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Invited Commentary

Something Old, Something New, Something for the Marathon for the Red, White, and Blue

Sedgley, Matthew D. MD1; Hudson, Korin MD1,2; Madsen, Clifford Marc DO3,4; O'Connor, Francis G. MD, MPH5

Author Information
Current Sports Medicine Reports: October 2020 - Volume 19 - Issue 10 - p 393-395
doi: 10.1249/JSR.0000000000000755
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Race medicine has evolved from the time of the death of Pheidippides, following the battle at Marathon (1), to the modern era where we see an ever-growing number of participants in endurance races worldwide. Race-day medical protocols are often as varied as the races themselves, generally drawing on local resources to manage not only common complaints like blisters and muscle pain but also true race-day emergencies, such as collapse and cardiac arrest (2).

In April 2019, the International Institute for Race Medicine (IIRM) sponsored a meeting comprised of race-medicine experts from around the country gathered at the Consortium for Health and Military Performance (CHAMP) headquarters in Bethesda, MD. This group was tasked with reviewing the protocols for the Marine Corps Marathon, one of the largest marathons in the world.

The team assembled a who's who in marathon and racing medicine, including physicians, athletic trainers, physical therapists, and members of local Emergency Medical Services (EMS). The medical director and medical coordinator for the Marine Corps Marathon, as well as representatives from The Korey Stringer Institute, Boston Marathon, Baltimore Marathon, and several members of the U.S. military's medical corps, were all in attendance. Everyone was comfortable with the concepts of race medicine and imagined that this review would be a simple update of existing protocols (3–5). It became clear, however, that we were instead going to tackle a wholesale revision of the race-day medical algorithms. Every person committed to a deep dive into the protocols to ensure that each was updated to include the best available evidence, and when necessary, our own expert opinion.

Ultimately, we created a significantly revised set of protocols and algorithms for the care of the race-day athlete that we feel can be applied in multiple environments. We are grateful to have this opportunity to present some of the highlights from this meeting. Full algorithms are available online at

Master Algorithm—Evaluating the Collapsed Athlete

To begin, algorithms and protocols are effective ways to implement a standardized plan of care for both high-frequency/low-severity and low-frequency/high-severity events. When clinicians who may be strangers to one another gather to care for tens of thousands of athletes one day a year, well-defined protocols help define terminology, describe available resources, and delineate an emergency action plan for the care of ill or injured athletes.

One of the most critical steps when creating or implementing a set of algorithms is to make sure to use the correct one for the situation. Therefore, we felt that to begin, we needed guidelines for the intake of an injured runner. This most important protocol became the “jumping off point” for all the others. The evaluation follows the familiar format of a primary and secondary survey, quickly identifying potential life-threats, and then guiding the clinician to the next appropriate algorithm.

The algorithm begins with the Alert, Voice, Pain, Unresponsive evaluation to assess whether the patient 1) is alert, 2) responds to verbal stimulus, 3) responds to a painful stimulus, or 4) is unresponsive. For patients who are unresponsive, we move quickly to evaluate circulation/pulse, airway patency, and adequacy of breathing/respirations. If pulses and respirations are adequate but the patient has altered mental status, a further evaluation proceeds to exclude hyperthermia, hypothermia, or exercise-associated collapse (EAC), based on assessment and evaluation of core temperature. Specific treatment algorithms for hypothermia and hyperthermia follow with active external warming or cooling as required.

Emergency Cardiac Care

Any patient with absent pulse or inadequate airway or respirations will immediately be treated according to the emergency cardiac care algorithm, which will be familiar to those who are comfortable with basic life support CPR training, and focuses on high-quality chest compressions, minimizing “hands off” time, and rapid defibrillation when appropriate (6,7).

It also is important to take the totality of experience into the guidelines. With years of experience caring for U.S. service men and women, as well as thousands of runners in endurance races, our panel of experts opted to include a recommendation that clinicians consider intravenous bicarbonate during prolonged or refractory cardiac arrest. This treatment is very unlikely to be harmful and may aid in the resuscitation of the endurance athletes who may have a profound acidosis at the time of collapse.

