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.

Abstract

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.

Introduction

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).

Discussion

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.

Conclusion

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.

References

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.

Defibrillators Let Lay People Save Lives

By Denise Grady

October 26, 2000 - Many people who suffer cardiac arrest and would otherwise die can be saved if ordinary people are trained to use defibrillators to shock them back to life, researchers are reporting today.

In two studies, one conducted at casinos and the other on airliners, survival rates were 53 percent and 40 percent for people who had cardiac arrest and who were treated almost immediately with portable defibrillators, a smaller version of the electrical paddles used in emergency rooms.

Those survival rates are far greater than overall rates in the United States, which are dismally low, 2 percent to 5 percent, because most victims are not defibrillated fast enough. About 225,000 Americans a year suffer cardiac arrest.

Ideally, the shock to the chest should be given within three minutes of the victim’s collapse and is unlikely to work after ten minutes. Each minute of delay drops the odds of survival by 7 percent to 10 percent. Defibrillation is the only effective treatment of ventricular fibrillation.

The two new studies, which appear in the New England Journal of Medicine, reflect a larger trend in the United States to train lay people to use portable defibrillators and make the devices available in large workplaces and public places like sports stadiums, train and ferry terminals, airports, amusement parks, health clubs, community and senior citizen centers and shopping malls.

The drugstore chain C.V.S. has begun offering defibrillators on its Web site by prescription for about $3,000, for people at risk of cardiac arrest.

A rule adopted by the Federal Aviation Administration that took effect in September gave airlines three years to train flight attendants and put defibrillators on all planes that can carry at least 30 passengers and one attendant. American Airlines has defibrillators on all its flights, and most other airlines in the nation have begun including them, as have some foreign airlines.

Portable defibrillators weigh four to seven pounds and cost $2,500 to $4,000. Lay people can be taught to use them in five or six hours.

The American Heart Association estimates that if the national survival rate for cardiac arrest victims could be increased to 20 percent, 50,000 lives would be saved.

The people in the studies were treated with a type of portable defibrillator that first monitored the heart and then shocked it only if the machine detected a particular abnormal rhythm, ventricular fibrillation, which accounts for 80 percent of all cases of cardiac arrest. In that condition, the main pumping chamber of the heart quivers instead of beats and loses the ability to pump blood. People in that condition have no heartbeat or breathing but do have some electrical activity in their hearts. In some cases, ventricular fibrillation is brought on by underlying heart disease, and in some cases the cause in unknown. Ventricular fibrillation causes sudden death and is different from the more common type of heart attack, myocardial infarction, in which blockages in coronary arteries choke off blood supply to the heart. People with myocardial infarction would not be helped and instead would be harmed by defibrillation.

Portable defibrillators, sometimes described as "idiot-proof," will not deliver a shock for any condition other than ventricular fibrillation, because shocking a healthy person or someone with another type of heart problem could be dangerous or even fatal. The machine will not fire if a patient’s heart has no electrical activity, because a shock will not restart such a heart.

The machines have recorded voices that talk users through the steps of defibrillation and cardiopulmonary resuscitation. A study last year showed that sixth-grade students could follow the directions and took only 27 seconds longer to do so than emergency medical technicians or paramedics.

The idea of equipping casinos with defibrillators came from Richard Hardman, an author of one study and coordinator of emergency medical services in Clark County, Nev., which includes Las Vegas. Mr. Hardman said that in 1995, his department noticed that the county had a higher rate of cardiac arrests than other areas with similar populations and that more than 60 percent occurred in hotel casinos.

Dr. Terence Valenzuela, one of authors and a professor of emergency medicine at the University of Arizona, said: "I don’t think there’s anything dangerous to your health about casinos. There are just a lot of high-risk people there. They’re older; there are a lot of smokers; and they congregate there for long periods of time."

Hoping to improve survival, Mr. Hardman and his colleagues approached the casinos about defibrillators. Initially, he said, they resisted, mistakenly fearing that people could be harmed by defibrillators and that the casinos would be liable.

"But defibrillators are applied to somebody who’s essentially dead, with no pulse and no breathing," Mr. Hardman said. "You really can’t make that condition any worse."

Once that was understood, the casinos agreed to have their security guards trained. The first to try it was Boyd Properties, which owns the Stardust, the El Dorado, the California and other casinos in Las Vegas and elsewhere.

The officers, already certified in CPR, then had five to six hours of training to use defibrillators, which were brought into the casinos in March 1997.

