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A Guide to Treating Ironman Triathletes at the Finish Line

Lester B. Mayers, MD; Timothy D. Noakes, MB ChB, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 8 - AUGUST 2021


In Brief: The unique physiologic characteristics of an ironman triathlete present challenges to physicians covering ultraendurance events. Cardiovascular emergencies at the finish line are rare. Occult blood in postrace urine is common but rarely of clinical significance. Medical volunteers must distinguish between signs of dehydration, heatstroke, hyponatremia, and postural hypotension and offer appropriate treatment. Recumbent positioning and oral hydration often suffice to stabilize a conscious collapsed athlete, but serious abnormalities require swift evacuation to a hospital.

Triathletes are "made," not born. They are highly trained competitive runners, swimmers, and cyclists who race in a multiple-phase endurance event. An ironman triathlon (IT) consists of a consecutive 2.4-mile swim, 112-mile cycle, and 26.2-mile run with brief transition periods between segments. Mean weekly training distances and paces reported for IT athletes are 7.2 miles of swimming at 30 minutes per mile, 227 miles of cycling at 18.7 mph, and 45 miles running at 7:42 per mile (1). The mere ability to train for an IT denotes a superior medical and orthopedic constitution in these athletes.

In addition, IT athletes have competed in a variety of endurance events for years and typically possess excellent health and superior physiologic characteristics. They are experienced at contending with environmental variations, equipment failures, and emotional stressors, and they know their fluid and nutritional requirements. Despite this self-knowledge, recent studies suggest that one common error made by competitors during ITs and other ultraendurance events may be overhydrating with water, resulting in dilutional hyponatremia (2-4).

Physical hazards unique to the swim phase include corneal abrasion from swim goggle displacement caused by being kicked, hypothermia, and water aspiration. In addition, competitors may hyperventilate and need to be removed from the water. Falls while cycling may produce "road rash" or significant trauma. Pressure neuropathies of the hands and perineum may also occur in the bicycling segment. Blisters and toenail trauma may result from the run. General exhaustion, postural hypotension, and electrolyte disturbances with nausea, vomiting, and dizziness are late-race symptoms. Muscle cramps are common. Nevertheless, 92% of IT athletes complete the race in most events (5). Table 1 lists some of the conditions commonly seen by IT physicians; we detail the significant ones in the ensuing sections.


TABLE 1. Conditions Associated With Collapse During or After Prolonged Exercise


Exercise-associated collapse (postural hypotension)

Muscle cramps

Heatstroke

Hypoglycemia

Hyponatremia

Hypothermia

Cardiac arrest

Other medical conditions

Orthopedic conditions: stress and frank fractures that cause falls


Common Medical Considerations

Cardiovascular conditions. IT athletes studied by echocardiography, Doppler ultrasound, and electrocardiography have increased left ventricular mass, resting bradycardia, high stroke volumes, increased left ventricular internal dimensions, normal diastolic function (6-8), and increased multivalvular regurgitation (9). The left ventricular hypertrophy is concentric and probably results from the many hours training at increased systolic blood pressure with increased stroke volume (7). Postrace studies reveal slight decreases in end-diastolic dimension and fractional shortening that suggest cardiac muscle fatigue. Of interest, prerace Doppler-detected mitral regurgitation is not observed in athletes studied after the event.

Plasma troponin levels are elevated in 10% to 25% of finishers and in most athletes tested after an ultramarathon (10). Following an IT, 27% of tested athletes had elevated troponin T blood levels (11). Abnormal echocardiographic segments were frequently seen in this group, and postrace ejection fractions were reduced by an average of 24%. These findings suggest possible myocardial fatigue and/or damage (11). All of these postrace changes appear to be transient and without clinical significance.

In spite of measured cardiac functional changes, clinical cardiac emergencies are rarely seen at the finish line. Documented cardiac fatalities in marathons suggest that approximately 1 per 50,000 participants risks fatal arrhythmia or myocardial infarction, with most episodes occurring during the event—not at or after the finish (12).

