Outcomes from sudden cardiac arrest in US high schools: a 2-year prospective study from the National Registry for AED Use in Sports

Catastrophic injuries and exertional medical events in lacrosse among youth, high school and collegiate athletes: longitudinal surveillance over four decades (1982-2020)

OBJECTIVE

To determine the incidence rates (IRs) of catastrophic injuries and exertional medical events in lacrosse athletes.

METHODS

Catastrophic injuries and exertional medical events in lacrosse in the US among youth or amateur, high school and college athletes were analysed from the National Center for Catastrophic Sport Injury Research (NCCSIR) database from 1982/83 to 2019/20. Frequencies, IRs per 100,000 athlete-seasons (AS) with 95% confidence intervals (CIs), and incidence rate ratios (IRRs) with 95% CIs were calculated. Participation data were gathered from the National Federation of State High School Associations (NFHS), National Collegiate Athletic Association (NCAA) and USA Lacrosse.

RESULTS

Sixty-nine catastrophic events (16 youth or amateur, 36 high school and 17 college; 84% male) occurred in US lacrosse from 7/1/1982 to 6/30/2020. Thirty-six percent of all incidents were fatal. The overall IR was 0.5 per 100,000 AS (95% CI: 0.4-0.7). There were 15 cases of non-traumatic sudden cardiac arrests (SCAs) and 15 incidents of commotio cordis. Fatality rates from SCA and commotio cordis decreased 95% (IRR = 0.05; 95% CI: 0, 0.2) from 1982/83-2006/07 to 2007/08-2019/20. Incidence rates were higher for collegiate versus high school 1982/83-2019/20 (IRR = 3.2; 95% CI: 1.8, 5.7) and collegiate versus youth 2005/06-2019/20 (IRR = 8.0; 95% CI: 3.0, 21.4) level. Contact with a stick or ball (41%) and contact with another player (20%) were the primary mechanisms of injury.

CONCLUSIONS

The incidence of catastrophic events during lacrosse was higher among collegiate than high school or youth athletes. SCA from an underlying cardiac condition or from commotio cordis was the most common catastrophic event. Fatality rates from catastrophic injuries have declined significantly over the study period, perhaps driven by protective measures adopted by lacrosse governing bodies.

Community-level bystander treatment and outcomes for witnessed out-of-hospital cardiac arrest in the state of Connecticut

Background

Prior reports have demonstrated underutilization of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use in patients with witnessed out-of-hospital cardiac arrest (OHCA) in Connecticut. This study aimed to identify community-level risk factors that contribute to low rates of bystander intervention to improve statewide OHCA outcomes.

Methods

We analyzed 2,789 adult patients with witnessed, non-traumatic OHCA submitted to the Connecticut Cardiac Arrest Registry to Enhance Survival (CARES) between 2013-2022. Patients were grouped by zip code, and associated municipal characteristics were acquired from 2022 United States Census Bureau data. Use of bystander CPR, attempted bystander AED defibrillation, and patient survival with favorable neurological function were determined for 19 of the 20 most populous cities and towns. Pearson correlation tests and linear regression were used to determine associations between OHCA treatment and outcomes with population size, racial/ethnic demographics, language use, income, and educational level.

Results

Bystander CPR was lower in municipalities with population size > 100,000 and in communities where > 40% of residents are non-English-speaking. AED use was also lower in these municipalities, as well as those with per capita incomes < $40,000 or > 1/3 Hispanic residents. Communities with populations > 100,000, > 40% non-English-speaking, per capita income < $40,000, and > 1/3 Hispanic residents were all associated with lower survival rates.

Conclusions

OHCA pre-hospital treatment and outcomes vary significantly by municipality in Connecticut. Community outcomes might be improved by specifically targeting urban population centers and Hispanic communities with culturally sensitive, low, or no-cost CPR and AED educational programs, using instructional languages other than English.

Exercise related versus non exercise related out of hospital cardiac arrest - A retrospective single-center study

Background

Physical activity prevents cardiovascular disease, but it may also trigger acute cardiac events like sudden cardiac death in patients with underlying heart disease. The chance of surviving an out-of-hospital cardiac arrest remains low, despite improving medical treatment and rescue chain. Prior studies signaled increased survival in exercise related out-of-hospital cardiac arrest.

Objective

The aim of this study was to evaluate the differences between exercise related out-of-hospital cardiac arrest and out-of-hospital cardiac arrest during daily activity in an urban setting.

Methods

Retrospective analysis of all out-of-hospital cardiac arrests from 2014 to 2021 treated at a cardiac arrest center of a tertiary hospital. The primary outcome was survival to discharge. Secondary outcomes included differences in pre-hospital care, in-hospital treatment, hypoxic ischemic encephalopathy, and laboratory parameters.

Results

478 OHCA patients were reviewed of which 432 patients (exercise related 36 (8.4%) vs. daily activity 396 (91.6%)) were included in the analysis. Patients suffering an exercise related arrest were younger (57 vs 65 years, p = 0.002) and mostly male (88.9 vs 74.5%, p = 0.054).The exercise related cohort received bystander cardiopulmonary resuscitation (77.8 vs 53.4%, p = 0.005) to a higher extent and had a shorter no-flow time (1.5 vs 2 min, p = 0.049). Exercise related arrest patients more often presented with a shockable rhythm (80.6 vs 64.1%, p = 0.032).At hospital admission exercise related arrest patients had a higher initial pH (7.24 vs 7.19, p = 0.015). In the exercise related group, a cardiac cause was numerically more frequent compared to the daily activity group (80.6 vs 68.7%, p = 0.09). In both groups myocardial infarction (47.2 vs 43.2%) was the most common cause, but a primary arrhythmic event (33.3 vs 25.5%) was more often documented in exercise related arrest patients. Exercise related arrest was mostly related to endurance training (52.8%) followed by ball sports (19.4%) and occurred directly during exercise in 77.8% of cases. Patients suffering exercise related arrest had higher survival till discharge (66.7 vs 47.7%, p = 0.036).

Conclusion

Based on this observational data from a highly selected group of out-of-hospital cardiac arrest patients treated at a cardiac arrest center, patients suffering an exercise related out-of-hospital cardiac arrest, differed in substantial characteristics and in the first line response compared to daily activity out-of-hospital cardiac arrest patients. The better survival to discharge of the exercise related out-of-hospital cardiac arrest group might be driven by these beneficial differences. This study underlines the need for public awareness for the importance of a fast first response and a broad distribution of automated external defibrillators in public sport areas since most of the exercise related out-of-hospital cardiac arrest patients presented with a cardiac cause and an initial shockable rhythm.

Resuscitation on the field of play: a best-practice guideline from Resuscitation Council UK

Sudden cardiac arrest (SCA) is the leading cause of sudden death in athletes during high-level, organised sport. Patient-related and event-related factors provide an opportunity for rapid intervention and the potential for high survival rates. The aim of this consensus was to develop a best-practice guideline for dedicated field-of-play medical teams responding to SCA during an organised sporting event. A task-and-finish group from Resuscitation Council UK identified a stakeholder group of relevant experts and cardiac arrest survivors in March and April 2022. Together, they developed a best-practice guideline using the best available evidence. A public consultation period further refined the guideline before it was finalised in December 2023. Any sudden collapse, without rapid recovery during sporting activity, should be considered an SCA until proven otherwise. Field-of-play medical teams should be empowered to access the collapsed athlete as soon as possible and perform initial essential interventions in situ. This includes a suggested minimum of three cycles of cardiopulmonary resuscitation and defibrillation in persistent shockable rhythms while other aspects of advanced life support are initiated. There should be careful organisation and practice of the medical response, including plans to transport athletes to dedicated facilities for definitive medical care. This best-practice guideline complements, rather than supersedes, existing resuscitation guidelines. It provides a clear approach to how to best treat an athlete with SCA and how to organise the medical response so treatments are delivered effectively and optimise outcomes.