The first person saved, on July 1, 1997, was a man in his 70’s who collapsed at a slot machine in a Boyd casino. He was staying at a hotel that didn’t have a defibrillator.

"His wife observed the defibrillator being used and was made aware that if it had happened where they were staying, he probably wouldn’t have survived," Mr. Hardman said, adding that the wife moved into the Boyd hotel.

The man recovered; the idea caught on; and more than 70 casinos, most in Nevada, now have defibrillators, Mr. Hardman said. The study included 105 people who collapsed and were defibrillated between March 1997 and October 1999; 56 recovered. None had brain damage, which can follow cardiac arrest if the heart was not restarted quickly and the brain was deprived of oxygen.

Nevada, New York and at least a dozen other states have passed laws to exempt people from liability when they use a defibrillator to save someone.

A surveillance tape from one of the casinos, provided by Dr. Valenzuela, shows a man collapsing at a roulette table. Guards rush to him, remove his shirt and frantically shave his chest, while nearby casino patrons gamble on, barely looking away from their cards or dice. The guards slap two large adhesive patches, containing the defibrillator’s electrodes, onto the man’s chest. Within seconds, the defibrillator commands them to deliver a shock. They move clear of him to avoid being shocked, one presses a button, and the man’s body jerks as the defibrillator fires. The victim’s heart rate and breathing are restored, and within minutes he is sitting up and talking. An ambulance team wheels him out on a stretcher, past other gamblers, most still oblivious of the man who has essentially died and been revived in their midst.

The second study, by researchers at the University of Texas Southwestern Medical Center at Dallas, examined the use of defibrillators by American Airlines, which began putting them on planes in March 1997. The airline now includes them on all flights and has trained its 24,000 flight attendants to use them.

Six of fifteen passengers who needed shocks between June 1997 and July 1999 survived.

Copyright © New York Times, Inc.

A Defibrillator Near You? Advocates call for distribution in schools, public areas

By Felice Buckvar.

July 18, 2000 - WHEN JOHN ACOMPORA answered the telephone early June 12 the first words he heard were, "There was another incident on Long Island." Acompora knew exactly what the caller, a doctor friend, was referring to. Another youngster had suffered cardiac arrest from a fatal blow to the chest. This time it was 7-year-old Ryan Blanco of Centereach, hit by a line drive while practicing baseball with his brother.

"Not again!" Acompora exclaimed, immediately reliving March 25 when his son Louis, 14, a healthy, athletic lacrosse player, blocked a ball with his chest during a game, and in front of players, coaches, friends and his parents, walked a few steps, then collapsed. His heart had gone into arrhythmia; the heart was not pumping because the rhythm was chaotic.

With the memory of that day and the sorrow of losing their son still so achingly fresh, the Acomporas have found a cause. "The only known way to reverse a death like Louis' is with a defibrillator," John Acompora said. "It should be readily available. We're on a campaign now to get every school district in Suffolk County, New York State and the United States of America to have a defibrillator program."

In addition to the equipment carried by ambulances, almost every fire truck and police car on Long Island now comes equipped with an automated external defibrillator. Their use is also being expanded in the city. This easy-to-use, lightweight machine is attached with wires to pads placed on a victim's chest and transmits the shocks that can re-establish a viable heart rhythm. But this device usually must be brought to victims after 911 has been called and a vehicle has arrived at the emergency site. The window of opportunity for defibrillation is five minutes or brain damage occurs, and each minute that passes from the beginning of the attack reduces the likelihood of survival by 10 percent.

Suffolk County Legis. Andrew Crecca (R-Hauppauge) agrees with the Acomporas' goals. He sponsored a bill to grant $2,500 to Suffolk school districts to purchase a defibrillator. Discussion on the bill was tabled in a budget committee meeting in June, but Crecca said, "It was more of a monetary issue than anything else. Members liked the idea of getting defibrillators not only into the schools but into other public places." The legislature will vote on the establishment of a task force on the issue at its meeting on Aug. 8.

At a meeting on July 10 in Albany, members of the Community Health and Pupil Services team and others at the state Education Department decided they would send a document as soon as possible guiding schools on proper placement and use of defibrillators, according to Donna J. Kopec, regional manager in eastern New York State for Emergency Cardiovascular Care Programs for the American Heart Association. She attended the meeting, as did school nurses and administrators and a physician-moderator.

"The tone from the state Education Department was very supportive of the concept. They did not have to be talked into it," she said.