Hematologic considerations. Up to 95% of IT athletes exhibit a decrease in serum haptoglobin levels after an event, and 30% have occult blood in postrace urine (13). Although these results suggest that "footstrike hemolysis" and renal ischemia and/or bladder contusion are frequent occurrences in an IT, there seem to be no observable clinical consequences.

Musculoskeletal considerations. Muscle cramps during exercise are a difficult problem. Muscle pain occurring during exercise is often attributed to metabolic factors, including acids, other ions, proteins, and hormones, but no single factor has been identified. A more likely cause is damage to the connective tissue in muscle caused by the repetitive eccentric muscle contractions associated with prolonged weight-bearing exercise (14).

Muscle cramps after exercise have been assumed to result from fluid-electrolyte imbalances, but studies have indicated otherwise (14,15). Certainly, muscle cramping after prolonged exercise occurs in athletes who have normal plasma electrolyte levels and normal hydration (16). A more likely explanation is fatigue-induced neuromuscular changes with increased baseline electromyographic activity.

Rest and maintaining cramp-prone muscles in a lengthened position are established therapies. We have found active contraction of the antagonist of the cramped muscle useful in reducing muscle spindle and motor neuron activity by reflex inhibition (15). Although massage and gentle stretching of involved muscles is considered beneficial, no objective evidence of the efficacy of these maneuvers exists. Nevertheless, many athletes consider this treatment helpful, and it should be offered. Fortunately, most muscle cramping will resolve within 30 minutes regardless of the treatment employed.

After ultraendurance events, total creatine kinase (CK) and CK isoenzyme levels, including CK BB, CK MB, and CK MM, are markedly elevated. In addition, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and myosin heavy chain fragments are increased (17,18).

These changes reflect a considerable degree of muscle protein leakage consequent to skeletal muscle fiber damage; nevertheless, recovery occurs within a few days, and no clinical sequelae have yet been reported. There is no correlation between muscle enzyme leakage and postrace muscle soreness or weakness (17). The elevated CK MB levels are expected at the end of an IT and should not be interpreted to support a diagnosis of myocardial infarction in the absence of an appropriate history, symptoms, and electrocardiographic changes.

Skin and nail problems. Any skin or foot problems should be assessed when possible. Large blisters (greater than 1 to 1.5 in.) may be aspirated at their edges with a fine needle and syringe and dressed. Smaller blisters and most toenail trauma can be cleaned and dressed.

Pulmonary issues. IT athletes with allergic rhinitis or asthma are usually quite experienced at managing these problems but may encounter some surprises when competing away from home. Treatment of these conditions after an IT event should follow standard clinical practice.

Fluid-Electrolyte Imbalances

Clinical examination for dehydration or overhydration is a critical responsibility for the volunteer physician in the finish area (19). Most IT competitors are expert at feeding and drinking during the cycle phase of the event, but meeting fluid requirements poses a greater challenge to the athletes during the marathon run.

Dehydration. Dehydration becomes likely, especially in the elite runners, when the race is run in extreme heat and humidity (20). Dehydration, up to 10% of body weight loss, significantly impairs the endurance athlete's performance and could have some health consequences.

Indications to use intravenous (IV) fluids in collapsed IT athletes are rare (see "Triathletes: IV or Not IV," page 42). IV normal saline should be given only when there is clear evidence that: (1) the athlete has significant dehydration (shown by dry mucous membranes, the inability to spit, loss of skin turgor, sunken eyeballs, etc), (2) the dehydration is causing significant cardiovascular instability or other specific medical problem, (3) the dehydration cannot be effectively treated by oral fluid replacement, and (4) if the patient is unconscious and serum sodium concentration is more than 130 mmol/L (16).

