CE Article: Emergency Care in Athletics, Part 2

Editor's Note: This article is no longer applicable for CE credit.

Objectives

At the conclusion of this activity, participants will:

• Understand common causes of sudden cardiac arrest in athletes;
• Be able to describe several best practices related to care of the spine-injured athlete;
• Understand best-practice treatment of exertional heatstroke;
• Recognize symptoms of exertional sickling; 
• Be able to explain how multiple-patient care might differ with lightning strike vs. other types of MCI. 

EMS providers routinely provide both standby coverage and emergency response to athletic events. Either way and in either role, it’s important for the EMS provider to embrace their membership on the sports medicine team. The first part of this series looked at what the sports medicine team is, along with how EMS can better integrate into it. This part discusses common emergency conditions that occur among athletes and have been identified as causes of sudden death. Having a greater understanding of these conditions can help the EMS provider better anticipate patient care needs. 

Cardiac Emergencies

When young athletes sustain a sudden cardiac arrest (SCA), it is always headline news. Younger people aren’t supposed to have that happen! The reality is that sudden cardiac death is the leading cause of death among young athletes.¹ Studies estimate that sudden cardiac deaths occur to one in every 50,000–80,000 athletes per year, with a higher incidence among males, Blacks, and men’s basketball players.¹ 

Hypertrophic cardiomyopathy, a condition where the left ventricular walls become enlarged without a corresponding increase in chamber size, has long been the top-reported cause of this in athletes.¹ Various other congenital cardiac anomalies have also been implicated, but the common theme of a sudden arrest remains the same. While some athletes may have cardiac-related symptoms (palpitations, chest discomfort, shortness of breath, dizziness, etc.) ahead of time, many times a young, otherwise-healthy athlete will just suddenly arrest. 

Two atypical presentations of SCA among athletes reported in the literature include the sentinel seizure and commotio cordis.² Sentinel seizures occur when an individual experiences a fatal arrhythmia, the brain loses oxygen supply, and thus seizure activity occurs. The true problem is SCA, but the seizure is often seen as the first symptom. Assume the possibility of SCA when an otherwise-healthy young athlete collapses and exhibits seizure activity.

Commotio cordis, also known as cardiac concussion, occurs when a person receives a blow to the chest during a vulnerable window during diastole of the heart. This concussive force, occurring during the upstroke of the T-wave, triggers ventricular fibrillation SCA. Commotio cordis can occur in both contact and noncontact sports and should be suspected anytime an athlete experiences blunt trauma to the chest followed by sudden collapse.² 

Certainly early defibrillation and early CPR are the hallmarks to improving survivability in any cardiac arrest, and SCA in athletes is no different. It’s important that every member of the sports medicine team respond as if any sudden collapse of an athlete might be SCA. 

Head/Spinal Injury

Traumatic brain injury and spinal cord injury are discussed together as in many cases: If one is present, the other must be suspected. In collision sports the risk of these types of trauma is presumed to be greater. It’s important that members of the sports medicine team realize the possibility of these types of injury in any sport. A cheerleader with neurological deficits after falling from the top of a pyramid formation may well be what you find upon response to the local school gymnasium.

In terms of traumatic brain injury, concussions receive the most publicity. It is estimated that 1.6–3.8 million traumatic brain injuries occur yearly in sports, maybe more due to underreporting of concussion symptoms.³ A form of mild TBI, a concussion can occur from either a direct or indirect blow to the head but results in no structural damage to the brain. Concussion symptoms vary but range from mild headache to loss of consciousness. 

While the topic of concussion goes much deeper than what is discussed here, the biggest take-home point is that no athlete experiencing any symptom of concussion should be allowed to return to play until they have received medical clearance. Returning an athlete to play prior to a concussion being resolved can have catastrophic consequences should they experience a second concussion.⁴

Spinal injury is also a frequently discussed topic in sports medicine circles. When an athlete sustains this type of injury, the entire sports medicine team must function cohesively to ensure the best outcome. In 2020 the Spine Injury in Sport Group, composed of experts from a variety of healthcare specialties, released consensus recommendations regarding care of the suspected spine-injured athlete.⁵ Key points included:^5,6

• Transport of suspected spinal injury to a Level 1 or 2 trauma center;
• Airway access should always be established prior to transport. In American football helmet face masks should be removed to facilitate this;
• If the decision is made to remove all equipment, helmet and shoulder pads must both be removed to facilitate the best cervical spine alignment;
• Reasons to consider full equipment removal prior to transport include:
  • Facilitating better airway management;
  • Prioritizing chest access such as in the need for CPR;
  • In some cases, if enough trained personnel are present, it may make more sense to remove equipment prior to transport than relying on ED staff to do so;
  • Expedited care once at the ED;
  • Equipment technology advances that make it easier to facilitate removal in the field;
• The eight-person lift-and-slide technique has been found to produce less cervical spine motion when transferring a supine athlete to a spine board, while the log roll-push is the preferred technique for prone athletes;
• Ideally two trained rescuers should be involved with face mask removal, while 2–4 should be involved in shoulder pad removal, depending on the technique. 

