On-the-Field Acute Care and Emergency Procedures

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On-the-Field Acute Care and Emergency Procedures
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• Most injuries are not life-threatening, but do
  require prompt care
• Emergencies require immediate attention
• Time is a critical factor
• Mistakes in initial injury management can
• Prolong the length of time for rehabilitation
• Cause life-threatening complications
• Permanent disability

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Emergency Action Plan

• Primary concern
• Cardiovascular function
• CNS function
• Key to emergency aid
• Initial evaluation of the injured athlete
• Prearranged plan that can be implemented on a
  moments notice
• The sports medicine team must at all times act
  reasonably and prudently

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Emergency Action Plan

• Separate plans should be developed for each
  facility
• Outline personnel
• Athletic trainer
• Coaches
• Athletic training interns
• Administrators
• Security

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Emergency Action Plan

• Roles for personnel
• Contacting EMS
• Provide EMS with the following information
• Type of emergency
• Location of emergency
• Suspected injury
• Present condition of injured athlete
• Current medical care being provided
• Location of phone being used
• Hang up last!!!
• Opening of gates and facility access
• Going to hospital with athlete
• Parental notification
• Health insurance notification
• Press releases

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• Identify necessary equipment
• Spine board/stretchers
• Splints
• Airway management/oxygen
• Tools for equipment or helmet removal
• Policies and procedures for helmet or equipment
  removal

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Cooperation between Emergency Care Providers

• Cooperation and professionalism
• Certified 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
• All individuals involved in plan should practice
  to familiarize themselves with all procedures
  (including equipment management)

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Parental Notification

• ATC should try to obtain consent from parent
  prior to emergency treatment for athletes who are
  minors
• 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

• Establish presence of life-threatening
  condition/injury
• Injuries requiring cardiopulmonary resuscitation
• Evaluate to determine need
• Should be certified
• American Heart Association
• American Red Cross
• National Safety Council
• Airway
• Breathing
• Circulation
• Injuries with severe profuse bleeding
• Shock
• Used to correct life-threatening conditions

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Primary Survey

• Establish Unresponsiveness
• Gently shake and ask athlete Are you okay?
• If no response
• EMS should be activated
• Positioning of body should be noted
• Adjust position of body in the event CPR is
  necessary
• Equipment Considerations
• Equipment may compromise lifesaving efforts
• Removal of equipment may compromised situation
  further
• Facemask should be removed with appropriate loop
  strap cutters
• Anvil Pruner
• Trainers Angel
• FM Extractor
• Pocket mask/barrier mandated by OSHA during CPR
  to avoid exposure to bloodborne pathogens

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Secondary Survey

• Life-threatening condition ruled out
• Gather specific information about injury
• Assess vital signs
• Perform more detailed evaluation
• Non life-threatening injuries/conditions

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Unconscious Athlete

• Must be considered to have life-threatening
  condition
• Note body position
• Establish 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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Supine Unconscious Athlete

• Athlete is not breathing
• ABCs should be established immediately
• Athlete is breathing, nothing should be done
  until consciousness resumes
• Life support
• monitored and maintained until EMS arrives
• Once stabilized, a secondary survey should be
  performed

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Prone Unconscious Athlete

• Athlete is not breathing
• Log roll
• Establish ABCs
• Athlete is breathing
• Nothing should be done until consciousness
  resumes
• After consciousness returns
• Carefully log roll
• Continue to monitor ABCs
• Life support should be monitored and maintained
  until EMS arrives
• Once stabilized, a secondary survey should be
  performed

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Opening the Airway

• Head-tilt, chin lift method
• Push down on the forehead
• Lifting the jaw
• Moves tongue away from the back of the throat

• Modified jaw thrust
• Use with suspected neck injury

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Establishing Breathing

• Look
• Listen
• Feel
• If not breathing initiate CPR

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Airway Management Tools
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Establishing Circulation

