# Race Safety and Medical Emergencies · Triathlon Level 6: Advanced

Triathlon · Level 6: Advanced · Insporta Book (https://book.insporta.app/triathlon/level-6/race-safety-and-medical-emergencies/)

Race Safety and Medical Emergencies in Triathlon (Level 6: Advanced) on Insporta: 100 sourced facts behind 10 tests. Covers: deaths and cardiac arrest.

What the data say about deaths in triathlon, swim emergencies and SIPE, heart health, exertional heat stroke, hyponatraemia, collapse at the finish, crashes and concussion, cold-water rescue, bystander CPR and how race medical services are organised.

## Test 1: Deaths and Cardiac Arrest in Triathlon

- Of the sudden deaths and cardiac arrests, 90 happened in the swim, far more than on the bike or run. (Source: Harris et al., Annals of Internal Medicine 2017 (US triathlon deaths and cardiac arrests, 1985-2016))
- 85% of the 135 cases were men. (Source: Harris et al., Annals of Internal Medicine 2017 (US triathlon deaths and cardiac arrests, 1985-2016))
- The mean age was 46.7 years, so middle-aged men made up much of the risk. (Source: Harris et al., Annals of Internal Medicine 2017 (US triathlon deaths and cardiac arrests, 1985-2016))
- The study reported 1.74 fatal events per 100,000 participants over 2006-2015. (Source: Harris et al., Annals of Internal Medicine 2017 (US triathlon deaths and cardiac arrests, 1985-2016))
- Clinically silent cardiovascular disease was present in an unexpected proportion of those who died. (Source: Harris et al., Annals of Internal Medicine 2017 (US triathlon deaths and cardiac arrests, 1985-2016))
- A swimmer in trouble can slip under unnoticed in a crowd, and rescuers need time to reach them and start resuscitation. (Source: Endurance-event medicine reference)
- Risk increased with age and was highest in older men. (Source: Harris et al., Annals of Internal Medicine 2017 (US triathlon deaths and cardiac arrests, 1985-2016))
- The authors concluded that death and cardiac arrest during triathlon are not rare and deserve prevention efforts. (Source: Harris et al., Annals of Internal Medicine 2017 (US triathlon deaths and cardiac arrests, 1985-2016))
- Middle-aged men with risk factors carry most of the risk, so a pre-participation medical review is sensible. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- Spreading swimmers out lowers congestion, contact and panic in the first minutes, where many problems begin. (Source: Endurance-event medicine reference)

## Test 2: Swim Emergencies

- The rules tell an athlete in an emergency to raise an arm overhead and call for assistance. (Source: World Triathlon Competition Rules (18 January 2025), 4.1)
- Once official assistance is rendered in the swim, the athlete must retire from the competition. (Source: World Triathlon Competition Rules (18 January 2025), 4.1)
- Standing on the bottom or holding an inanimate object to rest is allowed; using it to progress is forbidden. (Source: World Triathlon Competition Rules (18 January 2025), 4.1)
- Someone drowning is usually struggling to breathe, so they cannot call out or wave; it looks quiet, not dramatic. (Source: Endurance-event medicine reference)
- SIPE is fluid in the lungs during swimming, causing breathlessness, cough and sometimes frothy or blood-tinged sputum. (Source: Endurance-event medicine reference)
- Cold water, a constricting wetsuit, high blood pressure and heavy pre-race drinking all raise the pressure in the lung vessels. (Source: Endurance-event medicine reference)
- Suspected SIPE is an emergency: exit the water, sit upright, and get medical care and oxygen. (Source: Endurance-event medicine reference)
- SIPE recurs in a substantial share of people, so a medical review is needed before open-water racing again. (Source: Endurance-event medicine reference)
- Water safety crews are positioned to see distress early and reach a swimmer within seconds. (Source: Endurance-event medicine reference)
- Matching swim-exit records to starters confirms everyone has left the water, so a missing swimmer is searched for at once. (Source: Endurance-event medicine reference)

## Test 3: Heart Health for Endurance Athletes

- Exertional chest pain, fainting, unexplained breathlessness or palpitations are warning signs needing assessment before racing. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- Over about 35, coronary artery disease dominates; inherited conditions are the main cause in younger athletes. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- In younger athletes, inherited cardiomyopathies and electrical disorders are the leading causes. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- Unexplained sudden death of a close relative at a young age can point to an inherited heart condition. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- European cardiology bodies support ECG screening of athletes; US bodies do not recommend it routinely, citing false positives and cost. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- Decades of endurance training, particularly in men, are associated with a higher rate of atrial fibrillation. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- Training enlarges the heart chambers and slows the resting heart rate; these are normal adaptations, though they must be told apart from disease. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- Viral infections can inflame the heart muscle (myocarditis), and intense exercise during the illness increases that risk. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- Palpitations with dizziness can signal a dangerous rhythm, so the athlete stops and seeks medical help. (Source: Sports cardiology reference (ESC / AHA athlete guidance))
- The finding is real, but whether this calcified plaque carries the same risk as in non-athletes is still debated. (Source: Sports cardiology reference (ESC / AHA athlete guidance))

