The inter-association task force for preventing sudden death in secondary school athletics programs: best-practices recommendations

Incidents and patterns of commotio cordis among athletes in the USA from 1982 to 2023

INTRODUCTION

Commotio cordis is a rare event that occurs following blunt, non-penetrating trauma to the chest, precipitating a ventricular arrhythmia. Commotio cordis requires immediate medical attention through cardiopulmonary resuscitation and defibrillation, often resulting in death. Commotio cordis is most common condition among young male athletes. The purpose of this study was to describe the incidents and patterns of commotio cordis among young athletes participating in organised sports in the USA from academic years 1982-1983 through 2022-2023.

METHODS

This was a retrospective, descriptive epidemiology study using surveillance data from the National Center for Catastrophic Sport Injury Research. The study included all commotio cordis incidents captured in the database. We calculated descriptive statistics (counts and proportions) overall and stratified by outcome and athlete sport.

RESULTS

Over the study period, 64 incidents of commotio cordis were captured. The majority occurred among males (n=60) and were caused by contact with an object/apparatus (n=39) or contact with another player (n=20). The most common sports were baseball (n=20), lacrosse (n=17) and football (n=13). Over half of these incidents resulted in death (n=34), although survival from commotio cordis increased over the study period. A higher proportion of fatal incidents occurred among football athletes and were caused by contact with another player.

CONCLUSIONS

Commotio cordis remains most common among young male athletes who participate in organised baseball, lacrosse and football. Although survival has improved over time, greater awareness and emergency preparedness for commotio cordis in an organised sport are needed to facilitate prompt recognition and intervention.

Secondary School State Athletic Association Health and Safety Policy Development Processes

BACKGROUND

The National Federation of State High School Associations provides recommendations regarding health and safety policies; however, policy development is governed at the state level. Given interstate differences in governance, the primary purpose was to describe processes that State High School Athletic Associations (SHSAAs) utilize to develop a new policy. The secondary objective was to determine what methods associations use to implement new policies.

METHODS

A cross-sectional survey requested SHSAA (n = 51) representatives to report how athlete health and safety policies are introduced, revised, approved, and implemented within their state. The 22-question survey was developed to gather variables for the aims of the study. Descriptive statistics were calculated for each survey item.

RESULTS

Of states who responded (n = 33), most reported a 2-committee (n = 24, 72.7%) process for developing and vetting policies, with initiation from the Sports Medicine Advisory Committee (n = 27, 81.8%), followed by an executive-level committee (n = 18, 66.7%). States reported total time from policy initiation to final approval ranged from 2 weeks to over 12 months. When a new policy was approved, most states indicated implementation began with an e-mail (n = 24, 72.7%) sent to Athletic Directors (n = 26, 78.8%). School principal or district superintendent were reported as the position in charge of compliance (36.4%, n = 12).

CONCLUSIONS

Most SHSAAs use a 2-step process to write and review an athlete health and safety policy before approval. SHSAAs that require a longer policy development time could delay the implementation of important health measures. SHSAAs could consider additional communication methods to ensure information reaches all stakeholders.

Preventing Exertional Heat Stroke in Football: Time for a Paradigm Shift

CONTEXT

Among American sports, football has the highest incidence of exertional heat stroke (EHS), despite decades of prevention strategies. Based on recent reports, 100% of high school and college EHS football fatalities occur during conditioning sessions. Linemen are the at-risk population, constituting 97% of football EHS deaths. Linemen heat up faster and cool down slower than other players.

EVIDENCE ACQUISITION

Case series were identified from organized, supervised football at the youth, high school, and collegiate levels and compiled in the National Registry of Catastrophic Sports Injuries. Sources for event occurrence were media reports and newspaper clippings, autopsy reports, certificates of death, school-sponsored investigations, and published medical literature. Articles were identified through PubMed with search terms "football," "exertional heat stroke," and "prevention."

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

Football EHS is tied to (1) high-intensity drills and conditioning that is not specific to individual player positions, (2) physical exertion as punishment; (3) failure to modify physical activity for high heat and humidity, (4) failure to recognize early signs and symptoms of EHS, and (5) death when cooling is delayed.

CONCLUSION

To prevent football EHS, (1) all training and conditioning should be position specific; (2) physical activity should be modified per the heat load; (3) understand that some players have a "do-or-die" mentality that supersedes their personal safety; (4) never use physical exertion as punishment; (5) eliminate conditioning tests, serial sprints, and any reckless drills that are inappropriate for linemen; and (6) consider air-conditioned venues for linemen during hot practices. To prevent EHS, train linemen based on game demands.

STRENGTH-OF-RECOMMENDATION TAXONOMY

n/a.

National Athletic Trainers' Association Position Statement: Emergency Action Plan Development and Implementation in Sport

OBJECTIVE

An emergency action plan (EAP) is a written document detailing the preparations and on-site emergency response of health care professionals and other stakeholders to medical emergencies in the prehospital setting. The EAP is developed to address any type of catastrophic injury response and should not be condition specific. The objective of this National Athletic Trainers' Association position statement is to provide evidence-based and consensus-based recommendations for developing and implementing an EAP for sports settings.

METHODS

These recommendations were developed by a multidisciplinary expert panel that performed (1) a comprehensive review of existing EAP evidence, (2) a modified Delphi process to define consensus recommendations, and (3) a strength of recommendation taxonomy determination for each recommendation.

RESULTS

An EAP is an essential tool designed to facilitate emergency preparedness and an efficient, coordinated emergency response during an athletic event. A comprehensive EAP should consider modes to optimize patient outcomes, the various stakeholders needed to develop the plan, the factors influencing effective implementation of the EAP, and the roles and responsibilities to ensure a structured response to a catastrophic injury.

CONCLUSIONS

These evidence-informed recommendations outline the necessary steps for emergency planning and provide considerations for the immediate management of patients with catastrophic injuries. Increasing knowledge and implementation of the EAP to manage patients with catastrophic injuries improves the overall response and decreases errors during an emergency.

Emergency Medical Planning for an Ultramarathon Open Water Swim: A Case Review of "Swim Tuff"

ABSTRACT

Ultramarathon open water swimming (OWS) events are one of the toughest endurance challenges in the world. The sport has gained notoriety with athletes swimming across the English Channel, Diana Nyad swimming from Cuba to Florida, and the 5- and 10-km OWS in the Olympic schedule. The athletes who participate are exposed to dangerous conditions that expose risks inherent to the sport. The optimal time to prepare for an emergency is before it happens. The aim of this paper is to present an emergency action plan (EAP) designed for the "Swim Tuff" event, a record-breaking ultramarathon swim that took place in Rhode Island, United States. This article identifies an overview of Swim Tuff, the challenges experienced, and how the team designed and implemented risk mitigation strategies. The professionals looking over athletes completing an OWS should be educated and aware of the unique circumstances inherent to the sport.

2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play

Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.

Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A 20-Year Study

BACKGROUND

Understanding the incidence, causes, and trends of sudden cardiac death (SCD) among young competitive athletes is critical to inform preventive policies.

METHODS

This study included National Collegiate Athletic Association athlete deaths during a 20-year time frame (July 1, 2002, through June 30, 2022). Athlete deaths were identified through 4 separate independent databases and search strategies (National Collegiate Athletic Association resolutions list, Parent Heart Watch database and media reports, National Center for Catastrophic Sports Injury Research database, and insurance claims). Autopsy reports and medical history were reviewed by an expert panel to adjudicate causes of SCD.

RESULTS

A total of 143 SCD cases in National Collegiate Athletic Association athletes were identified from 1102 total deaths. The National Collegiate Athletic Association resolutions list identified 117 of 143 (82%), the Parent Heart Watch database or media reports identified 89 of 143 (62%), the National Center for Catastrophic Sports Injury Research database identified 63 of 143 (44%), and insurance claims identified 27 of 143 (19%) SCD cases. The overall incidence of SCD was 1:63 682 athlete-years (95% CI, 1:54 065-1:75 010). Incidence was higher in male athletes than in female athletes (1:43 348 [95% CI, 1:36 228-1:51 867] versus 1:164 504 [95% CI, 1:110 552-1:244 787] athlete-years, respectively) and Black athletes compared with White athletes (1:26 704 [1:20 417-1:34 925] versus 1:74 581 [1:60 247-1:92 326] athlete-years, respectively). The highest incidence of SCD was among Division I male basketball players (1:8188 [White, 1:5848; Black, 1:7696 athlete-years]). The incidence rate for SCD decreased over the study period (5-year incidence rate ratio, 0.71 [95% CI, 0.61-0.82]), whereas the rate of noncardiovascular deaths remained stable (5-year incidence rate ratio, 0.98 [95% CI, 0.94-1.04]). Autopsy-negative sudden unexplained death (19.5%) was the most common postmortem examination finding, followed by idiopathic left ventricular hypertrophy or possible cardiomyopathy (16.9%) and hypertrophic cardiomyopathy (12.7%), in cases with enough information for adjudication (118 of 143). Eight cases of death were attributable to myocarditis over the study period (1 case from January 1, 2020, through June 30, 2022), with none attributed to COVID-19 infection. SCD events were exertional in 50% of cases. Exertional SCD was more common among those with coronary artery anomalies (100%) and arrhythmogenic cardiomyopathy (83%).

