sudden death

Monday, December 4, 2017

Citius, Altius, Fortius. Nowhere in the Olympic motto does it say higher, faster, stronger, suddenly die. And for that reason, when an athlete collapses on the court, our ability to understand the body is more than a little strained. For the basketball fans watching North Carolina State hosting South Carolina State, the collapse of Tyvoris Solomon was more than unexpected, it was not understandable. There is a happy ending because of the quick actions of the South Carolina medical staff and with CPR, Mr. Solomon was resuscitated, resting in hospital and able to talk about he cheated sudden death. Actually, he doesn’t remember…he remembers sitting on the bench and then nothing until he awoke in the ambulance. Other elite athletes have been less fortunate and have died on the court. Regardless of the success rate in television fiction, sudden death is often permanent.

There are a variety of causes of sudden death but most all revolve around the heart and its ability to pump blood to the body. Not only does the muscle have to work, but also there needs to be normal electricity to allow the electric pump that is the heart to squeeze in a coordinated fashion. If the brain loses blood supply for even a few seconds, it turns off and the victim can fall unconscious to the floor. The most common cause of this sudden in an athlete is hypertrophic cardiomyopathy, an abnormal thickening of the heart muscle that causes the fatal heart rhythm of ventricular fibrillation or V-Fib. Instead of sending a coordinated electrical signal to all heart muscle cells to squeeze at the same time, the electricity is chaotic, each cell squeezes to its own drummer, the heart quivers like a bowl of Jello-O and no blood gets pumped to the body.

                

Normal Heart Rhythm                                         Ventricular Fibrillation 9V Fib)

The question becomes, how do we find those at risk before sudden death becomes sudden? There has always been debate about how much time, effort and money should be spent on screening all high school and college athletes just to find the one person at risk. There is some debate by medical experts as to whether heart screening with EKGs and echocardiograms (heart ultrasound) would actually work, but there are guidelines on how to find athletes who might have a higher risk of heart abnormalities that could lead to sudden death.

This is where school administrator, parents and the medical community have to step up and realize the importance of the yearly pre-participation exam.

These findings that should trigger a more intense look for heart problems that could result in sudden death:

  • Family History
    • Family member who had premature sudden cardiac death
    • Heart disease in a family member who is younger than 50
  • Personal History
    • Heart Murmur
    • High Blood Pressure
    • Previous passing out event
    • Unexplained fatigue
    • Unexpected shortness of breath with activity
    • Chest pain with activity
  • Physical Exam
    • Listening for a heart murmur
    • Feeling for normal pulses in the groin
    • Blood pressure measurements
    • Assessing for Marfan Syndrome (a genetic disease that is associated with abnormal aorta)

Sudden death may not be completely preventable, but instead of blindly filling out paperwork and having a perfunctory physical exam in a school gym, taking the time and effort to actually have an athlete examined may be lifesaving.

And the last most important thing to do…learn CPR, know where the nearest AED is located, and come to the aid of somebody in distress. Don’t expect that somebody else will step up. There is no guarantee that there will be a trainer, nurse or doctor nearby to take the lead.

 

 

 

 

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concussion: looking out for those who are injured

Monday, November 13, 2017

As the NFL again takes flak this week for its head injury awareness with potential injuries to the Seahawks’ Russell Wilson, the Colts’ Jacoby Brissett and the Falcons’ Devonta Freeman, it’s important to remember that concussion symptoms can be subtle and have a delayed onset. The concept that a brief assessment on the sideline is sufficient to say yeah or nay on the diagnosis fails to meet the criteria set in the most recent consensus statemen from the 5th international conference on concussion in sport, held in Berlin in late 2016.

The bottom line for initial assessment is that all athletes, regardless on level of competition, should be removed from the field of play, if concussion is suspected. If the diagnosis is not in doubt, for example a player who is knocked out, briefly confused or has difficulty with balance, the player should not return to the game. If the diagnosis isn’t confirmed but suspicion exists, then the player needs to undergo sideline testing. But there is not one perfect test that can confirm or deny the diagnosis. Sideline screening can be done but it takes at least 10 minutes for most testing to be completed. While it can occur on the sideline, it is often better to find a quiet place to interview and examine the potentially injured player.

From the consensus guidelines:

“In cases where the physician may have been concerned about a possible concussion, but after the sideline assessment (including additional information from the athlete, the assessment itself and/or inspection of videotape of the incident) concussion is no longer suspected, then the physician can determine the disposition and timing of return to play for that athlete.”

And also from the same guidelines, an athlete with a sport related concussion should not be allowed to return to play on the day of injury.

There is a caveat that symptoms may be delayed and repeated evaluations are warranted. The problem is that the symptoms can be very subtle, from difficulty concentrating, to sleep disturbances, to changes in personality. The ability for the brain to function and process information may be affected so that concussed high school and college athletes may drop a full grade point in their classes for the ensuing semester.

As hard as it is to diagnose subtle head injury, it’s just as hard to decide when the brain has healed enough to allow the athlete to return to play. There is no test that confirms brain healing and most athletes recover within a month. Practically, return to play strategies take about a week if the athlete remains symptom free. That said, concussion symptoms may last for months.

Unfortunately for those who decide whether a Seahawk or Colt or Falcon can return to play, instant replay allows fans at home and in the stadium to witness the consequences of a hit to the head and judge for themselves whether the possibility of a concussion might exist. And when a referee sends a player off because of concussion concern, it’s incumbent upon the team’s medical staff to follow through with a thorough assessment. The player may not know what happened or realize that they were concussed; it’s up to the coaching and medical staff to protect the brain, even if the player actively refuses that help.

Until that is the standard of care, the NFL will continue to get flak.

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