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Denise L. Wunderler, DO, FAOASM Primary Care Sports Medicine Physician

Department of Orthopedic Surgery Fort Knox, Kentucky

AOASM Annual Conference 2014, Tampa

¨  Gain an understanding of how to successfully prepare for an international sports medicine trip

¨  Review vaccines and traveler’s diarrhea ¨  Discuss performance considerations regarding

altitude and jet lag

¨  Can be challenging ¨  Usually great preparation leads to a smooth,

successful trip ¨  But you can’t anticipate everything ¨  Goal: be as prepared as you can be

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¨  With whom are you traveling? ¡  Athletes, coaches, other staff, family members ¡  Make contact with them early to open the lines of

communication for questions or concerns ú  Allows better planning for everyone ú  Be aware of any allergies or known medical problems ú  standard vaccines should be UTD, including tetanus ú  Gives them time to obtain needed vaccines for a specific

country

ú  obtain complete list of ALL meds (Rx, OTC, herbs, “natural remedies”, vitamins, supplements; daily/PRN)

ú  determine if an athlete is taking a banned substance ú  need for a therapeutic use exemption (TUE)?

­  For athletes with a documented medical condition who need a prohibited substance/prohibited method

­  At least 30 days before the competition ú  Old/new injuries, any taping that is needed

¨  I made a chart with the Team Delegation’s names, meds, allergies, other

¨  Where are you going? ¡  Local vs. international

ú  http://www.cdc.gov/travel (specific country) ú  what is allowed in the country/through customs

­  Some prescription meds are illegal in other countries- need to check with the embassy or consulate for that country; must have a letter from your doctor stating the med and that it was prescribed for you

­  I would not recommend carrying any narcotics ­  Letter for epi pens in my luggage

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ú  what can be brought on the plane in carry-on bag ú  small stock of Ibuprofen, Acetaminophen, Tums, Pepto-

Bismol, Immodium, throat lozenges ú  tablets in original containers or marked clearly with the name

and dose ú  Depending on the destination, specific vaccinations will be

needed- check CDC website

¡  Packed supplies will be different if it is international ¡  How much are you going to bring

ú  the more you bring, the more you carry ú  If you need an item, how difficult will it be to obtain

­  i.e. Moist heat packs for shoulder/back- it took our Peruvian delegate 2 days to locate them for us in Lima

­  i.e. Meds- if purchased overseas, they may not be made according to US standards, may be ineffective, contain contaminants, or may be in unsafe drug combinations

¡  Encourage them to bring healthy snacks from home

¨  cdc.gov ¨  who.int

¨  Routine vaccinations need to be up-to-date (MMR, DPT, polio, etc)

¨  Hepatitis A ¨  Typhoid Fever ¨  Hepatitis B ¨  Yellow Fever ¨  Malaria ¨  Rabies

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¨  Transmission: viral contaminated food/water, illegal drugs, intimate relations

¨  nausea, anorexia, fever, malaise, abdominal pain, dark urine, clay-colored stools, jaundice, joint pain

¨  Tx: supportive

¨  Hepatitis A vaccine (inactivated/killed) or IG ¡  begin 2-4 weeks (ideally) prior to travel; there is some

protection no matter when it is given ¡  for immediate, temporary protection, immune globulin can

be given ¡  for long-term protection, 2 vaccine doses are required 6

months apart

¨  Transmission: Contaminated food/water

¨  insidious onset, F/C, constipation, abdominal pain, HA, rose-colored macular rash on abdomen and chest (“rose spots”), malaise, myalgia

¨  Salmonella typhi bacteria ¨  Tx: fluoroquinolone

(cipro); Injectable third-generation cephalosporins; Azithromycin

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¨  Inactivated (killed)- IM (Typhim Vi) ¡  one shot at least 2 weeks before travel ¡  booster q 2 yrs if at risk

¨  live, attenuated (weakened)- PO (Vivotif) ¡  4 doses- one capsule QOD for a week (day 1, day 3, day 5,

day 7) ¡  final dose should be given at least 1 week before travel;

given 1 hr before a meal with lukewarm/cold beverage ¡  booster q 5 yrs if at risk

¨  Transmission: blood/body fluid, IV drug use, intimate relations

¨  Fever, fatigue, loss of appetite, N/V, abdominal pain, dark urine, clay-colored stools, joint pain, jaundice

¨  Tx: supportive if acute

¨  Vaccine (Hep B surface Ag): ¡  3 doses: time 0, 1 month, 6 months ¡  May last at least 20 years

