National Athletic Trainers’ Association Position Statement: Preventing Sudden Death in Sports

http://www.nata.org/sites/default/files/Preventing-Sudden-Death-PositionStatement_2.pdf

Objective:

To present recommendations for the prevention and screening, recognition, and treatment of the most common conditions resulting in sudden death in organized sports.

Background:

Cardiac conditions, head injuries, neck injuries, exertional heat stroke, exertional sickling, asthma, and other factors (eg, lightning, diabetes) are the most common causes of death in athletes.

Recommendations:

These guidelines are intended to provide relevant Information on preventing sudden death in sports and to give specific recommendations for certified athletic trainers and others participating in athletic health care.

Summary:

  • Have updated Emergency Action Plans (EAP) for all athletic venues
    • Practice EAPs annually

The following rules apply to every EAP:

  1. Every organization that sponsors athletic activities should have a written, structured EAP.
  2. The EAP should be developed and coordinated with local EMS staff, school public safety officials, onsite first responders, school medical staff, and school administrators.
  3. The EAP should be specific to each athletic venue.
  4. The EAP should be practiced at least annually with all those who may be involved.

Those responsible for arranging organized sport activities must generate an EAP to directly focus on these items:

  1. Instruction, preparation, and expectations of the athletes, parents or guardians, sport coaches, strength and conditioning coaches, and athletic directors.
  2. Health care professionals who will provide medical care during practices and games and supervise the execution of the EAP with respect to medical care.
  3. Precise prevention, recognition, treatment, and RTP policies for the common causes of sudden death in athletes.
  • Asthma
    • Athletes who have or is suspected of having asthma need a thorough medical history and physical exam
    • ATs should educate asthmatic athletes about the use of medications, spirometry devices, asthma triggers, recognition of signs and symptoms, and compliance with condition
    • ATs should be aware of the major asthma signs and symptoms and other conditions that could worsen asthma
    • Spirometry tests should be done at rest and with exercise in a sport specific environment
    • For acute asthma attack, the athlete should use a short-acting β2-agonist to relieve symptoms
      • If 3 administrations of medication do not relieve the distress the athlete should be referred to the appropriate medical facility
    • Inhaled corticosteroids or leukotriene inhibitors can be used for asthma prophylaxis and control
    • Supplemental oxygen should be offered to improve athlete’s available oxygenation during an acute attack
    • Lung functions should be monitored with a peak flow meter
      • Values should be at least 80% of predicted values before the athlete can participate
    • If feasible, remove athlete from an environment with trigger factors (ex: smoke, allergens)
    • Physical activity should be initiated at low aerobic levels and exercise intensity gradually increased while monitoring occurs for recurrent asthma symptoms
  • Catastrophic Brain Injuries
    • Coordinate educational sessions with athletes and coaches on the recognition of concussions and their signs and symptoms
    • Educate coaches and athletes on the serious nature of concussions and the importance of reporting concussions
    • ATs should enforce the use of certified helmets
      • Educate athletes that helmets do not prevent cerebral concussions
    • A comprehensive management plan for the acute care of an athlete with a potential intracranial hemorrhage or diffuse cerebral edema should be implemented
    • If an athlete’s symptoms persist, worsen or level of consciousness deteriorates after a concussion they should be immediately referred to a physician trained in concussion management
    • Oral and written instructions for home care should be given both to the athlete and to a responsible adult
    • Returning a concussed athlete to play should follow a graduated progression that only starts once the athlete is symptom free
    • Monitor the athlete periodically throughout and after these sessions to make sure symptoms do not return
    • For more information see the NATA Concussion Management Position Statement
  • Cervical Spine Injuries
    • ATs should familiarize themselves with sport-specific causes of catastrophic cervical spine injuries and understand the physiological responses in spinal cord injuries
    • Coaches and athletes must be educated about the mechanisms for cervical spine injuries and pertinent safety rules
    • Corrosion resistant hardware and proper maintenance of all helmets should be standard
    • In the initial assessment if any of the following are present, alone or in combination, requires the initiation of the spine injury management protocol:
      • Unconsciousness
      • Altered level of consciousness
      • Bilateral neurologic findings
      • Significant midline pain with or without palpation
      • Obvious spinal deformity
    • Cervical spine should be in the neutral position and manual stabilization applied immediately
    • Do not apply traction
    • Immediate attempts to secure the airway should attempted
    • If rescue breathing becomes necessary the person with the most experience should establish the airway and begin rescue breathing
