Ciguatera is a foodborne illness caused by eating certain reef fish whose flesh is contaminated with toxins originally produced by dinoflagellates such as Gambierdiscus toxicus which live in tropical and subtropical waters
Scombroid poisoning: Signs/symptoms?
Symptoms are allergic in nature from histamine, and are commonly the result of the spoiling of dark-fleshed fish (which then releases histamine into the flesh)
Bacteria have grown during improper storage of the dark meat of the fish and the bacteria produce scombroid toxin
Typical signs/symptoms of rhabdomyolysis in athletes
Increased muscle tone (secondary to muscle injury)
Typically normothermic and normotensive (unlike heat stroke)
What is the Athletic Female Triad?
Amenorrhea
Disordered eating (anorexia or bulimia)
Osteoporosis
Fifth disease: Signs/symptoms?
Characterized by a “slapped-cheek” appearance in children and arthralgias in adults (aka erythema infectiosum)
Cause: Parvovirus B19V associated with pure red-cell aplasia, particularly in patients with chronic immunosuppression or chronic hemolysis
What sign(s) imply pneumothorax in an acute asthma attack?
Patients who appear to be stable or improving and then experience sudden deterioration
Need to rule out in all unstable patients with asthma.
Samter's triad includes? (Cue: pulmonary)
Asthma
Aspirin sensitivity
Nasal polyps
What is "Sickling" in an athlete? Mechanism?
Collapse, cramping, or struggling in an athlete with sickle-cell trait
Mechanism:
High tissue temperatures,
Decreased O2 in the blood
Displaced O2 from HbS by lactic acidosis
Increased HbS by dehydration
Treating Sickling in an athlete
15 minutes of soaking in a cold tub (high tissue temp)
Receiving supplemental oxygen (dec O2)
Drinking fluids (dehydration)
Distinguishing Sickling from Heat Illness (Cramping)
Sickling: "slump to a stop" bc legs become too weak to hold up athlete
Heat cramping: "hobble to a halt" bc FULLY CONTRACTED mm no longer function
High Altitude Pulmonary Edema (HAPE) Signs and Symptoms?
HA
Tachypnea
Dry Cough
Decrease Exercise Performance
Dizziness
Fatigue
Peripheral & Central Cyanosis
Insomnia
GI disturbance
Late Signs: Bloody/pink sputum & Resp Distress
Regarding the heart, name a few structural or arrhythmogenic causes of a syncopal event during exercise
Prolonged QT interval
Heart block
Hypertrophic cardiomyopathy (and conditions like it)
Wolff-Parkinson-White (as well as other pre-excitation syndromes)
Best single prognostic indicator for sudden death in an athlete with hypertrophic cardiomyopathy (HOCM)?
Decrease in BP with exercise
Others:
History of multiple sudden deaths in the family
Nonsustained ventricular tachycardia
Marked left ventricular hypertrophy (> 3cm)
Resuscitation from sudden death
Name some PE findings seen in athletes with hypertrophy cardiomyopathy (HOCM)
Systolic ejection murmur which DECREASES with squatting (inc venous return) and fist clenching
INCREASES with standing and Valsalva maneuver (decreases venous return)
Name two drugs (or drug classes) that can increase the QT interval
Stimulants (and common cold meds)
Albuterol
Albuterol has been associated with which electrolyte imbalance?
Hypokalemia
Which anti-hypertensive drug class is preferred in athletes with HTN? Exception?
Angiotensin-receptor blockers and angiotensin-converting enzyme (ACE) inhibitors (meds ending in -pril)
Exceptions: Athlete with h/o cholinergic urticaria and HTN--increased risk for exercise-induced anaphylaxis 2' to increase bradykinins
Why is Diltiazem (and other nondihydropyridine calcium channel blockers) not used in ENDURANCE ATHLETES with HTN?
Negative inotropic and chronotropic effects
Why is Metoprolol (and other beta blockers) discouraged in athletes? Which sport forbids?
May suppress cardiovascular performance required for aerobic exercise
Athletes who participate in long-range riflery, beta blocks may confer an unfair advantage
Why are diuretics banned by the International Olympic Committee?
This class of drugs has the ability to hide the presence of androgenic steroids
Conditions/factors that increase risk for Primary Exertional HA?
Dehydration
Hot weather
High altitude
Also Women > Men; 20-30 yo, throbbing bilaterally
Most common cause of sudden cardiac arrest in the older (>35 yo) athlete (runner)?
