Sudden Cardiac Arrest
According to F-MARC (The FIFA Medical Assessment and Research Center), "any player that suddenly collapses without contact with another player or object and lies unconscious on the pitch should be presumed to be having a cardiac arrest until proven otherwise".
"Such a player should have cardiopulmonary resuscitation (CPR) started immediately. Ideally, an automatic external defibrillator (AED) should be made available at the sideline for instantaneous use." (Football Emergency Medicine Manual, FIFA, pg. 51)
The FIFA Football Emergency Medicine Manual requires that a defibrillator (automatic or manual) be on site for all FIFA matches, "preferably located at least at the side of the field near the fourth referee and at the designated medical station if more than one is present." (Football Emergency Medicine Manual, FIFA, pg. 30)
The Exception To The Rule
"The Laws of the Game state that medical personnel can only enter the field at the invitation of the referee. However, the exception to the rule is if there is a serious (life-threatening) injury. ... A player who suddenly collapses in a non-contact situation may very often happen to be out of the sight of the referee and there may consequently be a delay in the referee becoming aware of this emergency situation."
"It would therefore appear acceptable under those very rare and exceptional circumstances of a non-contact collapse for the team physician to run onto the field even before the referee instructs him to do so to get to the player as swiftly as possible to start resuscitation and defibrillation in a bid to save the player's life."(Football Emergency Medicine Manual, FIFA, pg. 56)
What To Do…
The management of Sudden Cardiac Arrest (SCA) within the stadium (including fans) can be divided into four phases (D.A.R.T.):
◊ Diagnosis: Based on 3 criteria:
►unconsciousness- a lack of response to any type of stimulus;
►abnormal or absent breathing - a patient without a pulse may have abnormal breathing for one or two minutes before breathing becomes absent; and
►failure to detect a carotid pulse in ten seconds (the right and left common carotid arteries is located on either side of the front of the neck just below the angle of the jaw and next to the larynx or voice box).
◊ Assess Likely Cause: In the absence of a crush-type injury (i.e. someone - or something - falling hard on the chest of someone else), it can be assumed that the cause is ischemic (a restriction of the blood supply to the brain). The most common cause is a sudden event called ventricular fibrillation, a type of arrythmia where the lower chambers of the heart twitch rapidly and irregularly, decreasing the heart's blood pumping ability and therefore the blood supply to the body and the brain. Ventricular fibrillation may respond to the "shock" from an AED or manual defibrillator, which helps to reestablish the heart's normal rhythm.
Some of the other possible causes of SCA are ventricular asystole (an absence of electrical activity where the ventricles do not contract) and pulseless electrical activity or PEA (where the electrical activity of the heart is present but it does not produce a mechanical contraction of the heart - no pulse).* (Football Emergency Medicine Manual, FIFA, pgs. 37-38)
In these two cases, standard CPR (described below) and emergency cardiac medications are the recommended treatments of choice. An AED will, however, still help to identify the type of heart rhythm present and if a "shock" by the machine is appropriate.
* PEA does not include ventricular fibrillation or ventricular tachycardia (a very fast heartbeat, usually over 100 beats per minute). Although, like PEA, these conditions may cause the loss of a palpable pulse, they are treated differently from PEA (that is, they may respond to the "shock" of an AED).
► Call for immediate emergency medical service back-up. It is vital to have the telephone numbers for all emergency contacts on hand (even if some emergency personnel are on site)
► Begin Cardiopulmonary Resuscitation (CPR) by either performing:
1. Standard CPR (30:2): 30 chest compressions : 2 rescue breaths (start with compressions, which should be about 5 cm deep and at a pace of 100 compressions per minute) or
2. Compressions-only CPR at a pace of 100 per minute (which is becoming the treatment of choice when performed by non-medical personnel)
► Obtain a defibrillator (AED) as soon as possible [Figure 1].
1. If an AED is available within the first 5 minutes after an SCA, the AED should be used immediately, interrupting chest compressions.
2. If the AED is available 5 minutes or more after an SCA, perform the initial 2 minutes of chest compressions before using the AED.* (Football Emergency Medicine Manual, FIFA, pgs. 38-41)
* This assumes that chest compressions were not started immediately and continued consistently after the SCA. If they were, the AED should be used immediately once available.
