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Copyright © 2012 National Athletic Trainers' Association, IncTo present recommendations for the prevention and screening, recognition, and treatment of the most common conditions resulting in sudden death in organized sports.
Cardiac conditions, head injuries, neck injuries, exertional heat stroke, exertional sickling, asthma, and other factors (eg, lightning, diabetes) are the most common causes of death in athletes.
These guidelines are intended to provide relevant information on preventing sudden death in sports and to give specific recommendations for certified athletic trainers and others participating in athletic health care.
Keywords: asthma, cardiac conditions, diabetes, exertional heat stroke, exertional hyponatremia, exertional sickling, head injuries, neck injuries, lightning safety
Sudden death in sports and physical activity has a variety of causes. The 10 conditions covered in this position statement are
Catastrophic brain injuries Cervical spine injuries Exertional heat stroke Exertional hyponatremia Exertional sickling Head-down contact in football Sudden cardiac arrest(Order does not indicate rate of occurrence.)
Recognizing the many reasons for sudden death allows us to create and implement emergency action plans (EAPs) that provide detailed guidelines for prevention, recognition, treatment, and return to play (RTP). Unlike collegiate and professional teams, which usually have athletic trainers (ATs) available, nearly half of high schools as well as numerous other athletic settings lack the appropriate medical personnel to put these guidelines into practice and instead rely on the athletic director, team coach, or strength and conditioning specialist to do so.
To provide appropriate care for athletes, one must be familiar with a large number of illnesses and conditions in order to properly guide the athlete, determine when emergency treatment is needed, and distinguish among similar signs and symptoms that may reflect a variety of potentially fatal circumstances. For the patient to have the best possible outcome, correct and prompt emergency care is critical; delaying care until the ambulance arrives may result in permanent disability or death. Therefore, we urgently advocate training coaches in first aid, cardiopulmonary resuscitation (CPR), and automated external defibrillator (AED) use, so that they can provide treatment until a medical professional arrives; however, such training is inadequate for the successful and complete care of the conditions described in this position statement. Saving the life of a young athlete should not be a coach's responsibility or liability.
For this reason, we also urge every high school to have an AT available to promptly take charge of a medical emergency. As licensed medical professionals, ATs receive thorough training in preventing, recognizing, and treating critical situations in the physically active. Each AT works closely with a physician to create and apply appropriate EAPs and RTP guidelines.
Throughout this position statement, each recommendation is labeled with a specific level of evidence based on the Strength of Recommendation Taxonomy (SORT). 1 This taxonomy takes into account the quality, quantity, and consistency of the evidence in support of each recommendation: Category A represents consistent good-quality evidence, B represents inconsistent or limited-quality or limited-quantity evidence, and C represents recommendations based on consensus, usual practice, opinion, or case series.
The following rules apply to every EAP:
Every organization that sponsors athletic activities should have a written, structured EAP. Evidence Category: B
The EAP should be developed and coordinated with local EMS staff, school public safety officials, onsite first responders, school medical staff, and school administrators. Evidence Category: B
The EAP should be specific to each athletic venue. Evidence Category: BThe EAP should be practiced at least annually with all those who may be involved. Evidence Category: B
Those responsible for arranging organized sport activities must generate an EAP to directly focus on these items:
Instruction, preparation, and expectations of the athletes, parents or guardians, sport coaches, strength and conditioning coaches, and athletic directors.
Health care professionals who will provide medical care during practices and games and supervise the execution of the EAP with respect to medical care.
Precise prevention, recognition, treatment, and RTP policies for the common causes of sudden death in athletes.
The EAP should be coordinated and supervised by the on-site AT. A sports organization that does not have a medical supervisor, such as an AT, present at practices and games and as part of the medical infrastructure runs the risk of legal liability. Athletes participating in an organized sport have a reasonable expectation of receiving appropriate emergency care, and the standards for EAP development have also become more consistent and rigorous at the youth level. Therefore, the absence of such safeguards may render the organization sponsoring the sporting event legally liable.
