Do not move player requiring resuscitation on field until return of spontaneous circulationBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2448 (Published 02 April 2012) Cite this as: BMJ 2012;344:e2448
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Drs Lyon and Wiggins illustrate a vital aspect of Sudden Cardiac Arrest (SCA) management on the sports field. Effective chest compressions, with minimal interruption, keeps the player alive until and between AED defibrillation shocks, if and when necessary. However, one cannot remain on the field of play for extended periods, and it is therefore part of the resuscitation process that an ambulance be brought onto the field to transfer the player off the field or that a decision be made to expiditiously remove the player off the field if ambulance access is not possible.Such transfer should be undertaken on a rigid type stretcher under all circumstances, so that effective continuation of chest compression can resume immediately after transfer actions, whether at the side of the field or in the back of the ambulance, as part of the process of moving the player to the stadium medical centre or nearest most appropriate emergency department.
Ambulance transfer of a player in SCA, with full chest compressions and intermittent AED defibrillation, if and when necessary, is a vital aspect of this type of resuscitation and is contrary to the wide held view that pulseless patients should not be transported to hospital emergency departments with en route CPR and AED use.Therefore it is mandatory that medical crews providing medical standby services at sport events be adequately trained in these sport-related resuscitation modifications if the player in SCA is to be affored the greatest chance of survival back to normality.
Competing interests: No competing interests
We read the recent letter by Lyon et al with interest . European public interest has recently focused on cardiac arrest occurring in the overtly healthy. Firstly, Fabrice Muamba, a UK premier league football player collapsed during a live televised match. Cardiac arrest was quickly diagnosed, cardiopulmonary resuscitation (CPR) started and an external automated defibrillator (AED) attached. Despite over 70 minutes of CPR before return of spontaneous circulation, Mr Muamba walked out of hospital a few weeks later having reportedly made an excellent recovery. By contrast, Piermario Morosini tragically died playing Serie B football in Italy. Unfortunately, there was then a long delay before CPR was started and no AED was available .
Much of the debate following these events has revolved around cardiac screening, which can identify those at risk , but false negatives (and positives) can occur and genetic or acquired disease may only express after the screening episode. Both of the football players above, had themselves had been screened in the past.
A key step to reducing mortality therefore remains CPR. Presently in Europe around 10% of individuals survive an out of hospital cardiac arrest . The most important determinant of survival is the presence of trained lay rescuer who is “ready, willing and able to act .”
Herein lies a problem; CPR is an overtly medical procedure for the lay person.
There are psychological barriers to an individual to stepping forward to intervene in a situation by starting CPR, including fear of doing something wrong, lack of knowledge and worry about contracting an infection from the casualty, particularly from mouth-to-mouth ventilation . The result in the UK is bystander CPR only being performed in 30% of cases .
A cultural change is needed. CPR needs to be de-medicalised, made simpler and de-stigmatised. There is now plenty of evidence that mouth to mouth ventilation has no impact on adult patient outcome in witnessed cardiac arrest and unnecessary . Many people will have seen the recent British Heart Foundation (BHF) national CPR television advert campaign in which the actor and retired football player, Vinnie Jones, shows how to perform hands only CPR to rhythm of the Bee Gees song “Staying Alive.” Hopefully this will help to improve the willingness of bystanders to perform CPR.
Whilst training works , delivery needs to be on a population scale. We support the BHF and UK Resuscitation Council campaigns for CPR to be taught in schools . This approach has international guideline recommendation , and evidence of benefit. For example, in a German study, pupils aged 10 were taught CPR once yearly over a 4 year period by their own teachers, the latter having attended a one hour training course . The training markedly increased confidence and willingness to help in the event of a cardiac arrest. In the United States, 32 states now advocate CPR teaching in schools . In Seattle, where 17,792 secondary school students were taught CPR in 2010, bystander CPR rates of 61% and survival of 49% from out of hospital arrest (in a shockable rhythm) have been reported . Lay CPR training was thought to be central to these impressive figures.
Finally, the recent UK and Italy football experience shows the importance of an emergency response plan to cardiac arrest in high risk areas  Although having trained lay responders is the most important part of this, it should also involve having access to an AED. Early defibrillation is crucial with a 10% fall in success rate with each minute that passes after the onset of ventricular fibrillation . Devices are now extremely easy to use – switch on, copy the diagram showing pad positioning and follow the machine’s verbal instructions.
We, the authors of this article have all been involved with patients who have made full recovery following prolonged resuscitation after effective, prompt CPR (and usually defibrillation) but sadly far more cases with delayed CPR and subsequent death or poor neurological outcome. Recent, public events have highlighted the importance of CPR, and we believe that the time is now right to encourage the UK government to consider how we best train as many people as possible in this basic, lifesaving skill.
1) Lyon RM, Wiggins C. Do not move player requiring resuscitation on field until return of spontaneous circulation. BMJ 2012; 344: e2448.
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Competing interests: Dr Sado receives a clinical research training fellowship grant from the british heart foundation to study cardiomyopathy and cardiovascular magnetic resonance.
