Cardiac Arrest in the Athlete

Cardiac Arrest in Athletes
Best Practices
Sports Medicine Management
Jim Kyle, MD, FACSM
The Kyle Group
Team Physician Concord University
Medical Director Sports Medicine, Beckley ARH
Associate Clinical Professor Marshall University
Disclosures:
Dr Jim Kyle, MD, FACSM
The Kyle Group
Pregame EMS checklist
Friday Night Medical Time Out
Athlete Sudden Death
Historical Perspective
New interest in diagnosis of
congenital cardiac anomaly in late
1980’s
Widespread availability of
Echocardiogram
High Profile Athlete Deaths
High Profile Athlete Deaths
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1986
1986
1988
1990
Len Bias - Maryland Basketball
Flo Hyman - USA Volleyball
“Pistol” Pete Maravich - NBA
Hank Gathers - Loyola
Marymount Basketball
SCA – High profile Athlete
• 1986 – Flo Hyman,
a 31 year old star
on the USA National
Volleyball Team,
in Japan, died
during competition.
• Cause of Death: ?
SCA – High Profile Athlete
• 1988- Pistol Pete
Maravich 1970’s star
basketball player for LSU
averaging 40+ points per
game. NBA Hall of Fame.
Died suddenly playing
pick-up basketball age 40
• Cause of death: ?
Coronary Artery Anomalies
Magnetic Resonance Imaging
The Faces of SCA
Hank Gathers - Basketball SCA
• 1989- Hank Gather led
the nation in scoring
and rebounding for
Loyola Marymount
• Projected Top 5 NBA
• December 1989 he
experience a syncope
episode during game
Hank Gathers Tragedy
• DX: exercise related complex
ventricular tachycardia
• RX: Beta Blocker- Inderal 200qd
• Return to play in three weeks
• Courtside cardiac monitor
defibrillator
Hank Gathers Tragedy
• March 1990 – Conference
Tournament
• Collapse during game
• Courtside Cardiac monitor
was not used
• VF recorded rhythm (7min)
• Resuscitation efforts failed
IHSS – Idiopathic Hypertrophic
Sub-Aortic Stenosis
Cause of Sudden Cardiac Death
Ten Year Review 158 Athletes
B. Maron, JAMA 1996
Cause of Sudden Cardiac Death
Ten Year Review 158 Athletes
B. Maron, JAMA 1996
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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
Most Common Causes of SCD in
the U.S.
1980-2006
1049 SCA
*76 in 2005-06
2%
2%
2%
HCM
8%
CAA
5%
Myocarditis
ARVC
36%
3%
Channelopathies
MVP
3%
LAD bridge
3%
CAD
Aortic rupture
3%
AS
4%
Dilated CM
4%
WPW
6%
17%
Other
Possible HCM
Maron BJ et al. Circ 2009;119:1085-92.
HCM – Hypertrophic
Cardiomyopathy
• HCM is the most common cause of sudden
death in US athletes
• Incidence 1 in 500 persons
• Asymmetrical hypertrophied, non dilated
left ventricle
• Heterogeneous clinical, morphological and
genetic expression
Hypertrophic Cardiomyopathy
Figure
Normal
Without
Obstruction
With
Obstruction
Hypetrophic Cardiomyopathy
Disorganized myocardial architecture and
replacement scarring results in an electrically
unstable and unpredictable myocardial
substrate and risk of reentrant ventricular
tachyarrhythmia
Sports Venue SCA Preparation
Sudden Cardiac Arrest in Athletic Medicine
2001 36(2): 205-209
Glenn C. Terry, * James M. Kyle,† James M. Ellis, Jr,‡ John Cantwell,§
Ron Courson,∥ Ron Medlin¶
*Venue Medical Officer, Athlete Care, Olympic Stadium, 1996, and The Hughston
Clinic, PC, Columbus, GA
†Venue Medical Staff, Olympic Stadium, 1996, and Jackson General Hospital, Ripley,
WV
‡Venue Medical Director, Olympic Stadium, 1996, and Summit Medical Services,
Forest Park, GA
§Chief Medical Officer, 1996 Olympic Games, and Cardiology of Georgia, Atlanta, GA
∥University of Georgia Athletic Association, Athens, GA
¶Atlanta Falcons, Atlanta, GA
The Casino Project
The Casino Project
SCA - Common Locations
1.