The purpose of this position statement is to provide an overview of the critical information for each condition (prevention, recognition, treatment, and RTP) and indicate how this information should dictate the basic policies and procedures regarding the most common causes of sudden death in sports. Our ultimate goal is to guide the development of policies and procedures that can minimize the occurrence of catastrophic incidents in athletes. All current position statements of the National Athletic Trainers' Association (NATA) are listed in the Appendix.
Athletes who may have or are suspected of having asthma should undergo a thorough medical history and physical examination. 2 Evidence Category: B
Athletes with asthma should participate in a structured warmup protocol before exercise or sport activity to decrease reliance on medications and minimize asthmatic symptoms and exacerbations. 3 Evidence Category: B
The sports medicine staff should educate athletes with asthma about the use of asthma medications as prophylaxis before exercise, spirometry devices, asthma triggers, recognition of signs and symptoms, and compliance with monitoring the condition and taking medication as prescribed. Evidence Category: C
The sports medicine staff should be aware of the major asthma signs and symptoms (ie, confusion, sweating, drowsiness, forced expiratory volume in the first second [FEV1] of less than 40%, low level of oxygen saturation, use of accessory muscles for breathing, wheezing, cyanosis, coughing, hypotension, bradycardia or tachycardia, mental status changes, loss of consciousness, inability to lie supine, inability to speak coherently, or agitation) and other conditions (eg, vocal cord dysfunction, allergies, smoking) that can cause exacerbations. 4 , 5 Evidence Category: A
Spirometry tests at rest and with exercise and a field test (in the sport-specific environment) should be conducted on athletes suspected of having asthma to help diagnose the condition. 2 , 6 Evidence Category: B
An increase of 12% or more in the FEV1 after administration of an inhaled bronchodilator also indicates reversible airway disease and may be used as a diagnostic criterion for asthma. 7
For an acute asthmatic exacerbation, the athlete should use a short-acting β2-agonist to relieve symptoms. In a severe exacerbation, rapid sequential administrations of a β2-agonist may be needed. If 3 administrations of medication do not relieve distress, the athlete should be referred promptly to an appropriate health care facility. 8 Evidence Category: A
Inhaled corticosteroids or leukotriene inhibitors can be used for asthma prophylaxis and control. A long-acting β2-agonist can be combined with other medications to help control asthma. 9 Evidence Category: B
Supplemental oxygen should be offered to improve the athlete's available oxygenation during asthma attacks. 10 Evidence Category: B
Lung function should be monitored with a peak flow meter. Values should be compared with baseline lung volume values and should be at least 80% of predicted values before the athlete may participate in activities. 11 Evidence Category: B
If feasible, the athlete should be removed from an environment with factors (eg, smoke, allergens) that may have caused the asthma attack. Evidence Category: C
In the athlete with asthma, physical activity should be initiated at low aerobic levels and exercise intensity gradually increased while monitoring occurs for recurrent asthma symptoms. Evidence Category: C
In 2009, asthma was thought to affect approximately 22 million people in the United States, including approximately 6 million children. 4 Asthma is a disease in which the airways become inflamed and airflow is restricted. 4 Airway inflammation, which may lead to airway hyperresponsiveness and narrowing, is associated with mast cell production and activation and increased number of eosinophils and other inflammatory cells. 2 , 3 Cellular and mediator events cause inflammation, bronchial constriction via smooth muscle contraction, and acute swelling from fluid shifts. Chronic airway inflammation may cause remodeling and thickening of the bronchiolar walls. 12 , 13
Clinical signs of asthma include confusion, sweating, drowsiness, use of accessory muscles for breathing, wheezing, coughing, chest tightness, and shortness of breath. Asthma may be present during specific times of the year, vary with the type of environment, occur during or after exercise, and be triggered by respiratory infections, allergens, pollutants, aspirin, nonsteroidal anti-inflammatory drugs, inhaled irritants, exposure to cold, and exercise. 5
Athletes suspected of having asthma should undergo a thorough health history examination and prepartici-pation physical examination. Unfortunately, the sensitivity and specificity of the medical history are not known, and this evaluation may not be the best method for identifying asthma. 14
Performing warmup activities before sport participation can help prevent asthma attacks. With a structured warmup protocol, the athlete may experience a refractory period of as long as 2 hours, potentially decreasing the risk of an exacerbation or decreasing reliance on medications. 6 In addition, the sports medicine team should provide education to assist the athlete in recognizing asthma signs and symptoms, understanding how to use medication as prescribed (including potential adverse effects and barriers to taking medications, which can include failure to recognize the importance of controlling asthma, failure to recognize the potential severity of the condition, medication costs, difficulty obtaining medications, inability to integrate treatment of the disease with daily life, and distrust of the medical establishment), and using spirometry equipment correctly. 2 , 4 , 5
