Emergency Minute - Sudden Cardiac Death In Athletes

What happened to Damar Hamlin? What would make an athlete collapse? What is the most likely cause of sudden cardiac death? Should you have your kids wear chest protectors or get them elective Echocardiograms? Join me for a discussion on these topics. Don't forget to follow me for inside looks into healthcare. 

Transcript

Welcome back everyone, how are y’all feeling? Thanks for joining us this week for another episode of Emergency Minute. This week I can’t wait to talk to you about Episode 7 – Sudden Cardiac Death in Athletes. Before we get started, I wanted to thank each and every one of you for listening, commenting, sharing, and reviewing. Much love to you. This week’s show is for all of you. Lastly, I have some of my podcasts on video now on YouTube now, so be sure to check them out as well at DrJParente. And don’t forget to click subscribe.

Obviously, the catalyst for this podcast idea was brought on by the near tragedy of what happened to Damar Hamlin from the Buffalo Bills on national TV when he collapsed. Today I’m going to discuss some things that could cause an athlete to collapse on the field and we’re going to take a closer look at Damar’s situation. I also will discuss things that you can do to minimize the likelihood of this happening to one of your kids or loved ones and what to do in the unlikely event that this would occur.

Before we get started, I wanted to take a moment to commend all of those involved in taking care of Damar, especially those on the field. I don’t have any inside knowledge of who is all on the sidelines and their respective levels of training, but I can tell you what they did is nothing short of heroic. You see, in the hospital, when someone arrests right in front of us, we have a controlled environment. Meaning, we control a lot of the variables that will impact someone’s care. They patient is likely hooked up to a monitor, meaning we can recognize it faster and respond quicker. The patient probably has an IV for quick administration of medications such as epinephrine. We have multiple people in the room that help with things like CP, establishing an airway, giving medications, etc. Well, what about on a football field? 

First and foremost, you aren’t exactly expecting someone to collapse and have a devastating cardiac condition. That wouldn’t be high up on your mind. You’re trained to look for injuries, broken bones, cuts and scrapes, things like concussions. Not exactly approaching every situation like it could be cardiac arrest. But even so, a well-trained professional should be able to recognize a full arrest fairly quickly and easily. But now, here’s the hard part. His uniform! You have an NFL player, laying on the ground, lifeless, as the clock is ticking. You have to get his helmet off to intubate him (which means establishing an airway, breathing for him). You would have to use trauma shears to cut off his jersey and expose his chest to listen to lung sounds, heart sounds (if there are any), and ultimately for CPR. You probably have obstacles on his arms like wrappings and tape and such to establish an IV to give life saving meds. How far is the AED if he needs shocked? How quickly can they get IV supplies, or maybe, as we often do in the ER, perform an IO. Which is an intraosseous line, or an IV that gets drilled into your bone, typically your humerus or your tibia. 

The odds of someone surviving what is termed OHCA (out of hospital cardiac arrest) is about 10%. The odds of walking out of the hospital without significant disability is less than 8%. So for Damar to be with us today is truly a testament to everyone who played a role in his care. 

Lastly, I did put out a tweet and tagged the NFL and implored them to have a board-certified emergency medicine trained physician on the sideline for every NFL game and the tweet kind of went bananas. From what I had read, the NFL didn’t always have an EM physician on the sidelines; however, I have since learned that they do, and they wear a red hat, which is kind of cool. Part of the reason the tweet went bananas is because of how engaged everyone was with what happened that night; but another reason was that many other healthcare professionals tweeted at me saying that they were just as qualified and in some instances more qualified than EM physicians to respond in a situation like that. I wanted to set the record straight, that by no means was my tweet meant to be demeaning to nurses, medics, trainers, family physicians, sports medicine physicians, etc. I simply believed it would be a good idea to have an EM physician on the sidelines for these games, and it turns out, they are. So, the NFL must agree with me. You’re welcome. Moving on…

Immediately after this, I was on Twitter to see if anyone had any additional information, and I learned something that was very helpful: did you know everyone on Twitter is a doctor? The immediate response was that it was from a head injury, and he was showing signs of a concussion. If you haven’t already listened to my last podcast, Episode 6 Concussions, I’d recommend you do that as soon as you’re done with this one. Could a head injury have caused the symptoms that he displayed that night? We’ll talk about that. But we’re also going to talk about cardiac reasons why athletes collapse on the field or on the court in more detail. 