    • If the spine is not in a neutral position, ATs should attempt to regain neutral cervical spine
    • However the contraindications for realigning the cervical spine include:
      • Pain caused or increased with movement
      • Neurologic symptoms
      • Muscle spasms
      • Airway compromise
      • Physical difficulty in repositioning the cervical spine
      • Resistance
      • Apprehension of the patient
    • Manual stabilization of the cervical spine should be converted to external devices such as foam head blocks
    • After external devices are placed, manual stabilization should resume
    • Spine injured athletes should be immobilized with a long spine board or other full body immobilization device
    • Primary acute treatment goals in equipment laden athletes are to ensure that the cervical spine is immobilized in neutral and vital life functions are accessible
    • For removal of equipment please see the NATA Consensus Statement on Appropriate Prehospital Management of the Spine-Injured Athlete
      • http://www.nata.org/sites/default/files/Executive-Summary-Spine-Injury-updated.pdf
    • If possible a team physician or AT should accompany the athlete to the hospital
  • Diabetes Mellitus
    • Diabetes mellitus is a chronic metabolic disorder characterized by hyperglycemia, caused by either absolute insulin deficiency or by restistance to the action of insulin at the cellular level, which results in an inability to regulate blood glucose levels
    • Normal blood glucose levels are between 70-100mg/dL
    • Each athlete with diabetes should have a personalized care plan that includes glucose monitoring, treatment guidelines for hypoglycemia and hyperglycemia, and emergency contact information
    • Prevention stragies for hypoglycemia are described by the American Diabetes Association (ADA) and include blood glucose monitoring, insulin adjustments, and urine testing for ketone bodies
    • Hypoglycemia signs and symptoms include:
      • Tachycardia
      • Sweating
      • Palpitations
      • Hunger
      • Nervousness
      • Headache
      • Trembling
      • Dizziness
      • Severe cases include loss of consciousness or possibly death
    • Hyperglycemia can occur with or without ketosis
    • Hyperglycemia without ketosis signs and symptoms include:
      • Nausea
      • Dehydration
      • Reduced cognitive function
      • Feelings of sluggishness
      • Fatigue
    • Hyperglycemia with ketosis signs and symptoms include the previous S&S along with:
      • Kussmaul breathing (abnormal deep, very rapid sighing respirations)
      • Fruity odor to the breath
      • Unusual fatigue
      • Sleepiness
      • Loss of appetite
      • Increased thirst
      • Frequent urination
    • Mild hypoglycemia can be treated with administering ~10-15g of carbohydrates and reassessing the blood glucose levels immediately after and 15 minutes later
    • Sever hypoglycemia is a medical emergency requiring the activation of EMS and if a medically trained person is available to administer glucagon
    • ATs should follow the ADA guidelines for exercising during hyperglycemic periods
    • The team physician should determine the safe blood glucose range for an athlete returning to play after a mild episode of hypoglycemia or hyperglycemia
  • Exertional Heat Stroke
    • During PPE, athletes should be questioned on history of heat illness
    • Special considerations for those wearing protective equipment are needed
    • Acclimatization should be done over a period of 7-14 days
    • Athletes should maintain a consistent level of euhydration and replace fluids lost through sweat
    • ATs need to educate coaches, athletes, administrators on prevention of exertional heat stroke and that S&S is a medical emergency
    • 2 main criteria for EHS are:
      • Core body temp of >104 to 105 degrees
        • Taken by rectal temp
      • CNS dysfunction
    • Rectal and gastrointestinal temperatures are the only proven methods for taking accurate core body temp
    • Core body temp must be lowered to less than 102 degrees within 30 minutes of collapse
      • Cold water immersion is the fastest cooling method
    • Athlete with EHS should be cooled first and transported second
    • RTP should include
      • A period of no activity in an asymptomatic state
      • Normal blood enzymes before RTP begins
      • Gradual RTP under medical supervision
        • Start low intensity in a cool environment
        • Advance to high intensity in a warm environment
      • Exertional Hyponatremia
        • Is a rare condition with serum sodium at less than 130 mEq/L
        • Athletes should consume adequate dietary sodium at meals when participating in hot environments
        • Post exercise rehydration should aim to correct fluid loss
        • Body weight changes, urine color, and thirst off cues to the need for rehydration
        • EH most often occur in endurance athletes who ingest an excessive amount of hypotonic fluid
        • ATs need to recognize EH S&S during or after exercise
          • EH S&S include:
            • Overdrinking
            • Nausea
            • Vomiting
            • Dizziness
            • Muscular twitching
            • Peripheral tingling or edema
            • Headache
            • Disorientation
            • Altered mental status
            • Physical exhaustion
            • Pulmonary edema
            • Seizures
            • Cerebral edema
          • In severe cases EH encephalopathy can occur and may present with confusion, altered CNS function, seizures, and a decrease in level of consciousness