Athletes with asthma may display the following signs and symptoms: confusion, sweating, drowsiness, FEV1 of less than 40%, low level of oxygen saturation, use of accessory muscles for breathing, wheezing, cyanosis, coughing, hypotension, bradycardia or tachycardia, mental status changes, loss of consciousness, inability to lie supine, inability to speak coherently, or agitation. 2 , 4 , 5 Peak expiratory flow rates of less than 80% of the personal best or daily variability greater than 20% of the morning value indicate lack of control of asthma. The sports medicine staff should consider testing all athletes with asthma using a sport-specific and environment-specific exercise challenge protocol to assist in determining triggers of airway hyperresponsiveness. 6
Treatment for those with asthma includes recognition of exacerbating factors and the proper use of asthma medications ( Figure 1 ). A short-acting β2-agonist should be readily available; onset of action is typically 5 to 15 minutes, so the medication can be readministered 1 to 3 times per hour if needed. 10 If breathing difficulties continue after 3 treatments in 1 hour or the athlete continues to have any signs or symptoms of acute respiratory distress, referral to an acute or urgent care facility should ensue. For breathing distress, the sports medicine team should provide supplemental oxygen to help maintain blood oxygen saturation above 92%. 10
Asthma pharmacologic management. Abbreviations: CPR, cardiopulmonary resuscitation; PEF, peak expiratory flow; SABA, short-acting β2-agonist. Casa DJ, Preventing Sudden Death in Sport and Physical Activity, 2012: Jones & Bartlett Learning, Sudbury, MA. www.jblearning.com. Reprinted with permission.
Proper use of inhaled corticosteroids can decrease the frequency and severity of asthma exacerbations while improving lung function and reducing hyperresponsiveness and the need for short-acting β2-agonists. 15 , 16 Leukotriene modifiers can be used to control allergen-, aspirin-, or exercise-induced bron-choconstriction and decrease asthma exacerbations. 17
No specific guidelines describe RTP after an asthma attack in an athlete. However, in general, the athlete should first be asymptomatic and progress through graded increases in exercise activity. Lung function should be monitored with a peak flow meter and compared with baseline measures to determine when asthma is sufficiently controlled to allow the athlete to resume participation. 11 Where possible, the sports medicine staff should identify and treat asthmatic triggers, such as allergic rhinitis, before the athlete returns to participation.
The AT is responsible for coordinating educational sessions with athletes and coaches to teach the recognition of concussion (ie, specific signs and symptoms), serious nature of traumatic brain injuries in sport, and importance of reporting concussions and not participating while symptomatic. Evidence Category: C
The AT should enforce the standard use of certified helmets while also educating athletes, coaches, and parents that although such helmets meet a standard for helping to prevent catastrophic head injuries, they do not prevent cerebral concussions. Evidence Category: B
The AT should incorporate the use of a comprehensive objective concussion assessment battery that includes symptom, cognitive, and balance measures. Each of these represents only one piece of the concussion puzzle and should not be used in isolation to manage concussion. Evidence Category: A
A comprehensive medical management plan for acute care of an athlete with a potential intracranial hemorrhage or diffuse cerebral edema should be implemented. Evidence Category: B
If the athlete's symptoms persist or worsen or the level of consciousness deteriorates after a concussion, the patient should be immediately referred to a physician trained in concussion management. Evidence Category: B
Oral and written instructions for home care should be given to the athlete and to a responsible adult. Evidence Category: C
Returning an athlete to participation after a head injury should follow a graduated progression that begins once the athlete is completely asymptomatic. Evidence Category: C
The athlete should be monitored periodically throughout and after these sessions to determine whether any symptoms develop or increase in intensity. Evidence Category: C
Cerebral concussion is classified as mild traumatic brain injury and often affects athletes in both helmeted and nonhelmeted sports. 18 , 19 The Centers for Disease Control and Prevention estimated that 1.6 to 3.8 million sport-related concussive injuries occur annually in the United States. 20 Although they are rare, severe catastrophic traumatic brain injuries, such as subdural and epidural hematomas and malignant cerebral edema (ie, second-impact syndrome), result in more fatalities from direct trauma than any other sport injury. When these injuries do occur, brain swelling or pooling of blood (or both) increases intracranial pressure; if this condition is not treated quickly, brainstem herniation and respiratory arrest can follow. Catastrophic brain injuries rank second only to cardiac-related injuries and illnesses as the most common cause of fatalities in football players. 21 However, the National Center for Catastrophic Sport Injury Research reported that fatal brain injuries have occurred in almost every sport, including baseball, lacrosse, soccer, track, and wrestling. 22 For a catastrophic brain injury such as second-impact syndrome, which has a mortality rate approaching 50% and a morbidity rate nearing 100%, prevention is of the utmost importance.