• Locate carotid artery
• Palpate pulse while maintaining head tilt
  position

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Establishing Circulation

• Locate femoral artery in femoral triangle
• Palpate pulse

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Anatomical Landmarks forChest Compressions

• If no pulse initiate chest compressions
• 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
• Causes of chocking in athletics
• Mouth pieces
• Broken dental work
• Tongue injury
• Gum
• Blood clots from head and facial trauma
• Vomit
• Obstructed individual
• Cannot breath, speak, or cough
• May become cyanotic
• Perform appropriate measures for choking

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Automatic External Defibrillators (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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Supplemental Oxygen

• May 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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Universal Medical Precautions Biohazardous Waste
Management

• Use protective gloves on both hands
• Dont remove gloves until after the wound is
  bandaged
• Protect yourself and the athlete you are treating
  from infection!

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Glove Removal

• Clean to clean
• Dirty to dirty

• Grab left glove in middle of left palm by right
  gloved hand
• Pull left glove off
• Hold left glove in middle of right palm
• Use one finger of left (ungloved hand) to pull
  right glove inside out over left glove
• Place both gloves in biohazard container
• Wash or disinfect hands

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Control of Hemorrhage

• Abnormal loss of blood
• 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
• Reduce risk of bloodborne pathogens exposure

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Hemostasis Techniques(Control of Bleeding)

• Direct pressure
• Firm pressure (hand and sterile gauze)
• Placed directly over site of injury against the
  bone

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Elevation

• Reduces pressure
• Gravity facilitates venous and lymphatic drainage
  

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Pressure Points

• Eleven points
• Pressure is applied to slow bleeding

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Cryotherapy

• Ice Application
• Constricts blood vessels
• Slows blood flow to tissues
• Reduces metabolic needs of tissues (oxygen)
• Prevents secondary tissue death

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Internal Hemorrhage

• Invisible unless
• manifested through body opening
• X-ray or other diagnostic techniques
• Non life threatening internal hemorrhage
• Beneath skin (bruise) or contusion
• Intramuscular
• In joints
• Life threatening hemorrhage
• Bleeding within body cavity
• Difficult to detect
• Must be hospitalized for treatment
• Could lead to shock if not treated accordingly

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Shock

• Generally occurs with
• Severe bleeding
• Severe fluid loss from
• Vomiting
• Diarrhea
• Dehydration
• Fractures
• Internal injuries
• Decrease in blood available in circulatory system
• Vascular system loses capacity to maintain fluid
  portion of blood
• Due to vessel dilation
• Disruption of osmotic balance
• Movement of blood cells slows
• Decreasing oxygen transport to the body

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Predisposing Conditions for Shock

• Extreme fatigue
• Exposure to heat or cold
• Illness

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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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Types of Shock

• 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

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Signs and Symptoms of Shock

• Wet, White,Weak
• Diaphoretic
• Moist clammy skin (excess sweating)
• Pale (decreased blood flow to skin
• Cold (from loss of blood flow
• Vital Signs
• Weak rapid pulse
• Increasing shallow respiration
• Decreased blood pressure
• Systolic below 90mm Hg
• Diaphoretic
• Urinary retention and fecal incontinence
• Irritability or excitement,
• Possibly thirsty

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Management of Shock

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

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Vital Signs

• Secondary survey of vital signs
• Pulse assessment of heart function
• Normal
• Adult 60-80 beats per minute
• Well conditioned athletes may be lower 40-60 bpm
• Childs pulse 80-100 bpm
• Rapid and weak pulse could indicate
• Shock
• Bleeding
• Diabetic coma
• Heat exhaustion
• Rapid and strong could indicate
• Heatstroke
• Fright
• Strong and slow indicates
• Skull fracture
• Stroke
• No pulse cardiac arrest or death

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Secondary SurveyRespiration

• Normal Respiration
• Adult 12 breaths per minute
• Child 20-25 breaths per minute
• Abnormal Respiration
• Shallow - shock
• Irregular or gasping - cardiac compromise
• Frothy w/ blood - chest injury

