So let's get started. I'm going to talk tonight about etiology and management of the collapsed athlete. I have no disclosures. Goals tonight are to review the initial evaluation and management of the collapsed athlete. We're going to discuss causes and treatments for cardiac arrest in athletes. And I want to emphasize the key factors in improving outcomes in cardiac arrest resuscitation, and then review other causes of down and unresponsive athletes and relevant treatments there. And I want to start with a case. This case you may have heard of from a few years ago. I'm going to show a video. It's always uncomfortable when I watch it, and I feel the need to apologize before showing it, but I feel like it's really important to show, that I don't show it to point fingers or to place blame, but to look for places where we can improve. So I'm going to start this video here. I want you to keep an eye on this player in the bottom left. Trying to move on her, goes up with a double clutch right hand, no call. And the rebound by Noko is- So he's down on the ground. He's been down on the ground for several seconds. There's actually a fairly quick response. You see the woman running in from the right. That's an AED in her hand. And he's down, he's thrown on the ground. And as far as I can tell, from the video that I've seen, I think the AED gets opened at some point. It doesn't get used. He's still prone. And while there are medical professionals, personnel on the floor, crane and stalkers, there's no assassination happening at this point. So you can see there the AED's open. It's a foot, two feet away from him. And now you start to see a few signs of, let's call for help. He's still prone on the ground. No one's checked a pulse. You can't tell if he's breathing because you can't see his face. And they're getting a towel. And we'll talk a lot about steps to go through for cardiac arrest. Things that are important when you're assessing a downed athlete. Primary thing, everyone's done BLS, ABCs. And really we'll talk about CAB circulation being the most important. You have to see what's going on so that you can respond appropriately. You can see EMS starting to come in from the top left. Not a lot of sense of urgency here. He's still prone. They still don't know if he's in cardiac arrest. Zikup Shah on the far side of the court in the corner. They're bringing out the stretcher for him. And he's still on his stomach. He had a collision of some sort. We did not see it and not speculating at all. So let's talk about what went wrong. So an AED arrives at 22 seconds into the video. You know, it's not entirely clear exactly when he collapsed but sometime in the first five to 10 seconds of the video. But literally seconds after he collapsed there was an AED within feet of him. It was left on the floor unused. It was over four minutes before the monitor that EMS brought in was put on him. He was prone. There was no attempt to roll him over, assess his ABCs. No determination that he was in cardiac arrest. No CPR defibrillation done for a long time. He arrived at the hospital 16 minutes after his collapse. They got return of circulation about 44 minutes into the arrest. But by that point, his brain was not viable. He was taken off life support two days later. And the cause of death was determined to be sudden cardiac death. And it actually turns out, I wrote no medical history before he was actually diagnosed with hypertrophic cardiomyopathy about a year before that event. After a syncable episode. Did not have an ICD placed and I'm not involved at all in any of, I don't have any information about what went into those decisions. But certainly medical personnel on the sideline, you have to be aware of these sorts of things. And a wrongful death suit was filed and then ultimately settled with the family. And a quote from the lawsuit is, despite this undeniably dire situation, no life-saving measures were attempted. No CPR was initiated and no defibrillator was used. So when you see someone collapse, it's a witness arrest until proven otherwise. You have to assess their airway, their breathing and their circulation. And really the emphasis now with the Red Cross, with the American Heart Association is circulation first, because that's the most important thing to deal with. So your approach scene safety, obviously in any situation, if you're not safe, you're not able to help. Activating EMS, making sure that not only are you going to have an initial resuscitation, but that there's going to be something to move that athlete to especially, or that patient to, especially if they are in cardiac arrest. And then early CPR, early defibrillation and getting them to where they need to go. Just a word on scene safety. Again, you can't be helpful if you become a patient yourself, check the surroundings. There might be some sort of external cause that caused this person to collapse. You might have to deal with teammates, bystanders, crowds, depending on the situation, vehicles, if you're covering like a road race or something like that. Or you could be in a lake, if you're covering a swimming event or triathlon or something like that. We'll talk a little bit about lightning at the very end or heat, cold, animals, all these things just sort of to be aware of. And this is not something that takes a long time, just a second or two, look around, make sure you're safe before you start to act, because you can't become a patient yourself. Again, any PPE that may be relevant. And then you want to follow your BLS sequence that we all learned. So you assess for a response. Hey, are you okay? Tap on the shoulder, tap on the face, sternal rub, whatever you need to do. If you don't get a response, you want to activate EMS immediately. And then simultaneously for about five or 10 seconds, check for pulses, check for breathing. It's not a long evaluation. You don't sit and look for 30 seconds, try to figure out, are they breathing? Are they not? Is it an agonal breath? Is it real breath? If you're not sure, if it doesn't seem like they clearly have a strong pulse, if they're clearly breathing, start CPR. You're not going to do harm doing unnecessary CPR. If you need to do it, do it. And the second responder, someone else, goes to get an AED. As soon as they get back, you put it on. You only pause CPR for rhythm analysis and shock. You keep going the rest of the time. And you do two-person CPR and switching out compressions every two minutes or when you get tired. This is why. And if this is the only slide that you come away remembering from this talk, make it this one. Early defibrillation saves lives. This is your survival curve. It's not really a curve, it's a cliff. You start within the first minute, your chances of survival, if you're defibrillated with a V-fib arrest are 85 to 90%. By five minutes, that's 50%. By 10 minutes, it's close to zero. This is something that drops off rapidly and early defibrillation can save lives. How do we know this? This is one