CONCLUSIONS

The incidence of SCD in college athletes has decreased. Male sex, Black race, and basketball are associated with a higher incidence of SCD.

Catastrophic Sports Injuries: Causation and Prevention

➤ Catastrophic injuries in U.S. high school and college athletes are rare but devastating injuries.➤ Catastrophic sports injuries are classified as either traumatic, caused by direct contact during sports participation, or nontraumatic, associated with exertion while participating in a sport.➤ Football is associated with the greatest number of traumatic and nontraumatic catastrophic injuries for male athletes, whereas cheerleading has the highest number of traumatic catastrophic injuries and basketball has the highest number of nontraumatic catastrophic injuries for female athletes.➤ The incidence of traumatic catastrophic injuries for all sports has declined over the past 40 years, due to effective rule changes, especially in football, pole-vaulting, cheerleading, ice hockey, and rugby. Further research is necessary to reduce the incidence of structural brain injury in contact sports such as football.➤ The incidence of nontraumatic catastrophic injuries has increased over the last 40 years and requires additional research and preventive measures. Avoiding overexertion during training, confirming sickle cell trait status in high school athletes during the preparticipation physical examination, and developing cost-effective screening tools for cardiac abnormalities are critical next steps.

Exertional Heat Illness: Adoption of Policies and Influencing Contextual Factors as Reported by Athletic Administrators

BACKGROUND

Little is known about the adoption by athletic administrators (AAs) of exertional heat illness (EHI) policies, and the corresponding facilitators and barriers of such policies within high school athletics. This study describes the adoption of comprehensive EHI policies by high school AAs and explores factors influencing EHI policy adoption.

HYPOTHESIS

We hypothesized that <50% of AAs would report adoption of an EHI policy, and that the most common facilitator would be access to an athletic trainer (AT), whereas the most common barrier would be financial limitations.

STUDY DESIGN

Cross-sectional.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 466 AAs (82.4% male; age, 48 ± 9 years) completed a validated online survey to assess EHI prevention and treatment policy adoption (11 components), as well as facilitators and barriers to policy implementation. Access to athletic training services was ascertained by matching the participants' zip codes with the Athletic Training Locations and Services Project. Policy adoption, facilitators, and barriers data are presented as summary statistics (proportions, interquartile range (IQR)). A Welch t test evaluated the association between access to athletic training services and EHI policy adoption.

RESULTS

Of the AAs surveyed, 77.9% (n = 363) reported adopting a written EHI policy. The median of EHI policy components adopted was 5 (IQR = 1,7), with only 5.6% (n = 26) of AAs reporting adoption of all policy components. AAs who had access to an AT (P = 0.04) were more likely to adopt a greater number of EHI-related policies, compared with those without access to an AT. An AT employed at the school was the most frequently reported facilitator (36.9%).

CONCLUSION

Most AAs reported having written EHI policy components, and access to an AT resulted in a more comprehensive policy.

CLINICAL RELEVANCE

Employment of an AT within high school athletics may serve as a vital component in facilitating the adoption of comprehensive EHI policies.

Sudden cardiac arrest in athletes and strategies to optimize preparedness

Sudden cardiac arrest (SCA) is the leading cause of death in young athletes. Despite efforts to improve preparedness for cardiac emergencies, the incidence of out-of-hospital cardiac arrests in athletes remains high, and bystander awareness and readiness for SCA support are inadequate. Initiatives such as designing an emergency action plan (EAP) and mandating training in cardiopulmonary resuscitation (CPR) and automated external defibrillator use (AED) for team members and personnel can contribute to improved survival rates in SCA cases. This review provides an overview of SCA in athletes, focusing on identifying populations at the highest risk and evaluating the effectiveness of different screening practices in detecting conditions that may lead to SCA. We summarize current practices and recommendations for improving the response to SCA events, and we highlight the need for ongoing efforts to optimize preparedness through the implementation of EAPs and the training of individuals in CPR and AED use. Additionally, we propose a call to action to increase awareness and training in EAP development, CPR, and AED use for team members and personnel. To improve outcomes of SCA cases in athletes, it is crucial to enhance bystander awareness and preparedness for cardiac emergencies. Implementing EAPs and providing training in CPR and AED use for team members and personnel are essential steps toward improving survival rates in SCA cases.

Pedestrian Safety Among High School Runners: A Case Series

BACKGROUND

Participation in high school cross-country and track has increased over the last few decades. At the same time, the rate of pedestrian-involved motor vehicle crashes (MVCs) has also increased. In the context of organized sport, pedestrian safety among runners is often not highlighted, despite the risk of catastrophic injury.

PURPOSE

To describe incidents of pedestrian-involved MVCs involving student athletes captured by the National Center for Catastrophic Sport Injury Research (NCCSIR) at the University of North Carolina at Chapel Hill.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 5.

METHODS

This study utilized surveillance data from the NCCSIR from 2011 to 2020. It presents descriptive statistics, including frequencies and percentages, detailed summaries, and a Haddon Matrix.

RESULTS

There were 8 incidents involving 11 student athletes, resulting in 9 fatalities. Of these, 5 cases occurred in the afternoon or early evening, 4 occurred in the Fall, and 6 occurred in a rural area. Haddon Matrix analyses of case descriptions indicate schools should implement a runner safety program for all new runners and ensure that runner safety measures are included in emergency action plans.

CONCLUSION

Runner-related MVCs are relatively rare, but tragic, incidents. Pedestrian safety measures should be incorporated into school-sponsored practices and training runs.

CLINICAL RELEVANCE

Pedestrian safety should be incorporated into runner safety and injury prevention efforts.

Mediating Effect of Sports Safety Awareness between Sports Activity Habits and the Intention to Complete Safety Education among Korean Adolescents

BACKGROUND

As the importance of safety during sports activities continues to gain emphasis socially, the interest in creating a culture of safety and safety education to support this is also increasing. However, no study has examined the willingness of adolescents to complete safety education voluntarily. To identify methods of building a culture of sports safety among adolescents, this study investigated the structural relationship among three related variables: sports activity habits, intention to complete safety education, and sports safety awareness of Korean adolescents.

METHODS

Data on 3928 adolescents aged 13-18 years old from the 2019 Sports Safety Accident Survey conducted by the Korea Sports Safety Foundation were analyzed. This encompassed frequency analysis, scale reliability, validity verification, descriptive statistics analysis, path analysis, and mediating effect verification.

RESULTS

The results indicated that sports activity habits among these adolescents had a positive effect on their sports safety awareness and on their intention to complete safety education; further, their sports safety awareness had a positive effect on their intention to complete safety education. The results also showed that sports safety awareness had a partial mediating effect between sports activity habits and intention to complete safety education. The willingness of adolescents to voluntarily complete safety education is particularly important, as adolescence is a critical period when lifelong safety habits can be formed.

CONCLUSIONS

Based on the results, discussions on creating safe sports activity habits for adolescents and continuous education on sports safety awareness are needed. Ultimately, we need to improve sports safety awareness by paying attention to the development and implementation of sports safety education programs for adolescents as a national policy and, through this, increase their willingness to complete safety education.

Universal Training Precautions: A Review of Evidence and Recommendations for Prevention of Exercise-Related Injury, Illness, and Death in Warfighters and Athletes

Facing pressure to train for victory, warfighters and athletes encounter numerous health risks that are directly related to their regular physical training. The concept of universal training precautions (UTPs) signifies universal processes designed to prevent unnecessary bodily harm, including injury, illness, and death, during physical training programs. Although no formal guidelines exist for collectively implementing a defined set of UTPs to address a broad scope of exercise-related health risks, recommendations and guidelines have been published relating to preventing sudden death during high school sports and collegiate conditioning sessions. A long list of critical topics must be considered as UTPs, including physical fitness factors, transition-period accommodation, hydration, environmental factors and acclimatization, appropriate recovery, use of medications and dietary supplements, and importantly, leadership. In this article, we outline in detail, with corresponding Strength of Recommendation Taxonomy ratings, what should be considered universal recommendations to minimize the risk of warfighters and athletes coming to harm when participating in group physical activities.

