20 Yards From The Finish Line - Page #4
 

Working Diagnosis:
Primary – Cardiac Arrest 2/2 STEMI 2/2 CAD

Secondary – Acute systolic heart failure, cardiogenic shock, pulmonary contusions, bilateral iatrogenic pneumothoracies, hypercarbic hypoxic respiratory failure, mixed acid-base disorders with respiratory and anion gap metabolic acidoses 2/2 hypoventilation and lactic acidoses, hepatic shock, DIC/ischemic coagulopathy, SIRS

Treatment:
ACLS - compression-only CPR initially with early, multiple defibrillations (8 total shocks; the first within1-2 min. of collapse – 2 at the race site, 4 in transit, 2 in ER) as well as Atropine x 1, Epinephrine x 3, CaCl x 1, NaHCO3 x 2, Mag Sulfate 2 grams x 1, & Epi. gtt; all over 45 min. before return of spontaneous circulation.

Circulatory support with isotonic IVF and albumin as well as Norepinephrine, Epinephrine, Vasopressin

Cardiac catheterization & PCI with stent x 1 to proximal LAD

Therapeutic hypothermia

Prone mechanical ventilation for refractory hypoxia and pulmonary contusions; Bilateral tube thoracotomies

10 units FFP for DIC

2 units PRBC for acute hemorrhagic anemia

Outcome:
Her family decided to transition to comfort care due to her irreversible conditions of multisystem organ failure from cardiac arrest. She passed away 22 hrs. after collapsing near the finish line.

Editor's Comments:
This somber case highlights the potential serious complications to mass-participation events. While a majority of participants have no significant clinical history, a small minority have cardiac history including ischemia, previous infarct, or unknown cardiac disease. These runners may be drawn to shorter events like a half-marathon or 10k and demonstrate the importance of emergency preparedness for even the simplest of races.
The risk for sudden death is approximately 1 in 50,000 to 90,000 depending on how the data is collected. Most of the deaths are due to undiagnosed athrosclerotic disease manifesting as plaque rupture. The remainder of the deaths are attributable to other causes of cardiac sudden death, usually cardiomyopathy or anomolous coronary arteries. Importantly, the majority of fatal cardiac events occur within 1 mile of the finish line, and this fact is useful in designing emergency race care.
Of note, some people may be discouraged from participating in mass events due to the risk of death. However, mass events save lives by limiting vehicle fatalities due to road closure. The net reduction is about 1.8 crash deaths saved for each case of sudden cardiac death observed.

References:
Editor References:
1. Maron BJ, Poliac LC, Roberts WO. Risk for sudden cardiac death associated with marathon running. J Am Coll Cardiol. 1996 Aug;28(2):428-31.
2. Pedoe DT. Sudden cardiac death in sport--spectre or preventable risk? Br J Sports Med. 2000 Apr;34(2):137-40.
3. Redelmeier DA, Greenwald JA. Competing risks of mortality with marathons: retrospective analysis. BMJ. 2007 Dec 22;335(7633):1275-7.

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