1. Vanderbilt Sports Medicine Urban Adventure for a Young Ultra-marathoner Rachel Biber Brewer, MD Primary Care Sports Medicine Fellow Vanderbilt University Medical Center Nashville, Tennessee February 5, 2011

2. Vanderbilt Sports Medicine Case Presentation, History JS is 19 year-old runner and college freshman presenting to the ED via EMS due to a chief complaint of generalized weakness, vomiting, and headache. He stated he felt like his “head was going to explode.” He recently moved into the dorm while starting college 4 days earlier.

3. Vanderbilt Sports Medicine History, continued In his hometown 7 days prior to presentation, he was running on the road and was struck by a car. He was thrown 25 feet and briefly lost consciousness. He was evaluated at an outside ED and released.

4. Vanderbilt Sports Medicine History, continued He has not run in the interim and returns because of excessive weakness, increasing headaches, nausea, vomiting, intermittent vertigo and blurred vision.

5. Vanderbilt Sports Medicine Past Medical History Medical History – Healthy Social History – College freshman – Ran cross-country in HS and progressed to marathons and ultras Medications/EtOH/Drug Use – None

6. Vanderbilt Sports Medicine Training/Nutrition History Training for his second 50k. He reports drinking 5-10 liters of water per day. He has not run over the past week (after initial injury) but continues to maintain the same hydration habits.

7. Vanderbilt Sports Medicine Physical Exam Vitals: normal with exception of BP elevated, 138/82 General: AAOx3, appears fatigued, NAD HEENT: small posterior scalp wound; PERRLA; left scleral hemorrhage, no nystagmus, normal visual acuity CV/Resp: normal GI: normal Musculoskeletal: left ankle lateral abrasion; bilateral hand edema Neuro: CN 2-12 intact; 5/5 motor strength upper/lower extremities; sensory intact to light touch

8. Vanderbilt Sports Medicine Differential Diagnosis Traumatic brain injury Hyponatremia Drug overdose Alcohol intoxication Adrenal insufficiency

9. Vanderbilt Sports Medicine Questions?

10. Vanderbilt Sports Medicine Imaging

11. Vanderbilt Sports Medicine

12. 4/25/2015Footer

13. Vanderbilt Sports Medicine Labs BMP: Na 119, K 3.1, Cl 88, CO2 26, BUN 7, Cr 0.53, Gluc 88 CPK: 186 Serum Osmolality: 241 mosm/kgH20 Urine: Osmolality 330 mosm/kgH20, K 10, Na 117 Drug Screen: Negative Thyroid studies: normal Cortisol stim test: normal

14. Vanderbilt Sports Medicine Diagnosis Syndrome of inappropriate antidiuretic hormone secretion (SIADH) due to head trauma exacerbated by excessive free water replacement Left zygomatic arch fracture, left anterior and lateral maxillary sinus fracture

15. Vanderbilt Sports Medicine Treatment The patient’s Na gradually corrected while inpatient. – He was hospitalized for approximately 36 hours. His free water intake was initially restricted at 500cc per day and then gradually liberalized to 1.5L at discharge.

16. Vanderbilt Sports Medicine Time ElapsedFluid Resuscitation Sodium (mEq/L) Free H2O Restriction -- 119-- 2 hrs2L NS119500cc 7 hrsNS 100cc/hr121500cc 13 hrsNS 100cc/hr119500cc 19 hrsNS 100 cc/hr119500cc 23 hrsNS 100 cc/hr125500cc 30 hrsNS 100 cc/hr128500cc 34 hrsNS 100 cc/hr129500cc 38 hrsIVF d/c1301.5L 4 days (f/u)--1412L 1 week--1412.5L 2 weeks--143d/c H20 restriction

17. Vanderbilt Sports Medicine Treatment Principles Fluid restriction is the mainstay of treatment in this case  normal mental status. Rapid correction can lead to osmotic demyelination. When hyponatremia is hyperacute (as in exercise-associated hyponatremia), 3% NaCl can be used more liberally. 4/25/2015Footer

18. Vanderbilt Sports Medicine Treatment His Na was 130 at discharge and 141 forty- eight hours later. His headache, nausea/vomiting, vertigo, blurred vision, and weakness completely resolved. His fluid intake was further liberalized after discharge while continuing to monitor sodium levels (which remained normal). Facial fractures managed non-operatively. 4/25/2015Footer

19. Vanderbilt Sports Medicine Outcome/Follow-up The patient’s free water was gradually liberalized and restriction was discontinued at approximately 2 weeks. He returned to training one week after discharge and successfully completed his second 50k five weeks later. Education regarding proper hydration and nutrition for ultra-running training and racing.

20. Vanderbilt Sports Medicine Key Points There is a wide variability in sweat rates and renal water excretory capacity during exercise. – Absolute drinking/sodium intake guidelines are difficult to attain. No data to support that Na supplementation or consumption of electrolyte containing fluids can prevent exercise associated hyponatremia in those drinking to excess. Education of race directors as well as endurance athletes, especially those at risk. 4/25/2015Footer

21. Vanderbilt Sports Medicine Key Points Hyponatremia comes in different forms in athletes and it is crucial to recognize it clinically, as well as understand treatment and prevention. Nutrition education and strategy is an integral part of race preparation and training in all endurance athletes. 4/25/2015Footer

22. Vanderbilt Sports Medicine Questions?

23. Vanderbilt Sports Medicine SIADH 4/25/2015Footer ETIOLOGY CNS disturbances: stroke, hemorrhage, infection, trauma, pyschosis Malignancies: most often due to small cell carcinoma of the lung Drugs: chlorpropamide, carbamazepine, oxcarbazepine, high dose IV cyclophosphamide, selective SSRI’s Major surgery: abdominal or thoracic surgery Pulmonary disease: pneumonia Hormone deficiency: adrenal insufficiency, hypothyroidism Idiopathic

24. Vanderbilt Sports Medicine Exercise Associated Hyponatremia The occurrence of hyponatremia during or up to 24 hours after prolonged physical activity. Has emerged as an important cause of race- related death and life-threatening illness among endurance athletes. Presentation  edema, N/V, headache, weakness, progressing to AMS seizures, etc Pathogenesis  increased fluid intake +/- persistent secretion of ADH 4/25/2015Footer

25. Vanderbilt Sports Medicine 4/25/2015Footer Risk Factors for EAH ATHLETE-RELATEDEVENT-RELATED Excessive drinking behaviorHigh availability of drinking fluids Weight gain during exercise>4 hours of exercise duration Low body weightUnusually hot or cold environmental conditions Female sex Slow running/performance pace Event inexperience NSAID use (association vs. cause) MEDICAL RISK FACTORS Altered renal excretory capacity potentially impaired by drugs (e.g. thiazide diuretics), intrinsic renal disease, low solute diet, SIADH EAH Consensus Development Conference, 2007, Cin J Sport Med, 2008.