In Queens, fire trucks, EMS vehicles, ambulances in the 911 system and police emergency services trucks carry defibrillators. In general, patrol cars do not, but each precinct has at least one defibrillator and staff trained in its use. Some precincts are involved in a pilot program to train officers.

In addition, enterprises such as the U.S. Tennis Association and the Sheraton LaGuardia East Hotel have the devices, with security personnel trained to use them.

One Long Islander who unqualifiedly supports public access to automated defibrillators in schools and elsewhere is Julie Lycksell, an operating room nurse in cardiovascular procedures at St. Catherine's Hospital in Smithtown. In 1998, she collapsed while celebrating her birthday at a Port Jefferson restaurant with her husband. Luckily, all the steps the American Heart Association considers important in its "chain of survival" fell into place.

Among other things that went according to recommendations: 911 was called, early CPR and defibrillation were administered, and she received early advanced care.

Lycksell was later moved to St. Francis Hospital in Roslyn where doctors implanted an internal defibrillator. Since then, she has had no further incidents, and she is back to work.

The majority of victims of cardiac arrest are older than 65. Although a recent brochure from the American Heart Association states that only 5 percent of those who suffer sudden cardiac arrest now survive and predict that 20 percent more may be saved under optimum conditions, even more dramatic results seem to be coming about.

James Sciammarella, a doctor of emergency medicine at Mercy Medical Center in Rockville Centre and volunteer chairman of Operation Heartbeat for the Long Island region, said, "Nine out of 12 who suffered cardiac arrest at Chicago's O'Hare Airport were resuscitated" with emergency treatment that included use of automated defibrillators.

In Nassau County, of 27 uses of automated defibrillators by police in the latter part of 1999, when the program was implemented, there were four positive pulse reactions. Since Jan. 1, 74 uses resulted in 10 positive pulses. The present scenario is usually that the police car is the first responder to a 911 call, followed by an ambulance with emergency medical technicians who take over at the scene after the police have started CPR and defibrillation.

Pearl Logliandro, 81, of Mineola, is a recent survivor. On April 30, she collapsed. "She was pretty much gone," Mary Warnecke, her daughter, said. A registered nurse at Mercy Medical Center in Rockville Centre and a trustee of the village, Warnecke added, "I would say that usually in the community, there is a 1 percent chance of survival when an elderly person suffers sudden cardiac arrest." Warnecke was at work, but her husband, Thomas Warnecke, was with Logliandro in their home. A volunteer emergency medical technician, he called 911 and started CPR. Police on patrol in Mineola arrived quickly and used an automated defibrillator to establish a pulse. They were followed by an ambulance with emergency personnel who took over the procedures. Logliandro eventually required bypass surgery and returned home June 22.

One of the police officers, John Larson of Nassau's Third Precinct, did the CPR while his partner, Michael Walters, set up their automated defibrillator.

Larson said he had been trained in an extensive program on emergency medical techniques and then received additional training in a four-hour course reviewing CPR and adding the use of a defibrillator.

He explained how easy the device is to use: "The machine advises you to shock or not to shock. The machine tells you to stand clear if a shock is going to be administered." In both Lycksell's and Logliandro's cases, the police officers administered the shocks. Increasingly, public access defibrillators are being purchased for use by trained lay persons such as the lifeguards at Splish Splash, a 40-acre water park in Calverton, staff members at the Mid-Island Y Jewish Community Center in Plainview and the security staff of Cablevision Systems Corp. in Bethpage. The latter owns 28 defibrillators, one for each security office and patrol vehicle.

In the Three Village School District Herbert Friedman, director of Health, Physical Education, Recreation and Athletics, plans to "move forward and implement a defibrillator program for the fall," he said.

Meanwhile, in other states, such as Florida and Wisconsin, fund-raising drives by students, parents, businesses and service organizations, with grants for training, have been putting automated defibrillators into schools.

Felice Buckvar is a freelance writer.

Copyright © Newsday, Inc. Produced by Newsday Electronic Publishing.

Matters of the Heart: A Comprehensive Look at Commotio Cordis, and What is Being Done to Prevent It

by Paul Ohanian, Lacrosse Magazine Online Staff

In March 2000, Louis Acompora was a goalie on the Northport (N.Y.) High School freshman lacrosse team. He likely shared the same hopes that many other 14-year-old players harbor: enjoy a good season, improve on his skills and prepare to join the varsity team in future seasons.