of my favorite studies. What they wanted to do was prove that getting to people faster and responding faster would make a difference. So they went somewhere where there are always cameras and there's always security. They went to casinos in Vegas and they went to the security teams and said, here are a bunch of AEDs. If you see someone go down, go to them with the AED. Don't go check on them and then come back and have to find it, just take it immediately to them. Out of 105 V-fib cardiac arrests, 56 of those patients survived a hospital discharge. That is an absurdly high number. The rate of survival for just your general out of hospital cardiac arrest is in the single digits, single digit percents. This is so far above and beyond that, it's insane. And if you look at the response times, three and a half minutes to defibrillator placement, four and a half minutes to delivery of shock. They're still very high on that survival curve. The survivor weight was 74% for those who got their first defibrillation within three minutes, 49% after three minutes, again, early defibrillation. And we'll talk a little bit about resuscitation science a little bit here. The timeline for cardiac defibrillation, why is it so important to do it so quickly? In the first five minutes you're in something that's called the electrical phase. The cardiac muscle cells still have their energy stores, still have their ATP, are still essentially normal cells. They're just not functioning normally. The electrical signals are not organized. So if you defibrillate them, you reboot them, they can go back to being normal cardiac cells and the heart can beat and can confuse the body. In the five to 10 minute range, you get into what we call the hemodynamic phase and you start to deplete the energy stores of those myocytes. They start to lose their ADP, they start to go into anaerobic metabolism and they start to die. And as you lose more and more cardiac cells, your chances of recovering a functioning heart get smaller and smaller. One thing you can do to prolong the amount of time that you have to get that defibrillation is maintaining adequate arterial pressure in your coronary arteries. And the way you do that is effective CPR. After 10 minutes, you're in what we call the metabolic phase. And there are no interventions that have yet been shown to impact survival at that point. 10 minutes. Early defibrillation and early CPR save lives. Bystander CPR has also been shown to improve outcomes when there are longer EMS response times. Now, obviously this doesn't apply as much to us, we're on the sidelines, we see things happen, but it shows that CPR is effective. Again, early defibrillation and early CPR save lives. You also need to do effective CPR. Quality chest compressions are crucial to really having a good cardiac arrest management. You need good rate and good depth. Average rate, 100 to 125 compressions a minute. I know we've probably all heard the beat of staying alive. You can do that one. And depth is important because you have to squeeze the heart and look at that graphic there. You basically are doing an external cardiac compression, squeezing the heart to circulate blood. So you have to be able to press it hard enough to squeeze the blood out. Compressions are not kind and gentle. They cause sternal fractures, they cause rib fractures, they can cause pneumothoraxes, hemothoraxes, other traumatic injuries. That's okay. I don't care about the status of your rib cage if you don't have a pulse. The pulse is the most important thing. Don't worry about breaking someone's ribs. Do effective compressions. They're also gonna be tiring. This is a full body workout for someone doing CPR. It's hard to do it for two full minutes. I do CPR in the ER. It's rare that I make it more than a minute, minute and a half before I wanna switch out. So have extra people and switch before you get tired because generally if you're someone who's in the rotation for doing compressions, you're gonna come back around and need to go again. Also, minimize the time off the chest. You really need to do compressions for as much as possible. First few seconds of compressions don't actually circulate any blood. If you have a pause greater than 10 seconds, the heart empties and you have to essentially prime the pump to refill the heart, to actually be able to push blood forward through the body and perfuse the coronary arteries. So if you look at that graph on the right, that's coronary perfusion pressure as a function of compressions. And if you look, if every time there's a stop in compressions, it drops all the way down and you're not actually gonna perfuse the coronaries until you get up to a certain level. So you really wanna minimize hands-off time. If you can keep the breaks to under 10 seconds, you can increase survival by three times in out-of-hospital cardiac arrests. So excessive pauses for pulse checks, ventilations, defibrillation, intubation, IV access, other interruptions can cause harm. Compression-only CPR has actually been proven to be a viable alternative, especially when you don't have a full team of people who are familiar with CPR, to be able to perform it well on a patient. When they looked, it actually improved survival from 7.8% to 13.3%. And the reasoning is that you're not stopping to give breaths, you're just doing compressions, compressions, compressions. And your body does, for those first five to 10 minutes, the amount of oxygen circulating in your blood is high enough to still oxidate your tissues if you can get the blood circulating. One other thing I'll mention here, emergency action plans are very important. Preparation improves survival. You need to have an emergency action plan if you're in charge of any sort of event, any sort of arena, any sort of team, this should be something that's written out, should include communication guidelines, who's gonna be in charge, who's gonna talk to who, where is your personnel gonna be, where's EMS, where's your AED? If you look on the pictures here, the one on the top is not one that I took, it's one that I found, but an AED blocked by a bookshelf. That's not a good place to put an AED. The amount of time it's gonna take you to get that AED out, move the bookshelf, get it out of that case, take it out and pull it all the way to wherever your patient is, you're losing valuable, valuable time. So the one on the bottom, that is me. I worked in an event a couple of months ago at a big arena, and a couple of days before I was there kind of scouting it out, trying to find out where the AED was. This was a wooden box that was locked in a back hallway behind an elevator, nowhere near the court, nowhere near anything. And the only key was a security guard who was kind of around the corner back towards the entrance. So one, hopefully he's not the one having the arrest because then I don't know how you open the box, but also there's really no way that this is gonna be a useful AED. So have a plan, know where your