Rationale

• Rightful concern is raised when returning the player population to training and competition in the context of suspected or confirmed COVID-19 infection; given that the infection is still relatively novel, much of the emerging evidence is difficult to contextualise in our player
• Adverse cardiac and respiratory outcomes have been acknowledged in COVID-19 infection. The prevalence of cardiac and respiratory injury in community infection is unknown.  However, cardiac involvement has been found in up to 22% of hospitalised patients compared to 1% for other viral illnesses[1]^,[2].
• Exercise in the context of a current or recentCOVID-19 infection poses the risk of viral myocarditis, with the potential for associated cardiac dysfunction and fatal arrythmia[3] . This is mitigated by investigations and detailed return to play protocol in clinical relevant presentations[4]
• Despite strict biosecurity measures implemented by various sports, as based on RTT Elite Sports guidance Stage 2¹, it must be acknowledged this will act only as a risk mitigation measure for COVID-19 transmission; a zero risk environment cannot be achieved, even in the presence of frequent antigen testing for asymptomatic individuals[5]
• For most sports, a return to the sporting environment requires temporary breaching of social distancing measures during certain technical training, match play and essential medical care (see Table 2). Consequently, appropriate PPE will need to be utilised where indicated in these scenarios.
• Aerosol-generating procedures (AGPs) are recognised to be a high source of virus transmission, these also include situations where there is a high possibility of generating a cough or sneeze. Within sport there are many scenarios that are, or have the potential to become AGPs;
  • Cardiopulmonary resuscitation (CPR)
  • Airway management: any suction of upper airway, use of airway adjuncts and emergency surgical airway procedures
  • Breathing Management: any form of manual ventilation- mouth-to-mouth ventilation is not recommended in the current circumstance. Bag valve mask using a viral filter is preferable[6].
  • Medical emergencies in the context of reduced and impaired consciousness, with a risk of or actual airway compromise, that would require the above interventions.
  • Nose and throat procedures such as managing epistaxis or oral lacerations[7]^,[8]^,[9]

NB: Nebulising, high flow oxygen administration via facemask and nasopharyngeal swabbing are not considered AGPs.

 

PPE in the context of cardiopulmonary resuscitation

The UK government guidance as published by the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG)[10] have detailed that they do not consider chest compressions or the use of an Automatic External Defibrillator (AED) as AGPs. However, this view is not shared by the Resuscitation Council UK (RCUK[11]), the European resuscitation council (ERC²⁰), the International Liaison Committee on Resuscitation (ILCOR)[12] and the World Health Organistaion[13]. This view is also supported by the British Medical Association (BMA)[14]. All have taken the position that chest compressions themselves are an potentially aerosol generating and thus requiring Level 3 PPE. In the context of a shockable cardiac arrest, RCUK advise 3 stacked shocks be administered in a monitored arrest in Level 2 PPE, in the absence of compressions and airway management, whilst additional support is donning the appropriate PPE[15].

Given that sport typically follows the professional guidance of the Royal Colleges and RCUK, we felt it unwise to contradict these organisations in these unprecedented times of the COVID-19 pandemic.  This is due to the relative lack of current evidence, and a desire not to increase the exposure risk for medical staff  in the event of an arrest [see Figure 2]. We acknowledge that most sports environments utilise AEDs,  and thus the sports’ guidance has been adapted to suit the required needs. In summary:

• AED use is not considered an AGP
• Compressions are considered potntially aerosol generating, and can only be commenced in the absence of Level 3 PPE with a cover over the player’s face (e.g.a non-rebreather mask with oxygen attached or a towel) such as there is a minimal delay to the start of compressions
• Medical responders are ideally already in Level 2 PPE
• Awaiting support responders who are in Level 3 PPE

It is important that all medical teams amend their EAP to reflect these changes during this period.

The response time for a medical emergency in individual sports needs to be appropriately risk assessed with the new addition of time taken to don appropriate PPE; this is imperative when considering airway interventions, chest compressions and all clinically relevant scenarios. As time is critical in determining successful outcomes, it is recommended that during both training and matchday activities trained staff should either be wearing or have access to Level 3 PPE in a time frame that will not detrimentally affect the outcome of the clinical situation. Individual donning times will vary according to experience and the availability of “donning buddies”.

It must be remembered hat, once any AGP is commenced, all involved that are not in Level 3 PPE must step back 2m when outdoors, and vacate the room if indoors.

 

Special considerations for youth sport

As cardiac arrest in children occurs for a variety of  reasons, ventilation is often crucial to a child’s chance of survival. If the decision is made to perform rescue breathing [due to compression only CPR being less effective if a respiratory problem is the cause] despite the risk to the responder, a bag valve mask^25,[16] is preferable.

 

Optimised pitchside medical cover at all training and matches would consist of: 

• One appropriately trained responder* in Level 2 PPE with the ability to don Level 3 with minimal delay, if required. Forexample having additional available PPE on person or in the emergency pitchside bag.
• One appropriately trained responder* who is either already wearing or has immediate access to Level 3 PPE and can respond immediately
• Additionalsupport personnel that can don the appropriate level of PPE to assist in a medical emergency with minimal delay, when required.

Additional (support) personnel that can don the appropriate level of PPE to assist with extrication

*Appropriately trained responders are those with a current ATMMiF/IMMOFP/PHICIS/ICIR/UEFA FDEP/ITMMiF or equivalent qualification.

 

 

[1]Clerkin  KJ, Fried  JA, Raikhelkar  J,  et al.  Coronavirus disease 2019 (COVID-19) and cardiovascular disease.   Circulation. Published online March 21, 2020.

[2] Driggin  E, Madhavan  MV, Bikdeli  B,  et al.  Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic.   J Am Coll Cardiol. Published online March 18, 2020.

[3] https://jamanetwork.com/journals/jamacardiology/fullarticle/2766124

[4] https://journals.sagepub.com/doi/full/10.1177/2047487320930596

[5] https://www.acpjournals.org/doi/pdf/10.7326/M20-1495

[6] https://www.erc.edu/covid

[7] https://www.entuk.org/sites/default/files/files/COVID%2019%20Epistaxis%20Management.pdf

[8] https://www.nature.com/articles/s41415-020-1552-4.pdf

[9] https://www.fgdp.org.uk/sites/fgdp.org.uk/files/editors/FGDP%20CGDent%20Implications%20of%20COVID-19%20for%20the%20safe%20management%20of%20general%20dental%20practice%2016%20June%202020%20ed1.1.pdf

[10] https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/phe-statement-regarding-nervtag-review-and-consensus-on-cardiopulmonary-resuscitation-as-an-aerosol-generating-procedure-agp

[11] https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation/statement-on-phe-ppe-guidance/

[12] https://costr.ilcor.org/document/covid-19-infection-risk-to-rescuers-from-patients-in-cardiac-arrest

[13] https://apps.who.int/iris/bitstream/handle/10665/331695/WHO-2019-nCov-IPC_PPE_use-2020.3-eng.pdf

[14] https://www.bma.org.uk/advice-and-support/covid-19

[15] https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation/covid-community/

[16] https://www.gov.uk/government/publications/novel-coronavirus-2019-ncov-interim-guidance-for-first-responders/interim-guidance-for-first-responders-and-others-in-close-contact-with-symptomatic-people-with-potential-2019-ncov