Sadly, Acompora never had a chance to realize those goals.

During a game, Acompora absorbed a shot that hit him in the chest. Despite wearing a chest protector, the impact of the ball sent him into cardiac arrest. Coaches and officials performed CPR on site, but Acompora was pronounced dead-on-arrival at the hospital.

Following his death, Louis' parents -- Karen and John -- learned that the rare incident that claimed their son's life actually has a name: commotio cordis. It occurs when an individual receives a blow to the chest in a very precise spot over the heart at a very precise moment in the cardiac cycle. The blunt blow -- which doesn't even need to have extreme force -- imparts an electric charge to the heart, causing ventricular fibrillation in an otherwise normal heart.

The Acomporas also learned that their son might have survived if Northport had had an automated external defibrillator, commonly known as an AED, onsite. These portable machines help increase the likelihood of surviving sudden cardiac arrest (SCA) by shocking the heart back into its normal rhythm.

Data collected by Dr. Barry Maron of the Minneapolis Heart Institute chronicles 188 cases of commotio cordis, encompassing a variety of sports-related and non-sports-related instances. His findings reveal that victims who receive defibrillation within one to two minutes of sustaining impact have the best chance for survival. Additionally, the data suggest that early CPR application is just as important as early AED application in helping victims survive.

What's Being Done

US Lacrosse recently took a leadership role among sport-based organizations in addressing commotio cordis.

"Injury research shows that lacrosse is a relatively safe sport to play, but the risk of catastrophic injury still exists, as it does in every sport," said Steve Stenersen, executive director of US Lacrosse. "In the rare case of a commotio cordis episode, or if SCA should afflict a spectator or official, the prompt and proper use of an AED greatly increases the odds of the victim's survival."

In May, the organization hosted the first commotio cordis summit in Baltimore, bringing together leading researchers, medical experts and equipment manufacturers. The Acomporas, along with two other lacrosse families that have been victimized by commotio cordis -- the Boiardis and the Macks -- were among those in attendance.

George Boiardi was a senior defenseman at Cornell when he was stuck in the chest by a ball during a game in March 2004. He lost consciousness and, despite resuscitation efforts that included the application of CPR and an AED, passed away. An autopsy was not performed, but many believe commotio cordis caused his death.

John Mack was a 17-year-old player at Binghamton (N.Y.) High. During an indoor game in late November 2006, he was struck in the chest by a stick. He spent two days in a hospital on life support before passing.

"We are committed to the health and safety of all lacrosse players," said Dr. Vito Perriello, a member of US Lacrosse's Sports Science and Safety Executive Committee. "We will not rest until this is where it should be."

Among the conclusions reached by summit participants was that greater knowledge of and access to AEDs was critical to countering commotio cordis. US Lacrosse has committed to simplifying the process for schools, teams and leagues to obtain AEDs.

The organization recently announced a strategic alliance with Cardiac Science Corporation to increase the awareness and availability of AEDs to its members and affiliated programs (see sidebar).

"We encourage lacrosse organizations around the country to purchase AEDs as an additional step in the quest to provide the safest possible environment for players, coaches, officials and spectators," said Stenersen.

Since Louis' death, the Acomporas have taken a leading role in increasing the access to AEDs. They established the Louis Acompora Foundation, the primary mission of which is to lobby all states to pass laws requiring schools to have a defibrillator. In 2002, New York became the first state to pass such a law.

"These machines are of obvious benefit after a [commotio cordis] event occurs," Maron said.

Checking Gear

Summit participants also concurred that continued work towards the prevention of commotio cordis incidents is as important as treatment.

"Prevention is the best method and our ultimate goal," said Perriello. "Discovering what materials are the most effective is the goal."

The research of Dr. Mark Link of the New England Medical Center and Dr. Cynthia Bir of Wayne State University -- who have used animal surrogates and mechanical models to study the causes of commotio cordis -- is providing equipment manufacturers with greater understanding of the phenomenon. Initial findings indicate that two contributing factors in occurrences of commotio cordis are the density of the impact object and the ability of the protective device to dissipate the energy of the impact.

Using that data, equipment manufacturers can pursue chest protector design variances that may help curb future incidents. Prototypes with air pockets or shape geometries that dissipate and reflect force are being considered. Developing softer balls, especially for use in youth baseball and lacrosse leagues, also remains an option.

Kyle Sweeney, a member of the U.S. men's team and a vice president at equipment manufacturer Maverik, attended the summit. He said that the information is still far from conclusive and that making equipment changes now would be premature.

