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Advanced Cardiac Life Support


Sudden Cardiac Arrest Protocol Algorithm

The overall rate of catastrophic injury during athletic competition is less than 1 in 100,000.  Per the National Center for Catastrophic Sports Injury Research (NCCSIR), 42% of the 92 captured catastrophic injuries/illnesses reported from July 1, 2014 to July 30, 2015 were due to sudden cardiac arrest (SCA) and other cardiac related conditions.1  The leading causes of SCA in athletics are hypertrophic cardiomyopathy (25%), commotio cordis (20%), and coronary artery anomalies (14%).   While early interventions to prevent cardiac arrest would be ideal, efforts to effectively screen for predisposing factors remain limited.  In 55% to 80% of SCA cases in athletics, the athlete is asymptomatic until the onset of the cardiac event, with the underlying cause being identified only after death.2,3 The survival rate following SCA in young athletes is disconcertingly lower than expected, and may be significantly lower than survival rates in older persons. 4

The rate of SCA in persons 35 years or older has been estimated to be 1 in 1000 persons.5 Jones et al reported a 2.1% annual probability of a SCA on high school campuses when factoring in older persons, such as employees, spectators, officials, coaches, and visitors.6  Even when considering young athletes and older persons, the risk of a SCA remains low.  Unfortunately, the reality is that the majority of resuscitation efforts following SCA will not result in a return of spontaneous circulation (ROSC) and ultimate survival.7  This is particularly true when cardiac arrest is due to blunt trauma.8 However, the single most influential factor affecting survival from an out-of-hospital SCA in any population, and for any reason, is the initiation of high-quality CPR, early defibrillation, and subsequent ACLS intervention.  Studies examining trained lay-rescuers providing effective CPR and rapid defibrillation within 3-5 minutes have demonstrated survival rates of 41% to 74%.9-18  Therefore, an effective strategy to ensure early recognition of cardiac arrest, immediate initiation, continuation and monitoring of high-quality CPR, timely defibrillation, and diagnosis and treatment of reversible underlying causes of cardiac arrest is essential to improving the survival rate in young athletes and non-athletes alike.  Evidence Category: A

According the AHA, essential elements of high-quality CPR include:7

Aside from high-quality CPR, defibrillation of ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT) is the only rhythm-specific intervention that has been demonstrated to increase survival.  Therefore, other ACLS interventions such as vascular access, drug therapy and advanced airway placement are recommended considerations only if they can be performed without interruption of on-going delivery of high-quality CPR.  The AHA recommends the following shock energy for defibrillation of VF/pulseless VT:

If an athlete, or other patient, is observed to collapse or is found unconscious, it should be assumed they are in cardiac arrest until cardiac arrest is otherwise ruled out.  The first provider to aid the victim should immediately initiate high-quality CPR by beginning chest compressions.  The second provider should retrieve and begin setting up a defibrillator by placing the pads, and turning on the unit to check the rhythm.  Pads should be placed on the exposed chest in an anterior-lateral position.  Anterior-posterior, anterior-left infrascapular, and anterior-right infrascapular are acceptable alternative pad placement locations.    If an organized rhythm is detected, a pulse check should be performed.  If the victim presents as pulseless, high-quality CPR should resume immediately with chest compressions.7  Evidence Category: A

The diagnostic accuracy of provider pulse checks has been questioned.  In 1996 Eberle, et al reported that in 10% of cases subjects failed to recognize an absent pulse as pulessness, while in 45% of cases subjects failed to identify a pulse despite there being a systolic blood pressure ≥80 mm Hg.19  Accuracy of AEDs are much more impressive.  In 81% of cases an AED will advise a shock for patients who have a shockable rhythm.  Operator error (eg. moving the patient during analysis) is attributed to much of the 19% error.  With respect to delivering a shock when there is an actual shockable rhythm, an AED may be as accurate as 99.9%.20,21,22  It is common for vital signs and arrest rhythm to evolve during management of a critical injury.  Since rhythms evolve during the course of care and the accuracy of AEDs appear to be more sensitive and specific than provider pulse checks in determining the appropriateness of initiating high-quality CPR, medical teams should consider placement of an AED or cardiac monitor early in the management of injuries/illnesses that result in unstable vital signs or that are known reversible causes of cardiac arrest.  This may help providers more quickly identify the onset of cardiac arrest and the need to initiate high-quality CPR.  Evidence Category:B

Diagnosis and treatment of reversible causes of cardiac arrest is essential to ROSC and ultimate survival.  Upon completion of the first 2 min cycle of high-quality CPR the medical team should begin assessing for and treating any known reversible causes of cardiac arrest.  Common conditions that are known reversible causes of cardiac arrest include:7

Best-practice emergency action plans in the athletic environment will have a combined BLS and ACLS out-of-hospital approach.  This approach may be implemented by 1) ensuring that properly trained BLS providers are available during all events, with a designated plan for initiating high-quality CPR within 3-5min and activation of the EMS system to transfer care to a team providing ACLS, or 2) having both BLS and ACLS providers available during events with the ability to provide immediate ACLS and transport to appropriate receiving facilities.  Evidence Category C

In a combined BLS and ACLS system termination of resuscitative efforts is guided by the AHA guidelines for BLS termination of resuscitative efforts which states that rescuers who start BLS should continue resuscitation until one of the following occurs:23

The AHA’s “BLS termination of resuscitation rule” states that all 3 of the following criteria must be present before moving a patient to an ambulance for transport or terminating resuscitative efforts:

  1. arrest was not witnessed by EMS provider or first responder;
  2. no return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis; and
  3. no AED shocks were delivered.

Once care has been transferred to ACLS providers, a different set of criteria may be considered in determining the appropriateness of terminating resuscitative efforts.  The National Association of EMS Physicians (NAEMSP) suggests that terminating resuscitative efforts may be appropriate in patients with witnessed arrest who do not respond to at least 15 min of ACLS care.8  Although literature suggests that expeditated transport is essential, patients suffering traumatic cardiac arrest seem to benefit from ACLS interventions, such as advanced airway placement and insertion of IV lines, as long as they do not delay or interrupt delivery of the first 2 min of high-quality CPR.7  This is particularly relevant to the sports medicine team because most arrests in athletics will result from blunt trauma or a known reversible cause, rather than a penetrating injury.  Therefore, in the management of SCA, sports medicine teams should plan to provide 2 min of uninterrupted high-quality CPR before initiating other ACLS intervention, and continue ACLS for 15 min before deciding to move the patient to an ambulance for transport to the nearest appropriate receiving facility. Evidence Category: A

Ancillary Content

Checking Pulse Checks Sports Emergency Care White Paper