Episode #354: Man Collapses 50-Meters From The Finish Line (Medical Mystery)

Summary

In this episode of the Barbell Medicine podcast, Dr. Jordan Feigenbaum and Dr. Austin Baraki delve into a medical mystery involving a 61-year-old man who collapsed just before finishing a marathon. The discussion covers the initial assessment, diagnostic challenges, and the eventual diagnosis of _____. The episode emphasizes the importance of understanding exercise-associated collapse and the need for emergency preparedness in fitness settings.

🎧 Listen on Apple Podcasts: https://podcasts.apple.com/us/podcast/episode-354-man-collapses-50-meters-from-the-finish/id1199780143?i=1000715485498

Key Takeaways

Episode Timestamps

Clinical Pearls

References

• https://pubmed.ncbi.nlm.nih.gov/37919145/ 
• https://pubmed.ncbi.nlm.nih.gov/27447266/ 

Transcript

Presentation

61 year old man presents to the ED via ambulance after collapsing 50m before the finish line of a marathon. 

Ambient temperature was 11*C or about 50*F.

While running about a 9 min mile pace for the duration of the event, the patient collapsed unconsciously. The on-site medical staff went to him immediately, where he was found to be gasping. CPR was initiated and an AED was placed, which did not advise any shocks. 12 lead performed on scene- normal with strong peripheral pulses.

The patient was transferred to the on-site emergency tent. The critical care team assessed him. He was breathing fast and using accessory muscles.  Both pupils were dilated this time and he had R pupillary deviation.  

His BP was 200/102, HR 122, but body temp was normal. 

Due to labored breathing, the patient was intubated prior to arriving to the hospital

He arrived to the emergency department 1 hour after he collapsed where he remains unconsciousness and ventilated with a glasgow coma scale of 3/15. 

No medical history is currently available. 

Thots/play along at home

Exam/Workup

• BP now 130’s/80’s 
• Patient is unconscious, GCS 3/15
• Pupils are both dilated, with R larger than L
• No rigidity in his extremities, reflexes normal no focal MSK deficits 
• Rushed to imaging
  • TEE
    • Normal
  • CT head
    • Unremarkable except for hyperdense spot on pituitary gland
• Other testing
  • Troponins
    • I 101 ng/L 
    • ​​normally elevated post-endurance race and their role is limited in this context.
  • ABG normal
    • pH 7.35
  • Chemistry
    • Normal Na+ 135
    • K+ 3.4 
    • Glucose 104
    • Lactate now normal 
  • Tox screen negative for common recreational substances
• Thots?

Further Workup

• Patient given 100mg of hydrocortisone in ED for suspected pituitary apoplexy
• Transferred to ICU 
• EEG
  • Normal 
• Extubated overnight > breathing fine on room air, transferred to neurology ward
  • No visual signs, no n/v, MAEW 
• Brain MRI
  • 1cm hemorrhage on left, anterior pituitary gland c/w adenoma 
  • No compressions of optic chiasm or invasion of cavernous sinus 
• Endocrine workup
  • ACTH stimulation test
    • Normal 
  • Thyroid studies normal
  • Testosterone studies normal
  • Growth hormone studies normal 
• Cardiac MRI
  • No scars, edema
  • Normal
• Cardiac CT
  • Significant disease of epicardial coronary arteries 
  • 45% stenosis at middle track of LAD and RCA 

Diagnosis/Course

• Exercise associated collapse 2/2 likely cardiac arrhythmia from previously unknown coronary artery disease during exhaustive exercise
  • Terminated prior to AED connection 
• Patient was discharged from the hospital on HD #4
• Underwent coronary angioplasty with 4 stents placed in RCA with 0% residual stenosis  
• Later had adenoma removed from pituitary 
• Why this diagnosis
  • Clearly EAC, but cause is diagnosis of exclusion
    • No cardiac arrest based assessment at scene + BP +pulses
    • Not MI or ACS based on EKG and TEE  
    • Not heat stroke due to normal body temp
    • Not hyponatremia or electrolyte disorder due to ABG 
    • Not endocrine due to normal function
      • Self contained pit bleed, no AMS 
    • Not neuro (stroke) due to normal CT and MRI 

Pearls

• Exercise associated collapse
  • National Center for Catastrophic Sport Injury Research (NCCSIR) of the United States has tracked and analyzed catastrophic injury among high school and collegiate athletes for over 40 years. The NCCSIR categorizes athletic injury as either direct (traumatic) or indirect (exertional)
  • Collapse is a specific type of injury
    •  can be defined as failure of a physiologic system (eg, cardiovascular, pulmonary, nervous, or musculoskeletal); in the sporting environment, collapse means the athlete is unable to continue participating and unable to remove themselves under their own power from the race course or field due to such a failure.
    • Exertion
      • Of the 86 events recorded july 21 to july 22, 86% in HS, over half were fatal (56%), and half occured during practice
        • Heat 
    • Trauma
      • E.g. post traumatic collapse
      • Tackling in football, ice hockey, lacrosse, gymnastics
    • Not necessarily loss of consciousness
      • MSK injury 
      • Sickle cell trait (ECAST)
    • But it could be
      • Neurological (stroke)
      • Arrhythmia  
  • The most common medical condition encountered during an endurance sporting event is exercise-associated postural hypotension (EAPH), which is usually self-limited and benign “weak, wobbly, dizzy”
    • After individual stops= loss of skeletal pump to move blood from lower limbs back to heart=  pooling > lightheadedness  
    •  leading cause for evaluation in the finish-line medical tent
    • Feet up 
  • In a study of 153,208 runners participating in half and full marathon races  over an eight-year period, the overall incidence of EAC was 1.5%
    • Risk factors= longer race
    • Slower speed 
    • High temperature and humidity 
    • Uphill
  • Differential
    • Sudden cardiac arrest
    • Exertional heat stroke
    • Exercise associated hyponatremia

• < 130 mmol/L na+ 
• Overdrinking hypotonic fluids + excessive losses (esp for events < 4h) 
• Risk of encephalopathy and pulmonary edema. Potentially fatal 
• Pretty common in endurance athletes, e..g 10-20% of marathon finishers and much higher than that in those > 4hr duration 
• Problem really is hypotonic beverages like water and sports drinks consumed in a greater amount of weight loss
• Could also be large sodium losses, but this is not really a big issue for acclimated individuals (sodium loss is low)
  • Early indications lightheadedness, dizzy, nausea, puffiness of extremities or face, muscle cramps that do not resolve, weight gain, later AMS, seizures, etc 

• Anaphlyaxis 
• Asthma exacerbation
• Trauma 
• Seizure 
• hypoglycemia /insulin shock 
• What do
  • Have a good history on client, e.g. known meds/ conditions
  • BLS – CPR/AED
  • EMS
  • Stay calm
• Resources
  • https://pubmed.ncbi.nlm.nih.gov/27447266/