Document 6426541

4/1/14 Denise L. Wunderler, DO, FAOASM
Primary Care Sports Medicine Physician
Department of Orthopedic Surgery
Fort Knox, Kentucky
AOASM Annual Conference 2014, Tampa
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Gain an understanding of how to successfully
prepare for an international sports medicine trip
Review vaccines and traveler’s diarrhea
Discuss performance considerations regarding
altitude and jet lag
Can be challenging
Usually great preparation leads to a smooth,
successful trip
But you can’t anticipate everything
Goal: be as prepared as you can be
1 4/1/14 ¨ 
With whom are you traveling?
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Athletes, coaches, other staff, family members
Make contact with them early to open the lines of
communication for questions or concerns
ú  Allows better planning for everyone
ú  Be aware of any allergies or known medical problems
ú  standard vaccines should be UTD, including tetanus
ú  Gives them time to obtain needed vaccines for a specific
country
ú  obtain complete list of ALL meds (Rx, OTC, herbs, “natural
remedies”, vitamins, supplements; daily/PRN)
ú  determine if an athlete is taking a banned substance
ú  need for a therapeutic use exemption (TUE)?
­  For athletes with a documented medical condition who need a
prohibited substance/prohibited method
­  At least 30 days before the competition
ú  Old/new injuries, any taping that is needed
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I made a chart with the Team Delegation’s names,
meds, allergies, other
Where are you going?
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Local vs. international
ú  http://www.cdc.gov/travel (specific country)
ú  what is allowed in the country/through customs
­  Some prescription meds are illegal in other countries- need to
check with the embassy or consulate for that country; must have
a letter from your doctor stating the med and that it was
prescribed for you
­  I would not recommend carrying any narcotics
­  Letter for epi pens in my luggage
2 4/1/14 ú  what can be brought on the plane in carry-on bag
ú  small stock of Ibuprofen, Acetaminophen, Tums, Pepto-
Bismol, Immodium, throat lozenges
ú  tablets in original containers or marked clearly with the name
and dose
ú  Depending on the destination, specific vaccinations will be
needed- check CDC website
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Packed supplies will be different if it is international
How much are you going to bring
ú  the more you bring, the more you carry
ú  If you need an item, how difficult will it be to obtain
­  i.e. Moist heat packs for shoulder/back- it took our Peruvian
delegate 2 days to locate them for us in Lima
­  i.e. Meds- if purchased overseas, they may not be made
according to US standards, may be ineffective, contain
contaminants, or may be in unsafe drug combinations
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Encourage them to bring healthy snacks from home
cdc.gov
who.int
Routine vaccinations need to be up-to-date (MMR,
DPT, polio, etc)
Hepatitis A
Typhoid Fever
Hepatitis B
Yellow Fever
Malaria
Rabies
3 4/1/14 ¨ 
Transmission: viral
contaminated food/
water, illegal drugs,
intimate relations
nausea, anorexia, fever,
malaise, abdominal pain,
dark urine, clay-colored
stools, jaundice, joint
pain
Tx: supportive
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Hepatitis A vaccine (inactivated/killed) or IG
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begin 2-4 weeks (ideally) prior to travel; there is some
protection no matter when it is given
for immediate, temporary protection, immune globulin can
be given
for long-term protection, 2 vaccine doses are required 6
months apart
Transmission:
Contaminated food/water
insidious onset, F/C,
constipation, abdominal
pain, HA, rose-colored
macular rash on abdomen
and chest (“rose spots”),
malaise, myalgia
Salmonella typhi bacteria
Tx: fluoroquinolone
(cipro); Injectable thirdgeneration cephalosporins;
Azithromycin
4 4/1/14 ¨ 
Inactivated (killed)- IM (Typhim Vi)
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one shot at least 2 weeks before travel
booster q 2 yrs if at risk
live, attenuated (weakened)- PO (Vivotif)
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4 doses- one capsule QOD for a week (day 1, day 3, day 5,
day 7)
final dose should be given at least 1 week before travel;
given 1 hr before a meal with lukewarm/cold beverage
booster q 5 yrs if at risk
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Transmission: blood/
body fluid, IV drug use,
intimate relations
Fever, fatigue, loss of
appetite, N/V, abdominal
pain, dark urine, claycolored stools, joint
pain, jaundice
Tx: supportive if acute
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Vaccine (Hep B surface Ag):
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3 doses: time 0, 1 month, 6 months