2.
3.
4.
Casino
Airport
Sport Venues
Golf Course
The Casino Project
• 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
COMMOTIO CORDIS
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
Cardiac Concussion
Sudden Death: Commotio Cordis
The Faces of SCA
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%
“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%
“Non V-Fib” Cardiac Concussion
• 3* Heart Block
• LBBB
• ^ST segment
2010 Update: Cardiac Concussion
• 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% )
2007 SUMMIT
SCA in Athletes NATA Summit
2007 Consensus Statement
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American Academy of Emergency
Medicine
American Academy of Pediatrics
American College of Emergency
Physicians
American College of Sports Medicine
American Heart Association
American Medical Society for Sports
Medicine
American Orthopedics Society for Sports
Medicine
American Osteopathic Academy for
Sports Medicine
American Physical Therapy Association,
Sports Physical Therapy Section
National Association of Emergency
Medical Service Physicians
National Association of Emergency
Medical Technicians
National Athletic Trainers’ Association
National Collegiate Athletic Association
National Federation of State High School
Associations
Sudden Cardiac Arrest Association
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
2007 NATA Position Paper
SCA in Athletes Summit (Courson, Drezner)
Athlete Collapse – Suspect SCA
 Sentinel Seizure awareness
 Agonal Respiration
Schools need a formal EAP
 Simply response with 911 activation , rapid CPR
 Early Defibrillation
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
• 2013 : SCA in US High Schools (Drezner) 59 SCA
71% Survival 89% in Athletes N=2149 Schools
AED’s in Sudden Cardiac Arrest
• Survival
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Overall: 71%
When shock delivered onsite: 87%
AED onsite: 80%
AED brought by offsite EMS: 50%
Schools with EAP: 79%
Schools without EAP: 44%
“The single greatest factor affecting survival from
SCA is the time interval from cardiac arrest to
defibrillation.”
Drezner JA, et al. BJSM 2013
2010 AHA GUIDELINES
SCA – ROSC
Survival Hospital D/C
2010 AHA Guidelines
EARLY
DEFIBRILLATION
2010 AHA GUIDELINES
ABC now
Reversed
CAB
SCA – ROSC
Survival Hospital D/C
2010 AHA Guidelines
PUSH HARD
PUSH FAST
SPORTS ARENA SCA
Current Best Practice
WHEN TO SHOCK FIRST
CPR FIRST
CONTINUE CPR AFTER SHOCK
TIMING OF RESCUE BREATHING
DELAYED SCA WITH ECAST
SCHOOL SCA ADULTS > ATHLETES
Student Athlete Collapse
Witnessed SCA
Sequence of Actions AED @ site On-Hand
1. Activate 911
2. Apply AED electrodes and single shock
3. Rapid initiation of CPR – 2 minutes or until
athlete responsive
4. AED Analyze rhythm & Shock
5. CPR – 2 mins - AED, Airway Options
Student Athlete Collapse
Un-Witnessed SCA
Sequence of Actions AED @ site On-Hand
1. Activate 911
2. Rapid initiation of CPR
3. Apply AED electrodes and single shock
4. Continue CPR – – 2 minutes or until
athlete responsive
5. AED Analyze rhythm & Shock
Student Athlete Collapse
Witnessed SCA
Sequence of Actions AED
not On-Site
1. Activate 911
2. Rapid initiation of CPR until athlete
responsive or AED
3. Apply AED electrodes and single shock
4. CPR – 2 minutes
5. Analyze rhythm & Shock, Airway Options
Student Athlete Collapse
Un-Witnessed SCA
Sequence of Actions AED not On-Site
1. Activate 911
2. Rapid initiation of CPR until athlete
responsive or AED
3. Apply AED electrodes and single shock
4. CPR – 2 minutes
5. Analyze rhythm & Shock, Airway Options
SPORTS ARENA SCA
Current Best Practice
TIMING OF RESCUE BREATHING
After 5mins of CPR early if
DELAYED SCA WITH ECAST
SCHOOL SCA ADULTS > ATHLETES
The Faces of SCA
SPORTS ARENA SCA
Current Best Practice
WHEN TO SHOCK FIRST
CPR FIRST
CONTINUE CPR AFTER SHOCK
TIMING OF RESCUE BREATHING
DELAYED SCA WITH ECAST
SCHOOL SCA ADULTS > ATHLETES
2010 AHA Post SCA Guidelines
Therapeutic Hypothermia
Saving the Brain
2002 -NEJM publications –
Hospital D/C with intact CNS doubled
2005 – AHA Post Resuscitation Guidelines
2009 - Early start in field with 35*Saline or
Ice bag application
2012 – Cool and Cath Quick
Rhythm Strip –
Unresponsive Athlete in Training Room
High Index of Suspicion
O2 IV NS Bolus, EMS- BiCarb
Training Room ECAST
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Conditioning Focus
Remove athlete if leg, back pain SOB
Vital Sign with O2 therapy
EMS alert
IV Fluids, Normal Saline Bolus
Case Study ECAST
Dale Lloyd II
September 2006
Rice
5’9” 190lb
Struggling during
sprints Teammates
attempted to assist,
Coach Staff advice to
“leave alone”,
unaware of SCT
Case Study- SCT Football Death
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19yo African American defense back
Texas University NCAA Div 1
collapsed during training late Sept 2006.
