| Step 1: Identify athletes who require immediate EMS activation and initiate treatment |
- Assess responsiveness, airway, breathing, and circulation
- Activate EMS for athletes with one or more of the following:
- No responsiveness
- No respirations or agonal respirations
- No pulse or irregular pulse
| Initial interventions: - Call for help/activate EMS
- Initiate CPR
- Attach AED
- Manage per standard BLS/ACLS protocols
- Transfer to ED expeditiously
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| Step 2: Perform focused evaluation for life-threatening conditions requiring immediate intervention |
Focused history: - Site and timing of collapse (eg, mid-course – serious cause more likely; after finish line – EAPH more likely)
- Pre-collapse signs and symptoms (eg, chest pain, respiratory distress, seizure, diarrhea, vomiting)
- Known comorbidities (eg, asthma, diabetes, ischemic heart disease, hypertrophic cardiomyopathy) – information may be available from family, race registration database, notes on racing bib, or medical alert bracelet
- Measure vital signs, including rectal temperature IF altered mental status present
- Assess mental status
- Perform chest auscultation
- Assess skin and mucous membranes for hives, swollen lips or tongue, facial pallor, facial flushing with perioral pallor
- Fingerstick or serum glucose
- Serum sodium
- Hemoglobin
- ECG or rhythm strip
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| Step 3: Activate EMS if cardiac emergency suspected |
Clinical findings: - Collapse during exercise (mid-course)
- Deterioration of airway, breathing, circulation, mental status
| Initial interventions: - Initiate CPR as indicated
- Attach AED
- Manage per BLS/ACLS protocols
- Transfer to ED immediately
|
| Step 4: Initiate treatment for exertional heat stroke if identified |
Clinical findings: - Rectal temperature >40°C
- Altered sensorium
- Facial pallor
| Initial therapy: - Begin rapid cooling; ice water immersion if possible
- Secure airway if necessary
- Monitor patient and vital signs – including rectal temperature – closely
- Activate EMS; transfer to ED
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| Step 5: Initiate treatment for other life-threatening conditions and transport or monitor as indicated |
| Condition and suggestive clinical findings/risk factors | Initial therapy | Disposition and/or monitoring |
- Anaphylaxis
- Hives
- Swollen lips, tongue
- Wheezing
- Vomiting, diarrhea
| - Administer epinephrine IM
| - Activate EMS; transfer to ED
|
- Exercise associated hyponatremia
- Seizure preceded collapse
- Frequent stops for water at break stations; slow runner with prolonged time on course
- Signs may include: facial pallor; edematous hands and fingers
| - Administer 100 mL of 3% hypertonic saline IV
| - Activate EMS; transfer to ED
|
- Insulin shock (acute hypoglycemia)
- Poor intake of food/glucose before or during event
- Diabetic; insulin pump may be found
| - Provide oral simple-sugar snacks (if no aspiration risk), or IV dextrose if needed
| - Monitor fingerstick/serum glucose
- Discharge if clinically improving and meets criteria (see below); transfer to hospital if not improving
|
- Acute asthma exacerbation
- Wheezing; poor air flow
- Dry, hacking cough may be present
- Asthmatic; inhaler may be found
| - Administer albuterol via inhaler with spacer or nebulizer
| - Monitor RR, breathing, chest examination, mental status
- Discharge if improving steadily with treatment and meets criteria; transfer to hospital if not improving
|
- Hypothermia
- Rectal temperature <35°C
- Signs may include: uncontrolled shivering; altered mental status; sluggish movement
| - Remove all wet clothing
- Cover with warm blankets
- Perform active external rewarming if necessary and equipment available
- Avoid excessive or jarring movements
| - Monitor vital signs and mental status every 10 to 15 minutes
- Transfer to hospital if temperature not steadily increasing to normothermic or complications develop
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| Step 6: Initiate treatment for EAPH once life-threatening diagnoses ruled out |
| Interventions and monitoring | Response to treatment |
- Position with legs and pelvis above level of heart*
- Monitor vital signs and sensorium every 10 to 15 minutes until stable
- Offer oral fluids if sensorium is clear
| - Patients with EAPH typically show signs of recovery within 10 to 15 minutes
- If vital signs and sensorium are not improving after 15 minutes:
- Obtain point-of-care glucose and sodium (if not obtained previously)
- Administer isotonic saline IV at "keep vein open" rate pending results of point-of-care tests
- Treat exertional hyponatremia or hypoglycemia if warranted based on results of point-of-care tests
- Transfer to hospital if no significant improvement after 30 minutes of appropriate treatment
|
| Discharge criteria for EAPH and other benign conditions |
- Hemodynamic and clinical stability
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- Ambulatory without symptoms or need for assistance
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- Responsible adult to accompany patient
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