Figure 1 Steps for the use of an average AED 1. Diagnose cardiac arrest. 2. Open AED carrying case. 3. Connect the AED cable to the machine, if not already attached. 4. Attach the patient electrode pads onto the patient's bare chest by removing all clothing covering the chest, according to the positions illustrated on the pads (wipe off any moisture, water or perspiration if necessary [before applying the electrodes]). 5. Switch on the AED if it is not already on. 6. Allow the AED to analyze the patient's cardiac rhythm, following the voice prompts exactly. 7. If prompted by the AED voice prompt, deliver the required shock by pressing the flashing red button. 8. If a shock is not required, or after any delivered shock, immediately commence chest compressions. 9. Re-analyze the cardiac rhythm after every two minutes of cardiac resuscitation, if signs of life have not occurred in the interim. (Football Emergency Medicine Manual, FIFA, pg. 40)
Steps for the use of an average AED
1. Diagnose cardiac arrest.
2. Open AED carrying case.
3. Connect the AED cable to the machine, if not already attached.
4. Attach the patient electrode pads onto the patient's bare chest by removing all clothing covering the chest, according to the positions illustrated on the pads (wipe off any moisture, water or perspiration if necessary [before applying the electrodes]).
5. Switch on the AED if it is not already on.
6. Allow the AED to analyze the patient's cardiac rhythm, following the voice prompts exactly.
7. If prompted by the AED voice prompt, deliver the required shock by pressing the flashing red button.
8. If a shock is not required, or after any delivered shock, immediately commence chest compressions.
9. Re-analyze the cardiac rhythm after every two minutes of cardiac resuscitation, if signs of life have not occurred in the interim.
(Football Emergency Medicine Manual, FIFA, pg. 40)
◊ Transport: once the emergency medical service has arrived, a decision must be made regarding transportation to the nearest medical facility.
► "Adequate chest compressions and manual rescue breathing is very difficult to perform in a moving ambulance and it is therefore more appropriate to undertake the initial resuscitation with the assistance of a defibrillator on location in the stadium for the first ten minutes, and only then to consider transporation to a hospital if no signs of life have occurred." (Football Emergency Medicine Manual, FIFA, pg. 40)
► "If the cardiac arrest is considered to be ischemic in origin and a defibrillator has not been available in the first place, it is mandatory to either immediately bring a defibrillator to the patient or take the patient to a defibrillator" - whichever is safer, more appropriate, and more practical. (Football Emergency Medicine Manual, FIFA, pgs. 40)
○ If it is decided that it is best to transport the patient to a defibrillator, "then compression-only cardiac resuscitation will probably be the most practical technique in a moving ambulance." (Football Emergency Medicine Manual, FIFA, pgs. 40-41)
Preventing Sudden Cardiac Arrest
The best method—have a proper medical evaluation before the season begins.
Ideally, all players aged 16 or 17 should have a thorough cardiovascular screening by a cardiologist." (Football Emergency Medicine Manual, FIFA, pg. 55)
This involves performing:
1. A proper personal and family medical history
2. Appropriate blood tests to assess heart health risks
3. A proper evaluation of the player (physical inspection of the player, blood pressure, listening to the heart and lungs, assessing circulation, etc...)
4. An Electrocardiogram (which tests the electrical activity of the heart)
5. An Echocardiogram (to assess the movement and look of the heart and its valves).
6. Follow-up special diagnostic testing may be required.
What To Look Out For
According to F-MARC, "when SCA occurs in previously apparently healthy individuals, there are usually no symptoms of note.[It occurs without warning.] The possible warning symptoms (if they do occur) are... [heart] palpitations, dizziness...[chest pain, difficulty breathing, and faintness]. Some of these symptoms may occur as a one-off and will most often be ignored." (Football Emergency Medicine Manual, FIFA, pg. 55)
Most Common Causes of SCA*
► people under the age of 35, SCA occurs, most commonly, because of an underlying cardiac abnormality. One of the main causes is a condition called hypertrophic cardiomyopathy, where the muscle of the heart wall or walls becomes abnormally thickened (making it harder to pump the blood) and the muscle cells become disorganized, which is thought to create an electrically unstable environment. Another common cause is arrythmogenic right ventricular dysplasia (ARVD), a genetic disorder - usually affecting the lower right chamber of the heart called the right ventricle - where the heart muscle cells die prematurely and become replaced by fat and scar tissue, weakening the heart and interfering with its normal electrical activity. In this age group, there are various types of heart conditions that may be conducive to the occurrence of SCA.