Hyponatremia. Quite a different scenario is more probable in elite triathletes who slow substantially during the marathon, or in slower runners. Present data suggest that the etiology of hyponatremia relates to the excessive replacement of fluid lost by sweating (a dilute sodium solution) by ingesting large volumes of even more dilute fluids (water or sports drinks, all of which have relatively low sodium content). Hyponatremia is more common in women, slower runners, and especially in those finishers who maintain or even increase their body weight during the marathon race (4,21).

Slower runners sweat less (sweat rate is determined by the metabolic rate, which is proportional to mass times running speed) but have greater opportunity to drink as they walk more and run at a lower exercise intensity. At these lower exercise intensities, gastric emptying is definitely higher and intestinal absorption is possibly higher than during exercise at higher intensities (22).

In addition, these fatigued or slower runners may believe that drinking itself will reverse their fatigue and allow them to run faster. As a result, overhydration becomes increasingly more likely in athletes who take more than 11 hours to complete the IT, equivalent to a marathon time in excess of 4 hours (21).

Mild levels of overhydration (3% to 5%) seriously interfere with athletic performance and can be fatal if incorrectly managed (21). Signs of overhydration include edema of the hands with swelling of the fingers. This can be diagnosed by observing increased tightness of any rings or bracelets, especially watchbands. Tightness of the identification bracelet worn by all IT athletes, which is fitted well before the race starts, provides a helpful clue to overhydration.

Hyponatremia occurs in 10% to 40% of ultraendurance athletes postrace (2,4,23,24). Most of these individuals are asymptomatic, with serum sodium concentrations greater than 130 mmol/L. Evidence indicates that all athletes with symptomatic hyponatremia have a fluid overload of 3 to 6 L (2,21,25). Moderate hyponatremia (serum sodium concentration of 126 to 130 mmol/L) may be associated with cerebral symptoms that may include confusion and disorientation with slowed mental functioning.

Severe hyponatremia (serum sodium concentrations less than 126 mmol/L) may cause seizures, coma, and death (25). The unconscious athlete should have his or her bladder catheterized and should be evacuated to a hospital facility promptly for definitive management. He or she must not receive fluids either orally or intravenously except, perhaps, 3% saline solution given at rates no faster than 50 mL/hr (16). In view of the gravity of this problem (19), facilities for measuring serum sodium and potassium are available in the medical finish area at Ironman USA-sponsored events.

The treatment of less severe hyponatremia (serum sodium levels more than 130 mmol/L) is usually one of "masterful inactivity." Provided there is an adequate flow of very dilute urine, recovery will occur, albeit slowly, and may take 10 to 24 hours (25).

Abnormalities in Body Heat

Hypothermia. Low body temperature may occur during the swim phase of the IT (1 to 2 hours for most athletes) if the water is cold. Mild hypothermia (core temperature > 94°F) may be treated with rewarming, and the athlete may reenter the race if able.

Heatstroke. Heat illness may complicate the cycling and running portions of the race (8 to 15 hours) if conditions are hot and humid. Heatstroke is the only properly defined heat injury in which there is a failure of thermoregulation as the rate of heat production exceeds the rate of heat loss, resulting in a rise in body temperature. When body temperature exceeds about 41°C (105.8°F), mental symptoms begin to develop that are similar to those experienced in hyponatremia. There is a clouding of consciousness and disorientation leading in some to unusually belligerent actions, including physical violence, culminating in coma. Heart rate is usually very rapid, but blood pressure is low due to a large reduction in total peripheral resistance, probably caused by abnormal vasodilation in the cutaneous and splanchnic circulations.

The immediate diagnosis of heatstroke is based on a high index of suspicion for any athlete who exhibits an altered level of consciousness. Any triathlete with altered mentation (confusion, disorientation, bizarre behavior, or altered arousal) should be presumed to have either heatstroke or hyponatremia and be evaluated and treated promptly. Once treatment has commenced, hospital evacuation will be necessary if complications arise or if the condition fails to improve.

