Interassociation Recommendations On Preventing Catastrophic Injury And Death In Collegiate Athletes Published in Journal of Athletic Training

SOURCE: National Athletic Trainers' Association (NATA)

Endorsed by National Athletic Trainers’ Association and Twelve Other Medical and Sports Medicine Organizations

DALLAS, TX – The Journal of Athletic Training, the National Athletic Trainers’ Association’s (NATA) scientific publication, released today “Preventing Catastrophic Injury and Death in Collegiate Athletes: Interassociation Recommendations Endorsed by 13 Medical and Sports Medicine Organizations”. The paper includes recommendations in six areas that address the prevention of catastrophic traumatic (caused directly by participation in a sports activity) and non-traumatic (result of exertion while participating in a sports activity) injury and death. The recommendations stem from the Second Safety in College Football Summit in 2016 and have been reviewed and endorsed by relevant stakeholders and endorsing organizations. The paper also provides an actionable checklist for use by those with a responsibility to the health and wellbeing of collegiate student athletes.

“Almost all cases of non-traumatic catastrophic injury and death are preventable and or treatable,” said NCAA Chief Medical Officer, Dr. Brian Hainline. “We’ve seen a clear improvement in policies, research, education and medical care but there is still much more to be done. This document provides a roadmap for all participating institutions to put best practices in place and ensure the safety of our student athletes.”

New findings

  • Strength and conditioning sessions in American football are particularly high risk events for non-traumatic catastrophic injury and death.
  • NCAA rule modification led to a dramatic decrease in death from exertional collapse associated with sickle cell trait
  • Non-traumatic deaths in American football have remained steady for five decades.

“Policies and rule modifications are important, however, they are often the result of a catastrophic injury or death of a student athlete,” said NATA President, Tory Lindley, MA, ATC. “This document exercises a commitment to continued improvement in athlete safety. As health care professionals, and a vital part of the sports medicine team, athletic trainers are dedicated to ensuring a gold standard of care from prevention to treatment.”


The best practice recommendations are organized into six key areas that will help athletics health care administrators ensure policies are in place and followed. Recommendation highlights include:

1. Sportsmanship

Sportsmanship is foundational to NCAA athletics competition and creates a moral and ethical framework that rejects an intentional effort by athletes to use any part of their body, uniform or protective equipment as a weapon to injure another athlete or themselves.

  • A player should be ejected immediately from completion for a first infraction.
  • Video replay (when available) after the event can verify missed calls and lead to suspension from the next competition. It is crucial for conferences to commit to this responsibility.
  • Officials who fail to call such infractions should be educated and/or disciplined appropriately.
  • In helmeted sports, rules should be further developed to prohibit and penalize the initiation of contact with the head/helmet and should be enforced.

2. Protective Equipment

Protective equipment that is used in sport must be manufactured and maintained according to guidelines issued by a standards organization such as the National Operating Committee on Standards for Athletic Equipment and ASTM International. The legality of the equipment is dependent upon compliance, certification or both. In some cases, such as with football helmets, equipment must be maintained through a reconditioning process. Where the responsibility exists, member organizations must be vigilant about this process.

  • Every member school should establish policy to ensure annual certification, recertification and compliance as appropriate, with all protective equipment standards.

3. Acclimatization and Conditioning

Many non-traumatic deaths take place during the first week of activity or a transition period in training. It takes approximately seven to 10 days for the body to acclimatize to the physiologic and environmental stresses placed upon it at the start of a conditioning or practice period. It is imperative to recognize the vulnerability during these periods and ensure that both proper exercise and heat acclimatization are implemented.

  • Training and conditioning sessions should be introduced intentionally, gradually and progressively to encourage proper exercise acclimatization and to minimize the risk of adverse effects on health.
  • Training and conditioning sessions should be exercise-science based and physiologically representative of sports and performance components.
  • During the first four days of a transition period, training and conditioning sessions should be appropriately calibrated and include limitations on total volume and intensity of activity.
  • All training and conditioning sessions should be documented.

4. Emergency Action Plan (EAP)

Venue-specific EAPs should be available to all members of the athletics and emergency medical system community and located centrally and at each athletics activity venue. The EAP should be rehearsed with sports medicine and coaching staffs at least once a year and included in new employee orientations. Equipment necessary to execute the EAP should also be available at all venues.