Heat Illness

Heat illness is actually a broad term to describe a variety of different conditions, including heat rash, heat cramps, heat syncope, heat exhaustion, and heatstroke. Remember that symptoms of heat illness don’t necessarily progress along a continuum. It’s possible that upon initial contact a patient will already be experiencing exertional heatstroke, a true life-threatening condition. Given its severity, heatstroke is the only type of heat illness we’ll focus on here. 

Heatstroke is identified clinically by a core body temperature greater than 105ºF, along with neurological system changes.^7,8 When an athlete experiences heatstroke, the “cool first, transport second” approach gives them the best chance for a positive outcome. While this mind-set goes against much of what we’ve been taught in EMS, exertional heatstroke has a 100% survival rate when immediate and appropriate cooling is initiated.^7,8

A rectal temperature, considered the only valid measure of core temperature in cases of exertional heat illness, should be obtained as part of the patient assessment, and then immediate cold-water immersion instituted. The goal with cooling therapy is to reduce core temperature to 102ºF or below within 30 minutes. Cold-water immersion cools most rapidly; when unable to utilize it, alternative options include ice-water towels rotated every few minutes, cold-water dousing with ice massage, or a cold shower with ice.⁸ 

One other alternative for cooling that may be more easily deployed by EMS is tarp-assisted cooling with oscillation (TACO). The TACO method involves placing the patient inside a tarp held up by rescuers at the corners while it is filled with ice water, similar to cold-water immersion. Obviously the patient’s head and face are left exposed to protect the airway. The tarp is then gently moved around, or oscillated, to keep cold water moving against the patient’s body. Studies have found the cooling rate with this method comparable to cold-water immersion.^9,10 

One method of cooling that does not cool fast enough is ice packs at the armpits, groin, and neck. These can take as much as 70 minutes to bring the patient’s body temperature down to an appropriate range.⁸ The NATA position statement on exertional heat illness recommends to stop cooling once the core temperature reaches 102ºF or below or if there’s no ability to monitor rectal temperature after 10–15 minutes.⁷ The patient should then be transported to the ED.

Exertional Sickling

When an athlete carries the sickle cell trait, strenuous exercise can lead to exertional sickling. The U.S. military identified that recruits with sickle cell trait were 30 times more likely to die during basic training than those without it.¹¹ With intense exercise the misshapen sickle cells accumulate in the blood, blood flow is reduced, hypoxemia occurs, and tissue breakdown follows, resulting in fulminant rhabdomyolysis. A state of dehydration, which certainly can exist with athletes, worsens this phenomenon. Presenting signs and symptoms will typically be:^11,12

• Severe cramping or muscle weakness (however, muscles look and feel normal, unlike heat cramps); 
• Slumping to the ground as opposed to the sudden collapse seen in SCA;
• Patients will still have the ability to speak;
• Rapid respirations, but further exam reveals normal air movement, ruling out asthma;
• Rectal temperature less than 103ºF, which rules out heatstroke.

Treatment should focus on stopping the athletic activity; cooling the athlete as needed; standard patient assessment; initiation of high-flow oxygen; anticipation of rhabdomyolysis, which would warrant IV fluids; and notification of the receiving ED regarding potential for exertional sickling and pending rhabdomyolysis.¹² 

Asthma and Anaphylaxis

Two other potential triggers to an EMS response include asthma and anaphylaxis—the sports environment may serve as a catalyst for either. Exertion may trigger bronchospasm in asthma, and potential allergy triggers such as bees, pollen, latex, etc. may all be encountered by the athlete practicing or competing. There have even been cases reported of exercise-induced anaphylaxis, although this is a far less common cause. 

Since there is some overlap between the symptoms of asthma and anaphylaxis, it’s important responding EMS providers obtain a thorough history from the patient, coaches, parents, and/or teammates to help differentiate which condition they face. 

