It is common to hear that “when you work in an Emergency Department (ED), you have to be prepared for everything”. In my experience as a medical student, this could not be more true. I’ve seen tea overdose, collision scooter vs horse, and anything in between. All these experiences will contribute to my formation and made me realize that we are not prepared for many situations. Some of these situations may involve specific populations we’re not so familiarized with and sometimes can change the way we manage an emergency.
Here, I want to discuss some of these “special populations” which may demand a different approach than the usual – and that is what makes emergency medicine so interesting. Let’s talk about one of these subgroups of patients: athletes, and what makes them unique.
Athletes: What do I need to know about them?
- Heart and Hemodynamic: The “athlete’s heart syndrome (1)”
- Morphological, functional and electrical changes
- Lower heart rate;
- Hypertrophic left ventricle (LV)
- Lifelong cardiac remodelling could lead to arrhythmogenic pathways
- Morphological, functional and electrical changes
- Changes in autonomic nervous system – vagal tonus
- Pulmonary efficiency:
- Unlike what may be the first thought, the respiratory system does not differ greatly in athletes from non-athletes (2).
- High energy trauma:
- Be aware that professional athletes are constantly at risk of high energy traumas, in special head traumas (concussions) and limb trauma (fractures);
How could this be a problem?
- Late signs of hypovolemia
- The athlete’s autonomic nervous system has pronounced vagal tonus, which leads to the famous resting bradycardia – this could disguise a tachycardia, one of the early signs of hypovolemia (2).
- Delay in seeking help
- Elite athletes may delay seeking help or admit they are not feeling well for fear of losing a competition or training sessions.
- Besides that, in amateur (and sometimes even in professional) level competitions, staff and coaches often are not trained to identify conditions that need prompt medical assistance
Common situations and how to manage
Exercise and health always have been put together in a “cause and consequence” relation. Besides their undeniable positive effects, exercise on the professional level also has its sidebacks and associated risks. Here I want to discuss some physiological changes we observe in the elite athletes and a very common condition in the ED: the sport-related concussion.
The current literature organize the signs and symptoms of sport-related concussion in 4 domains
- Somatic
- Headache, dizziness, gait disturbances, vertigo, nausea and vomiting, near vision impairment
- Cognitive
- Impaired memory (amnesia), slowed speech, confusion,
- Sleep
- Insomnia
- Emotional
- Irritability, labile humour
Given the rapid onset and short duration, the patient might present to the ED with minor or no symptoms; However, the emergency physician still plays an important role, providing supportive care to relieve remaining symptoms and rule out more severe conditions.
Attention
- Due to the mechanism of trauma, always rule out cervical spine lesions or instability.
- Also, signs of basilar skull fracture (racoon eyes, Battle’s sign, CSF rhinorrhea)
- A Glasgow Coma Scale < 13 should raise awareness for a more severe brain lesion.
- Does this patient need a head CT?
- Canadian CT head rule (adults)
- PECARN CT rule (under 16)
Management (4)
When to admit
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References and Further Reading
- Carbone A, D’Andrea A, Riegler L, Scarafile R, Pezzullo E, Martone F, America R, Liccardo B, Galderisi M, Bossone E, Calabrò R. Cardiac damage in athlete’s heart: When the “supernormal” heart fails! World J Cardiol 2017; 9(6): 470-480 Available from: URL: http://www.wjgnet.com/1949-8462/full/v9/i6/470.htm DOI: http://
dx.doi.org/10.4330/wjc.v9.i6.470 - ACSM’s advanced exercise physiology. — 2nd ed.;Peter A. Farrell, Michael Joyner, Vincent Caiozzo ISBN 978-0-7817-9780-1
- McCrory P, Meeuwisse W, Dvorak J, et al. Br J Sports Med 2018;51:838–847
- Bazarian JJ, Raukar N, Devera G, et al. Recommendations for the Emergency Department Prevention of Sport-Related Concussion. Ann Emerg Med. 2020;75(4):471-482. doi:10.1016/j.annemergmed.2019.05.032
