HEART HEALTH FOR NEBRASKA’S YOUTH A SUMMARY REPORT OF SUDDEN CARDIAC ARREST IN NEBRASKA SCHOOLS

AWARENESS – PREVENTION – AND RESPONSE

SUDDEN CARDIAC ARREST IN NEBRASKA SCHOOLS

▪ Is their a significant problem?

▪ What do we know about the issue in Nebraska?

▪ What can we do about Sudden Cardiac Arrest in Nebraska?

IS THERE A SIGNIFICANT PROBLEM?

Sudden cardiac arrest (SCA) is a leading cause of death in the U.S., killing more than 325,000 people each year. That’s more than the total death rate for breast cancer, lung cancer, and HIV/AIDS combined.

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INCIDENCE IN ATHLETES

• Sudden cardiac death in young athletes is very rare.

• About 100 such deaths are reported in the United States each year.

• The chance of sudden death occurring to any individual high school athlete is about one in 200,000 per year.

• Sudden cardiac death is more common: in males than in females; in football and basketball than in other sports; and in African-Americans than in other races and ethnic groups.

Sudden Cardiac Arrest can happen to anyone

Consider the Facts

Sudden Cardiac Arrest

Foundation: 2013

1 in 50 schools in America

will have a cardiac arrest

incident each year.

Average survival rate of an

out-of-hospital child

cardiac arrest in the U.S. is

less than 7.8%.

American Heart Association:

2013

Did You Know?

In the United States, a

young competitive athlete

dies suddenly every three

days. (Heart Rhythm

Society, 2007)

WHAT DO WE KNOW ABOUT THE ISSUE IN NEBRASKA?

In Nebraska, …

It depends on:

Who you talk to….

How you collect data…

How you diagnose cause of death…

If death occurs…

WHAT CAN WE DO ABOUT SUDDEN CARDIAC ARREST IN NEBRASKA?

Health Care Providers

School Administrators

School Nurses, Coaches and Athletic Trainers

We need a collaborative Team Approach

NEBRASKA STUDENT

ATHLETE CARDIAC

SCREENING TASK FORCE

Mission

Our Mission is to

encourage participation

in all levels of athletics

and physical activities

by Nebraska youth and

to promote their health,

safety, and well-being

while doing so.

American Academy of Pediatrics/Nebraska Chapter Representative Chris Erickson, MD

American Heart Association/ Nebraska Chapter Representative Brian Krannawitter

American College of Cardiology/ Nebraska Chapter Representative Dale Hansen, MD

Bryan Heart/University of Nebraska Lincoln Athletic Cardiology Steve Krueger, MD,

Christine Lawless, MD

David Lawton RN, PhD.

Nebraska Academy of Family Physicians/Representative Monty Mathews, MD

Nebraska State School Nurses /Representative Kim Nelson Zollman RN,

APRN

Nebraska State Physician’s Assistant Association/ Representative Tamara Dolphens, PA

Nebraska State Activities Association (NSAA)/Representative Ron Higdon,

Dennis Connolly, MD

Kody Moffatt, MD

Nebraska Department of Education/Representative Julane Hill

Nebraska Department of Health and Human Services Representative Peg Ogea-Ginsburg

University of Nebraska-Lincoln Athletic Medicine/ Representative Lonnie Albers, MD

Nebraska State Athletic Trainers Association/ Representative Rusty McKune ATC

Senior Editor- 4th PPE monograph, AAP Bill Roberts, MD

Bryan Heart/ AED project Andy Merliss, MD

University of Nebraska, College of Education and Human Science Lisa Franzen-Castle PhD.

University of Nebraska, Department of Statistics David Marx, PhD

Nebraska State Senate, Legislative Aide to Senator Jim Smith Lisa Johns

Nebraska Chiropractic Physicians Association Mark Knoll, DC

Nebraska Association of Nurse Practitioners Sharon Gossman RN APRN,

FNP-C

Nebraska Task Force: Participating organizations:

