1. Athlete Sudden Cardiac Death EMERGENCIES IN MEDICINE Park City 2012 Jim Kyle, MD, FACSM Emergency Department Director, Beckley ARH Team Physician Concord University Associate Clinical Professor Marshall University

2. Sports Trauma Trends Head / Neck Case Long term subtle neuro deficit Heat Stress Injury Performance enhancement supplements Sudden Cardiac Arrest Unrecognized congenital conditions Cardiac concussion

3. Sudden Cardiac Death in Athletes Incidence of SCD high school athletes 1:100,000 to 200,000 VanCamp & Maron college athletes 1:65,000 – 69,000 VanCamp & Drezner 1:50,000 marathoners, 1:15,000 joggers ~ 110 athletic deaths per year in US Maron no national surveillance system; true incidence unknown; most likely underestimated

4. The Faces of SCA

5. 1990 - Hank Gathers Tragedy DX: exercise related complex ventricular tachycardia RX: Beta Blocker- Inderal 200qd Return to play in three weeks Courtside cardiac monitor defibrillator

6. Hank Gathers SCA Medication had been decreased due to side effects Cause of death -HCM Cardiac monitor defibrillator legal issue: $32 Million law suit

7. Cause of Sudden Cardiac Death Ten Year Review 158 Athletes B. Maron, JAMA 1996

8. 1985-95 sudden death organized sports 138 cases of Sudden Cardiac Death Ages 12-40, median age=17 90% Male 68% occurred in Football and Basketball 62% High School, 22% College, 7% Professional

9. The Faces of SCA

10. SCA in Athletes “The unexpected death of an athlete during exercise is tragic irony.... much remains unknown regarding optimal screening strategies, pathophysiologic mechanisms,and prevention” Mark Link, MD Tufts University

11. Cardiac Concussion

12. Little League Baseball Sudden Death A 16yo player was struck in the chest by the baseball thrown from home plate as he attempted to steal third base. Shortly after standing he collapsed with seizure like activity and stopped breathing.

13. Little League Baseball Sudden Death The coach initiated CPR and local EMS documented arrival of an ACLS team 8 minutes after receiving the call from the field. Attempts to resuscitate were unsuccessful.

14. Cardiac Concussion Commotio Cordis - sudden death during sports play after a blunt blow to the chest Maron, NEJM, 1995 25 case 1977-95, Average Age = 11 (3-19) 18 playing baseball or softball, “Little League Sudden Death” 24 male Vulnerable window 15-30 msec prior to peak of T wave inducing V- Fib Link, NEJM, 1998

15. Laboratory Cardiac Concussion

16. Sudden Death: Commotio Cordis

17. 2001 Commotio Cordis Update 2001 update - 128 cases 84% cases fatal Early defibrillation with on site AED only effective treatment AED documented in 41 cases, 19 survived = 46%

18. Cause of Sudden Cardiac Death Ten Year Review 158 Athletes B. Maron, JAMA 1996

19. “Sudden Death in Young Athletes” Maron NEJM 2003, Sudden Death in 387 Young Athletes  1. Hypertrophic Cardiomyopathy – 34 %  2. Commotio Cordis – 20%  3. Coronary-artery Anomalies – 14%

20. 2010 Update: Cardiac Concussion

21. 224 Cases: NEJM, B Maron, M Estes Mean Age = 15: 26% < 10yo Range: 6mos – 50yo 95% Male, 78% White Survival rate  15% 1990-1999  35% 2000-2009 ( 2006-09 > 50% )

22. The Casino Project

23. 1997 – Security Guards at Star Dust trained by Clark County EMS, Richard Hardman in use of Life-Pak 500 1997- 2000: 200+ cases of witnessed SCA with 57% survival Time to AED- 3 mins, Shock 4 mins 6,500 Security Guards trained

24. Public School AED Program 1999: Planning for Scholastic Cardiac Emergencies, WV Med Jour. The Ripley Project 2000: Milwaukee City school after 4 case SCA Project ADAM 2001: Long Island schools lacrosse focus Acompora Foundation (www.la12.org) 2007: 91% College, 35% High School with AED 2011: Saves > Deaths Commotio Cordis

25. “Non V-Fib” Cardiac Concussion Link,NEJM: 4/10 impacts during QRS = complete heart block

