Unofficial translation. The Spanish version is the official one and prevails in case of discrepancy.
Methodological Note
This document is an institutional technical recommendation of the Sociedad Panameña de Medicina Deportiva (SPMD) for the medical planning of sports events in Panama, designed to be applicable in other Latin American countries. It was developed through a structured narrative review of consensus statements, guidelines and studies of real events, complemented by systematic searches in PubMed, Europe PMC and Crossref using the EvidenX platform (September 2026).
Reference verification
Each reference was individually verified: existence of the DOI, match of authors, title, journal, volume and pages, PubMed identifier (PMID) where available, and reading of the abstract to confirm that it supports the statement for which it is cited. Statements without verifiable support were removed or labeled as expert consensus. It complements the SPMD guidelines on exercise prescription and cardiovascular prevention [36, 37].
Levels of evidence
- [A] Meta-analyses, systematic reviews or randomized clinical trials.
- [B] Observational studies, registries and cohorts, including studies at real events.
- [C] Expert consensus, institutional position statements or adaptation of standards to the local context.
This recommendation is not a formal clinical guideline developed with AGREE II methodology and does not replace individual clinical judgment. Its application must take into account the particularities of each event, local conditions and current legislation. The risk scale in section 2 is an adapted operational tool; it has not been formally validated.
Version Note — v2.0
Latin American Edition: from the number of ambulances to response time
Version 2.0 revises v1.6 (DOI 10.5281/zenodo.22087227) to adapt it to the resource reality of Latin America. It retains the risk scale, the pre-participation evaluation, the emergency action plan and the responsibilities framework, and introduces:
| Change | Section |
|---|---|
| Operational model based on response time: main medical post + post 2 + advanced life support unit (ALS Alpha unit) + motorcycles with AED, instead of one advanced life support ambulance every 10 km | §4 |
| Two levels in each table: Essential Minimum (mandatory floor) and Recommended (COPAMEDE/SBMEE optimal standard) | §4 |
| Care profile of the event: clinical, trauma or mixed (includes extreme sports and obstacle course races) | §2.2 |
| Accessibility: urban, difficult access, remote and aquatic, each with its own requirements | §2.3 and §6 |
| Updated management of heat stroke: cold-water immersion as the standard, "cool first, transport second", field alternatives | §5 |
| Removal of requirements not applicable at the minimum level (helicopter, ventilator per post, mandatory pharmacist) and of the "SPMD Technical Observer" | §4 and §9 |
| Complete review of references: corrections, new verified sources and removal of unsupported citations | §10 |
Contents
1. Introduction — Panama and Latin America
2. Event Classification: three axes
2.1 Risk scale · 2.2 Care profile · 2.3 Accessibility · 2.4 Adjustment rules
3. Cardiovascular Emergencies and Sudden Death
3.1 Epidemiology · 3.2 Pre-participation evaluation · 3.3 Chain of survival · 3.4 AED · 3.5 EAP · 3.6 CPR
4. Operational Model of Medical Coverage
4.1 Response-time principle · 4.2 Units · 4.3 Motorcycle calculation · 4.4 Two levels
4.5 Staffing · 4.6 Care profile · 4.7 Certifications · 4.8 Equipment
5. Heat and Exertional Heat Stroke
6. Difficult-Access, Remote and Aquatic Events
7. Emergency Protocols (response, evacuation, MCI-START)
8. Public Health Management
9. Communication, Training, Regional Framework and Responsibilities
10. References
1. Introduction — Panama and Latin America
Panama, like much of Latin America, has seen growth in marathons, triathlons, obstacle course races, extreme sports, open-water crossings and mountain races. This growth is positive, but it demands medical coverage proportional to the risk and achievable with the available resources. Copying requirements designed for large events in high-income countries—for example, several advanced life support ambulances along the course—makes the event more expensive, discourages compliance and does not necessarily shorten the time to defibrillation, which is what determines survival in cardiac arrest.
In long-distance races, cardiac arrest is rare (1.01 per 100,000 marathon participants) and bystander-initiated resuscitation is one of the main predictors of survival [3]. With teams distributed along the course, CPR in less than 1 minute and defibrillation in less than 3 minutes, full neurological recovery reached 95.5% in a Japanese series of 3.2 million runners [4]. That is why this edition organizes coverage around a single metric: time to AED.
