Resuscitation on the field of play: a best-practice guideline from the International Liaison Committee on Resuscitation

Understanding Sudden Cardiac Arrest in Athletes

Sudden cardiac arrest (SCA) is the leading cause of sudden death in athletes during high-level, organized sport. While infrequent, these devastating events require a rapid and coordinated medical response to optimize the chances of survival. Several key factors set the stage for potential high survival rates in these situations:

• Patient-related factors: Athletes are generally younger, fitter, and more likely to have had a witnessed event with early resuscitation efforts. These factors contribute to better outcomes compared to the general population.

• Event-related factors: The presence of dedicated medical teams and the potential for fewer distractions (unlike public settings) provide an opportunity for immediate intervention and high-quality care.

To address this critical issue, the International Liaison Committee on Resuscitation (ILCOR) collaborated with Resuscitation Council UK to develop a best-practice guideline for field-of-play medical teams responding to SCA during organized sporting events. This comprehensive framework aims to empower responders, optimize treatment, and improve outcomes for athletes experiencing cardiac arrest on the field of play.

Recognizing Sudden Cardiac Arrest

Any unexpected collapse of an athlete, without rapid recovery, should be presumed to be SCA until proven otherwise. While agonal breathing and seizure-like activity are recognized signs of SCA, athletes may also continue breathing more regularly and even have their eyes open following the collapse.

Key points on recognizing SCA in the field of play:

• Sudden collapse can occur at any time during sporting activity, away from the point of action, or immediately after blunt-force trauma to the chest (commotio cordis).
• Even if the athlete regains consciousness quickly, they should be removed from the field of play for prompt medical assessment and not allowed to continue their activity.
• Anyone on or beside the field of play, in an official capacity, should be trained to recognize the signs of SCA and immediately alert the field-of-play medical team.

Empowering the Field-of-Play Medical Team

Field-of-play medical teams should be positioned to access a collapsed athlete as soon as it is safe to do so. Officials should halt play when necessary, as the athlete’s safety must be the top priority, regardless of the competitive situation.

Preparation and organization of the field-of-play medical team:

• The team should have a clearly identified leader with relevant experience in leading resuscitation efforts.
• They should regularly practice their emergency response, including location, communication, role allocation, and management of SCA.
• There should be predefined arrangements for emergency medical service (EMS) response and access protocols to the field of play.
• The team should liaise closely with the sports team’s own medical personnel, who may reach the athlete first.

Delivering High-Quality Resuscitation

When responding to a suspected SCA, the field-of-play medical team should approach and initially treat the athlete where they have collapsed, unless the location presents immediate safety concerns.

Key steps in the resuscitation process:

1. Assess for signs of life and responsiveness, recognizing the unique presentations of SCA in the field of play.
2. Start high-quality chest compressions immediately, with minimal interruptions.
3. Attach a defibrillator as soon as possible, aiming to deliver the first shock within 2 minutes of collapse.
4. For athletes in a persistent shockable rhythm, deliver a minimum of three shocks (one shock per 2-minute cycle) on the field of play before considering movement.
5. Continue high-quality CPR, provide ventilation support, and administer medications as indicated.

The field-of-play medical team should have an AED readily available and ensure all team members are trained in its use. They may also choose to use a manual defibrillator if they have the appropriate expertise.

Transporting the Athlete to Definitive Care

When the field-of-play medical team agrees it is safe and appropriate to do so, they should move the athlete to an ambulance for immediate transfer to a hospital. This process should be predetermined and regularly practiced to minimize interruptions to high-quality CPR.

Considerations for transporting the athlete:

• There should be a clear, predetermined plan for the safest and most efficient route off the field of play.
• The field-of-play medical team should liaise with the ambulance service and local hospitals to identify an appropriate receiving facility, preferably a “cardiac arrest center” with expertise in out-of-hospital cardiac arrest management.
• A brief handover using a standardized format should be provided upon arrival at the hospital to ensure continuity of care.

Addressing Special Circumstances

The field-of-play medical team should be prepared to manage various sport-specific and participant-specific challenges that may arise when responding to an athlete’s collapse. These can include:

• Sport-specific challenges: Rescuing an athlete from water, managing traumatic injuries in equestrian or high-speed events, etc.
• Participant-specific challenges: Resuscitating children or athletes with physical impairments.

The team should regularly train for these scenarios to ensure they can provide the best possible care while maintaining their own safety.

Comprehensive Emergency Action Planning

Effective implementation of these guidelines requires close collaboration between various stakeholders, including competition organizers, venue management, medical providers, and national sports governing bodies.

A comprehensive emergency action plan, based on the sport’s regulations and venue-specific risk assessments, is crucial for a prompt and coordinated response to an athlete experiencing SCA. This plan should be regularly reviewed and rehearsed by all involved parties.

Disseminating Best Practices

High-profile sporting teams and organizations have a unique opportunity to lead by example and disseminate best practices for recognizing, responding to, and managing SCA in the field of play. This includes:

• Educating players, staff, officials, and local communities on the signs of SCA and the importance of bystander CPR and AED use.
• Ensuring the availability of AEDs in sporting venues and training facilities, with clear signage and accessibility.
• Providing regular training and refreshers on SCA recognition and response for all personnel involved in sporting events.

By proactively addressing this critical issue, the sports community can empower responders, improve outcomes, and ultimately save more lives on the field of play.

Conclusion

This best-practice guideline from the International Liaison Committee on Resuscitation provides a comprehensive framework for field-of-play medical teams to respond effectively to sudden cardiac arrest in athletes. By prioritizing prompt recognition, high-quality resuscitation, and efficient transportation to definitive care, the guideline aims to optimize the chances of survival and neurological recovery for those experiencing this devastating event.

Through the implementation of these guidelines, the sports community can demonstrate its commitment to player safety and lead the way in advancing resuscitation practices. By working together and disseminating best practices, we can ensure that athletes receive the best possible care and increase the likelihood of positive outcomes when SCA occurs on the field of play.