AEDS IN NEBRASKA SCHOOLS: EVIDENCE OF AVAILABILITY AND

EFFICACY

CHRISTINE E. LAWLESS 1,3,5, CHRISTOPHER ERICKSON 2,3, JOHN KUGLER 2,3, LONNIE ALBERS 3,5,

DAVID LAWTON 3, RON HIGDON 4, DAVID MARX 5 , ANDREW MERLISS 3, STEVEN KRUEGER 3,5

SPORTS CARDIOLOGY CONSULTANTS LLC, CHICAGO, IL USA (1), CHILDREN’S HOSP ITAL & MEDICAL CENTER, OMAHA, NE, USA (2), BRYAN HEART ATHLETIC CARDIOLOGY LINCOLN, NE, USA (3), NEBRASKA SCHOOL ACTIVITIES ASSOCIATION (4), AND UNIVERSITY OF NEBRASKA,

LINCOLN, NE, USA (5)

PURPOSE: To assess emergency preparedness, and AED outcomes in Nebraska’s high schools and middle schools

Measures of emergency preparedness

1) Availability of AED 2) Location/Accessibility of AED 3) Emergency preparedness protocol in place / How often drilled? 4) Training of staff, coaches, students, school nurses

AED outcomes – Ask school nurse to recall 1) Was AED used at the school in the past 5 years? 2) If yes, follow up phone call to those reporting AED events

BACKGROUND

▪ ACC 2012 THINK TANK - Attendees representing over 35 organizations identified gaps in quality of American athlete CV care, and suggested ways to improve it.

▪ One proposed strategy- Optimize use of existing clinical tools

▪ Could best be accomplished at the state level (models NJ, TN, NC, WA)

▪ In Jan 2014, a Nebraska state-wide task force was created to improve CV care for young athletes

▪ Goal:

▪ Measure baseline quality

▪ Devise interventions to improve quality

▪ Re-test to determine if interventions were effective

BACKGROUND- MEASURES OF QUALITY

▪ What is level of emergency preparedness in Nebraska schools? (Ref: AHA, Hasinski, Circulation, 2004) How often is the AED used, and what are the outcomes?

▪ Who is clearing the athletes and what is their present knowledge base and training?

▪ Are recommended NSAA (Nebraska School Activities Association) PPE forms being used?

SURVEY CREATION

▪ Used template from Tennessee study with assistance of the author.

▪ Modified template to fit Nebraska

▪ Combined Surveys

▪ Used data from Nebraska School Activities Association

▪ Used data and received support from the Nebraska School Nurses Association

RESULTS- ≥ 1 AED IN 298/307, 97.1%

0

10

20

30

40

50

60

0 1 2 3 4 ≥ 5

% o

f sc

ho

ols

Number of AEDs

RESULTS- AED ACCESSIBILITY AND LOCATION

22.2

63.4

17.1

3.7

8.1

25.9

5.7

4.7

12.4

4.7

0 50 100

Inside school gym

Just outside school gym

Outside principal's office

Inside principal's office

Inside school nurse office

School lobby/entrance

Football stadium/playing field

Travels with teams

School hallway- not near gym/principal

Athletic trainers office

% of schools

RESULTS- AED FUNDING SOURCE

42 42

2

24.8

0

5

10

15

20

25

30

35

40

45

Donations School purchase

Funding campaign

Other

% of schools

RESULTS- OUTCOMES OF AED USE OVER PAST 5 YEARS, N=17

AED opened in 17 cases in 16 Nebraska schools

Shock delivered (8) No shock delivered (9)

Students (2, one athlete) Staff/Referee/spectator (6)

2/2 survived to hospital D/C One athlete with unknown diagnosis; One non-athlete with long QT

5/6 survived to hospital D/C 1/6 did not survive

D/C= discharge

7/8 survived, 87.5% resuscitation rate

RESULTS- EMERGENCY ACTION PLAN (EAP)

HAVE EAP

84.7

% of schools

Yes

No

Do not know

FREQUENCY OF REHEARSAL/DRILLS

81.9

% of schools

Annually

Monthly

Q 2 yrs

Do not know

RESULTS- WHAT STUDENTS AND STAFF ARE REQUIRED TO HAVE CPR / AED TRAINING?

.

Type of staff % of responding schools

School nurse 68.4

Administrative staff 37.5

Athletic director 41.7

Athletic trainer 21.8

All coaching staff 49.9

Student- for HS graduation 5.2

Do not know 5.9

N/A 9.5

CONCLUSIONS

▪ AED availability in Nebraska schools is excellent, exceeding 97%.

▪ School administrators can anticipate about 6% AED use over 5 years, primarily in the older non-student population.

▪ Defibrillation rate is high, with the majority of patients surviving to hospital discharge.