The safety of an event is not measured by the number of ambulances, but by the time it takes for a defibrillator to reach any point on the course. Ambulances remain essential for advanced life support and transport; the first response is provided by mobile teams with AEDs.
2. Event Classification: three axes
Risk (how much) · Care profile (what type of care) · Accessibility (how far the hospital is)
2.1 Risk scale (10 criteria, 9 to 36 points) [C]
Adapted from the Event Risk Grading Scale of the São Paulo Municipal Secretariat [31]. The sum of the 10 criteria ranges from 9 to 36 points.
| Criterion | Description | Score |
|---|---|---|
| Type of event | School or recreational: 1 · National or local: 2 · Mid-scale international: 3 · Mass international: 4 | 1–4 |
| Location | Open and uncovered: 1 · Open with cover: 2 · Permanent enclosed: 3 · Temporary enclosed: 4 | 1–4 |
| Duration | <4 h: 1 · 4–6 h: 2 · 6–12 h: 3 · >12 h: 4 | 1–4 |
| Audience characteristics | Family: 1 · General without conflicts: 2 · Diverse with tourists: 3 · With history of rivalry: 4 | 1–4 |
| Predominant age | ≥65 or <10 years: 1 · 11–16: 2 · 17–35: 3 · Mixed 36–65: 4 | 1–4 |
| Number of attendees | Up to 500: 1 · 501–1,000: 2 · 1,001–5,000: 3 · >5,000: 4 | 1–4 |
| Access control | Ticketed: 1 · Free with registration: 2 · Open: 3 | 1–3 |
| Audience accommodation | Seated: 1 · Mixed: 2 · Standing: 3 | 1–3 |
| Alcoholic beverages | Not permitted: 1 · Controlled sale: 2 · Unrestricted: 3 | 1–3 |
| Temporary structures | None: 0 · <30 m²: 1 · >30 m²: 2 · Suspended: 3 | 0–3 |
| Level | Score | Description |
|---|---|---|
| LOW | 9–15 | Local event, small scale, short duration |
| MODERATE | 16–22 | Regional or national event, medium attendance |
| HIGH | 23–29 | International event, high attendance or long duration |
| SPECIAL | 30–36 | Mass event (>10,000 attendees) or highly complex event |
2.2 Care profile [B/C]
In addition to the risk level, the medical director defines which type of care predominates. In trail races in Brazil, 66% of encounters were due to systemic illness (exercise-associated collapse, heat stroke, hyponatremia) and 34% to injuries [25]; in obstacle course races, knee and anterior cruciate ligament injuries predominate [23]; BMX has some of the highest injury rates in multisport studies, with contusions, lacerations and fractures [24].
| Profile | Examples | Medical team | Additional equipment |
|---|---|---|---|
| Clinical | Road race, marathon, road cycling, open-water swimming | Emergency, internal medicine or sports medicine physician | AED, cold-water immersion, glucometry, IV fluids, rectal thermometer |
| Trauma | Skateboarding, BMX, downhill mountain biking, motocross, combat sports, rugby | Orthopedics/traumatology or physician trained in prehospital trauma | Spine board, cervical collar, splints, vacuum mattress, analgesia |
| Mixed | Obstacle course races, triathlon, trail, adventure races | Both: clinical physician at the main medical post and trauma physician at post 2 | Both kits; the ALS unit carries trauma equipment |
2.3 Accessibility [C]
The third axis is the actual time to a hospital with definitive-care capacity. A triathlon in Panama City and a crossing in Guna Yala may have the same risk score and completely different needs.
| Category | Time to hospital | Examples in Panama | Operational consequence |
|---|---|---|---|
| A · Urban | Up to 60 min by road | Marathons, 10 km races and triathlons in the capital | Standard model of section 4 (if >20 min, 2nd ALS unit — §2.4) |
| B · Difficult access | Stretches without vehicle access, even if the hospital is nearby | Cerro Ancón, trails, parks | Foot teams with AED, stretcher bearers and vehicle extraction point |
| C · Remote | >60 min or only by boat, aircraft or on foot | Volcán Barú, Guna Yala, Darién, islands | Prolonged stabilization post and planned evacuation (§6) |
| D · Aquatic | Sea, river or crossing | Open-sea swimming, crossings | Boat or personal watercraft with AED, lifeguards on kayak or board (§6) |
2.4 Adjustment rules
- Events with accessibility C or D are planned, logistically, at least at the HIGH level, even if their score is lower.
