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

• 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

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

• 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

– 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

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)

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 athlete’s life

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

• 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

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)

– With athlete supine and not breathing, ABC’s 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 ABC’s– If prone and breathing, nothing should be done until

consciousness resumes --then carefully log roll and continue to monitor ABC’s

– Life support should be monitored and maintained until emergency personnel arrive

– Once stabilized, a secondary survey should be performed

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

• 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, Trainer’s Angel, FM Extractor)

– Use of pocket mask/barrier mandated by OSHA during CPR to avoid exposure to bloodborne pathogens

• ABC’s of CPR– A - airway opened– B - breathing restored– C - circulation restored– Generally when A is restored B & C will follow

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

• Modified technique can be used when neck injury is suspected

• Modified jaw thrust maneuver

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

Means of Artificial Respiration

Establishing Circulation

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

• 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

• 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)

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

• 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

• 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

• 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

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

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

• INSERT Oxygen administration photo

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

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

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

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

• 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

– 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

• 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

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 (athlete’s may be slightly lower)• Child’s 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

– 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

• 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

• 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

• 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 individual’s pupils are regularly shaped

• Disparities must be known by the athletic trainer in the event that a condition arises

• 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

– 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 athlete’s 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

– 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

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

• 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

• 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

• 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

– 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

– 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

• 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

– 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

– 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

– 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

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

• 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

• 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

– 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

• 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

• 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 can’t be transported comfortably in seated position

• 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

– 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

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

– 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

– 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

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 person’s limitations as real– Accept own limitations as provider of first aid– Be empathetic and calm, being obvious that

athlete’s feelings are understood and accepted