AEDs are, have them in places that are easy to get to and you can get to quickly. Also know the training and the integration of your responders. What are their jobs gonna be? Do you have basic EMS? Do you have paramedics? Do you, what's the training of your athletic trainers? Know where your ambulance is, how far away it is if you have to call it and where it's gonna go. Do you need to call where they're going? And then make sure your equipment is up to date. Do you have functioning BBMs? Do you have, is your AED being checked regularly for its battery life? Does it still work? And then you need to plan a review and simulation of this stuff. And it needs to be done at least yearly, I would say every six months, if not more often, so that you practice this stuff. I'm in the ER, I do codes fairly regularly. And even I feel like I could always practice more. I could always be a little bit more comfortable. And if you're primarily in the office and then you're doing coverage and hopefully this kind of thing isn't happening very often, it's the kind of thing you have to practice so that you're good at it. Again, just to recap, scene has to be safe. If you're in doubt, you're unlikely to cause harm with CPR. Delaying or failing to start CPR in a patient without a repulse will reduce the chance of survival. Early CPR and early defibrillation save lives. Compressionally, CPR is a viable alternative if you don't have enough help. And your skills and your instincts will fade without regular practice and simulation. So do something, practice it. If in doubt, do CPR, put the AED on, it won't let you shock if it doesn't need a shock. And early defibrillation and early effective CPR save lives, be prepared. Why did I spend so much time talking about cardiac arrest in a general collapse talk? Well, sudden cardiac death is the leading non-traumatic cause of death in young athletes. This happens a lot more often than we would like. The highest risk is in black male college basketball athletes, but there's high risk for basketball, for soccer, for football. And it's really something that, you know, if you're a men's division one basketball player, your risk is one in, I believe it's around 5,000. This is overall for basketball on the chart there. So really it's much higher than you might realize. The primary causes are cardiomyopathies, the most common there being hypertrophic cardiomyopathy. There are also several arrhythmia syndromes, most common being regatta and long QT, as well as coronary artery anomalies. MIs certainly happen, young athletes also, but we also deal with older athletes quite often. Aortic dissection, certainly those have marfans are at higher risk, and then commotion cortis. Cardiomyopathies, just to talk about them a little bit, the most common, again, hypertrophic cardiomyopathy is a genetically induced pathology. It involves myocyte hypertrophy and interstitial fibrosis. You get a thickened intraventricular septum, which can then obstruct the outflow tract. You're often asymptomatic, but you can, once you do have enough fibrosis and hypertrophy there to start reducing blood flow, you can have chest pain, you can have arrhythmias, you can have syncope, and certainly you can have sudden death. Also common is arrhythmogenic right ventricular cardiomyopathy. This is more genetically heterogeneous. You get the myocardium replaced with fiber fatty tissue, which leads to wall thinning, aneurysm formation, and arrhythmias there. Endurance sports can actually accelerate the wall thinning in ARBC. And then dilated cardiomyopathy, third most common cause for cardiomyopathies, you get a dilated left ventricle that's not caused by ischemia or valvular disease. You get remodeling with increased chamber volume and reduced systolic function, which can then lead, again, to arrhythmias, syncope, and sudden death. Arrhythmia syndromes, Brugada, I think, is probably the most well-known. It's a cardiac ion channel mutation, alters the excitation wavelength. There are some diagnostic EKG changes. You can see some examples there. And it predisposes patients to ventricular tachycardia or ventricular fibrillation. Most people are actually asymptomatic. We don't really fully know yet what predisposes some people to arrhythmias, but certainly if you see someone with this on a screening EKG, best to refer them to cardiology to let them have further testing and possibly some intervention prior to their returning to sport. And for some reason, it actually occurs more often at night with increased vagal tone. Long QT is also very common. There are several different ion channel abnormalities that can cause long QT. It affects repolarization. Can be genetic or it can be acquired. There can be some medication effects, electrolyte abnormalities that can lead to it. It's more common in women than in men. And then we'll talk about this. I'm sure probably all of you are familiar with this case, but I wanted to show the video here. And I want you all to look at the response to this because I think overall as physicians, as sports medicine physicians and as societies, we've gotten better at recognizing and responding to these kinds of events. And obviously there's a very, very good outcome in this one, but when you watch the response here, it seems very well-organized, very well-rehearsed. Everyone seems to have roles and know what they're doing. So again, 24-year-old male, professional football player with no past medical history, and he was hit in the chest on a tackle. We'll watch just the first minute or so of this video. Essentially, a left-side linebacker in the run game as well. So the hit here actually happens about seven seconds into the video. He stands up because while he's fibrillating now, he hasn't lost profusion to his brain. He collapses in about 11 or 12 seconds into this video. And by 19 seconds, there is a team out there assessing. There is someone at the head assessing his airway. There's someone at the chest. They're starting to take off equipment. They have awareness about what's going on. They're trying to do some crowd control. And you can see hand signals. You can see calling for help. You start to have officials and players standing in the way. I wish I had a video of this resuscitation because I think it's outstanding. I don't. What I have is the network TV feed, which then cuts out here. So I'm actually gonna move on from this. If I can, oops, figure out how to do that. Because there's not much else that you can see. But what went right here, there's early recognition that this was not normal, that this was not just a hit where someone went down, that something was legitimately, crucially wrong. There was early CPR. Within a minute, minute and a half, they had started CPR. There's early defibrillation. He got return of spontaneous circulation much, much earlier compared to Zeke Upshaw. Rapidly transported to the hospital, had ICU care, was actually cooled as well. He was cleared to return to play four months after