Cage Side Medicine with Dr. Jon Lucas, MD: Preventing combat sport deaths

by Dr. Jon Lucas, MD |

This is the second UG Guest Blog from Dr. Jon Lucas, MD.

Preventing Combat Sport Deaths

The tragic death of a fighter is always accompanied by questions of “what could have been done to prevent this.” There has been a lot of discussion recently in the mixed martial arts community about the best way to protect fighters from brain injury and reduce the risk of death from brain trauma during a fight. However, head trauma is not the only risk that athletes face during competition, as sudden deaths also occur in non-combat sports such as basketball and marathon running. The death of an amateur fighter in an unregulated event in Michigan in April of 2013 ruled to be secondary to a cardiac arrhythmic disorder illustrates the risk of non-head trauma related death. This article will discuss some of the cardiac causes of sudden death in athletes and strategies for preventing these tragedies.

Cardiac abnormalities that predispose to sudden death during exertion can be thought of in three broad categories:
•Electrical abnormalities;
•Structural abnormalities; and,
•Situational occurrences. 
First we will briefly discuss some examples of these cardiac abnormalities, and then discuss prevention strategies.

Electrical Abnormalities

The conduction system within the heart carries the electrical impulse to the heart muscle cells and causes them to contract, creating the heartbeat. Electrical abnormalities are differences in this conduction system. Examples of electrical abnormalities include arrhythmias and abnormalities of conduction. Ventricular tachycardia and ventricular fibrillation are two arrhythmic causes of cardiac death. Conduction abnormalities include Wolff-Parkinson-White, long QT syndrome, and Brugada syndrome.

Ventricular tachycardia occurs when the bottom chambers of the heart (ventricles) begin beating on their own without the usual control from the normal conduction system. Ventricular fibrillation is when the muscle cells in the ventricles contract erratically without the heart squeezing effectively. Wolff-Parkinson-White syndrome is a second, abnormal electrical connection between the top and bottom chambers of the heart that can allow a “short circuit” causing the heart to race (supraventricular tachycardia), or allow the ventricles to race in response to an atrial (top chambers of the heart) arrhythmia.  Long QT and Brugada syndromes are abnormalities of the ion channels within the cardiac muscle cells, leading to an increased risk of dangerous arrhythmias.

Structural Abnormalities

Structural abnormalities that increase the risk for sudden cardiac death include coronary artery abnormalities, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, obstructive lesions, coronary artery disease, and aortic arch abnormalities. The coronary arteries are small blood vessels that supply the heart muscle. Changes in these arteries from prior insults such as Kawasaki disease, narrowing from cholesterol related coronary artery disease, or abnormal courses of the arteries into the heart muscle can all lead to a sudden death during exertion secondary to insufficient blood supply to the cardiac muscle. Hypertrophic cardiomyopathy is an abnormality of the heart muscle that leads to significant thickening of the cardiac muscle and predisposes to restriction of the amount of blood the heart can pump during exercise.  Arrhythmogenic right ventricular cardiomyopathy causes changes in the heart muscle on the right side of the heart, and increases the likelihood of dangerous arrhythmias. Obstructive lesions include any conditions that restrict the pumping of blood from the heart. A typical example is aortic valve stenosis.  Aortic arch abnormalities predispose to sudden death by allowing enlargement of the vessel which leads to an increased risk for rupture during exertion.  This can occur secondary to an abnormality of the wall of the vessel, as occurs in Marfan syndrome, or as the result of abnormal forces on the aortic walls from a valve abnormality or high blood pressure.

Situational Occurrences

Situational occurrences include myocarditis, and commotio cordis.  Myocarditis is an inflammation of the heart muscle that can occur after certain viral illnesses, which increases the likelihood of a dangerous arrhythmia occurring.  Commotio cordis occurs when a sharp blow to the chest causes a ventricular arrhythmia.  Commotio cordis is more frequently associated with getting hit by hard objects such as baseballs, lacrosse balls or hockey pucks (as happened to Chris Pronger for the Saint Louis Blues during the 1998 playoffs), but there have been examples in combat sports such as this case at a karate tournament:

What Can Be Done?

There is not currently a wide consensus amongst experts as to how best screen athletes for these conditions prior to participation in sports. Some of the conditions create findings likely to be detected by screening physical examinations, such as murmurs from obstructive lesions or physical features of Marfan syndrome, but the majority of the conditions would not be evident on a physical examination and would require further studies to be detected. A ECG would likely be abnormal in patients with hypertrophic cardiomyopathy, long QT syndrome and Brugada syndrome; but there is a significant false positive rate (ECG is abnormal when patient does not have the condition) when trying to detect myocardial hypertrophy by ECG in athletes, and patients with long QT syndrome and Brugada syndrome can have normal resting ECGs at times.  Patients with episodes of ventricular arrhythmias are likely to have a normal resting ECG unless they happen to have an episode of arrhythmia at the time the study is performed.  An echocardiogram (ultrasound of the heart) would detect hypertrophic cardiomyopathy, congenital heart disease, obstructive lesions, aortic arch abnormalities, and in expert hands can often detect abnormalities in coronary artery origins.

