Preventing Sudden Death 1- Exam 1

Acclimatization

A complex series of adaptive responses that demostrate improved homeostatic balance in multiple organs; usually requires 10-14 days for responses to develop adequately.

Ventricullar fibrillation

A lethal ventricular arrhythmia characterized by rapid ventricular depolarization leading to disorganized and asynchronous contraction of the ventricular muscle and inability to pump blood effectively

Exertional heat stroke

A medical emergency involving life-threatening hyperthermia with concomitant central nervous system dysfunction; treatment involves cooling the body

Ion channel disorder

A primary electrical disease of the heart predisposing to lethal ventricular arrhythmias and characterized by mutations in ion channel proteins that lead to dysfunctional sodium, potassium, calcium, and other ion transport across cell membranes

Alert, Verbal, Painful, unresponsive

AVPU Scale

Myocarditis

Acute inflammation of the myocardium. Flu like symptoms progressing to symptoms of congestive heart failure

Acclimation

Adaptive changes that occur in response to experimentally induced changes in particular climatic factors

Ninth initiative

Adopt concussion and head injury policies that are in line with leading sports health organization recommendations

Tenth Initiative

Adopt policies for the creation and implementation of policies for the appropriate management of exertional heat stroke

Sixth initiative

Adopt policies for the creation and implementation of supervision policies and exercise acclimatization policies, specifically for strength and conditioning sessions

Seventh initiative

Adopt policies promoting the installation of AEDs that can be accessed within 1 minute of any athletic venue

Fifth initiative

Adopt policies that implement standards for coaching education, continuing education, and certification in first aid, cardiopulmonary resuscitation (CPR), and recognition of emergency conditions

Fourth initiative

Adopt policies that promote hiring on-site medical care, such as athletic trainers, who are trained in the prevention, diagnosis, and treatment of emergency medical conditions

Third initiative

Adopt policies that promote the creation and maintenance of optimal emergency action plans that cover all potential emergency scenarios

Second Initiative

Adopt policies that promote the creation and use of environmental monitoring measures for practice and game modifications or cancellations

Eighth initiative

Adopt policies that promote the creation and use of pre-participation exams (PPEs) that utilize specific screening questions to target the top reasons why athletes die in sports.

Athletic trainers, EMTs, physicians, coaches

An athletic emergency situation may involve:

Creatine kinase

An indicator for muscle damage causing eplosive rhabdomyolysis

Circulation, Airway, Breathing, Severe bleeding, Shock, Spinal Injury

CAB Sx3

Cardiac impact and dysfunction of EHS

COagulopathies (disseminated intravascular coagulation; DIC). Tachypnea, hyperventilation

Pathophysiology of EHS

Can result in cascade of physiologic responses (Attempt to maintain thermal equilibrium), damage to cell membranes, endotoxemia, increased cytokine production (hypotension, tachycardia, inadequate organ perfusion), reduced ability of liver to detox, multi-organ dysfunction syndrome/failure; systematic inflammatory reponse syndrome (SIRS)

Smoking, hyperlipidemia, family history of SCD, premature coronary artery disease at age 55, diabetes mellitus

Cardiovascular Risk Factors (other than age and gender)

Emergency personnel, communication, equipment, transportation, and venue directions with map

Components of the EAP

Automated external defibrillator (AED)

Computerized device that analyzes the heart rhythm, determines whether a shock is needed to restart a normal rhythm, charges to an appropriate shock dose, shocks a patient's heart, and uses audio and visual instructions to guide the rescuer

Coronary artery disease

Condition in which plaque builds up inside the coronary arteries

Misdiagnosis, no care or delay in care, inefficient cooling modality, immediate transport (transport too soon)

Death from EHS is preventable. Why they die:

Heat balance equation (S=M-(+-Work) +-E+-R+-C+-K)

Describes the net rate at which a person generates and exchanges heat with his or her environment.