National Athletic Trainers' Association Position Statement: Emergency Action Plan Development and Implementation in Sport

OBJECTIVE

An emergency action plan (EAP) is a written document detailing the preparations and on-site emergency response of health care professionals and other stakeholders to medical emergencies in the prehospital setting. The EAP is developed to address any type of catastrophic injury response and should not be condition specific. The objective of this National Athletic Trainers' Association position statement is to provide evidence-based and consensus-based recommendations for developing and implementing an EAP for sports settings.

METHODS

These recommendations were developed by a multidisciplinary expert panel that performed (1) a comprehensive review of existing EAP evidence, (2) a modified Delphi process to define consensus recommendations, and (3) a strength of recommendation taxonomy determination for each recommendation.

RESULTS

An EAP is an essential tool designed to facilitate emergency preparedness and an efficient, coordinated emergency response during an athletic event. A comprehensive EAP should consider modes to optimize patient outcomes, the various stakeholders needed to develop the plan, the factors influencing effective implementation of the EAP, and the roles and responsibilities to ensure a structured response to a catastrophic injury.

CONCLUSIONS

These evidence-informed recommendations outline the necessary steps for emergency planning and provide considerations for the immediate management of patients with catastrophic injuries. Increasing knowledge and implementation of the EAP to manage patients with catastrophic injuries improves the overall response and decreases errors during an emergency.

2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play

Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.

Causes of sudden cardiac arrest and death and the diagnostic yield of sport preparticipation screening in children

OBJECTIVE

Evidence on the increased risk of sports-related sudden cardiac arrest and death (SCA/D) and the potential benefit of cardiovascular preparticipation screening (PPS) in children is limited. We assessed the burden and circumstances of SCA/D and the diagnostic yield of cardiovascular PPS in children aged 8-15 years.

METHODS

Data on the incidence and causes of SCA/D from 2011 to 2020 were obtained from the Veneto region (Italy) sudden death registry, hospital records and local press. During the same period, we assessed the results of annual PPS in 25 251 young competitive athletes aged 8-15 years who underwent 58 185 evaluations (mean 2.3/athlete) in Padua, Italy.

RESULTS

Over 10 years, 26 SCA/D occurred in children aged 8-15 years in the Veneto region: 6 in athletes (incidence 0.7/100 000/year, all ≥12 years) versus 20 in non-athletes (0.7/100 000/year, 17/20 ≥12 years). In total, 4/6 athletes versus 1/20 non-athletes survived. The cause of SCA/D remained unexplained in four athletes and in nine non-athletes. No athlete suffered SCA/D from structural diseases potentially identifiable by PPS. The incidence of SCA/D in athletes and non-athletes was 0.2/100 000/year in the 8-11 years group versus 1.3/100 000/year in the 12-15 years group. PPS identified 26 new diagnoses of cardiovascular diseases (CVDs) at risk of SCA/D, more often in children ≥12 years old (0.06%/evaluation) than <12 years old (0.02%/evaluation, p=0.02). Among athletes with a negative PPS, two suffered unexplained SCA/D during follow-up, one during exercise.

CONCLUSIONS

In children aged 8-15 years, the incidence of SCA/D and the yield of PPS for identifying at-risk CVD were both substantially higher in those ≥12 years, suggesting that systematic PPS may be more useful beyond this age.

Catastrophic Sports Injuries: Causation and Prevention

➤ Catastrophic injuries in U.S. high school and college athletes are rare but devastating injuries.➤ Catastrophic sports injuries are classified as either traumatic, caused by direct contact during sports participation, or nontraumatic, associated with exertion while participating in a sport.➤ Football is associated with the greatest number of traumatic and nontraumatic catastrophic injuries for male athletes, whereas cheerleading has the highest number of traumatic catastrophic injuries and basketball has the highest number of nontraumatic catastrophic injuries for female athletes.➤ The incidence of traumatic catastrophic injuries for all sports has declined over the past 40 years, due to effective rule changes, especially in football, pole-vaulting, cheerleading, ice hockey, and rugby. Further research is necessary to reduce the incidence of structural brain injury in contact sports such as football.➤ The incidence of nontraumatic catastrophic injuries has increased over the last 40 years and requires additional research and preventive measures. Avoiding overexertion during training, confirming sickle cell trait status in high school athletes during the preparticipation physical examination, and developing cost-effective screening tools for cardiac abnormalities are critical next steps.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Out-of-Hospital Cardiac Arrests during Mass-Participation Endurance Events: A Case Series

INTRODUCTION

Mass-participation endurance events take place throughout the United Kingdom. Although out-of-hospital cardiac arrests (OHCAs) occur during these events, little is known about them. This case series aims to describe the number, type, etiology, and outcome of OHCAs treated by a UK-based specialist sports medicine provider over a period of 8 y.

METHODS

The medical records of a UK-based sports medicine provider were reviewed from 2014 to 2022. Anonymized information from OHCAs during this time was recorded. This included type of event, patient demographics, details of OHCA, and patient outcomes.

RESULTS

Ten OHCAs were identified during the course of 110 sporting events. These included the cases of 9 participants and 1 spectator. Return of spontaneous circulation (ROSC) was achieved on-site in all patients. Eight survived beyond 24 h and achieved a full neurological recovery. Seventy percent of these patients achieved ROSC within 4 min of cardiopulmonary resuscitation being initiated. The 2 patients who died both presented with a nonshockable rhythm.

CONCLUSIONS

OHCAs during mass-participation endurance events are rare. However, medical providers must be prepared to respond promptly. Quick interventions can result in a full neurological recovery.

Congenital coronary artery anomalies in sports medicine. Why to know them

The anomalous origin of a coronary artery (AOCA) is a challenging topic, due to its rarity, the complexity of the pathophysiological aspects, the clinical presentation (often silent), the difficulty of diagnosis, and the potential risk of causing acute cardiovascular events up to sudden cardiac death, particularly when triggered by heavy physical exercise or sport practice. Increasing interest in sport medical literature is being given to this topic. This paper reviews current knowledge of AOCAs in the specific context of the athletic setting addressing epidemiological and pathophysiological aspects, diagnostic work-up, sports participation, individual risk assessment, therapeutic options, and return to play decision after surgery.

Current status of cardiopulmonary resuscitation training and automatic external defibrillator availability in high schools in Halifax, Nova Scotia, Canada

Background

School-based cardiopulmonary resuscitation (CPR) training and early use of an automated external defibrillator (AED) have proven to increase the survival of victims of sudden cardiac arrest (SCA). This study aimed to determine the status of CPR training, availability of AEDs, and medical emergency response programs (MERPs) in high schools in Halifax Regional Municipality.

Method

High school principals were asked to participate in a voluntary online survey comprising questions about demographics, AEDs availability, CPR training for staff and students, the existence of MERPs, and perceived barriers. Three autogenerated reminders followed the initial invitation.

Results

Out of 51 schools, 21 (41%) responded, only 10% (2/21) and 33% (7/21) reported providing CPR training to students and staff, respectively. About 35% (7/20) of the schools reported having AEDs, but only 10% (2/20) have MERPs for SCA. All respondents reported in favor of AED availability in schools. The reported barriers to CPR training included limited financial resources (54%), perception of low priority (23%), and time constraints (23%). Respondents reported limited financial resources (85%) and the lack of trained staff to use (30%) as the main reasons for the unavailability of AEDs.

