Posted on 09/07/2023
Matthew Martinez, MD
Matthew Martinez, MD

Key takeaways:

  • A well-planned, well-rehearsed emergency action plan is essential to prevent death from on-field sudden cardiac arrest.
  • Such a plan was successfully followed after the collapse of NFL player Damar Hamlin. 

Editor’s Note: Sept. 7 marks the beginning of the 2023 NFL season. On Sept. 11, Damar Hamlin will play his first game since his sudden cardiac arrest in January. This edition of Sports Cardiology Corner discusses the kind of planning that went into the response that saved his life. 

When Damar Hamlin of the Buffalo Bills went into sudden cardiac arrest Jan. 2, 2023, during a “Monday Night Football” game, we were all reminded of the importance of a plan.

The keystone of cardiac health and safety in athletes is a well-planned, well-rehearsed emergency action plan (EAP) with an emphasis on rapid CPR and automated external defibrillator use. 

Thankfully, sudden cardiac arrest (SCA) in athletes on the competitive field is rare, but failure to immediately recognize SCA and rapidly execute an EAP can cost lives. The immediate response in Hamlin’s case was planned for and rehearsed; the National Football League and many other professional sporting organizations perform mock on-field emergencies and have a “medical timeout” prior to any formal competition to review the EAP and assign responsibilities should SCA or other emergencies arise. 

The essence of an EAP

This coordinated effort is not limited to professional athletes. EAPs are recommended for every organization, school and institution that sponsors athletic or performance activity and are required at the collegiate and professional levels. 

The EAP coordinator should lead the planning and documentation of a specific organization/ venue/ team plan. The document should be distributed to all stakeholders and displayed in a public setting for review. Stakeholders may include coaches, medical directors and athletic trainers. Members from local emergency medical services (EMS) should be involved in the initial stages of planning, with special emphasis on facility access and transport to higher levels of medical care. A clear and well-rehearsed plan is critical to success.

Role of nontraditional stakeholders

We further submit a call to action for nontraditional stakeholders, including staff members, coaches, players and officials, to become integral team members as part of an effective EAP. 

SCA can happen during off-hours and more broad education and SCA prevention involvement would afford the ability to respond to SCA at any time. Game officials can often be the first witness to SCA and can alert first responders or be the first responders. The Professional Referee Organization (PRO) representing game officials for Major League Soccer now trains its members on recognition and response to cardiac and neurologic emergencies, and other organizations have followed suit. 

Traditionally, EMS training has been performed by certified individuals and matches local requirements (e.g., workplace) and venue (e.g., stadium) needs. However, widespread education with informal training for staff, players and officials will increase the number of individuals prepared to recognize SCA and further solidify the chain of survival. We have begun this initiative with PRO, United States Tennis Association (USTA) and many university student-athletes to expand the “workforce” of first responders. We believe anyone can be a first responder.

Activation of the EAP

A collapsed athlete should immediately lead to activation of the EAP. Features consistent with SCA during athletic activity include noncontact athlete collapse, unresponsiveness and seizure-like activity. All of these should be presumed SCA until proven otherwise. The athlete should be checked for responsiveness and, if SCA is confirmed, prompt initiation of CPR and placement of an AED should follow. 

AEDs should be regularly maintained, accessible at all times, and its whereabouts known to all potential users. Delivery of a shock from the AED should ideally occur within 3 minutes of SCA recognition if the etiology of the SCA is a shockable rhythm. The next step is to transfer the athlete to a hospital capable of advanced cardiac care with a formulated plan to best practices of those who experience SCA. The selected hospital should be aware of being a destination and have priorities for pre-hospital care aligned with the EAP coordinator and EMS, and best practices for post-cardiac arrest critical care.

It is critical that the EAP is rehearsed at least once per year with all stakeholders present and at all relevant facilities (eg, stadium, swimming pool, rowing facility, etc). Rehearsals allow for regular practice, review and edits to the EAP. Special consideration can be given to athletes who may be competing with known cardiac conditions that may alter the EAP (ie, an athlete with an implantable cardioverter defibrillator). Further, as mentioned previously, prior to competitive games, the EAP coordinator should review the plan in a “medical timeout” with relevant game officials, athletic trainers and medical staff.

The ECG screening debate 

On-field cardiac events in young athletes often reopen debate over whether to include an ECG in preparticipation screening. 

The preparticipation physical evaluation (PPE) of athletes includes a physical examination and personal and family history, as recommended by the American Heart Association and the NCAA. The addition of an ECG to preseason screening has been shown to improve the likelihood of detecting CV conditions that may be associated with SCA. For instance, in a study published in HeartRhythm in 2020, the discovery rate of CV conditions associated with sudden death was 0.24% with an ECG/history/physical compared with 0.04% with history/physical alone (P = .02).

Proponents for adding ECG to the PPE argue that the addition of ECG screening could save additional lives. Opponents argue that there is no evidence that ECG screening saves lives, but rather, that such screening could cause harm to otherwise healthy and asymptomatic individuals.

Potential harms include unnecessary restriction of activity, varying access to care due to additional costs, false-positive and false-negative readings due to unfamiliarity with ECG interpretation in athletes, and risk for downstream unnecessary procedures or additional testing. In addition, several potential and important causes of SCA, including anomalous coronary arteries and catecholaminergic polymorphic ventricular tachycardia, are not detectable on a screening ECG. Furthermore, acquired CVD in athletes (eg, myocarditis, commotio cordis, stimulant use) would not be detected on a PPE or ECG.

Everyone on both sides of this debate agrees that those reviewing athlete ECGs must be appropriately skilled, with sufficient resources in place for downstream care. Both AHA and NCAA recommendations state that a screening ECG may be used in select circumstances when adequate resources are available. 

It is critical to reemphasize that no matter how much athletic ECG criteria improve to reduce false positives, and no matter how thoroughly the PPE is performed, we will never be able to predict all athletic SCA events. Even in the best and most experienced hands, the majority of sudden deaths during sport occur in athletes who previously had normal screening, including all the most recent high-profile cases. This underscores the critical, lifesaving aspect of the well-rehearsed EAP with CPR and AED use. This unquestionably meets the goal of saving the lives of athletes, coaches and spectators. As such, there is no substitute for having a well-planned and rehearsed EAP for immediate CPR and AED application in the event of a SCA.

Well-implemented EAPs save lives

Damar Hamlin’s SCA highlights the effectiveness of a well-implemented EAP and the overarching intersection between the sports medicine and sports cardiology communities. Regardless of the SCA etiology, the best intervention for cardiac and safety athletes is prompt use of CPR and AEDs and a well-prepared and well-rehearsed EAP. 

As all athletes and performance artists are taught from a young age, practice makes perfect. We endorse the same approach for cardiac arrest preparation. The EAP should be routinely rehearsed and revised with input of all stakeholders and continued reinforcement of CPR/AED training for all members of the sports organization. Training of nontraditional stakeholders such as game officials and the athletes themselves holds promise to grow the pool of those trained in high quality CPR and AED use. The best defense, one might argue, is the best offense: Planning, practice and preparedness will give any SCA victim the best chance to survive the ultimate fight. 

By Matthew W. Martinez, MD, Benjamin D. Levine, MD, Jonathan H. Kim, MD, MSc, Eugene H. Chung, MD, MPH, Eli M. Friedman, MD

SOURCE: Cardiology Today