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Preventing Sudden Death in Secondary Schools

in 2013, an Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs published a series of recommendations, including urging all high schools to have an AT on staff to take care of emergency situations and provide care for student athletes. 

To prevent and reduce injuries and death, the task force developed the following guidelines for schools:

  1. Create an emergency action plan in collaboration with coaches, athletic trainers, other medical professionals and campus safety officials and coordinate with the local emergency medical service (EMS) system. It should be site-specific, reviewed each season and updated as necessary. 
  2. Have athletic trainers on staff: the document reiterates the critical role athletic trainers play in preventing sudden death in sport such as prevention, diagnosis, emergency care and treatment. 
  3. Ensure that athletes acclimatize progressively to training demands and environmental conditions for optimal safety. Conditioning should be phased in gradually: the first seven to 10 days of any new cycle should be considered transitional. Exercise and conditioning should not be used as punishment.
  4. Create concussion management team: Concussions should be assessed with a comprehensive evaluation tool: team physicians and athletic trainers should consult a neuropsychologist when necessary, to interpret test scores. 
  5. Annual brain and spine safety education: An annual brain and spine safety education program and in-season behavior modification "check-ups" should be conducted for all student athletes. Be cognizant of athletes' medical conditions.
  6. Safe helmets: Athletic trainers and school officials should enforce the standard use of certified helmets.
  7. Management plan for spine and brain injuries: A comprehensive medical-management plan for acute care of potential spine or brain injury should be implemented if the patient has altered levels of consciousness, substantial neurologic concerns, midline spine pain or obvious spinal column deformity
  8. Return to play protocol after concussion.  The athletic trainer and team/treating physician should work together to implement a gradual return to participation progression for the concussed athlete. No secondary school athlete with a suspected concussion should be permitted to return to practice, game or activity on the same day; and should follow a supervised six-step gradual return from no activity to light, sport-specific, non-contact, limited and then full return to participation. The patient should also receive a written release from a medical professional trained in concussion evaluation and management.
  9. Heat acclimatization: Before the season begins, all teams should follow a heat acclimatization program that focuses on phasing in equipment use, intensity and duration of exercise and total practice time.
  10. Heat illness education: Administrators, coaches, athletes and parents must be educated about common causes and risk factors of heat stroke.
  11. Modify or cancel practices in extreme heat: Activities should be modified when environmental conditions are extreme.
  12. Provide for adequate hydration: Water or sports drinks must be available and placed at key locations on the field for players to drink quickly and freely during practice, conditioning sessions and competitions. 
  13. Cold-water immersion in case exertional heat stroke suspected.  Exertional heat stroke should be suspected in any athlete who exhibits extreme hyperthermia and central nervous system dysfunction during exercise in the heat. If EHS is suspected, cold-water immersion should be implemented before transport; all schools should have a cold water immersion tub; all patients with EHS should be monitored thoroughly for return to play considerations and cleared by a physician.
  14. Cardiovascular screening: Athletes should undergo cardiovascular screenings before participation in competitive activities.
  15. AED on site: An automated external defibrillator (AED) should be on-site and readily available within three minutes (with one minute being ideal) for all organized sports activities.
  16. Education and training  in use of AED: School staff, medical professionals, coaches and athletes should be educated annually about location and use of AEDs.
  17. Assume sudden cardiac arrest until proven otherwise: Any athlete who has collapsed and is unresponsive should be assumed to be in SCA until proven otherwise.
  18. Implement cardiac chain of survival in case of SCA: Proper management includes: prompt recognition of SCA (brief seizure-like activity occurs in 50 percent of young athletes with SCA and should not be mistaken for a seizure); early activation of the EMS system (call 9-1-1); early CPR beginning with chest compressions; early use of an AED; and transport of the patient with SCA to a hospital capable of advanced cardiac care.
  19. Test for exertional sickling.  Exertional sickling is a medical emergency occurring in athletes carrying the sickle cell trait. When the red blood cells change shape or "sickle" this causes those cells to clump in small blood vessels, leading to decreased blood flow. The drop in blood flow and oxygen delivery leads to a breakdown of muscle tissue and cell death, known as fulminant rhabdomyolysis. Efforts to obtain newborn screening results of sickle cell trait (SCT) status during the pre-participation physical are recommended. In the absence of these results, SCT screening should be considered for all athletes performing intense activity, with football being the highest risk sport for athletes with sickle cell trait. No patient who has SCT should be denied sports participation.
  20. Educate about signs and symptoms of exertional sickling. All personnel overseeing athletic activity should be educated on the signs and symptoms of exertional sickling and aware of preventive and immediate treatment measures. Symptoms include low back pain, muscle pain, cramping or weakness, fatigue, difficulty recovering from exercise and shortness of breath.  Simple precautions during exercise, including modification of training intensity and monitoring environmental conditions, can prevent complications from SCT: patients with SCT should be allowed longer periods of rest and recovery; and athletes with signs and symptoms should be removed from participation and managed with rest, hydration and cooling. 
  21. Activate EMS in case of collapse from exertional sickling, provide oxygen if available, attach an AED and transport the patient to the hospital. Health care professionals overseeing the patient's care should monitor the patient for metabolic complications.

The task force's recommendations were designed to provide secondary school administrators, physicians, athletic trainers, coaches, athletes and others with best practices for preventing sudden deaths, establishment of emergency action plans and providing appropriate medical care. The secondary school athletic population, comprising more than 7 million athletes, leads the nation in athletic deaths with cardiac conditions, heat stroke and head injuries being the three leading causes of death. Each of these causes, as well as exertional sickling, is specifically addressed in the statement.

The task force was spearheaded by NATA in collaboration with the National Strength and Conditioning Association. Supporting organizations include the Canadian Athletic Therapists Association and the National Interscholastic Athletic Administrators Association.

In addition to those associations, the following task force member organizations have also endorsed the new consensus statement: American College of Sports Medicine; American Medical Society for Sports Medicine; American Orthopaedic Society for Sports Medicine; American Osteopathic Academy of Sports Medicine; Gatorade Sports Science Institute; Korey Stringer Institute; Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center; National Center for Catastrophic Sport Injury Research; National Council on Strength and Fitness; and National Federation of State High School Associations.

"Most deaths are preventable through proper recognition and emergency protocols," said Task Force Chair Douglas J. Casa, PhD, ATC, FNATA, FACSM, director of athletic training, University of Connecticut Neag School of Education; and chief operating officer, Korey Stringer Institute.

"These best practice recommendations serve as a roadmap for policy consideration regarding the safety of secondary school athletes. We have addressed today the leading causes of sudden death in this age group. With continued education, research and advocacy, we can continue to reduce the number of fatalities and keep young athletes safe while playing the sports they love."

The health and safety of student athletes is of paramount concern to health care professionals, organizations, administrators, coaches, athletes and others. Yet there is no national organization at the secondary school level authorized to make policies and provide universal guidelines. The life-saving health policies are implemented state by state by coaches and athletic administrators, and depending on the state, with varying input and influence of sports medicine professionals.

 

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