his cardiac arrest, which is amazing. And he actually played in preseason last week. So I think that there are ways to do this right. And if you have a team that's very comfortable and you practice and you know your roles and you know what to look for, you can save lives. And that's exactly what happened here. We don't have official confirmation that this was commotio cortis. We're all pretty sure that's what this was. You can see him get hit directly in the chest. And what happens here is you have a structurally normal heart and you have an arrhythmia induced by a mechanical distortion of myocardium. Usually that's a baseball, lacrosse ball, hockey puck, something about that size, usually round, that's hard, that causes enough of an impact to depolarize the myocytes in that ventricle. So if it hits you directly over the left ventricle. It's still rare, even if it hits you in the exact right spot, because you have to hit the exact right part of the EKG, which is only about 1% of the cardiac cycle. It's a little bit more if you're more tachycardic. So in a case like this with football, with Tamar Hamlin, who also other risk factors are, if you're thinner, you have a greater compliance with your chest wall, you're more likely, but he's running around, he's making a tackle, his heart rate's probably a little higher than a baseball player who gets hit, like a pitcher on a comeback line drive or something like that. Is it preventable? We're not really sure, they've done a lot of testing where they shoot baseballs at sedated pigs to induce ventricular fibrillation. They're kind of gruesome if you read them. And it also does not seem, we don't seem to really have chest protectors that do a good job of preventing it. But it is thankfully very, very rare, just because of what everything that needs to line up exactly right for it to happen. But it is reversible. Again, this is a structurally normal heart that just got hit, it basically got defibrillated and you need to defibrillate it again, reset it again, and you can go right back to having a normal heart. There may be underlying risk factors aside from just the chest wall variables. We don't really know, if you dig deep into the pig studies, you'll find that actually some of the pigs that got shot with baseballs never went into ventricular fibrillation no matter how many times they shot them, and some went every single time. So it's hard to know. There's certainly more work that could be done there, but thankfully this is very rare. And then one more case I actually had when I was a fellow, this is the end of my fellowship. I was working at a half Ironman, and a 48-year-old male who had finished his triathlon about two hours prior to presentation. He came to the medical tent, felt weak, he was nauseous, he had vomited, and he was pale and sweaty, and he just didn't look good. And so if you see these kinds of things, especially he finished two hours before, this is common in someone who finished two minutes before to feel nauseous, to feel sweaty, to feel weak, but have a high index of suspicion in these kinds of cases. We threw an EKG on him, and this is that. This was his actual EKG. So for the non-cardiologists in the room, hopefully you can still spot this, in two, three ABF, this is a very large inferior MI. And this is something that you have to worry about. So there is an increased risk of MI and death during exercise, sort of paradoxical, because you think exercise is good for you, it's good cardiovascular health, and that's true. The chart on the right is your baseline risk for an MI. And if you exercise five times a week, it's pretty good. If you exercise one to two times a week, even, it's better than average, your average sedentary person who doesn't exercise at all. But during exercise, it spikes up. And someone who, even in someone who exercises five times a week, you have two times the average risk of an MI during exercise. If you don't exercise at all, that risk jumps up to one to 200 times your baseline risk. And so if you're covering an event like a 5K, where you have a bunch of people who think, oh, it's not that bad, I can do that, even though I haven't run in six months and haven't done any meaningful exercise in a year and a half, be on the lookout, because you will see people with MIs. And it doesn't always cause chest pain. Consider with unusual shortness of breath, nausea, vomiting, abdominal pain, back pain, shoulder pain, and of course, syncope. So when you have that collapsed athlete, have that in the back of your mind as something to say, like, could this be an MI? And certainly if you have the right patient population, it doesn't have to be 60s, 70s, 80s, it can be 50s, 40s, 30s, I've even seen 20s, in patients with the right risk factors. So what if they do have a pulse? So we'll continue on with our down collapsed athlete, looking at ABCs, airway and breathing. Is this a respiratory issue? And I've sort of broken down into respiratory issues into upper respiratory and lower respiratory. Is this a mouth or a throat issue? Is there an obstruction? Does someone take a lacrosse stick to the larynx? Do they have some sort of fracture or contusion? Do you need to manage their airway? Or is a lower respiratory issue? Is it lungs? Is it a pneumothorax? Is it an allergic reaction? Do they get stung by a bee? Is it some sort of asthma? That's caused them to become hypoxic and collapse. But the most important thing to know is how to manage an airway. And you really wanna just keep this simple. You need to get oxygen into the lungs because if they're not breathing, they're not doing that for themselves. So the number one easiest thing to do, the first thing to do is head positioning. The most common obstruction for an airway is the back of the tongue. You can see in the picture there, when the chin is brought forward, the tongue can collapse against the back of the throat and can close off the airway. So a simple head tilt, chin lift, or a jaw thrust, if you're concerned about cervical spine issues, can help open up that airway. And even just that can get some people breathing again. If you have access to supplemental oxygen, great. You can throw that on either through a mask or a nasal cannula, through a BBM. But if you don't have that, room air is 21% oxygen. So that's enough that we all live on every day. And if you have a BBM that's not connected to oxygen, you can still use that and you can get 21% oxygen into their lungs. The BBM is your friend. This is the most important airway skill that you can have. Forget being a great intubator, forget tricks with bougies and glide scopes and things like that. If you can adequately form a seal with a BBM, and it's hard, it takes a lot of hand strength. People who do like bouldering and rock climbing and things like that, no, it can take time to develop good grip strength. And you really need to press that mask onto the face to get a good seal. If you have more than one person, have no shame. We do