- If the referral hospital is more than 20 minutes away, a second ALS unit is added (§4.4).
- When the scale and the response-time calculation (§4.3) diverge, the one indicating greater coverage prevails.
3. Cardiovascular Emergencies and Sudden Death
3.1 Epidemiology [B]
| Data | Finding | Ref. |
|---|---|---|
| Cardiac arrest in long-distance races (USA, 10.9 million runners) | 0.54 per 100,000; in marathons 1.01 per 100,000; 71% fatal. Bystander CPR was among the main predictors of survival | [3] |
| Road races in Japan (3.2 million runners) | 1.31 per 100,000; with CPR <1 min and AED <3 min, full neurological recovery in 95.5% | [4] |
| Sports-related sudden death in the general population (France) | >90% in recreational sports; 93% witnessed, but bystander CPR in only 30.7%; CPR and initial defibrillation were the main predictors of survival | [5] |
| College athletes (NCAA, 2003–2013) | Sudden cardiac death 1:53,703 athlete-years; the most frequent autopsy finding was autopsy-negative sudden unexplained death (25%) | [6] |
Most arrests at events are witnessed. What separates life from death is that someone starts CPR immediately and that an AED arrives within minutes [3–5].
3.2 Cardiovascular pre-participation evaluation [B/C]
The pre-participation evaluation (PPE) seeks to identify conditions that increase the risk of sudden death, without unnecessary exclusion. It is based on the ESC recommendations [7], the international criteria for ECG interpretation in athletes [8] and the Brazilian position statement on cardiovascular emergencies at events [1].
| Component | Content | Indication |
|---|---|---|
| Medical history | Family history of sudden death (<50 years) · exertional syncope or chest pain · palpitations · supplements and substances | All competitive athletes |
| Physical examination | Auscultation · blood pressure · femoral pulses · Marfan stigmata | All competitive athletes |
| Resting ECG | Interpretation according to international criteria [8] | Recommended in competitive athletes; mandatory in the presence of symptoms or family history |
| Exercise test / echocardiogram | According to clinical or ECG findings | When indicated, not routinely |
| Classification | Management |
|---|---|
| ELIGIBLE | Participation without restrictions |
| ELIGIBLE WITH RESTRICTIONS | Intensity adjustment and scheduled follow-up |
| TEMPORARILY NOT ELIGIBLE | Suspend until resolved or work-up completed (e.g., active myocarditis) |
| NOT ELIGIBLE | Non-correctable high-risk condition: counseling and alternatives |
3.3 Chain of survival adapted to the event
| 1. Recognize | 2. Activate | 3. Immediate CPR | 4. Defibrillate | 5. Advanced support |
|---|---|---|---|---|
| Collapse, unresponsive, absent or abnormal breathing | Radio to the medical command center; activate EMS (911/SUME) if appropriate | Compressions immediately; do not wait for the physician | AED in ≤3 min (Recommended) or ≤5 min (Essential Minimum) | ALS unit: airway, venous access, drugs, transport |
3.4 AED — Automated External Defibrillator
| Criterion | SPMD 2026 Standard |
|---|---|
| Access time | Essential Minimum: ≤5 min to any point · Recommended: ≤3 min [2, 4] |
| Carriers | Motorcycles, bicycles or foot teams; medical posts; hydration stations with a trained volunteer |
| Verification | Battery and pads checked the day before; documented log |
| Trained personnel | All security staff, officials, volunteers and organizers — not just the physician |
| Model | AED with voice prompts in Spanish; prefer models with compression feedback |
3.5 Emergency Action Plan (EAP)
- Event medical lead and their chain of substitution.
- Map showing the location of AEDs, medical posts, motorcycles, ambulance access routes and extraction points.
- Activation protocol: signal, dedicated radio channel, internal number.
- At least two referral hospitals with actual transport time and prior agreement.
- Agreement with the public EMS (911/SUME) as backup when the event ALS unit is transporting.
- Documented prior drill and incident log for subsequent analysis.