Conclusion

This survey showed that all respondents overwhelmingly favour having access to AEDs. However, the availability of CPR and AED training for staff and students in schools remains inadequate. Emergency action plans have not been devised, and few schools have AED devices. More education and awareness are needed to ensure lifesaving equipment and practices in all Halifax Regional Municipality schools.

Association between basic life support and survival in sports-related sudden cardiac arrest: a meta-analysis

AIMS

To evaluate the association of basic life support with survival after sports-related sudden cardiac arrest (SR-SCA).

METHODS AND RESULTS

In this systematic review and meta-analysis, a search of several databases from each database inception to 31 July 2021 without language restrictions was conducted. Studies were considered eligible if they evaluated one of three scenarios in patients with SR-SCA: (i) bystander presence, (ii) bystander cardiopulmonary resuscitation (CPR), or (iii) bystander automated external defibrillator (AED) use and provided information on survival. Risk of bias was evaluated using Risk of Bias in Non-randomized Studies of Interventions. The primary outcome was survival at the longest follow up. The meta-analysis was conducted using the random-effects model. The Grading of Recommendations Assessment, Development, and Evaluations (GRADE) approach was used to rate certainty in the evidence. In total, 28 non-randomized studies were included. The meta-analysis showed significant benefit on survival in all three groups: bystander presence [odds ratio (OR) 2.55, 95% confidence interval (CI) 1.48-4.37; I2 = 25%; 9 studies-988 patients], bystander CPR (OR 3.84, 95% CI 2.36-6.25; I2 = 54%; 23 studies-2523 patients), and bystander AED use (OR 5.25, 95% CI 3.58-7.70; I2 = 16%; 19 studies-1227 patients). The GRADE certainty of evidence was judged to be moderate.

CONCLUSION

In patients with SR-SCA, bystander presence, bystander CPR, and bystander AED use were significantly associated with survival. These results highlight the importance of witness intervention and encourage countries to develop their first aid training policy and AED installation in sport settings.

Secondary School Athletic Coaches' Perceptions and Knowledge of the Athletic Training Profession

CONTEXT

Coaches play a role in streamlining care, especially by directing student-athletes in need of further medical attention to the athletic trainer (AT). The AT-coach relationship holds great potential for incorporating collaborative care, and yet, little is known about coaches' perceptions and knowledge of ATs.

OBJECTIVE

To investigate coaches' perceptions of athletic training and their knowledge regarding the roles and responsibilities of ATs in secondary schools.

DESIGN

Concurrent mixed-methods study.

SETTING

Cross-sectional online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

Secondary school athletic coaches from 10 sports with the highest participation rates during the 2017-2018 season (n = 1097). Most respondents were male (n = 795, 72.4%), and their average age was 44.7 ± 11.4 years.

MAIN OUTCOME MEASURE(S)

Participants completed a web-based questionnaire containing demographics and quantitative measures assessing their perceived value and knowledge of ATs, as well as open-ended questions. Descriptive statistics summarized the demographic data. Counts and percentage responses for quantitative measures were reported. Open-ended responses were analyzed using the general inductive approach.

RESULTS

Approximately 93% of respondents considered an AT a trusted source of medical information and a key member of the sports medicine team. Most respondents selected injury prevention (98.9%), first aid and wound care (97%), therapeutic interventions (89.9%), and emergency care (85.8%) as skills ATs are qualified to perform. Forty-six percent of respondents were willing to coach without an AT employed. Coaches trusted ATs as part of the "athletic team" and as gatekeepers, referring student-athletes for advanced care when warranted. Regarding the AT role, coaches emphasized the treatment of minor injuries and the idea of "coverage versus care."

CONCLUSIONS

Secondary school coaches valued the athletic training profession and were knowledgeable regarding various roles and responsibilities ATs frequently perform. However, they may view ATs as luxuries instead of necessities, as evidenced by the fact that just under half of responding coaches were willing to coach without an AT employed at the school.

Sudden Cardiac Arrest in Basketball and Soccer Stadiums, the Role of Automated External Defibrillators: A Review. For the BELTRAN Study (BaskEtbaLl and soccer sTadiums: Registry on Automatic exterNal defibrillators)

Sudden cardiac arrest (SCA) during sports events has a dramatic impact on stadium-goers and the public and is often associated with poor outcomes unless treated with an automated external defibrillator (AED). Despite this, stadiums vary in AED use. This review aims to identify the risks and incidences of SCA, and the use of AEDs in soccer and basketball stadiums. A narrative review of all relevant papers was conducted. Athletes across all sports face an SCA risk of 1:50,000 athlete-years, with the greatest risk of SCA in young male athletes (1:35,000 person-years) and black male athletes (1:18,000 person-years). Africa and South America have the poorest soccer SCA outcomes at 3% and 4% survival. AED use on-site improves survival greater than defibrillation by emergency services. Many stadiums do not have AEDs implemented into medical plans and the AEDs are often unrecognisable or are obstructed. Therefore, AEDs should be used on-site, use clear signalling, have certified trained personnel, and be incorporated into stadiums' medical plans.

Automated external defibrillators and basic life support practices in secondary schools: a nationwide study

AIM

Cardiac arrest prevention in schools has recently gained momentum. The survival benefit in schools who have access to defibrillators is clear, with far better survival outcomes in children or adults who sustain a cardiac arrest on school grounds. The main objectives of this study were to assess sudden cardiac arrest prevention in Maltese schools, specifically the availability of defibrillators and staff competence in delivering resuscitation.

METHODOLOGY AND RESULTS

An online-based questionnaire was distributed to all secondary schools across the Maltese archipelago. Data were collected, tabulated, and analysed using SPSS V.23. Most schools (n = 40, 74.1%) completed the questionnaire. Two schools documented a cardiac arrest in the past 10 years. 87.5% agreed that cardiac arrest prevention is an important health topic. Most have a defibrillator on the premises (n = 37, 92.5%). Only one defibrillator is usually available (n = 27, 75.0%). Despite the majority claiming its ease of accessibility (n = 35, 97.2%), most were not available on every floor (n = 37, 97.2%). Only one-third were close to a sporting facility (n = 11, 30.6%). Schools do not organise regular resuscitation courses (n = 21, 58.3%), with eight schools having five or more certified staff members (23.5%). The number of defibrillators did not influence the frequency of resuscitation courses at school (p = 0.607), and there was no association with the number of certified individuals (p = 0.860).

CONCLUSION

Defibrillators are not readily available at secondary schools and are often installed in low-risk areas. Most schools have only one staff member certified in resuscitation. These factors should be addressed with urgency.

The Effect of a Statewide Policy on High School Emergency Action Plans

Institutions sponsoring athletics must be prepared for emergencies. Due to this, more governing bodies are requiring a sports-related emergency action plan (EAP). Yet, the effects of these policies are unknown. We compared adoption of EAPs and associated best practices in Oregon high schools before and after a policy requiring an EAP. Athletic directors were invited to complete a survey during the year before the policy went into effect and again the following year. We assessed whether the school had a written EAP and if they did, was the EAP venue specific, available at the venue, distributed to personnel, and annually reviewed and rehearsed. Pre/post-policy proportions were analyzed using Fisher exact tests for all schools and then schools that completed both surveys. There was a significant increase of schools that reported having an EAP after the policy went into effect (all schools: 55% to 99% [p < 0.001] and schools responding both years: 60% to 98% [p < 0.001]). Venue specific EAPs also significantly increased but only when analyzing all responses (59% to 71% [p = 0.03]). No best practice recommendations related to EAP availability, distribution, review, or rehearsal changed after the policy. Schools met the minimum requirements of the policy, but other related best practices did not significantly improve.

