HEATAND ICKLE CELL …EHI vs ECAST with SCT and without SCT ... · Build up intensity slowly while training, e.g., paced progressions. Use adequate rest and recovery between repetitions,

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HEAT AND

SICKLE CELL

…EHI vs

ECAST

HEAT AND

SICKLE CELL

…EHI vs

ECAST

“…Dr Kark found that the risk of mild to

moderate EHI among Marine recruits at

Parris Island…was the same for those with SCT and without SCT…This was

contrary to the expected results.”Grant et al. Public health implications of sickle cell trait: a report of the CDC meeting. Am J Prev Med

2011;41(S64):S435-S439

ECAST & EHI ARE SEPARATE

SYNDROMES

EHI rates for black recruits with SCT not significantly different from black recruits without SCT

Kark JA Ward TW Exercise and Hemoglobin S Sem in Hematol 1994;31(3):181-225

Historic military case reports: sudden death in SCT sans major heat stress

Jones SR, Binder RA, Donowho EM Jr. Sudden death in sickle celltrait. N Engl J Med. 1970;282:323–5

Koppes GM, Daly JJ, Coltman CA, Butkus DE. Exertion-induced rhabdomyolysis with acute renal failure and disseminated intravascular coagulation in sickle cell trait. Am J Med. 1977;63:313–7

12 risk factors for EHS discussed with 20 listed and not a word about SCT as a risk factor of EHS

Armstrong LE, Casa DJ Predisposing factors for exertional heat illness. In Exertional Heat Illnesses, edited by Lawrence E Armstrong, 151-66, Human Kinetics, 2003

Cause of Non-Traumatic Death

NCAA Football 2000-16

0

2

4

6

8

10

12

9

1

6

11

SCD

Asthma

EHS

ECAST

Characteristics of Non-Traumatic Collapse

ECAST

Weakness > pain

Slumps to ground

Responsive,

initially

No palpable

cramp

Temp < 103° F

Can occur early in

workout

SCDGasping, gurgling,

snorting, or

moaning

Unprotected fall

Unresponsive

Limp or seizing

Temp irrelevant

No warning

EHS

Fuzzy thinking

Bizarre behavior

Incoherent

Can be in coma

Temp > 106° F

Usually occurs late

in workout

Asthma

Usually known

asthma

Prior episodes,

poor control

Breathless,

may/not wheeze

Gasping, panicky,

on hands/knees

Auscultate: moving

little air

Usually occurs

after sprinting

0

1

2

3

4

5

6

2000 2002 2004 2006 2008 2010 2012 2014

2

1 1

0

3

1

2

0

3

2

3

5

0 0

1 1

ECAST Deaths in Athletes

#25 – 2000-2015

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Too much, too fast, too long, too hard…Especially in the presence of modifiers:

• Environmental heat• Acute illness

• New to altitude• Incessant pace / ‘heroic effort’• Relentless ‘coaching’• Uncontrolled asthma

Modifiers may make the activity too

intense for that athlete on that day

Eichner, ER. Sickle cell trait in sports. Current Sports Medicine Reports 2010;9(6):347-51

An ‘Injury’ whose ‘Insult’ is Intensity

Eichner’s Quintus

1. Asymptomatic Sickle Cell Trait

2. Ischemic events

3. Ischemic events with visceral or muscular infarcts

4. Severe rhabdomyolysis with residuals (kidney disease, splenic disease, MI)

5. Fulminant rhabdomyolysis with death

Eichner’s QuintusLow Oxygen

Tension

Sickling

More SicklingMore Ischemia

Infarcts

Ischemia,↓↓↓↓ 02 Tension

Rhabdomyolysis

ARF / Hyperkalemia

MultipleSystemFailure

DeathDeathDeathDeath

Back or LegCramping Sensation

(Ischemia)

SplenicInfarcts

Muscle Infarcts& Myonecrosis

All deaths in athletes with [sickle cell trait] occurred in black Division

I football athletes during…conditioning

Harmon KG, Drezner JA, Klossner D, Asif IM. Sickle cell trait associated with a RR of death of 37 times in National Collegiate Athletic Association football athletes: a database with 2 million athlete-years as the denominator. Br J Sports Med. 2012;46(5):325-330

Maron BJ, Harris KM, Thompson PD, Eichner ER, Steinberg MH. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 14: sickle cell trait: a scientific statement from the american heart association and american college of cardiology. J Am Coll Cardiol. 2015 Dec 1;66(21)

[lethal…collapse in athletes with SCT] were most common in

college football players during conditioning drills

Signs & SymptomsFatigue

Legs like jell-o

“My chest hurts”

“I can’t catch my breath”

Ischemic pain / ‘cramp’

Low back pain, ‘cramp’, spasm

Leg pain, ‘cramp’, spasm

Hyperventilating

"I'm trying. I'm not weak. I just can't go on." Aaron O’Neal

Do you or someone in your family have sickle

cell trait or disease?

