Perspective:

Mass gathering events in sports arenas create challenges regarding the cardiovascular safety of both athletes and spectators. A comprehensive medical action plan, to ensure properly applied cardiopulmonary resuscitation (CPR), and wide availability and use of automated external defibrillators (AEDs), is essential to improving survival from sudden cardiac arrest (SCA) and sudden cardiac death (SCD) at sporting events. This paper outlines minimum standards for cardiovascular care to assist in the planning of mass gathering sports events across Europe.

Both athletes (owing to physical exertion) and spectators (owing to emotional excitation with increased catecholamine levels) are at risk of SCD. Recent studies suggest an incidence of SCA of 1 per 500,000 to 1 per 600,000 spectators in major European soccer arenas, and in one study, as high as 1 per 260,000. Components of an effective medical action plan include:

1. Medical director. Ideally, a locally licensed physician should be the responsible medical director at a mass gathering sports event. A physician familiar with local medical resources can positively impact decision-making in the field, as well as transportation, and triage decisions.

2. Arena and event-specific planning. Careful examination of arena-specific factors and barriers to care should be made by the medical director and his/her team prior to the event, in order to optimize appropriate treatment should a cardiovascular emergency occur.

3. Level of care. Basic cardiac life support (BCLS) including AED should be considered the minimum acceptable level of care at any mass gathering event. Every effort should be made to deliver adequate CPR to bridge the gap to defibrillation and to ensure early defibrillation within 5 minutes from the time of collapse to victims of SCA.

4. Personnel. All personnel should be trained and certified in cardiovascular emergency care. Recommendations for personnel include:

• Presence of at least 1–2 physicians (not including team physicians) per 50,000 spectators is strongly encouraged. On-site physicians should (ideally) be certified in CPR/advanced cardiac life support (ACLS).
  
  
• Presence of at least 1 nurse per 10,000 spectators to deliver first-aid and be ambulatory as an additional first responder to a cardiovascular emergency.
  
  
• Medical technicians (MTs), primarily utilized as mobile emergency responders, numbering at least 2 per 10,000 spectators.
  
  
• Other event volunteers utilized in positions throughout the arena for purposes other than direct patient care should be aware of how to alert on-site trained emergency care providers and the emergency medical services (EMS) system. Ideally at least 50% of nonmedical volunteers should be trained in basic CPR and first-aid, in case patient contact is required.

5. Medical equipment. Proper equipment for ACLS, including AEDs and oxygen, and emergency care medication are required.

6. Communication. An efficient communication system is essential to ensure quick response times.

7. Treatment facilities. Treatment facilities or on-site medical rooms are important for large volumes of patients, as well as in locations with prolonged transport times. The number of rooms needed, will depend on the size and characteristics of the arena.

8. Transportation resources. The number and type of transportation resources should be individualized according to internal and external local logistics and the size of the arena, and described in the medical action plan (MAP). Ground ambulances, golf charts, and/or modified mini-ambulances as well as helicopters could be used.

9. Documentation. All emergency care performed in the arena must be documented in a standardized format and records saved, ensuring confidentiality and patient safety.

10. Collaboration with the local EMS and nearest hospital. It is essential to collaborate with the local EMS system in developing a MAP so on-site emergency responders complement the resources available.

11. Numbers. Arena size numbers of AEDs, physicians (MDs), nurses (RNs), MTs, and ambulances: