Resources

Increased exposure and recognition of athletic trainers calls for an increasingly greater need to demonstrate levels of skill and competency. The Foundation provides funding for education programs to meet this need. The Foundation provides funding for educational opportunities at the national and district levels as well as home study for the individual. A wide variety of educational materials are available free to NATA members such as summit proceedings, palm cards and supplements to the Journal of Athletic Training.

The NATA Continuing Education Committee selects an Annual Education Topic. Topics to date are:

1994-1996 Head Injury
1996-1997 Sudden Death
1997-1998 Pharmacology
1998-1999 Psychology of Rehabilitation
1999-2000 Lumbar Spine Pain in Athletes
2000-2001 The Hand and Wrist in Sport
2001-2002 Infectious Disease: Considerations for Physical Activity
2002-2003 Care of Athletes W/Physical or Cognitive Impairment
2003-2004 Emergency Preparedness
2004-2005 Evidence-Based Athletic Training

Education Programs funded by the NATA Foundation:

(for more information on any programs, please call 800-TRY-NATA, ext. 141)

• Home study [Professional Achievement Self Study (P.A.S.S.)
• Symposium at the NATA Annual Meeting
• Lecture Exchanges with the AOSSM, ACSM and AMSSM
• Summits - call 800-TRY-NATA, ext 147 to order proceedings
• Palm Card on Pre-Participation Physicals - call 800-TRY-NATA, ext. 147 to order

Home Study [Professional Achievement Self-Study - PASS - Program)

*A portion of proceeds benefits the Foundation

Statement of the Summit Conference on
Sudden Death in the Athlete

WRITING GROUP: Steven P. Van Camp, M.D., Chair; Eugene F. Luckstead, M.D.; Luis Palacios, M.D.; Malissa Martin, Ed.D., A.T.C.; Herb Amato, D.A., A.T.C.

Three to four million young men and women participate annually in organized high school and college athletics in the United States. These athletes clearly experience the benefits of participating in athletics. Unfortunately, each year a small number of athletes suffer significant sports-related injuries, leading to permanent disability or death (1,2). Sudden death of athletes is often highly publicized (3,4) heightening public awareness and concern (5). These tragic deaths have significant impact on athletes, coaches, sports administrators, sports organizations and entire communities, in addition to the immediate family.

In October 1996, the National Athletic Trainers' Association Research and Education Foundation hosted a Summit titled "Sudden Death in the Athlete." Sports and medical organizations that work with athletes were invited to participate.

The participating organizations developed a consensus on the most appropriate approach to the problem of sudden death in athletes. While sports-related deaths may be both traumatic and nontraumatic, it was agreed by the representatives to focus upon nontraumatic deaths (those resulting from the physical exertion involved in sports, not as the result of direct bodily injury). It is also recognized that traumatic sports injuries, both fatal and non-fatal, including non-penetrating blunt chest trauma, represent a serious problem requiring the attention of medical and sports organizations.

Nontraumatic sports deaths are primarily cardiovascular in nature, however, approximately 20 to 25 percent of these deaths are due to noncardiovascular causes, including heat-related illness, rhabdomyolysis in individuals with sickle cell trait, and drug-related deaths (1).

The frequency of nontraumatic sports deaths, while not known with certainty, has been estimated in a study of high school and college athletes using data obtained through the National Center for Catastrophic Sports Injury Research (NCCSIR) (1). These data indicate an occurrence of approximately 16 nontraumatic sports deaths per year in organized high school and college athletics in the U.S. The estimated annual death rates were 7.5 and 1.3 deaths per million male and female athletes, respectively; 6.6 per million male high school and 14.5 per million male college athletes; and 1.2 per million female high school and 2.8 per million female college athletes.

With respect to specific sports, the increased frequency of athletes dying while participating in basketball and football reflects a greater number of participants in those sports rather than increased risk of nontraumatic deaths (1). The small numbers of deaths, however, limit statistical comparisons.

Multiple cardiovascular disorders have been found to cause sudden death in athletes (1,2). These disorders are primarily congenital or familial conditions and, less frequently, acquired conditions (Table 1).

It has been suggested that one of these cardiovascular disorders (hypertrophic cardiomyopathy) is disproportionately prevalent in African-American athletes (6). However, available data do not support the concept that there is an increased prevalence of any of these cardiovascular disorders within specific racial groups.

The preparticipation physical evaluation of athletes has been addressed by a task force from multiple medical organizations (7). The specific issue of cardiovascular preparticipation screening of competitive athletes was addressed by a panel appointed by the American Heart Association Science Advisory and Coordinating Committee. The medical/scientific statement from that panel was published by the American Heart Association (8); endorsed and published by the American College of Sports Medicine (9); endorsed by the Board of Trustees of the American College of Cardiology; and supported by the American Academy of Pediatrics Section on Cardiology. The recommendations from the organizations participating in the Summit on "Sudden Death in the Athlete" go beyond the cardiovascular preparticipation screening of athletes. They include monitoring of participating athletes, rapid response to medical emergencies, and appropriate follow-up for athletes experiencing symptoms suggestive of cardiovascular or other disorders that may result in a nontraumatic sports death. It is the ultimate purpose of these recommendations to reduce the frequency of these tragedies.