this in the ER all the time. In patients who are coding, we have extra people. One person holds a seal, the other person squeezes the bag. You don't have to do it all yourself. But if you can get oxygen into a patient, into their lungs, and if they also have a pulse, you can do that all day. You can do that for days if you need to. Hopefully you're not in a situation where you would need to do it for days, but that is not an unstable airway. You are able to breathe for them. You've done your job. You just have to keep oxygenating them. So this is the most important skill you can practice, the most important skill you can learn in managing an airway in someone who's collapsed. There are some tools you can use to help. You can have nasal and oral airways. Nasal for people who do have a gag reflex, oral for people who don't. Don't stick an oral airway into someone with a gag reflex. You'll get vomiting. You'll get aspiration. No good. And then you have things that you can get all the way down into the back of the throat, LMAs, combi tubes, king airways, things like that, that let you either block off the esophagus and ventilate the trachea, or give you options where you basically, one tube goes down each, and then you figure out which one is the right one, and you use that one. If you don't have those, again, the most important thing is being able to create a good seal with a BBM and get them oxygenated that way. Don't do these things. Do do these things. Please don't try these things. Unless you are an airway physician at a game that has airway physicians, do not try to intubate someone. Again, if you can oxygenate them with a BBM, that is fine. They don't need to be intubated. They can be intubated at the hospital. Don't try to correct someone. I shouldn't have to say this. I wish I didn't have to say this. I've seen things. Don't do MacGyver-y things with pocket knives, ballpoint pens, coffee straws, things like that. You don't know what you're doing. I don't even really know what I, you know, I know how to do a crank, but I would not know how to use a ballpoint pen and a pocket knife to create an airway in the field without making a big mess and doing harm to a patient. Don't do these things. Thank you. Moving on. What if they have a pulse and they're breathing? Well, like any good mnemonic, we have more letters we can add. We can add D and E here. So we'll talk some about the D, which is disability. So assess level of consciousness and their mental status and orientation. And if they're altered, check for possible causes. And we'll go over a bunch of those through the rest of the talk. And then exposure and environment. You want to assess their full body. Expose them if you need to. Look into your surroundings. See what may have caused it. Were there injuries? Were there other environmental factors at play? And then if those are normal, if they have a normal mental status, but focal neuro deficits, assume there's a spinal injury and take appropriate spinal precautions. So the first thing we'll talk about is trauma. Just to briefly mention it, head and neck injuries can certainly be a cause for collapse in a player being unable to get up. Things that you really have to worry about. We see a lot of head injuries. We see a lot of concussion, but you need to know when your suspicions need to be a little bit higher and when someone's going to need emergent evaluation. So for head injuries, altered mental status that persists, focal neurologic deficits persist in vomiting. For neck, again, altered mental status, focal neuro deficits and midline spinal tenderness. For focal neurologic deficits, especially if you have bilateral symptoms, we'll see a lot of stingers in football. Bilateral symptoms are not a stinger until proven otherwise on an MRI. Athletes with head injuries that don't have concerning features might be fine with observation and close follow-up with concussion precautions and whatever else you're gonna need to do on that front. But keep an eye out for those red flags. Another thing to think about for trauma is internal bleeding and shock, which can certainly be a cause for altered mental status and collapse there. And especially in some of your higher impact sports, your organs at risk, basically everything in your abdominal cavity, liver, spleen, bladder, intestines, kidneys. So you wanna check their vital signs. If you have access to an ultrasound, you can do a fast exam. Are they peeing blood? Most of the time, if you're assessing someone's design, then you probably won't see their urine, but if you happen to, and are they at risk for a pelvic fracture? Do they have a fall from a height, fall off a 10 meter diving board or something like that, where you may have some internal bleeding that might benefit from a pelvic binder, which you can even use a sheet to tie them just to sort of provide some tamponade for internal bleeding. So if you have significant blunt trauma and you have altered mental status, just baseline assume their shock and badness and get them to a hospital. Next, we're gonna talk some about heat-related illness and dehydration. This is something very common, especially this time of year. Heat illness is really a broad spectrum of conditions. You can have minor disturbances and just your ability to regulate yourself. It's everything up to heat stroke with multi-organ system failure and everything in between. Heat illness right now is extremely common, especially in American football. We're right in the middle of summer practice, two-a-day workouts, and you're basically combining every perfect storm of risk factors that you could. You have people who are a little bit deconditioned, you have the hottest time of the year, you have larger athletes wearing a lot of padding, and there are frequently serious injuries and deaths from heat stroke in high school and college football. They've put in a lot of precautions to try to avoid this. We can talk about some of the risk factors and some of the things you can do to mitigate those. So strenuous exercise in high temperature and humidity, lack of acclimatization, obesity, dehydration, certain medicines and supplements, and then anyone with a history of heat illness, you have to have a higher index of suspicion there if they collapse. And so prevention, sort of the opposite of the risk factors, acclimatize, wear the proper clothing, you may need to adjust medications, activity modifications, so taking breaks, doing some sets in air conditioned facilities, things like that, pre-hydration and hydration. In terms of heat illness, the most mild thing would be exercise-associated muscle cramps, really more of an exercise than a heat-related condition. It can happen in swimmers, ice hockey players, people who aren't out in the heat, and the significance is really just in the athlete's inability to perform, and you just need to hydrate these people. So if they've collapsed and they're cramping, but they're talking to you, they're awake, they're otherwise