May last at least 20 years
5 4/1/14 ¨ 
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Transmission:
Flavivirus infected
Mosquito
Most have no illness or
mild illness- sudden
onset of F/C, severe HA,
back pain, general body
aches, N/V, fatigue,
weakness
Tx: supportive, close
observation
Live, attenuated virus vaccine
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single dose protects against disease for 10 years or more
booster dose q 10 years if continued risk
Transmission:
Plasmodium (parasite)
infected mosquito
high fevers, chills,
diaphoresis, HA, N/V,
malaise/myalgias
Tx: depends on disease
severity, species of
parasite, part of the
world in which the
infection was acquired
6 4/1/14 ¨ 
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NO vaccine available
Doxycycline 100 mg PO daily for prevention
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Begin 1-2 days prior to exposure
Discontinue 4 weeks after exposure
Side effects include diarrhea, nausea, dyspepsia, HA,
photosensitivity
insect repellent with 30-50% DEET
long pants/sleeves and hats to prevent insect bites
remain indoors in a screened or air-conditioned area
during peak biting period (dusk and dawn)
Transmission: saliva from the bite of an infected
animal (or brain/nervous system tissue)
Dogs in developing countries
General weakness, fever, HA, itching at the bite site,
eventually cerebral dysfunction, delirium
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Almost always fatal once symptoms begin
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Tetanus shot (if not received in last 10 years)
Tx: supportive
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Do not touch/feed animals (including dogs, cats)
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Pre-exposure:
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Post-exposure prophylaxis if never immunized:
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pets that look healthy may have rabies, other diseases
Inactivated/killed viral vaccine- IM
wound cleansing (greatly reduces likelihood of rabies) with
soap/water/virucidal agent (ie. povidine-iodine)
¡  vaccine on days 0, 3, 7, 14 + HRIG (human rabies immune
globulin) local infusion at wound site + additional amount IM
at site distant from the vaccine
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Post-exposure prophylaxis if previously immunized:
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wound cleansing + vaccine on days 0 and 3
7 4/1/14 ¨ 
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Are you the only medical staff for your team?
Physician duties
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BE PROACTIVE and stay in the loop of
communication with the team
Do your best to keep everyone healthy
ú  if they had a hint of a symptom (GI, blister, URI, etc), they
knew to tell me immediately
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ATC duties
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This lists prohibited substances/methods that can
enhance athletic performance
updated annually
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separated by substances that are prohibited at all times, in
competition, and in particular sports)
Full list at http://list.wada-ama.org/
ALL TIMES:
Anabolic steroids, growth factors, blood products, gene
doping are prohibited
Danazol- anabolic steroid for endometriosis, fibrocystic
breast disease, hereditary angioedema
All beta-2 agonists
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Taping, ice, everything else
I refreshed basic taping with an ATC before traveling
except inhaled salbutamol (albuterol) max 1600 mcg over 24 hrs,
inhaled formoterol max 54 mcg over 24 hrs, or inhaled salmeterol
(long-acting beta agonist) when used in accordance with
manufacturer’s regimen
Clomiphene- for ovulation induction
Insulins
Masking agents: acetazolamide (Diamox), probenecid (for
gout)
8 4/1/14 ¨ 
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IN COMPETITION:
Stimulants
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methylphenidate (Concerta, Ritalin)
Pseudoephedrine (PSE) (Sudafed)- for nasal congestion, when
[urine] is >150mcg/mL
ú  WADA advises athletes to stop taking PSE 24 hours before the
in-competition period
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Narcotics- Fentanyl, hydromorphone (Dilaudid),
oxycodone (in Percocet, OxyContin)
Marijuana
All glucocorticosteroids (prednisone)- PO, IV, IM, PR
IN COMPETITION IN CERTAIN SPORTS:
Alcohol ([blood alcohol] of 0.10g/L)
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archery and shooting (both also prohibited out-ofcompetition), automobile, billiards, darts, golf, skiing/
snowboarding- ski jumping, freestyle aerials/halfpipe and
snowboard halfpipe/big air
MONITORING PROGRAM:
substances not on prohibited list, but which WADA
