Management of Sudden Cardiac Arrest
Emergency Care in Sports (ECS) Conference
May 30 – June 1, 2013 Athens, Georgia
Ron Courson, ATC, PT, NREMT-I, CSCS
Senior Associate Athletic Director - Sports Medicine
University of Georgia
Athens, Georgia
Objectives
• present SCA case studies
• review pathophysiology of
sudden cardiac arrest
• define appropriate
emergency preparedness
for SCA at athletic venues
• recommend guidelines for
management of SCA in
athletes
– REACT
SCA Case Study 1
• December 4, 2012, Utah
State University
• 22YOWM basketball
player
– junior forward
– 6’6”, 205 lbs.
• collapsed during practice
• no previous symptoms of
palpitations, dizziness or
syncope
• no family history of
sudden death; sister (D-I
VB player) has heart
murmur
SCA Case Study 1
• evaluated on court by
certified athletic trainer
• determined to be in
cardiac arrest; CPR
initiated; EAP activated
• AED applied
– analysis < 2 minutes
– 1 shock delivered
– converted to perfusing
rhythm
• transported by EMS to
local hospital and
subsequently airlifted to
Intermountain Medical
Center in Murray, UT
SCA Case Study 1
• angiogram revealed normal
coronary arteries
• echocardiogram normal
• implantable cardioverter
defibrillator (ICD) implanted
3 days following SCA
• athlete remains in good
health and has received
medical clearance to return
to basketball for 2013-14
season
SCA Case Study 2
• May 12, 2011
– SEC Outdoor T&F
Championships
– Athens, Georgia
• 60YO T&F coach
• History of prior
coronary artery
bypass surgery
• Collapsed in track
in-field
• Unconscious;
unresponsive
• Determined to be in
cardiac arrest
SCA Case Study 2
• Immediate CPR
• Defibrillation with AED;
successfully
resuscitated on field
• Transported to hospital
• Emergency cardiac
catheterization
• Surgery next day to
place implantable
defibrillator and
pacemaker
• Subsequent re-do
CABG surgery
SCA Case Studies
• Demonstrate effectiveness
of emergency action plan
– advance planning
– recognition of emergency
– emergency
communication
– appropriate medical
equipment on site
– rapid response by
campus police and EMS
– communication with
hospital
Pathophysiology of
Cardiac Arrest
Electrical Phase
Less than four minutes following arrest, the cardiac
muscle uses its sugar/oxygen stores.
Circulatory Phase
From four to ten minutes following arrest, the cardiac
muscle switches to anaerobic metabolism.
Metabolic Phase
Greater than ten minutes following arrest, cardiac cells
swell, rupture, and die.
REACT
Recognize
Evaluate
Activate EAP/EMS
Cardiac Care
Transport
Target goal of <3 minutes from
time of collapse to first shock is
strongly recommended
REACT: Recognize
• When a young athlete
collapses, SCA can
be confused for other
less serious causes of
collapse
• Prompt recognition of
SCA is essential to
prevent critical delays
in CPR and
defibrillation
Rothmier JD, Drezner JA. Sports
Health. 1:1. 16-20. 2009
REACT: Recognize
• Athletes usually display no
symptoms prior to event
 Few athletes are identified as
at risk prior to episode
 Deaths are usually associated
with intense physical activity
 Ryan Shay suffered cardiac arrest and
died about 5.5 miles into the 2008 U.S.
Olympic Team Trials — Men's Marathon
on Saturday, November 3, 2007
Rothmier JD, Drezner JA. Sports
Health. 1:1. 16-20. 2009
REACT: Recognize
• Barriers to
recognizing SCA
include:
– Presence of brief
seizure-like activity
– Inaccurate rescuer
assessment of pulse
or respirations
REACT: Recognize
“Sentinel Seizure”
Terry GC et al. SCA in Athletic
Medicine. JAT. 2001
14
REACT: Recognize
“Sentinel Seizure”
• In a series of studentathletes with SCA,
greater than half were
reported to have brief
seizure-like activity
immediately following
collapse
• Mistaking SCA for a
seizure can prevent
initiation of life-saving
medical care Rothmier JA and Drezner JA.
Sports Health. 2009
15
REACT: Recognize
“Agonal Respirations”
• When heart stops beating with
SCA the breathing center in the
brain is still alive for a couple of
minutes and will cause the
victim to take a few abnormal
breaths, or agonal respirations
• These abnormal breaths
associated in dying may appear
as snoring, gasping, or snorting
and will disappear in a couple of
minutes.