Preventing catastrophic brain injuries in sports, such as skull fractures, intracranial hemorrhages, and diffuse cerebral edema (second-impact syndrome), must involve the following: (1) prevention and education about traumatic brain injury for athletes, coaches, and parents; (2) enforcing the standard use of sport-specific and certified equipment (eg, National Operating Committee on Standards for Athletic Equipment [NOCSAE] or Hockey Equipment Certification Council, Inc [HECC]–certified helmets); (3) use of comprehensive, objective baseline and postinjury assessment measures; (4) administration of home care and referral instructions emphasizing the monitoring and management of deteriorating signs and symptoms; (5) use of systematic and monitored graduated RTP progressions; (6) clearly documented records of the evaluation and management of the injury to help guide a sound RTP decision; and (7) proper preparedness for on-field medical management of a serious head injury.
Prevention begins with education. The AT is responsible for coordinating educational sessions with athletes and coaches to teach the recognition of concussion (ie, specific signs and symptoms), serious nature of traumatic brain injuries in sport, and importance of reporting their injuries and not participating while symptomatic. During this process, athletes who are at risk for subsequent concussion or catastrophic injury should be identified and counseled about the risk of subsequent injury.
As recommended in the NATA position statement on management of sport-related concussion, 23 the AT should enforce the standard use of helmets for preventing catastrophic head injuries and reducing the severity of cerebral concussions in sports that require helmet protection (eg, football, men's lacrosse, ice hockey, baseball, softball). The AT should ensure that all equipment meets NOCSAE, HECC, or American Society for Testing and Materials (ASTM) standards. A poorly fitted helmet is limited in the amount of protection it can provide, and the AT must play a role in enforcing the proper fit and use of the helmet. Protective sport helmets are designed primarily to help prevent catastrophic injuries (eg, skull fractures and intracranial hematomas) and not concussions. A helmet that protects the head from a skull fracture does not adequately prevent the rotational and shearing forces that lead to many concussions, 24 a fact that many people misunderstand.
The use of objective concussion measures during preseason and postinjury assessments helps the AT and physician accurately identify deficits associated with the injury and track recovery. However, neuropsychological testing is only one component of the evaluation process and should not be used as a standalone tool to diagnose or manage concussion or to make RTP decisions after concussion. Including objective measures of cognitive function and balance prevents premature clearance of an athlete who reports being symptom free but has persistent deficits that are not easily detected through the clinical examination. The concussion assessment battery should include a combination of tests for cognition, balance, and self-reported symptoms known to be affected by concussion. Because many athletes (an estimated 49% to 75%) 25 , 26 do not report their concussions, this objective assessment model is important. The sensitivity of this comprehensive battery, including a graded symptom checklist, computerized neuropsychological test, and balance test, reached 94%, 27 which is consistent with previous reports. 28 , 29
Multiple concussion assessment tools are available, including low-technology and high-technology balance tests, brief paper-and-pencil cognitive tests, and computerized cognitive tests. As of 2010, the National Football League, National Hockey League, and National Collegiate Athletic Association require an objective assessment as part of a written concussion management protocol. By using objective measures, which were endorsed by the Third International Consensus Statement on Concussion in Sport (Zurich, 2008), 30 , 31 ATs and physicians are better equipped to manage concussion than by relying solely on subjective reports from the athlete. Additionally, the often hidden deficits associated with concussion and gradual deterioration that may indicate more serious brain trauma or postconcussion syndrome (ie, symptoms lasting longer than 4 weeks) may be detected with these tools.