wishes to monitor in order to detect patterns of misuse
in sport
In competition only
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air sports (aeronautic), archery, automobile, karate,
motorcycling, powerboating
Beta-blockers
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(NOT PROHIBITED: caffeine, nicotine, phenylephrine,
synephrine)
Stimulants: caffeine, nicotine, phenylephrine, pseudoephedrine
<150mcg/mL, synephrine
Narcotics: Hydrocodone (in Vicodin), tramadol
NOTE: Intramuscular PRP was removed from the
prohibited list
*To inquire about a certain ingredient by sport, look at
http://www.globaldro.com/
9 4/1/14 ¨ 
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Meet the Head Physician of the event (which
could be you), other local event medical staff
Protocol to contact emergency staff
AED location
Ambulance access to facility
Training room facilities
local hospital locations
Bring contact information of people in case of
problems (trusted physicians, NGB staff)
Be familiar with the World Anti-Doping Code
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I kept a full printed copy in my binder
M-5 declaration of medications of each athlete
(before match)
M-10 injury report form (after match)
Random doping controls occurred
team physician is present for this
When preparing for travel, prepare for the most
common problems
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*food/water contamination-leading cause of illness in
travelers
Altitude
Jet lag
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GI meds- Loperamide, Tums,
Pepto-Bismol, ABX, Antiemetics, MVI, Docusate
ABX- Cipro, Clinda, Amox,
Augmentin, Vigamox gtts
Electrolyte-replacement
powder, MVI
Cough suppressants, throat
lozenges
Pain relievers- Acetaminophen,
Ibuprofen, Aspirin, topicals
Urgent: Epi pens, Albuterol
HFA
Allergies- Loratidine
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Traveler’s Diarrhea (Gastroenteritis)
Jet lag
Altitude
“Boil it, cook it, peel it, or forget it”
Can occur anywhere, however it mostly occurs in
developing countries
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Miconazole intravaginal
Topicals: Bacitracin,
Clotrimazole, Hydrocortisone
IVF
Injectables
Lac tray, wound/blister supplies
Glucometer, BP cuff,
stethoscope, pen light/
headlamp, thermometer,
otoscope
Pregnancy tests, UA, hemoccult
tests
Flow meter, pulse ox
Taping supplies, ice bags, Shark
SAM splints, joint braces
highest risk areas: Central and South America, Mexico,
Africa, Middle East, South Asia
Almost 50% of Americans visiting developing
countries
main sources of infection: Food and water
contaminated with fecal matter
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Prevalence of specific organisms varies with travel
destination
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Most common causes:
ú  E.Coli, Campylobacter, Salmonella, Shigella- mainly
bacterial abroad
ú  viral gastroenteritis in US
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Less common causes:
ú  protozoal parasites
ú  if diarrhea lasts >2 weeks OR if no response to ABX- Giardia
Iamblia, Entamoeba histolytica, Cyclospora cayetanensisseen in returning travelers
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Classic definition:
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Rarely life-threatening
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3 or more unformed stools in 24 hours with at least 1 of
the following symptoms: Fever, N/V, abdominal
cramps, tenesmus (urge to pass stool), bloody stools
Milder forms can present with less than 3 stools
Can also have bloating, general fatigue
Most occur within the first 2 weeks of travel and
last 4 days without treatment
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norovirus on cruise ships
1 in 5 travelers is bedridden for a day
> 1/3 must alter their activities
Those more susceptible: immunocompromised, those
with lowered gastric acidity (taking histamine H2
blockers or proton pump inhibitors), younger age and
adventurous travelers; luxury resorts or cruise ships
“Food poisoning” is part of the differential dx of TD:
gastroenteritis from preformed toxins (Staph aureus, Bacillus
cereus) has a short incubation time (1-6 hours) and symptoms
usually resolve within 24 hours
¡  Distinguish from TD by perioral numbness, flushing and
warmth
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12 4/1/14 ¨ 
Prevention:
A fluoroquinolone can be used for a maximum of 3 weeks in
a “critical” competition
¡  Bismuth subsalicylate (Pepto-Bismol)
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ú  ideally two 262 mg tables QID (with meals and in evening)
ú  Even though it has a 60% rate of protection, it is impractical for
athletes
ú  Not for those taking anti-coagulants or other salicylates
ú  Interferes with doxycycline absorption (malaria prophylaxis)