The key to the management of heatstroke is to lower the rectal temperature to below 38°C (100.4°F) as rapidly as possible. This is best achieved by placing the athlete's torso in a small, child-size plastic bathtub filled with ice-cold water, with the athlete's arms hanging out over the sides of the bath. Exposure in the bath for 5 to 10 minutes usually suffices.

Heatstroke is far more probable in a standard-distance triathlon in which athletes run 5 to 15 km at high speed (3 min/km). These athletes run at up to 90% of their maximum oxygen consumption (VO2max). When conditions are hot and especially humid, there is a significant risk that heatstroke may develop, especially in the heavier, elite runners. Because the best IT athletes complete the marathon race at about 60% to 65% VO2max, the rate of heat production is much lower, so the risk of heatstroke is lower at IT events.

To our knowledge, heatstroke has almost never been reported in an IT participant, although one of us (T.D.N.) encountered an instance at the 192021 Hawaiian IT when an elite athlete had increased his running speed and had maintained a high rate of energy expenditure over the last 16 km (10 miles) of the race when conditions were hot and humid.

Postural Hypotension

Very prolonged exercise in the heat increases cutaneous blood flow and may lead to a progressive redistribution of blood from the central circulation to the capacitance veins in the limbs. With cessation of exercise, the pumping action of the leg muscles becomes inactive, reducing venous return, and facilitating postural hypotension. This probability is increased because the pressure-raising reflexes (vasoconstriction of the cutaneous and splanchnic circulations and of the arterioles supplying the previously active lower limb muscles) are generally reduced in trained athletes and, most especially, after very prolonged exercise in the heat. As a result, on cessation of exercise, postural hypotension is common (26).

Postural hypotension has been called, we believe misleadingly, heat exhaustion or heat syncope (16). The term is inaccurate because there is no evidence for abnormal heat retention in the body with this condition.

Causes. Intense lower-extremity muscle exertion during the cycle and run phases of the IT lasts 8 to 15 hours. The metabolic consequences of this remarkable degree of work output creates a circulatory alteration that may be thought of as an "upper-body steal syndrome," in which virtually all organs above the hips donate blood flow and nutrient energy to the working muscles of the lower extremities.

The increased lower-body circulatory demand and residual perfusion of the upper body are supplied by the excellent cardiac output of the highly trained endurance athlete. High rates of perfusion of the lower limbs increase the filling of the cutaneous capacitance veins. The extent to which these veins are filled is determined in part by the environmental temperature, which affects the skin temperature and hence the degree of vasodilation. Continuous muscle contraction prevents pooling of blood in these dilated veins, thereby maintaining venous return to the heart.

Upon completion of the event, however, cessation of leg muscle pumping action causes a sudden drop in venous return and cardiac output and hence in forward blood flow to the tissues. The resulting sudden decrease in upper-body perfusion produces central nervous system symptoms of dizziness and unsteadiness. Symptoms of "black spots" or a "black curtain" over the eyes may occur. Facial pallor, diminished or absent peripheral pulses, and profound reduction in blood pressure are common. Pulse rates will usually be inappropriately slow for the observed level of hypotension because of the high parasympathetic circulatory tone elicited by the endurance training that these athletes have undergone.

Reversing the effects. All of these findings may be reversed if the athlete is placed in a recumbent position with the legs and pelvis slightly elevated above the level of the heart. The increased venous return from the legs empties the blood from the dilated capacitance veins. In this way, circulatory stability measured as a supine blood pressure of 110/70 mm Hg or greater, and an appropriate heart rate of usually less than 100 beats per minute, is reestablished almost instantly.

Because the body temperature is not abnormally elevated in postural hypotension, its treatment will differ from the treatment of heatstroke. Because symptoms may in large part result from the sudden cessation of exercise, the first step in treatment is to place the athlete supine on a stretcher or bed with the feet elevated about 6 in.