Coronary artery disease
1:50,000 marathon runners
Most common cause of sudden cardiac arrest in the younger (<35 yo) athlete/runner?
Congenital cardiac defects
Tension Pneumothorax: Signs & Symptoms
Subcutaneous emphysema
Jugular venous distention
Absent or decreased breath sounds on the affected side
Pleuritic chest pain
Tachycardia
Progressive dyspnea
Cyanosis
Hyperresonance
Deviation of the trachea away from the affected side
Hypotension
Indications for needle thoracentesis in athlete with Tension Pneumothorax
Respiratory distress
An appropriate mechanism of injury
Typical physical findings (decrease breath sounds ipsilateral and tracheal deviation away from
Hemodynamic instability (hypotension)
A diagnosis of complex regional pain syndrome can be aided by obtaining a 3-phase bone scan. Of the following choices below, what diagnostic findings would be the most helpful?
a) Focal increased activity on bone scan
b) Diffuse increased activity with juxtaarticular accentuation uptake on the delayed images
c) Normal bone scan in late stage of syndrome
d) Phases 1 and 2 focal changes
b) Diffuse increased activity with juxtaarticular accentuation uptake on the delayed images
Update is typically diffuse; however, delayed images provide the most diffuse activity.
Patients with complex regional pain syndrome do not have focal increased activity.
What percentage of people with asthma have airways hyper-reactive to exercise AND are reported to have exercise-induced bronchoconstriction (EIB)?
a) 50% to 90% and 50%
b) 25% to 49%
c) >90%
d) 5%-20%
a) 50% to 90% and 50%
Hoagland’s criteria for diagnosing mononucleosis (four criteria):
Pharyngitis
Fever
Positive serologic markers
Lymphadenopathy
Heterophile and viral capsid antigen antibody tests are more sensitive than a complete blood count.
During the first week of illness, up to 25% of results from heterophile antibody tests will be negative.
Viral capsid antigen IgM may be ordered if a more sensitive diagnostic test is required, and itssensitivity rate is 97% (95%-99%) and its specificity rate is 94% (89%-99%).
Athletes participating in competitions who have documented asthma may benefit from which treatment to prevent bronchospasms induced by exercise (EIB)?
a) beta-adrenergic agonist
b) oral corticosteroids
c) inhaled corticosteroids
d) antihistamines
e) nasal steroids
a) beta-adrenergic agonist
What are Chilblains?
It is considered a mild form of a cold injury.
Condition characterized by localized inflammatory lesions that result from repetitive or acute exposure to cold.
Lesions are purple in color, edematous, and seen more often in young women than men.
A central area of pallor and anesthesia of the skin surrounded by edema characterizes a first-degree frostbite.
First, second and third degree cold injury (frostbite) characteristics:
First-degree: Central area of pallor and anesthesia surrounded by edema
Second-degree: Blisters with a clear milky fluid surrounded by edema and erythema
Third-degree: Differs from second-degree frostbite because the injury is deeper and the blisters are hemorrhagic.
Consuming alcohol predisposes a person to cold injury. Other risk factors include a prior cold injury, hand and arm exposure to vibration, and smoking. African-American women may be at increased risk of coldinjury.
Major vs. minor criteria for Marfan syndrome include the following:
Major:
Scoliosis > 20 degrees (>60% of patients)
Ectopia lentis (~50% of patients). Lens dislocation is usually superior and temporal and may present at birth or develop during childhood or adolescence
Aortic root dilatation involving the sinuses of Valsalva (70%-80% of patients). Manifests at an early age and is more common in men than women
Diastolic murmur over the aortic valve may be present
Dural ectasia (confirmed via computed tomography or magnetic resonance imaging) Frequently occurs in the lumbosacral spine
Minor:
High-arched palate
Erythema chronicum migrans is pathognomonic for
Lyme disease
Rash 6 cm in diameter on her abdomen that looks like an annular homogenous erythema with a central purpura
A 33-year-old woman who is a runner presents to you with questions about how to increase her running regimen for an upcoming marathon. She tells you that during the last 6 months she has only had 3 menstrual periods. You obtain a pregnancy test, and the results are negative.