ú  Side effects include: black stool, black tongue, constipation,
tinnitus
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Lactobacillus may protect up to 47%; more studies needed
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wash hands often with soap/water, esp before eating
ú  Antibacterial hand wipes/alcohol-based hand sanitizer (at least 60%
alcohol)
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Only use bottled water with an unbroken seal, boiled water
(best way to purify water), or carbonated beverages in cans/
bottles
avoid tap water, fountain drinks, and ice cubes
use bottled water for teeth brushing
Inspect hotel kitchens and inquire re: the source of fruits and
vegetables and the water in which they are washed and
prepared
confirm that water in a hotel setting is filtered, boiled, or bottled
no food from street vendors
Eat only fully cooked food
¡  eat hot foods when they are hot; cold foods when they are cold
¡  no room temp sauces
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ú  microbes can multiply in foods that are allowed to cool or warm to
room temp
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avoid raw/undercooked meat, fish, or shellfish
Do not eat reheated, cooked food
avoid leafy salads, unpeeled fruit/vegies in developing
countries
avoid dairy, unless it is pasteurized
boiled/baked/peeled foods are the safest
Boiling water is the best way to purify water
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Treatment:
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Loperamide (Imodium)
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500 mg BID x 1-3 days
drug of choice (for most parts of the world) where
invasive organisms like Campylobacter and Shigella are
common
Azithromycin
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two 2mg tablets after 1st loose stool, then 1 tab after each
subsequent loose stool; max 8 mg in 24 hours x 2days
limits symptoms to one day
Can be started after the 1st episode of diarrhea
if symptoms resolve within 24 hours, no further tx
Ciprofloxacin
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Boiled soups/bouillon/broth and electrolytereplacement solutions (have salt which was depleted
during diarrhea episodes)
Hydration
Complex carbohydrates- bananas, rice, bread, potatoes
Empiric tx with ABX and loperamide
in areas with quinolone-resistant Campylobacter (i.e.
Thailand) and for children and pregnant women
1 gram x1 dose OR 500 mg x 1-3 days
10mg/kg daily x 3 days
Rifaximin (newer ABX)
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can be used where noninvasive E.Coli is the main
pathogen (i.e. Mexico)
decreases symptoms x 1 day
200 mg PO TID x 3 days
14 4/1/14 ¨ 
Athletes face many challenges at altitude that can
effect performance:
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Therefore, acclimatization, proper sleep, sun protection,
hydration, good nutrition, and appropriate training are
important to help minimize these challenges
Acclimatize to help prevent altitude illness:
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avoid flying into high altitude cities
if going to higher altitude destination (above 8000 ft) consider
sleeping one night at a lower altitude
increase altitude gradually
Hydrate
limit activity initially
avoid alcohol
high carbohydrate diet can improve oxygenation and exercise
performance
There is no ideal preventative med for athletes
traveling to altitude
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Lower oxygen saturation in the air
increased radiation (sun)
compromised immune system
increased fatigue
Malnutrition and dehydration
overtraining
Ibuprofen (600 mg TID, 6 hours before ascent) can help
Recommended: athlete arrives early and resides x 2
weeks at the competition altitude
15 4/1/14 ¨ 
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At altitude, lack of hydration (due to plasma volume
drop à lower COà lower maximal aerobic power)
and iron (due to strong demand on erythropoiesis at
altitude) may negatively impact performance
Recommended that athletes are screened for serum
ferritin levels 8-10 weeks prior to going to altitude,
allowing time for supplementation; recommend
increased dietary iron intake through various foods
Rapid ascent above 2500 m (8200 ft) to a more
hypobaric, hypoxic environment is the main cause
of altitude illness
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AMS
HACE
HAPE
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AMS
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HA, dizziness, insomnia, anorexia, nausea, dyspnea,
fatigue
Tx: Descent*, O2, Gamow bag, Diamox, Dexamethasone,
Acetaminophen, Ibuprofen, Aspirin, Zofran
16 4/1/14 ¨ 
HACE
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HAPE
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Medical emergency!