So, what are some things that could make an athlete collapse on the field? The focus of this podcast will be cardiac causes, which are the most likely to lead to cardiac arrest and death, but let’s talk briefly about some of the other causes. In order to do this in an organized fashion, you have to compartmentalize them into different groups. 

So, the initial Twitter doctors were concerned about head injury, especially in light of some of the recent high profile, severe concussions we’ve seen recently in the NFL. The only way this could occur is if someone got hit so hard that they were knocked unconscious, but that wouldn’t explain the CPR on the field that Hamlin underwent. And furthermore, if you got hit that hard, it would be unlikely that you could take a few steps like Damar did, then collapse seconds later. Now you could have an Epidural Hematoma, in which case you could have what’s called a lucid interval, sort of the calm before the storm of bleeding inside the brain. But again, that wouldn’t explain the cardiac arrest. 

So, a close cousin to head injury would be severe cervical spine injury. Could this cause collapse? It would be unlikely. The only real possibility here would be a severe fracture to one of the veterbrae at the level or higher than C3. If you injured your spinal column and cord bad enough at that level, theoretically that would cause collapse, and if it had an associated hematoma (large collection of blood), theoretically it could put pressure on the phrenic nerve, paralyzing the diaphragm, and leading to respiratory arrest, which ultimately could potentially lead to cardiac arrest. However, the part that wouldn’t make sense in Damar’s case with this diagnosis is that this entire process would take several minutes at LEAST, if not longer. If someone, especially a young presumably health athlete, just stops breathing, it would take on average 4-6 minutes until the lack of oxygen would lead to a cardiac arrest. So, this isn’t the ticket, either. 

Now, there are some metabolic processes that can drop a healthy athlete to the ground, such as hypoglycemia or low blood sugar. But this wouldn’t cause cardiac arrest unless the glucose was really low and more than likely it would have to be low for a longer period of time. It would be ruled out as seconds before he ran down the field for the kickoff. Seizures can drop someone to the ground but again, wouldn’t cause cardiac arrest unless the seizure lasted so long that the patient went into respiratory arrest, which would then lead to cardiac arrest. So clearly this isn’t what happened to Damar. 

How about environmental causes? Sure, heat stroke can drop someone to the ground. But not cardiac arrest. And don’t be fooled by the weather outside and turn on the blinders and miss a diagnosis. I once had heat stroke in a patient who was running outside in 35-degree weather. Highest temperature I’ve ever seen in my career at 107.4 degrees. Figured out after the fact that it was from taking Theraflu prior to running a race. But I digress, moving on. 

What about anaphylaxis? Maybe he had a severe shellfish allergy and ate a big plate of shrimp before suiting up versus the Bengals and went into anaphylaxis on the field? I suppose that could cause collapse, but cardiac arrest wouldn’t be that sudden. Don’t get me wrong, true anaphylaxis is absolutely NASTY and escalates extremely fast. If you don’t get treatment ASAP, you will arrest. I don’t encourage people to call 911 very often as it is often over utilized in our world today, but this is one of those scenarios that could save your life. 

