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Planning
For Scholastic Cardiac Emergencies
James M. Kyle, MD, FACSM Joseph Leaman, MS, ATC Gregory A. Elkins, MD Abstract Fatalities during sports participation are usually cardiac in origin. Sudden Cardiac Arrest (SCA) from ventricular fibrillation has been reported in several sporting venues over the last decade. Successful treatment of stadium SCA requires a rapid response team equipped with defibrillator capabilities. Automated external defibrillators (AED) use by sports arena targeted responders may prevent catastrophic scholastic athlete and spectator cases of unexpected sudden cardiac death. Introduction High School athlete medical coverage has received increasing emphasis over the past decade. Mandatory pre season physical examinations have been standardized and expanded to detect athletes at risk for emergency medical conditions. Many school systems now employ full time certified athletic trainers for year round sporting event coverage. In West Virginia, the State Board of Education requires all high schools participating in interscholastic football to have an athletic trainer present at all practices and games. For the last ten years, the Sports Medicine Committee for the West Virginia Chapter of the American Academy of Family Physicians (AAFP) and the West Virginia Secondary Schools Activity Commission (SSAC-the state governing body of scholastic sporting events) has monitored event coverage utilizing a report card system. Prior to kickoff, documentation of "on the field" athletic trainer, ambulance, and team physician attendance is recorded for future analysis. The coach's role in injury prevention and emergency response has also expanded in scope. The National Federation of High School Sporting Associations routinely conducts workshops and seminars to enhance the health care of the student athlete. This includes safe wrestler weight loss, preventative programs for anabolic steroid abuse, and catastrophic head and neck injury prevention. In West Virginia, the Secondary Schools Activity Commission (SSAC - governing body of all scholastic sporting events) conducts mandatory pre-season programs on injury management provided by the sports medicine committee of the WV AAFP and representatives of the West Virginia Athletic Trainers Association (WVATA.) Coaches are encouraged to maintain a current CPR certification. The American Heart Association (AHA) recommends the Heart Saver classification of certification for all individuals responsible for adolescent emergency care. To maximize outcomes, automated external defibrillator (AED) training was incorporated by the AHA in the fall of 1998.
Sudden Cardiac Arrest Sudden Cardiac Arrest (SCA) has an estimated annual incidence of 0.7 to one per 1000 population. High school athlete sudden death is rare; however, sudden adult spectator sudden cardiac arrest has been reported at sports arenas. Unfortunately, one of the authors was in attendance for such an incident at a major college basketball game. Professional and collegiate sporting venues typically employ emergency medical response teams for spectator care coverage. High school event coverage is less organized and typically falls under the responsibility of the athletic director or school administrators. The entry of automated external defibrillator's into the sporting arena has become attractive as the result of numerous studies documenting increased survival rates with police and first responder programs. In addition, the AHA has endorsed the newly introduced, sophisticated, safe, and relatively inexpensive AED's for targeted responder groups. At the 1998 National Athletic Trainer Association (NATA) meeting in Baltimore, Maryland, most NFL trainers reported utilizing AED's. On the collegiate level, officials from the Southeastern Conference documented eight of twelve member schools with plans to provide AED coverage at practice and games in the upcoming school year. The University of Georgia program initiated in 1997 has become a model for other member schools. The program is designed for time to shock under five minutes from deployment, from one of the three training rooms equipped with Lifepak 500 AED's. Several high school trainers attended the AED workshop at the Baltimore convention. Many expressed a keen interest for incorporating AED's into their existing emergency event coverage; however, no existing high school AED programs were reported.
"The Ripley Project" High school sporting events traditionally enjoy a high priority in rural communities. In many locations, the high school campus becomes a focal point for public gatherings and a potential site for cardiac emergencies. The Jackson County West Virginia Board of Education operates two local high schools with an average enrollment of 1200 students. During the summer of 1997, the Board approved the purchase of two Lifepak 500 AEDs for deployment at high school sporting events. This action was prompted by encouragement from Emergency Department personnel at Jackson General Hospital, located in Ripley, WV, in response to a recent case of SCA in an adjacent county high school baseball player. The death occurred when a 16-year-old athlete was struck in the chest by a baseball from 90 feet as he attempted to slide into third base. Commotio Cordis (cardiac concussion) was the expected cause of death. Prior to the initiation of fall football practice, school administrators invited each appointed high school football trainer and coaching staff to attend a CPR re-certification and AED workshop. A course was conducted by staff from Jackson General Hospital, local Emergency Medical Services personnel, and the regional EMT coordinator. Faculty from the hospital staff included the local AHA Coordinator, and Emergency Department nurses. The five-hour course was attended by 26 school personnel including various head coaches and principals. The course was modeled from the casino targeted responder program initiated in select Las Vegas properties during early 1997. This program was under the supervision of the Clarke County Fire Department and monitored by the University of Arizona Department of Emergency Services. Components of initial education included emphasis on signs and symptoms of pending cardiac arrest and video CPR instructions including recent updates. All students were tested in one person CPR by AHA instructors prior to AED inservice and subsequent testing. Continuing education at three-month intervals was facilitated by impromptu drills during scheduled team practice and Faculty Senate Day teacher workshops combined with a quarterly newsletter with an educational focus. The Ripley pilot project received endorsement from the State Board of Education and prior to initiation of the project, the WV State legislature approved a grant providing funding for the placement of three additional AED's to first responder fire department units in strategic county locations. Members from the educational team for the coaching inservice also provided the education for local fire departments. Later reports indicated that Jackson County, WV, was among the first school systems implementing high school sporting arena early defibrillation programs.
