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 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:

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:

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

REACT: Recognize “Sentinel Seizure” In a series of student- athletes 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

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 Chances of success reduced 7-10% each minute Cummins RO. Annals Emer Med :

Collapse to Defibrillation Interval (minutes) Probability of Survival Minutes, Collapse to CPR From “Estimating Effectiveness of Cardiac Arrest Interventions: A Logistic Regression Survival Model,” TD Valenzuela et. al., Circulation 1997; 96:3308 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: 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 plan- review 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 Life- Threatening Medical Emergencies: The Medical Emergency Response Plan for Schools. A Statement for Healthcare Providers, Policymakers, School Administrators, and Community Leaders –

AED Recommendations 36 th 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.

ILCOR October 2002 Therapeutic Hypothermia After Cardiac Arrest Unconscious adult patients with spontaneous circulation after out-of- hospital 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.

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 Athletic training - making a difference…in health, sports, and life