Sudden Cardiac Death in Athletes: Facts and Fallacies

The benefits of exercise for cardiovascular and general health are many. However, sudden cardiac death (SCD) may occur in apparently healthy athletes who perform at the highest levels. A diverse spectrum of diseases is implicated in SCD in athletes, and while atherosclerotic coronary artery disease predominates in individuals of >35 years of age, primary cardiomyopathies and ion channelopathies are prevalent in young individuals. Prevention of SCD in athletes relies on the implementation of health policies aimed at the early identification of arrhythmogenic diseases (such as cardiac screening) and successful resuscitation (such as widespread utilization of automatic external defibrillators and training members of the public on cardiopulmonary resuscitation). This review will focus on the epidemiology and aetiologies of SCD in athletes, and examine fallacies in the approach to this controversial field. Furthermore, potential strategies to prevent these tragic events will be discussed, analysing current practice, gaps in knowledge and future directions.

Effects of Athletic Trainer Direct Employment on the Management of Sports-Related Injuries in High School Athletes

BACKGROUND

Hiring athletic trainers (ATs) in high schools has attracted rising interest as a potential way of improving adolescents' health by enhancing their safety and reducing their risk of injury.

OBJECTIVE

This study aims to determine if there is a difference in the referral patterns, injury diagnoses, and injury treatments performed at a metropolitan high school when an AT is employed versus not employed by the school.

DESIGN

This is a retrospective quantitative two-period study.

SETTING

The study was conducted in the high school athletic department in Norfolk, Virginia, and the study population was high school athletes (age 14-18).

MAIN OUTCOME MEASURES

Changes in referral patterns, injury diagnoses, and injury treatments performed at a local high school when an AT is employed versus not employed by the school; specifically, we examined the number of and percent changes in yearly treatments, referrals, evaluations, and re-evaluations during the two periods.

RESULTS

Our first t-test revealed a statistically significant increase in the number of reported injuries between 2011-2015 (M = 58.00, SD = 44.86) and 2016-2020 (M = 299.00, SD = 40.93, p = 0.006. The second t-test revealed a statistically significant increase in the number of referrals between 2011-2015 (M = 249.00, SD = 353.41) and 2016-2020 (M = 1188.00, SD = 158.21), p = 0.014. The third t-test revealed a statistically significant increase in the number of treatment items between 2011-2015 (M = 150.67, SD = 175.32) and 2016-2020 (M = 636.67, SD = 211.72), p = 0.01.

CONCLUSIONS

The present study found an increased frequency of reported injuries, referrals, and treatment after ATs directly joined the staff of a large metropolitan high school. These findings suggest that direct employment of ATs is associated with greater recording of injuries and treatment of conditions. A reduction in referrals occurs with the presence of directly employed ATs, which could result in improved health for student-athletes, but this needs further study.

Emergency Preparedness for Sudden Cardiac Arrest in Amateur Athletic Union Basketball Teams: An Opportunity to Improve Outcomes in Higher Risk Athletes

OBJECTIVE

To examine sudden cardiac arrest (SCA) awareness and emergency preparedness for SCA in Amateur Athletic Union (AAU) youth basketball teams.

DESIGN

Cross-sectional survey of AAU coaches and administrators.

SETTING

Random sampling of AAU club teams across the United States.

PARTICIPANTS

AAU club coaches and/or administrators.

INTERVENTIONS

Electronic survey (Qualtrics) accessed online and by cell phone. Each coach/administrator was invited to participate via email up to 3 times, spaced approximately 5 days apart.

MAIN OUTCOME MEASURES

Established and practiced emergency action plan (EAP), cardiopulmonary resuscitation (CPR) training, and automated external defibrillator (AED) access.

RESULTS

A total of 53/449 (12%) respondents completed the survey. Only 6% of responding AAU clubs had a written EAP and practiced it on an annual basis. Only 35% of clubs required CPR training for their coaches. Automated external defibrillator were available at practices and games in only 45% and 35% of AAU clubs, respectively. Over 50% of clubs did not have an affiliated athletic trainer or medical director.

CONCLUSION

The vast majority of AAU clubs in this study lack proper emergency preparedness for SCA. Given male basketball players are at highest risk of SCA compared with other young athlete populations, urgent interventions are needed to improve awareness, standardize training, establish EAPs, and ensure access to AEDs in AAU clubs.

The Effect of a Statewide Policy on High School Emergency Action Plans

Institutions sponsoring athletics must be prepared for emergencies. Due to this, more governing bodies are requiring a sports-related emergency action plan (EAP). Yet, the effects of these policies are unknown. We compared adoption of EAPs and associated best practices in Oregon high schools before and after a policy requiring an EAP. Athletic directors were invited to complete a survey during the year before the policy went into effect and again the following year. We assessed whether the school had a written EAP and if they did, was the EAP venue specific, available at the venue, distributed to personnel, and annually reviewed and rehearsed. Pre/post-policy proportions were analyzed using Fisher exact tests for all schools and then schools that completed both surveys. There was a significant increase of schools that reported having an EAP after the policy went into effect (all schools: 55% to 99% [p < 0.001] and schools responding both years: 60% to 98% [p < 0.001]). Venue specific EAPs also significantly increased but only when analyzing all responses (59% to 71% [p = 0.03]). No best practice recommendations related to EAP availability, distribution, review, or rehearsal changed after the policy. Schools met the minimum requirements of the policy, but other related best practices did not significantly improve.

Trends in Traumatic Brain Injury Related to Consumer Products Among U.S. School-aged Children Between 2000 and 2019

INTRODUCTION

Consumer product‒related traumatic brain injury in children is common, but long-term trends have not been well characterized. Understanding the long-term trends in consumer product‒related traumatic brain injury may inform prevention efforts. The study objective is to examine the trends in consumer product‒related traumatic brain injury in school-aged children.

METHODS

Data were extracted from the National Electronic Injury Surveillance System-All Injury Program for initial emergency department visits for consumer product‒related traumatic brain injury (2000-2019) in school-aged children and analyzed in 2021.

RESULTS

Approximately 6.2 million children presented to emergency department with consumer product‒related traumatic brain injury during 2000-2019. Consumer product‒related traumatic brain injury increased from 4.5% of overall consumer product‒emergency department visits in 2000 to 12.3% in 2019, and its incidence rate (cases per 100,000 population) was higher in males (681.2; 95% CI=611.2, 751.2) than in females (375.8; 95% CI=324.1, 427.6). The annual percentage change in consumer product‒related traumatic brain injury was 3.6% from 2000 to 2008, 13.3% from 2008 to 2012, and ‒2.0% through 2019. Average annual percentage change was higher in females (5.1%; 95% CI=3.4, 6.8) than in males (2.8%; 95% CI=1.6, 3.9). Consumer product‒related traumatic brain injury increased from 2000 to 2012 in females and then remained stable. In males, annual percentage change increased from 2008 to 2012 and then declined through 2019.

CONCLUSIONS

Traumatic brain injury incidence rate in school-aged children increased from 2000 to 2019, peaked in 2012, and then declined in males but not in females. Percentage increases were highest in females. Prevention strategies should continue, with a specific focus on reducing consumer product‒related traumatic brain injury in female children.

Individual Medical Emergencies Occurring at School

Children and adults may face emergency medical situations because of injuries, complications of chronic health conditions, or unexpected major illnesses that occur in schools. The American Academy of Pediatrics published a policy statement in 2001 titled "Guidelines for Emergency Medical Care in Schools," and in 2008, published its revision, "Medical Emergencies Occurring at School." Those statements focused on the preparedness of schools to address individual student emergencies. The increase in the number of children with special health care needs and chronic medical conditions attending schools, together with the added challenges faced by school districts to ensure that schools have access to on-site, licensed health care professionals on an ongoing basis, have contributed to added risks that medical and nonmedical personnel face in dealing with medical emergencies in schools. This newly revised policy statement serves as an update of the statement published in 2008 and reaffirmed in 2017, and intends to increase pediatricians' awareness of schools' roles in preparing for individual student emergencies and provide recommendations for the medical home and school physicians on how to assist and support school personnel. This statement does not address schoolwide or communitywide emergencies that might occur as a result of natural or man-made disasters.

Proper Recognition and Management of Exertional Heat Stroke in a High School Cross-Country Runner: A Validation Clinical Case Report

A 14-year-old female high school cross- country runner (height = 154 cm, mass = 48.1 kg) with no history of exertional heat stroke (EHS) collapsed at the end of a race. An athletic trainer assessed the patient, who presented with difficulty breathing and then other signs of EHS (eg, confusion and agitation). The patient was taken to the medical area and draped with a towel, and a rectal temperature (Tre) of 106.9°F (41.6°C) was obtained. The emergency action plan was activated, and emergency medical services was called. The patient was submerged in a cold-water immersion tub until emergency medical services arrived (∼15 minutes; Tre = 100.1°F; cooling rate: 0.41°F.min-1[0.25°C.min-1]). At the hospital, the patient received intravenous fluids, and urine and blood tests were normal. She was not admitted and returned to running without sequelae. Following best practices, secondary school athletic trainers can prevent deaths from EHS by properly recognizing the condition and providing rapid cooling before transport.

