Chapter 12: On-the-Field Acute Care and Emergency Procedures

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Chapter 12 On-the-Field Acute Care and Emergency
Procedures
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• When injuries occur, while generally not
  life-threatening, they require prompt care
• Emergencies are unexpected occurrences that
  require immediate attention - time is a factor
• Mistakes in initial injury management can prolong
  the length of time required for rehabilitation or
  cause life-threatening situations to arise

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Emergency Action Plan

• Primary concern is maintaining cardiovascular and
  CNS functioning
• Key to emergency aid is the initial evaluation of
  the injured athlete
• Members of sports medicine team must at all times
  act reasonably and prudently
• Must have a prearranged plan that can be
  implemented on a moments notice

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• Issues plan should address
• Separate plans should be developed for each
  facility
• Outline personnel and role
• Identify necessary equipment
• Established equipment and helmet removal policies
  and procedures
• Availability of phones and access to 911
• Athletic trainer should be familiar with
  community based emergency health care delivery
  plan
• Be aware of communication, transportation,
  treatment policies

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• Community based care (continued)
• Individual calling medical personnel must relay
  the following 1) type of emergency 2) suspected
  injury 3) present condition 4) current assistance
  5) location of phone being used and 6) location
  of emergency
• Keys to gates/locks must be easily accessible
• Key facility and school administrators must be
  aware of emergency action plans and be aware of
  specific roles
• Individual should be assigned to accompany
  athlete to hospital

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Cooperation between Emergency Care Providers

• Cooperation and professionalism is a must
• Athletic trainer generally first to arrive on
  scene of emergency, has more training and
  experience transporting athlete than physician
• EMT has final say in transportation, athletic
  trainer assumes assistive role
• To avoid problems, all individuals involved in
  plan should practice to familiarize themselves
  with all procedures (including equipment
  management)

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Parent Notification

• When athlete is a minor, ATC should try to obtain
  consent from parent prior to emergency treatment
• Consent indicates that parent is aware of
  situation, is aware of what the ATC wants to do,
  and parental permission is granted to treat
  specific condition
• When unobtainable, predetermined wishes of parent
  (provided at start of school year) are enacted
• With no informed consent, consent implied on part
  of athlete to save athletes life

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Principles of On-the-Field Injury Assessment

• Appropriate acute care cannot be provided without
  a systematic assessment occurring on the playing
  field first
• On-field assessment
• Determine nature of injury
• Provides information regarding direction of
  treatment
• Divided into primary and secondary survey

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• Primary survey
• Performed initially to establish presence of
  life-threatening condition
• Airway, breathing, circulation, shock and severe
  bleeding
• Used to correct life-threatening conditions
• Secondary survey
• Life-threatening condition ruled out
• Gather specific information about injury
• Assess vital signs and perform more detailed
  evaluation of conditions that do not pose
  life-threatening consequences

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Dealing with Unconscious Athlete

• Provides great dilemma relative to treatment
• Must be considered to have life-threatening
  condition
• Note body position and level of consciousness
• Check and establish airway, breathing,
  circulation (ABC)
• Assume neck and spine injury
• Remove helmet only after neck and spine injury is
  ruled out (facemask removal will be required in
  the event of CPR)

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• With athlete supine and not breathing, ABCs
  should be established immediately
• If athlete unconscious and breathing, nothing
  should be done until consciousness resumes
• If prone and not breathing, log roll and
  establish ABCs
• If prone and breathing, nothing should be done
  until consciousness resumes --then carefully log
  roll and continue to monitor ABCs
• Life support should be monitored and maintained
  until emergency personnel arrive
• Once stabilized, a secondary survey should be
  performed

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Primary Survey

• Life threatening injuries take precedents
• Those injuries requiring cardiopulmonary
  resuscitation, profuse bleeding and shock
• Emergency Cardiopulmonary Resuscitation
• Evaluate to determine need
• Should be certified through American Heart
  Association, American Red Cross or National
  Safety Council

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• Establish Unresponsiveness
• Gently shake and ask athlete Are you okay?
• If no response, EMS should be activated and
  positioning of body should be noted and adjusted
  in the event CPR is necessary
• Equipment Considerations
• Equipment may compromise lifesaving efforts but
  removal may compromised situation further
• Facemask should be removed appropriate clip
  cutters (Anvil Pruner, Trainers Angel, FM
  Extractor)
• Use of pocket mask/barrier mandated by OSHA
  during CPR to avoid exposure to bloodborne
  pathogens

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• ABCs of CPR
• A - airway opened
• B - breathing restored
• C - circulation restored
• Generally when A is restored B C will follow

