Sudden cardiac arrest on the field of play: turning tragedy into a survivable event
Neth Heart J
Sudden cardiac arrest on the field of play: turning tragedy into a survivable event
David M. Siebert 0 1
Jonathan A. Drezner 0 1
0 Department of Family Medicine, UW Medicine Center for Sports Cardiology, University of Washington , Seattle, WA 98195 , USA
1 David M. Siebert
Sudden cardiac arrest remains the leading cause of death in exercising athletes, and recent studies have shown that it occurs more frequently than historical estimates. While out-of-hospital cardiac arrest often proves fatal, advance preparation can improve outcomes and the chance of survival. First responders to a collapsed athlete on the field of play may include team medical personnel, coaches, other athletes, officials, venue staff, emergency medical services personnel, or lay bystanders. Prompt and accurate recognition of sudden cardiac arrest, a comprehensive and rehearsed emergency action plan, early cardiopulmonary resuscitation, and immediate access to and use of an automated external defibrillator are each pivotal links in the chain of survival. This review summarises the components of an effective emergency action plan, highlights the critical role of automated external defibrillators, and reviews the diagnosis and management of sudden cardiac arrest on the field of play.
Automated external defibrillator; Emergency action plan; Sudden cardiac death; Athlete; Collapse; Exercise
The sudden collapse and death of a young athlete on the
field of play is a tragic event with a profound impact on the
local community. Sudden cardiac arrest (SCA) is the
leading cause of sudden death in athletes, accounting for 75%
of all deaths during exercise and sport [
epidemiological data have shown that SCA strikes competitive
athletes more frequently than historical estimates. For
example, annual risks have been shown to be 2.3:100,000 in
Italian athletes [
] and 1–3:100,000 in professional soccer
]. The Fédération Internationale de Football
Association (FIFA) has begun a registry to study all cases of
soccer-related SCA to better understand the extent of the
]. In the United States, male athletes, African/
Afro-Caribbean athletes and basketball, American football
and soccer athletes are at highest risk [
cardiovascular diseases and conditions that precipitate SCA
comprise a heterogeneous group of disorders that usually
exhibit no symptoms or warning signs prior to the sentinel
event of SCA [
]. As a result, preparticipation
cardiovascular screening is challenging and the optimal strategy
to detect athletes with disorders at risk of sudden death
remains controversial [
]. Thus, medical personnel
responsible for athlete safety must be prepared to recognise,
respond to, and effectively treat SCA.
Emergency response planning for sudden cardiac arrest
SCA is a life-threatening event and requires a prompt and
coordinated medical response. Preparation and rehearsal
of an emergency action plan (EAP) are essential to
decrease the chance of a catastrophic outcome. Guidelines
for the development and implementation of an EAP have
been previously outlined [
] and are broadly supported
by the sports and medical communities. A comprehensive
EAP includes training of likely first responders to a
collapsed athlete, including on-site medical and club
personnel, as well as access to an automated external defibrillator
(AED), emergency medical services, and advanced care
facilities (Tab. 1). A thorough understanding of emergency
preparedness guidelines is imperative to allow for the
efficient execution of the medical response to SCA.
• Sudden cardiac arrest (SCA) in athletes is largely a survivable event (89%) with proper
preparation and access to an AED. However, SCA during sporting events can precipitate confusion
i.e. seizure-like movements, abdominal movements and gasping, agonal respiration and tongue
CPR should commence at the site of the athlete's SCA and not be delayed by moving the athlete
to a different location leading to worsening outcomes.
The collapse to defibrillation time is the single most important determinant of survival. The
collapse to defibrillation time should be under 3 minutes to allow a favorable outcome of survival.
AEDs should be strategically located in the schools & community, arenas and along the full
length of a mass-participation course to allow a favorable outcome.
Components of an emergency action plan
According to best-practice recommendations [
effective cardiac EAP includes the following:
1. Personnel training: All potential first responders,
including team medical staff (athletic trainers,
physiotherapists, and physicians), coaches, and appropriate school
or venue staff, should be trained in cardiopulmonary
resuscitation (CPR) and the use of an AED. An emphasis
on the prompt and accurate recognition of SCA is an
essential part of this training. SCA should be assumed
in any collapsed and unresponsive athlete and the EAP
2. Site or venue specificity: Each EAP should be carefully
designed for the specific site or venue at which it will
be executed. It should clearly depict the location of the
nearest AED, provide a facility map, and list emergency
contact phone numbers and relevant street address.