Evidence for Economic Evaluations of Athletic Trainer Services

OBJECTIVE

Literature suggests athletic trainers (ATs) can help address health needs in a more affordable way across a variety of settings. We aimed to assess if AT services are cost-effective when compared to no AT services or services by other health providers.

DATA SOURCES

We performed a keyword search in 5 databases: Medline (FirstSearch), PubMed, Web of Science, SPORTDiscus, and Google scholar. We also conducted a generic web search to identify any informal sources that may meet the eligibility criteria.

STUDY SELECTION

We used a comprehensive list of terms to search economic evaluation studies on ATs. We included studies that met all the following criteria: economic evaluation studies on AT services; original studies written in English; and published in the last 10 years(2011-present). we excluded studies that examined either only cost or only benefit of AT services.

DATA EXTRACTION

We extracted data using a predefined checklist that included major components of economic evaluation. We also extracted data regarding athletic training practice setting.

RESULTS

We extracted 5 articles in our review, most of which supported the use of AT services as economically viable. The practice settings studied in the articles included two high school settings, two military settings, and a community outreach program that included several practice settings. Only one of the studies used standard economic evaluation methodology and took insurance status into account.

CONCLUSION

Our review shows that AT services can be a cost-effective option for addressing health care needs. However, the literature remains sparse and there was an overall lack of consistency in outcome measures, analytical methods, and reporting practices, which reduced the comparability across studies. Future studies on this topic should address these limitations, which will provide critical economic evidence to inform decision making on investing in AT services across various settings.

Classic and exertional heatstroke

In the past two decades, record-breaking heatwaves have caused an increasing number of heat-related deaths, including heatstroke, globally. Heatstroke is a heat illness characterized by the rapid rise of core body temperature above 40 °C and central nervous system dysfunction. It is categorized as classic when it results from passive exposure to extreme environmental heat and as exertional when it develops during strenuous exercise. Classic heatstroke occurs in epidemic form and contributes to 9-37% of heat-related fatalities during heatwaves. Exertional heatstroke sporadically affects predominantly young and healthy individuals. Under intensive care, mortality reaches 26.5% and 63.2% in exertional and classic heatstroke, respectively. Pathological studies disclose endothelial cell injury, inflammation, widespread thrombosis and bleeding in most organs. Survivors of heatstroke may experience long-term neurological and cardiovascular complications with a persistent risk of death. No specific therapy other than rapid cooling is available. Physiological and morphological factors contribute to the susceptibility to heatstroke. Future research should identify genetic factors that further describe individual heat illness risk and form the basis of precision-based public health response. Prioritizing research towards fundamental mechanism and diagnostic biomarker discovery is crucial for the design of specific management approaches.

Sudden Death in High School Athletes: A Case Series Examining the Influence of Sickle Cell Trait

ABSTRACT

Athletes with sickle cell trait (SCT) have up to a 37-fold increased risk of exercise-related death. Exertional collapse associated with sickle cell trait (ECAST) is uncommon but can lead to exercise-related death due to exertional sickling. We present a case series of fatal ECAST in high school athletes aged 14 to 16 years. All 3 athletes experienced collapse during practice sessions with muscle pain or weakness. Upon evaluation at the hospital, the athletes had a significant metabolic acidosis that did not respond as expected to fluid resuscitation. Admitting diagnoses for the athletes included exertional heat stroke or dehydration. All 3 athletes had profound rhabdomyolysis leading to acute renal failure, worsening metabolic acidosis, and hyperkalemia. They rapidly progressed to disseminated intravascular coagulation, multiorgan system failure, and death. The autopsies of all 3 athletes showed extensive sickle cell vaso-occlusion involving the spleen liver, and muscles. Final clinical and pathologic diagnosis supported ECAST with fatal exertional rhabdomyolysis. Exertional collapse associated with sickle cell trait is an uncommon but potentially deadly condition that is often underrecognized or misdiagnosed as exertional heat stroke. The development of ECAST is thought to be multifactorial with exercise intensity, recent illness, and exercising conditions (ie, heat and altitude). Prevention should be the primary goal for athletes with SCT through exercise modification, education of precipitation factors, and cessation of exercise with recent illness. Athletes with suspected ECAST should undergo aggressive resuscitation with a low threshold for early transfer to a tertiary care facility for further management and potential hemodialysis.

Emergency Action Planning in School-Based Athletics: A Systematic Review

Introduction

A significant number of preventable catastrophic injuries occur in secondary school athletics. Compliance to Emergency Action Plan (EAP) recommendations is not well documented. The purpose of this systematic review was to identify compliance to EAP recommendations, access to an athletic trainer (AT) and automated external defibrillator (AED), and current legislative mandates in school-based athletics.

Methods

Electronic databases were searched to identify articles that met criteria for inclusion. Studies in English that focused on adoption, implementation, or compliance with EAPs or other national guidelines pertaining to athlete health were eligible for inclusion. Quality and validity were examined in each article and data were grouped based on outcome measures.

Results

Of 12,906 studies, 21 met the criteria for inclusion and full text review. Nine studies demonstrated EAP adoption rates ranging from 55% - 100%. Five studies found that EAPs were rehearsed and reviewed annually in 18.2% - 91.6% of schools that have an EAP. At total of 9.9% of schools were compliant with all 12 National Athletic Trainers Association (NATA) EAP guidelines. A total of 2.5% - 27.5% of schools followed NATA exertional heat illness guidelines and 50% - 81% of schools had access to an athletic trainer. In addition, 61% - 94.4% of schools had an AED available at their athletic venues. Four of 51 state high school athletic association member schools were required to meet best practice standards for EAP implementation, 7 of 51 for AED access, 8 of 51 for heat acclimation, and 3 of 51 for concussion management.

Conclusions

There was a wide range of EAP adoption and a low rate of compliance to EAP guidelines in U.S. schools. Barriers to EAP adoption and compliance were not well documented and additional research should aim to identify impeding and facilitating factors.

Athletic Administrators' Reporting of Emergency Preparedness Regarding Policies and Procedures in Iowa Secondary Schools

CONTEXT

Secondary schools that offer school-sponsored athletic events should follow best-practice guidelines to provide policies that promote student health and safety.

OBJECTIVE

To assess emergency preparedness from the perspective of athletic administrators (AAs) in Iowa secondary schools.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

Ninety-eight AAs from Iowa completed the survey (age = 45.33 ± 10.22 years, years as an AA = 9.37 ± 8.14, years in current role = 7.72 ± 7.09).

MAIN OUTCOME MEASURES(S)

The 6-section survey contained with questions about access to athletic trainers (ATs), emergency action plans (EAPs), cardiopulmonary resuscitation (CPR), automated external defibrillators (AEDs), concussions, heat illness, and other general policies. Descriptive statistics (percentages and frequencies) were reported. Relative risk was calculated to compare schools with and those without access to ATs (P < .05).

RESULTS

Most respondents (76.5%, n = 75/98) reported their school had access to a licensed AT. The majority had a written EAP (83.3%, n = 70/84), but fewer than half (39.2%, n = 31/79) reviewed it annually and fewer than 10% (n = 6/85) reported practicing it each year. All respondents (100%, N = 78/78) stated they had an AED on campus. All respondents (N = 77/77) indicated that they were familiar with the Iowa High School Athletic Association's (IHSAA's) concussion policy and had a concussion guideline in place. Many respondents (95.9%, n = 71/74) described being familiar with the IHSAA's heat illness policy, but more than half (62.1%, n = 41/66) noted they did not have a heat illness policy in place at their school.

CONCLUSIONS

Most respondents indicated their school had access to ATs, followed the state-mandated concussion guidelines, and had an AED. Although participants reported having written EAPs in place, levels of annual EAP review and practice were low. These results suggest that schools would benefit from educational opportunities to improve safety policies.

Socioeconomic factors and outcomes from exercise-related sudden cardiac arrest in high school student-athletes in the USA

Objective

Minority student-athletes have a lower survival rate from sudden cardiac arrest (SCA) than non-minority student-athletes. This study examined the relationship between high school indicators of socioeconomic status (SES) and survival in student-athletes with exercise-related SCA.

Methods

High school student-athletes in the USA with exercise-related SCA on school campuses were prospectively identified from 1 July 2014 to 30 June 2018 by the National Center for Catastrophic Sports Injury Research. High school indicators of SES included the following: median household and family income, proportion of students on free/reduced lunch and percent minority students. Resuscitation details included witnessed arrest, presence of an athletic trainer, bystander cardiopulmonary resuscitation and use of an on-site automated external defibrillator (AED). The primary outcome was survival to hospital discharge. Differences in survival were analysed using risk ratios (RR) and univariate general log-binomial regression models.

