Advances in Physical Education
2013. Vol.3, No.3, 131-135
Published Online August 2013 in SciRes (http://www.scirp.org/journal/ape) http://dx.doi.org/10.4236/ape.2013.33022
Cardiopulmonary Resuscitation Training in Sport
Universities: An Italian Survey
Andrea Scapigliati1, Saverio Giampaoli2, Alessia Marsili2,
Federica Valeriani2, Vincenzo Romano Spica2*
1Catholic University of the Sacred Heart, Rome, Italy
2University of Rome “Foro Italico”, Rome, Italy
Received December 17th, 2012; revised February 7th, 2013; accepted February 14th, 2013
Copyright © 2013 Andrea Scapigliati et al. This is an open access article distributed under the Creative Com-
mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, pro-
vided the original work is properly cited.
Background: Physical activity is associated to an increased risk of sudden cardiac death (SCD). Together
with primary prevention, prompt recognition and early management of SCD are crucial in order to im-
prove survival rate. During their duty, sport trainers and teachers can play a key role in secondary preven-
tion of cardiac arrest provided they have received an appropriate training in Cardiopulmonary Resuscita-
tion (CPR) during their curricular study. This is usually achieved through a Basic life Support and Defi-
brillation (BLS-D) Course which in Italy formally enables to Automated External Defibrillator (AED) use.
Objective: To investigate the presence, the type and the diffusion of cardiopulmonary resuscitation train-
ing in Sport and Exercise Sciences Universities in Italy. Design: Descriptive survey research design was
adopted for the study. Setting: The study sample consisted of 32 Italian Universities with Bachelor and
Master-Level Degrees in Sport and Exercise Sciences. Methods: Teaching secretary or directly deans/
course presidents were contacted by email or telephone in order to collect information on the availability
of BLS-D courses for Sport and Exercise Sciences students during the academic year 2010-2011. Results:
The compliance to the survey has been >93%. Only a reduced number of the contacted Universities of-
fered dedicated courses of Cardiopulmonary Resuscitation with license to Defibrillation according to cur-
rent local regulation. Conclusion: The described situation shows a limit in the generation of a sport train-
ers’ category highly specialized in cardiac and respiratory emergencies: only 6 Universities organize
BLS-D training with official certification.
Keywords: Basic Life Support; Defibrillation; Cardiopulmonary Resuscitation; Sudden Cardiac Death;
Cardiac Arrest; Sport; University; Public Health
Introduction
It is well recognized that regular physical activity reduces co-
ronary heart disease events (Nam, 2011). However, exposure to
vigorous exercise can increase the risk of sudden cardiac death
(SCD) up to three times as higher in competitive athletes as in
general population, acting as a trigger of cardiac arrest (CA) on
different age-related underling causes (American College of
Sports Medicine & American Heart Association, 2007; Thomp-
son et al., 2007; Batra & Balaji, 2012). Furthermore, sport prac-
tice can be associated with chest trauma (i.e., commotio cordis),
other accidents such as drowning, or behaviors (drug abuse and
doping) which are all potential causes of CA (Solberg et al.,
2011). Our knowledge on epidemiology of sport-related CA is
limited by difficult and discrepant data collection varying on
geographical basis (Borjesson & Pelliccia, 2009; Webner et al.,
2012). From a European perspective, in the restricted area of
Veneto Italian region, where a precious prospective registry of
CA in young athletes (≤35 years) is available, the SCD inci-
dence was 3.6/100.000 participants per year (Corrado et al.,
2006). In a recent France national survey based on ambulance
service data and media reports (susceptible of underreporting
bias), the overall incidence of sport-related sudden death in the
general population was 4.6 per million population per year,
90% during recreational sport activity and 6% in young com-
petitive athletes (Marijon et al., 2011). In all studies an over-
whelming male predominance was found. These data suggest
that CAs in competitive and top athletes are not only the more
visible aspect of a hidden but larger and more widespread phe-
nomena. Recent episodes of CA during excellence sport compe-
titions raised old questions on prevention and treatment of
sport-related CA considering the large population which prac-
tice physical activity at any level. Mandatory medical screening
as a tool of primary and secondary prevention has had a dra-
matic effect in the last three decades in decreasing SCD rate
among competitive athletes in Italy (Corrado et al., 2009; Corra-
do et al., 2012). However, once CA has occurred for any reason
(screening failure, unpredictable precipitating cause, fatal acci-
dent), bystander Cardiopulmonary Resuscitation (CPR) toge-
ther with Automatic External Defibrillator (AED) use is recog-
nized as the best intervention for early treatment of CA and is
associated with higher survival rate compared with no early
CPR, CPR alone without defibrillation and Emergency Medical
*Corresponding author.

