Epidemiology of Sudden Death in Young, CompetitiveAthletes Due to Blunt Trauma

WHAT’S KNOWN ON THIS SUBJECT: Fatalities caused by blunttrauma are known to occur in children and adolescents in avariety of circumstances, including while engaged in competitivein sports.

WHAT THIS STUDY ADDS: This unique national databaseprovides a prevalence for trauma-related catastrophes inchildren, adolescents, and young adults aged 21 or younger;establishes the epidemiology of events for which football conveyshighest risk; and provides visibility to underrecognized mortalityrisks associated with “second-impact syndrome.”

abstractBACKGROUND: Sudden deaths of young competitive athletes are highlyvisible events that have a substantial effect on families and communi-ties. Recent attention has focused predominantly on cardiovascularcauses, and less on traumatic organ damage.

OBJECTIVE: To define the clinical profile, epidemiology, and frequencyof trauma-related deaths in young US athletes.

METHODS: We analyzed the 30-year US National Registry of SuddenDeath in Young Athletes (1980–2009) by using systematic identificationand tracking strategies.

RESULTS: Of 1827 deaths of athletes aged 21 years or younger, 261(14%) were caused by trauma-related injuries, usually involving thehead and/or neck (mean: 16 � 2 years; 90% male) in 22 sports. Thehighest number of events in a single year was 16 (1986), with an aver-age of 9 per year throughout 30 years. The mortality rate was 0.11 in100 000 participations (95% confidence interval: 0.08–0.15). The larg-est number of deaths was in football (148 [57%]), including 17 highschool athletes who sustained concussions shortly before fatal headtrauma (“second-impact syndrome”). Football deaths were more fre-quent in defensive players, although the single most common positioninvolved was running back (61% of offensive players).

CONCLUSIONS: In a large community-based national registry, suddendeaths caused by blunt trauma in young athletes aged 21 years oryounger were relatively uncommon with 16 or fewer per year, aboutfourfold less than cardiovascular deaths. These fatalities were mostfrequent in football, and an important proportion of deaths after headblows in high school football were associated with a recent history ofsymptomatic concussion. Pediatrics 2011;128:e1–e8

AUTHORS: Mathew Thomas, BS,a Tammy S. Haas, RN,a

Joseph J. Doerer, MD,a James S. Hodges, PhD,b Brittany O.Aicher, BA,a Ross F. Garberich, MS,a Frederick O. Mueller,PhD,c Robert C. Cantu, MD,d and Barry J. Maron, MDa

aMinneapolis Heart Institute Foundation, Minneapolis,Minnesota; bDivision of Biostatistics, University of Minnesota,Minneapolis, Minnesota; cNational Center for CatastrophicSports Injury Research, Chapel Hill, North Carolina; anddEmerson Hospital, Concord, Massachusetts

KEY WORDSsudden death, trauma, athletes

www.pediatrics.org/cgi/doi/10.1542/peds.2010-2743

doi:10.1542/peds.2010-2743

Accepted for publication Mar 4, 2011

Address correspondence to Barry J. Maron, MD, HypertrophicCardiomyopathy Center, Minneapolis Heart Institute Foundation,920 E 28th St, Suite 620, Minneapolis, MN 55407. E-mail: hcm.maron@mhif.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2011 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

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Although participation in competitiveathletics is usually regarded ashealthy and safe, athletes are never-theless subject to an unpredictablerisk for sudden death while engagingin a variety of sports.1 Although mostdata regarding these tragic events hasfocused on cardiovascular causes,2–4

other risks of the athletic field involvetrauma-related injuries5 or commotiocordis.6 Most previous reports of blunttrauma that cause structural organdamage have been tabulated duringrelatively short time periods, often in-cluding early eras of risk or largelyconfined to nonfatal events in small co-horts, and in single sports.5,7–12 In addi-tion, the risks associated with previ-ous head blows and concussions havebeen the subject of substantial recentattention in the media and medical lit-erature.13–27 For these reasons, we be-lieve it is timely to interrogate ourlarge US national registry, assembledthroughout 30 years, to assess the ep-idemiology and frequency of trauma-related sudden deaths in children, ad-olescents, and young adults aged 21years and younger engaged in compet-itive athletics, compared with the inci-dence of those events caused by car-diovascular disease over the sameperiod.