Results

Of 111 cases identified (mean age 15.8 years, 88% male, 49% white non-Hispanic), 75 (68%) survived. Minority student-athletes had a lower survival rate compared with white non-Hispanic student-athletes (51.1% vs 75.9%; RR 0.67, 95% CI 0.49 to 0.92). A non-significant monotonic increase in survival was observed with increasing median household or family income and with decreasing percent minority students or proportion on free/reduced lunch. The survival rate was 83% if an athletic trainer was on-site at the time of SCA and 85% if an on-site AED was used.

Conclusions

Minority student-athletes with exercise-related SCA on high school campuses have lower survival rates than white non-Hispanic athletes, but this difference is not fully explained by SES markers of the school.

High Schools' Adoption of Evidence-Based Practices for the Management of Exertional Heat Stroke

CONTEXT

Exertional heat stroke (EHS) deaths can be prevented by adhering to best practices.

OBJECTIVE

To investigate high schools' adoption of policies and procedures for recognizing and treating patients with EHS and the factors influencing the adoption of a comprehensive policy.

DESIGN

Cross-sectional study.

SETTING

Online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

Athletic trainers (ATs) practicing in the high school (HS) setting.

MAIN OUTCOME MEASURE(S)

Using the National Athletic Trainers' Association position statement on exertional heat illness, we developed an online questionnaire and distributed it to ATs to ascertain their schools' current written policies for using rectal temperature and cold-water immersion. The precaution adoption process model allowed for responses to be presented across the various health behavior stages (unaware if have the policy, unaware of the need for the policy, unengaged, undecided, decided not to act, decided to act, acting, and maintaining). Additional questions addressed perceptions of facilitators and barriers. Data are presented as proportions.

RESULTS

A total of 531 ATs completed the questionnaire. Overall, 16.9% (n = 62) reported adoption of all components for the proper recognition and treatment of EHS. The component with the highest adoption level was "cool first, transport second"; 74.1% (n = 110) of ATs described acting on or maintaining the policy. The most variability in the precaution adoption process model responses was for a rectal temperature policy; 28.7% (n = 103) of ATs stated they decided not to act and 20.1% (n = 72) stated they maintained the policy. The most frequently cited facilitator of and barrier to obtaining rectal temperature were a mandate from the state HS athletics association (n = 274, 51.5%) and resistance to or apprehension of parents or legal guardians (n = 311, 58.5%), respectively.

CONCLUSIONS

Athletic trainers in the HS setting appeared to be struggling to adopt a comprehensive EHS strategy, with rectal temperature continuing as the biggest challenge. Tailored strategies based on health behavior, facilitators, and barriers may aid in changing this paradigm.

State-Level Implementation of Health and Safety Policies to Prevent Sudden Death and Catastrophic Injuries Within High Schools: An Update

BACKGROUND

Mandated sports safety policies that incorporate evidence-based best practices have been shown to mitigate the risk of mortality and morbidity in sports. In 2017, a review of the state-level implementation of health and safety policies within high schools was released.

PURPOSE

To provide an update on the assessment of the implementation of health and safety policies pertaining to the leading causes of death and catastrophic injuries in sports within high school athletics in the United States.

STUDY DESIGN

Cross-sectional study.

METHODS

A rubric composed of 5 equally weighted sections for sudden cardiac arrest, traumatic head injuries, exertional heatstroke, appropriate health care coverage, and emergency preparedness was utilized to assess an individual state's policies. State high school athletic/activities association (SHSAA) policies, enacted legislation, and Department of Education policies were extensively reviewed for all 50 states and the District of Columbia between academic year (AY) 2016-2017 (AY16/17) and 2019-2020 (AY19/20). To meet the specific rubric criteria and be awarded credit, policies needed to be mandated by all SHSAA member schools. Weighted scores were tabulated to calculate an aggregate score with a minimum of 0 and a maximum of 100.

RESULTS

A total of 38 states had increased their rubric scores since AY16/17, with a mean increase of 5.57 ± 6.41 points. In AY19/20, scores ranged from 30.80 to 85.00 points compared with 23.00 to 78.75 points in AY16/17. Policies related to exertional heatstroke had the greatest change in scores (AY16/17 mean, 6.62 points; AY19/20 mean, 8.90 points; Δ = 2.28 points [11.40%]), followed by emergency preparedness (AY16/17 mean, 8.41 points; AY19/20 mean, 10.29 points; Δ = 1.88 points [9.40%]).

CONCLUSION

A longitudinal review of state high school sports safety policies showed progress since AY16/17. A wide range in scores indicates that continued advocacy for the development and implementation of policies at the high school level is warranted.

Secondary School Administrators' Knowledge and Perceptions of the Athletic Training Profession, Part I: Specific Considerations for Athletic Directors

CONTEXT

Athletic directors are charged with making impactful decisions for secondary school athletic programs that mitigate risks for stakeholders. This includes decision making regarding the provision of medical care for student-athletes. To date, few researchers have explored athletic directors' perceptions of the athletic training profession.

OBJECTIVE

To evaluate public school athletic directors' knowledge and perceptions of the athletic trainer (AT) role.

DESIGN

Concurrent mixed-methods study.

SETTING

Cross-sectional online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

Athletic directors representing all 50 states and the District of Columbia (N = 954; 818 men, 133 women, 3 preferred not to answer; age = 47.8 ± 9.1 years; time in current role = 9.8 ± 8.3 years).

MAIN OUTCOME MEASURE(S)

The questionnaire was composed of demographics, quantitative measures that assessed athletic directors' knowledge and perceived value of ATs, and open-ended questions allowing for expansion on their perspectives. Descriptive statistics were reported, with key quantitative findings presented as count responses and overall percentages. Qualitative data were analyzed using the general inductive approach.

RESULTS

A majority of respondents recognized ATs' role in injury prevention (99.8%), first aid and wound care (98.8%), therapeutic interventions (93.8%), and emergency care (91.6%). Approximately 61% (n = 582) identified AT employment as a top sport safety measure, and 77% (n = 736) considered an AT to be extremely valuable to student-athlete health and safety. Athletic directors appeared to recognize the value of ATs as they provided "peace of mind" and relieved coaches and administration of the responsibility for making medical decisions.

CONCLUSIONS

Athletic directors seemed to recognize the value ATs brought to the secondary school setting and demonstrated adequate knowledge regarding ATs' roles and responsibilities. Educational efforts for this population should focus on ATs' tasks that add to their perceived value but are not frequently in the public eye, which may influence hiring decisions.

Secondary School Administrators' Knowledge and Perceptions of the Athletic Training Profession, Part II: Specific Considerations for Principals

CONTEXT

Secondary school administrators fulfill many leadership roles, including creating and implementing policies to help ensure the safety of athletic programs. However, few researchers have examined principals' awareness and perceptions of the athletic trainer's (AT's) role.

OBJECTIVE

To explore secondary school principals' knowledge of the roles and responsibilities of ATs and perceptions of athletic training.

DESIGN

Concurrent mixed-methods study.

SETTING

Cross-sectional online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

Principals (n = 686; age = 48.1 ± 7.8 years, time in position = 7.1 ± 5.8 years) represented public secondary schools across the United States.

MAIN OUTCOME MEASURE(S)

The web-based questionnaire was composed of demographics, various quantitative items assessing knowledge and perceived value of ATs, and open-ended questions. Descriptive statistics summarized demographic data. Select quantitative measures are reported as count responses and overall percentages. Responses to open-ended questions were analyzed inductively.

RESULTS

We obtained a 5% response rate (686 of 13 517). Approximately 93% (n = 637) of responding principals considered an AT to be a trusted source of medical information. The most frequently selected skills they believed ATs were qualified to perform were injury prevention (99.1%), first aid/wound care (96.5%), and therapeutic intervention (91.4%). Sixty-three percent (n = 430) of participants considered an AT to be extremely valuable to student-athlete health and safety. Our results indicated that secondary school principals had a vague understanding of AT "training" and appreciated the immediacy of care ATs could provide. They also appeared to use decentralized hiring practices.

CONCLUSIONS

Secondary school principals identified ATs as a trusted source of medical information and recognized the role ATs played in the immediate care of athletic-related injuries. However, principals had a limited understanding of the qualifications and educational requirements of ATs. Future professional advocacy efforts targeting this stakeholder group should highlight all medical services an AT provides and emphasize the AT's value in schools that sponsor athletics programs.