          • EH should be included in differential diagnoses until confirmed otherwise
          • Mild cases of EH (130-135 mEq/L)should be managed by withholding fluids and consume salty foods
          • Severe cases of EH should be transported to an advanced medical facility during or after treatment
        • Exertional Sickling
          • AT should educate coaches, athletes, and parents about complications of exertion in athletes with the sickle cell trait (SCT)
          • Athletes with SCT should be informed that they should expect a normal and healthy life span, although associated complications may occur
          • Targeted education and tailored precautions may help keep the SCT athlete safe
          • Athletes with known SCT should be allowed:
            • longer rest periods and recovery time between conditioning repetitions
            • exclusion for performance tests such as mile repeats and serial sprints
            • adjustment of work cycles in the presence of environmental heat stress
            • not work out if feeling ill
            • supplemental oxygen for participation in high altitude environments
          • Screening for SCT by self-report is a standard of PPEs performed at NCAA institutions
          • AT should know S&S of exertional sickling such as:
            • Muscle cramping
            • Pain
            • Swelling
            • Weakness
            • Inability to catch one’s breath
            • Fatigue
            • And be able to differentiate between exertional sickling and other causes of collapse
            • Understand the usual settings for and patterns of exertional sickling
          • S&S of exertional sickling warrant immediate withdrawal of activity
          • High flow oxygen at 15L/min should be administered
          • Continue to monitor vitals and activate EMS if vitals decline
          • Sickling collapse should be treated as a medical emergency
          • ATs have a duty to make sure the treating physician is aware of the presence of SCT
          • There are no contraindications to participate in sports for athletes with SCT
        • Head-Down Contact in Football
          • Head-down contact is defined as initiating contact with the top or crown of the helmet and results in axial loading
          • Axial loading is the primary mechanism for catastrophic cervical spine injuries
          • Head-down techniques are dangerous and may result in catastrophic injuries
          • Spearing is the intentional use of a head-down contact technique
          • Sport helmets do not cause or prevent axial loading injuries of the cervical spine
          • Head-down contact injuries are preventable and are technique related
          • The safest technique is to make contact with the shoulder or chest while keeping the head up
          • Athletes who continually drop their heads before contact need additional coaching
          • Formal education on proper technique should be held at least 2x per season
          • Officials should enforce existing helmet contact rules
        • Lightning Safety
          • The best way to prevent lightning injuries is to stay indoors during lightning activity
          • When thunder is heard or lightning is seen, people should vacate to a safe location
          • Safe structures must be identified
            • Safe structures have 4 walls, a solid roof, plumbing, and electric wiring
            • Shelters with an open side do not have sufficient protection (ex: dugouts)
          • Cars or buses that are fully enclosed can also be safe places during a storm
          • People should remain in the safe locations until at least 30 minutes have passed since the last sound of thunder or lightning strike
          • Victims of lightning injuries are safe to touch
          • Triage the lightning victims by attending to those who appear to be dead first
            • Most deaths are due to cardiac arrest
            • Aggressive CPR and defibrillation may resuscitate these patients
          • Treat for concussive injuries, fractures, dislocations and shock next
        • Sudden Cardiac Arrest
          • Sudden cardiac death (SCD) is the leading cause of death in exercising young athletes
          • The underlying cause of SCD is usually a structural cardiac abnormality, HCM and coronary artery anomalies
          • Access to early defibrillation is essential
            • A goal of less than 3-5 minutes from time of collapse to delivery of 1st shock is strongly recommended
          • PPEs should include family history and pay attention to:
            • Episodes of exertional syncope
            • Chest pain
            • Personal or family history of sudden cardiac arrest
            • Family history of sudden death
            • Exercise intolerance
          • Sudden cardiac arrest (SCA) should immediately be suspected in any athlete who collapsed and is unresponsive
          • The ABC’s should be assessed and an AED should be applied as quickly as possible to analyze the heart rhythm
          • Myoclonic jerking or seizure like activity is often present after collapse from SCA and should not be mistaken for a seizure.
          • Occasional or agonal gasping should not be mistaken for normal breathing
          • CPR should be provided while AED is being retrieved
          • Interruptions in chest compressions should be minimized
          • Treatment should proceed in accordance with the updated AHA guidelines
          • All ATs should maintain and practice CPR certification skills

 

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