METHODS

Study Population

The US National Registry of SuddenDeath in Young Athletes was institutedat the Minneapolis Heart InstituteFoundation for the purpose of pro-spectively and retrospectively assem-bling data on the deaths of young ath-letes who participate in organizedcompetitive sports.2,4,28 The registry in-cludes a 30-year period (1980–2009)during which 1827 cases of athletes 21and younger at the time of their deathhave been enrolled, andwho representthe present study group.

Strategies for Identification

The study population was identified bypreviously reported methods2,4,28 withtargeted searches using a variety ofsources: (1) LexisNexis archival infor-mational database with searchable ac-cess to authoritative news, legal, andpublic records (n � 5 billion fromthousands of sources); (2) newsmediaaccounts systematically assembledthrough Burrelle’s Information Ser-vices (Livingston, NJ), with access to18 000 US newspapers and interna-tional media sources daily; (3) Internetsearches; access to online informationvia Web-based search engines (eg,Google, Yahoo); (4) reports from the USConsumer Product Safety Commission(Washington, DC); (5) accumulated re-cords of the National Center for Cata-strophic Sports Injury Research (Univer-sity of North Carolina, Chapel Hill, NC);and (6) reports directly to the registryand the Minneapolis Heart InstituteFoundation Web site (US National Regis-try of Sudden Death in Athletes), (www.suddendeathathletes.org), or reportsfrom high schools, colleges, medical ex-aminers, and parents.

Individual athletes were included inthis registry when identified throughthe aforementioned sources and if 2criteria were met: (1) participation inorganized team or individual sportsthat required regular competitionagainst others as a central compo-nent, placed a high premium onachievement, and required systematicand usually vigorous training (exclud-ing those participating in college-sponsored intramural sports); and (2)experienced sudden death at age 21 oryounger. A trauma-related deathwasde-fined as one caused by blunt-force im-pact to a vital organ, sustained duringparticipation in an organized athleticevent. Deaths from commotio cordiswere excluded from this analysis.6,29

As reported previously,2,4,28 systematicidentification and tracking strategies

were established to assemble detailedinformation on each case, including arequest for the autopsy report (withgross anatomic and toxicologic find-ings) and pertinent clinical and demo-graphic information. Selected data, re-lated to the event and demographics,were often derived from media ac-counts or telephone interviews withfamily members, witnesses, or offi-cials/coaches. When necessary, au-topsy findings were verified or ob-tained by direct communication withmedical examiners.

Definition

Concussion is defined as a trauma-induced alteration in mental status,usually characterized by confusionand amnesia that may or may not in-volve a loss of consciousness.16–22 Thisproject was reviewed by the Allina In-stitutional Review Board.

Statistical Methods

Numeric data are expressed asmean � SD. Proportions were com-pared with Pearson’s �2 or Fisher’s ex-act tests. Ages were compared using a2-sample t test. All tests were per-formed by using Stata 11.0 (Stata Corp,College Station, TX).

By search of online Web sites, directe-mail, or telephone contact, we as-sembled the number of participationsin organized competitive sports. To cal-culate the rate of sudden deaths, thetotal number of these events that oc-curred during the 5 years from the2003–2004 to 2007–2008 seasons wasdivided by the estimated number ofparticipations in all competitive sportsfor athletes aged 21 years or youngerin the United States during the sameperiod.30–32 The number of participa-tions was assembled from the recordsof several sports organizations, includ-ing the National Federation of State HighSchool Associations (35 854 456), the Na-tional Collegiate Athletic Association

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(1 994 962), the National Junior CollegeAthletic Association (245 732), and theNational Association of IntercollegiateAthletics (250 009) for high school andcollege athletes. Finally, the number ofparticipants in major and minor US pro-fessional sports (including baseball,football, and hockey) were tabulated.33

The confidence interval for rate per100 000 participations assumes a Pois-son distribution.

RESULTS

Trauma-Related Deaths

Of the 1827 youths registered who were21 or younger, 261 (14%) died as a resultofbodily traumaandvital organdamage.At least 4 such deaths were reported ineach of the 30 years. The proportion ofdeaths in themost recent 15-year periodfrom1995–2009 (129 [49%])was similarto the previous 15 years from 1980 to1994 (132 [51%]). Deaths were reportedfrom46 states andWashington, DC,mostcommonly in those with the largest pop-ulations: California (n� 37); Texas (n�26); Florida (n� 14); and Colorado (n�12), but none from Alaska, Maryland,Rhode Island, South Dakota, orWyoming.

