Medical Hockey Scenarios What Would You Do? Case Presentation. Dr. Noah Forman AOSSM August 2015

Transcription

1 Medical Hockey Scenarios What Would You Do? Case Presentation Dr. Noah Forman AOSSM August 2015

2 What Would You Do?

3 Discussion Points Mechanism of injury Assessment of injury and player presentation Are all lacerations equal? Secondary assessment Investigations Treatment Protective visor

4 Clinical Outcome

5 Acute Abdomen: Management and RTP decisions Josh Bloom, MD, MPH, CAQSM Carolina Hurricanes Carolina Family Practice & Sports Medicine Carolina Sports Concussion Clinic KEEP YOUR EDGE Hockey Sports Medicine 2015 August 28, 2015

6 Case 22 yr old healthy European Forward Presents after a game Played 17 + minutes can I talk to you for a minute? 1 day h/o vague abdominal pain No anorexia No fever Nl activity

7 Case continued Soft, abdomen, looks well Mild to moderate, but focal, RLQ tenderness No rebound, guarding, neg Rovsings, etc Monitor overnight see in office in am, NPO just in case Persistent TTP, let s make sure CT abdomen

8 Case continued Acute appendicitis on CT Uncomplicated laparoscopic appendectomy

9 Case continued RTP criteria How soon? Risks? Take home points Know your athlete Focal tenderness High index of suspicion Heal quickly

10

11 history 31 yo presents for PPE 9/13 No new medical complaints No history of significant diseases, meds, surgeries, allergies, drug/alcohol abuse Played in Stanley Cup Finals

12 exam # BP 110/64, P 60 irregular, R 14 HEENT: normal, no adenopathy or JVD CV: irregularly irregular, no M,G,R Lung: CTA Abdomen: soft, nontender, no masses, HSM

13 labs H/H: 17.8/53.8%, MCV 98.8, MCH 32 WBC: 3,500 with 39% PMN, 45% lymphs Chem panel: Cr 1.24, otherwise normal TSH: 2.57 Vitamin D: 70 U/A: normal, sg 1.017

14 ecg

15 ecg

16 further history Denies CP/pressure, tightness, palpitation, dizziness, lightheadedness, syncope, dyspnea, cough, wheeze, abdomen pain, GI or GU complaints No complaints of exercise intolerance No other MSK complaints 1/13 preseason: ecg NSR; H/H 16.1/49.5

17 further history Used creatine in the summer Denies use of ergogenic agents, AAS, GH, EPO, or other other supplements Lives Toronto, no travel to high altitude Drank 3 glasses of wine night before PPE FMH: + mother Afib, no hx sudden death

18 repeat labs H/H: 18/52.7%, MCV 99.1, MCH 33.8 WBC: 4,600 with 39% PMN, 45% lymphs Sed Rate: 1 CRP: <5

19 repeat ecg

20 repeat ecg

21 heart rate on ice

22

23 final diagnoses New onset Afib Polycythemia

24 plan What would you do?

25 plan Blood work for PC, including genetic testing normal; H/H 10/31: 15.1/44.3 Cardiovert and medicate vs ablation

26 plan Can t perform hockey in Afib Can t play on anticoagulants (CVA risk) Ablation: 3-6 months anticoagulants Mimi-Maze: 1 month anticoagulants, 3-4 months to play Cardioversion: 3 weeks anticoagulants with rhythm control medications

27 plan Pradaxa, TEE, then synch CV Flecanide 100mg BID for 2 weeks Verapamil SR 240mg qd for 3 weeks Pradaxa 150mg BID for 3 weeks Exercise with no contact

28 plan Within 2 days Afib returned Converted within 2 hours after restarting flecanide 150mg x 2 and verapamil 240mg No issues until March 3 Felt fatigued during first period

29 treatment Played short shifts Given flecanide 150mg evening dose between 2 nd and 3 rd period Given flecanide 100mg after game Converted to NSR about 2 hours later Changed flecanide evening dose to pregame

30 the event After 3 rd shift, collapsed on the bench Coaches yells for a doctor Immediately tended to by ATC No pulses, agonal respiration Called for paramedics and defibrillator Dragged to the tunnel, helmet/pads off

31 the event Chest compression 100/min, oral airway Monitor reads Vfib Defibrillated with 200J successfully to NSR Awoke A&O, BP 132/82, HR 120 How did I get back here? How much time is left in the first period? O 2, mask, nasal cannula, IV, amiodarone, ER

32 the event

33 the event

34 the event

35 the event

36 the event 0:00 = collapse 0:28 = off the bench 0:40 = pads off 0:43 = compressions 1:19 = life pack on 1:58 = pads applied 2:36 = rhythm check 2:40 = compressions 2:52 = charge complete 2:58 = shock delivered 3:03 = compressions 3:19 = awake in NSR

37 the event 10 sec

38 the event 18 sec

39 the event 24 sec

40 the event 28 sec

41 the event 46 sec

42 the event 46 sec

43 video-youtube the intersect

44 follow up Enzymes, ecg, echo, mri scan normal Afib off medication Successful cardiac ablation Multiple opinions regarding etiology and need for AICD Game day stress

45 follow up Flecanide toxicity, wide QRS 1:1 transmission aflut to vflut/fib J point elevation inferior leads Zio patch NSR, max exercise HR 150 AICD, play with protection???, remove???

46 lessons learned Be prepared and practice Review EAP with everyone including players, coaches, and security Security to control outside helpers Choose consultants wisely

47 thank you

48 Case Presentation 24 year old Olympic ice hockey player Fever x 24 hours Sore throat Headaches Nausea

49 PHYSICAL EXAM Temperature: 38.5 Enlarged tonsils Lymphadenopathy CNS Normal Chest :clear Abdomen normal

50 Diagnosis Pharyngitis Tonsillitis Lymphadenopathy

51 Concerns Can he play tonite? Tests? Any other advice? Treatment

52 TREATMENT Tylenol or Advil? Antibiotics? What else?

53 Follow up Antibiotics for 36 hours No improvement Fever, Sore throat, Vomiting, Rash Epigastric pain

54 TESTS Throat culture CBC Mono test Liver enzymes Ultrasound

55 RESULTS CBC Normal WBC 6000 Mono test negative Throat culture negative Liver enzymes are normal Ultrasound is booked for the end of the week

56 FOLLOW UP He starts to feel better in the next hours Tonsils are smaller and lymph nodes are decreasing Maculopapular rash on arms and trunk Abdomen is soft and normal

57 RETURN TO PLAY Can he return to play? Can he be removed from isolation?

58 DIFFERENTIAL DIAGNOSIS Tonsillitis Infectious Mononucleosis Cytomegalovirus Toxoplasma HIV, leukemia, Influenza

59 FURTHER RESULTS Repeat blood test shows positive mono test Ultrasound shows mild splenomegaly Can he play? When can he return?

60 FINAL DIAGNOSIS Infectious mononucleosis

61 COMPLICATIONS (Less 5%) Splenic rupture Airway obstruction CNS Hemolytic anemias and thrombocytopenia Hepatitis Myocarditis Chronic fatigue syndrome Myocarditis