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¨  Transmission: Flavivirus infected Mosquito

¨  Most have no illness or mild illness- sudden onset of F/C, severe HA, back pain, general body aches, N/V, fatigue, weakness

¨  Tx: supportive, close observation

¨  Live, attenuated virus vaccine ¡  single dose protects against disease for 10 years or more ¡  booster dose q 10 years if continued risk

¨  Transmission: Plasmodium (parasite) infected mosquito

¨  high fevers, chills, diaphoresis, HA, N/V, malaise/myalgias

¨  Tx: depends on disease severity, species of parasite, part of the world in which the infection was acquired

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¨  NO vaccine available ¨  Doxycycline 100 mg PO daily for prevention

¡  Begin 1-2 days prior to exposure ¡  Discontinue 4 weeks after exposure ¡  Side effects include diarrhea, nausea, dyspepsia, HA,

photosensitivity

¨  insect repellent with 30-50% DEET ¨  long pants/sleeves and hats to prevent insect bites ¨  remain indoors in a screened or air-conditioned area

during peak biting period (dusk and dawn)

¨  Transmission: saliva from the bite of an infected animal (or brain/nervous system tissue)

¨  Dogs in developing countries ¨  General weakness, fever, HA, itching at the bite site,

eventually cerebral dysfunction, delirium ¡  Almost always fatal once symptoms begin

¨  Tetanus shot (if not received in last 10 years) ¨  Tx: supportive

¨  Do not touch/feed animals (including dogs, cats) ¡  pets that look healthy may have rabies, other diseases

¨  Pre-exposure: ¡  Inactivated/killed viral vaccine- IM

¨  Post-exposure prophylaxis if never immunized: ¡  wound cleansing (greatly reduces likelihood of rabies) with

soap/water/virucidal agent (ie. povidine-iodine) ¡  vaccine on days 0, 3, 7, 14 + HRIG (human rabies immune

globulin) local infusion at wound site + additional amount IM at site distant from the vaccine

¨  Post-exposure prophylaxis if previously immunized: ¡  wound cleansing + vaccine on days 0 and 3

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¨  Are you the only medical staff for your team? ¨  Physician duties

¡  BE PROACTIVE and stay in the loop of communication with the team

¡  Do your best to keep everyone healthy ú  if they had a hint of a symptom (GI, blister, URI, etc), they

knew to tell me immediately

¨  ATC duties ¡  Taping, ice, everything else ¡  I refreshed basic taping with an ATC before traveling

¨  This lists prohibited substances/methods that can enhance athletic performance

¨  updated annually ¡  separated by substances that are prohibited at all times, in

competition, and in particular sports) ¨  Full list at http://list.wada-ama.org/

¨  ALL TIMES: ¨  Anabolic steroids, growth factors, blood products, gene

doping are prohibited ¨  Danazol- anabolic steroid for endometriosis, fibrocystic

breast disease, hereditary angioedema ¨  All beta-2 agonists

¡  except inhaled salbutamol (albuterol) max 1600 mcg over 24 hrs, inhaled formoterol max 54 mcg over 24 hrs, or inhaled salmeterol (long-acting beta agonist) when used in accordance with manufacturer’s regimen

¨  Clomiphene- for ovulation induction ¨  Insulins ¨  Masking agents: acetazolamide (Diamox), probenecid (for

gout)

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¨  IN COMPETITION: ¨  Stimulants

¡  methylphenidate (Concerta, Ritalin) ¡  Pseudoephedrine (PSE) (Sudafed)- for nasal congestion, when

[urine] is >150mcg/mL ú  WADA advises athletes to stop taking PSE 24 hours before the

in-competition period ¡  (NOT PROHIBITED: caffeine, nicotine, phenylephrine,

synephrine) ¨  Narcotics- Fentanyl, hydromorphone (Dilaudid),

oxycodone (in Percocet, OxyContin) ¨  Marijuana ¨  All glucocorticosteroids (prednisone)- PO, IV, IM, PR

¨  IN COMPETITION IN CERTAIN SPORTS: ¨  Alcohol ([blood alcohol] of 0.10g/L)

¡  air sports (aeronautic), archery, automobile, karate, motorcycling, powerboating

¨  Beta-blockers ¡  archery and shooting (both also prohibited out-of-

competition), automobile, billiards, darts, golf, skiing/snowboarding- ski jumping, freestyle aerials/halfpipe and snowboard halfpipe/big air