## Test 4: Exertional Heat Stroke

- Exertional heat stroke combines a core temperature usually above 40 °C with central nervous system dysfunction. (Source: Exertional heat illness consensus (ACSM and sports-medicine guidance))
- Cooling usually stops around 38.9 °C to avoid overshooting into hypothermia. (Source: Exertional heat illness consensus (ACSM and sports-medicine guidance))
- Oral, ear and skin readings are unreliable after exercise; rectal temperature is the field standard. (Source: Exertional heat illness consensus (ACSM and sports-medicine guidance))
- Immersing the body in cold or iced water cools fastest and is the gold-standard treatment. (Source: Exertional heat illness consensus (ACSM and sports-medicine guidance))
- Delaying cooling for transport costs time at high temperature; cooling on site first is what saves lives. (Source: Exertional heat illness consensus (ACSM and sports-medicine guidance))
- Rapid on-site cooling makes survival near universal; delay is what makes heat stroke deadly. (Source: Exertional heat illness consensus (ACSM and sports-medicine guidance))
- Antipyretics lower a raised set point in infection; in heat stroke the set point is normal and heat production overwhelms loss. (Source: Exertional heat illness consensus (ACSM and sports-medicine guidance))
- Rotating towels soaked in iced water over the body and head is a practical second choice when immersion is not possible. (Source: Exertional heat illness consensus (ACSM and sports-medicine guidance))
- WBGT is read at the finish area every 30 minutes from three hours before the start, in direct sun 1.5 m above ground. (Source: World Triathlon Competition Rules (18 January 2025), 10.3)
- Wet-bulb globe temperature blends air temperature with humidity, radiant heat and airflow, which is why it tracks heat stress. (Source: World Triathlon Competition Rules (18 January 2025), 10.3)

## Test 5: Exercise-Associated Hyponatraemia

- It is a blood sodium below 135 mmol/L during or up to 24 hours after exercise. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))
- Weight gain during a race means fluid intake exceeded losses, the main setting for hyponatraemia. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))
- As sodium falls, brain swelling causes confusion, seizures and coma, which is a medical emergency. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))
- Severe cases get a small bolus of hypertonic saline; normal saline and extra water can worsen it. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))
- Hyponatraemia and heat illness or dehydration can look alike, but giving fluids to a hyponatraemic athlete is harmful. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))
- Long race times with generous drinking give the most opportunity to take in more fluid than is lost. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))
- Non-osmotic ADH release during exercise limits water excretion, so excess drinking dilutes the blood. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))
- It can appear during exercise or in the day afterwards, especially if heavy drinking continues after the finish. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))
- On average lower body mass and longer times mean a given drinking pattern dilutes sodium more. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))
- Non-steroidal anti-inflammatory drugs have been associated with hyponatraemia in some studies, though not consistently. (Source: Exercise-associated hyponatraemia consensus (Hew-Butler et al., 2015))

## Test 6: Collapse at the Finish

- Most finish-line collapses are a drop in blood pressure on stopping, which is benign when recognised. (Source: Endurance-event medicine reference)
- Leg muscles pump blood back to the heart while running; stopping suddenly lets blood pool, so pressure drops. (Source: Endurance-event medicine reference)
- Lying flat with the legs and pelvis elevated restores blood to the heart and brain. (Source: Endurance-event medicine reference)
- With legs raised, recovery is usually quick; failure to improve is a sign to look for another cause. (Source: Endurance-event medicine reference)
- Collapsing while still racing is not explained by stopping, so cardiac, heat or sodium causes must be ruled out. (Source: Endurance-event medicine reference)
- Unresponsive with abnormal breathing means cardiac arrest until proven otherwise: CPR and a defibrillator immediately. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- Confusion plus heat suggests heat stroke, which needs a rectal temperature and immediate cooling. (Source: Exertional heat illness consensus (ACSM and sports-medicine guidance))
- Heat stroke, hyponatraemia and low blood sugar each need different urgent treatment. (Source: Endurance-event medicine reference)
- An alert athlete with low glucose is treated with fast sugar by mouth; if not alert, medical staff give it another way. (Source: Endurance-event medicine reference)
- Discharge is a medical decision, taken once the athlete is assessed as safe to go. (Source: Endurance-event medicine reference)