Assessing Effective Practices and Barriers to Creating School and Community Partnerships for a Sudden Cardiac Death Prevention Program: A National Project ADAM® study

OBJECTIVES

Project ADAM (Automated Defibrillators in Adam's Memory) is a national collaborative to improve outcomes for out-of-hospital sudden cardiac arrest. Given Project ADAM's expansion, we sought to identify effective methods to partner with community leaders and understand barriers to engagement. Our aim was to establish effective practices to guide affiliates and optimize site operations and partnerships.

METHODS

We conducted a survey of all Project ADAM sites in 2020. Medical Directors and Program Coordinators were included for generalizability. The survey consisted of 20 questions covering the domains of communication, goals for partner organizations, partnership barriers, staff time commitments, and Project ADAM program needs.

RESULTS

Thirty-one members responded: 14 Medical Directors and 17 Program Coordinators. E-mail was the predominant method to initiate (58%) and maintain (87%) contact with partner organizations, though telephone (21%) and in-person visits (14%) were common for initiating contact. Presentations at school board, Emergency Medical Services, and athletic director meetings and student/family testimonials were powerful engagement tools. Barriers to partnership varied, revolving around limited school budgets, overburdened staff, and Covid-19. Limited time, difficulty coordinating schedules, and lack of dedicated resources were common challenges for Project ADAM sites. Only 36% of Medical Directors receive institutional recognition of Project ADAM effort.

CONCLUSIONS

Project ADAM's partnership with community stakeholders creates unique opportunities and challenges. Optimal communication methods should be identified early for each school, with regular interaction for long-term success. Institutional recognition of Project ADAM efforts may boost success. Additionally, the Covid-19 pandemic created numerous challenges and may spur operational changes.

Sudden death in young athletes: Is it preventable?

Sudden death in young athletes is a rare but always dramatic condition. Unlike all other rare diseases, the estimate of its real incidence is made complex not only because of the uncertain number of correctly identified cases (numerator) but also because of the uncertain estimation of the real number of the reference population, the athletes (denominator). New elements of complexity are also emerging with regard to prevention. The current two pillars of prevention are pre-participation screening (proactive strategy) and promoting use / access to the automated external defibrillator (reactive strategy). The standardization of procedures implemented over the past two decades for pre-participation screening can now allow us to assess the impact of this approach. The result is complex to evaluate. While screening may allow the identification of conditions potentially associated with SDA, and therefore the adoption of specific treatments, in about 0.4% of screened subjects, a single study investigated the yield in terms of mortality showing a positive predictive value of 4.7% with 25% sensitivity. Conversely, the reactive strategy appears considerably effective, due to the widespread use of the automated external defibrillators in sports facilities, calling for a homogeneous implementation worldwide. On a broader perspective, the vast attention devoted to SDA prevention in the world of sports represents a major driver for transfer of a reactive prevention strategy to the general population.

The Case for Home AED in Children, Adolescents, and Young Adults Not Meeting Criteria for ICD

Children, adolescents, and young adults with conditions such as cardiomyopathies and channelopathies are at higher risk of sudden cardiac death caused by lethal arrhythmias, especially ventricular fibrillation. Timely defibrillation saves lives. Patients thought to be at significantly high risk of sudden death typically undergo placement of an implantable cardioverter-defibrillator. Patients thought to be at lower risk are typically followed medically but do not undergo implantable cardioverter-defibrillator placement. However, low risk does not equal no risk. Compared with the general population, many of these patients are at significantly higher risk for lethal arrhythmias. We make the case that such individuals and families will benefit from having an at-home automatic external defibrillator. Used in conjunction with conventional measures such as training on cardiopulmonary resuscitation, an at-home automatic external defibrillator could lead to significantly shortened time to defibrillation with better overall and neurological survival. We recommend that the cost of such home automatic external defibrillators should be covered by medical insurance.

Lay rescuer use of automated external defibrillators in infants, children and adolescents: A systematic review

Importance

Automated external defibrillator (AED) use is increasing, but use in children is uncommon. A growing literature of use in children by lay rescuers warrants review.

Objective

A systematic review of AED effectiveness in children experiencing out-of-hospital cardiac arrest (OHCA).

Data Sources

PubMed, EMBASE, Cochrane Register of Controlled Trials.

Study Selection

Children, ages 0-18, experiencing OHCA with an AED applied by a lay rescuer. Control population: children with no AED application.

Data Extraction and Synthesis

Results are reported according to PRISMA guidelines. Two authors independently reviewed all titles and abstracts of references identified by the search strategy, then generated a subset which all authors reviewed.

Main Outcomes and Measures

Critical outcomes were survival with Cerebral Performance Category (CPC) 1-2 at hospital discharge or 30 days and survival to hospital discharge.

Results

Population: age categories: <1 year, 1-12 years, 13-18 years. Lay rescuer AED application resulted in improved survival with CPC 1-2 at hospital discharge or 30 days to hospital discharge in age groups 1-12 and 13-18 years (RR 3.84 [95 % CI 2.69-5.5], RR 3.75 [95 %CI 2.97-4.72]), respectively and hospital discharge in both groups(RR 3.04 [95 % CI 2.18-4.25], RR 3.38 [95 % CI 2.17-4.16]), respectively. AED use with CPR improved CPC 1-2 at hospital discharge and hospital discharge (RR 1.49 [95 % CI 1.11-1.97], RR 1.55[1.12-2.12]).

Conclusions

AED application by lay rescuers is associated with improved survival with a CPC of 1-2 at 30 days, and improved survival to hospital discharge for children 1-18 years. There are limited data for children < 1 year.

Exercise in the Genetic Arrhythmia Syndromes - A Review

Provide a brief summary of your article (100-150 words; no references or figures/tables). The synopsis appears only in the table of contents and is often used by indexing services such as PubMed. Genetic arrhythmia syndromes are rare, yet harbor the potential for highly consequential, often unpredictable arrhythmias or sudden death events. There has been historical uncertainty regarding the correct advice to offer to affected patients who are reasonably wanting to participate in sporting and athletic endeavors. In some cases, this had led to abundantly cautious disqualifications, depriving individuals from participation unnecessarily. Societal guidance and expert opinion has evolved significantly over the last decade or 2, along with our understanding of the genetics and natural history of these conditions, and the emphasis has switched toward shared decision making with respect to the decision to participate or not, with patients and families becoming better informed, and willing participants in the decision making process. This review aims to give a brief update of the salient issues for the busy physician concerning these syndromes and to provide a framework for approaching their management in the otherwise aspirational or keen sports participant.

Better outcomes from exercise-related out-of-hospital cardiac arrest in males and in the young: findings from the Swedish Registry of Cardiopulmonary Resuscitation

BACKGROUND

Survival from out-of-hospital cardiac arrest (OHCA) is higher if the arrest is witnessed and occurs during exercise, however, there is contradicting data on prognosis with regards to sex and age. The purpose of this study was to compare the outcomes and circumstances of exercise-related OHCA in different age groups and between sexes in a large unselected population.

METHODS

Data from exercise-related OHCAs reported to the Swedish Registry of Cardiopulmonary Resuscitation from 2011 to 2014 and from 2016 to 2018 were analysed. All cases of exercise-related OHCA in which emergency medical services attempted resuscitation were included. The primary outcome was survival to 30 days.