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Secondary SurveyBlood Pressure

• Systolic blood pressure is created by ventricle
  contraction
• Diastolic pressure is residual pressure
• Measured w/ s sphygmomanometer (blood pressure
  cuff)
• Inflate cuff (up to 200 mm Hg)
• Above antecubital fossa (crease at elbow)
• Slowly deflate cuff
• Listen with stethoscope for
• First beating sound (systolic)
• Final sound (diastolic)
• Kartokoff sounds (soft sounds)

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Secondary SurveyBlood Pressure

• Category Systolic Diastolic
• Optimal lt120 lt80
• Normal lt130 lt85
• High Normal 130-139 85-89
• Stage 1 HT 140-159 90-99
• Stage 2 HT 160-179 100-109
• Stage 3 HT gt180 gt110
• Elevated systolic or diastolic pressure alone is
  enough to meet the criteria
• HT Hypertension or high blood pressure

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Secondary SurveyTemperature

• Normal is 98.6 o F
• Measure with thermometer
• Oral
• Axillary
• Tympanic membrane
• Rectal
• Core temperature is best measured rectally
• Skin temperature

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Secondary SurveyTemperature

• Temperature changes can be the result of
• Disease or infection
• Cold of heat exposure
• Loss of body fluids
• Pain, fear, nervousness
• Signs and symptoms of lowered temperature are
• Chills
• Teeth chattering
• Blue lips
• Goose bumps
• Pale skin

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Secondary SurveySkin Color

• Can be an indicator of health
• Red
• Elevated temperature
• Heat stroke
• High blood pressure
• Blue (cyanotic)
• Airway obstruction
• Respiratory insufficiency
• Poor circulation

• White
• Insufficient circulation
• Shock
• Fright
• Hemorrhage
• Heat exhaustion
• Insulin shock

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Secondary SurveySkin Color

• Dark pigmented skin is slightly different in
  response
• Nail beds, and inside lips and mouth and tongue
  will be pinkish
• Shock,
• Skin around mouth and nose will have grayish cast
• Mouth and tongue will be bluish
• Hemorrhaging
• Mouth and tongue will become gray
• Fever is indicated by red flush tips of ears

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Secondary SurveyPupils

• Extremely sensitive to situation impacting
  nervous system
• Most individuals pupils are regularly shaped
• Abnormal pupil size must be known by the health
  care provider
• Pre participation exams
• Constricted pupils may indicate
• depressant drug
• Muscle injury to eye
• Dilated pupils may indicate
• Head injury
• Shock
• Use of stimulants
• Failure to accommodate may indicate
• Brain injury
• Alcohol
• Drug poisoning
• Pupil response is more important than size

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Secondary SurveyState of Consciousness

• Must always be assessed
• Alertness
• Awareness of environment,
• Response relative to vocal stimulation
• Glascow Coma Scale
• Conditions altering level of consciousness
• Head injury
• Heat stroke
• Diabetic coma

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Musculoskeletal Assessment

• Use logical process to adequately evaluate extent
  of trauma
• Critical knowledge
• Anatomy/kinesiology
• Mechanisms of injury
• Major signs and symptoms

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Secondary Assessment

• Assessment
• Head
• Spine
• Trunk
• Abdomen
• Upper extremities
• Lower extremities

• History
• Observation
• Palpation
• Special Tests

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Injury Assessment Medical History
HistoryOPS
Describe the events of the injury and those
leading up to it Past Medical History and Present
History of Injury Alphabet of assessment
Questions M Mechanism of injury, medications,
meals N Name of patient, name of examiner O
Old injuries to same side or opposite side,
Onset P Point tenderness, provocative,
palliative Q Quantity, Quality R Region of
pain, referred pain S Sounds or sensations
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Mechanism of Injury
How Did The Injury Happen?
What position was the joint in?
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MMedications

• Did the athlete take any medication today
• For current injury?
• For other injuries?
• For medical conditions?
• Is the athlete taking any supplements
• Is the athlete allergic to any medications?