"There was nothing that we could take away from that meeting regarding changes in protection," said Sweeney. "There's lots of research being done, but no real answer. There are so many variables that come into play on this issue. I'm glad I was there, even if it was just to confirm that we don't have an answer yet."

Dale Kohler, general manager for Brine, also attended the summit.

"More evidence needs to be compiled, and we need to keep working the problem," said Kohler. "We're all touched by the tragedy of commotio cordis, and there is no denying that it is happening. We walked away from the summit compelled to do something. We just don't know what that is yet."

The National Operating Committee on Standards for Athletic Equipment (NOCSAE) determines specifications for equipment. With commotio cordis research still incomplete, no current standard for chest protectors has been established. Lacking that standard, a national governing body, like US Lacrosse, cannot modify its rule book.

"The tough part is waiting for the science," said Dr. Trey Crisco, director of the bioengineering laboratory in the department of orthopaedics at Brown Medical School and Rhode Island Hospital. "Once you figure out the science, establishing the standard is pretty cut and dried."

Crisco said that mandating and enforcing the use of non-compromised equipment would go hand-in-hand with its production. Players would be prohibited from altering the protective gear to make it more comfortable, lightweight or form-fitting.

"Once adopted, compliance is done by self-certification by the manufacturers," said Crisco.

"We've got to continue to build on these points of discussion," said Dr. Fred Mueller of the Center for Catastrophic Sport Injury and a member of the US Lacrosse Sports Science and Safety Executive Committee. "Does equipment that appears effective in the lab also work in the field? Will organizations accept a mandate to use this equipment? Will manufacturers produce it?"

In many respects, the summit created more questions than it answered. Nevertheless, all participants agreed that the issues surrounding this phenomenon need to be explored further, with continued research, product testing and education, to make the sport safer.

For more information on AEDs and the partnership between US Lacrosse and Cardiac Science, including the special pricing options, visit www.uslacrosse.org or www.cardiacsciencepartners.com/usl.

Automated External Defibrillator Saves Young Athlete's Life: Davis Nwankwo Released From Hospital

NASHVILLE, Tenn., March 9 (AScribe Newswire) -- The quick actions of an athletic trainer and the use of an automated external defibrillator (AED) saved the life of Vanderbilt basketball student-athlete Davis Nwankwo (Nah-WONK-wo), said the team physician.

Nwankwo, a 19-year-old red-shirt freshman from College Park, Maryland, was released today from Vanderbilt University Medical Center. He could possibly sit on the Vanderbilt bench this evening when the Commodores play Auburn in the first round of the Southeastern Conference Tournament in Nashville.

Nwankwo collapsed approximately 15 minutes into practice when he suffered cardiac arrest on Monday at Memorial Gymnasium. Athletic trainer Mike Meyer was at his side immediately and initially found him to be breathing with a pulse.

"Shortly after his collapse he stopped breathing and a pulse could not be detected," explained Andrew Gregory, M.D., assistant professor of Orthopaedics and Pediatrics and team physician for Vanderbilt Basketball. "A student trainer had gone to get the automatic defibrillator. The defibrillator indicated a shock was necessary and one shock was delivered by Meyer."

That life-saving shock restored Nwankwo's heartbeat, and two rescue breaths were given by Meyer. Nwankwo then began breathing on his own.

Vanderbilt University Police responded within one minute of the 911 call for help, and Metro Nashville Fire Department paramedics were on the scene within six minutes. He was quickly transported to Vanderbilt's Emergency Department.

"Within two minutes of his heart stopping he was administered the life-saving care that he desperately needed," Gregory said. "The quick actions of Mike Meyer, the emergency responders and the Vanderbilt health care providers saved this young man's life."

Nwankwo's father, Adam, expressed his gratitude to those who saved his son's life.

"Davis is alive today all because of trainer Mike Meyer," Adam said. "There really are no words or anything that we can do to thank him enough."

Gregory said the incident revealed that Nwankwo suffered from an enlarged heart, or hypertrophic cardiomyopathy.

"It is unfortunately the end of his basketball career," Gregory said.

Vanderbilt head coach Kevin Stallings said he was happy Davis has been released from the hospital.

"While we are extremely disappointed that this means the end of Davis' playing career, we're very grateful that the prognosis for the rest of his life is good," Stallings said. "Mike Meyer is truly a hero. He single-handedly saved the life of Davis."

