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Review of the Management of Sudden Cardiac Arrest on the Football Field

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Review of the Management of Sudden Cardiac Arrest on the Football Field Review Br J Sports Med: first published as 10.1136/bjsm.2010.074526 on 14 June 2010. Downloaded from Review of the management of sudden cardiac arrest on the football fi eld Efraim Kramer,1 Jiri Dvorak,2 Walter Kloeck1 1University of the ABSTRACT 1 h of the onset of symptoms in a person who Witwatersrand, Football is the most popular sport on earth. When a appears to be healthy or affl icted with a medical Johannesburg, South Africa 6 7 2Schulthess Klinik and young, fi t popular player suddenly collapses and dies condition that is not considered fatal. An athlete, F-MARC (FIFA Medical during play, the tragic event is frequently screened and hence a football player, is a person participat- Assessment and Research and publicised worldwide. The reported incidence of ing in an organised team sport that requires sys- Center), Zurich, Switzerland sudden cardiac arrest (SCA) varies from 1:65 000 to tematic training and regular competition against 1:200 000 athletes. A broad spectrum of cardiac and others, and that places a high premium on athletic Correspondence to 8 9 Professor Efraim Kramer, non-cardiac causes have been implicated, and regular excellence and achievement. Faculty of Health precompetition medical assessments are recommended Sciences, Offi ce 10M12, as a preventive measure. Immediate cardiopulmonary INCIDENCE Division of Emergency resuscitation and early defi brillation is the treatment Medicine, University of the The true incidence of SCA among footballers is 10 Witwatersrand, 7 York Road, for SCA. High success rates can be achieved if this is not known, but can be predicted from available Parktown, Johannesburg, initiated promptly, preferably within seconds of the data in team-based athletes which reports an inci- 2123, South Africa; arrest. Trained medical responders must be allowed dence of 1 in 65 000 athletes to 1 in 200 000 ath- [email protected] to respond, ideally with a defi brillator (manual or letes,11–13 which in USA appears to equate to one automated) in hand, to a player who suddenly and SCA every 3 days14 and is 2.5 times higher than Accepted 19 April 2010 unexpectedly collapses and remains unresponsive on the in non-athletes.15 A prospective population-based fi eld. Immediate defi brillation of a pulseless ventricular study of SCD in young competitive athletes in the tachycardia or ventricular fi brillation, within 1 to 2 min Vento Region of Italy indicated an incidence of of onset, has a successful cardioversion rate exceeding SCD of 2.3 per 100 000 athletes per year from all 90%. Medical responders should be well trained and causes, and 2.1 per 100 000 athletes per year from rehearsed in the recognition of SCA, including distractors cardiovascular diseases.16 such as seizures, myoclonic jerks and agonal (gasping) A further problem is the realisation that the breathing. Prompt initiation of chest compressions on reported fi gures are probably underestimated the fi eld, together with early defi brillation, will result due to the absence of either postmortem results in many athletes’ lives being saved by immediate and/or mandatory reporting of SCA in sports in implementation of these simple recommendations. many countries including the USA. Whatever the true incidence may be internationally, there is no http://bjsm.bmj.com/ doubt that SCD is the leading cause of death in INTRODUCTION exercising young athletes11 17 and all efforts must Football (soccer), is the most popular sport on be undertaken to prevent its occurrence by screen- earth, with 260 million registered players1 repre- ing procedures such as the precompetition med- senting 208 national football associations and a ical assessment,18 19 or when necessary, through media viewership of billions. A number of foot- effi cient and effective emergency treatment.20 ball players reach the level of iconic stardom and are perceived by many young followers as role CAUSES OF SCA on October 2, 2021 by guest. Protected copyright. models to live up to. Therefore, when a young, A broad spectrum of cardiac and non-cardiac fi t, healthy, popular football player succumbs on causes, both congenital and acquired, have been the fi eld of play to a sudden cardiac arrest (SCA), implicated in causing SCA in athletes. Similar to particularly when viewed on live television, it other estimated data concerning SCA in athletes, becomes a tragic event with catastrophic effects the exact numbers cannot be accurately quanti- 2 3 to the family, followers and to the football fam- fi ed. However, from what is available from the 4 ily worldwide. Such a tragic event is beyond most USA and Italy, it appears that structural cardiac people’s imagination or expectation, for it involves disease accounts for 60–95% of the causes of elite athletes who are at the pinnacle of health and SCA,21–23 and mainly includes hypertrophic car- success. The collapse and sudden cardiac death diomyopathy, arrythmogenic right ventricular (SCD) of