## Test 7: Crashes and Concussion

- Any suspicion of concussion means stopping; it is not a decision to make on the athlete's own feeling. (Source: Concussion in Sport Group consensus (Amsterdam 2022))
- Consensus guidance rules out same-day return after a suspected concussion. (Source: Concussion in Sport Group consensus (Amsterdam 2022))
- Return follows graded stages, usually at least 24 hours each, moving on only if symptoms do not return. (Source: Concussion in Sport Group consensus (Amsterdam 2022))
- Red flags such as a worsening headache, repeated vomiting, seizure or deteriorating consciousness need emergency care. (Source: Concussion in Sport Group consensus (Amsterdam 2022))
- With possible spinal injury the head and neck are kept still and the helmet left on until trained help arrives. (Source: Endurance-event medicine reference)
- Helmet foam is designed to crush once; damage may be invisible, so it is replaced after an impact. (Source: Endurance-event medicine reference)
- The expanded foam compresses on impact, spreading and absorbing energy that would otherwise reach the brain. (Source: Endurance-event medicine reference)
- Falling onto the shoulder or hand transmits force to the clavicle, the classic cycling fracture. (Source: Endurance-event medicine reference)
- Symptoms can develop over hours, so a rider who seemed fine is still watched after a head knock. (Source: Concussion in Sport Group consensus (Amsterdam 2022))
- Most concussions happen without loss of consciousness, which is why milder signs must be taken seriously. (Source: Concussion in Sport Group consensus (Amsterdam 2022))

## Test 8: Cold Water: Stages and Rescue

- Cold shock passes in about a minute, useful muscle function lasts roughly ten, and hypothermic unconsciousness takes about an hour. (Source: Cold-water immersion and sea-survival reference)
- Muscles and nerves in the limbs cool first, so a swimmer loses the ability to swim before becoming hypothermic. (Source: Cold-water immersion and sea-survival reference)
- The gasp and uncontrolled breathing of cold shock can lead to inhaling water within the first minute or two. (Source: Cold-water immersion and sea-survival reference)
- Cold blood from the limbs returns to the core after rescue, so temperature can fall further for a time. (Source: Cold-water immersion and sea-survival reference)
- Loss of water pressure on the body, lifting upright and relief can drop blood pressure just as the swimmer is rescued. (Source: Cold-water immersion and sea-survival reference)
- Rough handling and sudden rewarming can trigger dangerous heart rhythms or collapse. (Source: Cold-water immersion and sea-survival reference)
- Warm, sweet drinks help an alert athlete; drowsy or confused athletes are not given anything by mouth. (Source: Cold-water immersion and sea-survival reference)
- Removing wet layers, insulating and sheltering stop further heat loss before active warming. (Source: Cold-water immersion and sea-survival reference)
- The neoprene slows heat loss and keeps the body afloat, buying time, but it does not remove cold shock. (Source: Cold-water immersion and sea-survival reference)
- Fat is an insulator, so lean athletes lose heat faster and need more protection in cold water. (Source: Cold-water immersion and sea-survival reference)

## Test 9: Bystander CPR and AEDs

- Check whether they respond and breathe normally, and call the emergency services and for an AED. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- Agonal gasps are common in the first minutes of cardiac arrest and must not be mistaken for breathing. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- Guidelines call for 100-120 compressions per minute. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- Compressions should push the chest down about 5-6 cm and let it recoil fully. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- Hands go in the centre of the chest on the lower half of the sternum. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- Hands-only CPR is recommended for untrained rescuers; trained rescuers use 30 compressions to 2 breaths. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- AEDs are designed for lay use: they analyse the rhythm and shock only when needed. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- Pads need dry skin, and the patient should be moved out of standing water; the delay should be brief. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- Every minute without CPR or a shock cuts survival by around 7-10%, which is why bystanders act at once. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))
- Fatigue makes compressions shallower within minutes, so swapping keeps them effective. (Source: Resuscitation guidelines (European Resuscitation Council / AHA))

## Test 10: Race Medical Organisation

- Any athlete who appears to officials or medical personnel as presenting a danger may be removed from the race. (Source: World Triathlon Competition Rules (18 January 2025), 6.3)
- Medical guidelines, including hot-weather guidelines and evacuation plans, come from the race medical director and the medical delegate. (Source: World Triathlon Competition Rules (18 January 2025), 15.1)
- Withdrawing athletes must tell a technical official, so no one is searching for a missing athlete. (Source: World Triathlon Competition Rules (18 January 2025), 2.1)
- Conditions, medicines and an emergency contact help medical teams treat an athlete who cannot speak for themselves. (Source: Endurance-event medicine reference)
- The WBGT thresholds for modifying competition for healthy adults follow ACSM's 2007 recommendations. (Source: World Triathlon Competition Rules (18 January 2025), 10.3)
- Decisions consider medical facilities, the weather forecast, season, distance, category, athlete fitness and age. (Source: World Triathlon Competition Rules (18 January 2025), 10.3)
- Unacclimatised or less-trained participants are at higher risk of heat illness when heat arrives unexpectedly. (Source: World Triathlon Competition Rules (18 January 2025), 10.3)
- Triage makes sure a collapsed, confused athlete is seen before one with blisters. (Source: Endurance-event medicine reference)
- The responsibility for remaining on the course rests with the athlete. (Source: World Triathlon Competition Rules (18 January 2025), 6.3)
- It sets how injured or ill athletes are reached, moved and handed to hospital care from every part of the course. (Source: Endurance-event medicine reference)

Sources: World Triathlon Competition Rules (2025), IRONMAN qualification announcements, and sport-, travel- and event-medicine reference

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