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Opening the Airway

• Head-tilt, chin lift method
• Push down on the forehead and lifting the jaw
  moves the tongue from the back of the throat

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• Modified technique can be used when neck injury
  is suspected
• Modified jaw thrust maneuver

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Establishing Breathing

• Look, listen and feel
• While maintaining pressure on forehead, pinch
  nose, hold head back
• Take deep breath, and create seal around lips and
  perform 2 slow breaths (raise chest 1.5- 2

• If breath does not go in, re-tilt and ventilate
  or
• airway is obstructed perform finger sweep

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Means of Artificial Respiration
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Establishing Circulation

• Locate carotid artery and palpate pulse while
  maintaining head tilt position

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• Locate margin of ribs and xiphoid process of
  sternum
• Two fingers width above xiphoid process, place
  heal of hand on lower portion of sternum
• Place other hand on top with fingers parallel of
  interlocked

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• Keep elbows locked with shoulders directly above
  patient
• Compress chest 1.5-2 (15 times per 2 breaths)
• After 4 cycles reassess pulse (if not present
  continue cycle)

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Obstructed Airway Management

• Choking is a possibility in many activities
• Mouth pieces, broken dental work, tongue, gum,
  blood clots from head and facial trauma, and
  vomit can obstruct the airway
• When obstructed individual cannot breath, speak,
  or cough and may become cyanotic
• The Heimlich maneuver can be used to clear the
  airway

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• Stand behind athlete with one fist against the
  body and other over top just below the xiphoid
  process
• Provide forceful thrusts to abdomen (up and in)
  until obstruction is clear

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• If athlete becomes unconscious, open airway and
  attempt to ventilate.
• If airway still obstructed, re-tilt and
  re-ventilate
• If not ventilation, perform 15 chest compressions
  and finger sweep to clear obstruction
• Be sure not to push object in further with sweep
• Repeat cycle until air goes in
• When athlete begins to breath on own, place in
  comfortable recovery position while lying on
  their side

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• Index finger should be inserted in mouth along
  cheek
• Using hooking maneuver, pull across to free
  impediment
• Attempt to ventilate after each sweep until
  athlete is breathing

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Using an Automatic External Defibrillator (AED)

• Device that evaluates heart rhythms of victims
  experiencing cardiac arrest
• Can deliver electrical charge to the heart
• Fully automated - minimal training required
• Electrodes are placed at the left apex and right
  base of chest - when turned on, machine indicates
  if and when defibrillation necessary
• Maintenance is minimal for unit

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Administering Supplemental Oxygen

• May prove to be critical in treating severe
  injury or illness
• Requires the use of bag-valve mask and
  pressurized container of oxygen
• Canister is green with yellow oxygen label
• Training is required
• Provides patient with a significantly high
  concentration of oxygen (up to 90)
• Deliver at a rate of 10-15 liters/minute

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• INSERT Oxygen administration photo

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• Secondary survey
• Life-threatening condition ruled out
• Gather specific information about injury
• Assess vital signs and perform more detailed
  evaluation of conditions that do not pose
  life-threatening consequences

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Control of Hemorrhage

• Abnormal discharge of blood
• Arterial, venous, capillary, internal or external
  bleeding
• Venous - dark red with continuous flow
• Capillary - exudes from tissue and is reddish
• Arterial - flows in spurts and is bright red
• Universal precautions must be taken to reduce
  risk of bloodborne pathogens exposure

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External Bleeding

• Stems from skin wounds, abrasions, incisions,
  lacerations, punctures or avulsions
• Direct pressure
• Firm pressure (hand and sterile gauze) placed
  directly over site of injury against the bone
• Elevation
• Reduces hydrostatic pressure and facilitates
  venous and lymphatic drainage - slows bleeding
• Pressure Points
• Eleven points on either side of body where direct
  pressure is applied to slow bleeding

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Internal Hemorrhage

• Invisible unless manifested through body opening,
  X-ray or other diagnostic techniques
• Can occur beneath skin (bruise) or contusion,
  intramuscularly or in joint with little danger
• Bleeding within body cavity could result in life
  and death situation
• Difficult to detect and must be hospitalized for
  treatment
• Could lead to shock if not treated accordingly

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Shock

• Generally occurs with severe bleeding, fracture,
  or internal injuries
• Result of decrease in blood available in
  circulatory system
• Vascular system loses capacity to maintain fluid
  portion of blood due to vessel dilation, and
  disruption of osmotic balance
• Movement of blood cells slows, decreasing oxygen
  transport to the body