"Davis is a valuable member of our Vanderbilt family," said Brock Williams, assistant vice chancellor and director of Sports Operations. "We will look after him and work out the details of his education with his family."

The 6-foot-10 forward has appeared in 23 games this season, scoring 12 points and grabbing 30 rebounds in a reserve role.

Dan Roden, M.D., professor of Medicine and Pharmacology, is one of the physicians who cared for Nwankwo and explained that his heart condition is genetic, and is the number one cause of sudden death in athletes.

"Davis would not be alive today had it not been for the quick action of trainer Mike Meyer, and the fact that an AED was readily available," Roden said. "His case is a great example of the importance of widespread use of AEDs in public places."

Nwankwo's attending physician, David Slosky, M.D., an assistant professor in the Cardiovascular Medicine Division, said the prognosis for Davis is good.

"He's a very lucky man," Slosky said. "The AED, the people, and the quick proximity to the hospital made a positive difference in the outcome of this incident."

Kim Lawson, deputy chief of the Nashville Fire Department, agreed, adding "AEDs prove their value every day. A countywide Public Access Defibrillator (PAD) program, coordinated by the Nashville Fire Department, encourages people to learn CPR, as well as the placement of AEDs in public places. This is a clear example of how an AED installation made a difference."

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CONTACTS:

John Howser or Jerry Jones, Vanderbilt Medical Center, 615-322-4747

Andre Foushee, Vanderbilt Media Relations, 615-343-1847 or 615-268-5534

Automated External Defibrillators: In Recreation and Athletic Centers - Get Ready

Editors - Dr. Neil Dougherty & Diane Bonanno

Introduction

The debate on whether automated external defibrillators (AED) should be used in recreation centers is currently underway nationally. It has been precipitated by the American Heart Association's (AHA) recommendations on "Public Access to Defibrillation" and the outcome of a recent lawsuit in Florida where the failure of a recreation facility to have an AED available in an emergency was a vital consideration in the jury's deliberation.

According to the AHA, automated external defibrillators should, at the minimum, be located in highly populated areas such as stadiums, malls, and office buildings, and places where emergency medical teams are not readily available such as airplanes, and large urban centers where traffic may play an important role in the response time of an emergency vehicle. If this occurs, they contend, almost 100,000 lives will be saved each year and many people agree. The growing acceptance of this idea is evident in a recent verdict that was brought against the Busch Entertainment Group and Busch Gardens Tampa Bay in a case involving a 13-year-old girl who collapsed and died after a roller coaster ride. One of the important factors in the jury finding for the plaintiff was the lack of an AED and trained personnel who could use it.

Acceptance is also growing in legislative circles around the country. In March of 1999 New Jersey became one of a growing number of states to pass a public law that set standards for the use of AEDs by individuals who were not medical people. Many believe laws of this kind will accelerate the adoption of AEDs in public places such as recreation centers, and that we are only a year or two away from AEDs becoming a recognized standard of care in these facilities. One contributing factor, of course, is that recreation centers are already required to have CPR trained staff in their fitness centers and pools because they are high-risk areas. It would require very little training beyond CPR to prepare a staff to properly use an AED.

While there is no way of accurately predicting whether a person may suffer a sudden cardiac arrest, we do know that everyone is vulnerable; even seemingly healthy young people who exercise regularly. We also know that the availability of an AED and someone trained in its use increases one's chances of surviving a potentially fatal heart attack if it occurs in our centers. In our view there is no more compelling argument for taking a proactive stance in this debate.

Background

Approximately 250,000 people die each year of sudden cardiac arrest. The vast majority of these deaths occur outside of a hospital where first responders can pro- vide only CPR to the person in distress until an ambulance arrives. While CPR can keep oxygen flowing to the brain, it does not provide the electrical shock to the heart that is generally needed to save the individual's life. Only a defibrillator can do that and even then the defibrillator is only effective if it is used within a short 10-minute window following the incident.

Responding rapidly with electrical shock is essential when dealing with sudden cardiac arrest. Every minute that defibrillation is delayed the victim's chance of survival decreases by about ten percent. Until recently this was a problem. Because defibrillators were administered only by paramedics who were frequently the last ones on the scene in an emergency, an ambulance delayed in traffic for ten or twelve minutes could very well arrive too late to be of assistance.

