New Guidelines For Managing Sudden Cardiac Arrest During School Athletics

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April 10, 2007 — New recommendations outlining the necessary components for emergency preparedness and standardized treatment protocols in the management of sudden cardiac arrest appear in the April issue of Heart Rhythm. Developed by a task force sponsored by the National Athletic Trainers' Association, the new guidelines are designed to help schools prepare for and respond to cardiac emergencies that happen on the athletic field.

"Our athletic trainers are very often the first responder, the first-line health professional caring for our athletes, but they are not always around because many high schools might have only one trainer. There is no way they can cover all the sports, or be at all the practices," Jonathan A. Drezner, MD, from the University of Washington in Seattle, told heartwire. "The real people that we need to train to recognize cardiac arrest are the people that are there everyday: our coaches, our teammates, or the officials. They need to be able to recognize cardiac arrest and initiate steps that have been predetermined in the emergency action plan."

Dr. Drezner told heartwire the best available estimate of sudden cardiac death in high school athletes is 1:100,000 to 1:200,000, although the estimated incidence is slightly higher in college-aged athletes. However, with no mandatory national reporting system, these numbers are believed to underestimate the real scope of the problem, he said. The cause of sudden cardiac death in 25% of cases is underlying hypertrophic cardiomyopathy, with coronary artery anomalies representing approximately 14% of sudden cardiac deaths in the United States.

The inter-association task force calls for athletic programs to undergo comprehensive emergency planning to ensure an efficient response to sudden cardiac arrest. According to the task force, the following items are critical for schools to be prepared for cardiac emergencies:

  • Schools or institutions sponsoring athletic events must have a structured emergency action plan.

  • The emergency action plan should be developed through discussions with local emergency medical service (EMS) personnel, school safety officials, onsite first responders, and school administrators.

  • The emergency action plan must be specific to the sporting venue and include emergency communication, personnel, equipment, and transportation to appropriate emergency facilities.

  • The emergency action plan should be practiced annually.

  • First responders should be trained and certified in cardiopulmonary resuscitation (CPR) and defibrillation.

  • Access to early defibrillation is essential, with a target time of less than 3 to 5 minutes from the time of collapse.

"Many schools are acquiring defibrillators through donations, and while that's not a bad thing, it's only solving half the problem," said Dr. Drezner. "You have the equipment, but do you have the plan that goes with it? If the defibrillator is kept in the nurses' office in a locked cabinet, it doesn't really do you much good if a player has a cardiac arrest on the football field, or basketball gym."

After the emergency action plan has been developed by EMS personnel, school officials, first responders, and administrators and the equipment has been reviewed, the emergency action plan must be ready to work smoothly when the situation arises. "This is something that has to be practiced," emphasized Dr. Drezner. "You have to get your likely first responders, your athletic trainers, your team physicians, your school nurses, coaches, and administrators, and bring them out to practice field and simulate a cardiac arrest. Go over that emergency practice plan, and go over it at least once a year."

In addition to these guidelines, the task force also establishes uniform recommendations for the management of sudden cardiac arrest in athletes, with the initial components being early activation of EMS, early CPR, early defibrillation, and rapid transition to advanced cardiac life support.

Heart Rhythm. 2007;4:549-565.

The complete contents of Heartwire, a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

Clinical Context

According to the current consensus statement, sudden cardiac arrest is the leading cause of death in young athletes. In those with sudden cardiac death, the underlying cardiac anomaly is usually structural, with hypertrophic cardiomyopathy and coronary artery anomalies representing 25% and 14% of cases, respectively, and commotio cordis representing 20% of cases. Vigorous exercise appears to be a trigger for lethal arrhythmias in athletes with occult heart disease. The incidence of sudden cardiac death is estimated at 1:100,000 to 1:200,000 in high school athletes and 1:65,000 to 1:69,000 in college athletes. About 110 sudden deaths occur in young competitive athletes per year in the United States. With the increasing availability of automated external defibrillators (AEDs), effective secondary prevention of sudden cardiac death is now available. The single greatest factor affecting survival after out-of-hospital cardiac arrest is the time interval from arrest to defibrillation. In commotio cordis, which most commonly occurs in male adolescents (mean age, 13.6 years) with a blunt nonpenetrating blow to the chest, survival rates decline 7% to 10% for every minute that defibrillation is delayed.

