0 Hyponatremia? - Heat Exhaustion? 0 "ATC rankings of - PDF document

"P'S'T PATS " ""'"O" "".",,;~:~,:~:o~' Research Fund E .", T.o.'mo"' HO u ood T.o.'mo"' Th an k yo Sponsors Sodium Depletion Illness (Hypovolemic Hyponatremia) Sandra Fowkes GodekPhD, ATC Professor/Director,The HEATInstitute Flyers West Chester Universily of Pennsylvania I N S'TIT"(n,'t " I N"S"TI,""" T " Ho.1 "'"0"".1..,.." A..Id."oo."d T.o.lmo"' Ho.' 'b" ,..1..11." A..Id.",o ."d T.o.lmo"' Introduction Introduction 0 Problems we are faced with - Why has the 0 Critical questions to which we don't have incidence of hyponatremia increased? all of the answers - The EHS (Tc)and dehydration dilemma 0 By the numbers - sweat sodium losses - Experimental versus FieldStudies 0 Hyponatremia versus heat exhaustion 0 Majorfluid regulating hormones - The body's response to lowblood pressure 0 Hypovolemic hyponatremia - Signs/symptoms 0 Three formsof hyponatremia - Management and prevention 0 Electrolytestudiesin FB and Ice Hockey - Na+supplemented versus un-supplemented [F:]" , ,"" lIIIiAtU [ N"S'T'T'1'OT " I NS"r",..:'t'tJ '1' " r Hoal"'"o" ,..1..,.." A..Id.",o ""d T.oalmo"' Hoal "'"." E..I..,.""".Id."," ."d T..almo"' I Problem- Which are Heat Illnesses? Problem - What causes Exertional Heat stroke?? HS ATC Survey DombekC"., 0 Heat Cramps (EAMC)? v...g"".1 JATSoppl2006 0 Hyponatremia? - Heat Exhaustion? 0 "ATC rankings of 14itemsthat predispose 0 - Symptomatic athletes to EHS revealed they consider.." dehydration 1. Dehydration (2.6 rank) This can be prevented!! 2. High Humidity (3.4 rank) 0 Exertional Heat Stroke (EHS) - YES 3. High ambient temperature (4.3 rank) 0 A heat illness is defined as a condition in 4. Acclimatization (5.1 rank) which the primary treatment is rapid 5. Physical fitness (5.7 rank) 6. History of heat illness (6.1 rank) cooling!! 7. Exercise intensity /6.2 rank) 1

1 .. E , ,FST-~,,>t~'UCT E I .eat .,." A.oid..,. T""""" .eat ._" E."""'" A.oido". T"""," Problem - What causes Exertional Is there a Significant correlation between Tcand level of Hydration? Heat stroke?? Dombek,C"',Y",gl"I,'JAT',ppl2006 . Dehydration was ranked significantly higher 0 than all other factors except high humidityll . However - The overwhelming expert . .. u ~ '" ':~'..': ,"',. consensus is that metabolic rate (exercise l" . " intensity) is the sinclle most important factor related to elevated core temperature " r= ,76 p< .DDDt " . - Dehydration at best has minimal affect I . So why do ATC's still think this way?? ." D...", , Where does your information come from? Bartolo;,/ AR. Fow'" God.. S, Sw..1 "I. "d 00" '.m"."I", "'PPO'" to ~, . . . , 'f~ II!! ,~,t D,hy,"'U.,lnd"," "",,'monl,lIy "",u. during ,,'u,1 p" on p",U" I' . . ColI'g' ,..'hall pia,.." ,J A!h/ T,,/n '39(2), 2004, ,--, , N;S~1'" .1""""I' .: .eat ".." ""'.'0' A."d.". o,d T,""'... ,... On... A...d.n.. .nd I.......... I Is there a Significant correlation Field Sludy during FBPraclice Experimenlal, fixed workload between T c and level of Hydration? 42 " " " 40 . ~ u 39 I '" U n. i 3H I , , '... '." "" '. ~.', En. 8" . , . , '" ., ., ., ,i~ "",",~."..,.." ",...'O.h",,"'.n .,., .0' " ""h"",II., r = .76, P < ,0001 r = 0,198, P = 0,294 J;Wc:L ;;\\{~ r= 0.198, p=0.294 I N'f§TI 4"'{JT E I ,iFS"'T..,'.:'F"tJ'1' E ,..I III,... ".,..11.,A...d.n....d T , Runners during a Marathon Run ner~'o~'~;~~~A':O'~:T;:;~on I 8 -7-.-0-,,-1;-12 . When runners get hot, (;-13-" -1S"""'~'" :' -2-'--4+" --0 ::., they slow down "" : ~ ~ . Some '" T ,,-,,<g reach Tcmaxearly ';;'" 107m;n ~,- 41.0 ii."" ~" I""~'F . Some at the end " :o ::-.rX'" . "., ",/ ..; .... ~ ~9'F -. 40.' ~ j ~ 40.. f"'~""""'-, " "" lIf< [ ,." ...~;- r 1C . ,., ~~ ~ ",1 ~--!, , . . .~'" . ,-~OSmi" '. Tcis not related to % ~"",~ .~v " ~ ::" . ~:: . . },- \ / . ::::-? 106' dehydration ~:::..."'-.,,~- ~ ".n ' ,,::.' "'[,' . Tcmax of 104 -106 DF ~ . , "',0 L.,...... are 3"! . 101'F ;;:'j 101.8 Of J I common and well '" ""-';:;":':,:~;r',:""".,';': '" 0 ;'."",i~9 T;"~~",I";" '" .) 3O"""::~["";':-lm;";;' ,;" Byrne, Lee, Chew el al MSSE 06 Byrne, Lee, Chew el al MSSE 06 r; toleratedlll IiIVCt' I 2