Sudden Death in the Young: Information for the Primary Care Provider

There are multiple conditions that can make children prone to having a sudden cardiac arrest (SCA) or sudden cardiac death (SCD). Efforts have been made by multiple organizations to screen children for cardiac conditions, but the emphasis has been on screening before athletic competition. This article is an update of the previous American Academy of Pediatrics policy statement of 2012 that addresses prevention of SCA and SCD. This update includes a comprehensive review of conditions that should prompt more attention and cardiology evaluation. The role of the primary care provider is of paramount importance in the evaluation of children, particularly as they enter middle school or junior high. There is discussion about whether screening should find any cardiac condition or just those that are associated with SCA and SCD. This update reviews the 4 main screening questions that are recommended, not just for athletes, but for all children. There is also discussion about how to handle post-SCA and SCD situations as well as discussion about genetic testing. It is the goal of this policy statement update to provide the primary care provider more assistance in how to screen for life-threatening conditions, regardless of athletic status.

Roundtable on Preseason Heat Safety in Secondary School Athletics: Heat Acclimatization

OBJECTIVE

To provide best-practice recommendations for developing and implementing heat-acclimatization strategies in secondary school athletics.

DATA SOURCES

An extensive literature review on topics related to heat acclimatization and heat acclimation was conducted by a group of content experts. Using the Delphi method, action-oriented recommendations were developed.

CONCLUSIONS

A period of heat acclimatization consisting of ≥14 consecutive days should be implemented at the start of fall preseason training or practices for all secondary school athletes to mitigate the risk of exertional heat illness. The heat-acclimatization guidelines should outline specific actions for secondary school athletics personnel to use, including the duration of training, the number of training sessions permitted per day, and adequate rest periods in a cool environment. Further, these guidelines should include sport-specific and athlete-specific recommendations, such as phasing in protective equipment and reintroducing heat acclimatization after periods of inactivity. Heat-acclimatization guidelines should be clearly detailed in the secondary school's policy and procedures manual and disseminated to all stakeholders. Heat-acclimatization guidelines, when used in conjunction with current best practices surrounding the prevention, management, and care of secondary school student-athletes with exertional heat stroke, will optimize their health and safety.

Influence of State-Level Emergency Planning Policy Requirements on Secondary School Adoption

CONTEXT

Emergency action plans (EAPs) are a critical component in the management of catastrophic sport-related injury. Some state high school athletics associations and state legislation have required that schools develop EAPs, but little research exists on the influence of a statewide policy requirement on local adoption of these policies.

OBJECTIVE

To examine the efficacy of a statewide policy requirement on local adoption of an EAP.

DESIGN

Cross-sectional study.

SETTING

Online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

Secondary school athletic trainers were invited to complete a survey (n = 9642); 1136 completed the survey, yielding an 11.7% response rate.

MAIN OUTCOME MEASURE(S)

Survey responses on the adoption of EAPs along with cardiopulmonary resuscitation and automated external defibrillator (CPR/AED) requirements were cross-referenced with published statewide policies to determine the prevalence of EAP adoption. We evaluated the adoption of emergency action plan components based on the National Athletic Trainers' Association's emergency planning position statement along with CPR/AED requirements to determine component-specific prevalence. We compared the prevalence of EAP and component adoption between states that required EAPs and specific components of EAPs and states without such requirements.

RESULTS

Athletic trainers in states that required adoption of an EAP reported including more components of the emergency planning position statement (mean = 8 ± 4, median = 9) than in states without a requirement (mean = 7 ± 4, median = 8). The adoption of EAP components did not differ between states that required specific components of the EAP versus development of the EAP only. However, schools in states with both EAP and CPR/AED training requirements reported higher rates of CPR/AED training implementation (95.5%) than states that only required CPR/AED training (81.6%, prevalence ratio = 1.10, 95% confidence interval = 1.01, 1.20).

CONCLUSIONS

Based on these data, statewide policy requirements for the development of an EAP may be associated with increasing adoption of EAPs.

Exertional Heat-Stroke Management Practices and Intentions Among Secondary School Football Athletic Trainers

CONTEXT

Athletic trainers (ATs) are educated and trained in appropriate exertional heat-stroke (EHS) management strategies, yet disparities may exist between intended and actual uses in clinical practice.

OBJECTIVE

To examine the intended and actual uses of EHS management strategies among those who did and those who did not treat patients with suspected cases of EHS during the 2017 high school (HS) American football preseason.

DESIGN

Cross-sectional study.

SETTING

Online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

A total of 1016 ATs who oversaw patient care during the 2017 HS American football preseason.

MAIN OUTCOME MEASURE(S)

Responding HS ATs recorded whether they had or had not managed patients with suspected EHS events during the 2017 HS American football preseason. Those who had managed patients with suspected cases of EHS reported the management strategies used; those who had not managed such patients described their intended management strategies. For each management strategy, z tests compared the proportions of actual use among ATs who managed patients with suspected EHS with the proportions of intended use among ATs who did not manage such patients.

RESULTS

Overall, 124 (12.2%) ATs treated patients with suspected EHS cases during the 2017 HS American football preseason. Generally, the proportions of intended use of management strategies among ATs who did not treat patients with suspected EHS were higher than the actual use of those strategies among ATs who did. For example, ATs who did treat patients with suspected EHS were more likely than those who did not treat such patients to intend to take rectal temperature (19.6% versus 3.2%, P < .001) and immerse the athlete in ice water (90.1% versus 51.6%, P < .001).

CONCLUSIONS

Inconsistencies occurred between intended and actual use of EHS management strategies. The standard of care for managing patients with suspected cases of EHS was not consistently used in clinical practice, although ATs who did not treat EHS stated they intended to use these management strategies more frequently. Future researchers should identify factors that preclude ATs from using the standard of care when treating patients with suspected cases of EHS.

Clinical Practice Guidelines for Exertional Rhabdomyolysis: A Military Medicine Perspective

ABSTRACT

Exertional rhabdomyolysis (ER) is an uncommon condition with a paucity of evidence-based guidance for diagnosis, management, and return to duty or play. Recently, a clinical practice guideline for diagnosis and management of ER in warfighters was updated by a team of military and civilian physicians and researchers using current scientific literature and decades of experience within the military population. The revision concentrated on challenging and controversial clinical questions with applicability to providers in the military and those in the greater sports medicine community. Specific topics addressed: 1) diagnostic criteria for ER; 2) clinical decision making for outpatient versus inpatient treatment; 3) optimal strategies for inpatient management; 4) discharge criteria; 5) identification and assessment of warfighters/athletes at risk for recurrent ER; 6) an appropriate rehabilitative plan; and finally, 7) key clinical questions warranting future research.

Summit on Exercise Collapse Associated with Sickle Cell Trait: Finding the "Way Ahead"

ABSTRACT

Although largely benign, sickle cell trait (SCT) has been associated with exertion-related events, to include sudden death. In 2011, a summit on SCT introduced the term exercise collapse associated with SCT (ECAST). A series of ECAST deaths in military personnel in 2019 prompted reevaluation of current efforts and led to a second summit in October 2019 hosted by the Consortium for Health and Military Performance of the Uniformed Services University in Bethesda, MD. The goals were to (1) review current service policies on SCT screening, (2) develop draft procedural instructions for executing current policy on SCT within the Department of Defense, (3) develop draft clinical practice guidelines for management of ECAST, (4) establish a framework for education on SCT and ECAST, and (5) prepare a research agenda to address identified gaps.

Perceptions of Secondary School Athletic Trainers in the Diagnosis of Exertional Heat Stroke

CONTEXT

Health care providers, including athletic trainers (ATs), may not be using the best practices for diagnosing exertional heat stroke (EHS), including rectal thermometry. Therefore, patients continue to be susceptible to death from EHS.

OBJECTIVE

To examine the health belief model and its association with using rectal thermometry as the best practice for diagnosing EHS.

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 208 secondary school ATs completed an online survey, and the data of 159 were included in the analysis.

MAIN OUTCOME MEASURE(S)

The survey contained 2 primary sections: AT characteristics and health belief model structured questions assessing perceptions and techniques used to diagnose EHS. Answers to the latter questions were rated on a 5-point Likert scale. We performed a binary logistic regression to ascertain the effects of the health belief model constants (eg, perceived susceptibility, barriers), age, sex, and the type of school at which the AT worked on the likelihood that participants would use best practice for diagnosing patients with EHS.