Heat exhaustion return to play

Determine cause of heat exhaustion, rule out heat stroke (normal enzyme levels, CK), ensure cause of event is eliminated/modified

Concussion, hyponatremia, severe heat exhaustion, exertional sickling, cardiac

Differential diagnosis of EHS

Prevention, recognition, treatment, return-to-play guidelines

EAPs are developed for each specific condition in relation to:

Heat exhaustion recognition

Excessive fatigue, fainting/collapse with minor cognitive changes (headache, dizziness, confusion). Weakness, vomiting, nausea, light-headedness, low BP.

Return to play for EAMC

Exercise as tolerable (muscle soreness), determine cause of muscle cramps, patient education, R/O cramping associated with exertional sickling cell trait

Work: rest/exercise intensity, uniform/equipment, WBGT/environmental conditions, hydration/access to fluids

Extrinsic factors affecting heat balance

Heat syncope recognition

Fainting or collapse with low rectal temperature (39 deg C). Assess responsiveness, breathing, HR to rule out cardiac

92.1

For WBGT, over what temp is the activity guideline "No outdoor workouts, cancel exercise, delay practices until a cooler WBGT reading occurs"

Timing of impact, impact velocity, location of impact, object hardness and shape

Four factors of commotio cordis resulting in V-Fib

Other signs and symptoms of EHS

Gastrointestinal hemorrhage, hepatic failure, elevated liver enzymes, explosive rhabdomyolysis

Cardiac screening

Goal is to identify young athletes with CV conditions/risk of SCD

RTP considerations for EHS

Has the athlete recovered from EHS? What caused EHS? What are the needs/requirements of sport/position?

Radiation (R)

Heat gained or lost due to the energy transferred in the infrared electromagnetic energy spectrum independent of air temperature

Convection (C)

Heat loss or gain through a transfer of either air or water

First initiative

High school and state high school athletics associations should adopt the 2009 NATA Heat Acclimatization Guidelines for Preseason Practices. Only 1 exertional heat stroke death occurred in collegiate level after NCAA mandated heat acclimatization guidelines in 2003

Marfan syndrome

Inherited disorder of connective tissue that affects multiple organ systems causing a progressive dilatation and weakness (cystic medial necrosis) of the proximal aorta that can lead to sudden rupture and death

Illness (febrile), lack of sleep, hydration, body composition, low physical fitness, lack of acclimation, zealousness

Intrinsic factors affecting heat balance

Exercise associated muscle cramps (EAMC)

Involuntary, painful skeletal muscle contractions during or after exercise.

Heat intolerance

Lower thermoregulatory efficiency and the inability to properly adapt to exercise in hot environments

Autopsy negative-sudden unexplained death

May be more HCM than than reported

Heatstroke, brain trauma and concussion, sickle cell trait, heart abnormalities

Medical conditions that lead to death, disability, or permanent injury

Establishing the safety of the scene and providing immediate care of the athlete

Most important roles in the EAP

Exertional heat stroke (EHS)

Most severe EHI. Defined by hyperthermia (>105F/40.5 C) associated with central nervous system disturbances (maybe multiple organ system failure. Result of metabolic heat production and environmental heat load. Excessive heat production and/or inhibited heat loss

Initial treatment of heat syncope

Move to shaded area, monitor vitals, elevate legs above heart, cool skin, rehydrate

Commotio cordis

Nonpenetrating, blunt trauma to the chest, usually from a firm projectile such as a baseball, lacrosse ball, or hockey puck, that induces ventricular fibrillation and sudden cardiac arrest

Competitive athlete

One who participates in an organized team or individual sport requiring systematic training and regular competition against others while placing a high premium on athletic excellence and achievement

Heat syncope

Orthostatic dizziness, often in unfit or unacclimatized individuals standing for long periods of tine in the heat, attributed to dehydration, venous pooling of blood, reduced cardiac filling, usually occurs during first 5 days of unaccustomed heat exposure

Hypertrophic cardiomyopathy

Pathologic hypertrophy of the ventricular wall muscle, usually asymmetric and involving the ventricular septum

Preparticipation screening, education and awareness, preparing athletic facilities for handling cardiac emergencies, exercise recommendations

Prevention of sudden cardiac death in adult athletes include:

Arrhythmogenic right ventricular cardiomyopathy

Progressive fibro-fatty replacement of the RV myocardium, causing wall thinning and RV dilation

