Thursday, February 1, 2001

Planning for Scholastic Cardiac Emergencies: The Ripley Project

James M. Kyle, M.D., F.A.C.S.M.
Chief of Rural Emergency Medicine, Marshall University School of Medicine, Huntington; Director, Emergency Department, Jackson General Hospital, Ripley; Team Physician and Athletic Primary/Emergency Care Physician at Olympic Stadium for the 1996 Centennial Olympic Games in Atlanta, GA.

Joseph Leaman, A.T.C.
Program Director of Sports Medicine, Health South, Parkersburg; Athletic Trainer for the Track and Field Venue for the 1996 Centennial Olympic Games in Atlanta, GA.

Gregory A. Elkins, M.D.
Medical Director, Lincoln Primary Care Center, Handin; Clinical Assistant Professor, Department of Family and Community Health, Marshall University School of Medicine, Huntington.

Fatalities during sports participation are usually cardiac in origin. Sudden Cardiac Arrest (SCA) from ventricular fibrillation has been reported in several sporting venues over the last decade. Successful treatment of stadium SCA requires a rapid response team equipped with defibrillator capabilities. The use of automated external defibrillators (AED) by responders in sports arenas is critical to help prevent catastrophic scholastic athlete and spectator cases of unexpected sudden cardiac death.

High school athlete medical coverage has received increasing emphasis over the past decade. Mandatory pre-season physical examinations have been standardized and expanded to detect athletes at risk for emergency medical conditions (1).

Many school systems now employ full-time certified athletic trainers for year-round sporting event coverage. In West Virginia, the State Board of Education requires all high schools participating in interscholastic football to have an athletic trainer present at all practices and games.

For the last 10 years, the Sports Medicine Committee of the West Virginia Chapter of the American Academy of Family Physicians (WVAAFP) and the West Virginia Secondary Schools Activity Commission (SSAC – the state governing body of scholastic sporting events) has monitored event coverage utilizing a report card system. Prior to kickoff, documentation of "on the field" athletic trainer, ambulance, and team physician attendance is recorded for future analysis.

The coach’s role in injury prevention and emergency response has also been expanded in scope. The National Federation of High School Sporting Associations routinely conducts workshops and seminars to enhance the health care of the student athlete. This includes safe wrestler weight loss, preventative programs for anabolic steroid abuse, and catastrophic health and neck injury prevention.

In West Virginia, the SSAC conducts mandatory pre-season programs on injury management provided by the Sports Medicine Committee on the WVAAFP and representatives of the West Virginia Athletic Trainers Association (WVATA). Coaches are encouraged to maintain a current CPR certification. The American Heart Association (AHA) recommends the Heart Saver classification of certification for all individuals responsible for adolescent emergency care. To maximize outcomes, automated external defibrillators (AED) training was incorporated by the AHA in the fall of 1998.

Sudden Cardiac Arrest
Sudden cardiac arrest (SCA) has an estimated annual incidence of 0.7 to one per 1000 population (2,3). High school athlete sudden death is rare; however, sudden cardiac arrest in adult spectators has been reported (4,5). In fact, one of these unfortunate incidents occurred at a major college basketball game when the author of this article was in attendance.

Professional and collegiate sporting venues typically employ emergency medical response teams for spectator care coverage. High school event coverage is less organized and typically falls under the responsibility of the athletic director or school administrators.

The entry of automated external defibrillators into the sporting arenas has become attractive as the result of numerous studies documenting increased survival rates with police and first responder programs (6,7). In addition, the AHA has endorsed the newly introduced, sophisticated, safe and relatively inexpensive AEDs for targeted responder groups. At the 1998 National Athletic Trainer Association (NATA) meeting in Baltimore, MD, most NFL trainers reported utilizing AEDs.

On the collegiate level, officials from the Southeastern Conference documented eight of 12 member schools with plans to provide AED coverage at practice and games in the upcoming school year. The University of Georgia initiated a program in 1997 which has become a model for other member schools. This program is designed for time to shock under five minutes from deployment, from one of the three training rooms equipped with Lifepak 500 AEDs.

Several high school trainers attended the AED workshop at the Baltimore convention. Many expressed a keen interest for incorporating AEDs into their existing emergency event coverage; however, no existing high school AED programs were reported.

The Ripley Project
High school sporting events traditionally enjoy a high priority in rural communities. In many locations, the high school campus becomes a focal point for public gatherings and a potential site for cardiac emergencies (8).

In Jackson County, WV, the Board of Education operates two high schools with an average enrollment of 1,200 students. During the summer of 1997, the Board approved the purchase of two Lifepak 500 AEDs for deployment at high school sporting events. This action was prompted by encouragement from Emergency Department personnel at Jackson General Hospital, located in Ripley, in response to a case of SCA in a 16-year-old high school baseball player in an adjacent county. This student had died when he was struck in the chest by a baseball from 90 feet as he attempted to slide into third base. Commotio Cordis (cardiac concussion) was the expected cause of death.

Prior to the start of fall football practice, school administrators invited each appointed high school football trainer and coaching staff to attend a CPR re-certification and AED workshop. This five-hour course was conducted by the staff form Jackson General Hospital, local Emergency Medical Services personnel, and the regional EMT coordinator. It was attended by the hospital’s AHA coordinator and nurses from the Emergency Department, as well as 26 school personnel, including various head coaches and principals.

The course was actually modeled from a casino responder program which was initiated in select Las Vegas properties during early 1997. Components of initial education included emphasis on signs and symptoms of pending cardiac arrest and video CPR instructions. All students were tested in one person CPR by AHA instructors prior to AED in-service and subsequent testing. Continuing education at three-month intervals was facilitated by impromptu drills during scheduled team practice and Faculty Senate Day teacher workshops combined with a quarterly newsletter with an educational focus.