Unfortunately, triathletes with postural hypotension have in the past been nursed on a horizontal bed, and their postural hypotension, assumed to be caused by dehydration, was treated with IV fluids, usually in large volumes. As IV fluids alone cannot increase venous return from the dilated capacitance veins in the legs, the treatment has no logical basis. In addition, no study has shown that collapsed athletes treated with IV fluids recover more quickly than they would have had they simply been nursed in the head-down position. (Perhaps a more appropriate use of the bags of IV fluids would be to place them under the foot of the bed to elevate it by about 6 in.!)

Classic Postrace Presentation and Procedure

The typical IT athlete will present in the medical area supported between two aides. The athlete will be an unhealthy shade of white or gray and may appear near-syncopal. Upright pulse and blood pressure may be unobtainable. He or she may complain of nausea and/or vomiting, with or without abdominal discomfort, and be crying out in pain from muscle cramping.

The immediate assumption is that at least part of, or perhaps the major contributor to, the symptoms result from the sudden cessation of exercise. Accordingly, the first step in treatment is to place the athlete on a stretcher or bed with the feet elevated about 6 in. Once the collapsed athlete is placed on the appropriately slanted bed so that he or she is lying in a head-down position, it is possible to begin to make a provisional diagnosis according to the guidelines provided below.

The initial medical exam. Evaluation (table 2) includes an assessment for one critical finding: level of consciousness. If the athlete is unresponsive, confused and disoriented—or exhibiting bizarre behavior or convulsions—heatstroke (or hypothermia depending on environmental conditions) or hyponatremia should be assumed to exist if no other obvious medical cause such as cardiac arrhythmia or cerebrovascular accident is discovered.

TABLE 2. Guidelines for Determining the Severity of a Collapsed Triathlete's Condition
Immediate Assessment Not Severe Severe

Mental state Conscious Unconscious or altered
Alert Confused, disoriented, or aggressive

Rectal temperature < 40°C (104°F) > 40°C (104°F)

Systolic blood pressure > 100 mm Hg < 100 mm Hg

Heart rate < 100 bpm > 100 bpm



Specialized Assessment Not Severe Severe

Blood glucose 4-10 mmol/L < 4 mmol/L or

Serum sodium 135-148 mmol/L < 135 mmol/L or > 148 mmol/L

Body weight loss 0%-5% > 10%

Body weight gain < 2% > 2%

Remember that one is dealing with athletes who began the race in high states of wellness. Thus, the probability is that the IT athlete's abnormal level of consciousness is more likely due to a pathologic condition resulting from participation in the triathlon than from a preexisting latent medical condition. However, the wary clinician needs to remember that very occasionally collapse may be due to aggravation of preexisting pathology such as a ruptured intracranial blood vessel. It should be noted, however, that IT athletes who have a serious medical condition, including heatstroke or hyponatremia, or a latent preexisting medical condition are more likely to collapse before the finish line.

Evaluation should involve prompt assessment of body temperature and plasma electrolyte concentrations, with appropriate initial treatment. Urgent hospital evacuation may be required.

If the athlete is conscious and coherent, postural hypotension may be assumed, and he or she should be placed in the recumbent position under a blanket with legs and pelvis elevated above the level of the heart. Wet clothes should be removed. The athlete should be asked about any significant medical illnesses, drug allergies, any unusual symptoms during the day's event (table 3), and fluid intake during the race. If fluid intake has been excessive (more than 1 to 1.5 L/hr) (27) and the athlete reports little urine production, fluid overload and hyponatremia need to be considered.