How about a respiratory cause? The only one that would be rapid is tension pneumothorax. This is where the lung collapses and begins to put pressure on the inner structures of your chest (you know, your heart, which you kind of need), causing severe respiratory distress, severe pain, drops your blood pressure, and ultimately you will arrest if someone doesn’t stab you or at least poke a hole in you. Anyone ever see the movie Three Kings? That scene is hilarious with George Clooney putting a needle into the chest of Mark Wahlberg with Ice Cube watching. Then Mark Wahlberg proceeds to run around and keeps letting air out of the valve and kudos to the director for taking this moment and making it comedic. And kudos to Hollywood, for making the procedure relatively realistic. So many times, I watch these movies and they do the dumbest, most inaccurate medical things and situations. Look, for like $100 a movie, I’ll gladly offer my input to the directors, just so I don’t have to cringe watching the final product on the big screen and see a foley catheter hanging out of someone’s nose or see someone intubated with a Yankaur suction catheter. Boy did I get off track. But the reality is, as nasty as a tension pneumothorax is, it wouldn’t cause sudden cardiac arrest. 

Which takes us to cardiac causes, which obviously are the most likely. So, the first one that comes to mind is Hypertrophic Obstructive Cardiomyopathy, which has had about 1,000 different names. It is known as HCM, “HOCM”, Idiopathic Hypertrophic Subaortic Stenosis, amongst others. What is HOCM? It is a genetic condition that causes hypertrophy, aka thickening of the cardiac septum (aka wall in the heart). This ultimately leads to an obstruction, which means the first symptom of this condition is death. So how’s that for pissing in your Cheerios to brighten your day? According to the literature, the incidence of this is 1:500, which seems extremely high. There are fewer than 100 deaths per year, which means that if you are a young athlete, your incidence of death is 1:220,000. Typically, this occurs in the 2nd/3rd decade of life but can occur later as well. 

Is this something that is preventable or something that can be caught? This is why it is important to go see your family doctor, especially if your child or young adult is having episodes of passing out, or nearly passing out (aka syncope). Your family doctor will listen for murmurs and ask about any family history of HOCM or other causes of sudden cardiac death. There is genetic testing available, but this is only recommended for those with family history and/or symptoms such as syncope. Most of the usual workup, such as history, physical, labs, chest Xray, and EKG are likely to be normal. If it is suspected, an Echocardiogram or an Ultrasound of the heart should be done and is about 80% accurate for detecting this diagnosis. However, the gold standard is really cardiac MRI to make the diagnosis. 

Quick story, a few years ago I was having some palpitations and I saw the cardiologist while I was at work. I’m not even sure my mom even knows this story, so we’re going to find out very quickly if she listens to my podcast haha. So, I get an EKG and these palpitations are just Premature Ventricular Contractions, AKA PVC’s, which usually aren’t a big deal and can be normal. But in some instances, like if they’re happening frequently or if you’re symptomatic, they do need to be investigated. Next step for me was a Holter monitor, which is essentially wearing an EKG for 24 hours. After meeting with the cardiologist, I’ll never forget what he said to me. “Well John, some of the palpitations look like non-sustained Ventricular Tachycardia (to my non-medical people, non-sustained vtach is the thing that happens right before vtach, and vtach is the thing that happens before Vfib, and Vfib is the last thing anyone sees as you meet Jesus).” 

He said, “I’m going to send you to an EP specialist (electrophysiology cardiologist, which is basically someone who’s studied for 100 years on the electricity systems of the heart).” I told him that I had an upcoming vacation to Turks and Caicos, so I was nervous about all of this and leaving the country. And you know what he said to me? “Just take a life vest with you and wear it.” HAHA. Like, are you kidding me? So, I could just be cruising around at the beach, with my stylish life vest on, crushing my fourth margarita by 10am, only to get the unpleasant surprise of my heart going into Vtach and getting a crushing chest blow from my life vest that may or may not save my life. I was blown away. Til this day, I am honestly not sure if he was serious or messing with me. 

