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Of the more than 350,000 annual deaths that occur as a result of sudden cardiac arrest (SCA) each year, you might assume that only older adults need to be concerned about this deadly condition. Think again. SCA is the leading cause of death in young athletes. Most often, the death occurs during athletic training or competition.

Despite the proliferation of automated external defibrillators (AEDs), increased training, and an increased focus on pre-participation screening, SCA continues to strike down young athletes, officials, coaches and onlookers on our athletic fields.  

Related Statistics:

  • In the United States, a young competitive athlete dies suddenly every three days.
  • Young athletes are more than twice as likely to experience SCD than young non-athletes.
  • Most victims are male (90%).
  • Hypertrophic cardiomyopathy (HCM) is the leading cardiovascular cause of SCD (36%) in young athletes. (HCM is a disease that causes thickening of the heart muscle.) 
  • More than half of HCM sudden death victims are black athletes (52%).

Prevention Through Screening

Athletes should be screened each year through the use of a targeted history and physical examination by a physician. In some cases, and based on the results of the targeted history and physical exam, the athlete’s primary care physician may make a referral for additional screening.

* There is a grassroots effort to address the missed diagnosis of heart conditions in youth and a call for a more comprehensive approach to identifying these youngsters before cardiac arrest occurs.

Leagues and organizations should take appropriate measures to advocate for and/or require annual screening.

Commotio Cordis Deterrence and Prevention

Commotio Cordis is a condition where a blunt, but often relatively mild blow to the area of the chest directly over the heart from a baseball, lacrosse ball, puck, fist, shoulder or knee during a precise moment of the heart’s cycle that leads to sudden cardiac arrest.

Recent studies have shown promising results for the use of chest protection technology in preventing Commotio Cordis, however, quick recognition of Commotio Cordis and responsive action are still critical to survival. 

Signs and Symptoms of Commotio Cordis

  • Look for an athlete who was hit in the chest by an object such as a baseball, baseball bat, or lacrosse ball
  • There should be no apparent trauma
  • The athlete will typically stumble forward momentarily and followed by unconsciousness, no breathing, and no pulse (cardiopulmonary arrest)

Factors Leading to Commotio Cordis

“Timing of Impact” refers to the timing of the object hitting the chest during the cardiac cycle.  The heart is most vulnerable when it is struck at the beginning of the T-wave.  This part of the cycle indicates the refilling of the heart’s ventricles.

Recent studies have shown promising results for the use of chest protection technology in preventing Commotio Cordis, however, quick recognition of Commotio Cordis and response is critical to survival.

Learn more about chest protection technology

Learn about the US Lacrosse equipment-related rule changes designed to enhance heart protection for youth players, specifically to reduce the risk of the rare yet potentially catastrophic injury of commotio cordis.

Early Recognition of Sudden Cardiac Arrest-Prodromal Signs

Nearly half of all cases of sudden cardiac arrests, warning signs and symptoms are present beforehand. Coaches, parents and children should be aware of these signs and symptoms and seek medical help immediately when they are observed.

  • Racing heart rate or heart palpitations
  • Dizziness or lightheadedness especially with exercise
  • Repeated unexplained fainting
  • Fainting when excited, startled, during exercise or right after exercise
  • Seizures during or immediately after exercise
  • Chest pain or discomfort with exercise
  • Excessive shortness of breath or unusual fatigue during exercise (not related to asthma)

NFHS Training Program on Early Warning Signs

Emergency Response Plans and Drills

In the words of Benjamin Franklin, “If you fail to plan, you are planning to fail”. Injury and medical emergencies are a reality. Despite even the very best and rigorous prevention measures, they do happen, often without any warning. 

Preparing for an incident before it occurs is extremely valuable in ensuring that coaches have the necessary equipment, know where to go, and know what to do when an emergency occurs.  These are critical elements of a functional Emergency Response/Action Plan. In some cases, Emergency Response Plans may not be written or are untested, serving no substantive purpose in these instances.  

The National Athletic Trainers Association (NATA), US Lacrosse and a host of other reputable organizations have emergency response planning information as well as templates and resources that provide information on how to prepare and train for emergencies. When using these resources, be sure that the plan is rational, tested and practiced. 

US Lacrosse EAP Resource

Drill Resource from AZ SHARE

High-Quality Training

Coaches should be trained in First Aid, CPR and the use of an AED, as well as sports specific emergencies such as concussion. Training provides essential skills and can help increase the comfort and confidence level of those trained. 

There are advantages to selecting training agencies that not only offer certification from well recognized national organizations, but can also articulate how they aim to meet or exceed the standards established by those certifying bodies such as the American Heart Association, American Red Cross, the Health and Safety Institute and the National Safety Council.


Questions to ask of your prospect training providers include:

  • What is the instructor to student ratio?
  • What is the manikin to student ratio?
  • Do students receive the printed or digital learning tools in advance?
  • Is the course length in accordance with the recommended time established by the certifying organization?  
  • Do they offer references from recognized companies that are leaders in workplace safety?
  • Are instrumented manikins used in order to measure CPR quality?
  • Can scenarios be contextualized for a lacrosse setting?

There are countless agencies and individuals who offer training. However, because they offer training does not mean that the training is of high quality. Asking these questions can help in selecting a provider of quality training.

