Cardiopulmonary Resuscitation in Sports

Using chest compressions and rescue breaths with a view of sustaining supply of oxygenated blood to vital organs, especially brain, is what constitutes cardiopulmonary resuscitation (CPR); the ultimate aim being to prevent death or permanent damage to brain tissue due to lack of oxygen.

Paramedics tend to use terms such as CPR, basic life support (BLS) or adult basic life support more often while ‘mouth-to-mouth respiration’ is more of a layman’s term.

CPR and Survival Rates in Cardiac Arrest Patients

According to a study carried out by the University of Amsterdam, the outcomes of out-of-hospital cardiac arrests can be altered favourably by timely administration of CPR1. While studying the effects of CPR on survival rates of cardiac arrest patients, Fergusson found that not only does CPR positively influence survival rates but it may be the single most effective treatment to buy time until ‘expert help’ arrives2. Furthermore, research has shown that the chances of survival more than double if CPR is administered during the intervening period before hospitalization3.

With more than three-quarters of cardiac arrests occurring out-of-hospital3 and the proven effectiveness of CPR in increasing chances of survival, CPR does indeed appears to be the proverbial ‘kiss of life’.

Importance of CPR in Sports

Cases of cardiac arrest leading to death in athletes, either due to cardiovascular causes (sudden death) or a blunt trauma to the chest (commotio cordis), have always intrigued sport medicine researchers. Increased adrenergic drive combined with altered anatomical and physiological variables in high intensity sports can cause abnormal rhythms of the heart4. These cardiac arrhythmias render the heart inefficient (as a pump); circulation and oxygenation of brain suffers resulting in death.

Sudden death in sports is not a rare phenomenon by any stretch of imagination. An Italian study spanning 2 decades had reported an incidence of 1 in 100,000 population per year and definitely identified the association of sports with cardiac arrest5 (incidence of 2.3 per 100,000 in athletes as compared to 0.9 per 100,000 in non-athletes6).

A more recent study carried out in France reports an incidence of 4.6 per million population per year; 6% of these being in competitive athletes7.

In a retrospective study of the causes of mortality and types of injuries in crevasse accidents, Hohlrieder et. al. reported that trauma and asphyxia were mainly responsible for deaths. Of the survivors, the ones who suffered cardiac arrests and were administered CPR continuously during evacuation responded favourably and had a much better chance of survival then those who suffered other life threatening injuries like critical multisystem trauma and hypothermia8.

Notwithstanding the benefits of sport and physical activity, close relation of sudden death with these has tempted Corado et. al. to call physical activity a ‘double-edged sword’9.

Aims of Delivering CPR

As stated earlier, the immediate goals of delivering CPR is to maintain patent airways and normal blood circulation without the use of (or with barest minimum) equipment until such a time that expert help arrives or the victim is relocated to the hospital.

The above are achieved by delivering ‘chest compressions’ and ‘rescue breaths’.

The purpose of the whole exercise is twofold:

1. To ensure proper oxygenation of blood as it passes through the lungs

2. To maintain pumping of the heart so that oxygenated blood is supplied to the brain (interruption of blood supply to the brain for as little as 10 seconds can cause irreversible damage)

CPR Procedure: The Sequence of Events

The acronym ‘DR-ABC’ or ‘Doctors’ ABC’ can be used to remember the steps in delivering CPR.

1. Danger: assess immediate danger to the patient, other players and self. For example, before running on to the field to attend to an athlete who has ‘gone down’, it should first be confirmed that the referee has stopped the game.

2. Response: check if the athlete is conscious; gentle tapping on the shoulder or asking if he/she is OK can do the trick.

If there is response, put the athlete in recovery position (provided there are no injuries) and check regularly.

If there is no response, call emergency (911/999) and initiate CPR.

3. Airway: tilt head backwards and lift the chin so as to open the mouth; obstructions if any are to be removed gently.

4. Breathing: ‘look, listen and feel’ for respiration: look for chest movements, listen to breath sounds by bringing your ear close to the athlete’s nose and feel the warmth of the athlete’s breath on your cheek.

If breathing, put the athlete in lateral recovery position and dial emergency services; keep checking the athlete’s condition periodically.

If not breathing, call emergency and start CPR.

5. Circulation: can be assessed by feeling the carotid pulse by the side of the neck. This should be done for not more than 10 seconds.

If pulse is present, put the patient into recovery position and monitor.