3.6 High-quality CPR [A/C]
| Component | AHA 2020 Standard [9] |
|---|---|
| Compressions | 100–120/min · depth 5–6 cm · full recoil · minimal interruptions |
| Ratio | 30:2 without advanced airway; continuous compressions with advanced airway |
| Rotation | Every 2 minutes or sooner if fatigued |
| AED | Apply without stopping CPR; pause only for analysis and shock; resume immediately |
| Drugs (advanced support) | Epinephrine 1 mg IV/IO every 3–5 min; amiodarone 300 mg for refractory VF/VT |
4. Operational Model of Medical Coverage
4.1 Response-time principle [B/C]
The COPAMEDE/SBMEE position statement (2026) adopts time to defibrillation as the main metric and proposes calculating AED distribution according to the travel speed of the response teams [2]. The Japanese experience with a mobile rapid-response AED system in road races supports positioning teams along the course to start compressions within 1 minute and defibrillate within 3 [4]. The SPMD adopts this principle with two targets:
| Level | Time-to-AED target | Nature |
|---|---|---|
| Essential Minimum | ≤5 min at any point on the course | Mandatory — floor that cannot be lowered |
| Recommended | ≤3 min at any point on the course | Target whenever resources allow |
4.2 Units of the model
| Unit | Composition | Function |
|---|---|---|
| Main medical post (finish) | Physician · nurse · 2 first responders · AED · oxygen · cooling area | Care, stabilization and observation. At a half marathon in Singapore there were more encounters at the finish than along the course [13] |
| Post 2 | Physician · first responder · AED | Located in the final third or at the highest-risk point. Its physician travels on the physician motorcycle when needed |
| ALS Alpha unit (advanced life support) | Physician · nurse or paramedic · driver | Travels to the victim and performs the transport; while it transports, the physicians at the posts continue providing care on site |
| Physician on motorcycle | Driver (nurse, firefighter or first responder) + post 2 physician + AED | Assessment on the course and transport decision |
| Basic motorcycles | Driver-first responder with AED, oxygen and first-aid kit | First response: CPR and defibrillation |
| Fixed AED | At each hydration station, with a volunteer trained in CPR/AED | First link while the motorcycle arrives |
4.3 Calculation of motorcycles by response time
A mobile unit at 40 km/h covers about 667 m per minute [2]. Positioned at the center of its segment, it covers 6.7 km with a 5-minute target and 4 km with a 3-minute target. Every unit with an AED positioned on the course counts as a mobile unit: ALS unit, physician on motorcycle and basic motorcycles. The calculation assumes immediate radio activation; if activation is delayed, reduce the segment per unit.
Mobile units = course distance ÷ segment per unit (6.7 km for ≤5 min; 4 km for ≤3 min), rounded up.
Basic motorcycles = mobile units − ALS units positioned on the course − physician on motorcycle. On courses longer than 5 km, at least 1 basic motorcycle (redundancy while the ALS unit is transporting).
| Course | Essential Minimum (≤5 min) | Recommended (≤3 min) |
|---|---|---|
| 5 km | 0 basic motorcycles + physician on motorcycle + ALS Alpha unit | 0 basic motorcycles + physician on motorcycle + ALS Alpha unit |
| 10 km | 1 basic motorcycle | 1 basic motorcycle |
| 21.1 km | 2 basic motorcycles | 4 basic motorcycles |
| 42.2 km | 5 basic motorcycles | 9 basic motorcycles |
- The table assumes 1 ALS Alpha unit; each additional ALS unit positioned on the course replaces one basic motorcycle.
- Loops or out-and-back courses: calculate based on the length of road used, not the race distance; one unit covers both directions.
- Topography: on climbs, stretches without vehicle access or uncontrolled traffic, reduce the segment per unit or use foot teams (1 AED per km) or bicycles [2].
- Positioning: prioritize the final third and the finish, where demand tends to concentrate [13].
