Too often this past year an apparently healthy adolescent football or basketball player has unexpectedly died from sudden cardiac arrest. Though shocking, it is estimated that this occurs in the U.S. every nine days. This year, Oregon high school football star Hayward Demison and Minnesota high school basketball star Zach Gabbard each collapsed playing football. Though fortunately both survived, tragically, most have not. Reggie Garrett, a star high school quarterback from Texas, collapsed throwing a touchdown pass and later was pronounced dead at the hospital. In Massachusetts, Michael Ellsessar, 16, took two hits after catching a football pass, got up, staggered, and then collapsed in cardiac arrest. Michigan high school basketball player, Wes Leonard, collapsed and died after scoring the winning shot for his team. The 16-year-old sophomore Angela Gettis of California suffered sudden cardiac arrest in while cheerleading at her high school's football game. Matthew Hammerdorfer, 17, from Colorado took a powerful hit to the chest during a rugby game, collapsed on the field, and was airlifted to a hospital, where he died. His situation was somewhat unique; his family knew of his genetic heart condition. Most families have had no prior warning. The apparently healthy athlete's sudden cardiac arrest leaves their family, coach, team and the community shocked and devastated. Outside of the sports arena, in past years there have also been the rare instances when an adolescent with a silent, lethal cardiac disorder tragically dies in a therapeutic wilderness program.

Many children die each year from cardiac conditions that do not make the news. Because there is no mandatory reporting system in the U.S., precise figures are not available. According to some estimates, more than 100 young athletes die each year in sports-related incidents, with close to half of these deaths attributed to sudden cardiac arrest. Recent retrospective research shows the rate of sudden cardiac death to be one in every 43,770 student-athletes per year, making it the leading medical cause of death among college athletes. Most are due to unrecognized heart disorders where the first indication of a disorder was the sudden cardiac arrest. Other times, there were clues that might have raised the suspicion of cardiac disease that could have been monitored. Apparently the cardiac lesions responsible for sudden death in children may be hidden, with no abnormalities found during their doctor's exam. A surge in adrenaline, an obvious element of sports participation, or in an adventure activity, is what typically triggers fatal arrhythmias.

Given the prevalence of this condition across the population, the occurrence of the rare death due to sudden cardiac arrest in a therapeutic wilderness program is not surprising. In these settings, just as in sports events, it is likely that the combination of an undiagnosed heart condition, in combination with a surge in adrenaline, is the likely reason for the sudden cardiac arrest.

Because less than half of athletes who die suddenly had symptoms of heart disease preceding their death, some physicians recommend ECG screening for young athletes, since the risk for sudden death is almost twice that of the non-athlete. Robert Myerburg, MD, University of Miami in Florida notes that "about 70% of the athlete deaths that occur among unscreened athletes are due to conditions that can reasonably be expected to be identified by ECG screening." Leigh Vinocur, MD, emergency physician and Director of Strategic Initiatives at the University of Maryland School Medicine questions why ECGs aren't given as part of routine sports physicals. Recent studies from the Annals of Internal Medicine found adding an ECG to a routine sports physical doubled the number of cases of potential heart problems detected, and would cost an additional $80 per athlete. Their computer model cost analysis showed the cost was actually "feasible". It is within the range of other accepted screening tests used today, as cost-effective as the PAP exam for detecting cervical cancer and the mammogram for detecting breast cancer.

Although the American Heart Association concludes it is neither prudent nor practical to recommend the routine use of ECGs for screening athletes, they do recommend ECGs for all children taking stimulant medications. In contrast to the competitive athlete, there is no evidence that routine ECG screening will prevent sudden death in children using stimulant medication. The link between stimulants and sudden death is tenuous at best. Based upon an FDA report of 12 sudden deaths in children less than 18 years old taking Adderall, autopsies among the deaths that occurred over a five-year period demonstrated five had silent cardiac disorders, during a time when 30 million prescriptions were written for Adderall. Given large number of children using these prescribed stimulants, occasionally children taking these medicines may also harbor silent, lethal cardiac disorders.

The tragic occurrence of a young person's sudden cardiac arrest emphasizes the need for careful assessment of family history for heart disease, along with careful documentation of any symptoms indicating risk, prior to engaging in any type of intense physical activity. School athletes are required to have routine PPE physicals. In addition, admissions protocol for therapeutic wilderness programs requires thorough medical histories of the applicant, as well as his or her family's medical history.

Dr. Silva, Pediatric electrophysiologist at St. Louis Children's Hospital warns "Certain symptoms prompt further evaluation: fainting, particularly during exercise, feeling of heart racing out of proportion to activity level (or at rest), chest pains, family history of sudden cardiac death, cardiomyopathy (heart muscle disease) or cardiac ion channelopathy."

Know the personal and family health history of each participant. The presence of an automated external defibrillator [AED] at sports events with appropriate instruction in its use is advocated by many. Though AEDs are obviously not possible at every wilderness activity, staff should have current training in Cardio Pulmonary Resuscitation [CPR] and knowledge of how to contact rapid responders. An undiagnosed heart condition in combination with intense physical activity and a surge in adrenaline is suspected to be to be the cause of sudden cardiac arrest. People who work with adolescents where high levels of activity occur should be as informed as possible about the health histories of individuals who participate, and be prepared to manage one of these unlikely, but disastrous events.

References used:

ABC News interview with Dr. Douglas Zipes, editor of Heart Rhythm.
http://abcnews.go.com/Health/HeartDisease/ecg-blanket-screenings-answer-preventing-sudden-death/story?id=13078093&page=2
http://www.thebostonchannel.com/r/27111338/detail.html
http://www.huffingtonpost.com/leigh-vinocur-md/sudden-cardiac-death-_b_821483.html
http://www.medpagetoday.com/Cardiology/MyocardialInfarction/25265
Todd Neale, Staff Writer, MedPage Today, April 24, 2011, Reviewed by Zalman S. Agus, MD; Emeritus Professor, University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
The National Athletic Trainers' Association (NATA)


Robert Myerburg, MD, University of Miami in Florida
Data from the National Collegiate Athletic Association (NCAA), combined with media reports and colleagues Kimberly Harmon, MD, of the University of Washington in Seattle
Circulation: Journal of the American Heart Association, April 19