Recent improvements in technology and statutory immunity have made it possible for first responders to provide what only medical personnel could do previously. The latest generation of automated external defibrillators are lightweight, affordable, easy to maintain, and most importantly, easy to use. With these new devices, personnel no longer have to be trained to interpret the electrical rhythm of a patient's heart before defibrillation is applied. The machine does it for the operator and cues the appropriate response. This, in conjunction with the civil liability immunity many states provide, makes it more likely that people who suffer a sudden cardiac arrest will receive the rapid care they need.

Making automated external defibrillators a part of the emergency action plans at gymnasiums and recreation centers will complete the American Heart Association's "Chain of Survival" which advocates:

(1) Early access to care through a system such as 911,

(2) Early cardiopulmonary resuscitation or CPR,

(3) Early access to defibrillation, and

(4) Early advanced care.

It is the last link in providing our clients with the best protection possible when it comes to sudden cardiac arrest.

In an effort to lay the groundwork for installing AEDs in any given recreation center or gymnasium one should consider the following critical questions:

•If AEDs are used, where should they be located?

•Who should be charged with the responsibility of using the AEDs in an emergency?

•Who should train and test personnel in the use of the AED?

•Who should supervise the program?

•Where should the AED be physically located in each facility?

•What is the chain of events in the emergency action plan for cardiac arrest?

•What are the start-up costs?

•What are the annual costs?

•What automated defibrillator should be selected?

•What is the timeline for start-up?

Locating the AEDs

The American Heart Association has suggested that automated external defibrillators be located:

•Wherever there are 1,000 or more people in a close area

•Where the likelihood of sudden cardiac arrest is increased because of the population in attendance

•Where emergency vehicles might have difficulty responding to a crisis in time to be of assistance, and

•Where the activity might increase a person's risk for cardiac arrest.

Because most recreation centers and athletic facilities attract I 000 or more people of varying ages and abilities to a variety of high risk activities throughout the course of a normal day's programming or during the progress of a special event, and because they are already required by industry standard to have personnel trained in CPR, these facilities are perfect sites for AEDs.

When considering the location of the AED one should give thought to the following:

Is there a location in your facility that is staffed the entire time that the building is open? In general the AED should be kept at a central location which is constantly staffed. Remember, how- ever, that for every one-minute delay the likelihood of survival decreases by ten percent and that defibrillation will most likely be needed in the aerobics room and at contests with a large number of spectators. The AED should not be under lock and key when the building is open.

Administrators may opt to locate the Automated External Defibrillators at the front desk, administrative center or nurse's office in each building. While these are not always the locations that are most centrally located, they appear to be the most logical place to store the AED.

• Each would normally be equipped with a communication device which means that it receives all of the emergency calls from the various rooms in the building.

• There should be a phone located at each site which can be used to call the police in an emergency.

• These sites are often staffed by more than one person which means that one could be called upon to deliver the AED to the emergency while someone else notifies the police.

• The people staffing these sites are usually an integral part of all of the emergency action plans.

• The AED can be moved rapidly to any location in a building.

If a special event is scheduled on out- door space the administrator and the Safety Committee can review the particulars of the event and determine whether an AED and a person trained to use it should be assigned to the event.

Develop a dialogue with outside groups that use your facility to determine how your AED units may or may not be used in conjunction with their emergency action plans for activities under their control.

Assigning Responsibility for AED Use

The number of people who are given the responsibility of using the AED in an emergency should be kept to a minimum. This will lessen confusion during the crisis and improve quality control overall. They should also be an integral part of the response team for all emergencies and have the necessary basic training in CPR.

Specific guidelines that could be considered in the selection of persons charged with the responsibility of using the AED include:

- A designated responder (DR) must be on duty in the buildings whenever the facilities are used.

- All DRs should hold current certifications in First Aid and CPR for the Professional Rescuer,

- DRs should be well trained in deploying the organization's emergency action plans.

- DRs should have experience handling emergencies and should be an integral part of every action plan.

- DRs should meet monthly to review their CPR skills.

- The pool of DRs should be kept very small to facilitate quality control.

Where there is a designated responder all other staff and administrative personnel should recognize and yield to their authority in an emergency.

While lifeguards may soon be required to learn to use an AED as part of their certification requirements, their role in a cardiac arrest emergency in the pool should remain that of the CPR provider. The primary responsibility of an AED responder should remain with the designated responder. The lifeguard should only be called upon to use an AED as a backup should the original action plan fail. To be sure that the lifeguard is prepared to act as a backup, their skills should be reviewed each month during their in-service training.