4.4 Two levels compared (example: marathon)
COPAMEDE/SBMEE recommends, in its optimal standard, advanced life support ambulances at the start, at the finish and every 5 km [2]. The SPMD adopts this scheme as the Recommended level. For the Essential Minimum level, and in accordance with the response-time principle of the same position statement, it prioritizes defibrillation by mobile teams and reserves advanced support for transport.
| Element | Essential Minimum (SPMD) | Recommended (COPAMEDE/SBMEE) |
|---|---|---|
| Time to AED | ≤5 min | ≤3 min |
| Medical posts | 2 (main + post 2) | Main + additional posts according to the course |
| ALS unit | ≥1 ALS Alpha unit + agreement with public EMS; 2nd ALS unit if HIGH/SPECIAL risk or hospital >20 min away | ≥2; at start, finish and every 5 km [2] |
| Basic transport ambulance | 1 if >5,000 participants or distance ≥21 km | According to the medical director's plan |
| Motorcycles | 5 basic + physician on motorcycle | According to §4.3 (≤3 min), minus the ALS units positioned on the course |
| Physicians | 3 (main medical post, post 2, ALS Alpha unit) | 2–3 per 1,000 participants [2] |
4.5 Minimum staffing and sizing [B/C]
At road events, demand for care varies widely with distance and heat: from 1.7 to 2.6 encounters per 1,000 participants at a half marathon in Singapore [13], 8.3 per 1,000 in 21 and 56 km races in South Africa [11] and 19.1 per 1,000 in a 90 km ultramarathon [12]. In trail races in Brazil, 4.5% of athletes required care [25].
| Role | Essential Minimum | Adjustment |
|---|---|---|
| Physicians | 3: main medical post, post 2 (with physician motorcycle) and ALS Alpha unit | +1 physician at the main medical post for every 5,000 participants above 5,000 [C] |
| Nursing | 1 at the main medical post | +1 for each additional physician [C] |
| First responders / emergency medical technicians | 2 at the main medical post · 1 at post 2 · 1 per motorcycle | According to segment and expected demand |
| Volunteers trained in CPR/AED | 1 per hydration station | All volunteers at HIGH/SPECIAL events |
4.6 Care profile and staffing
Apply the table in section 2.2. In the mixed profile, the clinical physician remains at the main medical post (heat and cardiac arrest) and the trauma-trained physician at post 2, located at the obstacles or stretches with the highest risk of falls.
4.7 Certifications
| Level | Medical director | Health team |
|---|---|---|
| LOW | Current license to practice | BLS recommended |
| MODERATE | Current license to practice · ACLS or PHSLS or equivalent recommended | BLS mandatory |
| HIGH | License to practice · ACLS or PHSLS or equivalent mandatory · experience at events | BLS mandatory · ACLS for physicians · prehospital trauma training in trauma or mixed profile |
| SPECIAL | All of the above · event medicine course (e.g., REMC of the World Academy of Endurance Medicine [16]) recommended | All of the above · specific training in sports events |
License to practice: current professional authorization in the country (in Panama, the "idoneidad" issued by the Consejo Técnico de Salud). BLS/ACLS: American Heart Association or recognized equivalent. PHSLS: SBMEE prehospital sports life support course.
4.8 Infrastructure and equipment by level
| Element | LOW | MODERATE | HIGH | SPECIAL |
|---|---|---|---|---|
| Medical posts | 1 (main) | 2 | 2 + additional according to the course | According to the course + medical command center |
| AED | Post + mobile unit | According to §4.3 (≤5 min) | According to §4.3 (≤3 min recommended) | ≤3 min + AED at access points |
| Monitor-defibrillator | In the ALS unit | In the ALS unit | ALS unit + main medical post | ALS unit + all posts |
| Cooling (WBGT >25 °C) | Tub with water and ice | Tub at main medical post | Cooling area | Cooling area with redundancy |
| Aircraft | — | — | Only if accessibility C | According to accessibility and plan |
5. Heat and Exertional Heat Stroke
Exertional heat stroke is one of the leading potentially fatal conditions in athletes, but it is preventable and treatable with an adequate medical response [17]. When cooling is delayed by more than 30 minutes, organ damage, morbidity and mortality increase [19].
5.1 WBGT index — SPMD operational thresholds [C]
| WBGT | Risk | Action |
|---|---|---|
| <21 °C | Low | No restrictions |
| 21–25 °C | Caution | Increase hydration; monitor at-risk athletes |
| 25–28 °C | Alert | Cooling area active; shade; reduce intensity in at-risk athletes |
| 28–30 °C | Danger | Consider modifying schedule, distance or format |
| >30 °C | Extreme danger | Cancel or reschedule |
In tropical climates the WBGT can be high from early morning. Measure from 6:00 and decide on start, pause or cancellation based on data. At the Falmouth Road Race, WBGT correlated strongly with the incidence of heat stroke [20].