TABLE 3. Helpful Information to Obtain From Each Collapsed Triathlete


Amount of fluid ingested during the race

Amount of urine passed during the race

Occurrence of vomiting and/or diarrhea before and during the race

Amount of carbohydrate ingested before and during the race

Medications taken before and during the race

Recent intercurrent illness

Race preparation, heat acclimatization

Training schedule, training volume


Physical examination. Exams should include vital signs with the patient recumbent, inspection of mucous membranes, and assessment of skin turgor for dehydration. Overhydration is suggested by hand edema, increased tightness of rings, bracelets, or watchbands, and weight gain during the event. Quick assessment should include pupillary reactions, neck suppleness, cardiac and pulmonary auscultation, abdominal palpation, and foot inspection. If these findings are normal, the athlete should be reassured that he or she will probably feel much improved in 20 to 30 minutes. Athletes may be advised to take oral fluids (juice, electrolyte-containing rehydration drink, soup, or water if the latter is the only fluid that appears to be palatable) provided that they exhibit no evidence of overhydration.

If cardiovascular status remains persistently abnormal after the athlete is placed in the head-down position, then the heart is responding inappropriately to an adequate venous return, and the possibility of a primary cardiac condition must be considered.

Finishing Lines

Volunteer physicians staffing the medical areas at triathlons may not be familiar with the unique medical needs of ultraendurance athletes. Physicians should know the signs and symptoms of dehydration, heatstroke, hypothermia, hyponatremia, and postural hypotension yet maintain suspicion for preexisting pathologies. The administration of fluids should not be an automatic first response. Determination of the athlete's condition and the correct treatment could be a life-and-death decision.

Dedication

All "guidelines for medical care" are encumbered by the innate variability of individual patients and their unique clinical characteristics. Nevertheless, the authors of this article hope that it will prove to be a useful guide for physicians from many different medical disciplines who come together to volunteer their services to the remarkable athletes who participate in the Ironman Triathlon. We dedicate it to the athletes in the hope that it will enhance the quality of the medical care they receive at Ironman triathlon events.

References

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  10. Laslett L, Eisenbud E, Lind R: Evidence of myocardial injury during prolonged strenuous exercise. Am J Cardiol 1996;78(4):488-490
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  20. Dennis SC, Noakes TD: Advantages of a smaller bodymass in humans when distance-running in warm, humid conditions. Eur J Appl Physiol 1999;79(3):280-284
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Triathletes: IV or No IV?

Unless there are clinical signs of dehydration, including persistent cardiovascular instability in the supine head-down position suggesting marked reduction in the circulating blood volume, routine administration of intravenous (IV) fluids is generally not recommended for ironman triathletes for the following reasons:

Risks. Administering IV water and/or sodium to adequately hydrated individuals may create water and electrolyte imbalances that did not already exist. In patients with symptomatic hyponatremia, death may result from IV fluid administration. There are also small risks for hematoma, infection, and syncopal reactions.

Logistics. IV fluid administration confines the athlete to the treatment cot for 1 to 2 hours during a time when many other athletes are appearing for evaluation and treatment and when friends and relatives are waiting for the athlete outside the medical area. By contrast, our experience shows that treatment with recumbent positioning and oral hydration usually allows the athlete to leave the medical area in 20 to 30 minutes. Furthermore, placing and maintaining an IV drip uses up valuable medical manpower that might be better employed dealing with seriously ill patients.

Expense. Average cost for IV fluids at IT events is around $10,000 (verbal communication with Lyle Harris, Ironman USA race director, September 1999). These funds divert support from other services that could be offered to the athletes.

If athletes treated with recumbent positioning and oral hydration are stable within 30 minutes and symptoms have largely resolved, they can resume an upright posture. If this is tolerated, they can be discharged. If signs and symptoms of postural hypotension, vomiting, or severe muscle cramping persist, plasma electrolytes should be assessed and the total clinical picture reassessed. When in doubt, consult with a colleague experienced in postrace care of these athletes.


Dr Mayers is director of sports medicine at Pace University in Pleasantville, New York. Dr Noakes is a professor of exercise and sport science at University of Cape Town and Sports Science Institute of South Africa in Newlands, South Africa. Address correspondence to Lester B. Mayers, MD, Division of Sports Medicine-Athletics Dept, Pace University, 861 Bedford Rd, Pleasantville, NY 10570; e-mail to [email protected].


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