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• Extreme fatigue, dehydration, exposure to heat or
  cold and illness could predispose athlete to
  shock
• Several types of shock
• Hypovolemic - decreased blood volume resulting in
  poor oxygen transport
• Respiratory - lungs unable to supply enough
  oxygen to circulating blood (may be the result of
  pneumothorax)
• Neurogenic - caused by general vessel dilation
  which does not allow typical 6 liters of blood to
  fill system, decreasing oxygen transport
• Cardiogenic - inability of heart to pump enough
  blood

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• Psychogenic - syncope or fainting caused by
  temporary dilation of vessels reducing blood flow
  to the brain
• Septic - result of bacterial infection where
  toxins cause smaller vessels to dilate
• Anaphylactic - result of severe allergic reaction
• Metabolic - occurs when illness goes untreated
  (diabetes) or when extensive fluid loss occurs
• Signs and Symptoms
• Moist, pale, cold, clammy skin
• Weak rapid pulse, increasing shallow respiration
  decreased blood pressure
• Urinary retention and fecal incontinence
• Irritability or excitement, and potentially thirst

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• Management
• Maintain core body temperature
• Elevate feet and legs 8-12 above heart
• Positioning may need to be modified due to injury
• Keep athlete calm as psychological factors could
  lead to or compound reaction to life threatening
  condition
• Limit onlookers and spectators
• Reassure the athlete
• Do not give anything by mouth until instructed by
  physician

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Secondary Survey

• Once athlete is deemed stable secondary survey
  can begin
• Assessment of vital signs
• Pulse - direct extension of heart function
• Normal is 60-80 beats per minute (athletes may
  be slightly lower)
• Childs pulse is generally 80-100 bpm
• Rapid and weak could indicate shock, bleeding,
  diabetic coma or heat exhaustion
• Rapid and strong could indicate heatstroke,
  fright
• Strong and slow indicates skull fx or stroke
• No pulse cardiac arrest or death

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• Respiration - 12 breaths per minute or 20-25 for
  children
• Shallow - shock
• Irregular or gasping - cardiac compromise
• Frothy w/ blood - chest injury
• Must assess movement of air through mouth and
  nose
• Blood Pressure
• Measured w/ s sphygmomanometer indicating
  arterial pressure
• Systolic blood pressure is pressure created by
  ventricle contraction (normal 115-120 mm Hg)
• Diastolic pressure is residual pressure present
  between beats (normal 75-80 mm Hg)
• Females are usually 8-10 mm Hg less

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• Above 135 mm Hg may be high and below 110 may be
  low for systolic
• Should stay between 60 and 85 mm Hg for diastolic
• Must inflate cuff above antecubital fossa (up to
  200 mm Hg)
• Slowly deflate cuff listening for first beating
  sound (systolic) and final sound (diastolic) with
  stethoscope
• Temperature
• Normal is 98.6 o F
• Measure with thermometer in mouth, under armpit,
  against tympanic membrane
• Core temperature is best measured rectally
• Changes in temperature can be reflected in skin
  temperature

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• Temperature changes can be the result of disease,
  cold exposure, pain, fear, nervousness
• Lowered temperature is often accompanied by
  chills, teeth chattering, blue lips, goose bumps
  and pale skin
• Skin Color
• Can be an indicator of health
• Red - Elevated temp, heat stroke, or high blood
  pressure
• White - insufficient circulation, shock, fright,
  hemorrhage, heat exhaustion, or insulin shock
• Blue (cyanotic) - airway obstruction or
  respiratory insufficiency

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• Dark pigmented skin is slightly different in
  response
• Nail beds, and inside lips and mouth and tongue
  will be pinkish
• With shock, skin around mouth and nose will have
  grayish cast and mouth and tongue will be bluish
• During hemorrhaging, mouth and tongue will become
  gray
• Fever is indicated by red flush tips of ears
• Pupils
• Extremely sensitive to situation impacting
  nervous system
• Most individuals pupils are regularly shaped
• Disparities must be known by the athletic trainer
  in the event that a condition arises

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• Constricted pupils may indicate use of a
  depressant drug
• Dilated pupils may indicate head injury, shock,
  use of stimulant
• Failure to accommodate may indicate brain injury,
  alcohol or drug poisoning
• Pupil response is more important than size

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• State of Consciousness
• Must always be assessed
• Alertness and awareness of environment, as well
  as response relative to vocal stimulation
• Head injury, heat stroke, diabetic coma can alter
  athletes level of consciousness
• Movement
• Inability to move may indicate serious CNS
  deficits impacting motor control
• Hemiplegia (inability to move one side) may be
  the result of brain trauma or stroke
• Bilateral upper extremity sensory motor deficits
  could indicate cervical spine injury
• Pressure on spine or injury below the neck could
  result in compromised function of lower limbs

