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Exercise Associated Collapse
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Contents
Other Names
- EAC
- Exercise-Associated Collapse
Background
- Exercise associated collapse (EAC) is defined as a collapse in conscious athletes who are unable to stand or walk unaided as a result of lightheadedness, faintness and dizziness or syncope causing a collapse that occurs after completion of an exertional event[1]
- Important to distinguish from other, more serious causes of collapse
Epidemiology
- Up to 25 of every 1000 marathon participants seeks post race medical attention[2]
- However this is highly dependent on environmental conditions
- The Gothenburg half marathon, the worlds largest, reports an incidence of 1.53 per 1000 runners[3]
- They also reported a 2:1 male to female treatment ratio
- EAC represents the most common condition to seek medical attention
- 59-85% of visits after marathons and ultramarathons[4]
- Incidence of EAC appears to increase as the race distance, temperature, and humidity increase[5]
Pathophysiology
- Due primarily to pooling of blood in lower extremities once athlete stops running[6]
- Lower extremities require increased blood flow during exercise, resulting in a decrease in peripheral vascular resistance
- Upon cessation of activity, the legs no longer assist in venous return and large volumes of blood pool in the lower extremities
- This is sometimes termed orthostatic intolerance (OI)
- Studies support increased susceptibility to in exercise-trained athletes
- Increase in lower extremity compliance, increased diastolic chamber compliance, distensibility contribute to OI[7][8]
- Trained athletes have increased vascular volume and stroke volume
- The baroreflex, responsible for maintaining blood pressure, is impaired due to this increase in volume[9]
- Thus endurance athletes are more dependent on venous return, especially when upright and following exercise
- Hyperthermia
- Heat stress, increased skin temperature do contribute to OI[10]
- It may also impair the aforementioned baroreflex
- Dehydration
- Currently no compelling evidence to support dehydration as contributor to OI and EAC[11]
Risk Factors
- Increased distance
- Increased temperature
- Increased humidity
- Endurance events
Differential Diagnosis
- Cardiac Arrest
- Hypoglycemia
- Exercise Induced Anaphylaxis
- Exercise Associated Hyponatremia
- Exertional Heat Stroke
- Heat Exhaustion
- Acute Mountain Sickness
- High Altitude Cerebral Edema
- High Altitude Pulmonary Edema
- Hypernatremia
- Exercise Associated Postural Hypotension
Clinical Features
- History
- Witnessed collapse
- The athlete will likely endorse lightheadedness, faintness and dizziness or syncope
- Physical Exam
- Patient should be lucid, full conscious and A+Ox3
- Often HR >100, BP <100
Evaluation
- Primarily a clinical diagnosis
- Exclude hyperthermia related causes by checking vital signs including core temperature and weight
- Exclude hyponatremia by checking point of care blood gas or electrolytes
- Serum glucose should be checked
- Exercise Associated Postural Hypotension (EAPH) can present similarly
- Distinguished from this entity by having no change in blood pressure from supine to standing position
Classification
- N/A
Management
- The most important thing in collapsed athletes is to exclude other, life threatening etiologies
- Vital signs and point of care electrolytes, glucose should be checked
- Treatment directed at prevention of pooling of blood in lower extremities
- The easiest treatment is to have post-activity athletes continue walking and not stop and stand in one position
- Oral hydration is preventative and therapeutic[12]
- Trendelenberg can promote restoration of normal hemodynamics[13]
- Peripheral skin cooling may increase peripheral vascular resistance, decrease cardiovascular strain and improve OI[14]
- Conservative therapy should lead to recovery in 60-90 minutes
- Individuals prone to OI
- consider wearing compression stockings while running[15]
- Can also consider Antihistamine medications
- Hyperthermia and dehydration are not considered primary etiologies of EAC
- Total body cooling and IV fluids should be avoided
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Needs to be updated
Complications
- The most feared complication is missing other causes of collapse
See Also
References
- ↑ Asplund, Chad A., Francis G. O'Connor, and Timothy D. Noakes. "Exercise-associated collapse: an evidence-based review and primer for clinicians." Br J Sports Med 45.14 (2011): 1157-1162.
- ↑ Roberts, William O. "A 12-yr profile of medical injury and illness for the Twin Cities Marathon." Medicine & Science in Sports & Exercise 32.9 (2000): 1549-1555.
- ↑ Lüning, H., et al. "Incidence and characteristics of severe exercise-associated collapse at the world’s largest half-marathon." PloS one 14.6 (2019).
- ↑ Holtzhausen, L. M., and TIMOTHY D. Noakes. "The prevalence and significance of post-exercise (postural) hypotension in ultramarathon runners." Medicine and science in sports and exercise 27.12 (1995): 1595-1601.
- ↑ . O’Conner FG, Pyne S, Brennan FH, Adirim T. Exercise associated collapse: An algorithmic approach to race day management. Am J Sports Med 2003;5:212-217. 229.
- ↑ Holtzhausen, L. M., and T. D. Noakes. "Collapsed ultraendurance athlete: proposed mechanisms and an approach to management." Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine 7.4 (1997): 292-301.
- ↑ Levine, Benjamin D., et al. "Left ventricular pressure-volume and Frank-Starling relations in endurance athletes. Implications for orthostatic tolerance and exercise performance." Circulation 84.3 (1991): 1016-1023.
- ↑ Levine, BENJAMIN D., et al. "Physical fitness and cardiovascular regulation: mechanisms of orthostatic intolerance." Journal of Applied Physiology 70.1 (1991): 112-122.
- ↑ Ogoh, Shigehiko, et al. "Cardiopulmonary baroreflex is reset during dynamic exercise." Journal of Applied Physiology 100.1 (2006): 51-59.
- ↑ Crandall, Craig G. "Heat stress and baroreflex regulation of blood pressure." Medicine and science in sports and exercise 40.12 (2008): 2063.
- ↑ Noakes, Timothy D. "Exercise in the heat: old ideas, new dogmas." International SportMed Journal 7.1 (2006): 58-74.
- ↑ Davis, J. E., and S. M. Fortney. "Effect of fluid ingestion on orthostatic responses following acute exercise." International journal of sports medicine 18.03 (1997): 174-178.
- ↑ Anley, Cameron, et al. "A comparison of two treatment protocols in the management of exercise-associated postural hypotension: a randomised clinical trial." Br J Sports Med 45.14 (2011): 1113-1118.
- ↑ Durand, S., et al. "Skin surface cooling improves orthostatic tolerance in normothermic individuals." American Journal of Physiology-Regulatory, Integrative and Comparative Physiology 286.1 (2004): R199-R205.
- ↑ Privett, Sheena E., et al. "The effectiveness of compression garments and lower limb exercise on post-exercise blood pressure regulation in orthostatically intolerant athletes." Clinical Journal of Sport Medicine 20.5 (2010): 362-367.
Created by:
John Kiel on 13 June 2019 05:41:38
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Last edited:
28 January 2020 01:39:57
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