Directions to guide emergency medical service providers to
the location of SCA and previously defined venue entry
and exit points are recommended, especially in the case
of large stadiums, parks, or complexes.
3. Means of efficient communication: Reliable methods of
communication between on-site personnel and
emergency medical services should be established and tested
prior to competition. The reliability of cellular phone
service, especially at events with high spectator attendance,
4. Immediate AED access: Access to an AED must be
prompt, direct, and reliable. AEDs should be
strategically placed to allow retrieval, application, and shock
deployment within 3 min of collapse [
should be given to potential physical barriers to AED
retrieval, such as doors or gates. AEDs can be used by
any bystander, and public access to AEDs has clearly
improved survival from SCA [
]. Proper signage
should indicate to responders the location of an AED and
the devices should never be locked away or
inaccessible, especially during training and competitions. AEDs
should be maintained according to manufacturer
recommendations. Prior to each scheduled event, a ‘readiness’
check is also recommended to confirm the presence of
the AED in the designated location and to inspect the
indicator light to ensure proper functioning.
5. Regular review and rehearsal: All personnel potentially
involved in the care of an athlete with SCA should
review and rehearse the EAP at least once per year. Roles
for each rescuer should be clearly defined, and a mock
SCA scenario is recommended to practice a coordinated
response. Prior to each competition, brief review of the
EAP by home and visiting medical staffs is also
recommended. Adjustment of the EAP may be necessary when
personnel or community resources change.
6. Advanced cardiac care facility: The nearest advanced
cardiac care facility should be integrated within the
EAP and defined as the preferred receiving hospital for
a transferred athlete. This facility should have critical
care and advanced life support capabilities and, if
possible, proficiency in induced hypothermia, which may
improve outcomes after cases of resuscitated SCA [
The pending transfer of an athlete following SCA should
be communicated with the receiving cardiac care facility
as soon as possible.
7. Reset, debriefing, and reporting: If play is to continue
following transfer of an athlete, a reset of the EAP and
repositioning of related personnel is necessary prior
to resuming competition. This reset may include the
restoration of equipment to its original location and
the replacement or reassignment of personnel roles and
necessary emergency medical services. AED electrodes
should be replaced, and batteries and operational
status retested. A debriefing session should occur for all
rescuers involved in an athlete’s resuscitation to review
and document the medical response. Counselling and
psychological support should be provided to rescuers
CPR cardiopulmonary resuscitation, EAP emergency action plan, SCA sudden cardiac arrest, EMS emergency medical services, AED automated
and teammates as needed. Reporting of the event to
appropriate authorities can assist research efforts and may
improve future responses and the treatment of SCA.
Value, role, and placement of automated external defibrillators
Historical survival rates to hospital discharge following
outof-hospital cardiac arrest in the general population have
been poor, as low as 7.6% [
]. The time from collapse
to defibrillation following the onset of SCA is the single
most important determinant of survival [
]. Modern public
access AED programmes have yielded higher survival rates
of 19.7 to 44% [
]. A meta-analysis reported a median
survival rate of 40% with public access to AEDs [
Access to early defibrillation also improves survival in
young athletes with SCA. In a 2-year prospective
observational study of 2,149 high school campuses, student-athletes
with SCA survived 89 % of the time if prompt CPR and
defibrillation were provided [
]. Survival was also higher if
an on-site AED was used versus supplied by responding
emergency medical services [
AEDs should be strategically located to allow a
collapse-to-shock time of under 3 min. Epidemiological data
can also be considered to prioritise specific locations.