-- 1 I - I I g I rFS'T' ,"rU4' ., H..'ill,...".".1100 "ald.,.. .,dT,..tm.,. H..' ,",... ".'...11., A.ald.,.. .ad T,aaim.,' I ConcluSiOnSs y rne Lee Chew et al msse 06 . . Triathletes during a Race I I . Mean Tc max= 38.1°C I. 17 of the 18 runners had a T cmax ;:: 103 of I (100.6°F) I . Mean % dehy = 3% I . Change in mass was not -In my lab the experiment for them was ended : I. 10 of the 18 runners had a T cmax > 104 of related to finishing Tc I - In any lab in this country the trial is done . "Body mass loss of 3% was . % dehydrationrangedfrom 0.9%- 3.9% found to be tolerated by well . "Core temperature responses demonstrated trained tri-athletes ...m without any evidence of nosignificantrelationshipto absolutel:!.mass r % dehydration" ~ ",' .o Laurson et al BJSM 06 (lWCl ; ~;~;~OregUlatOry failure" , I I I I N""'Pl'c,T'tJ't " H..' ;II,... ...1...11., A.ald.,.. .,d T'..'m." "" I Tc and % Dehy in Pro Players I: ,os 107 I I ra ,065 ,.. Q( ) P a 0,39 Athletes get hot - so what's 45 different players in the '03 ,os 183 player practices big deal?? I ~'02 i . ';"": I '00 ~ 101 . = I g :"i4.... '03 " Players were symptomatic . ., : : :,::: .. ; ':-':. on only 4 occasions "" , :., '. 98 - LM F~'" Gad..5," al.JAT 2'" - "' ~ ~ . ~ . . BKS 97 Ii Iltl; ".1 11m. II~ ,"'. 11m. 11m. "'" 11m. ,~ , 2 3 , 5 . 7 8 ~Vvtl; P.~,' Doh"""M ,....--- . ~""" ." , N"S'T I 4'~lJT g I ""S'1' 1,"'1"'71' E H.aI "_.. , A.ald.,.. .ad T,.almaof Haai .,... ..aI , A.ald.,.. .,d h""'" I MajorHormones Involved in the The EHS and Dehydration Dilemma . It clouds the fluid/electrolyte : control of Blood Volume (BP) balance issue . Released . Released and provides a false sense of security when blood when blood ! . It promotesthethinkingthat drinkingto volume and blood volume and blood pressure are low pressure are high replace all fluid losses will prevent EHS . We don't - Vasopressin (ADH) - Naturetic Peptides . ANP know what causes EHS but it is - Renin-Angiotensin . BNP " NOT dehydration - Aldosterone . Urodilantin . 2 - 3% body mass loss during exercise is normal, expected and well tolerated ~1\Ct fii \VC i 3

( ""'5'1"">4' "1'1' r, IN'ST,"rUTE Heollll"e.. "0'"0110" A,o'do"oo o"d "'o'me"' Heal ;II"e.. "01"0110" A,oldo"oo o"d (,oatme"' The Body's Response to Low BP Angiotensin II (Salt/blood volume Depletion) -Causes Vasoconstriction of BloodVessels . Kidneys release Renin - Stimulates Brain to release Vasopressin . Renin combines withAngiotensinogen to (ADH) 0 Increases H2O reabsorption form Angiotensin I 0 Stimulates Thirst I. Angiotensin Iis converted to Angiotensin II - Stimulates adrenal cortex to release , by ACE Aldosterone 0 Angiotensin IIstimulatesseveral 0 Increases Na+reabsorption I mechanisms that raise blood pressure Body Fluids - t Blood Volume - t ri~, BP E H.ollII"... "0'"0110"A,o'do"oo o"d T..olme"' 280 mOsmlkg 290 mOsm/kg ./ Hyperhydralion --v- HYPOhYdrati;;;;- Euhydration r; Aldosterone "'" " T'" promotes Na+ Uptake in Kidneys II I'Ve,} I ,.S"I'"",XI"(j", E ( N';,F1'l,'1"'t)T E Heoll""e.. "0'"0110" A,aldo"oo o"d T,ealme"' Heal"'"0" "0'"0110" "o'do"oo o"d T,eo'me"' 290 mOsmlkg . What is Normal Body Mass? . 280 mOsm/kg ~~"")."Yd"'tiM'=""'" AVP Naturetic pepMes Aldosterone No thirst Thi"t Blood Electrolytes? ~ 290 mOsmlkg 280 mOsmlkg Blood Glucose? Hypohydration \. ) Hyperhydration y Body Temperature? Euhydration ~ 4