The highest number of trauma-relateddeaths recorded in any single year was16, in 1986, followed by 14 in 1985; 12occurred in 1982, 1984, 1997, and 2001(Figs 1 and 2). The average number oftrauma-related deaths has remainedrelatively constant (P� .21) and was 9per year (range: 4–16) throughout 30years, and also 9 per year for the mostrecent 10-year period of reporting(2000–2009).

Mortality rate in young athletes be-cause of blunt trauma was calculatedfor the recent 5-year period (2003–2004 to 2007–2008) using an estimated7 670 000 million participations peryear of youths aged 21 and younger inorganized high school and collegesports. The rate of trauma death was0.11 per 100 000 participations (95%confidence interval: 0.08–0.15). The

comparable rate for 1139 cardiovascu-lar deaths was 0.83 per 100 000 partic-ipations (95% confidence interval:0.74–0.93) (P� .0001) (Fig 1).

Demographics

The 261 athletes ranged in age from 8to 21 years at the time of death (mean:

16 � 2 years); 235 were male (90%),and 26 were female (10%) (Table 1).Deaths reported in white athletes (174[67%]) substantially exceeded those inblacks (39 [15%]), Hispanics (34[13%]), Asians including Pacific Island-ers (5 [2%]), and others (9 [3%]) (Ta-ble 1). In football, most deaths oc-

FIGURE 1Comparison of trauma-related (n � 261) and cardiovascular (n � 1139) deaths in competitiveathletes aged 21 and younger, 1980–2009. The remaining 427 deaths in this age group were due toother causes, including commotio cordis, heat stroke, and drugs.

FIGURE 2Trauma-related sudden deaths in competitive athletes aged 21 and younger, 1980–2009 (n � 261),tabulated according to year, and shown separately for football and other sports.

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curred in white athletes (85 [57%]),and males (147 [99%]). Overall, whiteand nonwhite athletes did not differsignificantly with respect to age (16�2 vs 17 � 2 years; P � .14), althoughwhite athletes were more likely to befemale (14% of deaths in whites werefemale versus 2.5% in nonwhites; P�.006).

Throughout the 30-year time period,there were significantly fewer trauma-related deaths (n � 261) than cardio-vascular deaths (n � 1139) (P �.0001) in athletes 21 and younger. Thefraction of trauma deaths decreasedfrom 56% in 1980 (10 of 18 deaths) to9% by 2009 (only 7 of 75 deaths). Theproportion of trauma-related deathsin the most recent 15-year period(1995–2009) was 13%, whereas theanalogous proportion was 30% in theinitial 15-year period (P � .0001).Black athletes accounted for a muchsmaller fraction of trauma-related fa-talities (15%) than of cardiovasculardeaths (37%; P� .0001).

Sports and Level of Participation

Athletes participated in 22 organizedcompetitive sports at the time of theirdeaths, most commonly in football(148 [57%]) but also track and field (27[10%]; predominantly pole vaulting,n� 22), baseball (18 [7%]), boxing (12[5%]), and soccer (11 [4%]) (Table 1).Most athletes were engaged in orga-nized high school (178 [68%]), middleschool (26 [10%]), and youth and otherorganized sports programs (21 [8%]).Remaining athletes had advanced be-yond the high school level into college(28 [11%]) and professional sports (8[3%]).

Circumstances

Trauma-related deaths occurred whenathletes were engaged in either com-petitive events (161 [62%]) or practicesessions (100 [38%]). Trauma thatcaused death was most frequentlyTA

BLE1ClinicalProfileofTrauma-RelatedDeathsin261CompetitiveAthletesAged21YearsandYounger

Count,n

(%)

Age,y

(�SD)

Gender

Race

Circumstance

TypeofTraumaticInjury

Male,

n(%)

Female,

n(%)

White,

n(%)

Black,

n(%)

Other,

n(%)a

Game,

n(%)

Practice,

n(%)

Multiple

Organ,n(%)

Head/Neck,

n(%)

Chest,

n(%)

Abdomen,

n(%)

Unspecified,

n(%)

Football

148(56.7)

16.3(2.1)

147(99)

1(1)

85(57)

30(20)

33(22)

105(71)

43(29)

0(0)

138(93)

1(1)

9(6)

0(0)

Trackandfield

27(10.3)

17(1.8)

25(93)

2(7)

22(81)

2(7)

3(11)

13(48)

14(52)

2(7)

22(81)

1(4)

0(0)

2(7)

Baseball

18(6.9)

15.2(3.2)

18(100)

0(0)