Recommendations

1. Preparticipation Screening for Cardiovascular Disorders. Prior to participating in high school and college sports, athletes should undergo a preparticipation history and physical examination. Ideally, this examination should be performed at least six weeks prior to the start of preseason training. With regard to the detection of cardiovascular disorders that place athletes at risk for sudden death and ultimately the prevention of sudden death, Summit participants support the American Heart Association (AHA) Panel recommendation (8) that a preparticipation examination should be "performed by an appropriately trained health care worker with the requisite training, medical skills, and background to reliably obtain a detailed cardiovascular history, perform a physical examination and recognize heart disease." Although there is varied consensus as to the appropriate frequency of preparticipation examinations, they should be performed as recommended by the AHA Panel upon entry into the sports program, and then at least every two years with an interim history obtained annually.The emphasis of the cardiovascular history should be on questions designed to identify those individuals at risk for sudden death. These include questions recommended by the AHA panel (8) regarding: "1) prior occurrences of exertional chest pain/discomfort or prior exertional syncope/near syncope as well as excessive, unexpected, and unexplained shortness of breath or fatigue associated with exercise; 2) past detection of a heart murmur or increased systemic blood pressure; and 3) family history of premature death (sudden or otherwise), or significant disability from cardiovascular disease in close relative(s) younger than 50 years old or specific knowledge of the occurrence of certain conditions (for example, hypertrophic cardiomyopathy, dilated cardiomyopathy, long Q-T syndrome, Marfan syndrome and clinically important arrhythmias)." In order to obtain accurate information, athletes and parents and/or guardians should be responsible for completing history forms for high school athletes.The physical examination as recommended by the AHA Panel (8) and the Pre Participation Evaluation Task Force (7) "should be conducted in an environment conducive to optimal cardiac auscultation... [and] … should emphasize (but not necessarily be limited to): (1) precordial auscultation in the supine and standing positions to identify, in particular, heart murmurs consistent with dynamic left ventricular outflow obstruction [present in some cases of hypertrophic cardiomyopathy]; (2) assessment of the femoral artery pulses to exclude coarctation of the aorta; (3) recognition of the physical stigmata of Marfan syndrome [see Table 2]; and (4) brachial artery blood pressure measurement in the sitting position.”An athlete identified through the preparticipation history and physical examination, or the interim history to have evidence of a cardiovascular abnormality should be referred to an appropriate medical specialist for further evaluation. It may then be determined whether he or she is eligible to participate in athletics. With regard to the eligibility of athletes for competition, the 26th Bethesda Conference sponsored by the American College of Cardiology and the American College of Sports Medicine regarding “Recommendations for Determining Eligibility for Competition in Athletes With Cardiovascular Abnormalities” (10) and/or the American Academy of Pediatrics “Medical Conditions Affecting Sports Participation (11) should be utilized.
2. Athletic field monitoring and recognition of problems and potential problems. Qualified personnel (coaches, athletic trainers) should have at the minimum current CPR and first aid certification. They should be present at all practices and competitions to monitor athletic participation, including weather conditions, recognition of injuries and other physical conditions, for example, cardiovascular, heat illness, choking, and dehydration. Ideally, a certified athletic trainer should be on site to supplement the capabilities of the coaches.
3. Emergency medical plan. A well-organized and practiced emergency medical plan should be in place prior to any practice or competition. It should be developed by school administrators, team physicians, school nurses, athletic trainers, coaches and appropriate emergency medical service personnel. The emergency plan should include: 1) A written plan of action for all sports venues (indoor and outdoor); 2) communication capabilities (availability of telephones and emergency telephone numbers); and 3) equipment, for example, stretchers, backboards, splints. The plan should be clearly understood by all coaches and involved personnel, and practiced on a regular basis.Information cards for all athletes should be kept in a confidential place by the coach or medical staff. This information should include the athlete’s name, address, telephone number, age, date of birth, parent/guardian’s name, with their address and telephone number, insurance information, specific medical information of importance (such as allergies, pre-existing medical conditions, eye wear, orthodontics, and prosthetics).
4. Medical Followup. All athletes who are injured, or who experience exercise-related difficulties suggestive of cardiovascular or other disorders should receive appropriate medical evaluation. This applies to orthopedic problems as well as to cardiovascular and general medical problems, and involves both emergency and non-emergency situations. Parents should be notified of all significant injuries and exercise-related difficulties. Return to practice and competition decisions in cases of suspected cardiovascular disorders should be made by appropriate medical specialists utilizing the 26th Bethesda Conference (10) and/or American Academy of Pediatrics’ Sports Medicine: Health Care for Young Athletes (12) guidelines.