Climate: Temp = 76*, mild wind
Eichner,R, et.al. Sickle Cell Trait and Fatal Rhabdomyolysis in Football
Training: A Case Study. Med Sci Sports Exerc. 2010;42(1) 3-7.
Workout Program
• 4:00 – weight lifting
• 4:30 - Outside sprints
• 16 sprints 100 yards
• Rest: 1 min first 4
2 min next 4, 1 min last 8.
Timeline Athlete Collapse
 4:55: Completes sprints
C/O bilateral lower extremity pain and SOB
Alert , over next 10 minutes became lethargic
 5:05: Unable to walk , EMS called
Cart to Training Room, O2 via BVM
 5:12 : University EMS arrived
IV and 100% Oxygen,
Fire Department EMS called
Sudden Death SCT
 All died under similar distinctive circumstances: noninstantaneous collapse with rapid deterioration (dyspnea,
fatigue, weakness and muscle cramping) over 10-45
minutes
 Each event occurred during vigorous or exhaustive
maximal physical exertion, usually during training (22)
 17 of 23 (74%) Summer or early Autumn
 20 deaths in southern or border states with Temp > 80*
 Florida (n = 5) , Texas (n = 4)
Maron, BJ, Eichner, ER, et.al. Sickle Cell Trait Associated With Sudden Death
in Competitive Athletes. Am J Card: 2012, 110(8)
Sudden Death SCT
 1980- 2010 registry and forensic database from
Minneapolis Heart Institute
 2462 deaths of young athletes participating in organized
competitive sports
 23 from Sickle Cell Trait
 CV Disease = 1,396 HCM = 375, Coronary Artery
Anomaly =131, Commotio Cordis = 98
Maron, BJ, Eichner, ER, et.al. Sickle Cell Trait Associated With Sudden Death
in Competitive Athletes. Am J Card: 2012, 110(8)
Sports Medicine Team
New Terms / Conditions to watch
 ECAST
 Exertional Sickling
 Warfighters
 Explosive Rhabdo
 Fulminant Ischemic Rhabdo
Interscholastic SCT Awareness
All states require SCT test at Birth
Coaching Staff with Strength and
Conditioning focus
Many Athletic Training Staff , Team
Physicians, EMS event coverage unaware
of presentation and rapid progression
 5 of 23 deaths in High School athletes
ED Management: Exercise Collapse
Associated with SCT (ECAST)
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Awareness that ECAST in Diff Dx
ABG monitoring for metabolic acidosis
Aggressive Fluid and Electrolyte Management
Anticipated Explosive Rhabdo
Early Dialysis ^K, to avoid lethal cardiac
arrhythmias ( within minutes to hours of syndrome
onset )
EKG PEARLS 2014
Current U.S. Practices
• High School (2005)
– 81% of states have adequate questionnaires
• ≥9 of 12 AHA-recommended components
• NCAA Division I (2012)1
– 42% use ECG (half of which also use ECHO)
• NCAA (2012)2
– 224 college team physicians
– 78% using recommended AHA screening
– 30% of division I schools using ECG and/or ECHO
1Coris,
et al. BJSM 2013.
2Asplund. CJSM 2014.
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%)
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
HCM EKG
TWI
Q Waves
HCM EKG
LVH with Old lateral wall MI ???