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• Abnormal Nerve Response
• Response to adverse stimuli can provide important
  information
• Numbness and tingling in limb w/ or w/out
  movement could indicate nerve or cold damage
• Blocked blood vessel could cause severe pain,
  lack of pulse, loss of sensation,
• Total loss of pain sensation may be caused my
  hysteria, shock, drug use or spinal cord injury
• Generalized local pain is an indicator that
  spinal injury is not present

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Musculoskeletal Assessment

• Must use logical process to adequately evaluate
  extent of trauma
• Knowledge of mechanisms of injury and major signs
  and symptoms are critical
• Once the mechanism has been determined, specific
  information can be gathered concerning the
  affected area

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• History should be taken
• Describe events of injury and those leading up to
  it
• Past history, previous injuries and treatment
  used
• Sounds (snaps, cracks, pops bone, ligament or
  tendon), grating, crepitus or rubbing, during or
  following the injury
• Visual Observation
• Inspection of injured and non-injured areas
• Look for gross deformity, swelling, skin
  discoloration

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• Palpation
• Palpate the area to help determine nature of
  injury(start away from site of injury)
• Determine extent of point tenderness, affected
  structures and other deformities (not apparent
  visually)
• Assessment Decisions
• Determine 1) seriousness of injury, 2) type of
  first aid and immobilization required, 3) need
  for immediate referral, 4) type of transportation
  from field to sideline, training room or hospital
  
• All information concerning the evaluation and
  decisions must be documented

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• Immediate Treatment
• Primary goal is to limit swelling and extent of
  hemorrhaging
• If controlled initially, rehabilitation time will
  be greatly reduced
• Control via RICE
• REST
• ICE
• COMPRESSION
• ELEVATION

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• REST
• Stresses and strains must be removed following
  injury as healing begins immediately
• Days of rest differ according to extent of injury
• Rest should occur 72 hours before rehab begins
• ICE
• Initial treatment of acute injuries
• Used for strains, sprains, contusions, and
  inflammatory conditions
• Ice should be applied initially for 20 minutes
  and then repeated every 1 - 1 1/2 hours and
  should continue for at least the first 72 hours
  of new injury
• Treatment must last at least 20 minutes to
  provide adequate tissue cooling and can be
  continued for several weeks
• For additional information refer to Chapter 15

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• Compression
• Decreases space allowed for swelling to
  accumulate
• Important adjunct to elevation and cryotherapy
  and may be most important component
• A number of means of compression can be utilized
  (Ace wraps, foam cut to fit specific areas for
  focal compression)
• Compression should be maintained daily and
  throughout the night for at least 72 hours (may
  be uncomfortable initially due to pressure
  build-up)
• Elevation
• Reduces internal bleeding due to forces of
  gravity
• Prevents pooling of blood and aids in drainage
• Greater elevation more effective reduction in
  swelling

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• Emergency Splinting
• Should always splint a suspected fracture before
  moving
• Without proper immobilization increased damage
  and hemorrhage can occur (potentially death if
  handled improperly)
• It is a simple process
• New equipment has also been developed
• Rapid form immobilizer
• Styrofoam chips sealed in airtight sleeve
• Moldable with Velcro straps to secure
• Air can be removed to make splint rigid

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• Air splint
• Clear plastic splint inflated with air around
  affected part
• Can be used for splinting but requires practice
• Do not use if it will alter fracture deformity
• Provides moderate pressure and can be x-rayed
  through
• Half-ring splint
• Used for femoral fractures
• Requires extensive practice
• Open fractures must be dressed appropriately to
  avoid contamination
• Splint where athlete lies and avoid moving them
• Splint one joint above and one below fracture

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• Lower Limb Splinting
• Fractures of foot and ankle require splinting of
  foot and knee
• Fractures involving knee, thigh, or hip require
  splinting of whole leg and one side of trunk
• Upper Limb Splinting
• Around shoulder, splinting is difficult but
  doable with sling and swathe with upper limb
  bound to body
• Upper arm and elbow should be splinted with arm
  straight to lessen bone override
• Lower arm and wrist fractures should be splinted
  in position of forearm flexion and supported by
  sling
• Hand and finger fractures/dislocations should be
  splinted with tongue depressors, roller gauze
  and/or aluminum splints

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• Splinting of the spine and pelvis
• Best splinted and moved with a spine board
• Total body rapid form immobilizers have been
  developed for dealing with spinal injuries
• Effectiveness has yet to be determined

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Moving and Transporting Injured Athletes

• Must be executed with techniques that will not
  result in additional injury
• No excuse for poor handling
• Planning is necessary and practice is essential
• Additional equipment may be required