RESULTS

Only 33.3% (n = 53) of the participating ATs reported they used best practice, including rectal thermometers to obtain core body temperature. The binary logistic regression was different for the 5 constructs: perceived susceptibility (\(\def\upalpha{\unicode[Times]{x3B1}}\)\(\def\upbeta{\unicode[Times]{x3B2}}\)\(\def\upgamma{\unicode[Times]{x3B3}}\)\(\def\updelta{\unicode[Times]{x3B4}}\)\(\def\upvarepsilon{\unicode[Times]{x3B5}}\)\(\def\upzeta{\unicode[Times]{x3B6}}\)\(\def\upeta{\unicode[Times]{x3B7}}\)\(\def\uptheta{\unicode[Times]{x3B8}}\)\(\def\upiota{\unicode[Times]{x3B9}}\)\(\def\upkappa{\unicode[Times]{x3BA}}\)\(\def\uplambda{\unicode[Times]{x3BB}}\)\(\def\upmu{\unicode[Times]{x3BC}}\)\(\def\upnu{\unicode[Times]{x3BD}}\)\(\def\upxi{\unicode[Times]{x3BE}}\)\(\def\upomicron{\unicode[Times]{x3BF}}\)\(\def\uppi{\unicode[Times]{x3C0}}\)\(\def\uprho{\unicode[Times]{x3C1}}\)\(\def\upsigma{\unicode[Times]{x3C3}}\)\(\def\uptau{\unicode[Times]{x3C4}}\)\(\def\upupsilon{\unicode[Times]{x3C5}}\)\(\def\upphi{\unicode[Times]{x3C6}}\)\(\def\upchi{\unicode[Times]{x3C7}}\)\(\def\uppsy{\unicode[Times]{x3C8}}\)\(\def\upomega{\unicode[Times]{x3C9}}\)\(\def\bialpha{\boldsymbol{\alpha}}\)\(\def\bibeta{\boldsymbol{\beta}}\)\(\def\bigamma{\boldsymbol{\gamma}}\)\(\def\bidelta{\boldsymbol{\delta}}\)\(\def\bivarepsilon{\boldsymbol{\varepsilon}}\)\(\def\bizeta{\boldsymbol{\zeta}}\)\(\def\bieta{\boldsymbol{\eta}}\)\(\def\bitheta{\boldsymbol{\theta}}\)\(\def\biiota{\boldsymbol{\iota}}\)\(\def\bikappa{\boldsymbol{\kappa}}\)\(\def\bilambda{\boldsymbol{\lambda}}\)\(\def\bimu{\boldsymbol{\mu}}\)\(\def\binu{\boldsymbol{\nu}}\)\(\def\bixi{\boldsymbol{\xi}}\)\(\def\biomicron{\boldsymbol{\micron}}\)\(\def\bipi{\boldsymbol{\pi}}\)\(\def\birho{\boldsymbol{\rho}}\)\(\def\bisigma{\boldsymbol{\sigma}}\)\(\def\bitau{\boldsymbol{\tau}}\)\(\def\biupsilon{\boldsymbol{\upsilon}}\)\(\def\biphi{\boldsymbol{\phi}}\)\(\def\bichi{\boldsymbol{\chi}}\)\(\def\bipsy{\boldsymbol{\psy}}\)\(\def\biomega{\boldsymbol{\omega}}\)\(\def\bupalpha{\bf{\alpha}}\)\(\def\bupbeta{\bf{\beta}}\)\(\def\bupgamma{\bf{\gamma}}\)\(\def\bupdelta{\bf{\delta}}\)\(\def\bupvarepsilon{\bf{\varepsilon}}\)\(\def\bupzeta{\bf{\zeta}}\)\(\def\bupeta{\bf{\eta}}\)\(\def\buptheta{\bf{\theta}}\)\(\def\bupiota{\bf{\iota}}\)\(\def\bupkappa{\bf{\kappa}}\)\(\def\buplambda{\bf{\lambda}}\)\(\def\bupmu{\bf{\mu}}\)\(\def\bupnu{\bf{\nu}}\)\(\def\bupxi{\bf{\xi}}\)\(\def\bupomicron{\bf{\micron}}\)\(\def\buppi{\bf{\pi}}\)\(\def\buprho{\bf{\rho}}\)\(\def\bupsigma{\bf{\sigma}}\)\(\def\buptau{\bf{\tau}}\)\(\def\bupupsilon{\bf{\upsilon}}\)\(\def\bupphi{\bf{\phi}}\)\(\def\bupchi{\bf{\chi}}\)\(\def\buppsy{\bf{\psy}}\)\(\def\bupomega{\bf{\omega}}\)\(\def\bGamma{\bf{\Gamma}}\)\(\def\bDelta{\bf{\Delta}}\)\(\def\bTheta{\bf{\Theta}}\)\(\def\bLambda{\bf{\Lambda}}\)\(\def\bXi{\bf{\Xi}}\)\(\def\bPi{\bf{\Pi}}\)\(\def\bSigma{\bf{\Sigma}}\)\(\def\bPhi{\bf{\Phi}}\)\(\def\bPsi{\bf{\Psi}}\)\(\def\bOmega{\bf{\Omega}}\)\(\chi _6^2\) = 22.30, P = .001), perceived benefits (\(\chi _6^2\) = 71.79, P < .001), perceived barriers (\(\chi _6^2\) = 111.22, P < .001), perceived severity (\(\chi _6^2\) = 56.27, P < .001), and self-efficacy (\(\chi _6^2\) = 64.84, P < .001). Analysis of these data showed that older ATs were at greater odds (P ≤ .02) of performing best practice.

CONCLUSIONS

These data suggested that the health belief model constructs were associated with the performance of best practice, including using rectal thermometry to diagnose EHS. Researchers should aim to create tailored interventions based on health behavior to improve the adoption of best practice.

Exertional Heat Illness Preparedness Strategies: Environmental Monitoring Policies in United States High Schools

Background and objectives: Environmental monitoring allows for an analysis of the ambient conditions affecting a physically active person’s ability to thermoregulate and can be used to assess exertional heat illness risk. Using public health models such as the precaution adoption process model (PAPM) can help identify individual’s readiness to act to adopt environmental monitoring policies for the safety of high school athletes. The purpose of this study was to investigate the adoption of policies and procedures used for monitoring and modifying activity in the heat in United States (US) high schools. Materials and Methods: Using a cross-sectional design, we distributed an online questionnaire to athletic trainers (ATs) working in high schools in the US. The questionnaire was developed based on best practice standards related to environmental monitoring and modification of activity in the heat as outlined in the 2015 National Athletic Trainers’ Association Position Statement: Exertional Heat Illness. The PAPM was used to frame questions as it allows for the identification of ATs’ readiness to act. PAPM includes eight stages: unaware of the need for the policy, unaware if the school has this policy, unengaged, undecided, decided not to act, decided to act, acting, and maintaining. Invitations were sent via email and social media and resulted in 529 complete responses. Data were aggregated and presented as proportions. Results: Overall, 161 (161/529, 30.4%) ATs report they do not have a written policy and procedure for the prevention and management of exertional heat stroke. The policy component with the highest adoption was modifying the use of protective equipment (acting = 8.2%, maintaining = 77.5%). In addition, 28% of ATs report adoption of all seven components for a comprehensive environmental monitoring policy. Conclusions: These findings indicate a lack of adoption of environmental monitoring policies in US high schools. Secondarily, the PAPM, facilitators and barriers data highlight areas to focus future efforts to enhance adoption.

Regional Requirements Influence Adoption of Exertional Heat Illness Preparedness Strategies in United States High Schools

Background and objectives: Exertional heat stroke (EHS) continues to be a prevalent health issue affecting all athletes, including our pediatric populations. The purpose of this study was to evaluate the effect of a state policy requirement for EHS prevention and treatment on local high school policy adoption in the United States (US). Materials and Methods: Athletic trainers (ATs) from high schools across the US participated in an online survey (n = 365). This survey inquired about their compliance with nine components of an EHS policy which was then compared to their state requirements for the policies. Evaluation of the number of components adopted between states with a requirement versus states without a requirement was conducted with a Wilcoxon Sign Rank test. Finally, an ordinal logistic regression with proportional odds ratios (OR) with 95% confidence intervals (CI) were run to determine the effect of a state requirement and regional differences on the number of components adopted. Results: ATs working in states with a requirement reported adoption of more components in their heat modification policy compared to states that did not require schools to develop a heat modification policy (with requirement mean = 5.34 ± 3.68, median = 7.0; without requirement mean = 4.23 ± 3.59, median = 5.0; Z = -14.88, p < 0.001). ATs working in region 3 (e.g., hotter regions) reported adopting more components than those in region 1 (e.g., cooler regions) (OR = 2.25, 95% CI: 1.215-4.201, p = 0.010). Conclusions: Our results demonstrate a positive association between state policy requirements and subsequently increased local policy adoption for EHS policies. Additionally, the results demonstrate that regional differences exist, calling for the need for reducing disparities across the US. These findings may imply that policy adoption is a multifactorial process; furthermore, additional regional specific investigations must be conducted to determine the true determinants of high school policy adoption rates for EHS policies.

Nontraumatic Exertional Fatalities in Football Players, Part 2: Excess in Conditioning Kills

BACKGROUND

The incidence of nontraumatic fatalities in high school (HS) and National Collegiate Athletic Association (NCAA) football players has continued at a constant rate since the 1960s.

PURPOSE

To describe the causes of nontraumatic fatalities in HS and NCAA football players and provide prevention strategies.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

We reviewed 187 fatalities in HS and NCAA nontraumatic football players catalogued by the National Registry of Catastrophic Sports Injuries during a 20-year period between July 1998 and June 2018.