Studies demonstrate that the incidence of SCA in United States
athletes is higher in certain subgroups, specifically male
athletes, African/Afro-Caribbean athletes and American
football, basketball, and soccer players [
]. In schools and
community complexes, the gymnasium is the most likely
site for SCA and offers a central location for AED
placement that services a number of sporting activities and large
public gatherings [
]. The size of the venue and
number of anticipated event spectators may also influence AED
placement, as on-site medical personnel may be best
positioned to assist a collapsed spectator prior to emergency
medical services arrival. Guidelines are available regarding
the number and location of AEDs in large sporting venues
and arenas [
For large mass-participation events such as marathons
and triathlons, emergency care is ideally provided along
the full length of the course. However, SCA during
longdistance runs occurs more frequently in the late stages of the
]. These data should be considered when making
resource allocation decisions, such as the pre-race
distribution of AEDs, placement of roaming or bicycle emergency
medical service responders, and organisation of finish line
‘catchers’ and medical volunteers.
Recognising sudden cardiac arrest
Exercise can increase the risk of SCA in athletes with
underlying structural or electrical cardiac disorders [
athlete who collapses without obvious head trauma and is
unresponsive on the field of play should be assumed to be
in SCA until proven otherwise. Blunt trauma to the chest
causing collapse, usually from a firm projectile, is
consistent with commotio cordis and should also be treated as
In over 50% of cases, athletes with SCA demonstrate
brief myoclonic or seizure-like activity following collapse
]. Thus, SCA should not be mistaken for an epileptic
seizure, which may delay the initiation of CPR, retrieval of
an AED, or even discourage these critical steps altogether.
Athletes with SCA may also display abdominal movements
or gasps that can be mistaken for normal breathing. In this
scenario, rescuers may misinterpret these agonal
respirations and delay the recognition and treatment of SCA. To
avoid life-threatening delays in resuscitation, brief
seizurelike activity and/or agonal respirations should be assumed
due to SCA in a collapsed and unresponsive athlete, and
initial management steps for SCA should be taken
immediately, unless a non-cardiac cause of collapse is clearly
determined. Furthermore, the myth of a need to prevent ‘tongue
swallowing’ after collapse has been shown to delay
bystander chest compressions  and should be discouraged
as an unnecessary procedure during resuscitation.
Management of sudden cardiac arrest
Management of SCA on the field of play starts with making
a prompt diagnosis. Once SCA is suspected or confirmed,
the EAP should be initiated expeditiously. If multiple
rescuers are available, one rescuer should begin CPR while
another rescuer contacts emergency medical services and
a third retrieves the closest AED if one is not already on
the field of play. If there is only one rescuer, emergency
medical services should be activated and then an AED
obtained if readily available, with the rescuer returning to the
victim to apply the AED and begin CPR.
CPR should commence at the site of athlete arrest,
beginning with chest compressions in the case of a witnessed
collapse. Moving the athlete to a different location may
delay the resuscitation and could lead to worse outcomes
]. Medical personnel should be prepared to quickly
remove protective padding, clothing, or other equipment that
may impede the initiation of CPR; this may require
specialised tools or equipment. Chest compressions should be
at least five to six centimetres or two inches in depth, allow
complete chest recoil, and occur at a rate of 100–120 per
]. CPR should continue uninterrupted until an
AED is applied and begins to analyse the athlete’s cardiac
Rescuers should exercise considerable caution in
excluding SCA in a collapsed and unresponsive athlete. Since the
vast majority of these athletes are in ventricular
fibrillation, an AED should be applied and turned on for rhythm
analysis as soon as possible. AEDs are extremely accurate
in recommending a shock when ventricular fibrillation or
rapid ventricular tachycardia is present. If defibrillation is
provided, chest compressions should resume immediately
after shock delivery. If a shock is not advised, CPR should
be continued until advanced life support providers take over
or the victim starts to move. High-quality CPR should
continue until return of spontaneous circulation is achieved or
death is declared at a receiving facility [
SCA in athletes is a life-threatening event that can
precipitate confusion during sporting events. Development and
rehearsal of a site-specific EAP is essential to ensure an
efficient response and the best chance of survival. With
prompt and accurate recognition of SCA, provision of high
quality CPR, and access to early defibrillation via
strategically placed AEDs, SCA in an exercising athlete is largely
a survivable event.
Conflict of interest D.M. Siebert and J.A. Drezner declare that they
have no competing interests.
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