  • EAPs should be developed for: head and neck injury; cardiac arrest; heat illness and stroke; exertional rhabdomyolysis; exertional collapse associated with sickle cell trait; any exertional or non-exertional collapse; asthma; diabetic and mental health emergencies.
  • EAPS should be consistent with the NCAA Concussion Safety Protocol Checklist to help establish policies regarding diagnosis, management and eventual return to play and classroom.
  • Head injury
    • EAPs should be created for concussions; moderate to severe traumatic brain injury and cervical spine injuries.
  • Cardiac emergencies
    • The location of AEDs should be documented, reflect a goal of collapse-to-shock in less than three minutes and checked at least monthly to ensure they are fully charged
    • Survival from a cardiac emergency drops by 7-10% for every minute of active arrest. Probability of survival is 89% with properly administered CPR and automated external defibrillators (AEDs).4,5
  • Exertional heat illness emergencies
    • During warm weather events and fall preseason practices, resources should be available to ensure full-body ice water immersion can be conducted in a timely manner, before patient transport and continued until the body has cooled to a temperature below 102 degrees Fahrenheit.
    • To differentiate heatstroke, characterized by extreme hyperthermia and central nervous system dysfunction, healthcare providers should be prepared to measure core body temperature using rectal thermometry.
    • Cold water immersion is the most effective immediate treatment of exertional heatstroke with fatality rates close to zero if the body temperature is brought to less than 40 degrees Celsius/104 degrees Fahrenheit within 30 minutes of collapse.6

5. Responsibilities of Athletics Personnel

Physical activity should never be used for punitive purposes. Exercise as punishment abandons sound principles and elevates risk above any reward.

  • All athletics personnel should intervene when they suspect that physical activity is being used for punishment.
  • All training and conditioning sessions should be administered by personnel with competency in the safe and effective development of those activities and with the necessary training to respond to emergency situations.
  • NCAA bylaws in all three divisions require that strength and conditioning professionals have strength and conditioning certification from either a nationally accredited or a nationally recognized certification program.
  • All strength and conditioning professionals and sports coaches should have a reporting line into the sports medicine or sports performance lines of the institution, not to the football coach.

6. Education and Training

Beyond strength and conditioning professionals, each institution should adopt requirements for the education and training of athletics personnel. That education should occur regularly.

  • Training should include information regarding EAPs; head and neck injuries; cardiac events; environmental monitoring; exertional heat illness and heat stroke; exertional collapse associated with sickle trait; asthma; rhabdomyolysis; diabetic emergency; any exertional or non-exertional collapse; proper training and periodization principles.

Participating organization that have endorsed the above recommendations: The American Association of Neurological; American Medical Society for Sports Medicine; American Orthopaedic Society for Sports Medicine; American Osteopathic Academy of Sports Medicine; College Athletic Trainers’ Society; Collegiate Strength and Conditioning Coaches Association; Congress of Neurological Surgeons; Korey Stringer Institute; National Athletic Trainers’ Association; National Collegiate Athletic Association; National Strength and Conditioning Association; National Operating Committee for Standards on Athletic Equipment; Sports Neuropsychology Society. The American Academy of Neurology affirmed the value of this document.


About NATA: National Athletic Trainers’ Association (NATA) – Health Care for Life & Sport

Athletic trainers are health care professionals who specialize in the prevention, diagnosis, treatment, and rehabilitation of injuries and sport-related illnesses. They prevent and treat chronic musculoskeletal injuries from sports, physical and occupational activity, and provide immediate care for acute injuries. Athletic trainers offer a continuum of care that is unparalleled in health care. The National Athletic Trainers' Association represents and supports 45,000 members of the athletic training profession. For more information, visit


1. Yau R, Kucera KL, Thomas LC, et al. Catastrophic sports injury research: Thirty-fifth annual report Fall 1982-Spring 2017. Chapel Hill, NC: National Center for Catastrophic Sport Injury Research at the University of North Carolina at Chapel Hill; September 25, 2018.

2. Kucera KL, Klossner D, Colgate B, et al. Annual survey of football injury research: 1931-2017. Chapel Hill, NC: National Center for Catastrophic Sport Injury Research at the University of North Carolina at Chapel Hill for the American Football Coaches Association, National Collegiate Athletic Association, & National Federal of State High School Associations.; February 16, 2018.

3.  Van SC, Bloor CM, Mueller FO, et al. Non-traumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27:641-647.

4. IOM (Institute of Medicine). Strategies to improve cardiac arrest survival: A time to act. Washington D.C.: Institute of Medicine;2015.

5. Hainline B, Drezner JA, Baggish A, et al. Interassociation Consensus Statement on Cardiovascular Care of College Student-Athletes. J Am Coll Cardiol 2016;67:2981-2995.

6.  Casa DJ, Demartini JK, Bergeron MF, et al. National Athletic Trainers’ Association position statement: Exertional heat illness. J Athl Train 2015;50:986-1000.


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