Once the athlete has been thoroughly evaluated and identified as having sustained a concussion, a comprehensive medical management plan should be implemented. This begins with making a determination about whether the patient should be immediately referred to a physician or sent home with specific observation instructions. Although this plan should include serial evaluations and observations by the AT (as outlined earlier), continued monitoring of postconcussion signs and symptoms by those with whom the athlete lives is both important and practical. If symptoms persist or worsen or the level of consciousness deteriorates after a concussion, the athlete should be immediately referred to a medical facility. To assist with this, oral and written instructions for home care should be given to the athlete and to a responsible adult (eg, parents or roommate) who will observe and supervise the athlete during the acute phase of the concussion while at home or in the dormitory. The AT and physician should agree on a standard concussion home instruction form similar to the one presented in the NATA position statement 23 and Zurich guidelines. 30 , 31
The proper preparedness for on-field and sideline medical management of a head injury becomes paramount if the athlete has a more serious and quickly deteriorating condition. If the athlete presents with a Glasgow coma score of less than 8 or other indications of more involved brain or brainstem impairment appear (eg, posturing, altered breathing pattern), the AT or other members of the sports medicine team must be prepared to perform manual ventilations through either endotracheal intubation or bag-valve-mouth resuscitation. These procedures should be initiated if the athlete is not oxygenating well (ie, becoming dusky or blue, ventilating incompletely and slower than normal at 12 to 15 breaths per minute). 32
Normal end tidal carbon dioxide partial pressure of 35–45 mm Hg usually result from a bagging rate of 12 breaths per minute. Hyperventilation may be indicated if the athlete demonstrates obvious signs of brain-stem herniation (eg, “blown” pupil or posturing). In the event of impending cerebral herniation, increasing the rate to about 20 breaths per minute will achieve the objective of reducing the end tidal carbon dioxide partial pressure below the recommended 35 mm Hg. Additionally, the sports medicine team should aim to reduce intracranial pressure by elevating the head to at least 30° and ensuring that the head and neck are maintained in the midline position to optimize venous outflow from the brain. Intravenous (IV) diuretics such as mannitol (0.5 to 1.0 g/kg) may also decrease intracranial pressure but would typically be administered in a controlled medical environment by personnel trained in these techniques. 32 Obviously, being prepared for immediate transfer to a medical facility is extremely important under these conditions.
Returning an athlete to participation should follow a graduated RTP progression ( Table 1 ). If the exertional activities do not produce acute symptoms, he or she may progress to the next step. No more than 2 steps should be performed on the same day, which allows monitoring of both acute (during the activity) and delayed (within 24 hours after the activity) symptoms. The athlete may advance to step 5 and return to full participation once he or she has remained asymptomatic for 24 hours after step 4 of the protocol. The athlete should be monitored periodically throughout and after these sessions with objective assessment measures to determine whether an increase in intensity is warranted. If the athlete's symptoms return at any point during the RTP progression, at least 24 hours without symptoms must pass before the protocol is reintroduced, beginning at step 1.
