On-the-Field Acute Care and Emergency Procedures

1. On-the-Field Acute Care and Emergency Procedures

2. 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

3. 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

4. Emergency Action Plan • Separate plans should be developed for each facility • Outline personnel • Athletic trainer • Coaches • Athletic training interns • Administrators • Security

5. 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

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

7. 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)

8. 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 athlete’s life

9. 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

10. 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

11. 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 • Trainer’s Angel • FM Extractor • Pocket mask/barrier mandated by OSHA during CPR to avoid exposure to bloodborne pathogens

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

13. 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)

14. Supine Unconscious Athlete • Athlete is not breathing • ABC’s 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

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

16. 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

17. Establishing Breathing • Look • Listen • Feel • If not breathing initiate CPR

18. Airway Management Tools

19. Establishing Circulation • Locate carotid artery • Palpate pulse while maintaining head tilt position

20. Establishing Circulation • Locate femoral artery in femoral triangle • Palpate pulse

21. 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)

22. 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

23. 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

24. 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

25. Universal Medical PrecautionsBiohazardous Waste Management • Use protective gloves on both hands • Don’t remove gloves until after the wound is bandaged • Protect yourself and the athlete you are treating from infection!

26. 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

27. 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

28. Hemostasis Techniques(Control of Bleeding) • Direct pressure • Firm pressure (hand and sterile gauze) • Placed directly over site of injury against the bone

29. Elevation • Reduces pressure • Gravity facilitates venous and lymphatic drainage

30. Pressure Points • Eleven points • Pressure is applied to slow bleeding

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

32. 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

33. 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

34. Predisposing Conditions for Shock • Extreme fatigue • Exposure to heat or cold • Illness

35. 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

36. 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

37. 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

38. 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

39. Vital Signs • Secondary survey of vital signs • Pulse assessment of heart function • Normal • Adult 60-80 beats per minute • Well conditioned athlete’s may be lower 40-60 bpm • Child’s 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

40. 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

41. 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)

42. Secondary SurveyBlood Pressure Category Systolic Diastolic Optimal <120 <80 Normal <130 <85 High Normal 130-139 85-89 Stage 1 HT 140-159 90-99 Stage 2 HT 160-179 100-109 Stage 3 HT >180 >110 Elevated systolic or diastolic pressure alone is enough to meet the criteria HT = Hypertension or high blood pressure

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

44. 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

45. 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 Secondary SurveySkin Color

46. 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

47. Secondary SurveyPupils • Extremely sensitive to situation impacting nervous system • Most individual’s 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

48. 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

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

50. Secondary Assessment • Assessment • Head • Spine • Trunk • Abdomen • Upper extremities • Lower extremities • History • Observation • Palpation • Special Tests