Bernhardt DT, Roberts WO PPE Preparticipation Physical Evaluation, 4th ed, AAP 2010

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https://www.ok.gov/health2/documents/NBS%20English%20Brochure.pdf

Test results are available:

Okla St Department of Health

Newborn Screening Program

(405) 271-6617

• Authorized Release of Information

• Date of Birth

• Birthmother’s name

Ideally, sickle cell trait athletes should set their own pace.

Engage in a slow and gradual preseason conditioning and lifting regimen.

Build up intensity slowly while training, e.g., paced progressions.

Use adequate rest and recovery between repetitions, especially during serial sprints and

intense station or mat drills.

Not to participate in “preseason conditioning tests.”

Be excused from performance tests such as timed serial sprints or miles, especially if these are not normal sports activities.

Not be urged to perform all-out exertion of any kind beyond 2-3 minutes without a breather.

Stop activity immediately upon struggling, i.e., at the earliest onset of any undue symptom, such as cramping, pain, weakness, breathlessness, or fatigue.

Report any symptoms to ATC and coach. Seek prompt medical care for any unusual distress.

Stay well hydrated at all times, especially in hot and/or humid conditions.

Curb activity in very hot or humid conditions.

Curb activity when new at altitude, even a “jump” of only 2,000 ft. Cut training effort, monitor closely, have ready access to supplemental oxygen.

Control asthma to cut risk of exertional sickling [Nina has no reported history of exercise-induced asthma].

Decrease activity sharply during any illness, especially with fever, vomiting, or diarrhea.

Decrease activity after nights of poor sleep.

Sickle Cell Trait Precautions

0

1

2

3

4

5

6

7

8

9

10

2000 2002 2004 2006 2008 2010 2012 2014 2016

1 1

0 0

2

1 1

0

2

1 1

0 0 0

1

0

The Eichner Effect: Ending Death

ECAST DeathSickle Cell Trait & the

Athlete

Task Force Consensus Statement is released

NCAA DI Bylaw: SCT Status in PPE

2000-2016Years With At Least

1 ECAST Death

Years With

No ECAST Death

No SCT screening 8 3

SCT screening 1 5

Fisher exact probability test for this 2 x 2 table: Statistically significant (P = 0.0498)

Preventing Div-1 Football ECASTDeaths

Statistical SignificanceStatistical Significance

*Eichner ER. “A stitch in time” and “if 6 was 9”. preventing exertional sickling deaths; probing team rhabdomyolysis outbreaks. Curr Sports Med Rep. 2016. In press

.Adams WM, Huggins RA, Stearns RL, Anderson SA, Kucera KL, Casa DJ. Policy changes reduce exertional sickling related deaths in Division I collegiate football players [abstract]. J Athl Train. 2016. In press

There is no evidence that any player has ever died an

ECAST death as SCT status is known, athlete and staff are

educated, and precautions are heeded

There is no evidence that any player has ever died an

ECAST death as SCT status is known, athlete and staff are

educated, and precautions are heeded

1963- John Anders, Univ of New Mexico

1970 - Hosie Moss, Ft Scott Community College

1974 - Polie Portier, Univ of Colorado

1980 - Gregory Pratt, Abilene Christian Univ

1982 - Charles Tomahsah, OK Panhandle St Univ

1985 - Charles Mitchell, Henderson St Univ

1986 - Venable, HS

1986 - Eric Sorey, Univ of Southern Mississippi

1987 - Parnell Sylvio, Univ of Indiana

1987 - Carleton Oats Jr, Utah St Univ

1990 - Chris Cooper, Univ of New Mexico

1992 - Thomas Eric Curry, Univ of Georgia

1993 - Damion Smith, Florida HS

1995 - Damon Terrell, Univ of Arizona

1999 - Timothy Harlan, California HS

2000 - Preston Birdsong, Tennessee Tech Univ

2000 - Michah Wimberley, Ohio Jr High

2001 - Devaughn Darling, Florida St Univ

2004 - Aaron Richardson, Bowling Green St Univ

2004 - Ivan Okafor, Texas HS

2004 - David Colston, Prairie View A&M

2005 - Aaron O’Neal, Univ of Missouri

2006 - Bobby Stephens, Florida Jr High

2006 - Dale Lloyd, Rice Univ

2008 - Ereck Plancher, Univ of Central FL

2008 - Chad Wiley, North Carolina A&T

2009 - Ja’Quayvin Smalls, W Carolina Univ

2009 - Edwin 'Dek' Miller, Maryland HS

2010 - Bennie Abram, Univ of Mississippi

2010 - Olivier Louis, Florida HS

2011 - Tyquan Brantley, South Carolina HS

2011 - Al Smith Jr, Texas HS

2011 - Isaiah Laurencin, Florida HS

2014 - Ted Agu, Univ of Cal, Berkeley

2015 - Josh Warren, Texas HS

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