Miklós Fehrér, Marc-Vivien Foe, Daniel dysplasia and congenital coronary artery anoma- 5 Jarque, Antonion Puerta and Phil O Donnel are lies in the under-35-year-old group, and coronary vivid examples of this tragic event. artery disease in the over-35-year-old group, all of which induce ventricular fi brillation (VF) as the DEFINITIONS main presenting rhythm in SCA.24 In the under- SCA can be defi ned as the sudden, unexpected 16-year-old age group, commotio cordis (cardiac cessation of cardiac output, usually of cardiac ori- contusion) is thought to be responsible for up to gin but not necessarily so, in a previously healthy 20% of SCAs. It is very uncommon after 21 years appearing individual. SCD is defi ned as the sud- of age.25 26 Commotio cordis is the induction of den, unexpected natural death occurring within VF during the vulnerable repolarisation period of 540 Br J Sports Med 2010;44:540–545. doi:10.1136/bjsm.2010.074526 bjsports74526.indd 540 11/11/2011 2:11:07 PM Review Br J Sports Med: first published as 10.1136/bjsm.2010.074526 on 14 June 2010. Downloaded from the myocardium due to a blunt, non-penetrating, usually high after SCA are postulated to be due to oxygen deprivation to the velocity, blow to the chest either from a small solid object,27 brain as a result of the non-perfusing cardiac arrhythmia. To including a football28 or from contact with another player. the unsuspecting responder, these seizure-like activities may Other cardiac causes of SCA include myocarditis, ruptured appear as an epileptic seizure36 with consequent delay in crit- aortic aneurysm, aortic valve stenosis, mitral valve prolapse, ical initial management steps for SCA including cardiopulmo- dilated cardiomyopathy, drug-induced cardiac arrhythmias nary resuscitation (CPR) and external defi brillation. To avoid and the ion-channelopathies29 which include the long and these life-threatening delays in diagnosis and management short QT syndrome (caused by sodium or potassium ion chan- after SCA, any athlete who collapses on the fi eld of play and nel genetic mutations), Brugada syndrome (defective sodium is unresponsive must be regarded as being in life-threatening channel gene) and familial catecholaminergic polymorphic cardiac arrest until it is proved otherwise.37 Accordingly, sei- ventricular tachycardia30 (abnormal ryanodine receptor reg- zure-like activity must be regarded and taught as a sign of SCA ulating calcium release). Non-cardiac causes of SCA include and not as a standard tonic–clonic seizure per se, and train- asthma, heat stroke, cerebral artery rupture and exertional ing of CPR and automated external defi brillator (AED) use for rhabdomyolysis secondary to sickle cell trait. potential fi rst responders in sports environments is strongly recommended. FIELD IDENTIFICATION OF SCA Another major obstacle to rapid recognition of SCA on the It is common during a football match for players to collapse football fi eld is the presence of abnormal or agonal breath- on the fi eld, mainly following contact with an opponent, for ing38 in SCA patients during the fi rst few minutes of arrest either a genuine or spurious31 injury (fi gure 1). The majority of while the brain has suffi cient oxygen supplies. Standard CPR these incidents are resolved with little therapeutic interven- training since 200539 has emphasised that the apparent lack tion from the team physician within a few minutes. According of normal breathing patterns is to be regarded as a sign of car- to the International Football Association Board Rules of the diac arrest and if present in an unresponsive person, equates Game, if a player appears injured, the referee may stop play, to a diagnosis of cardiac arrest, with immediate activation of approach the injured player and assess whether medical assis- an emergency action plan and emergency medical services. tance is required. Once the referee has determined that med- In addition, the inability to adequately assess the presence ical assistance is required, they will then authorise one, or at or absence of a pulse has led to its detection being removed most two doctors, to enter the fi eld.32 This applies to the side- from layperson CPR training and is likewise de-emphasised in line medical stretcher bearers as well. A consequence of this healthcare professionals. rule, when response is required to a collapsed player, is some Sportspersons and other potential fi rst responders, must delay in waiting for the referee to fi rst approach the injured make every effort to respond expeditiously to the side of a player, determine the urgency of the situation and if needs be, collapsed footballer, particularly if no contact has occurred. summon the medical responders onto the fi eld.33 If unresponsiveness is established, SCA should be regarded If a player collapses to the ground as a consequence of as being present, despite apparent signs of life, with activa- bodily contact with an opposition player during competition, tion of the emergency action plan which includes immediate the referee is nearby and will visualise the incident and thus CPR and defi brillator retrieval.
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