Graduated Return-to-Play Sample Protocol
| Exertion Step | Activities |
| 1. | 20-min stationary bike at 10–14 mph (16–23 kph) |
| 2. | Interval bike: 30-s sprint at 18–20 mph (29–32 kph), 30-s recovery × 10 repetitions; body weight circuit: squats, push-ups, sit-ups×20 s×3 repetitions |
| 3. | 60-yd (55-m) shuttle run×10 repetitions with 40-s rest, plyometric workout: 10-yd (9-m) bounding, 10 medicine ball throws, 10 vertical jumps×3 repetitions; noncontact, sport-specific drills× 15 min |
| 4. | Limited, controlled return to practice with monitoring for symptoms |
| 5. | Full sport participation in practice |
Although some state concussion laws have allowed provisions for allied health care professionals to make the RTP decision, it is recommended that a physician with training and experience in concussion management be involved in a structured team approach. A concussion management policy outlining the roles and responsibilities of each member of the sports medicine team should be adopted. At a minimum, the AT should document all pertinent information surrounding the evaluation and management of any suspected concussions, including (a) mechanism of injury; (b) initial signs and symptoms; (c) state of consciousness; (d) findings on serial testing of symptoms, neuropsychological function, and balance (noting any deficits compared with baseline); (e) instructions given to the athlete, parent, or roommate; (f) recommendations provided by the physician; (g) graduated RTP progression, including dates and specific activities involved in the athlete's return to participation; and (h) relevant information on the player's history of prior concussion and associated recovery patterns. 23 This level of detail can help prevent a premature return to participation and a catastrophic brain injury such as second-impact syndrome.
Athletic trainers should be familiar with sport-specific causes of catastrophic cervical spine injury and understand the physiologic responses in spinal cord injury. Evidence Category: C
Coaches and athletes should be educated about the mechanisms of catastrophic spine injuries and pertinent safety rules enacted for the prevention of cervical spine injuries. Evidence Category: C
Corrosion-resistant hardware should be used in helmets, helmets should be regularly maintained throughout a season, and helmets should undergo regular reconditioning and recertification. 33 Evidence Category: B
Emergency department personnel should become familiar with proper athletic equipment removal, seeking education from sports medicine professionals regarding appropriate methods to minimize motion. Evidence Category: C
During initial assessment, the presence of any of the following, alone or in combination, requires the initiation of the spine injury management protocol: unconsciousness or altered level of consciousness, bilateral neurologic findings or complaints, significant midline spine pain with or without palpation, or obvious spinal column deformity. 34–39 Evidence Category: A
The cervical spine should be in neutral position, and manual cervical spine stabilization should be applied immediately. 40 , 41 Evidence Category: B
Traction must not be applied to the cervical spine. 42 , 43 Evidence Category: B Immediate attempts should be made to expose the airway. Evidence Category: CIf rescue breathing becomes necessary, the person with the most training and experience should establish an airway and begin rescue breathing using the safest technique. 44 , 45 Evidence Category: B
If the spine is not in a neutral position, rescuers should realign the cervical spine. 46 , 47 However, the presence or development of any of the following, alone or in combination, is a contraindication to realignment 45 , 48 : pain caused or increased by movement, neurologic symptoms, muscle spasm, airway compromise, physical difficulty repositioning the spine, encountered resistance, or apprehension expressed by the patient. Evidence Category: B
Manual stabilization of the head should be converted to immobilization using external devices such as foam head blocks. 47 , 49 Whenever possible, manual stabilization 50 is resumed after the application of external devices. Evidence Category: B
Athletes should be immobilized with a long spine board or other full-body immobilization device. 51 , 52 Evidence Category: B
The primary acute treatment goals in equipment-laden athletes are to ensure that the cervical spine is immobilized in neutral and vital life functions are accessible. Removal of helmet and shoulder pads in any equipment-intensive sport should be deferred 53–56 until the athlete has been transported to an emergency medical facility except in 3 circumstances 57 : the helmet is not properly fitted to prevent movement of the head independent of the helmet, the equipment prevents neutral alignment of the cervical spine, or the equipment prevents airway or chest access. 53 , 54 , 58 Evidence Category: C
Full face-mask removal using established tools and techniques 59–61 is executed once the decision has been made to immobilize and transport. Evidence Category: C
If possible, a team physician or AT should accompany the athlete to the hospital. Evidence Category: C
Remaining protective equipment should be removed by appropriately trained professionals in the emergency department. Evidence Category: C
A catastrophic cervical spinal cord injury occurs with structural distortion of the cervical spinal column and is associated with actual or potential damage to the spinal cord. 62 The spinal injury that carries the greatest risk of immediate sudden death for the athlete occurs when the damage is both severe enough and at a high enough level in the spinal column (above C5) to affect the spinal cord's ability to transmit respiratory or circulatory control from the brain. 63 , 64 The priority in these situations is simply to support the basic life functions of breathing and circulation. Unfortunately, even if an athlete survives the initial acute management phase of the injury, the risk of death persists because of the complex biochemical cascade of events that occurs in the injured spinal cord during the initial 24 to 72 hours after injury. 64 Because of this risk, efficient acute care, transport, diagnosis, and treatment are critical in preventing sudden death in a patient with a catastrophic cervical spine injury.