Long story short, I saw the specialist, I had Holter monitor, EKG’s, bloodwork, Echo, and the gold standard Cardiac MRI, and saw the specialist again. So, I’m standing across from this insanely intelligent, highly trained physician, who literally was triple-boarded in multiple specialties, and you know what he says to me? “Everything looks good, your palpitations don’t appear to be dangerous, and your heart structure and function look good. Basically, just cut back on caffeine, alcohol, and stress in your life.” And it was at this moment I thought to myself, I’d rather wear the life vest! Haha. 

In all seriousness, it was a pretty scary time for me. I never told my family because I don’t like to make anyone worry, especially when there’s nothing to worry about, as was eventually proven after weeks of testing and about $20,000 in workups haha. But I am truly grateful I was Ok, and it gave me a great appreciation for those experiencing palpitations and what that workup looks like.  

So, who are some famous people who have died from HOCM? The 2 that come to mind for me are Reggie Lewis and Hank Gathers. HOCM is the leading cause of sudden cardiac death in young athletes. So could HOCM have caused the collapse and near death of Damar Hamlin? Absolutely. In fact, it is the most likely cause statistically. 

What is the treatment for HOCM? First and foremost, stop all strenuous physical activity. There are medications that can help manage the symptoms and slow the progression of the disease, but make no mistake, it is a progressive disease, it will continue to get worse and eventually you will get symptoms. At this point, you start getting into more advanced surgical options such as a myomectomy, which is a fancy word for carving off some of the enlarged heart tissue and heart transplants, which occur in only about 6% of all HOCM patients. 

Another cardiac or more accurately vascular cause of sudden death would be Pulmonary Embolism, or PE, which is a blood clot to the lungs. Most blood clots originate in the leg (about 95%) and then bust loose, travel to the lungs, and wreak havoc. In most instances, patients will experience chest pain, shortness of breathing, passing out, etc.; however, in some cases, more rarely, a patient can experience sudden cardiac death if they have a massive PE, or a saddle PE. So how does this occur? Essentially, imagine the clot is like a cork that blocks the pulmonary vessels. The right side of the heart then works hard to keep pushing that cork out, unsuccessfully. This ultimately causes the blood to stop coming into the heart to begin with (AKA preload), which leads to cardiac collapse and arrest. Would this be a possibility for Damar? Absolutely. 

It’s reported that up to 10% of prehospital arrests can be from massive PE, but this is thought to be an underestimate as it is very difficult to prove and most of the patients who come in as cardiac arrests (mainly the elderly), don’t get autopsies as they likely have viable medical reasons why they died. So, it’s difficult to say what the actual incidence is, but it is very high up on the list of what may have happened to Damar. 

Now, there are many other cardiac causes of sudden cardiac death that are less common. Heart attacks, cardiac artery aneurysm, numerous types of dysrhythmias, Brugada Syndrome is another hot topic, amongst others. But let’s look at the second most common cause of sudden cardiac death: Commotio Cordis. 

Ah yes, the enigma that is Commotio Cordis, Latin for agitation of the heart. Which is synonymous with being a Cleveland Browns fan, which clearly agitates my heart every week during football season. This disease entity is fascinating to so many because it’s so strange, and thankfully, so rare. This is a cardiac arrest that is cause by blunt trauma to the chest that leads to Vfib, ventricular fibrillation. What’s strange about this diagnosis is that the heart is structurally normal, there’s nothing wrong with it. The thought is that the object hits the heart, and just the right moment of the electrical impulse, causing a short circuit, causing the arrest. It’s like the heart is “stunned” for lack of a better term. 

Thankfully, less than 30 cases are reported annually. The mean age for this is 15, it’s extremely rare past 20 years old. It is 95% in boys, but is that just a bias from boys being more likely to participate in sports with contact to the chest like baseball, football, etc.? There’s a lot of contention surrounding exactly what causes commotio cordis, but there are a few known variables. First, the impact must occur over the anterior chest, right over the heart. We know this. Secondly, the force must be significant enough, but not too significant. What does that mean? Well, it must be hard enough to cause this cardiac rhythm disruption, but not hard enough that it would cause something like cardiac contusion. They estimated that a force of roughly 50 Joules as enough to cause it; but getting into a car crash and having the steering wheel crushing your chest causing cardiac contusion, would likely be too forceful to cause commotio cordis. So how much is 50 Joules? Not much, honestly. A thrown baseball that hits just right, a punch to the chest, or, perhaps, a shoulder to the chest of a football player that hits just right? Perhaps. 