RESULTS

In total, 635 cases of exercise-related OHCA outside of the home were identified. The overall 30-day survival rate was 44.5% with highest survival rate in the age group 0-35 years, compared with 36-65 years and >65 years (59.6% vs 46.0% and 40.4%, p=0.01). A subgroup analysis of 0-25 years showed a survival rate of 68.8%. Exercise-related OHCA in females (9.1% of total) were witnessed to a lower extent (66.7% vs 79.6%, p=0.03) and median time to cardiopulmonary resuscitation (CPR) was longer (2.0 vs 1.0 min, p=0.001) than in males. Females also had lower rates of ventricular fibrillation (43.4% vs 64.7%, p=0.003) and a lower 30-day survival rate (29.3% vs 46.0%, p=0.02).

CONCLUSION

In exercise-related OHCA, younger victims have a higher survival rate. Exercise-related OHCA in females was rare, however, survival rates were lower compared with males and partly explained by a lower proportion of witnessed events, longer time to CPR and lower frequency of a shockable rhythm.

Cardiopulmonary Resuscitation and Defibrillator Use in Sports

Sudden cardiac arrest (SCA) in young athletes is rare, with an estimated incidence ranging from 0.1 to 2 per 100,000 per athlete year. The creation of SCA registries can help provide accurate data regarding incidence, treatment, and outcomes and help implement primary or secondary prevention strategies that could change the course of these events. Early cardiopulmonary resuscitation (CPR) and defibrillation are the most important determinants of survival and neurological prognosis in individuals who suffer from SCA. Compared with the general population, individuals with clinically silent cardiac disease who practice regular physical exercise are at increased risk of SCA events. While the implementation of national preparticipation screening has been largely debated, with no current consensus, the number of athletes who will be diagnosed with cardiac disease and have an indication for implantable defibrillator cardioverter defibrillator (ICD) is unknown. Many victims of SCA do not have a previous cardiac diagnosis. Therefore, the appropriate use and availability of automated external defibrillators (AEDs) in public spaces is the crucial part of the integrated response to prevent these fatalities both for participating athletes and for spectators. Governments and sports institutions should invest and educate members of the public, security, and healthcare professionals in immediate initiation of CPR and early AED use. Smartphone apps could play an integral part to allow bystanders to alert the emergency services and CPR trained responders and locate and utilize the nearest AED to positively influence the outcomes by strengthening the chain of survival. This review aims to summarize the available evidence on sudden cardiac death prevention among young athletes and to provide some guidance on strategies that can be implemented by governments and on the novel tools that can help save these lives.

Bystander interventions and survival after exercise-related sudden cardiac arrest: a systematic review

OBJECTIVE

To evaluate the provision of bystander interventions and rates of survival after exercise-related sudden cardiac arrest (SCA).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, Cochrane Library and grey literature sources were searched from inception to November/December 2020.

STUDY ELIGIBILITY CRITERIA

Observational studies assessing a population of exercise-related SCA (out-of-hospital cardiac arrests that occurred during exercise or within 1 hour of cessation of activity), where bystander cardiopulmonary resuscitation (CPR) and/or automated external defibrillator (AED) use were reported, and survival outcomes were ascertained.

METHODS

Among all included studies, the median (IQR) proportions of bystander CPR and bystander AED use, as well as median (IQR) rate of survival to hospital discharge, were calculated.

RESULTS

A total of 29 studies were included in this review, with a median study duration of 78.7 months and a median sample size of 91. Most exercise-related SCA patients were male (median: 92%, IQR: 86%-96%), middle-aged (median: 51, IQR: 39-56 years), and presented with a shockable arrest rhythm (median: 78%, IQR: 62%-86%). Bystander CPR was initiated in a median of 71% (IQR: 59%-87%) of arrests, whereas bystander AED use occurred in a median of 31% (IQR: 19%-42%) of arrests. Among the 19 studies that reported survival to hospital discharge, the median rate of survival was 32% (IQR: 24%-49%). Studies which evaluated the relationship between bystander interventions and survival outcomes reported that both bystander CPR and AED use were associated with survival after exercise-related SCA.

CONCLUSION

Exercise-related SCA occurs predominantly in males and presents with a shockable ventricular arrhythmia in most cases, emphasising the importance of rapid access to defibrillation. Further efforts are needed to promote early recognition and a rapid bystander response to exercise-related SCA.

Sudden cardiac death in sports: could we save Pheidippides?

Hereditary diseases under the age of 35 are the most common underlying heart disease, leading to sudden cardiac death (SCD) in competitive sports, while in older people, atherosclerotic coronary artery disease (CAD) is the main cause. The following preventive measures are recommended: (a) The pre-participation cardiovascular screening, (b) the genetic testing, (c) the use of implantable cardioverter-defibrillator (ICD), (d) the prohibition of doping in sports, (e) the prevention of 'exercise-induced' cardiac complications, (f) the reduction of high-risk factors for CAD, and (g) the use of cardiopulmonary resuscitation. The cost-effectiveness of the electrocardiograms in the pre-participation screening programs remains questionable. Genetic testing is recommended in borderline cases and positive family history. Athletes with ICD can, under certain conditions, participate in competitive sports. Excessive endurance exercise appears to harm the endothelium, promotes inflammatory processes and leads to fibrosis in the myocardium, and calcium deposition in the coronary vessels. Cardiac arrest may be reversed if cardiopulmonary resuscitation is performed and a defibrillator is immediately used. Thus, equipping all fields with automatic external defibrillators are recommended.

Socioeconomic factors and outcomes from exercise-related sudden cardiac arrest in high school student-athletes in the USA

Objective

Minority student-athletes have a lower survival rate from sudden cardiac arrest (SCA) than non-minority student-athletes. This study examined the relationship between high school indicators of socioeconomic status (SES) and survival in student-athletes with exercise-related SCA.

Methods

High school student-athletes in the USA with exercise-related SCA on school campuses were prospectively identified from 1 July 2014 to 30 June 2018 by the National Center for Catastrophic Sports Injury Research. High school indicators of SES included the following: median household and family income, proportion of students on free/reduced lunch and percent minority students. Resuscitation details included witnessed arrest, presence of an athletic trainer, bystander cardiopulmonary resuscitation and use of an on-site automated external defibrillator (AED). The primary outcome was survival to hospital discharge. Differences in survival were analysed using risk ratios (RR) and univariate general log-binomial regression models.

Results

Of 111 cases identified (mean age 15.8 years, 88% male, 49% white non-Hispanic), 75 (68%) survived. Minority student-athletes had a lower survival rate compared with white non-Hispanic student-athletes (51.1% vs 75.9%; RR 0.67, 95% CI 0.49 to 0.92). A non-significant monotonic increase in survival was observed with increasing median household or family income and with decreasing percent minority students or proportion on free/reduced lunch. The survival rate was 83% if an athletic trainer was on-site at the time of SCA and 85% if an on-site AED was used.

Conclusions

Minority student-athletes with exercise-related SCA on high school campuses have lower survival rates than white non-Hispanic athletes, but this difference is not fully explained by SES markers of the school.

State-Level Implementation of Health and Safety Policies to Prevent Sudden Death and Catastrophic Injuries Within High Schools: An Update

BACKGROUND

Mandated sports safety policies that incorporate evidence-based best practices have been shown to mitigate the risk of mortality and morbidity in sports. In 2017, a review of the state-level implementation of health and safety policies within high schools was released.

PURPOSE

To provide an update on the assessment of the implementation of health and safety policies pertaining to the leading causes of death and catastrophic injuries in sports within high school athletics in the United States.

STUDY DESIGN

Cross-sectional study.

