Sideline Management of Sudden Cardiac Arrest

Abstract

Background:

Sudden cardiac arrest (SCA) is the leading cause of student-athlete mortality, often described interchangeably as sudden cardiac death (SCD). For persons aged ≤35 years, structural heart disease, such as hypertrophic cardiomyopathy, is historically the most common etiology. Regarding individuals aged >35 years, coronary artery disease is the main contributor to SCD during exercise.

Indications:

Though some athletes may endure prodromal symptoms prior to a SCA, approximately 25% to 50% do not. Up to 23,000 people aged <18 years die from SCA annually. SCA athlete deaths are reported to be the most common medical cause of death and the second most common overall behind motor vehicle accidents in this population. Therefore, it is important to acknowledge SCA prevalence and identify at-risk competitors.

Technique Description:

If a SCA is suspected, first assess surroundings for safety and athlete response to commands. Should there be no pulse, activate code. If necessary, an athlete’s shirt may be removed or cut to better access the bare chest for the automated external defibrillator (AED) pads. Apply pads and commence compressions. Refer to the AED for a shockable rhythm between compression cycles. Establish intravenous access as appropriate and if feasible. After 1 cycle of compressions, a shock is administered when a shockable rhythm is detected. Resume compressions if a pulse is not reestablished. If a pulse is reestablished, the athlete should then be immediately transported to the hospital.

Results:

A literature review yields illustration of the multifactorial criteria that comprise return-to-sports guidelines, including activity intensity, extent of cardiac disease, and psychological/physical benefit from sport. SCD incidence is higher in competitive versus recreational athletes. In general, consolidation of these investigations makes it apparent that utilizing a shared decision-making process and a progressive exercise program is warranted prior to play resumption in most cases. The greatest SCA/SCD survival determinant is collapse to defibrillation time.

Discussion/Conclusion:

The American Heart Association/American College of Cardiology and the European Society of Cardiology recommend preparticipation cardiac screening to identify cardiac conditions that predispose to SCA/SCD risk. SCD prevention in athletes hinges on the prompt availability of quality cardiopulmonary resuscitation and AEDs.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In this video, we aim to provide a basic overview describing sideline management of sudden cardiac arrest (SCA) while detailing some our most important findings following a brief review of pertinent literature to our discussed topic.

We report no disclosures affiliated with this project at this time.

Background

Highlighting a brief overview to guide our discussion, we expand upon throughout our presentation how SCA significantly contributes to student-athlete mortality as well as the importance of identifying at-risk athletes given that many do not experience prodromal symptoms, such as chest pain or palpitations. We then provide a brief visual demonstration of our proposed technique regarding how to run a sideline code, emphasize how determining return to sport is complex, and echo the importance of quality cardiopulmonary resuscitation (CPR) along with automated external defibrillator (AED) access.

SCA is defined as the abrupt termination of cardiac activity, electrical and mechanical, that is typically followed by halted circulation, breathing cessation, and unresponsiveness leading to instantaneous loss of consciousness and collapse. ¹

Often used interchangeably with sudden cardiac death (SCD) by convention, SCA can also be generally defined as an aborted SCD. ¹⁰ For persons ≤35 years of age, structural heart diseases are widely considered the most common etiology. These include hypertrophic cardiomyopathy (HCM), more commonly obstructive as opposed to nonobstructive, anomalous origin of a coronary artery, arrhythmogenic right ventricular cardiomyopathy, myocarditis, and coronary atherosclerosis. Though HCM accounts for approximately 36% of SCDs and is considered the most common etiology of SCA historically, there are some emerging data that suggest channelopathies may be the leading overall contributors to death in athlete arrests. ⁶ Channelopathies, or primary electric diseases of the heart, include long and short QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and early repolarization syndrome. For persons >35 years of age, coronary artery disease is the most prominent cause of SCA during exercise. There are also trauma cases, during or outside competition, that can lead to commotio cordis, a condition involving chest contact during the ventricular repolarization phase of a heartbeat resulting in subsequent arrest.^1,6