A. SCAPIGLIATI ET AL.
System (EMS) arrival (Koster et al., 2010). Therefore, it is like-
ly that public interventions aimed to a larger diffusion of CPR
training and AED deployment in sport venues can act as an ef-
fective tertiary prevention strategy. A recent Italian law impos-
es the presence of AED in sport facilities (Republic of Italy,
2012). Since sport trainers and teachers can play a crucial role
in prevention especially in recreational sport (where medical
screening is far less implemented) and are likely to be among
bystander rescuers in case of CA, a specific curricular educa-
tion program on SCD prevention and treatment could be effec-
tive in reducing sport-related unexpected deaths.
In Italy, professional sport trainers and teachers have usually
got a degree in Universities with Departments of Sport and
Exercise Sciences (SES). In this context, dedicated courses of
Basic Life Support and Defibrillation (BLS-D) with a specific
focus on sport setting, can provide students with the ability to
recognize and treat CA as well as altered level of consciousness
and respiratory emergencies, with specific skill to operate an
AED. In the present paper we investigated the diffusion of
BLS-D training courses in Italian Universities with Bachelor
and Master-Level Degrees in SES. The reported data are the re-
sult of a survey conducted in the Academic Year 2010-2011.
Methods
Thirty-two Italian Universities (Figure 1) with Bachelor and
Master-Level Degrees in SES (13 in the north, 9 in the centre,
and 10 in the south of the Country) had been identified through
the Registry of the Italian Ministry of Education, Research and
University and contacted electronically or by telephone in 2011
and 2012 for an interview. Questions were addressed to teach-
ing secretary or directly to deans/course presidents. The inter-
view was aimed to know if BLS-D courses dedicated to SES
students were available in Academic Year 2010-2011 and, when
present, if training was mandatory. Since Italian regulation cur-
rently allow the use of an AED by non-healthcare professionals
(lay persons) only after a formal training with certification (va-
lid for 1 year), a specific question addressed this information.
The items of the survey are summarized in Table 1. BLS-D
course was intended as including frontal lessons on SCD in
sport, CA, CPR and AED use together with skill teaching on
mannequins with CA simulation scenarios and AED training
devices. For this kind of course 4 - 6 hours are traditionally re-
quested with an instructor/students ratio of 1/5 - 6. Data collec-
tion was independently checked by two different researchers
and where information was missing Universities were contacted
again. If data interpretation was discrepant, discussion in pres-
ence of a third researcher allowed a final agreement. The col-
lected data were processed and presented in this paper in a ano-
nymous way.
Results
Survey Categori es
Thirty Universities out of 32 included in the interview pro-
vided the requested information (compliance to the survey of
>93%). According to the survey items (Table 1), the collected
data were summarized in six categories:
1) MH (Mandatory & Habilitation) Universities with man-
datory BLS-D training and final certification for AED use in
the Country;
2) OH (Optional & Habilitation) Universities with optional
Figure 1.
Distribution on the national land of the universities involved in the sur-
vey.
Table 1.
Items of survey.
Questions Answers
BLS-D course training Presence/Absence
Level of the degree involved Bachelor/Master, both
Teachers involved Relevant subject
Attendance Mandatory/Optional course,
number of students attending
AED use Formal/Informal certification
Certification agency Emergency Medical System
(EMS)/Scientific organization
Other kind of training No formal BLS-D course, other
BLS-D training and final certification for AED use in the Coun-
try;
3) MW (Mandatory Without habilitation) Universities with
mandatory BLS-D training but without final certification for
AED use in the Country;
4) OW (Optional Without habilitation) Universities where
the training was neither mandatory nor with certification;
5) GI (General Information) Universities were students re-
ceived only general information on CPR without training;
6) N/A (Not Available) University without any kind of edu-
cation on the subject.