¨  MONITORING PROGRAM: ¨  substances not on prohibited list, but which WADA

wishes to monitor in order to detect patterns of misuse in sport

¨  In competition only ¡  Stimulants: caffeine, nicotine, phenylephrine, pseudoephedrine

<150mcg/mL, synephrine ¡  Narcotics: Hydrocodone (in Vicodin), tramadol

¨  NOTE: Intramuscular PRP was removed from the prohibited list

¨  *To inquire about a certain ingredient by sport, look at http://www.globaldro.com/

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¨  Meet the Head Physician of the event (which could be you), other local event medical staff

¨  Protocol to contact emergency staff ¨  AED location ¨  Ambulance access to facility ¨  Training room facilities ¨  local hospital locations ¨  Bring contact information of people in case of

problems (trusted physicians, NGB staff)

¨  Be familiar with the World Anti-Doping Code ¡  I kept a full printed copy in my binder

¨  M-5 declaration of medications of each athlete (before match)

¨  M-10 injury report form (after match) ¨  Random doping controls occurred

¡  team physician is present for this

¨  When preparing for travel, prepare for the most common problems ¡  *food/water contamination-leading cause of illness in

travelers ¡  Altitude ¡  Jet lag

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¨  GI meds- Loperamide, Tums, Pepto-Bismol, ABX, Anti-emetics, MVI, Docusate

¨  ABX- Cipro, Clinda, Amox, Augmentin, Vigamox gtts

¨  Electrolyte-replacement powder, MVI

¨  Cough suppressants, throat lozenges

¨  Pain relievers- Acetaminophen, Ibuprofen, Aspirin, topicals

¨  Urgent: Epi pens, Albuterol HFA

¨  Allergies- Loratidine

¨  Miconazole intravaginal ¨  Topicals: Bacitracin,

Clotrimazole, Hydrocortisone ¨  IVF ¨  Injectables ¨  Lac tray, wound/blister supplies ¨  Glucometer, BP cuff,

stethoscope, pen light/headlamp, thermometer, otoscope

¨  Pregnancy tests, UA, hemoccult tests

¨  Flow meter, pulse ox ¨  Taping supplies, ice bags, Shark ¨  SAM splints, joint braces

¨  Traveler’s Diarrhea (Gastroenteritis) ¨  Jet lag ¨  Altitude

¨  “Boil it, cook it, peel it, or forget it” ¨  Can occur anywhere, however it mostly occurs in

developing countries ¡  highest risk areas: Central and South America, Mexico,

Africa, Middle East, South Asia ¨  Almost 50% of Americans visiting developing

countries ¨  main sources of infection: Food and water

contaminated with fecal matter

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¨  Prevalence of specific organisms varies with travel destination ¡  Most common causes:

ú  E.Coli, Campylobacter, Salmonella, Shigella- mainly bacterial abroad

ú  viral gastroenteritis in US ¡  Less common causes:

ú  protozoal parasites ú  if diarrhea lasts >2 weeks OR if no response to ABX- Giardia

Iamblia, Entamoeba histolytica, Cyclospora cayetanensis- seen in returning travelers

¡  norovirus on cruise ships

¨  Classic definition: ¡  3 or more unformed stools in 24 hours with at least 1 of

the following symptoms: Fever, N/V, abdominal cramps, tenesmus (urge to pass stool), bloody stools

¨  Milder forms can present with less than 3 stools ¨  Can also have bloating, general fatigue ¨  Most occur within the first 2 weeks of travel and

last 4 days without treatment

¨  Rarely life-threatening ¡  1 in 5 travelers is bedridden for a day ¡  > 1/3 must alter their activities

¨  Those more susceptible: immunocompromised, those with lowered gastric acidity (taking histamine H2 blockers or proton pump inhibitors), younger age and adventurous travelers; luxury resorts or cruise ships

¨  “Food poisoning” is part of the differential dx of TD: ¡  gastroenteritis from preformed toxins (Staph aureus, Bacillus

cereus) has a short incubation time (1-6 hours) and symptoms usually resolve within 24 hours

¡  Distinguish from TD by perioral numbness, flushing and warmth

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¨  Prevention: ¡  A fluoroquinolone can be used for a maximum of 3 weeks in

a “critical” competition ¡  Bismuth subsalicylate (Pepto-Bismol)