What is the most likely etiology of her menstrual dysfunction?
a) Increased testosterone
b) Increased luteinizing hormone (LH)
c) Decreased gonadotropin-releasing hormone
d) Increased prolactin
c) Decreased gonadotropin-releasing hormone
Menstrual dysfunction induced by exercise that coincides with a loss of menses typically occurs due to loss of the LH surge, which is caused by a disruption in the pulsatile secretion of gonadotropin-releasing hormone.
The causative factors for this disruption are not yet known, but it has been linked to an energy deficit that disrupts normal brain function.
Increased levels of testosterone and prolactin are not related to exercise-induced menstrual dysfunction.
There will be a relative decrease in LH, not an increase in LH.
Per the Advanced Trauma Life Support guidelines, what is the estimated minimum systolic blood pressure with a palpable radial pulse?
a) 40 mm Hg
b) 100 mm Hg
c) 80 mm Hg
d) 120 mm Hg
c) 80 mm Hg
The Advanced Trauma Life Support guidelines say that blood pressures (systolic) can be predicted based on palpable pulses.
Femoral pulses of 60-70 mm Hg
Carotid pulses 70-80 mm Hg
Radial pulses above 80 mm Hg
Which statement is correct about commotio cordis?
a) Little league baseball requires batters children aged <12 years to use chest protectors.
b) The apparent mechanism for death is ventricular fibrillation induced by an abrupt blunt precordial blow during a specific period in the cardiac cycle.
c) A blow in the left area of the heart, baseballs thrown at 20 mph, and blunt impacts have more deadly outcomes in cases of commotio cordis.
d) More than 25% of people with commotio cordis will survive if given cardiac support and rapid defibrillation and automated external defibrillator maneuvers are used.
e) For ventricular fibrillation to occur and cause commotio cordis, the impact must occur within the QRS of the cardiac cycle.
b) The apparent mechanism for death is ventricular fibrillation induced by an abrupt blunt precordial blow during a specific period in the cardiac cycle.
Ventricular fibrillation is the mechanism of death in persons with commotio cordis. It is induced by a blunt precordial blow occurring in the up-slope of the T wave, causing sudden death in athletes.
Although there have been discussions about chest protectors among little league baseball, no requirements currently exist.
More deadly outcomes are associated with baseballs thrown at more than 40 mph as well as blows in the precordial area and the center of the chest.
Less than 10% of persons with commotio cordis survive despite automated external defibrillator maneuvers and rapid defibrillation.
Absolute indications to terminate an exercise test are:
Patient wants to stop the test
Moderate to severe angina
ST elevation >1 mm without diagnostic Q waves
Drop in systolic blood pressure of ≥10mm Hg from baseline during increase workload with other evidence of ischemia
Poor perfusion
Neurologic symptoms (eg, near syncope)
Inability to monitor electrocardiography readings or systolic blood pressure
Sustained ventricular tachycardia
What HR change (during/following exercise) is predictive of increased mortality?
A heart rate recovery pattern that is abnormal following exercise testing is important on a prognostic level because a heart rate change <12 beats/minute from peak to 2 minutes into recovery is predictive of all-cause mortality in 6 years.
A 22-year old tennis player from Italy presents to you after passing out during a college tennis tournament. He does not report any chest pain. You order electrocardiography, which reveals an incomplete right bundle branch block and T-wave inversions in leads V1-V3. His family history is significant for the death of his grandfather of a heart problem at a young age.
What should most concern you about sudden cardiac death in this patient?
a) Coronary artery disease
b) Hypertrophic cardiomyopathy
c) Prolonged QT syndrome
d) Arrhythmogenic right ventricular dysplasia
d) Arrhythmogenic right ventricular dysplasia
Most common cause of sudden death in young athletes in the US is HCM.
However, in the Veneto region of Italy the most common cause is arrhythmogenic right ventricular dysplasia (cardiomyopathy) (ARVC), followed by premature CAD and HCM was rare and a distant third.
Right ventricle becomes thin because it is replaced with adipose tissue.
Results on electrocardiography may reveal premature ventricular contractions, right and left bundle branch block, and inverted T waves in the precordial leads.
What is/are the issue(s) with Floroquinolones as related to Sports Medicine?
1) Associated with an increased risk of tendon injury/rupture
2) Can cause QT interval prolongation (greater than 460-480 ms) (prolonged QT syndrome)
Give two examples of Sulfonylureas:
Mechanism of Action (MOA):
Issues in Athletes
Glucotrol and Amaryl (DiaBeta is a 3rd)
MOA: Inc Insulin production by the pancreas
Issue: Long-acting, therefore dose adjustments are necessary for athletes
Two examples of Thiazolidinediones and MOA
Actos and Avandia
Lower Insulin Resistance
Second line agent
Example of a Biguanides, MOA, issue(s) in athletes?