Indications

Pertaining to the general population, which includes athletes and nonathletes, some may endure prodromal symptoms prior to a SCA such as chest pain, syncope, palpitations, or/and seizure. However, it is reported that 25% to 50% of people who experience a SCA do not. ¹ It is estimated that >20,000 people aged <18 die from SCA annually. ⁹ A 20-year study involving the athletic population from 2002 to 2022 conducted by the National Collegiate Athletic Association (NCAA) found that SCA was the most common medical cause of death, comprising approximately 13% of this mortality type, while being the second most common overall behind motor vehicle accidents in this group.^9,11 Among NCAA athletes, Black and White Division I male basketball players had the highest incidence of SCD with an estimated ratio of 1:2000 over a 4-year career. SCD incidence is higher in competitive versus recreational athletes, but the total number of SCDs is greater in recreational athletes due to the higher number of competitors. ⁹ Risk factors can be attributed to congenital disorders that can prompt structural or arrhythmic etiologies, but it has been reported that SCA can occur just as much in structurally normal hearts compared to those with HCM. ¹² Examples of genetic disorders that may predispose to SCD are HCM, arrhythmogenic cardiomyopathy, Marfan syndrome, and long QT syndrome. ⁵

Please take a moment to view the slide detailing the written form of our technique before we present a brief, general visual demonstration of SCA sideline management.

Technique Description

If arrest is suspected, first assess the surroundings of the athlete. Then, assess whether the athlete can respond to commands prior to pulse assessment. If no pulse is detected, activate code, and signal the team. If necessary, an athlete’s shirt may be removed or cut to better access the bare chest for the AED pads. Apply pads and commence compressions. Place the heel of your dominant hand on the lower half of the sternum, then interlace your fingers with the other, overlying hand before aligning your shoulders above your hands during positioning. Ensure that your elbows are locked before commencing compressions. Please note that the compressions performed in this video are not to scale, to avoid damage to the mannequin devoid of recoil. Reserving commentary in reference to infants, prepubescent children, and adults with special airways, manual CPR should be performed at a rate of 100 to 120 compressions per minute at a depth of 2 to 2.4 inches with a compression-to-breath ratio of 30:2 and a pulse check every 2 minutes for most competitors who experience arrest.^7,8 Refer to the AED system for a shockable rhythm between compression cycles. Then, determine whether establishing intravenous access is appropriate and feasible. After 1 cycle of compressions, a shock is administered by the AED when a shockable rhythm is detected. If a pulse is not reestablished, resume compressions. If return of spontaneous circulation is achieved, athlete should then be safely and immediately transported to the hospital for further evaluation and monitoring.

Results

Upon literature review, it becomes apparent that the return-to-sport decision depends on several factors and that restrictions are usually based on expert opinion compared with controlled studies that would otherwise contribute to a specific outlined protocol.^5,10 This can involve assessment of desired activity intensity, cardiac disease extent, and psychologic/physical benefit from sport. For example, if the athlete is found to have a structural or electrical cardiac problem, such as Marfan syndrome or long QT, it is typically advised that the athlete avoid strenuous exercise under certain circumstances, such as “burst” exertion activities and/or rapid acceleration and decelerations such as those involved in sprinting, basketball, tennis, and soccer.^5,6 Additionally, there may be extreme environmental conditions involved that may affect blood volume and electrolyte levels, in turn posing risk of exacerbating an existing cardiac problem. This is where a shared decision-making process must take place. In the event an athlete is at increased risk of SCA, activities with stable energy expenditure, such as jogging, biking on flat terrain, and swimming laps, are preferred. ⁵ That said, patients with unusual or high-risk clinical features may require greater restriction. This would include individuals who have a history of syncope/presyncope during exertion, prior arrhythmic episodes, or placement of an implantable cardioverter-defibrillator.^5,10 In older patients, it has been acknowledged that the overall benefits of exercise in those with stable coronary disease far outweigh the risks. Regardless of age, progressive exercise programs are warranted following most SCA cases. ¹⁰

A 5-year Luxembourg study showed that the ratio of survival among patients receiving bystander CPR during a cardiac arrest was approximately 50%. ³ All SCA/SCD cases that did not involve CPR resulted in fatality. Upon further review of the literature, the greatest SCA/SCD survival determinant was associated with time from collapse to defibrillation. Estimated survival rates decline 7% to 10% per minute until shock administration. ⁴ The American Heart Association/American College of Cardiology and the European Society of Cardiology recommend preparticipation cardiac screening to identify at-risk event participants.^2,10

Discussion/Conclusion

The vitality of timely CPR and AED availability has long been stressed, even popularized on social media platforms. The statistics reported by the aforementioned Luxemburg study ³ and highlighting the rapid mortality increase that occurs with a delayed AED shock mirror previous reminders entailing how preparedness and continued efficiency optimization will likely save more lives.

Therefore, the main conclusions of this demonstration and review are that utilization of preparticipation cardiac screening is important to identify those with increased SCA/SCD risk and that SCA/SCD prevention in athletes hinges on quality CPR and prompt availability of AEDs.

Please see our attached references. Thank you for watching and taking the time to learn more about this topic alongside us.