ú  ideally two 262 mg tables QID (with meals and in evening) ú  Even though it has a 60% rate of protection, it is impractical for

athletes ú  Not for those taking anti-coagulants or other salicylates ú  Interferes with doxycycline absorption (malaria prophylaxis) ú  Side effects include: black stool, black tongue, constipation,

tinnitus ¡  Lactobacillus may protect up to 47%; more studies needed

¡  wash hands often with soap/water, esp before eating ú  Antibacterial hand wipes/alcohol-based hand sanitizer (at least 60%

alcohol) ¡  Only use bottled water with an unbroken seal, boiled water

(best way to purify water), or carbonated beverages in cans/bottles

¡  avoid tap water, fountain drinks, and ice cubes ¡  use bottled water for teeth brushing ¡  Inspect hotel kitchens and inquire re: the source of fruits and

vegetables and the water in which they are washed and prepared

¡  confirm that water in a hotel setting is filtered, boiled, or bottled

¡  no food from street vendors ¡  Eat only fully cooked food ¡  eat hot foods when they are hot; cold foods when they are cold ¡  no room temp sauces

ú  microbes can multiply in foods that are allowed to cool or warm to room temp

¡  avoid raw/undercooked meat, fish, or shellfish ¡  Do not eat reheated, cooked food ¡  avoid leafy salads, unpeeled fruit/vegies in developing

countries ¡  avoid dairy, unless it is pasteurized ¡  boiled/baked/peeled foods are the safest ¡  Boiling water is the best way to purify water

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¨  Treatment: ¡  Boiled soups/bouillon/broth and electrolyte-

replacement solutions (have salt which was depleted during diarrhea episodes)

¡  Hydration ¡  Complex carbohydrates- bananas, rice, bread, potatoes ¡  Empiric tx with ABX and loperamide

¨  Loperamide (Imodium) ¡  two 2mg tablets after 1st loose stool, then 1 tab after each

subsequent loose stool; max 8 mg in 24 hours x 2days ¡  limits symptoms to one day ¡  Can be started after the 1st episode of diarrhea ¡  if symptoms resolve within 24 hours, no further tx

¨  Ciprofloxacin ¡  500 mg BID x 1-3 days ¡  drug of choice (for most parts of the world) where

invasive organisms like Campylobacter and Shigella are common

¨  Azithromycin ¡  in areas with quinolone-resistant Campylobacter (i.e.

Thailand) and for children and pregnant women ¡  1 gram x1 dose OR 500 mg x 1-3 days ¡  10mg/kg daily x 3 days

¨  Rifaximin (newer ABX) ¡  can be used where noninvasive E.Coli is the main

pathogen (i.e. Mexico) ¡  decreases symptoms x 1 day ¡  200 mg PO TID x 3 days

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¨  Athletes face many challenges at altitude that can effect performance: ¡  Lower oxygen saturation in the air ¡  increased radiation (sun) ¡  compromised immune system ¡  increased fatigue ¡  Malnutrition and dehydration ¡  overtraining

¨  Therefore, acclimatization, proper sleep, sun protection, hydration, good nutrition, and appropriate training are important to help minimize these challenges

¨  Acclimatize to help prevent altitude illness: ¡  avoid flying into high altitude cities ¡  if going to higher altitude destination (above 8000 ft) consider

sleeping one night at a lower altitude ¡  increase altitude gradually ¡  Hydrate ¡  limit activity initially ¡  avoid alcohol ¡  high carbohydrate diet can improve oxygenation and exercise

performance

¨  There is no ideal preventative med for athletes traveling to altitude ¡  Ibuprofen (600 mg TID, 6 hours before ascent) can help

¨  Recommended: athlete arrives early and resides x 2 weeks at the competition altitude

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¨  At altitude, lack of hydration (due to plasma volume drop à lower COà lower maximal aerobic power) and iron (due to strong demand on erythropoiesis at altitude) may negatively impact performance

¨  Recommended that athletes are screened for serum ferritin levels 8-10 weeks prior to going to altitude, allowing time for supplementation; recommend increased dietary iron intake through various foods

¨  Rapid ascent above 2500 m (8200 ft) to a more hypobaric, hypoxic environment is the main cause of altitude illness