Glucophage (Metformin)
Dec glucose production in Liver
Inc glucose uptake in Muscle
Dec Insulin resistance
Not assoc with Hypoglycemia
Rare lactic acidosis with dehydration in athletes
The anti-hypertensive medication least likely to affect training for an endurance athlete.
B. ACE Inhibitor
What class(es) of Anti-hypertensive is/are banned by many sports organizations? Which anti-hypertensive are therefore preferred/become first line agents?
Diuretics and Beta-blockers are banned
Preferred: ACE Inhibitors, Ca Channel Blockers and Angiotensin II receptor blockers (ARBs)
Ca channel blockers and ACE Inhib are usually preferred to ARBs
Why are ACE Inhibitors not the first choice anti-hypertensive agent for treating Htn in athletes?
MOA: Lower BP by causing vasodilation therefore reduce afterload
Why is Amlodipine (Ca channel blocker) a good choice in athletes?
MOA: Vasodilation, dec HR and contractility
Amlodipine has LOW chronotropic effects
Normal Sodium level on Chem 7 (basic metabolic panel? Hyponatremia?
Normal Na+ = 136-144 mmol/L
HypoNa+ = <135
A soccer player was struck in the eye and presents to the training asking about return to play. How many days do you have to hold from play and why?
4-7 days--this is the time frame for the most common risk of a re-bleed in a hyphema
What is a "flail chest"? How is it recognized? Why does it occur?
Paradoxical chest wall movement (moves inward with inspiration and outward with expiration)
Fracture of at least 3 consecutive ribs in two locations (free floating chest wall segment)
HIGH RATE OF INTERNAL INJURY
What is Tietze Syndrome?
A rare, inflammatory disorder characterized by chest pain and swelling of the cartilage of one or more of the upper ribs (costochondral junction).
Onset of pain may be gradual or sudden and may spread to affect the arms and/or shoulders.
What is Paget-von Schroetter Syndrome? Which vessels are most commonly involved?
Etiology? Presentation? Treatment? RTP?
Effort Thrombosis/Spontaneous Thrombosis of the Axillary or Subclavian Veins (UE DVT)
Typically follows strenous UE activity or Trauma
BEWARE OF PE (in > 1/3 of patients)
Presentation: Vasc Changes: Edema, cyanosis, distal venous engorgment and PAIN
Treatment: Emergent Thrombolysis and anti-coagulation
RTP ~ 3.5 mos
What is Subclavian Steal Syndrome?
Signs/Symptoms/Presentation?
Subclavian A. stenosis/occlusion proximally leads to a REVERSAL of blood DOWN the Vertebral A. to the arm (at the expense of the vertebrobasilar circulation)
Subclavian Insufficiency: Arm weakness, Paresthesias, Exertional Claudication
Provocative Maneuver: Exercise of UE-->Reproduction of Sx, Loss of RADIAL PULSE
What is Iliofemoral (Ext Iliac) Endofibrosis?
Etiology?
Presentation?
Treatment?
aka Cyclist's Arterial Disease as most commonly affects elite cyclists 20-30 yo
External Iliac A stenosis secondary to mechanical (hip flexion) and stress stress (high blood flow due to exercise), compression from psoas hypertrophy or inguinal ligament
Presentation: Unilat LE pain (15% Bilat), weakness during intense exercise, +/- thigh edema, paresthesias, progressive worsening
Diagnosis: ABI post-exercise, Duplex US post-exercise, MRA, Angiography
Treatment: Activity modification, PTBA (minimally invasive: percutaneous transluminal balloon angioplasty) or invasive surgery (resection, graft, endarterectomy)
What is the etiology of Popliteal Artery Entrapment Syndrome (PAES)?
Presentation, Diagnosis, Treatment.
Congenital: Fibromuscular anomalies in popliteal fossa
Functional: Physiological impingement of the Pop A due to exercise-induced increased blood flow and muscle hypertrophy (gastroc, soleus, plantaris, SM)
Presentation:
Calf claudication, exertional leg pain, paresthesias, exertional calf fatigue.
