Cramping Syndromes Sodium Loss and Sickle Cell Trait E. Randy - - PowerPoint PPT Presentation

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Cramping Syndromes Sodium Loss and Sickle Cell Trait E. Randy - - PowerPoint PPT Presentation

Oct 14, 2022 241 likes •648 views

Cramping Syndromes Sodium Loss and Sickle Cell Trait E. Randy Eichner, MD Team Internist, OU Sooners OU Health Sciences Center Not All Cramps Are Alike None Below from Salty Sweating Writers cramp Fiddlers cramp Golfers

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SLIDE 1

Cramping Syndromes

Sodium Loss and Sickle Cell Trait

  • E. Randy Eichner, MD

Team Internist, OU Sooners OU Health Sciences Center

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SLIDE 2

Not All Cramps Are Alike

None Below from Salty Sweating

  • Writer’s cramp
  • Fiddler’s cramp
  • Golfer’s yips
  • Hurdler hamstring
  • Runner side stitch
  • Hypervent. tetany
  • Sleeper calf cramp
  • Sickler cramping
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SLIDE 3

Heat-Cramping Controversy

Muscle fatigue and what else?

  • Dehydration?
  • Low potassium?
  • Low calcium?
  • Low magnesium?
  • Muscle spindle/Golgi organ?
  • Is it quinine deficiency?
  • Or the dreaded Cramp-O-Ray?
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SLIDE 4

Heat Cramps: Salty Solutions

  • Stokers
  • Miners
  • Military
  • Hoover Dam
  • McCance
  • Tennis
  • Football
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SLIDE 5

Hoover Dam Saline Solution

Talbott & Michelsen, JCI 1933

  • “An important

criterion (was) …marked relief after (infusing)… normal saline. All cases…free from symptoms within six hours…”

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SLIDE 6

King of Tennis

Mike Bergeron (JSMS 2003)

  • 17 male players
  • All crampers, but

heat-acclimatized

  • Hot/humid match
  • Sweat 2.6 L/hr
  • Na+ loss/hr 2.7 g
  • One lost 12 g salt

an hour!

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SLIDE 7

Chris Legh in Lab

Top Australian Triathlete

  • 2-hr run; 2-h bike
  • Mimic Kona clime
  • Lost 8.8 L sweat
  • Drank 5.5 L fluid
  • Lost 3.8% body wt
  • Lost > 25 g salt!
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SLIDE 8

Cystic Fibrosis?

  • One gene: 1 in 20
  • r 25 whites
  • Mitigates typhoid,

cholera

  • Sweat sodium up

to 60-80 mmol?

  • Cake with salt
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SLIDE 9

Heat-Fit Football Player

  • 250 lb, 60-65% H2O
  • 17-18 gal water
  • 100 gm sodium or

50 tsp salt

  • In hot game, can

sweat 1-2 gal fluid, 5-10 tsp salt

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SLIDE 10

Fluid Turnover in 2-a-Days

Stofan JR et al., at ACSM 2005 Players 10.3 ±2.2 L/d (9 - 14 L/d)

Crampers 11.2 L/d Non-crampers 9.7 L/d

Note that top turnover is 3.5 gallons of fluid a day! No wonder they’re thirsty!

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SLIDE 11

Two groups (n=5): Crampers vs. Non-Crampers Matched: Age, Weight, Race, Position Measures: Sweat out, fluids in, sweat [Na], [K] Pilot Studies: June, July (Field Skills, Indoor Weights) Final Study: August (2-a-days; 2.5 hr practices)

SWEATY SOONER STUDY

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SLIDE 12

Crampers Are “Salty Sweaters”

Sweat sodium levels are always higher in crampers… Trends similar in all three studies, June, July, August…

20 40 60 80 100 June July August Cram p Non-Cram p

Sweat Sodium, mEq/L

OU Studies 1.7 1.4 2.1(P<.01)

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SLIDE 13

Crampers Dehydrate More

  • 1.6
  • 1.4
  • 1.2
  • 1
  • 0.8
  • 0.6
  • 0.4
  • 0.2

D e h y d ra tio n %

C NC C NC

Morning Evening Despite drinking, high sweat rates dehydrate

ES = 0.98 ES = 0.32

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SLIDE 14

Crampers Lose More Salt

1 2 3 4 5 6 A M PM C N C

Sweat [Na] x Sweat rate = GREATER TOTAL LOSS (P=.01)