• Do not let abnormal breathing
stop you from starting CPR.
REACT: Recognize
 High suspicion
of SCA should
be maintained
for any
collapsed and
unresponsive
athlete.
REACT: Recognize Evaluate
 Young athletes who
collapse shortly after
being struck in the
chest by a firm
projectile or by contact
with another player
should be suspected of
having SCA from
commotio cordis until
the athlete is clearly
responsive.
REACT: Evaluate
• Tap and shout
– “are you OK?”
– if no response, check
for pulse
REACT: Evaluate Activate EAP/EMS
• Check for carotid pulse
– no more than 10 seconds
• If no pulse, activate
EAP/EMS
– “John, go call 911: tell
them we have a cardiac
arrest in the gymnasium”
– “Anna, go get the AED
while I start CPR”
REACT: Activate EAP/EMS
 Every athletic
organization should
have a emergency
action plan (EAP)
 EAP should be
reviewed and practiced
regularly
REACT: Activate EAP/EMS
• EAP should be
reviewed and
practiced at least
annually
– a mock SCA
scenario is
recommended as a
practice method for
EAP and to review
AED access and
application
Rothmier JD and Drezner JA.
Sports Health. 2009
REACT: Activate EAP/EMS
• Equipment should be
centrally placed at
athletic venue and
highly visible or
brought to venue by
healthcare provider
• Equipment readiness
should be checked
regularly by on-site
health care providers
for each athletic
event
REACT: Activate EAP/EMS Cardiac Care
• Make the Call
– 911 or
– local emergency telephone number if
911 system not available
• Provide Information
– name, address, telephone # of caller
– condition of athlete
• “I have an athlete in cardiac arrest”
– first aid treatment initiated
• “we have started CPR and applied AED”
– specific directions
– other information as requested by
dispatcher
– EMS response provided is dictated by
information provided to dispatch by
first responders on scene
SCA Case Study 3
• 47YOWM college professor went into
SCA while playing recreational
basketball in University of Georgia
student recreation facility
• CPR administered by student worker;
student sent to activate EMS
• 911 call: “someone passed out in
gym”
• EMS arrives at scene with only jump
bag; had to return to unit for
additional equipment, resulting in
significant delay in time to
defibrillation
• EMS response provided is dictated
by information provided to dispatch
by first responders on scene
REACT: Cardiac Care
• CPR should be
implemented while
waiting for an AED
• AED should be
applied as soon as
possible and
turned on for
rhythm analysis in
any collapsed and
unresponsive
athlete
REACT: Cardiac Care
• Cardiac care begins
with high-quality CPR
until a defibrillator is
available
• CPR alone cannot
reinstitute normal
rhythm for hearts in VF
• Effective CPR has been
shown to extend the
ability of the heart to
survive for longer times
in fibrillation
REACT: Cardiac Care
American Heart Association 2010 CPR Guidelines
• “Push hard and fast”
– depth of compression at
least 2”
– rate of at least 100
compressions per minute
• Allow full chest recoil
• 30:2 compression to
breath ratio
• Start with CPR if
downtime is unknown
or greater than 4-5
minutes
• If downtime < than 4-5
minutes, use AED
REACT: Cardiac Care
• Single greatest determinate
of survival following SCA is
the time from collapse to
defibrillation, with survival
rates declining 7-10% per
minute for every minute
defibrillation is delayed
• Survival rates as high 49 to
75% with CPR plus
defibrillation within 3-5
minutes of collapse
100
90
Chances of success
reduced 7-10% each
minute
80
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
Cummins RO. Annals Emer Med.