16(89)

1(5.5)

1(5.5)

10(56)

8(44)

0(0)

16(89)

0(0)

0(0)

2(11)

Boxing

12(4.6)

18.9(1.8)

12(100)

0(0)

5(42)

3(25)

4(33)

9(75)

3(25)

0(0)

12(100)

0(0)

0(0)

0(0)

Soccer

11(4.2)

14.1(2.1)

8(73)

3(27)

10(91)

0(0)

1(9)

8(73)

3(27)

0(0)

9(82)

1(9)

1(9)

0(0)

Horseback-ridingb

8(3.1)

17.3(2.5)

2(25)

6(75)

8(100)

0(0)

0(0)

4(50)

4(50)

3(38)

3(38)

1(12)

1(12)

0(0)

Skiingc

8(3.1)

16.1(2.7)

3(38)

5(62)

8(100)

0(0)

0(0)

2(25)

6(75)

0(0)

5(62)

0(0)

0(0)

3(38)

Gymnastics

4(1.1)

16.5(1.3)

3(75)

1(25)

2(50)

0(0)

2(50)

2(50)

2(50)

0(0)

4(100)

0(0)

0(0)

0(0)

Softball

4(1.1)

14.8(4.3)

1(25)

3(75)

4(100)

0(0)

0(0)

1(25)

3(75)

0(0)

4(100)

0(0)

0(0)

0(0)

Basketball

3(1.1)

14.7(2.9)

3(100)

0(0)

0(0)

2(67)

1(33)

2(67)

1(33)

0(0)

3(100)

0(0)

0(0)

0(0)

Cheerleading

3(1.1)

16(4.4)

0(0)

3(100)

2(67)

0(0)

1(33)

0(0)

3(100)

0(0)

2(67)

0(0)

1(33)

0(0)

Hockey

3(1.1)

15.7(3.5)

3(100)

0(0)

3(100)

0(0)

0(0)

2(67)

1(33)

0(0)

3(100)

0(0)

0(0)

0(0)

Wrestling

3(1.1)

16.3(3.2)

3(100)

0(0)

1(33)

1(33)

1(33)

0(0)

3(100)

0(0)

3(100)

0(0)

0(0)

0(0)

Cycling

2(0.8)

16.5(4.9)

2(100)

0(0)

2(100)

0(0)

0(0)

2(100)

0(0)

0(0)

2(100)

0(0)

0(0)

0(0)

Lacrosse

2(0.8)

16.5(3.5)

2(100)

0(0)

2(100)

0(0)

0(0)

1(50)

1(50)

0(0)

2(100)

0(0)

0(0)

0(0)

Runningd

2(0.8)

19.5(2.1)

0(0)

2(100)

2(100)

0(0)

0(0)

0(0)

2(100)

2(100)

0(0)

0(0)

0(0)

0(0)

Rugby

1(0.4)

16(0)

1(100)

0(0)

0(0)

0(0)

1(100)

0(0)

1(100)

0(0)

1(100)

0(0)

0(0)

0(0)

Surfing

1(0.4)

13(0)

1(100)

0(0)

1(100)

0(0)

0(0)

0(0)

1(100)

0(0)

1(100)

0(0)

0(0)

0(0)

Weightlifting

1(0.4)

15(0)

1(100)

0(0)

1(100)

0(0)

0(0)

0(0)

1(100)

0(0)

1(100)

0(0)

0(0)

0(0)

Total

261

16.3(2.4)

235(90)

26(10)

174(67)

39(15)

48(18)

161(62)

100(38)

7(3)

231(89)

4(1)

12(4)

7(3)

aIncludesHispanic(n

�34),Asian(n

�3),AmericanIndian(n

�2),PacificIslander(n

�2),andunknown(n

�7).

bIncludesequestrian(n

�6)andjockey(n

�2).

cIncludesskiing(n

�7)andsnowboarding(n

�1).

dIncludestriathlon(n

�1)andcross-countryrunning(n

�1).

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confined to the head and/or neck (orspine-related) (231 [89%]), includingall 12 boxing deaths and 10 helmet-to-helmet blows in football. In baseball,there were 18 deaths, including 16 be-cause of head trauma, which resultedfrom hard-hit line-drives or other bat-ted balls (n� 8), bodily collisions (n�2), or errantly thrown or pitched balls(n� 6).