Metabolic Equivalent (MET)

Ratio comparing a person's metabolic rate while seated and resting to his or her metabolic rate while performing some task

Heat acclimatization, hydration education, fluid needs, recurrent crampers: full diet and electrolyte analysis, adequate training regimen

Recommendations for prevention of EAMC

Heat exhaustion treatment

Remove excess clothing and equipment, move to cooler area, body cooling via ice towels, fans. Place in supine position with legs above the level of the heart. FLuid replacement. Transfer to physician if IV needed or symptoms persist for more than 30 mins

Initial treatment for EAMC

Rest, passive stretching, ice massage. If sodium is depleted, give sodium containing fluids and food

CNS signs and symptoms of EHS

Restlessness, seizures, confusion, coma, cerebral edema, decerebrate, decorticate posturing

Heat syncope return to play

Rule out more serious cause of syncope (cardiac, heat stroke, sickle cell associated collapse), educate on exercise-associated collapse or lack of heat acclimatization

Exertional heat stroke, heat exhaustion, hyponatremia, hypoglycemia, exercise-associated collapse, cardiac arrhythmias, seizures

SCA differential diagnosis

Adults

SCD incidence is higher in _____ than young athletes

Time from arrest to defibrillation

Single greatest factor affecting survival from SCA:

System-specific screening questions, previous history, family history, existing medical conditions, signs and symptoms during exercise, physical examination

Specific screening questions that should be included in a PPE

Florida

State with the highest EHI rates per 100,000 athlete exposures

Tarp Assisted Cooling with Oscillation

TACO method

Body temperature

Temperature of the internal organs or thermal core as measured by a valid device

Sweat rate

The amount of sweat produced during a given amount of time, usually represented as liters per hour

First responder

The first person present at the scene of a sudden illness or injury

Evaporation (E)

The heat from the body is transferred to sweat, this liquid is then converted to a gaseous state and heat is transferred and removed.

Heat exhaustion

The inability to effectively exercise in the heat, secondary to cardiovascular insufficiency, hypotension, energy depletion, central fatigue. Elevated core body temperature (<40.5 deg C). High skin blood flow, sweating, dehydration. Often occurs in heat unacclimatized and.or dehydrated individuals. No organ damage

Epidemiology

The of the distribution and determinants of health-related states and events in specified populations. It is also the application of this study to the control of health problems.

Dehydration

The process of water loss leading to hypohydration. Usually measured by body mass loss, urine color, urine osmolality, urine specific gravity, or serum osmolality

Sudden cardiac death

The sudden death of an individual occurring during or within 1 hour after exercise, due to a cardiovascular disorder; often associated with exercise when it occurs in young athletes

Conduction (K)

The transfer of heat from one object to another that is in direct contact with it

Cardiac, head injuries, exertional heat stroke, exertional sickling, asthma, trauma, C-spine, other

Top reasons athletes die

Certification in CPR and first raid, knowledge concerning an injured or sick person, prevention of disease transmission, review of existing EAP

Training and knowledge that should be required for all athletic personnel associated with practices, competitions, skills instruction, and strength and conditioning

Profound CNS dysfunction, core body temperature >105 deg F

Two main diagnostic criteria for EHS

Exercise-associated muscle cramps, heat syncope, heat exhaustion, exertional heat injury, exertional heat stroke

Types of heat illnesses

6 METS

Vigorous exercise in an absolute exercise work rate of

Recognition of EAMC

Visible muscle group cramping, localized pain, thirst, dehydration, sweating, fatigue. Differentiate from sickle cell trait muscle pain

SCD

What is the leading cause of death in young athletes during exercise?

Electrolyte depletion, muscle fatigue/overload

What is thought to cause EAMC?

Indirect fatality

When exertion causes systematic failure while participating in a sport activity (or complication secondary to a nonfatal injury, ex. cardiac, sickling, EHS)

Direct fatality

When injury results directly from participation in the fundamental skills of the sport (i.e. tackling, catching a ball, etc)

North Carolina

Which state had the best KSI rating?

Colorado

Which state had the worst KSI rating?