Medical Hockey ScenariosWhat Would You Do?Case Presentation

Dr. Noah FormanAOSSMAugust 2015

What Would You Do?

Discussion Points

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

Clinical Outcome

Acute Abdomen:Management and RTP decisions

Josh Bloom, MD, MPH, CAQSMCarolina Hurricanes

Carolina Family Practice & Sports MedicineCarolina Sports Concussion Clinic

KEEP YOUR EDGEHockey Sports Medicine 2015

August 28, 2015

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

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

Case continued

• Acute appendicitis on CT

• Uncomplicated laparoscopic appendectomy

Case continued

• RTP criteria

• How soon?

• Risks?

• Take home points

– Know your athlete

– Focal tenderness

– High index of suspicion

– Heal quickly

Afib in Pro Hockey Playerhistory

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

Afib in Pro Hockey Playerexam

5’11” 195#

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

Afib in Pro Hockey Playerlabs

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

Afib in Pro Hockey Player ecg

Afib in Pro Hockey Playerecg

Afib in Pro Hockey Playerfurther 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

Afib in Pro Hockey Playerfurther 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

Afib in Pro Hockey Playerrepeat 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

Afib in Pro Hockey Playerrepeat ecg

Afib in Pro Hockey Playerrepeat ecg

Afib in Pro Hockey Playerheart rate on ice

Afib in Pro Hockey Playerfinal diagnoses

New onset Afib

Polycythemia

Afib in Pro Hockey Playerplan

What would you do?

Afib in Pro Hockey Playerplan

Blood work for PC, including genetic

testing normal; H/H 10/31: 15.1/44.3

Cardiovert and medicate vs ablation

Afib in Pro Hockey Playerplan

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

Afib in Pro Hockey Playerplan

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

Afib in Pro Hockey Playerplan

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

Afib in Pro Hockey Playertreatment

Played short shifts

Given flecanide 150mg evening dose

between 2nd and 3rd period

Given flecanide 100mg after game

Converted to NSR about 2 hours later

Changed flecanide evening dose to pregame

Afib in Pro Hockey Playerthe event

After 3rd 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

Afib in Pro Hockey Playerthe 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?”

O2, mask, nasal cannula, IV, amiodarone, ER

Afib in Pro Hockey Playerthe event

Afib in Pro Hockey Playerthe event

Afib in Pro Hockey Playerthe event

Afib in Pro Hockey Playerthe event

Afib in Pro Hockey Playerthe 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

Afib in Pro Hockey Playerthe event 10 sec

Afib in Pro Hockey Playerthe event 18 sec

Afib in Pro Hockey Playerthe event 24 sec

Afib in Pro Hockey Playerthe event 28 sec

Afib in Pro Hockey Playerthe event 46 sec

Afib in Pro Hockey Playerthe event 46 sec

Afib in Pro Hockey Playervideo-youtube the intersect

https://www.youtube.com/watch?feature=player_detailpage&v=9jivQgF6J1g

Afib in Pro Hockey Playerfollow up

Enzymes, ecg, echo, mri scan normal

Afib off medication

Successful cardiac ablation

Multiple opinions regarding etiology and

need for AICD

Game day stress

Afib in Pro Hockey Playerfollow 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???

Afib in Pro Hockey Playerlessons learned

Be prepared and practice

Review EAP with everyone including

players, coaches, and security

Security to control outside helpers

Choose consultants wisely

Afib in Pro Hockey Playerthank you

Case Presentation

• 24 year old Olympic ice hockey player

• Fever x 24 hours

• Sore throat

• Headaches

• Nausea

PHYSICAL EXAM

• Temperature: 38.5

• Enlarged tonsils

• Lymphadenopathy

• CNS Normal

• Chest :clear

• Abdomen normal

Diagnosis

• Pharyngitis

• Tonsillitis

• Lymphadenopathy

Concerns

• Can he play tonite?

• Tests?

• Any other advice?

• Treatment

TREATMENT

• Tylenol or Advil?

• Antibiotics?

• What else?

Follow up

• Antibiotics for 36 hours

• No improvement

• Fever, Sore throat, Vomiting, Rash

• Epigastric pain

TESTS

• Throat culture

• CBC

• Mono test

• Liver enzymes

• Ultrasound

RESULTS

• CBC Normal WBC 6000

• Mono test negative

• Throat culture negative

• Liver enzymes are normal

• Ultrasound is booked for the end of the week

FOLLOW UP

• He starts to feel better in the next 48- 72 hours

• Tonsils are smaller and lymph nodes are decreasing

• Maculopapular rash on arms and trunk

• Abdomen is soft and normal

RETURN TO PLAY

• Can he return to play?

• Can he be removed from isolation?

DIFFERENTIAL DIAGNOSIS

• Tonsillitis

• Infectious Mononucleosis

• Cytomegalovirus

• Toxoplasma

• HIV, leukemia, Influenza

FURTHER RESULTS

• Repeat blood test shows positive mono test

• Ultrasound shows mild splenomegaly

• Can he play?

• When can he return?

FINAL DIAGNOSIS

Infectious mononucleosis

COMPLICATIONS (Less 5%)

• Splenic rupture

• Airway obstruction

• CNS

• Hemolytic anemias and thrombocytopenia

• Hepatitis

• Myocarditis

• Chronic fatigue syndrome

• Myocarditis