What can be done to prevent this freak occurrence? How about chest protectors? Do they work? We’ve seen soccer moms and dads all over the country buying up the chest protectors for their kids playing baseball. Unfortunately, in a retrospective study looking at the data, the chest protectors have not been shown to reduce the incidence. In this analysis, 37% of the cases of Commotio Cordis occurred WITH chest protectors on. What else, what else can you do? The AHA (American Heart Association) recommends 3 things, and I’m giving you the short version. Number one, make sure people know about this thing. Two, when possible, use softer balls.  Three, try not to have repetitive chest trauma. The fact that these are the 3 official recommendations shows you how little is known about this disease entity. 

What about elective echocardiogram? We said earlier it is up to 80% accuracy for diagnosing HOCM. What about commotio cordis? See that’s the problem. Hearts with this are structurally normal, there’s nothing wrong with them. 

So, if your kids are in sports, what types of things can you do to ensure the best chance of survival in the unlikely event that something like that happens to one of the kids? You mean, besides using softer balls? I think no one could fault the parents out there buying up the chest protectors for their kids playing baseball, right? My kids wore them and I’m not ashamed to say that. I think there are 2 things to do, really. Be aware and ask about AED’s, or Automatic External Defibrillators). Most schools, most gyms by now should have these readily available. Your best chance of survival is early recognition and early defibrillation. And if you really want to look like a badass and at the same time potentially save someone’s life, if you see someone collapse and someone is running to grab the AED, just reach back and punch the victim in the chest with all your might. Haha. 

You may think I’m joking, but this is an actual technique called the precordial thump. I’ve done this a few times in my career when a patient codes and arrests right in front of me and we don’t have the pads hooked up. There’s nothing more gratifying, yet humerous, than absolutely walloping a patient who is basically dead, nailing them in the chest, and having them sit right up and look around in confusion. I’ve had this work a few times. Once, I had a patient that I dropped the hammer on his chest. He yelled out, sat up, and in one motion of yelling out a scream of pain said “ooooouuuuu what the hell did you do that for!?” and I could do nothing but laugh at this time and I had to explain to him what had just happened. 

So ultimately, what happened to Damar Hamlin? Well, he won’t tell us, and just an FYI, he doesn’t have to. It is very frustrating. The general public often get very pulled in when tragic things happen to celebrities, much less someone arresting on national TV. So, we all want to know, and rightfully so. But it’s not our healthcare, it’s not our right to know. It’s patient privacy, as frustrating as that may be, that’s the reality.

 Statistically, the most likely cause would be HOCM. And would essentially end his career in football and all other sports. The second most likely cause, just looking at the data, would be Commotio Cordis. There was a study done that looked back at these causes of sudden cardiac deaths dating back to 2003 and they came up with 26% of the deaths due to HOCM (which was actually closer to 33% if you added a slightly different form of HOCM to the list), and 20% Commotio Cordis. Now that also means that there’s still 47% chance of other causes as we briefly discussed here today. The real question is, if he had Commotio Cordis, would he risk it happening again by continuing his NFL career? Can lightning really strike twice in the same spot? Tough to say what I would do in that situation.   

Well thank you for joining me for this week’s episode of Emergency Minute – Sudden Cardiac Death in Athletes. If you like what you’ve been listening to please consider sharing this show with someone you know. You can follow me on any social media platform at Drjparente. Join us next week for a really exciting show on medical myths that just won’t die. Please help me make them go away. Again, you’re not going to want to miss this. And as always, peace love and happiness to everyone out there. Cheers guys!