Sudden cardiac death in sport: time to simplify the guidelines to base them on mechanism and collapse – not breathing assessment.

By Dr Jonathan Hanson (@SportsDocSkye)

Another on field cardiac death in sport. Another debate about screening and medical care.

The successful resuscitation of Premier League football player Fabrice Muamba in 2012, in stark contrast to the tragic death of Marc Vivian Foe 9 years earlier, broadcast the role of basic life support and early defibrillation is to all with an interest in sport.

Media scrutiny of the recent on field death of Patrick Ekeng in Bucharest focused on the medical care provided during the incident. Professionals and the public expect high standards.

The majority of first responders in sport are either physiotherapists or from a primary care background – a population without frequent exposure to critically unwell patients. Although an accepted standard of training in sports pre-hospital care exists through a number of worldwide courses (including under the auspices of FIFA and UEFA), the ability to act appropriately still requires situation awareness, pattern recognition and appropraite decision making and excellent technical skills in a time of crisis.

Are we overcomplicating the challenge in the sport setting? 

By adhering to guidelines designed to treat a person on the street or in hospitals do we make it harder for those who assume the responsibility of first responder in sport?

Drills, checks, and sound clinical governance will help minimise the practical skill loss (often quoted at 90% skill loss at 1 year). But how can we assist in making the decision making easier?

As an emergency medicine doctor and sports physician I have seen quite a lot of cardiac arrests. I cannot recall any of the cases I have seen in hospital looking like the patient in the Mark Vivian Foe video, Fabrice Muamba, or this week’s Patrick Ekeng case.

The wide staring eyes, the very rapid but inefficient respiratory effort from arresting in a state of hyper adrenergic exercise and lactate debt, and the small degrees of twitching or movement do not make up what I typically see in my cardiac arrest experience in hospitals in the unwell, elderly or in patients who have arrested a few minutes before I arrive. My cardiac arrest experience does not cover folks like Patrick Ekeng either.


Current basic life support guidelines rely upon either a 10 second assessment for “normal” breathing (European guidelines) or simple “scan for breathing” (American Heart Association guidelines) as the decision making step to commence basic life support. We are advised not to confuse normal breathing with “agonal breathing” which is defined as slow, irregular and inefficient breaths of a dying patient. This description does match not the rapid regular agonal breathing initially witnessed in Muamba, Foe or Ekeng.

Is it any wonder that inexperienced but trained pitch side medical staff find it difficult to recognise the unusual rapid variant of agonal breathing of cardiac arrest in athletes? Our niche patient group and speed of response point toward the need for customised guidelines. It’s easy to mistake agonal breathing for normal breathing if it looks slightly atypical and you’ve never seen it before with the additional pressures of the stadium environment TV coverage.

Our aim should be to make it easier for the responder to recognise the diagnosis and commence CPR/AED. Thus increasing the chance of survival from 6% (no CPR) to 35% (CPR plus AED). A survival rate of 35% still sounds poor – but it is a six times increase as compared to the survival rate with no CPR/ AED.


Resuscitation guidelines do evolve. Concerns over disrupting a pelvic haematoma through “springing the pelvis” on examination in the primary survey of trauma patients led to a revision of the approach to pelvic fracture diagnosis. Now the decision is based on mechanism rather than the examination. If the mechanism is suspicious, the pelvis is treated as fractured and a binder applied without any springing until imaging suggests otherwise.
In spinal immobilisation in sport, although guidelines support minimal handling and the use of split devices to minimise logrolling, we often deal with much larger and wider body shapes than the general public body shape. More often than not we face a moving and handling safety issue in addition to concerns about spinal injury. Only a tiny minority of spinally packaged athletes need to go onto hospital and they are generally not multiply injured. The majority are removed from the device at the medical room and so don’t need to worry about pressure areas etc. Hence we work around the guidelines to fit our situation, sometimes using out of vogue long spine boards to accommodate the additional size and moving and handling challenge, rather than carrying directly on split devices designed for “normal” heights and widths.


Why can’t we adjust the resuscitation guidelines?

The morbidity from inappropriate CPR is very small and the AED will not give a shock to someone who does not need it.

The decision around whether to begin CPR could be made purely on the mechanism of off-the-ball collapse, thus simplifying the first responder’s decision, increasing the likelihood of high quality compressions with minimal interruptions and prompt use of a defibrillator.

It’s time to make the change and move to a mechanism based decision on commencing CPR.

A sudden off-the-ball collapse in sport should always be regarded as a cardiac arrest and receive a response with CPR and AED. We should adjust our training accordingly and educate on agonal breathing in the post exercise state.

This is in keeping with FIFA’s 11 steps to prevent cardiac death – but this needs to be adopted more widely.

“Performance of the emergency medical plan

  • Immediate recognition of collapsed player
    1. Assume SCA if collapsed and unresponsive
    2. Seizure activity and/or agonal respirations—SCA”

This would benefit of the rescuer and thus benefit the athlete.


Dr Jonathan Hanson is a Sport and Emergency physician for the Sportscotland institute of sport and World Rugby Immediate care training management group.

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