Athlete SCA : Have We
Changed the Playing Field ?
Emergency Department
• Athlete Collapse – Assume Cardiac Etiology
(Sentinel Seizure)
• EKG Attention: Seattle Criteria -TWI, Qwaves,
LAH, LAD, LBBB
• Delta and Epsilon Waves, LQT
• Syncope, Near Syncope, Chest Pain Work Up:
Consider advanced imaging, Cardiac CT, MRI* vs
ECHO
Thank You – Ron Courson
Questions ??
Previous talks SCA
• Sara
• Feel free to use jmk
Cause of Sudden Cardiac Death
Ten Year Review 158 Athletes
B. Maron, JAMA 1996
Diagnostic EKG
Long QT Syndrome
• Autosomal Dominant 2 Phenotypes
(Romano-Ward most common)
• 7 Genotypes
LQT1 (45%), LQT2 (35%), LQT3 (10%)
• Bazett’s Formula: QTc = QT/ RR
• QTc > .44 (males) .46 (females) @ rest vs.
stress test with genotype specific pattern
Long QT Syndrome
• Intense exercise or sudden auditory or
emotional stimulus
• Torsades polymorphic V-Tach deteriorates
to V-Fib
• SADS homepage reports 2000-3000 / year
• Maron cohort 3% with baseline premorbid
EKG, negative autopsy
• 2004 Athens Olympics: 16 yo swimmer Dana
Vollmer with mother poolside AED
Long QT Syndrome
• LQT1 Sports play trigger
• LQT2, LQT3
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“Alarm Clock” Risk > Athlete
Genetic testing for genotype
1/3 of Mayo Clinic Referrals have LQT
Stress test for risk stratification
Treatment: Beta Blockers, ICD
Wolff-Parkinson-White Syndrome
• First described in 1930
• Short PR interval with slurred QRS
upstroke
• Predisposed to atrio-ventricular reentrant tachycardia via accessory path
• Atial Fibrillation with WPW –
diagnostic and therapeutic challenge
Wolff-Parkinson-White Syndrome
WPW
Wolff-Parkinson-White Syndrome
• The risk of sudden death in Athletes with
WPW is difficult to determined
• Symptomatic athletes should consider
catheter ablation
• Emergency care must recognize WPW to
avoid iatrogenic complications
Athletes at Risk for SCA
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Chief complaint of syncope
Chest Pain with or post activity
History of palpitations
Family History of Sudden death
Abnormal EKG
Athlete Pre-Season Screening
Echocardiogram / EKG
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
Athlete Pre-Season Screening
Echocardiogram / EKG
UGA 1995 –2009
• No HCM screens positive
• WPW (1) and Long QT (1)
• 15 with SVT with ablation RX
• 12 with valvular pathology
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
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
SCA – High profile Athlete
• 1986 – Flo Hyman,
a 31 year old star
on the USA National
Volleyball Team,
in Japan, died
during competition.
• Cause of Death: ?
Cause of Sudden Cardiac Death
Ten Year Review 158 Athletes
B. Maron, JAMA 1996
SCA – High profile Athlete
• 1986 – Flo Hyman, a 31 year old star on the
USA National Volleyball Team, in Japan,
died during competition.
• Cause of Death: Aortic Dissection
Marfans Syndrome
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Heritable disorder of connective tissue
Autosomal Dominant
Prevalence: 4-6 per 100,000
Occular, Skeletal and Cardiovascular
manifestations
• Complications can occur at any age
Marfans Syndrome
Cardiac Manifestations
• Mitral Valve Prolapse
• Aortic root dilatation
• Enlarged proximal ascending aorta
Aortic dissection occurs secondary to cystic
medial necrosis of proximal aorta.
* Serial Aortic root measurements after Dx
SCA – High Profile Athlete
• 1988- Pistol Pete
Maravich 1970’s star
basketball player for LSU
averaging 40+ points per
game. NBA Hall of Fame.
Died suddenly playing
pick-up basketball age 40
• Cause of death: ?
SCA – High Profile Athlete
• 1988- Pistol Pete Maravich
1970’s star basketball player for
LSU averaging 40+ points per
game. NBA Hall of Fame.
Died suddenly playing pick-up
basketball age 40
• Cause of death:
Coronary Anomaly