Unfortunately, even with a normal physical examination, ECG and echocardiogram, there is still a risk for sudden cardiac death due to situational occurrences, abnormalities that could progress after their screening such as hypertrophic cardiomyopathy, and abnormalities that are difficult to detect on screenings such as arrhythymogenic right ventricular cardiomyopathy and coronary artery abnormalities. Many of these cardiac abnormalities are genetic, so there may be warning signs in the fighters family history. 

Currently, the most commonly employed screening process is a tiered approach:
•A family history should be obtained that asks about any sudden cardiac deaths, in particular in patients who were less than 50 years of age. In addition, a relative with congenital deafness, seizure disorder, or an unexplained single car accident or drowning should be noted. 
•The fighter should be asked if they have ever passed out, had bouts of unexplained dizziness, palpitations, shortness of breath, exercise intolerance or chest pain. 
•A thorough cardiac examination should be performed, including blood pressure measurement, palpation of pulses in arms and legs, and cardiac auscultation. If there are any concerning findings on family history, physical examination or the fighters history, then further evaluation of those findings should be performed before the fighter is cleared to compete. 
•Some commissions require fighters to have an ECG performed prior to obtaining a license.  While I believe that this is a reasonable requirement, there is not currently widespread agreement amongst experts that an ECG should be part of pre-participation physical examinations. 

As mentioned above, despite even the most thorough screening evaluations, there remains a risk for sudden cardiac death during a fight.  Therefore, it is vital that a medical team including a physician and paramedic trained in ACLS are present during all mixed martial arts events.  Since arrhythmia is the final common pathway for the majority of the causes of sudden cardiac death, there should also be a defibrillator or AED available at cageside, as required by most athletic commissions.  With proper precautions, the risk of sudden cardiac death can be lowered, but at this time it cannot be completely eliminated.

If you are interested in more details about sudden cardiac death and pre-participation screening, I recommend reading the following articles:
Recommendations of the 36th Bethesda Conference: (J Am Coll Cardiol, 2005; 45:1322-1326)
Sudden Death in Young Competitive Athletes.  Clinical demographic, and pathological profiles”  Maron, BJ et al, JAMA, Vol. 276, No. 3, July 17, 1996 (Abstract available through link, full content requires purchase.         

I will also be happy to discuss this issue further in the Underground Forum.


tags: Video   medical   


Get the MMA Underground app. for iPhone and Andriod devices.
iPhone Application Andriod MMA Underground Application

Recent Comments »

powerful mary jane site profile image  

6/22/13 12:12 AM by powerful mary jane

Let em fight on big pillows, with fluffy mittens on their hands......

SC MMA MD site profile image  

6/21/13 11:28 AM by SC MMA MD

Both good articles. The current standards used for determining voltage criteria for left ventricular hypertrophy present the biggest hurdle to ECGs being accepted as a universal screen prior to sports participation, as there is such a high false positive rate particularly in teenage and young adult athletic males. There is growing support, including the group who wrote these articles, to accept an isolated finding of left ventricular hypertrophy in an otherwise normal ECG as a normal finding. If this gains widespread support, the current argument that ECG screening is too expensive because it causes too many false positives, leading to unnecessary restrictions from activity pending cardiology referral and in most cases echocardiography, becomes moot. Currently, I think that many if not most physicians are uncomfortable clearing a patient with an ECG showing left ventricular hypertrophy without further evaluation.

dakotajudo site profile image  

6/21/13 10:34 AM by dakotajudo

A couple new references on pre-participation screening - I just happen to be adding to my bibliography - are found in BJSM. These are free downloads, part of a series on the topic:

BernardHopkins site profile image  

6/21/13 10:06 AM by BernardHopkins

id like to see him write an article on preventing medical malpractice deaths. boxers arent dropping left and righti think these dumb ammy MMA fighters are getting jacked up on energy drinks/pills before fights and sending their heart rates through the roof probably 2 scoops of NO xplode erupting from his stomach

