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Non-exertional Collapse in Student-Athletes

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Syncope

  • Brief loss of consciousness with spontaneous recovery
  • Loss of postural tone and varying degrees of event recall also occur
  • Vasovagal syncope is a specific type of reflex syncope associated with decrease in heart rate and decrease in blood pressure
  • Frequent syncope episodes may result in physical injuries and psychological impact
  • Exercise-induced syncope may be predictive of adverse outcome, especially sudden cardiac death, and should be further evaluated

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Causes of Syncope

  • Causes range from benign to life threatening conditions.

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Reflux Syncope

Orthostatic Hypotension

Cardiac

Vasovagal (orthostatic or emotional)

Drug Induced

Arrhythmias (bradyarrhythmias, tachyarrhythmias)

Situational

Volume Depletion

Neurological (seizure, migraine)

Carotid sinus syndrome

Primary autoimmune failure

Structural (HCM, tumors, aortic stenosis)

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Secondary autoimmune failure

Cardiopulmonary

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Pulmonary Embolism

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Management of Syncope

  • Education
    • Educate patient on identification and early recognition of initial symptoms, avoidance of triggers
  • Increased fluids and salt intake may be beneficial, especially with vasovagal responses
    • Drink 2 L of fluid a day
    • Ingest 2-4 g of salt a day
  • Manage Airway, Breathing, Circulation and Neurologic Status
  • May need Oxygen and/or glucose administration

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Seizures

  • A collection of symptoms caused from the abnormal rhythmic discharges from the brain
  • 5-10% of the population will have at least one seizure in their lifetime
    • 0.5-1% of the population diagnosed with epilepsy
  • First seizure is usually before age 30
  • Contact sports does not appear to increase seizure activity
    • Participation not recommended in sports that could cause injury if a seizure occurs (parallel bars, diving, possibly swimming)
  • Seizure disorder should be well controlled prior to sport participation

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Seizure Classification: Partial Seizures

  • Partial seizures involve only a portion of the cortex and may go unnoticed
  • Simple Partial seizures
    • Symptoms include: visual, olfactory, and auditory sensations; sudden sweating, “goose bumps”, changes in heart rate and BP; isolated jerking movements of face, arm, or leg.
    • No loss of consciousness
  • Complex partial seizures will have altered LOC
    • Symptoms include: repetitive behaviors (lip smacking, undressing, grimacing, unresponsive to commands)
    • Symptoms usually last 3-5 minutes
  • Postictal state s/sx include headache, confusion, drowsiness, no memory of seizure

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Seizure Classification: Generalized Seizures

  • Generalized seizures involves both hemispheres of the brain and has a LOC
  • Absence (petit mal) generalized seizures often seen in childhood and include a brief lapse in consciousness without a change in posture
    • No postictal state
  • Tonic-clonic (grand mal) seizures start with sudden LOC, stiffening of muscles of arms, legs, chest, and back, and jerking of the body
    • May also have tongue biting, bodily sputum production, or bone fractures
    • Postictal state may last minutes to hours

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Risk Factors

  • Risk factor or triggers may predispose athletes to seizures:
    • Sodium Abnormalities
    • Glucose levels abnormalities
    • Severe head trauma
    • Hyperthermia
    • Hypoxia
    • Stress
    • Excessive fatigue
    • Insomnia
    • Illicit drug use

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Acute Management of Seizures

  • Manage Airway, Breathing, and Circulation
  • Help patient to ground or safe location
  • Cushion the head if possible
  • Remove any hazardous objects
  • Do not restrain a seizing patient
  • Do not place anything in the moth
  • Place athlete on side during postictal state
  • Activate EMS if:
    • First seizure episode
    • Seizure lasts longer than patient’s typical episode
    • Patient remains unresponsive
    • Respiratory or cardiac function appear unstable

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Resources

  • Ali, M, Maetos J, Kichloo, A, Masudi, S, Grubb, BP, Kanjwal, K. Management strategies for vasovagal syncope. Pacing Clinical Electrophysiology. 2021; 44:2100-2108.
  • Grubb, BP, & Olshansky, B. (Eds). (2007). Syncope: Mechanisms and management. John Wiley & Sons, Incorporated.
  • Parks, E.D. Seizure Disorders in Athletes. Athletic Therapy Today. 2006; 11(4): 36-38.