Lightning Strikes

Lightning safety at and around sporting events should always be a priority, as lightning continues to be among the top causes of storm-related fatalities. Following a lightning strike, victims may suffer from any of the following:^13,14

• Loss of consciousness
• Disorientation/confusion/amnesia
• Eye or visual issues
• Paralysis of extremities
• Blunt trauma such as fractures or head injury
• Visible burn pattern, which may not appear until later
• Cardiac arrest

In caring for victims of a lightning strike, it’s important to ensure your own safety and move victims to a safe location to treat if possible. Victims of lightning strike do not hold an electrical charge and are safe to touch. Be prepared to treat their traumatic injuries, burns, and symptoms of shock. Victims in cardiac arrest should receive prompt CPR and defibrillation. 

When responding to a lightning strike at a sporting venue, assume multiple patients and alert backup crews early. Normal MCI protocols direct us to withhold treatment from those already appearing deceased in order to give the most people the best chance of survival. Best practices in lightning strikes reverse this standard approach, as early CPR and defibrillation may save the lives of those already appearing deceased, and delaying care to others is unlikely to negatively impact their outcome.^13,14

Conclusion

Athletics are a major part of many people’s lives and ingrained within many communities. While athletics provide many positive benefits, the reality is that injuries and illnesses can and do occur with sports participation. This series has hopefully helped provide insight into the makeup of the sports medicine team, ways in which EMS providers can integrate into it, and some of the emergent conditions that might lead to EMS being needed at a sporting venue. The importance of frequent skills practice among the entire sports medicine team can’t be stressed enough. 

References

1. Peterson D, et al. Aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the USA: a 4-year prospective study. Brit J Sport Med, 2020 Nov 12 [epub online]. 

2. Terry G, et al. Sudden cardiac arrest in athletic medicine. J Athl Training, 2001; 36(2): 205–9.

3. University of Connecticut, Korey Stringer Institute. Traumatic brain injury, https://ksi.uconn.edu/emergency-conditions/traumatic-brain-injury/#.

4. Broglio S, et al. National Athletic Trainers’ Association position statement: Management of sport concussion. J Athl Training, 2014; 49(2): 245–65.

5. Mills B, et al. Consensus recommendations on the prehospital care of the injured athlete with a suspected catastrophic cervical spine injury. J Athl Training, 2020; 55(6): 563–72.

6. Courson R, et al. Best practices and current care concepts in prehospital care of the spine-injured athlete in American tackle football. J Athl Training, 2020; 55(6): 545–62.

7. Casa D, et al. National Athletic Trainers’ Association position statement: Heat illnesses. J Athl Training, 2015; 50(9): 986–1,000.

8. Raukar N, Casa DJ, Katch RK, Lemieux RA. Identification and treatment of exertional heatstroke in the prehospital setting. J Emerg Med Serv, 2017 May 9; www.jems.com/patient-care/identification-and-treatment-of-exertional-heat-stroke-in-the-prehospital-setting/. 

9. Luhring K, et al. Cooling effectiveness of a modified cold-water immersion method after exercise-induced hyperthermia. J Athl Training, 2016; 51(11): 946–51.

10. Belval L, Casa DJ, Adams WM, et al. Consensus Statement—Prehospital Care of Exertional Heat Stroke. Prehosp Emerg Care, 2018 May–Jun; 22(3): 392–7. 

11. National Athletic Trainers’ Association consensus statement: Sickle cell trait and the athlete, www.nata.org/sites/default/files/. 

12. University of Connecticut, Korey Stringer Institute. Exertional Sickling, https://ksi.uconn.edu/emergency-conditions/ exertional-sickling/.

13. University of Connecticut, Korey Stringer Institute. Lightning, https://ksi.uconn.edu/emergency-conditions/lightning/.

14. Walsh K, et al. National Athletic Trainers’ Association position statement: Lightning safety for athletics and recreation. J Athl Train, 2013; 48(2): 258–70.

Sidebar: Common Signs and Symptoms of Concussion  

• Headache
• Dizziness
• Trouble concentrating
• Sensitivity to light or sound
• Visual disturbances
• Ringing in the ears (tinnitus)
• Disorientation
• Confusion
• Inability to follow simple directions
• Memory loss
• Balance issues
• Vacant stare
• Unusual or atypical behavior

Brian Potter, MS, ATC, NREMT, completed a BS in athletic training at West Virginia Wesleyan College and an MS in health and physical education at Marshall University.