CONCLUSIONS- OPPORTUNITIES FOR IMPROVEMENT

The greatest opportunities for improvement in the Nebraska schools AED emergency preparedness plan are:

1. Education of staff/students in the performance of CPR/AED

2. Having EAP in place

3. Enhanced AED accessibility- Remove from locked offices

4. Obtaining AEDs for the remaining 3% of schools

GOING FORWARD

▪ Work with NSAA on identified opportunities for improvement in AEDs and EAPs

▪ EAPs in 100% of schools

▪ Obtain AEDS for remaining schools

▪ Education in CPR-AED

▪ Measures of other suspected quality gaps

▪ Use of 4th PPE less than ideal- NSAA Sports Med Advisory Committee (also task force members) working on enhanced use, and implementation of E-PPE

▪ Provider knowledge gaps abundant- Plan an intensive Nebraska state provider education program in the spring

▪ To include PEDS, Family Practice, PAs, NPs, RNs, ATCs and Chiropractors

LIMITATIONS

Outcomes:

▪ Based on recall

▪ Only asked about use of AEDs, not instances of SCA

▪ May have skewed results towards high resuscitation rate

overall

WHAT CAN SCHOOL NURSES DO TO HELP?

Is Heart Safe School Accreditation an option for your school (s)?

http://www.sads.org

WHAT CAN SCHOOL NURSES DO TO HELP?

Improve knowledge of heart disease in young and know the signs and symptoms

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HISTORY

1.Have you ever been denied or restricted participation in sports for any reason?

HISTORY

2. Have you ever passed out or nearly passed out during or after exercise?

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HISTORY

3. Have you ever had discomfort, pain, tightness or pressure in your chest with exercise?

4. Does your heart ever race or skip beats (irregular beats) during exercise?

5. Has a healthcare provider ever told you that you have any heart problems such as high blood pressure, high cholesterol, Kawasaki’s disease, a heart murmur or heart infection?

HISTORY

6. Has a healthcare provider ever ordered a test for your heart, such as an ECG or echocardiogram?

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HISTORY

7. Do you get lightheaded or feel more short of breath than expected during exercise? Do you have problems now completing a workout that you have done readily in the past?

8. Do you get more tired or short of breath more quickly than your friends or teammates during exercise?

HISTORY

9. Have you ever had an unexplained seizure?

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HISTORY 10. Does anyone in your family have:

▪ hypertrophic cardiomyopathy (HCM),

▪ Marfan syndrome,

▪ arrhythmogenic right ventricular cardiomyopathy (ARVC)

▪ long QT syndrome, short QT syndrome,

▪ Brugada syndrome, or

▪ catecholaminergic polymorphic ventricular tachycardia?

HISTORY

11. Has any family member or relative died of

heart problems or had any unexpected or

unexplained sudden death before age 50

(including asthma, drowning, unexplained

car accident)

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HISTORY

12.Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

13. Has anyone in your family had unexplained fainting, seizures, or near drowning?

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ELECTROPHYSIOLOGICAL ABNORMALITIES

▪ Long QT syndrome: an abnormal prolongation of the QT interval on the electrocardiogram (ECG). Commonly will have a genetic basis.

Occurs in about 1 in 10,000 individuals.

▪ WPW syndrome: an accessory conduction pathway in the myocardium which usually leads to “benign” tachycardic arrhythmias although can lead, in rare cases, to ventricular fibrillation.

▪ Arrhythmogenic right ventricular cardiomyopathy: another structural abnormality leading to sudden death in athletes (which is rare in the USA ).

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OTHER DISEASES WITH LOWER FREQUENCY

▪ Myocarditis: caused by an acute inflammation of the heart usually due to a virus in this age group. The most common virus is Coxsackie B.

▪ Dilated Cardiomyopathy: an enlargement of the heart for unknown reasons with myocardial scarring has also been reported.

▪ Electrophysiological abnormalities

▪ Marfan Syndrome

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Congenital Abnormalities of Coronary Arteries

The second most likely cause of sudden death in athletes is congenital abnormalities of the coronary arteries. These can account for 10-15% of sudden death in athletes.

The most common abnormality is origin of the left main coronary coming off the right sinus of Valsalva of the aorta. The artery then courses between the aorta and the pulmonary artery making it prone to compression during exercise leading to myocardial ischemia, which can trigger severe cardiac arrhythmias and sudden death.

