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Athlete Sudden Cardiac Death

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Athlete Sudden Cardiac Death EMERGENCIES IN MEDICINE Park City 2012 Jim Kyle, MD, FACSM Emergency Department Director, Beckley ARH Team Physician Concord University – PowerPoint PPT presentation

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Title: Athlete Sudden Cardiac Death


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 1100,000 to 200,000 VanCamp
    Maron
  • college athletes 165,000 69,000 VanCamp
    Drezner
  • 150,000 marathoners, 115,000 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
Cause of Sudden Cardiac Death Ten Year Review
158 Athletes B. Maron, JAMA 1996
  • 1985-95 sudden death organized sports
  • 138 cases of Sudden Cardiac Death
  • Ages 12-40, median age17 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
2010 Update Cardiac Concussion
  • 224 Cases NEJM, B Maron, M Estes
  • Mean Age 15 26 lt 10yo Range
    6mos 50yo
  • 95 Male, 78 White
  • Survival rate
  • 15 1990-1999
  • 35 2000-2009 ( 2006-09 gt 50 )

22
The Casino Project
23
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

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 gt 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 AnomaliesMagnetic Resonance
Imaging
36
Möhlenkamp et al. Circulation 20021062616-22.
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 Medicine1982 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 gt2/6 any diastolic,
    Abnormal S2, Systolic Clicks, BP gt140/90, 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 _at_ 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 gt.21 not shorted with
    hyperventilation) RBBB, LBBB
  • Long QT (gt.44men, gt.46 women)
    Short PR (lt0.12)
  • PVCs, AF, SVT
  • ST depression or T wave inversion 2 or more
    leads, Q wave 2 leads, V1 RS ratio gt1

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
  • AEDs with time to shock lt 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
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