► in people over the age of 35, the primary cause of SCA is coronary artery disease, where the arteries that supply blood to the heart tissues become hardened, narrowed, and then blocked. Coronary artery disease can also lead to a "heart attack," or myocardial infarction, where the blockage of blood and oxygen to the heart causes the heart muscle to become damaged and eventually die (an infarct). SCA can result from a "heart attack".*
∆ See http://www.fifa.com/aboutfifa/footballdevelopment/medical/playershealth/risks/heart.html for more information.
* Some signs and symptoms of a "heart attack" are the same as those specified for SCA (if initial signs and symptoms are present in SCA at all). Additional indicators of a "heart attack" include things like nausea, tightness in the chest, heavy sweating, disorientation, intense and prolonged chest pain, pain in the left shoulder, arm, jaw, and back…all before loss of consciousness occurs, itself a sign common to SCA.
Survival: It Can Be A Matter Of Time
Some sources tell us that a player's chance of survival decreases by 10% for every minute it takes to apply an AED. *F-MARC indicates "defibrillation administered in less than two to three minutes can provide survival outcomes of about 50%; however, rates fall sharply with each minute thereafter." (Football Emergency Medicine Manual, FIFA, pg. 51) "By four to five minutes, survival is 25% or less, and less than 10% after ten minutes." (Football Emergency Medicine Manual, FIFA, pg. 56)
* The best thing that we can do is simply to be prepared: have players evaluated, learn CPR, know how to use an AED, have emergency personnel and/or information immediately available, and be familiar with the signs and symptoms.
"I Have No Heart Problems: Am I At Risk?"
Although the risk of SCA is higher in players with structural heart disease, SCA is possible in individuals with apparently normal hearts. In a condition called commotio cordis ("a disturbance or concussion of the heart"), a non-penetrating blow to the chest wall directly over the heart initiates an altered heart rhythm and SCA. It is believed to happen when the blow comes within 10 to 30 milliseconds before a T-wave peak* (as identified on an electrocardiogram). This window for injury is only 1-3% of the time of a normal heart rhythm. Though very rare, it is most common in children and adolescents (mean age 13) since these groups tend to have a more compliant/flexible chest wall that appears to facilitate the transmission of the energy from the chest blow to the heart muscle. Picture the head butt from Zinedine Zidane (France) onto the chest of Marco Materazzi (Italy) in the 2006 FIFA World Cup to get a better idea of a risky blow to the chest.ª
* The T-wave is a segment of the normal heart rhythm that can be altered by diverse conditions in the body that affect the heart; it signals the time where the electrical cells that triggered the contraction of the ventricles (the lower chambers of the heart) are repolarizing or "recovering".
ª No such injury happened with this event, but the rare blow with the right amount of force to a player's chest at the wrong time could.
Football Is Good For Your Heart
Don't let all of this information scare you. The occurrence of Sudden Cardiac Arrest in football is extremely rare* and exercises like football actually improve the condition of your heart over time. The "healthy" heart is a muscle that can be trained just like the muscles of your limbs. In fact, football can improve your whole cardiovascular system by improving your heart's efficiency, decreasing resistance to your heart's pumping of the blood (decreasing blood pressure), and a whole lot more!
*In all sports, the incidence of SCA is "said to occur in 0.5/100,000 high-school and college athletes to 3.6/100,000 professional athletes per year ".(Football Emergency Medicine Manual, FIFA, pg. 54)
For more information on Sudden Cardiac Arrest, please go to FIFA's Medical Extranet site at https://extranet.fifa.com/medical/, sign up, and then go to the Publications section to find the F-MARC Football Medicine Manual, 2nd Edition and the Football Emergency Medicine Manual.
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