Lyon and Wiggings very successful in the letter focused on key aspects of the protocol in cases where CPR is needed. But we have to clarify some aspects. Cardiovascular problems that may end with a sudden death in athletes can be prevented with screening protocol which includes an ECG(1). This type of problem is not unique to elite athletes but in a sporting event may be affected amateur(2) athletes and spectators(3). It is therefore necessary basic training and updating of de coaches, physical education teachers..., so they cam act quickly(4), and know how to properly use the equipment for which there is no interruption in CPR before arrival of ambulances. During this action should be taken measures to protects patients and physicians from legal liability(5), and that both patient and physician have enough privacy, using a box in the field, similar to those used in the locker room tunnel. To make the right decisions for action is necessary to review how manage a CPR studying the cases ocurred(6), and finally determine a protocol that is widely reported.
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2. Stratil P, Sterz F, Haugk M, Wallmuller C, Schober A, Horburger D, et al. Exercise related cardiac arrest in amateur athletes on the tennis court. Resuscitation 2011;82(8):1004-07.
3. Leeka J, Schwartz BG, Kloner RA. Sporting Events Affect Spectators' Cardiovascular Mortality: It Is Not Just a Game. Am. J. Med. 2010;123(11):972-77.
4. Casa DJ, Guskiewicz KM, Anderson SA, Courson RW, Heck JF, Jimenez CC, et al. National Athletic Trainers' Association Position Statement: Preventing Sudden Death in Sports. J. Athl. Train. 2012;47(1):96-118.
5. Kane SM, White RA. Medical Malpractice and the Sports Medicine Clinician. Clin. Orthop. Rel. Res. 2009;467(2):412-19.
6. Kramer E, Dvorak J, Kloeck W. Review of the management of sudden cardiac arrest on the football field. Br. J. Sports Med. 2010;44(8):540-45.
Competing interests: No competing interests
Whether or not a regional air ambulance service provides support to cardiac events depends on how rural that area is and the corresponding likelihood of delay in transferring a patient to a cardiac centre. As ambulance response times in London are consistently below 8 minutes (1) and specialist hospitals are readily accessible, London patients are only considered for aero-medical support if they have suffered from major trauma.
Jones and Moorehouse suggest HEMS as a potential solution to the dilemma of whether to continue to try and obtain a cardiac output “stay and play” or to transfer to a specialist center whilst continuing CPR “scoop and run”. Despite HEMS being undoubtedly useful in expertly intubating the footballer and expediting transfer to a specialist unit their capabilities would not greatly supersede those of the attending paramedics, as unlike in a trauma scenario rapid sequence induction of anaesthesia is not required, indeed paramedics are trained to intubate arrested patients as part of their core competencies.
Whereas the use of ALS in pre-hospital, non-traumatic, cardiac arrest is a contentious issue, with intubation shown not to increase survival (2), skilled personnel, advanced techniques and helicopter transfer are shown to significantly benefit the outcomes for trauma patients (3). Although a helicopter extraction from White Hart Lane may have benefited this extremely unusual case (and looked astounding on match of the day), the standard use of HEMS in urban cardiac arrests would overwhelm the service and reduce the benefit to those that need it most – the severely injured.
1 – The information centre for health and social sciences. Ambulance services England. 2011. http://www.ic.nhs.uk/webfiles/publications/Audits%20and%20Performance/Am...
2 – Stieg IG, Wells GA, Field B et al. Advanced cardiac life support in out-of-cardiac arrest. New England Journal of Medicine. 2004. 351: 647-56 http://www.nejm.org/doi/full/10.1056/NEJMoa040325
3 - Helicopters and the civilian trauma system: national utilization patterns demonstrate improved outcomes after traumatic injury. Brown JB, Stassen NA, Bankey PE, J Trauma. 2010 Nov;69(5):1030-4; discussion 1034-6.
Competing interests: No competing interests
Whilst we support Lyon and Wiggins’ evidence based approach to field of play resuscitation we also believe that each situation must be judged on its merits. Each situation is completely different and the recent case, if anything, highlights this view. An OOH arrest with no bystander CPR is a completely different situation compared with an event where several team doctors and a consultant cardiologist are present. Would the patient have been in a better clinical state for 78 minutes of un-interrupted CPR on the White Hart Lane pitch rather than CPR before and during immediate transfer to the expertly staffed and equipped cardiac intensive care unit?(1)
We must be realistic; there will unfortunately always be breaks in totally effective CPR, even without transferring the patient; during shocks and during CPR giver transfers for example. Surely the key here is to minimise the frequency and length of breaks in effective CPR, whilst getting the patient to an appropriate area of higher care as soon as possible. The alternative is bringing the intensive care unit to the patient, which with London’s Helicopter Emergency Medical Service (HEMS), may have been a real possibility. Even with this remarkable service, we believe that it would be impossible to fully investigate and correct an electrolyte disturbance or toxicity pitch side, (two of the reversible causes of cardiac arrest).(2)
(1)Roan, Dan. Fabrice Muamba was 'dead' for 78 minutes - Bolton doctor [Internet]. 2012 [updated 2012 March 25; cited 2012 Apr 06]. Available from: http://www.bbc.co.uk/sport/0/football/17460781
(2)United Kingdom. Resuscitation Council. Adult Advanced Life Support. Resuscitation Guidelines. London: 2010
Competing interests: No competing interests