METHODS

A rubric composed of 5 equally weighted sections for sudden cardiac arrest, traumatic head injuries, exertional heatstroke, appropriate health care coverage, and emergency preparedness was utilized to assess an individual state's policies. State high school athletic/activities association (SHSAA) policies, enacted legislation, and Department of Education policies were extensively reviewed for all 50 states and the District of Columbia between academic year (AY) 2016-2017 (AY16/17) and 2019-2020 (AY19/20). To meet the specific rubric criteria and be awarded credit, policies needed to be mandated by all SHSAA member schools. Weighted scores were tabulated to calculate an aggregate score with a minimum of 0 and a maximum of 100.

RESULTS

A total of 38 states had increased their rubric scores since AY16/17, with a mean increase of 5.57 ± 6.41 points. In AY19/20, scores ranged from 30.80 to 85.00 points compared with 23.00 to 78.75 points in AY16/17. Policies related to exertional heatstroke had the greatest change in scores (AY16/17 mean, 6.62 points; AY19/20 mean, 8.90 points; Δ = 2.28 points [11.40%]), followed by emergency preparedness (AY16/17 mean, 8.41 points; AY19/20 mean, 10.29 points; Δ = 1.88 points [9.40%]).

CONCLUSION

A longitudinal review of state high school sports safety policies showed progress since AY16/17. A wide range in scores indicates that continued advocacy for the development and implementation of policies at the high school level is warranted.

Heat Safety in the Workplace: Modified Delphi Consensus to Establish Strategies and Resources to Protect the US Workers

The purpose of this consensus document was to develop feasible, evidence-based occupational heat safety recommendations to protect the US workers that experience heat stress. Heat safety recommendations were created to protect worker health and to avoid productivity losses associated with occupational heat stress. Recommendations were tailored to be utilized by safety managers, industrial hygienists, and the employers who bear responsibility for implementing heat safety plans. An interdisciplinary roundtable comprised of 51 experts was assembled to create a narrative review summarizing current data and gaps in knowledge within eight heat safety topics: (a) heat hygiene, (b) hydration, (c) heat acclimatization, (d) environmental monitoring, (e) physiological monitoring, (f) body cooling, (g) textiles and personal protective gear, and (h) emergency action plan implementation. The consensus-based recommendations for each topic were created using the Delphi method and evaluated based on scientific evidence, feasibility, and clarity. The current document presents 40 occupational heat safety recommendations across all eight topics. Establishing these recommendations will help organizations and employers create effective heat safety plans for their workplaces, address factors that limit the implementation of heat safety best-practices and protect worker health and productivity.

Increasing the Availability of Automated External Defibrillators at Sporting Events: A Call to Action from the American College of Sports Medicine

ABSTRACT

Given that most sudden cardiac arrests (SCAs) occur outside of a medical facility, often in association with exercise and sporting events, and given that early cardiopulmonary resuscitation (CPR) plus defibrillation is the strongest predictor of survival from SCA, this Call to Action from the American College of Sports Medicine recommends increasing the availability and effectiveness of early CPR plus defibrillation so that the time from collapse-to-first automated external defibrillator shock is less than 3 min.

Immediate Bystander Cardiopulmonary Resuscitation to Sudden Cardiac Arrest During Sports is Associated with Improved Survival-a Video Analysis

Background

Sudden cardiac arrest (SCA) during sports can be the first symptom of yet undetected cardiovascular conditions. Immediate chest compressions and early defibrillation offer SCA victims the best chance of survival, which requires prompt bystander cardiopulmonary resuscitation (CPR).

Aims

To determine the effect of rapid bystander CPR to SCA during sports by searching for and analyzing videos of these SCA/SCD events from the internet.

Methods

We searched images.google.com, video.google.com, and YouTube.com, and included any camera-witnessed non-traumatic SCA during sports. The rapidity of starting bystander chest compressions and defibrillation was classified as < 3, 3–5, or > 5 min.

Results

We identified and included 29 victims of average age 27.6 ± 8.5 years. Twenty-eight were males, 23 performed at an elite level, and 18 participated in soccer. Bystander CPR < 3 min (7/29) or 3–5 min (1/29) and defibrillation < 3 min was associated with 100% survival. Not performing chest compressions and defibrillation was associated with death (14/29), and > 5 min delay of intervention with worse outcome (death 4/29, severe neurologic dysfunction 1/29).

Conclusions

Analysis of internet videos showed that immediate bystander CPR to non-traumatic SCA during sports was associated with improved survival. This suggests that immediate chest compressions and early defibrillation are crucially important in SCA during sport, as they are in other settings. Optimal use of both will most likely result in survival. Most videos showing recent events did not show an improvement in the proportion of athletes who received early resuscitation, suggesting that the problem of cardiac arrest during sports activity is poorly recognized.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

Influence of State-Level Emergency Planning Policy Requirements on Secondary School Adoption

CONTEXT

Emergency action plans (EAPs) are a critical component in the management of catastrophic sport-related injury. Some state high school athletics associations and state legislation have required that schools develop EAPs, but little research exists on the influence of a statewide policy requirement on local adoption of these policies.

OBJECTIVE

To examine the efficacy of a statewide policy requirement on local adoption of an EAP.

DESIGN

Cross-sectional study.

SETTING

Online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

Secondary school athletic trainers were invited to complete a survey (n = 9642); 1136 completed the survey, yielding an 11.7% response rate.

MAIN OUTCOME MEASURE(S)

Survey responses on the adoption of EAPs along with cardiopulmonary resuscitation and automated external defibrillator (CPR/AED) requirements were cross-referenced with published statewide policies to determine the prevalence of EAP adoption. We evaluated the adoption of emergency action plan components based on the National Athletic Trainers' Association's emergency planning position statement along with CPR/AED requirements to determine component-specific prevalence. We compared the prevalence of EAP and component adoption between states that required EAPs and specific components of EAPs and states without such requirements.

RESULTS

Athletic trainers in states that required adoption of an EAP reported including more components of the emergency planning position statement (mean = 8 ± 4, median = 9) than in states without a requirement (mean = 7 ± 4, median = 8). The adoption of EAP components did not differ between states that required specific components of the EAP versus development of the EAP only. However, schools in states with both EAP and CPR/AED training requirements reported higher rates of CPR/AED training implementation (95.5%) than states that only required CPR/AED training (81.6%, prevalence ratio = 1.10, 95% confidence interval = 1.01, 1.20).

CONCLUSIONS

Based on these data, statewide policy requirements for the development of an EAP may be associated with increasing adoption of EAPs.

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Comparison of Out-of-Hospital Cardiac Arrests Occurring in Schools and Other Public Locations: A 12-Year Retrospective Study

Objective: Out-of-hospital cardiac arrests (OHCA) in schools and universities are uncommon. However, these institutions must plan and prepare for such events to ensure the best outcomes. To evaluate their preparedness we assessed baseline characteristics, survival outcomes and 12-year trends for OHCA in schools/universities compared to other public locations.Methods: We conducted a retrospective analysis of OHCA in schools/universities and public locations between 2008 and 2019 using Victorian Ambulance Cardiac Arrest Registry data.Results: We included 9,037 EMS attended cases, 131 occurred in schools/universities and 8,906 in public locations. Compared to public locations, a significantly higher proportion of EMS treated cases in schools/universities received bystander cardiopulmonary resuscitation (CPR) (95.5% vs. 78.5%, p < 0.001), public access defibrillation (PAD) (26.1% vs. 9.9%, p < 0.001) and presented in shockable rhythms (69.4% vs. 50.9%, p < 0.001). Unadjusted survival to hospital discharge rates were also significantly higher in schools/universities (39.6% vs. 24.2%, p < 0.001). The long-term unadjusted trends for bystander CPR in schools/universities increased from 91.7% (2008-10) to 100% (2017-19) (p-trend = 0.025), for PAD from 4.2% (2008-10) to 47.5% (2017-19) (p-trend < 0.001) and for survival to hospital discharge from 16.7% (2008-10) to 57.5% (2017-19) (p-trend = 0.004). However, after adjustment for favorable cardiac arrest factors, such as younger age, bystander CPR and PAD, survival was similar between schools/universities and public locations.Conclusion: The majority of OHCA in schools and universities were witnessed and received bystander CPR, however less than half received PAD. Developing site-specific cardiac emergency response plans and providing age appropriate CPR training to primary, secondary and university students would help improve PAD rates.