Special Considerations

Performance of quality cardiopulmonary resuscitation is essential for improving outcomes and saving cardiac arrest victims, regardless of the cause. It has been determined that performing compressions over football equipment inhibits compression depth and rate and reduced compression quality and outcomes. Up until recently, chest compression quality when performed over lacrosse shoulder pads has not been studied.

A study published in the Journal of Athletic Training concluded that lacrosse shoulder pads did not inhibit the ability to administer chest compressions with adequate rate and depth. With appropriate training to improve hand placement, the pads may be left in place while cardiopulmonary resuscitation is initiated during sudden cardiac arrest.

In contrast, a second study also published in the Journal of Athletic Training recommends the lifting or removal of shoulder pads to deliver chest compressions. 

Practicing high-quality CPR on manikins that have instrumented feedback, outfitted with a lacrosse helmet and shoulder pads will help learners to address these special circumstances.

AEDs and AED Deployment Strategies

Automated external defibrillators or AEDs are lightweight, portable devices that deliver an electric shock through the chest to the heart with a goal of stopping an irregular and chaotic heart rhythm or arrhythmia and allowing a normal rhythm to resume following sudden cardiac arrest. 

The person’s heart rhythm is analyzed by an integral computer algorithm through adhesive electrodes and the computer determines whether a defibrillator shock is needed. When a shock is recommended, the AED guides the user through the process of shock delivery. AEDs advise a shock only for ventricular fibrillation or another life-threatening condition called ventricular tachycardia.  

If sudden cardiac arrest is not treated within minutes, it will quickly lead to death. Time passes quickly. Consider time to detection, time to first compressions, 911 processing time, retrieval of the nearest AED and arrival of professional help. Minutes matter and seconds count.

Defibrillators should be kept in a state of readiness and accessible within 2 to 3 minutes of a player’s collapse. This applies for practices as well as games.

A number of strategies are employed to provide defibrillator coverage. This includes permanent placement of AEDs in weatherproof enclosures, storage in nearby structures and carried by coaches in purpose built cases and backpacks. Whatever the strategy, efforts are needed to insure rapid, reliable access and utilization.

Informal Lacrosse Coaches Facebook Page Poll 

An informal poll was conducted on a Lacrosse Coaches Discussion Group on Facebook. The results of the poll are reflected below:

All defibrillators should be readily available as and when the need arises. In an ideal world AEDs would available in unlocked or otherwise easily accessible locations.

However, there are instances where the levels of security are such that it is necessary to have these devices stored in a more secure environment such as schools, concession stands and other nearby structures. This is not only to protect against theft, but also to protect against vandalism, curiosity, weather, and mischievousness.

AEDs Stored in Nearby Structures

30% of poll participants indicated that AEDs are housed inside structures such as schools and concession stands. In these cases, the AED(s) may provide coverage to nearby athletic fields. 

For those who have AEDs in nearby structures, ask the following questions:

  • Is the AED maintained in a state of readiness?
  • Is the AED routinely inspected?
  • Is the structure open during at all times when practice and games are underway?
  • Can the AED be fetched and returned to the field in 2 to 3 minutes?

If you answered “no” or you are uncertain about the above questions, your strategy may be inadequate or inconsistent.

Carried to Practices and Games by Coaches

23% of poll participants indicated that AEDs are carried to practices and games by coaches. There is an advantage to this strategy as the AED can be utilized on your own fields as well as at “away” games and tournaments.

For those who have coaches carry AEDs, ask the following questions:

  • Is the AED maintained in a state of readiness?
  • Is the AED routinely inspected?
  • Is the AED brought to the sidelines for all practices and games?
  • Is the AED carrying coach present at all practices and games?

If you answered “no” or you are uncertain about the above questions, your strategy may be inadequate or inconsistent.  

Available in 24/7 Accessible Weatherproof Enclosures

4% of poll participants indicated that AEDs are available on a 24/7 basis in weatherproof enclosures. This relatively new deployment strategy has several advantages, most importantly 24/7 accessibility and protection from tampering, theft and the elements. Additionally, all those who use the fields have access to defibrillation and therefore negates the need for each team and organization to have and maintain their own AEDs.

For those who have AEDs in 24/7 accessible and weatherproof enclosures, ask the following questions:

  • Is the AED maintained in a state of readiness?
  • Is the AED routinely inspected?
  • If a secure access type of enclosure (requiring an access code), does your local EMS and dispatch agency have the access code?

If you answered “no” or you are uncertain about the above questions, you should contact the party responsible for the facilities for confirmation and corrective measures. 

Locations Without Reliable Defibrillation Strategies

42% of poll participants indicated that AEDs are not available or inconsistently available. While related regulations and laws may vary from state to state, the need for defibrillator coverage has been clearly established. The NATA led Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations related to AEDs are:

  • An AED should be on site and readily available within 3 minutes (with 1 minute being ideal) for all organized athletic activities. 
  • School staff, medical professionals, coaches, and athletes should be educated at least annually about the location, function, and use of AEDs

Conclusion 

Many deaths from sudden cardiac arrest are avoidable through proper screening, prevention, recognition, preparation and treatment.  Providing for a safety in athletics is an essential responsibility that is shared by organizations, teams, coaches, officials, parents and athletes.  

Through the utilization of available evidence, guidelines and resources, we have the ability to save hearts too young to die.

Having an emergency response plan, high-quality training and accessible equipment for your lacrosse program is essential.  Without a well thought out and rehearsed plan that includes a rapid and reliable defibrillation strategy, there should be no practices, no drills, no games.