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M
Meals
When was the last time the athlete ate any
food? Is the athlete adequately hydrated? Is the
athlete eating a good balanced diet?
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N
Names
Dont forget to put athletes name on injury
report! Dont forget to introduce yourself to the
athlete
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O Onset (When did the injury occur?)

• Acute
• Chronic
• Chronic/Acute
• Pain?
• Swelling
• How fast?

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OOld Injuries
Did the athlete ever have a similar injury to the
same body part? Opposite (injuries to the
contralateral side?) If yes, how severe and
when did they occur? Did the athlete go to to an
MD for the injury? Did the athlete go through a
formal rehabilitation program?
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Injury Assessment P
Provocative What makes your injury get/feel worse
Palliative What makes your injury get/feel
better?
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Injury Assessment P Point Tenderness

• Where is the pain?
• Have the athlete point with one finger where they
  feel the most pain.
• Does the athlete have point tenderness (pain in
  one localized area)?

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• Q
• Quantity (0-10 scale)
• Quality (describe the pain)
• Throbbing
• Stabbing
• Aching
• Other
• R
• Region (Where is the pain?)
• Point tenderness
• Diffuse pain
• Referred pain

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S Sounds or Sensations
Did the athlete feel or hear any sounds or
sensations?
Pops, Snaps, Crepitus (Grinding), Giving Way or
Tearing
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Injury Assessment Observation of Injuries
Discoloration
Swelling
H Observation P S
Deformity
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Palpation of Anatomical Structures
H O Palpation S
What structures are painful to palpation
(touch)? Palpate the area to help determine
nature and extent of injury Start away from site
of injury Start with gentle pressure, gradually
pressing harder until you reach a boney stop Do
you feel any Deformities (not apparent
visually)? Lumps, bumps, swelling or
defects? Changes in skin temperature or
texture?
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Special Tests
H O P Special Tests
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Injury Assessment Range of Motion and
Flexibility Assessment
Did the injury cause any loss on flexibility or
range of motion?
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Injury Assessment Strength Assessment
Did the injury cause a loss in muscle strength?
Machine Testing Isokinetic Testing
Manual Muscle Testing
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Manual Muscle Testing Grading Strength
Grade Against Gravity Full Rom
Added Resistance Amount of Strength 5/5
Yes Yes Yes /gt than other
side 4/5 Yes Yes Yes lt
than other side 3/5 Yes Yes
No lt than other side 2/5 No
Yes No lt than other side 1/5
No No No palpable contraction 0/5
No No No no palpable
contraction
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Injury Assessment Stress Tests
Grading Laxity 0 no laxity 1 0 - 5 mm 2
5 -10 mm 3 gt 10 mm
Assessment of Joint Stability for Ligamentous
Laxity Are the ligaments or the joint capsule
torn?
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Balance Proprioception Assessment
Did the athlete suffer a loss of proprioception
or balance from their injury?
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Cardiovascular Assessment

• Blood pressure
• Resting Heart Rate (RHR)
• Respiration
• Auscultation
• Heart Sounds
• Lung Sounds

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Neurological Assessment
Central Nervous System Peripheral Nervous System
What day is it?
Brain Function Motor Function Sensation Reflexes
Whats the score of the game? Do you know where
you are?
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Assessment Decisions

• Determine
• Seriousness of injury (What is the return to play
  status of athlete?)
• Type of first aid and immobilization required
• Need for medical referral
• 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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Return to Play Status

• Status
• Can continue with no restrictions
• Can continue with additional support or
  protection
• Cant continue.
• Doesnt need to see MD
• Needs to be referred to MD in next few days
• Needs immediate referral to MD
• Can transport self to MD
• Needs to be transported (not by EMS) to MD
• Needs to be transported by EMS to emergency room

• When is it okay for an injured athlete to play?
• What can you do to help the athlete achieve this
  goal?
• When should you refer the injured athlete to a
  medical doctor?