5.2 Treatment: cool first, transport second [B]
- Cold-water immersion is the standard: in 454 cases of heat stroke treated with immersion at the Falmouth Road Race, survival was 100% [20].
- Diagnosis by rectal temperature; cool on site to <39 °C and only then transport for full evaluation [18].
- The International Olympic Committee recommends a cooling area ("heat deck") within or adjacent to the main medical post [17, 18].
- If no tub is available: tarp-assisted cooling with water or active external cooling devices. The tarp does not cool faster than usual care and both are slower than immersion [21]; active external cooling devices outperform passive cooling [22]. They are alternatives, not substitutes for immersion.
6. Difficult-Access, Remote and Aquatic Events
Panama does not have a formal remote-area medicine system. Therefore, this section does not require nonexistent specialists: it requires capabilities and agreements with the institutions that already operate in the territory.
6.1 Category B — Difficult access
- Foot teams with AED (1 per km) or bicycles where the terrain allows [2].
- Stretcher bearers and a marked extraction point that the ambulance can reach.
6.2 Category C — Remote
- Prolonged stabilization post: oxygen for several hours, IV fluids, analgesia, monitor-defibrillator and temperature control (hypothermia at altitude, as on Volcán Barú; heat on the coast).
- Written evacuation plan: means (boat, 4×4, stretcher, aircraft), operator and actual time to hospital.
- Formal agreements with SENAN, SINAPROC, Red Cross, Fire Department, regional MINSA and MiAmbiente park rangers, depending on the territory.
- Communication without cellular coverage: VHF radio or satellite phone.
- Mandatory medical certificate, mandatory minimum gear and cut-off times at checkpoints.
Forensic recommendations on deaths in sport and recreation identify timely treatment of arrhythmias in remote regions as an area for improvement, and about 60% of them refer to the AED [30]. Drone delivery of AEDs reduced time to defibrillation in simulations in non-urban and mountain areas [28, 29]; it is a technology to consider in the future.
6.3 Category D — Aquatic
- Boat or personal watercraft with AED and rescue personnel; lifeguards on kayaks or boards distributed along the course.
- Cardiovascular disease is the leading cause of or contributing factor to death in swimming [26]; swimming-induced pulmonary edema is associated with cold water and strenuous exertion [27].
- Water exit point with access to AED, oxygen and a care area.
7. Emergency Protocols
7.1 Prior evaluation of the athlete
- Medical history with cardiovascular emphasis; ECG in competitive athletes and at HIGH or SPECIAL risk events [7, 8].
- Certificate of fitness at international events and with accessibility C or D.
- Identification of higher-risk athletes: known heart disease, diabetes, >45 years.
7.2 Response and evacuation plan
| # | Action | Responsible | Target time |
|---|---|---|---|
| 1 | Identify collapse and scene safety | Anyone | <10 s |
| 2 | Alert the medical command center | First responder | <30 s |
| 3 | Start CPR | Trained first responder | Immediate |
| 4 | AED arrival (motorcycle or fixed AED) | Nearest mobile unit | ≤5 min (≤3 min recommended) |
| 5 | Defibrillate if indicated and continue CPR | Response team | Upon AED arrival |
| 6 | Arrival of physician on motorcycle or ALS Alpha unit | Command center | As soon as possible |
| 7 | Activate public EMS if the ALS unit is busy | Command center | <2 min from collapse |
| 8 | Transport to referral hospital | ALS Alpha unit | According to protocol |
| 9 | Document and notify | Medical director | Post-stabilization |
7.3 Mass casualty incident — START method
| Color | Category | Management |
|---|---|---|
| RED | Immediate | Priority care and evacuation |
| YELLOW | Delayed | Second-priority care |
| GREEN | Minor | Regrouping and later care |
| BLACK | Deceased / non-salvageable | Resources for the salvageable |
More than 3 simultaneous victims activate the protocol: the medical director assumes medical command of the incident, the public EMS is activated and the referral hospitals are notified.
8. Public Health Management
- Safe drinking water and water quality control in aquatic activities.
- Food inspection; handwashing at strategic points.