Quality assurance issues
can be facilitated by critical review of AED usage provided by data display
programmed into newer AED units. Emergency Department physicians anticipated
to be utilized in the event of cardiac emergency should be incorporated
into plans for the initial course and subsequent continuing education
at three-month intervals. This concept must also be augmented with excellent
cellular phone or radio communication in rural areas.
Conclusion Recent technological advances in automated external defibrillator equipment design provide an opportunity for advanced treatment to become safe and expedient in the hands of targeted responders. As a result, communities are challenged to develop a mechanism for education and equipment acquisition. Historically, most communities support local schools for noteworthy projects. Additional grant funds are currently being sought for additional studies in an even more rural West Virginia county. Physician directed CPR and AED training for teachers, coaches, school administrators, and athletic trainers provides an attractive model for improving the safety of athletic participation and spectator safety at athletic events.
 References 1. Kyle JM, Walter RB, Forbase JK, Leaman JR, Hanshaw, SL Exercise Induced Bronchospasm in the Young Athlete; Guidelines for Routine Screening and Initial Management: accepted for publication in Medicine and Science in Sports and Exercise; August 1992 2. American Heart Association Report on the Public Access Defibrillation Conference December 3 - 10, 1994: Circulation 1995; 92:2740-2747 3. Automatic External Defibrillators for Public Access Defibrillation: Recommendations for Specifying and Reporting Arrhythmia Analysis Algorithm Performance, Incorporating New Waveforms, and Enhancing Safety: Circulation 1997; 95:1677-1682 4. Spaite DW, Criss EA, Valenzuela TD, Meislin HW, Smith R. Nelson A A new Model for Providing Pre-hospital Medical Care in Large Stadiums: Ann Emerg Med 1988; 17:825-828 5. Weaver WD, Sutherland K, Wirkus MJ Bachman R Emergency Medical Care Requirements for Large Public Assemblies and a New Strategy for Managing Cardiac Arrest in this Setting: Ann Emerg Med 1989, 18:155-160 6. White R; Police AED : Ann Emer Med 1996 7. Alonso-Serra HM, Delbridge TR, Auble TE, Mosesso VN, Davis EA Law Enforcement Agencies and Out-of-Hospital Emergency Care: Ann Emer Med 1997; 29:4 8. Kyle JM, Walter RB Sports Medicine Education for Rural Practice: The Physician and Sports Medicine; Vol. 16, No. 8 9. Kyle JM High Schools Help Conquer Cardiac Arrest: School Business Affairs; February 1998; 48-50 10. Sobel RK A Shocking Story: Handy Defibrillators; U.S. News & World Report; September 1998; 77 11. Maron, MD, Thompson, P, Puffer, J, McGrew C, Strong, W, Douglas P, Clark L, Mitten M, Crawford M, Atkins D, Droscoll D, Epstein A Cardiovascular Preparticipation Screening of Competitive Athletes: American Heart Association; Med Sci Sports Exerc December 1996; 28(12):1445-1452 12. Maron MD, Poliac MD, Kaplan MD, Mueller, PhD Blunt Impact to the Chest Leading to Sudden Death from Cardiac Arrest during Sports Activities: NEJM August 1996: Vol. 333, No. 6 13. Estes NA, Sudden Death in Young Athletes: NEJM, August, 1996, Vol. 333, No. 6 14. Amerongen MD, Rosen MD, Winnik MD, Horwitz DO Ventricular Fibrillation Following Blunt Chest Trauma from a Baseball: Pediatric Emergency Care; Vol. 13, No. 2, 1997 15. Kaplan MD, Karofsky MD, Volturo MD Commotio Cordis in Two Amateur Ice Hockey Players Despite the use of commercial Chest Protectors: Case Reports The Journal of Trauma; 1993 Vol. 34, No. 1 16. Maron, MD, Poliac MD, Kaplan MD, Mueller PhD; Blunt Impact to the Chest Leading to Sudden Death from Cardiac Arrest during Sports Activities: NEJM 1996 Vol. 333, No. 6 17.
Automatic external defibrillators for public access defibrillation: Recommendations
for specifying and reporting arrhythmia analysis algorithm performance,
incorporating new waveforms, and enhancing safety. Circulation 1997; 95:1677-1682
About The Authors Joseph R. Leaman, MS, ATC Served as an Athletic Trainer for the Track & Field venue during the 1996 Centennial Olympic Games. He completed his graduate studies and athletic training at Marshall University in Huntington, WV. He is currently Program Director of Sports Medicine at Health South in Parkersburg, West Virginia James M. Kyle, MD, FACSM Fellow in the American College of Sports Medicine and Chairperson for the Sports Medicine Advisory Group for Physio-Control Corporation. He is Chief of Rural Emergency Medicine at Marshall University School of Medicine, and Emergency Department Director for Jackson General Hospital in Ripley, WV. Dr. Kyle was a Team Physician at Olympic Stadium, and Athletic Primary/Emergency Care at Olympic Stadium, Atlanta '96. Gregory A. Elkins, MD Medical Director at Lincoln Primary Care Center in Hamlin, WV. He serves as Chairman of the Sports Medicine Committee of the West Virginia Chapter of the AAFP and is a Clinical Assistant Professor in the Department of Family and Community Health at the Marshall University School of Medicine. He serves on the Sports Medicine Committee for the WV SSAC (Secondary Schools Activities Commission.) He is charter member of the American Medical Society for Sports Medicine.
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