A high level of evidence (ie, prospective randomized trials) on this topic is rare, and technology, equipment, and techniques will continue to evolve, but the primary goals offered in the NATA position statement on acute management of the cervical spine–injured athlete 65 remain the same: create as little motion as possible and complete the steps of the EAP as rapidly as is appropriate to facilitate support of basic life functions and prepare for transport to the nearest emergency treatment facility.
Additional complications can affect the care of the spine-injured athlete in an equipment-intensive sport when rescuers may need to remove protective equipment that limits access to the airway or chest. Knowing how to deal properly with protective equipment during the immediate care of an athlete with a potential catastrophic cervical spine injury can greatly influence the outcome. Regardless of the sport or the equipment, 2 principles should guide management of the equipment-laden athlete with a potential cervical spine injury:
Exposure and access to vital life functions (eg, airway, chest for CPR, or use of an AED) must be established or easily achieved in a reasonable and acceptable manner.
Neutral alignment of the cervical spine should be maintained while allowing as little motion at the head and neck as possible.
Return to play after cervical spine injury is highly variable and may be permitted only after complete tissue healing, neurologic recovery, and clearance by a physician. Factors considered for RTP include the level of injury, type of injury, number of levels fused for stability, cervical stenosis, and activity. 66
Each athlete with diabetes should have a diabetes care plan that includes blood glucose monitoring and insulin guidelines, treatment guidelines for hypoglycemia and hyperglycemia, and emergency contact information. Evidence Category: C
Prevention strategies for hypoglycemia include blood glucose monitoring, carbohydrate supplementation, and insulin adjustments. Evidence Category: B
Prevention strategies for hyperglycemia are described by the American Diabetes Association (ADA) and include blood glucose monitoring, insulin adjustments, and urine testing for ketone bodies. 67 Evidence Category: C
Hypoglycemia typically presents with tachycardia, sweating, palpitations, hunger, nervousness, headache, trembling, or dizziness; in severe cases, loss of consciousness and death can occur. Evidence Category: C
Hyperglycemia can present with or without ketosis. Typical signs and symptoms of hyperglycemia without ketosis include nausea, dehydration, reduced cognitive performance, feelings of sluggishness, and fatigue. Evidence Category: C
Hyperglycemia with ketoacidosis may include the signs and symptoms listed earlier as well as Kussmaul breathing (abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis), fruity odor to the breath, unusual fatigue, sleepiness, loss of appetite, increased thirst, and frequent urination. Evidence Category: C
Mild hypoglycemia (ie, the athlete is conscious and able to swallow and follow directions) is treated by administering approximately 10–15 g of carbohydrates (examples include 4–8 glucose tablets or 2 tablespoons of honey) and reassessing blood glucose levels immediately and 15 minutes later. Evidence Category: C
Severe hypoglycemia (ie, the athlete is unconscious or unable to swallow or follow directions) is a medical emergency, requiring activation of emergency medical services (EMS) and, if the health care provider is properly trained, administering glucagon. Evidence Category: C
Athletic trainers should follow the ADA guidelines for athletes exercising during hyperglycemic periods. Evidence Category: C
Physicians should determine a safe blood glucose range to return an athlete to play after an episode of mild hypoglycemia or hyperglycemia. Evidence Category: C
Diabetes mellitus is a chronic metabolic disorder characterized by hyperglycemia, caused by either absolute insulin deficiency or resistance to the action of insulin at the cellular level, which results in the inability to regulate blood glucose levels within the normal range of 70–110 mg/dL. Type 1 diabetes is an auto-immune disorder stemming from a combination of genetic and environmental factors. The autoimmune response is often triggered by an environmental event, such as a virus, and it targets the insulin-secreting beta cells of the pancreas. When beta cell mass is reduced by approximately 80%, the pancreas is no longer able to secrete sufficient insulin to compensate for hepatic glucose output. 67 , 68