Training and Testing

Training and testing should be considered an essential part of the process of installing AEDs in any location. It is recommended that initial training be followed by a schedule of monthly testing and periodic retraining to be sure that the responder can perform the appropriate skills when needed.

There are several agencies that provide certification for AEDs. The choice is left to the discretion of the unit that intends to use the machine as a part of its action plan. Be sure to check your state laws for course requirements. New Jersey, for in- stance, requires that the course be found acceptable by the Department of Health and Senior Services.

The American Red Cross, The American Heart Association and the Safety Council all offer certification courses that cover the proper use of the Automated External Defibrillator, While they vary in length they basically cover the same material and are recognized by most authorities. Regardless of the program you decide to use you may wish to consider the following:

• It may be more convenient to secure AED training from the agency that provides your CPR training.
• Initially you will probably need to secure training from an outside agency or company.
• During the startup year, however, seriously consider having every member of the Safety Committee become certified instructors for the AED course you have adopted.

This will allow them to: (1) assist with the in-service training done by the certifying agency, (2) provide the monthly testing, and documentation of all personnel, and (3) assume the role of provider during the second year of operation.

- At the minimum, consider having your organization's Training Coordinator and the Risk Management Coordinator become certified to train AED instructors.

- Lifeguards, intramural supervisors, coaches and fitness assistants should be given the option of getting AED training after they have been trained in CPR for the Professional Rescuer and until such time as this training may become a standard of care for these positions.

- Although all personnel will not be required to become certified in the use of an AED, all staff training should contain a module on AEDs. The modules would include back- ground information on sudden cardiac arrest, the use of AEDs and the role AEDs will play in the organization's emergency action plans.

- Testing is one way of insuring that all personnel are performing their skills properly. It is also a method of helping staff members to feel more confident about their ability to de- liver assistance during an emergency. Every staff member charged with the primary responsibility of using an AED, should be tested by a member of the administrative cadre once a month and at least one of these testing periods should be the result of a surprise visit. If a staff member does not perform to the level expected by the tester, the individual should be required to schedule a private meeting with the tester to review their skills before they are scheduled to work their next shift.

- Copies of the certification cards and the records that verify monthly testing should be kept by: (1) the supervising physician, (2) the unit manager, and (3) the organization's Business Manager.

The Emergency Action Plan for Sudden Cardiac Arrest

There should be an emergency action plan for sudden cardiac arrest that: (I) requires staff members at the scene of the incident to notify the designated AED responder and to begin CPR, (2) designates who should notify emergency services and who should bring the AED to the emergency, and (3) identifies the AED responder and requires him or her to move to the scene of the emergency immediately.

General Program Supervision

An emergency response program that includes automated external defibrillators should and, in many states must, be supervised by a licensed physician. The physician would monitor the program, ensuring that the department or individual using the AED complies with all appropriate standards. This would include being sure that:

• all personnel have on record current certifications demonstrating that they have been trained in the proper use of an AED.

• the defibrillator is maintained and tested according to the manufacturer's specifications.

• the appropriate emergency service provider has been notified that the department has acquired an AED.

To facilitate program supervision, consider forming an Emergency Response Committee whose sole responsibility would be to take the actions necessary to insure that all provisions of the law are met and that the supervising physician is kept informed of all actions.

The Emergency Response Committee should consist of a representative of each of the high risk areas (i.e. outdoor recreation, fitness, aquatics) a representative of the facilities staff, the department's training coordinator and a senior administrator.

The chair of the committee should act as the department's office liaison with the supervising physician, local Emergency Ser- vices, and the training/certifying organization. It would be the chair's responsibility to ensure that all sections of the law are met and to provide the supervising physician with all the necessary documentation.

The chair should provide the supervising physician with (1) copies of all current certifications, (2) the minutes of all Emergency Response Committee meetings, (3) verification of all testing, (4) all maintenance and repair records for the AEDs, and (4) recommendations for any change in policy or procedures.

© Copyright School and Community Safety Society of America, November 1999, Volume 4, No. 2.

Neil Dougherty

Department of Exercise Science & Sport Studies

Rutgers University

Loree Gymansium

70 Lipman Drive

New Brunswick, NJ  08901-8525

(732) 932-8673  -  FAX (732) 932-9151

e-mail: NJD4@aol.com

Diane Bonanno

Rutgers University

Loree Gymansium

70 Lipman Drive

New Brunswick, NJ  08901-8525