okay, just try to get some fluid into them. One thing to be on the lookout for though, if you have persistent or systemic cramping or severe pain with no obvious muscle cramping, should raise your concern for other problems. Do they have exertional hyponatremia? Are they having a sickle cell crisis? So not necessarily with someone with sickle cell disease, but sickle cell trait in athletes can be very concerning. And we'll talk a little bit about that later. And rhabdomyolysis is also something to consider. So sickle cell trait and sickling in athletes with sickle cell trait, they're actually, in Division I athletes with sickle cell trait, they're 37 times higher risk for exercise-related death than those without sickle cell trait. And the mechanisms are phaso-occlusion that can lead to a cascade of rhabdo, hyperkalemia, acidosis, DIC, cardiac and renal failure. And what you see symptomatically is brief periods of intense exercise characterized by intense pain or even just weakness. As opposed to muscle cramping, there's a lack of spasm here, which can suggest muscle ischemia from vaso-occlusion. And of special importance here, high flow oxygen can actually be very helpful to help limit sickling and can reduce your morbidity, mortality in situations like that. Heat exhaustion, this is something, one of the most common causes of collapse that you'll see, especially if you work at any sort of a big event, big race, something like that. So your inability to maintain adequate cardiac output due to strenuous exercise and environmental heat. You often collapse during exercise or at the very end of exercise, sort of overlaps a lot with exercise-associated collapse, which isn't exactly this, but you do have a mild elevation temperature. And of note, your CNS is not affected. You're not altered. Your mental status is okay. You might be dehydrated, but it's not required to have heat exhaustion. And this is fairly simple to treat. You move them to a shaded or cool area. You put their feet up. You could take off any excess clothing they may have. If you check a temperature, you know, maybe elevated, maybe not, but you do want to cool them a little bit. Give them oral hydration if you can, or IV hydration if you have to, if they're having vomiting. Oral is generally better than IV, just physiologically. Even though people really want their IV fluids, oral is better if they can do it. If they're not improving, then you can transport them. But most of these people can be treated, you know, if you're in a big race, just in the medical tent and get them back to their post-race recovery. Heat stroke is what you really want to worry about and be on the lookout for. So this is a multi-system illness characterized by central nervous system dysfunctions. You can have encephalopathy, altered mental status. You can also have additional organ and tissue damage, kidneys, liver, muscles, in addition to very high body temperatures. So typically a core temperature above 104 degrees Fahrenheit is measured immediately after activity. And again, altered mental status. And what does that mean? Disorientation, headache, irrational or irritable behavior, emotional instability, confusion, seizures, just being altered, not able to wake up. You also frequently will have GI symptoms, vomiting, diarrhea. So your management here. So the severity of the heat illness may not be initially readily apparent, but people can get worse much, can get worse quickly. And they get worse directly related to the duration of the core temperature elevation. So rapid cooling is important. If you have, you should have a high index of suspicion with athletes with a temperature greater than 104, and you should cool them immediately if you have the ability to. So again, initial management, ABCs. If they don't have an airway, if they're not breathing, if they don't have a pulse, then you're in your BLS resuscitation mode. If that is all okay, and you're looking at their vital signs, their rectal temperature, you want to check glucose and sodium if you can, and their temperature, and you want to cool them right away. You cool them first and transport them second, because otherwise their body is cooking, their brain is cooking. You want to cool them down to at least 102, and then you're safe to take them out of whatever cooling method that you're using. If you don't have a rectal thermometer available, assume it's heat if it's the right situation. If it's a hot day and it's a marathon and they come in altered, assume it's heat and treat them for heat. Cool them until they begin to shiver for at least 15 to 20 minutes. Most people cool about one degree Celsius every five minutes. So that'll cool them three to four degrees. Common methods, cold water immersion, ice towels. If you're using towels, you need to rotate them because they will warm up pretty quickly. You can hose them down, you can pack them with ice, cold shower, put them in the shade. If you have ice available, but no tub, this is one of my favorites, you can do an ice burrito. Just of note, don't give people NSAIDs or acetaminophen. It's not a fever. Those aren't gonna be helpful. This is the ice burrito. You cover them with ice, you wrap them with a towel. It's really an effective way to cool people down fairly quickly. Some misconceptions about heat stroke. Athletes do not have to stop sweating when they develop heat stroke. They're almost always sweating profusely at the time they collapse. They also don't have to be dehydrated. It's a risk factor, but it's not a prerequisite. And just because they're lucid at the beginning does not mean that they won't progress. So keep a close eye on people who are very hypothermic. Shivering does not delay cooling. It does occur sometimes, not that often, when they're put in a cold water bath, but it's okay. They can shiver. That's not gonna cause any harm. And they will vasoconstrict peripherally if they're immersed in cold water, but that also is okay. They're still gonna cool off. So if they're hot, cool them. Next cause of collapse we're gonna talk about briefly is seizures. So you may have someone who collapses because of a seizure. They might have a known seizure disorder. Trauma can also cause seizures, hypoglycemia, other electrolyte abnormalities, toxicology, medications, drugs, and infection, although probably less likely to be the cause in an athlete. Do's and don'ts for a seizure. So most seizures are much less of a big deal than everyone wants to make them. Most of them resolve on their own. You wanna protect the athlete from further injury. You wanna make sure they're not gonna, you know, spasm into something, hit their head on something. Don't wanna let them fall or fall off of something. Don't try to restrain them. Just put some pillows around them, put some pads around them, blankets, whatever you have. Don't stick anything in their mouth. They're not gonna swallow their tongue. Most people, and most medical people know this, most people who are not