Grams sodium ES = 1.8 ES = 1.1

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SLIDE 15

Salt Depletion: NFL 2-a-Days

Godek et al, ACSM 2004

  • 6 NFL players, age ~ 26, wt. ~ 104k
  • Serum Na+ fell, 140 to 137 mmol/L,

by Day 3 (~ 200 mEq Na+ lost)

  • Or ~ 12 gm of salt lost by Day 3!
  • Plasma volume fell ~ 5% by Day 3
  • Conclusion: They need more Na+

during early 2-a-days

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SLIDE 16

Clues to Salt Depletion

Warning signs for athletes

  • Salt on your skin
  • Your sweat

– Burns eyes – Stings abrasions – Tastes salty

  • Heat cramping
  • Dizzy standing up
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SLIDE 17

Get More Salt in Diet!

And in Sports Drinks Onfield

  • Tomato juice
  • Salty soups
  • Baked beans
  • Pickles
  • Pretzels
  • Pizza
  • GLytes
  • Endurance formula
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SLIDE 18

The Water Hazard

  • HS linebacker locks up in 2nd half
  • Quaffs 9 L water
  • Seizure, Na+ 120
  • College LB locks up in practice
  • Quaffs 12 L water
  • Goofy, Na+ 121
  • College FB player with leg cramps
  • Given 8 L hypotonic fluid IV and po
  • Goofy, wet lungs, Na+ 121
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SLIDE 19

Cramp-Prone?

  • Lean and fit
  • Explosive
  • Many reps
  • Intense
  • Heavy sweater
  • Cakes in salt
  • Low salt diet
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SLIDE 20

Methods Methods

  • Measure

– Body weight change – Fluid intake – Core temperature

  • Calculate

– Sweat rate – % dehydration

  • Measure

– Body weight change – Fluid intake – Core temperature

  • Calculate

– Sweat rate – % dehydration

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SLIDE 21

8 subjects

129 +12 kg 190 +3 cm 22% fat Pre-session USG: 1.025 +0.007 (1002 mOsm/kg) Pre-session USG: 1.025 +0.007 (1002 mOsm/kg)

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SLIDE 22

Results - Pre-Season

  • Heat Stress

WBGT 22.9 +07 ºC No radiant contribution

  • Sweat rate

1.5 +0.3L/h

  • Dehydration

0.8 +0.4%

Peak avg 39.4 +0.6 ºC

35 35.5 36 36.5 37 37.5 38 38.5 39 39.5 40 40.5 Pre End

Core Temp, ºC

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SLIDE 23

Time (min)

  • 10

10 20 30 40 50 60 70 80 90 100

Change in Tc from Baseline, °C

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Field Drills (Vest) Heavy Lifting (Wts) Break, then Sprints

DB 23.9 +0.3 25 +0.4 ~24ºC RH 77.5 +1.6 76.8 +1.7 75% WBGT 22.3 +0.4 23.4 +0.5 22.5 ºC

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SLIDE 24

Lessons Learned

Radiopills hold promise in football

  • Can heat up fast and

even cramp up

  • In a June drill
  • No football gear
  • Dehydrated at start
  • Salt-depleted too?
  • Cool fast when stop,

despite cramping

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SLIDE 25

Features of Heatstroke

  • Fuzzy thinking
  • Confused, can’t follow plays, runs wrong way
  • Bizarre behavior
  • Blank stare, talks nonsense
  • Yells in rage, wants to fight
  • Physical decline
  • Incoordination, N/V, hyperventilation
  • Wobbles, staggers, collapses
  • Seizure, coma
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SLIDE 26

Day One Death in Dallas

Eric Brown, 17, Carter High, 8/2/04

  • Starting center
  • 3 ½-hr practice
  • Heat index 105
  • Sprints at end
  • Collapsed once?
  • Got through it
  • Seizure at home
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SLIDE 27

