8.00 WUNDERLER TRAVEL SPORTS MEDICINE · malaise, abdominal pain, dark urine, clay-colored stools,...
Transcript of 8.00 WUNDERLER TRAVEL SPORTS MEDICINE · malaise, abdominal pain, dark urine, clay-colored stools,...
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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