Sudden Death in the Young

      Your EMS crew is dispatched to the local neigborhood park for an injured person. Upon arrival, you see kids frantically waving from the basketball court. On arrival, you find a male patient in his late teens who is unresponsive and pulseless, and CPR is in progress.

   As you start resuscitation, you ask the friends to tell you what happened. They explain they had been playing basketball for about 30 minutes when the patient was running down the court and collapsed. You ask about medications, medical history and allergies as friends try frantically to reach the boy's parents. The friends say they don't know his medical history, and they absolutely deny any drugs or alcohol.

   CPR is ongoing, the patient is defibrillated and ALS care is continued en route. Despite your aggressive treatment and the hospital's efforts, he's pronounced dead by the emergency department physician. As you clean up the truck and write your report, you tell yourself, "We deal with older patients in cardiac arrest frequently, but not a young, healthy appearing kid like this. His friends have to be lying. There has to be more to this story."

   In the United States, it is estimated that 200–300 young people die each year from cardiovascular events during physical exercise.¹ While this number is relatively low compared with other causes of death in similar age groups and considering how many athletic events take place annually, several times a year, television media report an athlete's death. These deaths are always high profile and generate community attention. But what causes a healthy appearing child, teen or young adult to suffer fatal cardiac arrest?

   The generally accepted definition of sudden death is a sudden loss of consciousness from a cardiovascular event within an hour of the onset of symptoms. Sadly, diagnosis is often made upon autopsy.² In the U.S., 90% of deaths occur during competitive sports like basketball or football. Soccer has the highest death rate in Europe. Males are nine times more likely to die than females.³

   Many paramedics have responded to a child with chest pain. While the majority are non-cardiac, a 2007 study in the Journal of Pediatrics should raise awareness that it is possible for coronary artery disease to be present even in the young. Over an 11-year period, nine children ages 12 to 20 were diagnosed with myocardial infarction after arriving at an Ohio hospital with chest pain radiating to the left arm and jaw. Interestingly, there was no drug use involved and no other risk factors.⁴ In 2002, 33-year-old St. Louis Cardinals pitcher Darryl Kile was found dead in his hotel room after complaining of left shoulder pain during dinner with his brother the previous evening. Upon autopsy, he was found to have 90% occlusion of three heart vessels. San Francisco 49ers offensive lineman Thomas Herrion, age 23, died of coronary artery disease after suffering cardiac arrest following a preseason game in Denver.⁵

HYPERTROPHIC CARDIOMYOPATHY

   There are structural changes in the heart that are considered normal in athletes. Because the heart is a muscle, it functions as any other muscle. When it is worked, it grows. This increases the size and mass of the muscle to allow for increased stroke volume and cardiac output. The question is, what are normal physiologic changes compared to changes in a diseased heart? The typical answer is rest. When the athlete is noncompetitive for a period upwards of three months, the nondiseased "athletic heart" will remold and reshape itself, whereas the diseased heart will remain enlarged.⁶