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HYPERTROPHIC CARDIOMYOPATHY

▪ Patients with obstructive hypertrophic cardiomyopathy have a narrow outflow tract due to the bulging of the interventricular septum and the anterior displacement of the mitral valve.

▪ This may be associated with a systolic murmur at rest but the obstruction (and the murmur) is increased when the heart becomes smaller as with decreased preload (such as standing, performing a Valsalva maneuver, and adrenergic stimulation).

▪ In some cases the cardiac output can fall enough to cause syncope and death.

HYPERTROPHIC CARDIOMYOPATHY

▪ The most common cause of sudden death is ventricular fibrillation due to abnormal anatomical substrate and the presence of possible ischemia in the hypertrophied muscle, induced by increased heart rate and blood pressure during exercise as well as the intense sympathetic discharge.

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HYPERTROPHIC CARDIOMYOPATHY

▪ About 20-30% of individuals who die with this disorder have prior symptoms which include exertional or non-exertional chest pain, dyspnea on exertion, palpitations, lightheadedness, or syncope (especially with exercise).

▪ In some cases, there is a family history suggestive of sudden death in relatives.

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HYPERTROPHIC CARDIOMYOPATHY

▪ HCM is a genetic disorder.

▪ Its incidence is about 1 in 500 persons in the general population.

▪ Over 300 gene mutations involving the sarcomere proteins have been shown to lead to this condition.

▪ It is usually inherited as an autosomal dominant trait; however, the phenotypic expression may be delayed in many families.

▪ In addition, it may appear as a "de novo" mutation in individuals without a family history of the condition.

HYPERTROPHIC CARDIOMYOPATHY

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In the USA, HCM is the most common cause of sudden death in student athletes (25-30%). In HCM, there is abnormal hypertrophy (thickening) of the walls of the heart. Further, there is an associated disarray of myocardial fibers at the microscopic level.

ATHLETE’S HEART – REMODELING (THIS IS A HEALTHY HEART RESPONSE)

▪ Enlarged heart due to intensive training

▪ Symmetric increased wall thickness of left ventricle (LV) to 13-15mm

▪ Increased LV cavity > 55mm

▪ Bradycardia

▪ VO2 max > 45 ml/kg/min >110% predicted

▪ With de-conditioning, heart wall thickness returns to prior size

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SUDDEN CARDIAC DEATH

CAUSES OF SUDDEN DEATH IN YOUNG ATHLETES

Maron, B. J. et al. Circulation 2007;115:1643-1455

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ETIOLOGY

▪ In susceptible individuals, due to some form of structural cardiovascular abnormality or electrical disease of the heart, the typical increased adrenaline response to intense physical activity is itself a trigger for arrhythmias.

▪ Arrhythmias may be characterized as life-threatening electrical disturbances of the heart, most commonly ventricular fibrillation.

▪ Thus, the presence of such lethal arrhythmias leading to ventricular fibrillation is extremely rare in the absence of some form of underlying heart disease.

ASSISTING SCHOOLS IN PREPARATION FOR CARDIAC EMERGENCIES

▪ Prevention

Assess students’ risk levels for sudden cardiac arrest and sudden arrhythmia death syndromes.

▪ Readiness for Response

Anticipate and prepare for students with additional risks and health care needs.

▪ General Preparation

Build emergency response policies with input from the medical community that will be flexible enough to accommodate different students’ developmental levels.

The Role of the School

“Most schools are closer to achieving accreditation than they think. It does take a little effort,

but that effort is a small price to pay to be better prepared to save a life.” - Sarah McGraw-

Timmes, RN, Lancaster City Schools Nurse

•A typical school day consists of 6 hours. The average school-aged

child spends 28% of the day and 14% of his/her total annual hours in

school.

Schools are responsible for providing a safe platform for learning

and sharing.

•Clarity of school staff roles in an emergency is essential for

coordinated response.

Developing campus-wide response and communication methods

ensures effcient access to emergency equipment and minimizes

rumors.

Thank You! David Lawton RN 402-483-3345 david.Lawton@bryanheart.com 402-730-2155 docnrs@gmail.com

REFERENCES ▪ Parent Heart Watch, http://www.parentheartwatch.org/

▪ SADS, Sudden Arrhythmia Death Syndromes, http://www.sads.org/

▪ SCAA, Sudden Cardiac Arrest Association, http://www.suddencardiacarrest.org

▪ Be The Beat – American Heart Association http://bethebeat.heart.org/. Provides free resources to help teach CPR and AED in schools