If pulse is absent (or when in doubt), initiate chest compression followed by rescue breaths. Send your partner to get help. If you are alone, get help first and then return to initiate CPR.

There are exceptions to these general rules: in cases of drowning or in children, CPR should be imparted for a minute before going for help.

Although the sequence of events, ‘DR ABC’ in CPR has been followed for years, the new American Heart Association guidelines of 2010 suggest chest compressions to be initiated without wasting valuable time in assessing airway and breathing. Thus, ‘ABC’ is now ‘CAB’.

Chest Compressions and Rescue Breaths: How To?

Chest Compressions:

1. place your hands on top of each other and interlock fingers

2. place the heel of the bottom hand in the middle of the chest at the level of the sternum (breast bone)

3. take care that your arms are perpendicular to the ground so that you can deliver chest compressions efficiently; this will also ensure that you conserve energy and prevent fatigue

4. chest should be compressed a minimum of 4 to 5 cm; a full recoil should be allowed before commencing the next compression

5. rate of chest compressions should be 100 per minute (a total of 30 compressions should be given before delivering 2 breaths and then carrying on with compressions)

Rescue breaths:

1. Titling the head backwards, pinch the patient’s nose and make a seal over the patient’s mouth with yours. If a CPR kit is available, you can make use of a CPR mouthpiece.

2. If you have concerns over giving a ‘mouth-to-mouth’, carry on giving chest compressions till such a time that help arrives.

Please note that:

1. CPR involves giving alternate chest compressions and breaths: the ratio being 30:210

2. During chest compressions, do not worry if ‘crack a few ribs’; a few broken ribs won’t do much harm

3. Breaths should be forceful enough to make the chest rise up; do not go for the second breath till you see the chest deflate completely

4. If concerned about giving breaths, carry on with chest compression

5. After every couple of minutes, check for recovery; if patient is still not breathing, continue with CPR

6. Continue with the cycle of alternate compressions and breaths till such a time that patient recovers, expert help arrives or you become exhausted.

To conclude, there is a very real risk of a cardiac arrest and sudden death in competitive as well as recreational sports. In spite of the proven effectiveness of CPR in increasing survival chances in pulse-less and non-breathing athletes and the fact these events are witnessed by a number of individuals, very few of the victims are administered CPR7.

Thus, imparting CPR skills to coaches and support staff should be highly recommended11.

Reference List

(1) Waalewijn RA, Nijpels MA, Tijssen JG, Koster RW. Prevention of deterioration of ventricular fibrillation by basic life support during out-of-hospital cardiac arrest. Resuscitation 2002; 54(1):31-36.

(2) Ferguson JA. Impact of Lay-Administered CPR on Survival Rates. Can Fam Physician 1986; 32:817-820.

(3) Mclean JA. Basic life support. British Journal of Sports Medicine 2000; 34(2):141-142.

(4) Giada F, Conte R, Pescatore V, Brugin E. Sports and arrhythmias. Minerva Med 2011; 102(3):239-247.

(5) Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol 2003; 42(11):1959-1963.

(6) Corrado D, Basso C, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden cardiac death? J Cardiovasc Med (Hagerstown ) 2006; 7(4):228-233.

(7) Marijon E, Tafflet M, Celermajer DS, Dumas F, Perier MC, Mustafic H et al. Sports-related sudden death in the general population. Circulation 2011; 124(6):672-681.

(8) Hohlrieder M, Kroesslhuber F, Voelckel W, Lutz M, Mair P. Experience with helicopter rescue missions for crevasse accidents. High Alt Med Biol 2010; 11(4):375-379.

(9) Corrado D, Migliore F, Basso C, Thiene G. Exercise and the risk of sudden cardiac death. Herz 2006; 31(6):553-558.

(10) Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010; 81(10):1219-1276.

(11) Cross PS, Karges JR, Adamson AJ, Arnold MR, Meier CM, Hood JE. Assessing the need for knowledge on injury management among high school athletic coaches in South Dakota. S D Med 2010; 63(7):241-245.

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Dr. Deepak S Hiwale

Dr. Deepak S Hiwale, a.k.a "The Fitness Doc" specializes in sports medicine in addition to being an elite personal trainer. He currently runs an elite personal training company in West London. As a sports injury and fitness writer-presenter, he tries to disseminate as much knowledge as possible for the benefit of all. MBBS (University of Pune); MSC, Sports and Exercise Medicine (University of Glasgow); Diploma in Personal Training (YMCA Dip. PT, London).

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