SC MMA MD site profile image  

6/20/13 10:52 PM by SC MMA MD

I agree with buvaiser about the need for more BLS/CPR training and faster CPR and defibrillation when an arrest occurs.  BLS/CPR is easy to learn, and the classes are inexpensive.   If you own a gym or teach martial arts, I think you should take a weekend and learn BLS.  Statically, it is much more likely that a sudden arrest will occur during training than during an event, since so much more time is spent in hard training in the gym, but these deaths do not receive the same media attention as deaths at an event.  If an event occurs at the gym, there is no physician or paramedic on stand-by to perform CPR while you await EMS arrival.  Having trainers who can perform quality CPR is likely to make the difference between a successful resuscitation and a death.  You never know when someone in your gym might have an arrest, be it for a fighter or a grandparent watching the kids class. Many BLS/CPR training centers have started using computerized mannequins to monitor the depth and rate of compressions, to ensure that you are performing high-quality CPR.  When previously certified individuals re-certify for the first time using the mannequins, many of them comment about how physically hard it is to do compressions correctly, a fact all too familiar to paramedics and fire fighters.  Many of the Red Cross classes also teach AED use.   AEDs are designed to be easy to use, and they really are.  They will literally talk you though all the necessary steps, including CPR and placing the pads.  Multiple studies have shown that time to effective CPR and time to defibrillation are very important factors in arrest survival.  There are many arrests that have been captured on video, and all too often there is a delay in recognition of the severity of the problem, and delay in commencing CPR.  The episode at the karate tournament I referenced in the article was captured on video, and it remains on the internet.  Precious time passes with the victim lying on the mat, while officials contemplate the situation.  Unfortunately, the individual did not survive the arrest.  In contrast, when Pronger collapsed, a trainer was on him seemingly instantly.  This rapid response likely allowed him to survive.  I used to use the Pronger video in talks that I gave, but it was taken off the internet a few years ago (I assume secondary to copyright issues since it was from a network broadcast).  When I am ringside for a fight, the paramedics and a stretcher with an airway box and AED are also at ringside.  Prior to the start of the event, we discuss the route to the cage and route to the truck should a transport be necessary.  A few years ago in the southeast, a kickboxer died at an event secondary to head trauma, and the time it took to arrange transportation to the hospital was cited as a likely contributing factor.  When watching televised events, in particular UFC events, I notice that there are wide isles from the cage to the backstage corridors where the ambulances sit.  These not only provide a route for the fighters and their entourage to reach the cage, but also rapid access to evacuate a fighter should the unthinkable happen.

buvaiser site profile image  

6/20/13 9:26 PM by buvaiser

I defer to the expertise of sc mmma md about what is already required by commissions. my own 2 cents from taking care of folks who have out of hosp cardiac arrests seems to show recurrent problems and how they can be corrected.Screening: congenital heart problems and even situational heart problems can be extremely hard to detect esp in active young athletes until they drop dead. who would ever believe that dan hardy can have a deadly heart condition? as stated history of unexplained loss of conciousness or chest pain, new shortness of breath shouldn't be ignored. the history is the most important thing and should not be skipped. Lack of CPR/ACLS trained folks: people who are already sick are hard to bring back with chest compressions but young healthy folks can probably be kept alive for quite a while with good quality CPR (simple hard fast chest compressions and a good seal on mask vent). How about making it universal that not just paramedics and ringside physician are available but also teach cornerman to do cpr?Time of CPR: many times, cpr is not missing but started too late. this is probably why people survive in hospital cardiac arrests. when a guy loses consciousness, don't waste too much time looking for pulses and looking for breathing (which can be hard to tell). If a guy or gal doesn't wake right up when you smack them on the chest or pinch his nipples, a few chest compressions are unlikely to harm but can be life saving if started right away.Lack of Defib: this is just as big as lack of cpr. many of the fatal cardiac events start off as shockable (and easier to reverse) rhythms like v tach, v fib, rapid supraventricular or high reentrant rhythms..... wait a while and then you have rhythms that can't be shocked and are more likely fatal ... like asystole. early defib and cpr are about the only thing that really are known to make a difference. so should all events have multiple defibrillators carried by more than one person be available? i think so. the other problem is that lots of times, people don't know how to use the defibrillators. that should be verified before events.early transport to hospital: it takes too long to call for help and when it is there, it takes too long to get someone to a place where something definitive can be done. if not already required, all venues should have a path pre-cleared for paramedics... stretchers/equipment and an ambulance route in a larger venue.i know the whole "petey, my heart joke" is one we want to avoid but most importantly, i think fighters should be educated that heart problems ain't nuttin to fuck wit. that's right dan hardy that means you too.sorry for long post. FRAT: learn cpr, start it early, have lots of defibrillators and use them early. clear a path for paramedics. educate fighters and cornerman.

SC MMA MD site profile image  

6/20/13 8:27 PM by SC MMA MD

Agree with Kings21, I got chills reading about him hiding his seizure. That is a common problem with sports physicals though, athletes know that "no" is the correct answer to all of the "have you ever had a ..." questions during the physical, and they motivated to lie so they can keep competing

Kneeblock site profile image  

6/20/13 8:21 PM by Kneeblock


Kings21 site profile image  

6/20/13 7:25 PM by Kings21

Agree with this 100%. I do however hope that something like Mr. Volkmann hiding his seizure from doctors cause he has bills to pay doesnt come back to not only bite a promotion in the ass, but also have a horrible tragedy affect a family. I'm glad the UFC has some good medical exams before the fight but I think they can only do so much.

Jobe Watson's New and Improved Butler site profile image  

6/20/13 7:01 PM by Jobe Watson's New and Improved Butler