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• Placing Athlete on Spine Board
• EMS should be contacted if this will be required
• Must maintain head and neck in alignment of long
  axis of the body
• One person must be responsible for head and neck
  at all times
• Primary emergency care must be provided to
  maintain breathing, treating for shock and
  maintaining position of athlete
• Permission should be given to transport by
  physician

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• Steps to follow for spine boarding
• Perform primary survey
• Retrieve spine board
• Prone athlete should be log rolled onto back for
  CPR or secured to spine board
• All extremities should be placed in axial
  alignment
• Rolling require 4-5 individuals
• Neck must be maintained in original position as
  roll occurs
• Place spine board close to athlete
• Each assistant is responsible for a segment
• With board close, captain (at head) gives command
  to roll onto board
• Head and neck continue to be stabilized once on
  the board

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• If athlete is a football player, helmet must stay
  in place with face mask removed
• Head and neck are stabilized by strapping
• Trunk and limbs are secured
• If athlete is supine, straddle-slide method can
  be used
• Again requires 4-5 people (captain responsible
  for head and neck, 2 others for trunk and limbs,
  and 4th to slide the board)
• Scoop stretcher can be used, although not always
  considered safe for spinal injuries
• With prone athlete, halves of stretcher are
  placed at each side of prone athlete, and slid
  together until hinges lock, scooping athlete onto
  stretcher
• No log roll necessary

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• Ambulatory Aid
• Support or assistance provided to injured
  individual to walk
• Prior to walking, serious injury should be ruled
  out along with further injury with walking
• Complete and even support should be provided on
  both sides by individuals of equal height when
  providing ambulatory aid
• Arms of athlete are draped over shoulders of
  assistants, with their arms encircling his/her
  back

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• Manual Conveyance
• Used to move mildly injured athlete a greater
  distance than could be walked with ease
• Carrying the athlete can be used following a
  complete examination
• Convenient carry is performed by two assistants
• Stretcher Carrying
• Best and safest mode of transport
• With all segments supported athlete is lifted and
  placed gently on stretcher
• Careful examination is required is stretcher
  needed
• May be necessary if athlete cant be transported
  comfortably in seated position

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• Pool Extraction
• Requires special consideration
• When athlete does not have injuries to head or
  neck, instruct athlete to roll to back and then
  with cross-chest technique, pool athlete to side
  of pool
• If athlete not breathing, single rescuer should
  get athlete out of pool quickly and perform CPR
• With 2 rescuers, resuscitation should begin in
  water immediately
• (One supports head and shoulders, other provides
  rescue breathing)
• Athlete with suspected head or neck injury
  requires special consideration
• Must be approached in the water slowly not to
  disrupt water

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• Head-chin support method should be used
• Forearms stabilize chest and upper back, hands
  used to stabilize head and neck
• Roll athlete to the back and maintain horizontal
  position in water
• Athlete should be secured to spine board in water
  while stabilization is maintained
• Once on board, athlete should be stabilized and
  when removed from the pool, it should occur head
  first

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Proper Fit and Use of Crutch or Cane

• When lower extremity ambulation is contraindicate
  a crutch or cane may be required
• Faulty mechanics or improper fitting can result
  in additional injury or potentially falls
• Fitting athlete
• Athlete should stand with good posture, in flat
  soled shoes
• Crutches should be placed 6 from outer margin of
  shoe and 2 in front

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• Crutch base should fall 1 below anterior fold of
  axilla
• Hand brace should be positioned to place elbow at
  30 degrees of flexion
• Cane measurement should be taken from height of
  greater trochanter
• Walking with Cane or Crutch
• Corresponds to walking
• Tripod method
• Swing through without injured limb making contact
  with ground
• Four- point crutch gait
• Foot and crutch on same side move forward
  simultaneously with weight bearing

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• Cane Tripod technique
• Used on level surface and modified with stair
  climbing
• Unaffected support leg moves up one step while
  body weight is supported on crutch--followed by
  transfer of weight to unaffected leg and affected
  leg is pulled up to step
• Reversed when descending stairs
• Crutch walking follows a progression
• Non-weight bearing (NWB) to touch down weight
  bearing(TDWB) partial (PWB) and full weight
  bearing (FWB)
• When using cane or one crutch, support should be
  held on affected side

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Emergency Emotional Care

• Emergency care relative to emotional reactions to
  trauma must also be provided
• Accept rights to personal feelings, show empathy,
  not pity
• Accept injured persons limitations as real
• Accept own limitations as provider of first aid
• Be empathetic and calm, being obvious that
  athletes feelings are understood and accepted