- Isolation areas and immediate notification to MINSA of notifiable disease cases.
9. Communication, Training, Regional Framework and Responsibilities
9.1 Communication
- Dedicated radio channel for the medical team and a single command center with a map of the event.
- Redundancy: radio, telephone and location app.
- Predefined codes: Red (arrest), Yellow (urgent), Green (consultation).
9.2 Training
Mobilizing trained community responders increases CPR and defibrillation before EMS arrival (moderate-certainty evidence), although its effect on overall survival remains uncertain [10]. The SPMD recommends training volunteers, officials and security staff in CPR and AED use, and conducting a documented drill before each event.
9.3 Regional framework
This recommendation is consistent with the COPAMEDE/SBMEE position statement on the prevention of sudden death in sport [2] , with the Brazilian Society of Cardiology position statement on cardiovascular emergencies at sports events [1] and with the Brazilian review on medical planning for mass sports events [14]. As regulatory references, the following were considered: Standard 07 of the Brazilian Athletics Confederation [32], Resolution 01/2026 of the São Paulo Athletics Federation—which requires a medical post between 50 and 150 m after the finish, two ambulances (one advanced life support and one basic) and ambulance arrival within 5 minutes [33]—and the World Athletics competition medical guidelines [15]. At international events, the role of the Medical Delegate provided for in the World Athletics competition rules is followed [34].
9.4 Legal framework in Panama
- Athlete health data: Law 81 of 2019 on Personal Data Protection [35]; express consent at registration.
- Partnerships: PANDEPORTES, MINSA, CSS, municipalities, Red Cross, SINAPROC and SENAN.
- Panama needs a specific standard for medical coverage at events; until then, this recommendation serves as a technical reference.
9.5 Responsibilities
- Organizer: implement the measures in this document and provide the resources sized by the medical director.
- Medical director: validate the sizing (§2 and §4), verify certifications, prepare the EAP and deliver a post-event report within ≤15 days.
- Athlete: truthfully declare their health condition, follow the instructions of the medical team and consent to the use of their data for safety purposes.
- Sudden and unforeseeable events managed in accordance with these protocols do not, by themselves, imply an admission of fault by the organizer or the medical team.
| Deadline | Action |
|---|---|
| 30 days before | Medical plan and EAP sent to the organizer |
| 7 days before | Verification of certifications and documented drill |
| Event day | WBGT from 6:00; check of AEDs, motorcycles, ALS units and radios |
| 15 days after | Technical-medical report and incident log |
10. References
References are kept in their original language.
- Ritt LEF, Avanza Junior AC, Stein R, et al. Position Statement on Cardiovascular Emergencies at Sporting Events – 2026. Arq Bras Cardiol. 2026;123(4):e20260220. doi:10.36660/abc.20260220. PMID: 42233839.
- Confederación Panamericana de Medicina del Deporte (COPAMEDE); Sociedade Brasileira de Medicina do Exercício e do Esporte (SBMEE). Posicionamento Oficial: Prevenção da Morte Súbita no Esporte. Versión 1.0. Julio de 2026. Disponible en: https://sportsafetyreport.org/posicionamento
- Kim JH, Malhotra R, Chiampas G, et al. Cardiac arrest during long-distance running races. N Engl J Med. 2012;366(2):130-140. doi:10.1056/NEJMoa1106468. PMID: 22236223.
- Tanaka H, Kinoshi T, Tanaka S, et al. Prehospital interventions and neurological outcomes in marathon-related sudden cardiac arrest using a rapid mobile automated external defibrillator system in Japan: a prospective observational study. Br J Sports Med. 2022;56(21):1210-1217. doi:10.1136/bjsports-2021-104964. PMID: 35589377.
- Marijon E, Tafflet M, Celermajer DS, et al. Sports-related sudden death in the general population. Circulation. 2011;124(6):672-681. doi:10.1161/CIRCULATIONAHA.110.008979. PMID: 21788587.
- Harmon KG, Asif IM, Maleszewski JJ, et al. Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association athletes: a decade in review. Circulation. 2015;132(1):10-19. doi:10.1161/CIRCULATIONAHA.115.015431. PMID: 25977310.
- Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J. 2021;42(1):17-96. doi:10.1093/eurheartj/ehaa605. PMID: 32860412.
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