Most races have a robust roster of volunteers with vast knowledge and experience who are present in a temporary shelter at or near the finish line. Despite this, the on-site medical services available at most races cannot compare to in-hospital care for the treatment of cardiac arrest and other critical illness. Therefore, we agreed that athletes suffering from cardiac arrest (as well as stroke and other critical medical conditions) should be transferred by the EMS to the hospital as soon as reasonably possible after initial assessment, defibrillation (when indicated), and initiation of CPR.

Exercise-associated Collapse

The EAC algorithm was greatly simplified from the previous algorithm. The simplicity focuses on monitoring mental status/neurologic dysfunction. If the runner is improving, they are assessed for proper hydration, and if needed, exit to the new hydration guidance algorithm. If their mental status is not improving, then either prepare for EMS transport or exit this algorithm to the appropriate algorithm.


Emphasis was again placed on “treat first, transport second.” Added to this algorithm was clarification of how to proceed after the patient is cooled, including clarification on when to transport, and what to do if the temperature drops farther than expected. All methods of cooling that do not meet the acceptable rate of cooling (0.15°C·min−1) were removed from this algorithm. The only recommended methods of cooling are: 1) ice water immersion; or 2) ice water dousing, with ice massage, and ice packing (Quantico Method).


The protocol for hypoglycemia was simplified based on a definition of fingerstick glucose >60 mg·dL−1 and with treatment considerations based on whether the patient has normal or altered mental status (8). Furthermore, we recognize that there are a greater number of runners who use insulin pumps and long-acting agents. We recommend that insulin pumps be paused while treatment is rendered and recognize that patients on long-acting agents may require ongoing observation and care beyond that which can be provided in the medical tent.


To our great frustration, many in attendance reported that they still receive frequent inquiries regarding the safety of hypertonic saline in the endurance athlete with hyponatremia. We note that central pontine myelinolysis is not a phenomenon seen in this setting and has never been reported in these cases. We hope that by adding this specific verbiage to the protocols, clinicians volunteering at endurance races will be reassured that appropriate administration of hypertonic saline for athletes can be safely administered and is likely a lifesaving treatment. Additionally, this algorithm was greatly simplified (8).

Discharge Protocol

Athletes may present for medical care for conditions ranging from minor and mundane to critical and life-threatening. However, historically, our protocols did not include specific criteria for safe discharge from any of the medical tents. We acknowledge that many athletes may be quickly assessed, treated, and can either be discharged back to the race or to their own care. However, others are unable to return to the event and may either need to be bussed to the finish line or transported to a higher level of care.

Our discharge considerations centered on guaranteeing the health and safety of the athlete, even after they left our care, as well as maintaining adequate records of the encounter. To that end, all athletes must have normal mental status, temperature, and vital signs to be considered for discharge. We also recommend that a copy of any medical record be provided to the treated runner with another copy to be filed in the medical database for the race. Furthermore, runners should be discharged in appropriate clothing (e.g., dry clothing if treated for hypothermia) and with a friend or family member whenever possible. Pediatric and adolescent participants are becoming more common in large events and should be released to a parent or guardian at the time of discharge. Finally, a recommendation should be given for appropriate follow-up with the indicated health care provider.

For those runners who choose to leave the tent against medical advice (AMA), we recommend documentation of normal mental status and decision-making capacity, in addition to providing a copy of their medical care and encouraging rapid follow-up. We feel it is important that these athletes also sign an appropriate AMA form, both for record keeping and medicolegal purposes.


On behalf of IIRM and CHAMP, we are pleased to share the latest revision of our updated clinical algorithms for medical care in a mass participation event. It is important to note that as we modified these algorithms, rather a linear device, the entire group of protocols was developed to encourage continuous reevaluation and when the patient's status and on-going care requires it, circling back to the Master Algorithm to consider a broad differential diagnosis. Going forward, we hope to add additional protocols, including one addressing specific medical concerns facing the adaptive athlete, and one for exertional collapse associated with sickle cell trait. Given the current pandemic, we will likely find ourselves modifying protocols for the future to protect providers, athletes, and spectators. These may include topics, such as race cancelation (9), race reinitiation, recommendations for the safe return to endurance running after novel SARS coronavirus infection, and infection prevention.