Although the literature supports physical activity for people with type 1 diabetes, exercise training and competition can result in major disturbances to blood glucose management. Extreme glycemic fluctuations (severe hypoglycemia or hyperglycemia with ketoacidosis) can lead to sudden death in athletes with type 1 diabetes mellitus. 69–71 Prevention of these potentially life-threatening events begins with the creation of the diabetes care plan by a physician. The plan should identify blood glucose targets for practices and games, including exclusion thresholds; strategies to prevent exercise-associated hypoglycemia, hyperglycemia, and ketosis; a list of medications used for glycemic control; signs, symptoms, and treatment protocols for hypoglycemia, hyperglycemia, and ketosis; and emergency contact information. 72
Preventing hypoglycemia relies on a 3-pronged approach of frequent blood glucose monitoring, carbohydrate supplementation, and insulin adjustments. The athlete should check blood glucose levels 2 or 3 times before, every 30 minutes during, and every other hour up to 4 hours after exercise. Carbohydrates should be eaten before, during, and after exercise; the quantity the athlete ingests depends on the prevailing blood glucose level and exercise intensity. Finally, some athletes may use insulin adjustments to prevent hypoglycemia. These adjustments vary depending on the method of insulin delivery (insulin pump versus multiple daily injections), prevailing blood glucose level, and exercise intensity. 67 , 68 , 73 , 74
Athletes with type 1 diabetes may also experience hyperglycemia, with or without ketosis, during exercise. Hyperglycemia during exercise is related to several factors, including exercise intensity 75 , 76 and the psychological stress of competition. 77 When the insulin level is adequate, these episodes of hyperglycemia are transient. However, when the insulin level is insufficient, ketosis can occur. Exercise is contraindicated when ketones are present in the urine. Athletic trainers should know the ADA guidelines for athletes exercising during an episode of hyperglycemia. 67 In addition, the athlete's physician should determine the need for insulin adjustments during hyperglycemic periods.
Signs and symptoms of hypoglycemia typically occur when blood glucose levels fall below 70 mg/dL (3.9 mmol/L). Early symptoms include tachycardia, sweating, palpitations, hunger, nervousness, headache, trembling, and dizziness. These symptoms are related to the release of epinephrine and acetylcholine. As the glucose level continues to fall, symptoms of brain neuronal glucose deprivation occur, including blurred vision, fatigue, difficulty thinking, loss of motor control, aggressive behavior, seizures, convulsions, and loss of consciousness. If hypoglycemia is prolonged, severe brain damage and even death can occur. Athletic trainers should be aware that the signs and symptoms of hypoglycemia are individualized and be prepared to act accordingly. 78–80
Although the signs and symptoms of hyperglycemia may vary from one athlete to another, they include nausea, dehydration, reduced cognitive performance, slowing of visual reaction time, and feelings of sluggishness and fatigue. The signs and symptoms of hyperglycemia with ketoacidosis may include those listed earlier as well as Kussmaul breathing, fruity odor to the breath, sleepiness, inattentiveness, loss of appetite, increased thirst, and frequent urination. With severe ketoacidosis, the level of consciousness may be reduced. Athletic trainers should also be aware that some athletes with type 1 diabetes intentionally train and compete in a hyperglycemic state (above 180 mg/dL [10 mmol/L]) to avoid hypoglycemia. Competing in a hyperglycemic state places the athlete at risk for dehydration, reduced athletic performance, and possibly ketosis. 67 , 81
Treatment guidelines for mild and severe cases of hypoglycemia are shown in Table 2 . 82 , 83 The ADA provides guidelines for exercise during hyperglycemic periods. If the fasting blood glucose level is ≥250 mg/dL (≥13.9 mmol/L), the athlete should test his or her urine for the presence of ketones. If ketones are present, exercise is contraindicated. If the blood glucose value is ≥300 mg/dL (≥16.7 mmol/L) and without ketones, the athlete may exercise with caution and continue to monitor blood glucose levels. Athletes should work with their physicians to determine the need for insulin adjustments for periods of hyperglycemia before, during, and after exercise. 67
Treatment Guidelines for Mild and Severe Hypoglycemia 76 , 77