medical people, you'd be surprised about the number of people who still think that's a thing. If you have benzos available, again, not the highest priority. Most seizures resolve on their own. If it's going five minutes, 10 minutes, and nothing has happened, you certainly can give them. A lot of people who have seizures disorders, some of them will have rectal valium. You know, if they're seizing, they may not be able to tell you where it is. EMS often will have it. If you don't, you can do IV. If they don't have IV access, you can do IM. But again, most will resolve without treatment. And then if you have supplemental oxygen, a lot of people do become hypoxic during seizures, but that usually resolves after their seizure resolves, just because they're not gonna be able to take great adequate breaths while they're seizing. But, you know, if you don't have it, most people typically will do okay as long as they're not in status epilepticus. Next thing I wanna talk about is diabetic emergencies and electrolyte imbalances. They kind of go along together, and being able to have your index of suspicion of to know when to look for those things is important. So with under-differentiated altermental status, most people, most places will have an AccuCheck or some other way to check glucose. If you have an ISTAT, that's a great way to check stodium. It's a little more rare, but a lot of big races, you'll have them, because hyponatremia is certainly a risk factor. Hypoglycemia can happen usually in diabetic people who have issues with their medications or maybe an insulin pump malfunction, but can happen in people also who just haven't eaten enough and have blown through their energy stores. So you wanna give them oral or IV glucose if you can, oral if they're awake enough to swallow it. You can check for a diabetic bracelet or a tag to know, could this be a medication issue? Is it gonna need more long-term management? And then check for an insulin pump. If it's malfunctioning and it's still pumping insulin into someone who's hypoglycemic, you need to disconnect it. Hyperglycemia can also cause altermental status and collapse. Again, less likely in athletes, but it can happen with severe dehydration. You can have a diabetic athlete who goes into DKA or HHNK, and you really, the treatment there initially is gonna be fluids, fluids, fluids, more fluids. It's a dehydration problem for the most part, and you're not gonna be responsible on the sideline for starting insulin, but if you can get them started with fluids, that can really help. Excuse me. And then hyponatremia, certainly a risk for people in longer races who drink water. Most seasoned racers know you have to mix either Gatorade, Pedialyte, something with a salt solution, gels, things like that, but some people will drink too much water and you can become acutely hyponatremic and altered and collapse because of that. And so you wanna be aware of that. And if you have someone who comes in hot and altered and you cool them off and they're still altered and you have the ability to check a sodium, check a sodium because they may need treatment for that. The last thing I'm gonna talk about, environmental issues. And there are a lot of things that could go into environment but the one I wanted to talk about is lightning, which especially this time of year can be a little bit more of a risk. There are about 400 strikes a year in the US, about 10% of them are fatal. You can see on the map, I don't know what's going on with Florida. I mean, it's obviously weather is a part of it and population density is a part of it, but that still seems like a high number compared to the rest of the country. Golf courses are very common places, ball fields are very common. And what happens with the lightning strike is you get 30 to 100,000 amps delivered over the course of a thousandth to up to a 10th of a second. And it's gonna find the path of least resistance through your body to the ground. And if that goes through your heart, you can have cardiac involvement that can cause cardiac contusion, myocardial stunning, arrhythmias, even aortic injuries. And you're gonna also get arrhythmias from the resultant catecholamine surge that you get from being struck by lightning. Management here, again, initially scene safety. If there's still lightning, stay somewhere safe because if you're a patient, you can't help someone else. If it's a mass casualty situation, where let's say you're on a baseball field and no one called off the game and you now have 20 people who are all struck by lightning, you actually do what we call reverse triage. Typically in a mass casualty situation, people with no pulse and no breathing, you black tag them and you move on to people who are more salvageable. With lightning strikes, it's the opposite. It is a temporary injury to your heart and to your lungs. It stops you from breathing. It sends your heart into cardiac arrest, but everything else is actually okay. And if you treat them, if you support them through it, you can save them. So we don't black tag people in mass casualty lightning strikes. And then you just follow your BLS and your ACLS protocols if they are in cardiac arrest. So in summary, ABCs first, really CAB, assess for circulation. Assume that any collapsed athlete is in cardiac arrest until proven otherwise. Until you feel a good pulse, until you see them breathing, assume it could be a cardiac arrest and act accordingly because early CPR and early defibrillation save lives. Ventilation is the most important part of airway management. If you can ventilate someone adequately with a BVM, you have managed their airway and you can continue to do that for as long as you need to. You need to be prepared, you need to have a plan in place, and you need to practice, practice, practice. I don't do this often enough as a full-time ER doctor to feel like I'm 100% comfortable running every code. I wish I had more practice. Now, do I feel comfortable doing it? I do do it. I feel like I run codes well, but I feel like more practice is always better. And if this is something that you're doing, hopefully almost never, then you really need to know, be in that mindset to know what you need to do when it happens. Excuse me. For trauma, be aware of altered mental status, certainly for head and neck injuries, for focal neurologic deficits, persistent vomiting from head injuries, and then shock for any sort of large blunt trauma. For people who are overheated, cool them before you transport them, and then assess glucose and sodium if you have mental status that does not improve with correcting for heat. We have some questions here, just some review questions. So we're gonna let you guys do the polls. We'll give you a few seconds here. Oh, I get to take this also, I guess. All right, so the answer here, again, the survival rates after a V-fib arrest decrease approximately seven to 10% for every minute the defibrillation is delayed. It's a lot, it goes down quickly. The faster