Availability and Utilization of Automated External Defibrillators in New York State Schools

Background: Use of automated external defibrillators (AEDs) in out-of-hospital cardiac arrests (OHCAs) improve survival. Professional health organizations recommend that AEDs be available in crowded places, including schools but currently only 18 US states require them. Sudden cardiac arrest (SCA) research in the school-age population has largely focused on school sub-groups, leaving out the majority of US students and adults working in schools. New York State (NYS) has one of the largest student populations in the US. Our objective was to gain epidemiologic data on SCA across a variety of school levels and examine the availability and utilization of AEDs in a state that requires them. Methods: This was an observational, cross-sectional study utilizing an electronic survey. We included NYS school nurses and collected electronic surveys in January-March, 2018. We analyzed demographic data of school characteristics, SCA occurrences and AED use and availability. Results: Of 876 respondents (36.1% response rate), 71 (8.2%) reported SCAs, with 41 occurring in adults. AEDs were deployed in 59 of 71 (84.3%) events, 40 individuals had long-term survival. Most SCAs occurred in middle-schools. School size or number of AEDs/school had no bearing on short-term or long-term survival. AEDs were widely available in private schools, though this was not required by state law. Conclusions: Our data suggest a need for more comprehensive examination of SCA in US schools. Research comparing the availability and utilization of school AEDs between states that do and do not require them is needed and may have important clinical and policy implications for SCA emergency preparedness in US schools.

FIFA Sudden Death Registry (FIFA-SDR): a prospective, observational study of sudden death in worldwide football from 2014 to 2018

OBJECTIVE

To investigate the underlying causes and regional patterns of sudden death in football (soccer) players worldwide to inform and improve existing screening and prevention measures.

METHODS

From 2014 to 2018 cases of sudden cardiac death (SCD), survived sudden cardiac arrest (SCA) and traumatic sudden death were recorded by media monitoring (Meltwater), a confidential web-based data platform and data synchronisation with existing national Sudden Death Registries (n=16). Inclusion criteria were met when sudden death occurred during football-specific activity or up to 1 hour afterwards. Death during other activities was excluded.

RESULTS

A total of 617 players (mean age 34±16 years, 96% men) with sudden death were reported from 67 countries; 142 players (23%) survived. A diagnosis by autopsy or definite medical reports was established in 211 cases (34%). The leading cause in players >35 years was coronary artery disease (76%) and in players ≤35 years was sudden unexplained death (SUD, 22%). In players ≤35 years the leading cause of SCD varied by region: cardiomyopathy in South America (42%), coronary artery anomaly in North America (33%) and SUD in Europe (26%). Traumatic sudden death including commotio cordis occurred infrequently (6%). Cardiopulmonary resuscitation (CPR) resulted in a survival rate of 85% with the use of an automated external defibrillator (AED) compared with 35% without.

CONCLUSIONS

Regional variation in SCD aetiology should be verified by expansion of national registries and uniform autopsy protocols. Immediate access to an AED at training and competition sites, as well as CPR training for players, coaches and staff members, is needed to improve survival from SCA.

Aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the USA: a 4-year prospective study

Objective

To investigate the aetiology and incidence of sudden cardiac arrest and death (SCA/D) in US competitive athletes.

Methods

Prospective surveillance was conducted from 1 July 2014 to 30 June 2018 through the National Center for Catastrophic Sports Injury Research in collaboration with national sports organisations. Autopsy reports, death certificates, and medical records were reviewed by an expert panel to determine aetiology. Athlete participation statistics from the National Federation of State High School Associations and the National Collegiate Athletic Association (NCAA) were used to calculate incidence rates per athlete-years (AY). Comparisons of incidence rates were calculated using incidence rate ratios (IRR) with 95% CIs.

Results

331 cases of confirmed SCA/D (158 survivors; 173 fatalities) were identified; 15.4% in middle school, 61.6% in high school and 16.6% in college and professional athletes. Average age was 16.7 (11–29) years, and the majority were in male (83.7%), basketball (28.7%) or American football (25.4%) athletes. Common causes included hypertrophic cardiomyopathy (20.6%), idiopathic left ventricular hypertrophy (13.4%), coronary artery anomalies (12.0%) and autopsy-negative sudden unexplained death (9.6%). Coronary anomalies were more common in middle school athletes (28%), while cardiomyopathies (hypertrophic, arrhythmogenic, dilated, non-compaction or restricted) accounted for 47% of cases in college and professional athletes. Incidence was higher in male versus female athletes at the high school (1:43 932 AY (95% CI 1:38 101 to 1:50 907) vs 1:203 786 AY (95% CI 1:145 251 to 1:293 794); IRR 4.6 (95% CI 3.1 to 7.2)) and NCAA (1:34 906 AY (95% CI 1:25 385 to 1:49 173) vs 1:123 278 AY (95% CI 1:66 078 to 1:249 853); IRR 3.5 (95% CI 1.5 to 9.5)) levels. African American male NCAA Division I basketball players had the highest annual incidence rate of SCA/D (1:2087 AY (95% CI 1:1073 to 1:4 450)).

Conclusions

Cardiomyopathies account for nearly half of SCA/D cases in college and professional athletes, while coronary artery anomalies play a more prominent role than expected in middle school athletes. Over half of SCA cases in athletes result in sudden death, calling for improved prevention strategies.

CPR and AEDs save lives: insuring CPR--AED education and CPR--AED access in schools

PURPOSE OF REVIEW

Sudden cardiac arrest and sudden cardiac death are less common in children and adolescents than in the adult population. The outcomes from sudden cardiac arrest are generally quite poor in all ages and some data suggest that they are worse in the child and adolescent age group. In addition, the incidence of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use is generally quite low although it is somewhat variable across communities. This review has been written in order to review the data for pediatric bystander CPR and AED use as it relates to out-of-hospital cardiac arrest (OHCA) survival. The purpose of this article is also to review endeavors at CPR--AED education in the context of improving both community bystander CPR/AED interventions and OHCA survival. Finally, this review will attempt to suggest some potential educational interventions in order to increase both bystander CPR-AED use and OHCA survival in local communities.

RECENT FINDINGS

Findings from several recent studies suggest that the incidence of bystander CPR--AED intervention is relatively low and that OHCA survival is also quite low in most communities. Several studies also suggest that community educational efforts can increase bystander CPR--AED interventions. The increase in OHCA survival may be attributed to the community educational efforts, yet that increase in survival is relatively small. A prospective high-school study has shown that in this very specific environment, a high incidence of CPR--AED use can be achieved, and that as a result the OHCA survival can be relatively high.

SUMMARY

It would be beneficial to attempt to ensure that all schools have a CPR--AED program along with a group of individuals trained to do CPR and use an AED. Not only should all schools have a cardiac emergency response plan (CERP) but all schools should have CPR--AED programs and all students should learn CPR and AED use prior to graduation. This strategy will ensure that we will have a community of individuals who would perform CPR and use an AED in the community and that in so doing we could increase the incidence of bystander CPR/AED use and increase the OHCA survival rate.