Risky Ways for 2-a-Days

High schools; Dallas Morning News; Aug ’04

  • “Our first practice

the longest” (3.5 h)

  • Breaks in sun
  • End with 16 sprints
  • K+ pills at end
  • If collapse: “Get

fluid in them”

  • Wrong! Get them

in fluid! (Ice bath)

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SLIDE 28

Ice water immersion

  • n-site
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SLIDE 29

Dehydration Curbs Cycling

Walsh et al: Int J Sports Med 1994

  • Twice, in the heat, 6 cyclists ride for

1 hr at 70% VO2 peak, then closing sprint to exhaustion at 90%

  • One trial, oral fluids; one, without
  • Without fluids, dehydrated 1.8%
  • Without fluids, sprint 7 minutes
  • With fluids, sprint 10 minutes
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SLIDE 30

Learn Your Sweat Rate

And drink to match; don’t overdrink!

  • Weight lost in drill (in oz)
  • Plus fluid drunk in drill (in oz)
  • Equals how much to drink
  • Example:

– If loses 3 pounds (3 pints: 48 oz) – And drinks 16 oz (1 pint) – Drink 48 + 16 = 64 oz (4 pints) next drill

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SLIDE 31

Sickling Forces in Football

  • Severe hypoxemia
  • Hyperthermia
  • Acidosis
  • Dehydration
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SLIDE 32

12 Deaths, College Football

All From Sickling; Some Controversial

  • 1974 Colo., ran 800 m
  • 1985 Ark., ran ¾ mile
  • 1986 Miss., ran 1 mile
  • 1987 Ind., ran 1200 m
  • 1989 Utah, ran ¾ mile
  • 1990 NM, ran 800 m
  • 1992 Ga., ran 1000 m
  • 1995 Ariz., ran 900 m
  • 2000 Tenn., ran 800 m
  • 2001 Fla., 1 hr. mat drill
  • 2004 Ohio, ran ~ 10 min.
  • 2005 Mo., 1 hr. field drill
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SLIDE 33

Sickle Cell Trait

Another “Do or Die” Syndrome

  • 1 in 12 blacks
  • 1 in 10,000 whites
  • Generally benign
  • No anemia
  • No barrier to top

athleticism (e.g., NFL)

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SLIDE 34

Sickling Deaths in Military

  • All deaths in basic training of 2 M.

recruits in 5 yrs. (NEJM 1987)

  • Risk of puzzling sudden death 28-40

times higher with sickle trait

  • 12 such deaths; all tied to exertion
  • Absolute risk: One in ~ 3,000
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SLIDE 35

Air Force Cadets

  • 3 of 20,000: acute

renal failure from rhabdo

  • All 3 sickle trait; all

fit; one set record

  • 2 the same year,

when just 10 had sickle trait

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SLIDE 36

Death at Bowling Green

Aaron Richardson, Died 9/15/04

  • 3-sport HS athlete
  • Track champ, 100

to 400 m

  • Walked on for FB
  • Day 1, sprints for

10 min: cramps

  • Died, locker room
  • Autopsy: Sickling
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SLIDE 37

Risk: All-out exertion for 2-3 minutes without a breather

  • Windsprints, e.g., 300-m repeats x 3-4
  • Timed miles or half-miles
  • Running repeat hills, steps, ramps
  • Intense mat or conditioning drills
  • Accelerated weight lifting
  • Rarely, even in the game itself
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SLIDE 38

Sickle Trait Precautions

  • No d. 1 fitness test
  • No sprints > 500 m
  • No timed miles
  • Regular fluids
  • Stop at 1st sign of

trouble

  • Report to trainer
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SLIDE 39

Treatment: Presumed Sickling

  • Lie down
  • Oxygen by face mask
  • Vital signs
  • Immediate cooling
  • If not improved in 5 min., or if vital signs
  • r alertness decline

– Call 911, attach AED, start an IV, to ER fast

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SLIDE 40

Conclusions

  • Salty sweating: key in heat cramping
  • Radiopills: can prevent heatstroke?
  • If you lose weight: Drink more
  • If you gain weight: Drink less
  • If in doubt: Ice ’em down!
  • Mandatory testing and precautions

for sickle cell trait!