1989. 18:1269-1275
REACT: Cardiac Care
Probability of Survival
0.6
1
Minutes, Collapse to CPR
0.5
0.4
5
0.3
0.2
10
0.1
15
0
From “Estimating Effectiveness
of Cardiac Arrest Interventions:
A Logistic Regression Survival
Model,” TD Valenzuela et. al.,
Circulation 1997; 96:3308
0
2
4
6
8
10
12
14
16
Collapse to Defibrillation Interval (minutes)
18
20
REACT: Cardiac Care
REACT: Cardiac Care
 minimize Interruptions in CPR
 stop CPR only for rhythm
analysis and shock
 resume CPR immediately after
shock, beginning with chest
compressions, with repeat
rhythm analysis following 2
minutes or five cycles of CPR
 or until advanced life
support providers take over
 or the victim starts to move
 if two rescuers, change chest
compressor every two minutes
to ensure high quality CPR
REACT: Cardiac Care
REACT: Cardiac Care
REACT: Transport
• Transport to most
appropriate
medical facility for
cardiac care
AED Recommendations
NATA Official Statement: AEDs
• The NATA, as a leader in health care for the physically
active, strongly believes that the treatment of sudden
cardiac arrest is a priority. An AED program should be
part of an athletic trainers emergency action plan. NATA
strongly encourages athletic trainers, in every work
setting, to have access to an AED. Athletic trainers are
encouraged to make an AED part of their standard
emergency equipment. In addition, in conjunction and
coordination with local EMS, athletic trainers should take
a primary role in implementing a comprehensive AED
program within their work setting.
AED Recommendations
• Medical director designation
(and prescription)
• Emergency response planreview and update
• Collaboration with local EMS
• AED / CPR training of
designated ERT (emergency
response team) members
• Strategic deployment of AEDs
AED Recommendations
• Emergency
Cardiovascular Care
Committee Policy
Statement
– Response to Cardiac
Arrest and Selected LifeThreatening Medical
Emergencies: The Medical
Emergency Response Plan
for Schools. A Statement
for Healthcare Providers,
Policymakers, School
Administrators, and
Community Leaders
– www.americanheart.org
AED Recommendations
36th Bethesda Conference
– AEDs should be available
at educational facilities
that have competitive
athletic programs
(including intramural
sports and conditioning
classes), stadiums,
arenas, and training
sites, with trained
responders identified
among the permanent
staff. Devices should be
deployed so as to
provide a response time
of less than 5 minutes.
Automated Chest Compression Devices
Mechanical piston CPR device
Load-distributing band CPR device
Impedance Threshold Device
• Prevents unnecessary
air from entering the
chest during CPR. As
the chest wall recoils,
the vacuum (negative
pressure) in the thorax
is greater. This
enhanced vacuum pulls
more blood back to the
heart, doubling blood
flow during CPR.
• Studies have shown
that this mechanism
increases cardiac
output, blood pressure
and survival rates.
Patient ventilation and
exhalation are not
restricted in any way.
Therapeutic Hypothermia After
Cardiac Arrest
• Unconscious adult
patients with
spontaneous
circulation after out-ofhospital cardiac arrest
should be cooled to
32°C to 34°C for 12 to
24 hours when the
initial rhythm was
ventricular fibrillation
(VF).
• Such cooling may also
be beneficial for other
rhythms or in-hospital
cardiac arrest.
ILCOR October 2002
12-Lead Electrocardiogram
• Pre-hospital use of
12-lead EKG by
paramedics and
advance hospital
notification of
pathology
– Dramatic reduction in
cardiac cath times with
earlier notification
Time Out
• NATA released official
statement August 1,
2012 recommending
athletic health care
providers issue a
“Time Out” system
before athletic events
to ensure EAPs are
reviewed and in place.
NATA 2012
Time Out
• “Time Out” is a common
term both in sports and
medicine.
– Coaches and athletes call
time outs to gather a team
together and discuss game
strategies or to call a play.
– In medicine, doctors take a
time out immediately before
every surgery when all
operating room participants
stop to verify the procedure,
patient identity, correct site
and side.
NATA 2012
Time Out
• Athletic healthcare providers meet before the start of each
practice or competition to review the emergency action plan.
• Determine the role and location of each person present (i.e.
athletic trainer, emergency medical technician, medical doctor).
• Establish how communication will occur (voice commands,
radio, hand signals); what is the primary and secondary or back
up means of communication.
• An ambulance should be present at all high-risk events. The
medical staff should know who is assigned to call for it; if it is
on stand-by or required to be on-site; where it is located, what
routes it can to enter and exit the field in the least
unencumbered manner.
•
NATA 2012
Time Out
• Ensure that in the event of transport, a hospital has been
designated and is the most appropriate facility for the injury or
illness.
• Review and check/test all emergency equipment available to
confirm it is in working order and fully ready for use. For
example, make sure all sports medicine team members know
where automated external defibrillators are and how to use
them.
• Consider any issues that could potentially impact the EAP
(construction, weather, crowd flow), and plan accordingly and
in advance of sports participation.
NATA 2012
REACT
Recognize
Evaluate
Activate EAP/EMS
Cardiac Care
Transport
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