This is a task force report from a multidisciplinary group representing 15 US national organizations that convened an inter-association meeting to provide consensus on management and emergency preparedness for sudden cardiac arrest at high school and college athletic venues. The recommendations are in agreement with the American Heart Association guidelines for CPR and emergency cardiac care and the medical emergency response plan for schools.

Study Highlights

  • Emergency Preparedness
    • A written and structured emergency action plan is recommended for every school or institution that sponsors athletic events.
    • The emergency action plan should be developed with EMS personnel, school officials, first responders, and administrators.
    • The emergency action plan and equipment should be reviewed and practiced annually, and targeted first responders should be trained in CPR and AED use.
    • Emergency equipment should be at the site with quick access available, and personnel should be trained to use it.
    • AEDs placed at public locations can substantially improve survival from sudden cardiac arrest, and athletic venues should have them placed at prominent locations.
    • The emergency action plan should target a collapse-to-EMS call time and CPR initiation of less than 1 minute.
    • A target goal of less than 3 to 5 minutes from time of collapse to first shock by AED is strongly recommended.
    • Review of equipment readiness and the emergency action plan by on-site personnel for each event is desirable.
  • Management of Sudden Cardiac Arrest
    • In 55% to 80% of cases of sudden cardiac arrest, the athlete is asymptomatic until the cardiac arrest.
    • Initial components of sudden cardiac arrest management are early activation of EMS, early CPR, early defibrillation, and rapid transition to advanced life support.
    • Sudden cardiac arrest should be suspected for any collapsed and unresponsive athlete.
    • Young athletes who collapse after a blow to the chest by a firm projectile or by player contact should be suspected of sudden cardiac arrest from commotio cordis.
    • 1 or more trained rescuers should begin CPR while another alerts the EMS system by calling 911 (in the United States) and retrieving the AED.
    • The rescuer should open the airway using the "head tilt–chin left" maneuver and then look, listen, and feel.
    • If normal breathing is not detected within 10 seconds, 2 rescue breaths should be given followed by chest compressions.
    • An AED should be applied as soon as possible on any collapsed and unresponsive athlete for rhythm analysis and defibrillation if indicated.
    • New American Heart Association guidelines eliminate lay rescuer assessment of pulse and recommend that cardiac arrest be assumed if the unresponsive person does not demonstrate normal breathing.
    • A healthcare provider may feel for a pulse and initiate CPR if a pulse is not felt within 10 seconds.
    • CPR should be provided while awaiting the AED, and early bystander CPR can double or triple the chance of survival from ventricular fibrillation sudden cardiac arrest.
    • A universal compression-to-ventilation ratio of 30:2 is recommended for single rescuers and all sudden cardiac arrest cases.
    • Chest compressions ("push hard, push fast") should be at the rate of 100 per minute, allowing complete chest recoil and minimizing interruptions in compression.
    • CPR should resume immediately after initial shock, beginning with chest compressions.
    • For EMS personnel, 5 cycles (or 2 minutes) of CPR should be provided before defibrillation for witnessed arrest.
    • CPR should be continued until advanced life-support providers take over or the person starts to move.
    • Rescuers should be trained to recognize sudden cardiac arrest.
    • Rapid access to the person experiencing sudden cardiac arrest should be given to EMS personnel.

Pearls for Practice

  • Comprehensive emergency planning is recommended for high school and college athletic events and venues, including trained personnel and a target response time of 1 minute to CPR and 3 to 5 minutes to first shock by AED.
  • Sudden cardiac arrest should be suspected in any high school or college athlete who collapses and is unresponsive, and the updated American Heart Association guidelines should be followed for CPR and AED initiation.


Medscape Medical News 2007. ©2007 Medscape

Submitted by DMorgan on Fri, 05/04/2007 - 9:49am.