26. “Non V-Fib” Cardiac Concussion 3* Heart Block LBBB ^ST segment

27. Athletes at Risk for SCA Chief complaint of syncope Chest Pain with or post activity History of palpitations Family History of Sudden death Abnormal EKG

28. Athlete SCA : Have We Changed the Playing Field ? Emergency Department Athlete Collapse – Assume Cardiac Etiology (Sentinel Seizure) EKG Attention: Delta and Epsilon Waves, LQT Syncope, Near Syncope, Chest Pain Work Up: Consider advanced imaging, Cardiac CT, MRI* vs ECHO

29. ARVD – Prolonged QRS, Inverted T wave V1 – V2

30. ARVD – Arrhythmogenic Right Ventricular Dsyplasia Italian Sport Federation requires school athletes to have EKG and limited stress test on an annual basis EKG with prolonged QRS V1-V3 110 msec and inverted T wave Epsilon wave in 50%

31. ARVD Epsilon Wave

32. Athlete SCA : Have We Changed the Playing Field ? Emergency Department Athlete Collapse – Assume Cardiac Etiology (Sentinel Seizure) EKG Attention: Delta and Epsilon Waves, LQT Syncope, Near Syncope, Chest Pain Work Up: Consider advanced imaging, Cardiac CT, MRI* vs ECHO

33. ARVD with fatty (dark, arrows) RV myocardium By Cardiac CT Angiography Study N. Wilke, UF and Precision Imaging Centers, JAX, Florida

34. Cause of Sudden Cardiac Death Ten Year Review 158 Athletes B. Maron, JAMA 1996 25%

35. Coronary Artery Anomalies Magnetic Resonance Imaging

36. Möhlenkamp et al. Circulation 2002;106:2616-22.

37. Cardiac CTA: Common, Stenosed Ostium of RCA and LM N. Wilke, UF and Precision Imaging Centers, JAX, Florida

38. Athlete SCA : Have We Changed the Playing Field ? Athlete Screening Consider EKG – Corrado Italian Criteria Heart Murmur – Baseline ECHO with potential repeat to R/O HCM, Marfans Palpitations or SVT suspicion - Holter Monitor *2006 World Cup: FIFA required EKG, ECHO, Stress Test after Cameroon SCA

39. Italian Guidelines for Sports Medicine 1982 Law Competitive Athletes 12-35 PSPE Screening : PMH, FH, Physical Exam, and 12 lead EKG Positive findings: ECHO, Stress Test, Holter PMH: Syncope, Chest Pain, SOB, Palpitation PSPE: Heart Murmur systolic >2/6 any diastolic, Abnormal S2, Systolic Clicks, BP >140/90, Irr Rhythm, R/O Marfans EKG: Hypertrophy, Blocks, ST and T wave, Intervals

40. Italian Pre-Competition Screening D. Corrado,et.al. Sports Medicine Data Base,Veneto region, Italy: NEJM 1998 20 year screening for HCM 33,735 athletes 3016 (9%) referred for echocardiogram 22 had HCM- 16 @ risk identified EKG 49 deaths (1.6 per 100,000) 1 from HCM, 11 from ARVD (22%)

41. Italian Guidelines for Sports Medicine Abnormal EKG: LAH, RAH, R axis, L axis, LVH (20mm limb, 30mm pre-cordial), AV Block, 1*,2*, 3* (1* >.21 not shorted with hyperventilation) RBBB, LBBB Long QT (>.44men, >.46 women) Short PR (<0.12) PVCs, AF, SVT ST depression or T wave inversion 2 or more leads, Q wave 2 leads, V1 R:S ratio >1

42. 2007 NATA Position Paper SCA in Athletes Summit (Courson, Drezner) Most cases occur with Basketball, Football and Little League Baseball 9 to 1 Male/Female Athlete Collapse – Suspect SCA  Sentinel Seizure awareness AED’s with time to shock < 4 minutes Coach AED certification Schools need a formal Emergency Medical Plan Rapid ACLS availability

43. SCA in Athletes “The unexpected death of an athlete during exercise is tragic irony.... much remains unknown regarding optimal screening strategies, pathophysiologic mechanisms,and prevention” Mark Link, MD Tufts University