LR, Hopman MTE Exertional heat stroke and rhabdomyolysis: a medical record review and patient perspective on management and long-term symptoms. Sports Med Open. 2023; 9:(1) https://doi.org/10.1186/s40798-023-00570-y

Morrissey MC, Scarneo-Miller SE, Giersch GEW, Jardine JF, Casa DJ. Assessing the validity of aural thermometry for measuring internal temperature in patients with exertional heat stroke. J Athl Train. 2021; 56:(2)197-202 https://doi.org/10.4085/1062-6050-0449.19

Noakes TD, Sharwood K, Speedy D Three independent biological mechanisms cause exercise-associated hyponatremia: evidence from 2,135 weighed competitive athletic performances. Proc Natl Acad Sci U S A. 2005; 102:(51)18550-18555 https://doi.org/10.1073/pnas.0509096102

Noakes TD. Reduced peripheral resistance and other factors in marathon collapse. Sports Med. 2007; 37:(4–5)382-385 https://doi.org/10.2165/00007256-200737040-00028

O'Connor RE. Exercise-induced hyponatremia: causes, risks, prevention, and management. Cleve Clin J Med. 2006; 73:S13-S18 https://doi.org/10.3949/ccjm.73.suppl_3.s13

Périard JD, DeGroot D, Jay O. Exertional heat stroke in sport and the military: epidemiology and mitigation. Exp Physiol. 2022; 107:(10)1111-1121 https://doi.org/10.1113/EP090686

Roberts WO. A 12-yr profile of medical injury and illness for the Twin Cities Marathon. Med Sci Sports Exerc. 2000; 32:(9)1549-1555 https://doi.org/10.1097/00005768-200009000-00004

Scheer V, Hoffman MD. Exercise-associated hyponatremia: practical guide to its recognition, treatment and avoidance during prolonged exercise. German Journal of Sports Medicine. 2018; 311-318 https://doi.org/10.5960/dzsm.2018.349

Schwellnus M, Kipps C, Roberts WO Medical encounters (including injury and illness) at mass community-based endurance sports events: an international consensus statement on definitions and methods of data recording and reporting. Br J Sports Med. 2019; 53:(17)1048-1055 https://doi.org/10.1136/bjsports-2018-100092

Seal AD, Anastasiou CA, Skenderi KP Incidence of hyponatremia during a continuous 246-km ultramarathon running race. Front Nutr. 2019; 6 https://doi.org/10.3389/fnut.2019.00161

Seal AD, Kavouras SA. A review of risk factors and prevention strategies for exercise associated hyponatremia. Auton Neurosci. 2021; 238 https://doi.org/10.1016/j.autneu.2021.102930

Resuscitation Council UK. Adult advanced life support guidelines. 2021. https//www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines

Tunstall Pedoe DS. Marathon cardiac deaths: the London experience. Sports Med. 2007; 37:(4–5)448-450 https://doi.org/10.2165/00007256-200737040-00046

Walter E, Galloway R, Stacey M, Martin D, Roiz de sa D, Robertson B, Kipps K. Exertional Heat stroke: Faculty of Sport and Exercise medicine position statement. 2018;

Walter E, Steel K. Management of exertional heat stroke: a practical update for primary care physicians. Br J Gen Pract. 2018; 68:(668)153-154 https://doi.org/10.3399/bjgp18X695273

Whatmough S, Mears S, Kipps C. Serum sodium changes in marathon participants who use NSAIDs. BMJ Open Sport Exerc Med. 2018; 4:(1) https://doi.org/10.1136/bmjsem-2018-000364

Assessment and initial management of the collapsed endurance athlete

02 September 2023
Features
02 September 2023
Volume 15 · Issue 9

Abstract

Participation in endurance events such as marathons is increasingly popular. Those taking part in these events may collapse and require medical attention for a range of reasons, some of which are well known and recognised by prehospital providers. However, there are conditions that are specific to endurance exercise which may be less well known so potentially less likely to be recognised and managed appropriately. The most common cause of collapse in the endurance athlete is exercise-associated collapse. However, practitioners should be vigilant regarding life-threatening differentials such as exertional heatstroke and exercise-associated hyponatraemia, which are not uncommon. Identifying the cause of collapse in the endurance athlete is difficult as clinical presentations are often similar. The causes, symptoms and management of these conditions are discussed and a management algorithm proposed.

Participation in endurance events is popular, yet not without risk; a number of individuals will become ill with a fatality rate 0.4–3.3 per 100 000 entrants (Schwellnus et al, 2019). Endurance events such as running, cycling and triathlons present unique challenges to prehospital providers who may treat patients at these events when working either at the event or in their normal prehospital role in the area nearby.

In addition to illnesses such as cardiac arrest, arrhythmia and seizures that can be encountered, there are a number of conditions unique to endurance sports, which include exercise-associated collapse (EAC), exertional heatstroke and exercise-associated hyponatraemia (EAH).

Assessment and management of these patients can be difficult because of similarities in their initial clinical presentation and condition complexities. In this article, common causes of collapse unique to endurance sports medicine are discussed and an assessment framework is proposed for practitioners who may encounter these conditions. This proposed framework takes account of pathologies unique to sports medicine as well as other causes of collapse.

Subscribe to get full access to the Journal of Paramedic Practice

Thank you for visiting the Journal of Paramedic Practice and reading our archive of expert clinical content. If you would like to read more from the only journal dedicated to those working in emergency care, you can start your subscription today for just £48.

What's included

  • CPD Focus

  • Develop your career

  • Stay informed

Register
Or continue by

Signing in with your registered email address

Exercise
Runner
Collapse
Athlete
Heatstroke
Hyponatraemia