Survey Outp ut
As showed in Figure 2, the survey found that in the Aca-
demic Year 2010-2011, only one Italian University with De-
partment of SES had mandatory training in BLS-D with final
132

A. SCAPIGLIATI ET AL.
n = 30
Figure 2.
Results of the survey by categories. MH (Mandatory
& Habilitation), (1/30). OH (Optional & Habilitation),
(5/30). MW (Mandatory Without habilitation), (5/30).
OW (Optional Without habilitation), (3/30). GI (Gen-
eral Information), (6/30). N/A (Not Available), (10/
30).
certification for AED use in the Country (1/30, 3%). Five Uni-
versities (5/30, 17%) had a certified but optional BLS-D course
involving a range of approximately 20 - 100 students per year.
Overall Universities without AED use certification accounted
for 27% of the total, 5/30 with mandatory and 3/30 with optio-
nal BLS-D Course respectively. The rest of the Universities re-
sponding to the survey provided general information on CPR as
part of other courses (6/30), or had no official lessons covering
this issue (10/30). Among Universities with BLS-D courses and
AED use certification, the average numbers of participating stu-
dents was 36 (for this question the compliance of the survey
was 33%). The majority (>62%) of Universities offering the
BLS-D training organized courses both at the Bachelor and Ma-
ster-Level Degree. All the University in the MH and OH cate-
gories were localized in the north and in centre of the Country
(Figure 3). Where present, certification was provided by Emer-
gency Medical System in 4 cases, from National Resuscitation
Council in 2 cases.
Discussion
The National Context
The main result of the present survey is that only a minority
of students attending Italian Universities with Department in
SES are provided with formal training in CPR and AED use.
Furthermore, no uniformity of teaching is present among Uni-
versities in the Country, reflecting a lack of common strategy.
The presence of CPR and AED courses seems to depend more
on local initiative more than on public health and teaching na-
tional planning. These findings can be explained primarily with
the absence of a National regulation on education strategy and
University teaching about this specific topic. This lack, together
with discrepancies in local resources, can account for regional
differences in BLS/AED training offer along the Country. How-
ever a deeper reason for this inadequate and non homogeneous
frame is probably the poor general awareness about the crucial
role of first responders in the treatment of CA victims.
The Importance of Early Recognition of CA
The well known concept of the Chain of Survival (the inter-
dependent positive effect of a series of consecutive actions such
Figure 3.
Classification of survey results according to land localization of univer-
sities.
as Prevention, Early recognition and Call for help, Early CPR,
Early Defibrillation, Post-resuscitation care) in the context of
sport-related CA can rely on traditional healthcare professionals
(i.e. physicians and EMS) mainly in the very first (i.e. preven-
tion) and late links (i.e. the so called Advanced Life Support,
ALS, usually restricted to the hospital phase of treatment) (Ko-
ster et al., 2010). The central links of the chain (i.e. early CPR
and Defibrillation) are largely dependent on the first witnesses
of CA, their willingness to step in rescue and their skill to per-
form correct actions. Available data in the specific sport context
have proven how CA during sport activities is very often wit-
nessed. As reported in Drezner et al. (2007) survey, 97% of re-
ported CA involving student athletes or older nonstudents in-
volved in school-related sport activities were witnessed, 94%
received bystander CPR in about 1 minute from collapse and
most of them received an AED shock after a short interval from
collapse (<4 minutes). Noteworthy, the first responder was a
nontraditional health professional in the majority of cases (i.e.,
certified athletic trainers, coaches or teachers) when compared
with school physicians and nurses, while EMS personnel were
not on site at CA time in any case. In this series, overall survi-
val to discharge was an outstanding 64% when compared with
data related to out of hospital cardiac arrest in the general po-
pulation (about 10%) (Berdowski et al., 2010). In Marijon et al.