Often asymptomatic at rest
Usu unilateral (1/4 bilat)
Male > Female
Often < 30 yo
Decreased pulses with active DF/PF and knee extension and may have a post-exercise bruit
Treatment: Functional: Conservative (Relative rest, compression stockings, stretches, elevation), if refractory: surgery. Congenital: Surgery to release band compressing artery
Parameters/Measurements of Left Ventricular wall thickness in Athletic Heart vs. Hypertrophic Cardiomyopathy?
Other means of differentiating?
Athletic Heart: 13-15 mm (grey zone)
Hypertrophic Cardiomyopathy: 18-20 mm
Left Ventricular End Diastolic Diameter (LVEDD) Athletic > 55 mm; HCM < 45 mm
History-Fam Hx of SCD or HCM
A 19 yo basketball player has an episode of unexplained syncope during practice. He adamantly denies prior cardiac history and believes he was just dehydrated. Upon further questioning he admits that a cousin died suddenly at age 20 of cardiac causes. An EKG is obtained.
Which abnormality would be suggestive of right ventricular dysplagia (ARVD)?
E) T-wave inversion
Wolff Parkinson White: Diagnosis, Symptoms and Return to Play
Symptoms - Palpitations, Syncope, Dizziness
Diagnostics - EKG - delta wave c short PR interval and prolonged QRS
Treatment - RF Ablation for high risk pathways
RTP - 3 months after ablation
What is Brugada Syndrome?
Sodium ion channel disease (autosomal dominant)
Propensity for fatal ventricular arrhythmias
EKG - Partial RBBB c coved ST segment elevation
Risk - Most deaths occur at slow HR, often during sleep. Chronic intensive exercise increases vagal tone and therefore resting bradycardia. Exercise increases in core body temperature, a recognized trigger for SCD in Brugada
Rec/Tx - Abstain from chronic or prolonged intensive exercise. Consider ICD (survivors of aborted SCD, Sustained VT and Syncope)
Common EKG Findings in Athlete's Heart?
Sinus Bradycardia, early repolarization with ST elevation and peaked T-waves and voltage criteria for left ventricular hypertrophy
Swimmer presents with this lesion; what is it?
Molluscum Contagiosum
A pox virus associated with swimming pools
Highly contagious and appears to be spread by towels and kick boards (not the water)
RTP - No new lesions x 72 hrs, anti-virals x 120 hours, cover dried lesions
Wrestler presents with below rash on face; what is it?
Impetigo
A common bacterial infection caused by Staph pyogenes or Staph aureus
Highly contagious
Rx: Mupirocin (Bactroban) bid x 10 days, followed by oral Abx (Cephalexin or E-mycin) if lesions/rash persists.
RTP: After 72 hours of treatment and residual lesions (cannot be exudative or moist) covered
Wrestler presents with the rash shown below. Diagnosis? Treatment? RTP?
Tinea Corporis or Tinea Gladiatorum (Ringworm) a superficial fungal infection. Invades skin in a centrifugal pattern
Rx: A -cidal topical antifungal terbinafine (Lamisil) or naftifine (Naftin) or systemic therapy if disease is extensive. Hygeine is key to prevention
RTP: Must be treated for at least 72 hrs and covered before allowing return to wrestling
A rugby player presents to the medical tent with the below rash on his neck/face
Diagnosis? Treatment(s)? RTP?
Herpes Rugbeiorum (Scrum Pox) - contagious HSV infection spread by direct contact, infection facilitated by abrasive effects of facial stubble (hence name scrum pox). Stinging/burning sensation may be present before developing the vesicular lesions
RTP - No new lesions x 72 hrs, anti-virals x 120 hours, cover dried lesions
Treatments for H.pylori for PUD?
Triple therapy: 10-14 days Amoxicillin (1g bid), Clarithromycin (500mg bid), PPI
If fail, go to Quadruple therapy - Metronidazole, tetracycline, PPI, bismuth
Splenic Laceration presentation, imaging and RTP?
MOI - direct trauma to Left Upper Abd
Presentation - Sharp pain in LUQ initially, followed by dull left side/flank pain, Abd distension, +Kehr's sign (referral to left shoulder secondary to free intraperitoneal blood irritating diaphragm
RTP - >3 mos for non-surg cases; post-splenctomy once scar healed and can tolerate activity (as early as 3 wks)
Testicular Torsion vs Epididimitis
Workup of exercise-induced hematuria should be considered after how many hours of symptoms?