same symptoms as AMS + confusion and ataxia and
altered level of consciousnes
Can result in a coma and possibly death due to brain
herniation
Tx: immediate descent, O2, Dexamethasone, Gamow bag
Medical emergency!
dyspnea, tachypnea, moist cough (pink frothy sputum),
poor exercise tolerance, low-grade fever
Tx: descent*, rest, keep warm, O2*, Gamow bag, CPAP
mask or helmet, rehydration, Sildenafil, Tadalafil,
Nifedipine, Diamox, Albuterol/salmeterol inhaler
Athletes traveling to altitude for training/
competition are at risk for poor sleep quality as a
result of both jet lag and the altitude itself
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Considered to be a significant source of disturbance to
athletes, especially when traveling from west to east
Goal is to increase adaptation and minimize decrease in
performance
Sleep deprivation exacerbates the magnitude and
duration of jet lag
sleep when you can
hydrate before and during the trip
avoid alcohol
1 day of adjustment needed for each time zone crossed*
Travel Management Program (Samuels) – Preflight,
inflight, postflight components
Preflight:
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Within 7 days of travel
Getting a solid night sleep at least the night before the
flight
Decrease volume and intensity of training
adjust training to the destination time zone a few days
before departure
evening flight for eastward travel and layovers for travel
across 10 or more time zones to help with adapting
Inflight
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adjust watches to destination time zone
comfortable environment (pillows, etc) to facilitate sleep
and rest
minimize distractions (electronics)
eyeshades/earplugs to aid rest
noise-canceling listening devices to help relaxation
sleep and eat meals on the destination schedule (athletes to
bring meals if possible)
hydration is a priority
18 4/1/14 ¨ 
Postflight:
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Any special considerations re: the injured athlete
and returning home by air?
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2-4 days after arrival
Modification of behavior, not necessarily meds
scheduled light therapy, light avoidance, melatonin
napping and caffeine (improve alertness, minimize
fatigue)
? sedatives if insomnia for 1-2 days or not responding to
melatonin
Athlete with a pneumothorax may not be able to fly
A cast needs to be bivalved
Special seating- ie. if GI issues- obtain an aisle seat near a
bathroom; if lower extremity injury, obtain an aisle seat
Traveling in sports medicine can be challenging
However, the key to a successful trip is great
preparation and being proactive with the care of
your team
And remember, always strive to be a positive
ambassador- You are representing our country!
19 4/1/14 ¨ 
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www.cdc.gov
www.fivb.org
http://list.wada-ama.org
www.globaldro.com
www.cdc.gov
www.who.int
Epocrates
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Harrison, L. New Rifamycin Formulation Curtails Traveler's Diarrhea.
http://www.medscape.com/viewarticle/812427.2013.
Lipman GS, et al. Ibuprofen prevents altitude illness: A randomized controlled trial for prevention
of altitude illness with nonsteroidal anti-inflammatories. Annals of Emergency Medicine. 2012.
59(6): 484–490.
Samuels, C. H. Jet Lag and Travel Fatigue: A Comprehensive Management Plan for Sport
Medicine Physicians and High-Performance Support Teams. Clin J Sport Med. 2012. 22(3):
268-273.
Pipe, A.L. International Travel and the Elite Athlete. Clin J Sport Med. 2011. 21 (1): 62-66.
Koehle, M.S., et al. Canadian Academy of Sport and Exercise Medicine Position Statement:
Athletes at High Altitude. Clin J Sport Med. 2014. 24 (2): 120-127.
Koch, et al. A Successful Therapy of High Altitude Pulmonary Edema With a CPAP Helmet on
Lenin Peak (Case Report). Clin J Sports Med. January 2009; 19 (1): 72-73.
Michael Savino, D.O.
Lori Boyajian-O’Neil, D.O.
David Dyck, D.O.
Bill Feldner, D.O.
Andy Gregory, M.D.
Zenos Vangelos, D.O.
USA Volleyball
AOASM
20