RESULTS

The majority (n = 162; 86.6%) of fatalities occurred during a practice or conditioning session. Most fatalities, when timing was known, (n = 126; 70.6%) occurred outside of the regular playing season, with the highest incidence in the August preseason (n = 64; 34.2%). All documented conditioning sessions were supervised by a coach (n = 92) or strength and conditioning coach (n = 40). The exercise regimen at the time of the fatality involved high-intensity aerobic training in 94.7%. Punishment was identified as the intent in 36 fatalities. The average body mass index of the athletes was 32.6 kg/m2. For athletes who died due to exertional heat stroke, the average body mass index was 36.4 kg/m2, and 97.1% were linemen.

CONCLUSION

Most nontraumatic fatalities in HS and NCAA football players occurred during coach-supervised conditioning sessions. The primary cause of exertion-related fatalities was high-intensity aerobic workouts that might have been intended as punishment and/or excess repetitions. Exertion-related fatalities are potentially preventable by applying standards in workout design, holding coaches accountable, and ensuring compliance with the athlete's health and current welfare policies.

Nontraumatic Exertional Fatalities in Football Players, Part 1: Epidemiology and Effectiveness of National Collegiate Athletic Association Bylaws

BACKGROUND

Football has the highest number of nontraumatic fatalities of any sport in the United States.

PURPOSE

To compare the incidence of nontraumatic fatalities with that of traumatic fatalities, describe the epidemiology of nontraumatic fatalities in high school (HS) and college football players, and determine the effectiveness of National Collegiate Athletic Association (NCAA) policies to reduce exertional heat stroke (EHS) and exertional sickling (ES) with sickle cell trait (SCT) fatalities in athletes.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

We retrospectively reviewed 20 academic years (1998-2018) of HS and college nontraumatic fatalities in football players using the National Registry of Catastrophic Sports Injuries (NRCSI). EHS and ES with SCT fatality rates were compared before and after the implementation of the NCAA football out-of-season model (bylaw 17.10.2.4 [2003]) and NCAA Division I SCT screening (bylaw 17.1.5.1 [2010]), respectively. Additionally, we compiled incidence trends for HS and college traumatic and nontraumatic fatalities in football players for the years 1960 through 2018 based on NRCSI data and previously published reports.

RESULTS

The risk (odds ratio) of traumatic fatalities in football players in the 2010s was 0.19 (95% CI, 0.13-0.26; P < .0001) lower in HS and 0.29 (95% CI, 0.29-0.72; P = .0078) lower in college compared with that in the 1960s. In contrast, the risk of nontraumatic fatalities in football players in the 2010s was 0.7 (95% CI, 0.50-0.98; P = .0353) in HS and 0.9 (95% CI, 0.46-1.72; P = .7413) in college compared with that in the 1960s. Since 2000, the risk of nontraumatic fatalities has been 1.89 (95% CI, 1.42-2.51; P < .001) and 4.22 (95% CI, 2.04-8.73; P < .001) higher than the risk of traumatic fatalities at the HS and college levels, respectively. During the 20 years studied, there were 187 nontraumatic fatalities (average, 9.4 per year). The causes of death were sudden cardiac arrest (57.7%), EHS (23.6%), ES with SCT (12.1%), asthma (4.9%), and hyponatremia (1.6%). The risk of a nontraumatic fatality was 4.1 (95% CI, 2.8-5.9; P < .0001) higher in NCAA compared with HS athletes. There was no difference in the risk of an EHS fatality in NCAA athletes (0.86 [95% CI, 0.17-4.25]; P = .85) after implementation in 2003 of the NCAA football out-of-season model. The risk of an ES with SCT fatality in Division I athletes was significantly lower after the 2010 NCAA SCT screening bylaw was implemented (0.12 [95% CI, 0.02-0.95]; P = .04).

CONCLUSION

Since the 1960s, the risk of nontraumatic fatalities has declined minimally compared with the reduction in the risk of traumatic fatalities. Current HS and college nontraumatic fatality rates are significantly higher than rates of traumatic fatalities. The 2003 NCAA out-of-season model has failed to significantly reduce EHS fatalities. The 2010 NCAA SCT screening bylaw has effectively prevented ES with SCT fatalities in NCAA Division I football.

Design and Implementation of an Emergency Action Plan for Sudden Cardiac Arrest in Sport

Sudden cardiac arrest (SCA) is the leading cause of exercise-related fatalities in athletes. A comprehensive emergency action plan (EAP) is critical to facilitate a rapid and effective response to a cardiac emergency. SCA should be suspected in any athlete that collapses suddenly and is unresponsive. All potential responders to a collapsed athlete should be trained in the recognition of SCA, cardiopulmonary resuscitation, and use of an automated external defibrillator (AED). AEDs should be accessible on-site at sporting venues with a target collapse to first shock interval of less than 3 min. Every school, club, and sporting organization that sponsors athletic activities should have a written EAP for SCA. An EAP coordinator should be designated to foster compliance with training, practice, and rehearsal of the EAP at least once annually. Some sports require special considerations for equipment removal or access to emergency services in geographically broad or water-based venues.

Concussion and Mild-Traumatic Brain Injury in Rural Settings: Epidemiology and Specific Health Care Considerations

Background  Mild-traumatic brain injury (mTBI) and concussions cause significant morbidity. To date, synthesis of specific health care disparities and gaps in care for rural mTBI/concussion patients remains needed. Methods  A comprehensive literature search was performed using PubMed database for English articles with keywords "rural" and ("concussion" or "mild traumatic brain injury") from 1991 to 2019. Eighteen articles focusing on rural epidemiology ( n = 5), management/cost ( n = 5), military ( n = 2), and concussion prevention/return to play ( n = 6) were included. Results  mTBI/concussion incidence was higher in rural compared with urban areas. Compared with urban patients, rural patients were at increased risk for vehicular injuries, lifetime number of concussions, admissions for observation without neuroimaging, and injury-related costs. Rural patients were less likely to utilize ambulatory and mental health services following mTBI/concussion. Rural secondary schools had decreased access to certified personnel for concussion evaluation, and decreased use of standardized assessment instruments/neurocognitive testing. While school coaches were aware of return-to-play laws, mTBI/concussion education rates for athletes and parents were suboptimal in both settings. Rural veterans were at increased risk for postconcussive symptoms and posttraumatic stress. Telemedicine in rural/low-resource areas is an emerging tool for rapid evaluation, triage, and follow-up. Conclusions  Rural patients are at unique risk for mTBI/concussions and health care costs. Barriers to care include lower socioeconomic status, longer distances to regional medical center, and decreased availability of neuroimaging and consultants. Due to socioeconomic and distance barriers, rural schools are less able to recruit personnel certified for concussion evaluation. Telemedicine is an emerging tool for remote triage and evaluation.

Athletic Trainer Services in the Secondary School Setting: The Athletic Training Locations and Services Project

CONTEXT

Previous research from a sample of US secondary schools (n = 10 553) indicated that 67% of schools had access to an athletic trainer (AT; 35% full time [FT], 30% part time [PT], and 2% per diem). However, the population-based statistic in all secondary schools with athletic programs (n = approximately 20 000) is yet to be determined.

OBJECTIVE

To determine the level of AT services and employment status in US secondary schools with athletics by National Athletic Trainers' Association district.

DESIGN

Cross-sectional study.

SETTING

Public and private secondary schools with athletics.

PATIENTS OR OTHER PARTICIPANTS

Data from all 20 272 US public and private secondary schools were obtained.

MAIN OUTCOME MEASURE(S)

Data were collected from September 2015 to April 2018 by phone or e-mail communication with school administrators or ATs and by online surveys of secondary school ATs. Employment categories were school district, school district with teaching, medical or university facility, and independent contractor. Data are presented as total number and percentage of ATs. Descriptive statistics were calculated for FT, PT, and no AT services data for public, private, public + private, and employment type by state and by National Athletic Trainers' Association district.

RESULTS

Of the 20 272 secondary schools, 66% (n = 13 473) had access to AT services, while 34% (n = 6799) had no access. Of those schools with AT services, 53% (n = 7119) received FT services, while 47% (n = 6354) received PT services. Public schools (n = 16 076) received 37%, 32%, and 31%, whereas private schools (n = 4196) received 27%, 28%, and 45%, for FT, PT, and no AT services, respectively. Most of the Athletic Training Locations and Services Survey participants (n = 6754, 57%) were employed by a medical or university facility, followed by a school district, school district with teaching, and independent contractor. Combined, 38% of AT employment was via the school district.

CONCLUSIONS

The percentages of US schools with AT access and FT and PT services were similar to those noted in previous research. One-third of secondary schools had no access to AT services. The majority of AT employment was via medical or university facilities. These data depict the largest and most updated representation of AT services in secondary schools.