E) 72
An athlete presenting with flank pain, hematuria, and hypovolemic shock following blunt trauma should prompt which of the following?
B) IV hydration, surgical consultation, consideration for transfusion
The hypovolemic shock indicates a more serious renal trauma (class IV or V-more significant laceration and therefore warrants a much more aggressive intervention)
Cause(s) of Auricular Hematoma (cauliflower ear)? Treatment?
Shearing of the perichondrium from the cartilage of the ear
Treatment - Aspiration (acute and <2cm), I&D (acute and >2cm), if present >7 days referral. Splinting - Thermoplastic splint or compressive dressing
RTP - Non-contact - Immediately Contact - removal of compressive dressing and protective gear
Best Abx for Otitis Externa?
Usually caused by streptococcus, staphylococcus, or pseudomonas
Mild - Cipro HC (hydrocortisone) suspension
Moderate - Ciprofloxacin po
An athlete that is confronted with fever can have exercise performance impaired. Which of the following is NOT an effect that can be attributed to fever?
B) Decreased flexibility
For every degree above 37*C O2 consumption increases by 13%. Fever promotes dehydration and is detrimental to exercise performance
What's the risk of exercise when sick (fighting an infection and have a Fever)?
Myocarditis
Exercising in the acute phase of an illness may promote complications including myocarditis
Infection/Fever evoke a cytokine-medicated host response resulting in negative nitrogen balance, muscle protein degradation and deteriorated muscle function
Treatment options for URI keeping in mind NCAA and USADA restrictions?
Decongestants (except ephedrine) are allowed
Antihistamines are allowed (but can cause sedation)
URI and RTP
"The NECK CHECK"
If symptoms at Neck or Above - exercise x 10 mins - if worse STOP, if not may RTP
If symptoms BELOW the NECK or SYSTEMIC - rest until Sx resolve followed by gradual RTP
What are the Centor Criteria? Would are they used for?
Criteria to determine the likelihood of a bacterial infection in a sore throat
One point for eachHistory of Fever
Anterior Cervical Adenopathy
Tonsillar Exudates
Absence of a Cough
0-1 No testing, no Abx
2-4 Rapid Strep testing, Abx
4 Consider empiric Abx w/o testing
Mononucleosis is of concern in athletics secondary to the risk of splenic rupture. Which statement most accurately describes the criteria required for return to contact sports?
B) Contact sports should be considered only after three weeks from symptom onset and the athlete is clinically asymptomatic
Splenomegaly occurs in 50-100% of infected patients and peaks week 2-3
Imaging is UNRELIABLE to evaluate size in the absence of a baseline measurement
Incidence of splenic rupture is 0.1-0.2% and almost ALL occur in the first 3 weeks of illness
21 yo female track athlete presents for consultation after screening labs showed a hematocrit of 32. The most common cause of low hematocrit in athletes is?
C) Dilutional pseudoanemia
- Red cell mass is unchanged or even expanded in athletes
- Plasma volume expansion > RBC expansion
- Degree of expansion correlates with amount or intensity of exercise
- Plasma expansion occurs within 3 hours following acute exercise; will normalize in 3-5 days if training stops
- Will NOT affect MCV, Ferritin, RDW or haptoglobin
19 yo female nordic skier presents with fatigue and impaired ability to train. Lives at 4500' and trains at 7800' and reports NL menses. PE is WNL. Labs Hb=13.8, Hct=39, ferritin=19
Diagnosis?
Iron deficiency Anemia (low Hct, low ferritin, low serum Fe, low MCV (<80 - microcytic anemia), HIGH TIBC)
Ferritin NL>25µ/L
Hct NL for Females=34.9 to 44.5
Hb NL for Females=12.1 to 15.1 g/dl
Differentiating various types of anemia in athletes (via labs)
Haptoglobin is a protein present in blood serum that binds to and removes free hemoglobin from the bloodstream.
Thus it will be lower if there is an increase in hemoglobin in the bloodstream (from heel-strike hemolysis) in an attempt to clear it.
What is ECAST?