Nontraumatic Exertional Fatalities in Football Players, Part 2: Excess in Conditioning Kills

BACKGROUND

The incidence of nontraumatic fatalities in high school (HS) and National Collegiate Athletic Association (NCAA) football players has continued at a constant rate since the 1960s.

PURPOSE

To describe the causes of nontraumatic fatalities in HS and NCAA football players and provide prevention strategies.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

We reviewed 187 fatalities in HS and NCAA nontraumatic football players catalogued by the National Registry of Catastrophic Sports Injuries during a 20-year period between July 1998 and June 2018.

RESULTS

The majority (n = 162; 86.6%) of fatalities occurred during a practice or conditioning session. Most fatalities, when timing was known, (n = 126; 70.6%) occurred outside of the regular playing season, with the highest incidence in the August preseason (n = 64; 34.2%). All documented conditioning sessions were supervised by a coach (n = 92) or strength and conditioning coach (n = 40). The exercise regimen at the time of the fatality involved high-intensity aerobic training in 94.7%. Punishment was identified as the intent in 36 fatalities. The average body mass index of the athletes was 32.6 kg/m2. For athletes who died due to exertional heat stroke, the average body mass index was 36.4 kg/m2, and 97.1% were linemen.

CONCLUSION

Most nontraumatic fatalities in HS and NCAA football players occurred during coach-supervised conditioning sessions. The primary cause of exertion-related fatalities was high-intensity aerobic workouts that might have been intended as punishment and/or excess repetitions. Exertion-related fatalities are potentially preventable by applying standards in workout design, holding coaches accountable, and ensuring compliance with the athlete's health and current welfare policies.

Etiology of Sudden Cardiac Arrest and Death in US Competitive Athletes: A 2-Year Prospective Surveillance Study

OBJECTIVE

To determine the etiology of sudden cardiac arrest and death (SCA/D) in competitive athletes through a prospective national surveillance program.

DESIGN

Sudden cardiac arrest and death cases in middle school, high school, college, and professional athletes were identified from July 2014 to June 2016 through traditional and social media searches, reporting to the National Center for Catastrophic Sports Injury Research, communication with state and national high school associations, review of the Parent Heart Watch database, and search of student-athlete deaths on the NCAA Resolutions List. Autopsy reports and medical records were reviewed by a multidisciplinary panel to determine the underlying cause.

SETTING AND PARTICIPANTS

US competitive athletes with SCA/D.

MAIN OUTCOME MEASURES

Etiology of SCA/D.

RESULTS

A total of 179 cases of SCA/D were identified (74 arrests with survival, 105 deaths): average age 16.6 years (range 11-29), 149 (83.2%) men, 94 (52.5%) whites, and 54 (30.2%) African American. One hundred seventeen (65.4%) had an adjudicated diagnosis, including 83 deaths and 34 survivors. The most common etiologies included hypertrophic cardiomyopathy (19, 16.2%), coronary artery anomalies (16, 13.7%), idiopathic left ventricular hypertrophy/possible cardiomyopathy (13, 11.1%), autopsy-negative sudden unexplained death (8, 6.8%), Wolff-Parkinson-White (8, 6.8%), and long QT syndrome (7, 6.0%). Hypertrophic cardiomyopathy was more common in male basketball (23.3%), football (25%), and African American athletes (30.3%). An estimated 56.4% of cases would likely demonstrate abnormalities on an electrocardiogram.

CONCLUSIONS

The etiology of SCA/D in competitive athletes involves a wide range of clinical disorders. More robust reporting mechanisms, standardized autopsy protocols, and accurate etiology data are needed to better inform prevention strategies.

Design and Implementation of an Emergency Action Plan for Sudden Cardiac Arrest in Sport

Sudden cardiac arrest (SCA) is the leading cause of exercise-related fatalities in athletes. A comprehensive emergency action plan (EAP) is critical to facilitate a rapid and effective response to a cardiac emergency. SCA should be suspected in any athlete that collapses suddenly and is unresponsive. All potential responders to a collapsed athlete should be trained in the recognition of SCA, cardiopulmonary resuscitation, and use of an automated external defibrillator (AED). AEDs should be accessible on-site at sporting venues with a target collapse to first shock interval of less than 3 min. Every school, club, and sporting organization that sponsors athletic activities should have a written EAP for SCA. An EAP coordinator should be designated to foster compliance with training, practice, and rehearsal of the EAP at least once annually. Some sports require special considerations for equipment removal or access to emergency services in geographically broad or water-based venues.

Cardiac evaluation of young athletes: Time for a risk-based approach?

Pre‐participation cardiovascular screening (PPCS) is recommended by several scientific and sporting organizations on the premise that early detection of cardiac disease provides a platform for individualized risk assessment and management; which has been proven to lower mortality rates for certain conditions associated with sudden cardiac arrest (SCA) and sudden cardiac death (SCD). What constitutes the most effective strategy for PPCS of young athletes remains a topic of considerable debate. The addition of the electrocardiogram (ECG) to the medical history and physical examination undoubtedly enhances early detection of disease, which meets the primary objective of PPCS. The benefit of enhanced sensitivity must be carefully balanced against the risk of potential harm through increased false‐positive findings, costly downstream investigations, and unnecessary restriction/disqualification from competitive sports. To mitigate this risk, it is essential that ECG‐based PPCS programs are implemented by institutions with a strong infrastructure and by physicians appropriately trained in modern ECG standards with adequate cardiology resources to guide downstream investigations. While PPCS is compulsory for most competitive athletes, the current debate surrounding ECG‐based programs exists in a binary form; whereby ECG screening is mandated for all competitive athletes or none at all. This polarized approach fails to consider individualized patient risk and the available sports cardiology resources. The limitations of a uniform approach are highlighted by evolving data, which suggest that athletes display a differential risk profile for SCA/SCD, which is influenced by age, sex, ethnicity, sporting discipline, and standard of play. Evaluation of the etiology of SCA/SCD within high‐risk populations reveals a disproportionately higher prevalence of ECG‐detectable conditions. Selective ECG screening using a risk‐based approach may, therefore, offer a more cost‐effective and feasible approach to PPCS in the setting of limited sports cardiology resources, although this approach is not without important ethical considerations.

Special Article - Exercise-induced right ventricular injury or arrhythmogenic cardiomyopathy (ACM): The bright side and the dark side of the moon

There is still debate on the range of normal physiologic changes of the right ventricle or ventricular (RV) function in athletes. Genetic links to arrhythmogenic cardiomyopathy (ACM) are well-established. There is no current consensus on the importance of extensive exercise and exercise-induced injury to the RV. During the intensive exercise of endurance sports, the cardiac structures adapt to athletic load over time. Some athletes develop RV cardiomyopathy possibly caused by genetic predisposition, whilst others develop arrhythmias from the RV. Endurance sports lead to increased volume and pressure load in both ventricles and increased myocardial mass. The extent of volume increase and changes in myocardial structure contribute to impairment of RV function and pose a challenge in cardiovascular sports medicine. Genetic predisposition to ACM may play an important role in the risk of sudden cardiac death of athletes. In this review, we discuss and evaluate existing results and opinions. Intensive training in competitive dynamic/power and endurance sports leads to specific RV adaptation, but physiological adaptation without genetic predisposition does not necessarily lead to severe complications in endurance sports. Discriminating between physiological adaptation and pathological form of ACM or RV impairment provoked by reinforced exercise presents a challenge to clinical sports cardiologists.