you can defibrillate someone, the higher chance they have of surviving. All right, so what finding in an athlete with a head or neck injury is most concerning for a serious injury? Loss of consciousness, right arm weakness, blurry vision or bilateral hand tingling. We'll give folks about 20 seconds to chime in. Sure. All right, so yeah, bilateral hand tingling. Loss of consciousness actually happens quite often in players with concussions, even without concussions, who just have, excuse me, just have head injuries. Right arm weakness certainly could be a stinger, but any bilateral symptoms, you assume it's a spinal injury until proven otherwise, and typically that's with an MRI. So bilateral neural symptoms always should be concerning. And then question three, primary difference in presentation between heat exhaustion and heat stroke. Higher core temperature, altered mental status, vomiting, or your ability to sweat. All right, so yeah, again, most people got it, altered mental status, one of the key differentiating factors in heat stroke. Core temperature generally important, but not the defining characteristic there. And that's what I got. So happy to talk and answer questions. Great, thank you very much. That was fantastic. There are a few questions that will kind of go through. Can you hear me okay? Yeah. Okay, so Carrie had asked, what about return to play, especially after rhabdo or heat illness? Return to after rhabdo and heat illness. That I'm not entirely sure. This is one of those things I learned in fellowship and now I am a little bit more rusty on. James, if you have insight there. Yeah, I think, I mean, the big thing is there's not, I mean, for most of those, there's not a set time limit, but obviously symptoms have to withdraw, resolve, and they have to be completely back to normal. And then with, especially with heat illness, they need to undergo like a gradual acclimatization back. You don't want to just throw it right back into their sport. They've got to kind of gradually progress them and see how they do. Colbert asked, what is the cutoff for heat stroke? Is it 104 or 105? What I saw was 104, but really what's most important is their mental status. So if I saw someone and I was getting 102.9 and they were altered, I would still call it heat stroke and I would treat them accordingly. And then Daniel had asked about, is there a current policy statement for screening sickle cell trait disease in NCAA athletes? I believe it's required. It certainly was when I was a team physician that everyone, you either needed a waiver or you needed a negative sickle cell test. Yeah. So you, yeah. So you have to either have a test, they can produce the test. So like if they have access to their newborn screening, you know, you can use that. And then, or the athlete has to sign a waiver saying they don't want to be tested. I kind of, with the collapse athlete, you know, one of the things, you know, we talk about a lot, you know, especially with the NBA and the WNBA after what happened in the G league, you know, the league has changed a lot of their protocols. And so now we have a outside consultant company that comes in and we do practice runs with them. But one of the things that always comes up is how long, you know, obviously you'd like to get a pulse back before you transport, but how long would you really do CPR and stuff on the sidelines if you're not getting a pulse back before you'd put them in the ambulance and transport them to the ER? It depends on your situation. If you have a Lucas, if people aren't familiar with what a Lucas is, it's essentially a mechanical piston that can do CPR. The real issue is you want them to be getting effective CPR until they're in the hospital. And the hospital is not going to provide a whole lot better than what you're able to do on the field. You know, we can give Epi in the hospital, but there are actually studies looking at whether Epi is effective in cardiac arrest. And it's not clear that it is CPR. And especially in this cases like this, defibrillation is going to be key. If you're defibrillating them several times and they're still in V-fib and you're unable to get a pulse back, I would keep going, you know, at a certain point, I think you would have to transport. I don't have a definite timeframe for when that would be, but I would have a higher threshold and I would want to stay. And, you know, if I'm able to do effective CPR there, you know, if I can do effective CPR and transport and I can get them there without any break in continuity, then I think that that's fine to do. And certainly there are issues with crowd control and visibility and things like that, where you want to be able to move someone as soon as they're stable to move. But the more, the real key is timeliness and the faster that you can do it, the better. And that generally involves not moving them first. Great. Yeah. So for the fellows too, I think it's important to note, you know, this is one of the reasons that like the medical, like we talk about the medical timeout and it's so important. And so you can meet EMS staff beforehand and you can kind of go over a lot of these things with them. Like, where are you going to transport? You know, when are you going to transport, you know, different EMS personnel, you know, have different experience levels with covering, you know, sidelines and things like that and different experience with sports medicine physicians. So making sure they understand what we do as well. And then that you understand what they do because every state, the laws for EMS are different. So, you know, you need to know what the EMS laws are for your state. What, you know, what a paramedic is, what an EMT is. Some states have even like EMT1, EMT2 paramedic, you know, like, and so there's certain things that they can and can't do. And so it's good to know those for the state that you practice in. Yeah. It can even vary by locality too. There are some states where if you're near a big city, you may not have any intermediate EMTs because you're close enough to a hospital all the time. You don't really need them. You either have a paramedic or a basic, but if you're out in the middle of nowhere in that same state, it might be different rules and different personnel that you're working with. Okay. Does anyone else have any questions before we adjourn for the night? Okay. Well, thank you again. That was fantastic. A great topic. Very pertinent and very present lately as we've had quite a few high profile cases. So thank you very much guys. And like I said, the, if you know anybody that missed the lecture will be added to the YouTube channel for review, or if you just want to review it yourself, you can review it on the YouTube channel. Have a great night.

3rd Edition, CASE 06

3rd Edition

Cardiac

cardiac arrest

basic life support

CPR

defibrillation

emergency action plan

athlete collapse

cardiac conditions

EMS protocols

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