(2011) study, bystander CPR, time from collapse to start CPR
and defibrillation were the most important independent factors
associated with survival. Furthermore, in a wider preventive
strategy of SCD, non-traditionally health-related professionals
can play a two-level role. Together with their role in tertiary
prevention (i.e. treatment of CA once it has occurred), they can
take part to the primary and secondary prevention (i.e. general
and at risk population screening). Since neither ECG at rest nor
exercise testing screening are mandatory in leisure-time sport
activities, especially in middle aged/senior individual, trainers/
coaches/teachers can reinforce the first line screening with tu-
toring intervention, for instance with the administration of a
validated physical evaluation questionnaire such as proposed by
European Association of Cardiovascular Prevention and Reha-
bilitation (Borjesson, Urhausen et al., 2011).
The Importance of Curricular Trainings
Another reasons for poor diffusion of CPR training as found
in this survey could be the lack of widespread and accepted

A. SCAPIGLIATI ET AL.
recommendations on the specific topic. To work effectively, the
Chain of Survival must be based on proper plans and prepared-
ness. Skills acquisition in CPR is not for ever and frequent re-
training is necessary to maintain proficiency as well as equip-
ment (especially AED) needs periodic maintenance. While state-
ments on emergency preparedness and SCD management in
athletic facilities have been published in USA, a recent position
stand from the Sports Cardiology section of the European As-
sociation of Cardiovascular Prevention and Rehabilitation
(EACPR) aimed to fill a current gap about acute cardiovascular
care at sport arenas in Europe (Drezner et al., 2007; Borjesson
et al., 2011). A proper curricular training for SES Universities
should take in account the elements suggested in these state-
ments, enabling students to have an active role in elaborating
and implementing emergency plans in sport venues where they
could work. Specific features of sport-related CA should be co-
vered as well, such as how to deal with frequent seizure-like
activity and pulse/respiration presence (in 50% and 57% of
cases respectively in Drezner et al. (2007) study), a description
of commotio cordis and general information on pediatric CA,
foreign body airway obstruction treatment and rescue lateral
positioning of the victim. In our Institution we aimed to cover
with all these issues through a Course on Medical Emergencies
at Sport Venues including a formal BLS-D Course with AED
use certification. The none uniform distribution of BLS-D
courses, as showed in the results of the survey presented in this
paper, can clearly discriminate some regions (for example south
and islands in Italy) where students did not have the opportu-
nity to obtain a valid training in CRP inside their academic cur-
riculum studiorum. The described situation shows a limit in the
generation of a sport trainers category highly specialized in
cardiac and respiratory emergencies. This can be an important
safety issue for sport activities performed in minor leagues,
where the sport trainer/coach is generally the only reference for
athletes. The institution of mandatory and official courses in
CRP inside university teaching programs is highly auspicial, in
order to guarantee a wide distribution of sport trainers and assi-
stants able to face many medical emergencies. Considering the
need to have a formal certification to operate an AED in Italy, a
more effective cooperation with regional EMS and Scientific
Societies such as National Resuscitation Council seems urgent.
Most sport-related, sudden cardiac deaths occur in public sports
areas (track, gymnasium), where others athletes or insiders are
present: unfortunately only a reduced percentage of these wit-
nesses are potentially life-saving cardiopulmonary resuscitation
operators. The role of the bystanders in initiating resuscitation
should be valorized, starting from the bystanders par excellence
in sport facilities: coaches, trainers and assistant athletic train-
ers. Project focused on CPR training and placement of auto-
mated external defibrillators are thought to be both efficacious
and cost-effective, and for this reason a standardized, uniform
and ubiquitous teaching program should be provided to sport
students (Berger et al., 2004; Salib et al., 2005). Unfortunately
only a reduced number of Italian Universities with Bachelor
and Master-Level Degrees in sport and exercise sciences offers
dedicated courses for BLS-D with final national authorization/
license.
Acknowledgements
This work has been supported by the scientific collaboration
with the IRC Italian Resuscitation Council and the scientific
committee of ICSPS2013 (www.icsps-rome2013.it). Authors
thanks Dr. Elena Scaramucci (Sant’Andrea Hospital, Rome, Ita-
ly) for the collaborative discussion useful comments and critici-
sm.
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