¨  AMS ¨  HACE ¨  HAPE

¨  AMS ¡  HA, dizziness, insomnia, anorexia, nausea, dyspnea,

fatigue ¡  Tx: Descent*, O2, Gamow bag, Diamox, Dexamethasone,

Acetaminophen, Ibuprofen, Aspirin, Zofran

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¨  HACE ¡  Medical emergency! ¡  same symptoms as AMS + confusion and ataxia and

altered level of consciousnes ¡  Can result in a coma and possibly death due to brain

herniation ¡  Tx: immediate descent, O2, Dexamethasone, Gamow bag

¨  HAPE ¡  Medical emergency! ¡  dyspnea, tachypnea, moist cough (pink frothy sputum),

poor exercise tolerance, low-grade fever ¡  Tx: descent*, rest, keep warm, O2*, Gamow bag, CPAP

mask or helmet, rehydration, Sildenafil, Tadalafil, Nifedipine, Diamox, Albuterol/salmeterol inhaler

¨  Athletes traveling to altitude for training/competition are at risk for poor sleep quality as a result of both jet lag and the altitude itself

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¨  Considered to be a significant source of disturbance to athletes, especially when traveling from west to east

¨  Goal is to increase adaptation and minimize decrease in performance

¨  Sleep deprivation exacerbates the magnitude and duration of jet lag

¨  sleep when you can ¨  hydrate before and during the trip ¨  avoid alcohol ¨  1 day of adjustment needed for each time zone crossed* ¨  Travel Management Program (Samuels) – Preflight,

inflight, postflight components

¨  Preflight: ¡  Within 7 days of travel ¡  Getting a solid night sleep at least the night before the

flight ¡  Decrease volume and intensity of training ¡  adjust training to the destination time zone a few days

before departure ¡  evening flight for eastward travel and layovers for travel

across 10 or more time zones to help with adapting

¨  Inflight ¡  adjust watches to destination time zone ¡  comfortable environment (pillows, etc) to facilitate sleep

and rest ¡  minimize distractions (electronics) ¡  eyeshades/earplugs to aid rest ¡  noise-canceling listening devices to help relaxation ¡  sleep and eat meals on the destination schedule (athletes to

bring meals if possible) ¡  hydration is a priority

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¨  Postflight: ¡  2-4 days after arrival ¡  Modification of behavior, not necessarily meds ¡  scheduled light therapy, light avoidance, melatonin ¡  napping and caffeine (improve alertness, minimize

fatigue) ¡  ? sedatives if insomnia for 1-2 days or not responding to

melatonin

¨  Any special considerations re: the injured athlete and returning home by air? ¡  Athlete with a pneumothorax may not be able to fly ¡  A cast needs to be bivalved ¡  Special seating- ie. if GI issues- obtain an aisle seat near a

bathroom; if lower extremity injury, obtain an aisle seat

¨  Traveling in sports medicine can be challenging ¨  However, the key to a successful trip is great

preparation and being proactive with the care of your team

¨  And remember, always strive to be a positive ambassador- You are representing our country!

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¨  www.cdc.gov ¨  www.fivb.org ¨  http://list.wada-ama.org ¨  www.globaldro.com ¨  www.cdc.gov ¨  www.who.int ¨  Epocrates ¨  Yates, J. Traveler’s Diarrhea. Am Fam Physician. 2005. 71(11):2095-2100. ¨  Harrison, L. New Rifamycin Formulation Curtails Traveler's Diarrhea.

http://www.medscape.com/viewarticle/812427.2013. ¨  Lipman GS, et al. Ibuprofen prevents altitude illness: A randomized controlled trial for prevention

of altitude illness with nonsteroidal anti-inflammatories. Annals of Emergency Medicine. 2012. 59(6): 484–490.

¨  Samuels, C. H. Jet Lag and Travel Fatigue: A Comprehensive Management Plan for Sport Medicine Physicians and High-Performance Support Teams. Clin J Sport Med. 2012. 22(3):268-273.

¨  Pipe, A.L. International Travel and the Elite Athlete. Clin J Sport Med. 2011. 21 (1): 62-66. ¨  Koehle, M.S., et al. Canadian Academy of Sport and Exercise Medicine Position Statement:

Athletes at High Altitude. Clin J Sport Med. 2014. 24 (2): 120-127. ¨  Koch, et al. A Successful Therapy of High Altitude Pulmonary Edema With a CPAP Helmet on

Lenin Peak (Case Report). Clin J Sports Med. January 2009; 19 (1): 72-73.

¨  Michael Savino, D.O. ¨  Lori Boyajian-O’Neil, D.O. ¨  David Dyck, D.O. ¨  Bill Feldner, D.O. ¨  Andy Gregory, M.D. ¨  Zenos Vangelos, D.O. ¨  USA Volleyball ¨  AOASM