Exertional collapse associated with SCT (Sickle Cell Trait)
Mutation of ß-globin gene (chromosome 11q) GAG-->GTG
α2ß2 - Normal hemoglobin
α2ßS - Sickle Trait (heterozygote)
α2S2 - Sickle Cell Disease (homozygote)
Pathophys - O2 displaced from HbS with strenuous exercise, Lactic Acidosis, Increased tissue temperatures, Dehydration
Sickling leads to Vascular Obstruction --> Ischemic Rhabdomyolysis
ECAST risk factors
Heat
Altitude
Early Season (deconditioned athletes)
High intensity training
Presentation:
Muscle Pain and weakness but muscles look/feel normal (no cramping)
Athlete slumps to ground but usu can communicate (differs from cardiac arrest)
Tachypnea present (due to lactic acidosis) but can move air well (differs from acute asthma attack)
Rectal temp <103F (differs from heat stroke)
Most common injury(ies) sustained in school-aged children is/are?
Contusions and Strains
Adolescents - Overuse injuries more common (30-50%) than acute injury
What is the most common overload injury in adolescents?
Growth site injuries predominate with Osgood Schlatter disease most common
Difference between Peds and Adults with regard to...
Aerobic Capacity
Anaerobic Capacity
Metabolic costs of movement
Recovery from Concussion
Aerobic - Preadolescent capacity close to adult
Anaerobic - Less developed that adults and will not mature until puberty
Metabolic Costs - Higher in children (shorter stride length during running and greater inflexibility of antagonist muscle groups
Gender differences are virtually nonexistent in prepubescent athletes
Concussion - Incidence is lower in peds but recovery takes longer
Also - Speed, power and mass are lower in children
No difference noted in thermoregulatory responses (peds previously thought to have impaired thermoregulatory responses due to high ration of body surface to mass and diminished sweat capacity, but peds rely more on dry heat dissipation than on evaporative loss
Differentiating cholinergic urticaria from exercise-induced anaphylaxis (EIA)
Which does this woman have?
Cholinergic Urticaria
Cholinergic Urticaria - Predominantly skin findings, NO VASCULAR COLLAPSE
EIA - Systemic symptoms, Shock
A 39 yo recreational soccer player presents with rhinorrhea, sneezing, itchy throat and eyes. He denies fevers, chills or sick contacts, and otherwise feel well. You suspect allergic rhinitis. You recommend:
A) fexofenadine
Exercise and Rheumatoid Arthritis
What have clinical research shown? Beneficial or Detrimental?
Beneficial (RA and Juvenile RA) (however no proven benefit in JIA-juvenile idiopathic arthritis was noted with exercise)
Exercise can reduce pain, morning stiffness and fatigue. Can improve functional ability and psychological well-being
Studies have NOT demonstrated exacerbation of disease activity nor has it shown the ability to influence remission
Several studies have suggested risk of long term articular damage from activities that repetitively load the joints. Thus, should discourage high-impact loading activities.
What disease process is associated with these images?
Psoriatic Arthritis
Pauciarticular, asymmetric distribution
Assoc c Spondyloarthropathy, Enthesitis, Dactylitis (sausage fingers), nail abnormalities and Uveitis and Erosive "Pencil in Cup" changes on X-ray
Hallmark features of Reiter's Syndrome?
Reiter's Syndrome aka Reactive Arthritis
Arthritis following bacterial GI/GU infection
Hallmark: Asymmetric, oligoarthritis of LE assoc c conjunctivitis, urethritis and other articular/non-articular findings
M > F ages 20-40
What is Beck's Triad? What condition does it refer to?
Cardiac Tamponade
Hypotension
Jugular venous distenstion
Muffled heart sounds
What ECG abnormality(ies) are Floroquinolones associated with? What other sports/ortho related condition are they associated with?
ECG - prolonged QT syndrome (>460-480 msec)
Other Condition - Assoc c tendon injury (especially in pt > 50 and when combined with corticosteroids)
Drugs/agents ALWAYS prohibited (at ALL TIMES) by WADA
Anabolic Agents
Hormones
Beta-2-agonists
Hormone antagonists & modulators
Diuretics and Masking Agents
Enhancement of O2 transfer (Epo)
Chemical, physical and gene manipulators
Drugs/agents prohibited by WADA during/in competition
Stimulants
Narcotics
Cannabinoids
Glucocorticosteroids
WADA prohibited drugs/agents in particular sports
Alcohol
Beta-blockers
Which drugs/agents require a TUE (therapeutic use exemption)?
Beta-2-agonist
Insulin
Injected cortisone
Must be submitted 21 days prior to competition
Author
rsloan
ID
303757
Card Set
Sports Medicine Boards 2015
Description
General Medicine, Pulmonary, Cardiology, Ophthalmology, Rheum, GI