While these algorithms have been developed by experts from some of the world's largest marathons, we hope that they will inspire others, and that they can represent a basis for race protocols around the world. We recognize that there are clear limitations to creating written algorithms when medical knowledge increases and changes every year, and that the process of reviewing medical protocols is continuous. It is especially critical to review emergency action plans for any event, at least on an annual basis. To that end, we do not intend for this meeting to be a discrete event, but rather part of a continuous process. We look forward to wherever that road takes us.

The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official or as reflecting the view of the United States Army, United States Navy, or the Department of Defense. Citations of commercial organizations and trade names in this report do not constitute an official department of the Army or department of the Navy endorsement or approval of the products of these organizations.


1. Cartedge P, Holland T. The Histories, Herodotus. Penguin Classics Deluxe Edition. Manhattan (NY): Penguin Group (USA) LLC. 2014. 747 p.
2. Jaworski CA. Marathon. In: Rubin AL, editor. Sports Injuries & Emergencies: A Quick Response Manual. New York (NY): McGraw-Hill; 2003. 314–24 p.
3. American College of Sports Medicine. Mass participation event management for the team physician: a consensus statement. Med. Sci. Sports Exerc. 2004; 36:2004–8.
4. Roberts WO. Administration and medical management of mass participation endurance events. In: Mellion MB, Walsh WM, Madden C, et al., editors. Team Physician’s Handbook. Philadelphia (PA): Hanley & Belfus; 2002. 748–56 p.
5. Jones BH, Roberts WO. Medical management of endurance events. In: Cantu RC, Micheli LJ, editors. ACSM’s Guidelines for the Team Physician. Philadelphia (PA): Lea & Febiger; 1991. 266–86 p.
6. American Heart Association. Basic Life Support Provider Manual. AHA Product Number: 15–1010; ISBN: 978–1–61669-407-4.
7. Craig-Brangan KJ, Day MP. Update: 2017/2018 AHA BLS, ACLS, and PALS guidelines. Nursing. 2019; 49:46–9.
8. Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement of the third international exercise-associated Hyponatremia consensus development conference, Carlsbad, California, 2015. Clin. J. Sport Med. 2015; 25:303–20.
9. French JK, Frengley PA. Hypoglycemia induced seizures following a marathon. N. Z. Med. J. 1983; 96:407.

Additional Resources

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  • Sloan BK, Kraft EM, Clark D, et al. On-site treatment of exertional heat stroke. Am. J. Sports Med. 2015; 43:823–9. Epub 2015 Jan 28. PMID: 25632055.
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  • Owen BE, Rogers IR, Hoffman MD, et al. Efficacy of oral versus intravenous hypertonic saline in runners with hyponatremia. J. Sci. Med. Sport. 2014; 17:457–62. Epub 2013 Sep 18.PMID: 24148616.
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  • DeMartini JK, Casa DJ, Belval LN, et al. Environmental conditions and the occurrence of exertional heat illnesses and exertional heat stroke at the Falmouth Road Race. J. Athl. Train. 2014; 49:478–85. Epub 2014 Jun 27.PMID: 24972041.
  • Demartini JK, Casa DJ, Stearns R, et al. Effectiveness of cold water immersion in the treatment of exertional heat stroke at the Falmouth road race. Med. Sci. Sports Exerc. 2015; 47:240–5.
  • Hosokawa Y, Adams WM, Belval LN, et al. Exertional heat illness incidence and on-site medical team preparedness in warm weather. Int. J. Biometeorol. 2018; 62:1147–53. Epub 2018 Mar 29.PMID: 29594509.
  • Sedgley M. The missing algorithm: race cancelation protocol. Washington, DC: International Institute of Race Medicine: Marine Corps Marathon, MedStar Georgetown; 2017.

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