These recommendations are made in an attempt to provide a safe and healthy environment for sports participation and to minimize the risk of sudden death in athletes. Parents, athletes, coaches, athletic trainers, administrators, medical care providers and sports organizations should understand the risks associated with athletic participation. In addition to this awareness, it is also important to attempt to minimize the risk of severe injury and athletic deaths. The benefits of physical activity and sports participation are great. However, before a young athlete is allowed to participate, he or she should be evaluated with preparticipation history and physical examination, and subsequently, should participate in a program that provides on-field monitoring and recognition of problems, an appropriate emergency medical plan, and appropriate medical follow-up for any incurred injuries or difficulties.

Clearance for individuals to participate in sports is the responsibility of the team physician and/or the personal physician of the individual.

Participating Organizations

Representatives from the following organizations participated in the Summit on Sudden Death in the Athlete hosted by the National Athletic Trainers’ Association Research and Education Foundation October 1996, Dallas, Texas: American Academy of Pediatrics (Eugene Luckstead, M.D.), American College of Sports Medicine (Steven P. Van Camp, M.D.), American Medical Society for Sports Medicine (Luis Palacios, M.D.), American Orthopaedic Society for Sports Medicine (Irvin E. Bomberger), Institute for the Study of Youth Sports (Robert Malina, Ph.D.), Minneapolis Heart Institute Foundation (Barry Maron, M.D.), National Association for Intercollegiate Athletics (Pat Trainor, ATC), National Association for School Nurses (Emita Garcia, RN), National Association for Sport and Physical Education (Judith C. Young, Ph.D.), National Athletic Trainers’ Association Clinic/Industrial/Corporate Committee (Bruce McCrary, ATC), National Athletic Trainers’ Association Research and Education Foundation (Malissa Martin, Ed.D., ATC), National Athletic Trainers’ Association Secondary School Committee (Jon Almquist, ATC), National Collegiate Athletic Association (Bryan Smith, M.D., Randall W. Dick), National Federation of State High School Associations (John Heeney), and National Marfan Foundation (Cheryl Gassner, RN).

This statement is a product of the NATA Research and Education Foundation, not the National Athletic Trainers’ Association.

Table 1.
Cardiovascular Disorders Causing Sudden Death in Young Athletes

• Hypertrophic cardiomyopathy
• Coronary artery anomalies
• Myocarditis
• Aortic stenosis
• Dilated cardiomyopathy
• Atherosclerotic coronary artery disease
• Aortic rupture
• Nonspecific cardiomyopathies
• Coronary artery aneurysm
• Arrhythmogenic right ventricular dysplasia
• Wolff-Parkinson-White syndrome
• Long Q-T syndrome

Table 2.
Physical stigmata of Marfan’s syndrome

• Skeletal abnormalities
  • Arm span greater than height
  • Chest wall deformities
  • Kyphoscoliosis
  • High-arched palate
  • Hyperextensible joints
• Cardiovascular abnormalities
  • Murmur of aortic regurgitation
  • Murmur of mitral regurgitation
• Ocular abnormalities
  • Myopia (nearsightedness)
  • Ectopia lentis (upward displacement of lens of the eye)

References

Van Camp SP, Bloor CM, Mueller FO, Cantu RC and Olson HG. Nontraumatic sports death in high school and college athletes. Med. Sci. Sports Exerc. 27:641-647, 1995.

Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athlete: clinical, demographic and pathological profiles. JAMA 276:199-204, 1996.

Maron BJ. Sudden death in young athletes: lesions from the Hank Gathers affair. N. Engl. J. Med. 329:55-57, 1993.

Van Camp SP. What can we learn from Reggie Lewis’ death? Physician Sportsmed. 21:73-97, 1993.

Rhoden WC. Deaths of teen-age athletes raise questions over testing. The New York Times, March 14, 1994; Sect A:1 (col. 5).

Maron BJ, Poliac LC, Mathenge R. Hypertrophic cardiomyopathy as an important cause of sudden cardiac death on the athletic field in African-American athletes. J. Am. Coll. Cardiol. 29:462A, 1997.

Smith DM, Kovan JR, Rich BS, Tanner SM. Preparticipation Physical Evaluation. 2nd ed. Minneapolis, MN. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine.

American Heart Association Scientific Statement: Cardiovascular preparticipation screening of competitive athletes. Circulation 94:850-856, 1996.

American Heart Association Scientific Statement: Cardiovascular preparticipation screening of competitive athletes. Med. Sci. Sports Exerc. 28:1445-1452, 1996.

Maron BJ, Mitchell JH. 26th Bethesda Conference: Recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. J. Am. Coll. Cardiol. 24:845-899, 1994.

American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics 94:757-760, 1994.

American Academy of Pediatrics. Sports Medicine: Health Care for Young Athletes, 2nd ed. Elk Grove: American Academy of Pediatrics, 1991.