Other deaths resulted from multipleorgan damage (7 [3%]), abdominalblows that produced splenic ruptureor laceration of liver or intestine (12[4%]), or chest blows that caused lac-eration of the aorta or left ventricle (4[1.5%]); 7 (3%) were unspecified.

Consequences of Concussions

Of the 138 football players who died asa result of head/neck blows with sub-dural hematoma, 17 (12%) had a re-ported history of concussion a fewdays to 4 weeks prior, which was fol-lowed by persistent symptoms that in-cluded recurring headache, dizziness,disorientation, memory loss, visualdisturbances, seizures, and vomiting.This sequence of events is consistent

with “second-impact syndrome.”34–39

These athletes were 14 to 18 years ofage, and all competed at the highschool level; 9 were white, 5 black, and3 Hispanic.

Player Position and Risk of Death(Football)

The relationship between football posi-tion and trauma-related death riskwas analyzed in 123 of 148 players (Fig3). Overall, defensive positions wereassociated with greater numbers ofdeaths (n � 69) than were offensivepositions (n � 54). Among the 69deaths in defensive players, 24 (35%)were in backs, 24 (35%) were lineback-ers, 12 (17%) were linemen, and 9(13%) were special-teams players.

However, the player position in whichfatal trauma-related injury was sus-tained most commonly was offensiverunning back, accounting for 33 (61%)of deaths among offensive players,whereas the positions of quarterback(6 [11%]), lineman (5 [9%]), receiver (4[7%]), and special teams (6 [11%])were associated with distinctly lowerevent rates (Fig 3).

DISCUSSION

Sudden deaths in young trained athleteshave become a highly visible publichealth issue that has attracted consider-able media attention, with great impor-tance to the physician and lay communi-ties, particularly given the youthful ageandapparent goodhealthof the victims.1

Substantial emphasis has been directedtoward recognition and detection of un-suspected cardiovascular diseases, in-cluding various strategies for prepartici-pation screening.1–4 However, there hasbeen increasing attention (including inthe news media) on the risks in chil-dren and young adults of blunt traumaassociated with certain competitivesports (eg, particularly football) leadingto nonfatal concussion injury, permanentdisability, or even death.*

The national registry at the Minneapo-lis Heart Institute Foundation assem-bles deaths occurring nationwide inyoung competitive athletes and is aunique resource for events related toparticipation in competitive sports disci-plines at all levels. In acquiring thesedata, we were largely dependent on in-formation from the public domain andrecord that was assembled systemati-cally by using a variety of resources thatmost importantly include the powerfulLexisNexis database, informational ser-vices, and Internet search engines.1,2,4,28

The primary impetus of this reportwas to establish an estimate of thedemographic profile, epidemiology,and absolute number of trauma-related athlete deaths among athletesaged 21 or younger that occur annuallyin the United States (exclusive of com-motio cordis). Although several re-ports have addressed sudden deathcaused by blunt trauma on the athleticfield,5,7–9,21,38–40 such data have notbeen assembled previously through-out long periods of time (comparedwith the 3 decades in this study),

*Refs 5, 7–9, 13–22, 24–26, and 38–42.

FIGURE 3Trauma-related football deaths, according to player position (n� 148). Analysis includes 123 deaths;exclusive of the 16 players who died during practice drills, which inherently do not have designatedpositions, and 9 players who died during games for which the available information did not documenttheir position. DB indicates defensive back; DL, defensive lineman; LB, linebacker; OL, offensive line-man; QB, quarterback; RB, running back; ST, special teams; WR, wide receiver. a Kick returner (n� 4),punter (n� 1), field goal holder (n� 1). b Players tackling during kick-off or punt return (n� 9).

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nor in a large informative registry for-mat such as presented here (includ-ing�1800 deaths).

By accessing this database, we foundthat trauma deaths (predominantlyinvolving the head and neck) oc-curred in children, adolescents, andyoung adults during participation ina wide variety of 22 sports. Notably,the frequency of such deaths in ath-letes because of bodily traumaproved to be relatively low. The high-est number tabulated for 1 year was16, and the average over the last de-cade was 9 events per year. In abso-lute numbers, that rate does notseem to have changed significantlyover the 3 decades of study. Overall,this annual mortality proved to befar less (by about fourfold) than forcardiovascular-related deaths in thesame young registry population2 (Fig2), although the ratio of cardiovascu-lar to trauma deaths has increasedover time.