The Ripley pilot project received endorsement from the State Board of Education and prior to initiation of the project, the West Virginia Legislature approved a grant providing funding for the placement of three additional AEDs to first responder fire departments units in strategic county locations. Members from the educational team for the coaching in-service also provided education for local fire departments.

Reports indicated that Jackson County was among the first school systems in the United States implementing early defibrillation programs (9,10).

Most cases of indirect fatalities during sports play are cardiac in origin (11). In addition to structural and congenital causes precipitating SCA, the syndrome of cardiac concussion has received recent attention (12,13,14,15). A laboratory model of commotio cordis reported by the Cardiac Arrhythmia Services at Tufts New England Medical Center has defined late repolarization induced ventricular fibrillation as "the insult in Little League baseball" (16).

Although the incidence of SCA in the athletic arena is low, the impact on the community is devastating when a young, vibrant, apparently healthy athlete succumbs to sudden death during sports play. The recent availability of automated external defibrillators has provided a mechanism to prevent such loss.

The decision to investigate the feasibility of early defibrillation programs at the high school should consider the strength and motivation of current community CPR initiatives. School administrative personnel can structure sports team AED purchase with student CPR classroom teaching justification. Good citizenship mandates early defibrillation awareness during initial CPR teaching exposure.

Medical supervision for targeted responder AED program is an essential component fo success. Emergency Department personnel are traditionally in charge of the community cardiac emergency response and can provide invaluable insight into early defibrillation programs. Initial organization must include coordination with existing pre-hospital care providers to maximize survival rates. Adherence to the AHA chain of survival concept must be strictly enforced (1,2). The addition of a cellular phone to the AED carrying case is ideal for rural settings to promote 911 activation prior to initial resuscitation.

The chain of survival includes:
  1. Fast EMS activation (call 911);
  2. Early CPR by a first responder (target responder);
  3. Early defibrillation (the greatest single impact on survival statistics);
  4. Early advanced life support (such as intubation, external pacing and cardiac medications); and
  5. Late advanced life support involving dwelling pacemakers and defibrillators, medications and surgery (17).

Quality assurance issues can be facilitated by critical review of AED usage provided by data display programmed into newer AED units. Emergency Department physicians anticipated to be utilized in the event of cardiac emergency should be incorporated into plans for the initial course and subsequent continuing education at three-month intervals. This concept must be augmented with excellent cellular phones or radio communication in rural areas.

Recent technological advances in automated external defibrillator equipment design privde an opportunity for advanced treatment to become safe and expedient in the hands of targeted responders. As a result, communities need to develop a mechanism for education and equipment acquisition.

Historically, most communities support local high schools for noteworthy projects. Additional grant funds are currently being sought for additional studies in an even more rural West Virginia county. Physician directed CPR and AED training for teachers, coaches, school administrators, and athletic trainers provides and attractive model for improving the safety of athletic participation and spectator safety at athletic events.


1. Kyle JM, Walter RB, Forbase JK, Leaman JR, Hanshaw SL. Exercise induced bronchospasm in the young athlete: guidelines for routine screening and initial management. Medicine and Science in Sports and Exercise; August 1992.

2. American Heart Association Report on the Public Access Defibrillation Conference – December 3-10, 1994. Circulation 1995; 92:2740-7.

3. Automatic external defibrillators for public access defibrillation: recommendations for specifying and reporting arrhythmia analysis algorithm performance, incorporating new waveforms, and enhancing safety. Circulation 1997; 95:1677-82.

4. Spaite DW, Criss EA, Valenzuela TD, Mclalin HW, Smith R, Nelson A. A new model for providing pre-hospital medical care in large stadiums. Ann Emery Med 1988; 17:824-8.

5. Weaver WD, Sutherland K, Wirkus MJ, Bachman R. Emergency medical care requirements for large public assemblies and a new strategy for managing cardiac arrest in this setting. Ann Emery Med 1989, 18:155-60.

6. White R. Police AED, Ann Emer Med 1996.

7. Alonso-Serra HM, Delbridge TR, Auble TE, Mosesso VN, Davis EA. Law enforcement agencies and out-of-hospital emergency care. Ann Emer Med 1997; 29:4.

8. Kyle JM, Walter RB. Sports medicine education for rural practice. The Physician and Sports Medicine; Vol. 16, No. 8.

9. Kyle JM, High schools help conquer cardiac arrest. School Business Affairs 1998; 48-50.

10. Sobel RK. A shocking story: handy defibrillators. U.S. News & World Report. September 1998; 77.

11. Maron MD, Thompson P, Puffer J, McGrew C, Strong W, Douglas P, et al. Cardiovascular pre-participation screening of competitive athletes. American Heart Association: Med Sci Sport Exerc, December 1996; 28(12)1445-52.

12. Maron MD, Pollac MD, Kaplan MD, Mueller, PhD. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. NEJM August 1996; Vol. 333, No. 6.

13. Estes NA. Sudden death in young athletes. NEJM August 1996; Vol. 333, No. 6.

14. Amerongen MD, Rosen MD, Winnik MD, Horwitz DO. Ventricular fibrillation following blunt chest trauma from a baseball. Ped Emer Care 1997; Vol. 13, No. 2.

15. Kaplan MD, Karofsky MD, Volturo MD. Commotio cordis in two amateur ice hockey players despite the use of commercial chest protectors: case reports. J of Trauma 1993; Vol. 34, No. 1.

16. Maron MD, Pollac MD, Kaplan MD, Mueller PhD. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. NEJM August 1996; Vol. 333, No. 6.

17. Automatic external defibrillators for public access defibrillation: recommendations for specifying and reporting arrhythmia analysis algorithm performance, incorporating new waveforms, and enhancing safety. Circulation 1997; 95:1677-82.
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