Football, played on amateur levelsfrom middle school through college(and also professionally), is widelyrecognized as a highly physical sportwith inherent risks for bodily collisionand injury, but not necessarily associ-ated with the possibility of death. In-deed, football was the single mostcommon sport involved in these catas-trophes, with almost 60% occurring inchildren and adolescents, the vast ma-jority of which were in high school andmiddle school athletic competition.Nonfatal concussions in preadolescent(�14 years) athletes also have beenlinked disproportionately to competi-tive football.17

In addition, in football, we found a pre-dilection for fatal events at particularplayer positions. For example, deathswere more common in defensive posi-tions (eg, linebacker and defensivebackfield), presumably because suchplayers commonly initiate and deliverhigh-velocity blows while moving to-

ward the point of contact. However, of-fensive running backs, who are ex-posed to severe bodily contact inflictedby defensive players, were commonlyinvolved in fatal collisions.

Considerable attention has recentlyfocused specifically on the risks as-sociated with concussions in footballat all ages including children,16–27

and importantly the consequence ofrepeated head blows (“second-impactsyndrome”).13,34–39,41,42

In this regard, our data included a sub-set of 17 high school football playerswith death because of cerebral edemaand brain herniation or subdural he-matoma, in whom there was a recenthistory of concussion, after whichsymptoms such as headache, dizzi-ness, or memory loss persisted (com-prising 12% of all football-relateddeaths due to head injury). In somecases, these athletes were cleared forcompetition despite residual symp-toms from their previous head injury.These are potentially preventabledeaths, and increasing recognition ofthis syndrome has led to recommen-dations14,21,37,41,42 or regulations42 to re-move athletes from additional practiceor game participation after a sus-pected concussion or head injury untiltheir symptoms have abated. Taken to-gether, these observations under-score the importance of continued at-tention by coaches, athletes, andfamilies to the potential consequencesof violent collisions to further reducefatalities on the football field.

Certain sports with relatively low par-ticipation rates also seem to be asso-ciated with considerable risk. For ex-ample, the registry has tabulated 22trauma-associated deaths with polevaulting in this young age group, pre-dominantly from head injuries whenathletes fall outside the padded land-ing pit.12 Although the precise numberof at-risk competitors in this sport isunknown, the mortality risk associ-

ated with pole vaulting would never-theless seem to be particularly high.Similarly, competitive cheerleadingwas associated with 3 trauma-relateddeaths.43

Without a systematic and mandatoryreporting system for sudden cardiacdeaths in young competitive athletes,the true absolute number of theseevents that occur in the United Statescannot be known. Indeed, given thatimproved surveillance systems duringthe most recent 15 years accountedfor a greater proportion of suddendeaths detected during the study pe-riod, it is likely that the number ofevents identified overall would havebeen higher if a mandatory reportingsystem had been implementedthroughout the 30-year period.

The low risk of trauma death reportedhere during competitive sports (�9per year) is substantially less than thatobserved among other risks applica-ble to this age group, eg, cancer (2500per year), leukemia (700 per year), cys-tic fibrosis (175 per year), automobileaccidents (12 000 per year), homicides(6000 per year), meningococcemia(250 per year), or even lightning-related fatalities (50 per year).44–46

However, it was impractical to providea reliable calculation for the incidenceof death in our registry over the substan-tial 30-year period because denomina-tors accurately reporting the overall at-risk athlete population for each of 22individual sporting disciplines were notavailable. Nevertheless, using availabledata from the recent 5-year period, wewere able to estimate the overall fre-quency of these trauma deaths to be�0.11 per 100 000 participations.

CONCLUSIONS

Trauma-related deaths in young com-petitive athletes are relatively uncom-mon events relative to the vast num-bers of athletes participating safely ina wide variety of organized sports, and

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they occurred at a lower event rate inthis population than cardiovasculardeaths. Nevertheless, these cata-strophic events remain an importantpublic health issue with a devastatingeffect on families, communities, andphysicians, and of particular relevanceto the practicing pediatric community.Notably, in football the preventable“second-impact syndrome” has emerged

as a recognized risk. Most of the fatalevents reported here are potentiallypreventable, and our observations un-derscore the importance of developingmore effective equipment design,return-to-play decision strategies,modified blocking/tackling rules, andgreater attention to the education ofcoaches, trainers, parents, and ath-letes regarding the consequences of

repeated head blows and concussions.The ultimate aspiration of reportingthese data is the creation of a saferenvironment for young people on theathletic field.

ACKNOWLEDGMENT

This work was supported by the HearstFoundations (New York, NY).

REFERENCES

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