Ohio Department of Education Pupil Activity Supervisor Permit Program SPORTS MEDICINE EMERGENCIES & OTHER HEALTH C

1. Ohio Department of Education Pupil Activity Supervisor Permit ProgramSPORTS MEDICINE EMERGENCIES & OTHER HEALTH CONCERNS Summa Center for Sports Health Tom Bartsokas, MD, MS, FACSM Streetsboro, St. Thomas Hospital, Hudson Offices 1-330-379-5051

2. OBJECTIVES 1) Discuss life-threatening emergencies: • Sudden cardiac arrest • Respiratory problems • Anaphylactic reactions to insect stings • Exertional sickling in athletes with sickle cell trait 2) Provide an update on concussions in sports 3) Outline “top 3” recommendations for: • Diabetes (type 1 or insulin-dependent diabetes) • Infectious diseases

3. LIFE-THREATENING EMERGENCIES APPROACH TO THE DOWNED ATHLETE: PERFORMING THE PRIMARY SURVEY 1) Establish responsiveness. 2) Check Airway, Breathing, and Circulation. 3) Activate EMS if any abnormalities noted.

4. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST CPR REVIEW • Attempt to wake victim. • Assess breathing: • Look for chest movement. • Listen for air flowing through the mouth or nose. • Feel for air on your cheek. • If no breathing, attempt 2 rescue breaths. • If 1st rescue breath unsuccessful → • Open airway by using head tilt or jaw thrust. • In cases of neck injury, use ONLY jaw thrust!

5. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST CPR REVIEW (continued) 4) Check circulation bycarotid pulse (while assessing breathing). 5) Even if unsuccessful in opening airway, if victim has no pulse → begin chest compressions. 6) Compress the chest 1½-2 inches, allow the chest to completely recoil before the next compression, and compress at a rate equal to 100/minute.

6. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST CPR REVIEW (continued) 7) Perform 30 compressions, then 2 rescue breaths → return to chest compressions. 8) After 2 minutes of chest compressions and rescue breaths → stop CPR and recheck for breathing and pulse. No pulse, resume CPR until victim recovers or help arrives. 9) If you have access to AED, use it!

7. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST RATIONALE FOR EARLY USE OF AED & CPR • Nationwide survival rate from SCA is about 5%. • In communities where shocks from an AED and CPR are provided within 3-5 minutes → survival rates are as high as 48-74%.(AHA, 2003)

8. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST • Primary causes of SCA <35 years → mainly congenital abnormalities. • “Most sudden cardiac deaths in the young occur during or immediately following school sports, and nearly 90% occur in the presence of a teacher or coach.” Charles Berul, MD (Pediatric Cardiologist Children’s Hospital Boston) • Good news: These conditions are rare. Incidence of fatal collapse →1 in every 300,000 high school and college athletes.

9. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST Most Common Causes of SCA in Youth • HYPERTROPHIC CARDIOMYOPATHY (33-50%) • CORONARY ARTERY ANOMALIES (15-35%) • OTHER CARDIOMYOPATHIES (10-20%) • PRIMARY ELECTRICAL DISEASES: • Long QT Syndrome (15-25%) • Primary Ventricular Fibrillation (10-15%) • Wolff-Parkinson-White Syndrome (3-5%) • MYOCARDITIS (5%) • AORTIC RUPTURE IN MARFAN’S SYNDROME (5%) • COMMOTIO CORDIS

10. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST MYOCARDITIS • Accounts for 5% of sudden, out-of-hospital cardiac deaths in youth1. • When present, symptoms are not specific2. • A “bad cold” is suggested in most cases. • Diagnosis often missed  heart is grossly normal2. • Key to prevention is to remember “neck check” when advising athletes about exercising when ill3. 1Lecomte D, Fornes P, Fouret P, et al. Isolated myocardial fibrosis as a cause of sudden cardiac death and its possible relation to myocarditis. Journal of Forensic Science. 1993; 38: 617-621. 2Fontaine G, Fornes P, Fontaliran F. Myocarditis as a cause of sudden death. Circulation. 2001; 103: e12. 3Eichner ER. Infection, immunity and exercise: what should we tell patients? The Physician and Sportsmedicine. 1993; 21(1): 125-135.

11. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST PREVENTING SCA DUE TO MYOCARDITIS: USING THE “NECK CHECK” 1) OK to exercise as long as no: • Fever (resting oral temperature over 100° F) • Generalized body aches or muscle soreness • Severe sore throat • Deep, productive cough • Shortness of breath or wheezing 2) Probably OK to recommend exercise with nasal congestion, mild pharyngitis, and dry cough.

12. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST COMMOTIO CORDIS This condition is caused by blunt force precordial trauma during vulnerable period in cardiac cycle (ventricular repolarization), which leads to ventricular fibrillation. P wave → depolarization of atria QRS → depolarization of ventricles T wave → repolarization of ventricles

13. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST COMMOTIO CORDIS • Overall survival rate is only 15%. • Since 1995, 188 athleteshave died from blunt force injury to chest/heart. • Mean age → 14.7 years. • 96% were males. • Youth at risk due to smaller chest muscle mass. • Cases have occurred during baseball, softball, hockey, football, and martial arts.

14. LIFE-THREATENING EMERGENCIES: SUDDEN CARDIAC ARREST PREVENTIVE MEASURES RELATED TO COMMOTIO CORDIS • Encourage placement of AED units at athletic facilities. • Educate coaches and officials of the need for immediate CPR and AED care. The longer the delay, the greater the likelihood that death may occur. • Ensure all athletic protective equipment fits properly and is used as intended by the manufacturer. • Teach athletes to protect themselves and to avoid being hit in the chest by projectiles such as baseballs, lacrosse balls, and hockey pucks. Do not have athletes step in front of a shot to block it.

15. REFERENCES ON SUDDEN CARDIAC ARREST SUDDEN CARDIAC ARREST http://www.nata.org/statements/consensus/SCA_ statement.pdf AED USE IN SCHOOLS http://www.nata.org/statements/official/AEDofficial statement.pdf COMMOTIO CORDIS http://www.nata.org/statements/official/ASTFstmt Commotio CordisRevised091107(2).pdf

16. LIFE-THREATENING EMERGENCIES: RESPIRATORY PROBLEMS SOFT TISSUE INJURIES TO THE NECK September 2009 University of Southern California running back Stafon Johnson was doing a set of bench presses with 275 pounds, when the weight slipped out of his right hand and the bar fell onto his throat. He subsequently underwent 7 hours of surgery to repair a fractured larynx. This injury occurred at an elite, Division I athletic program, while being spotted by a strength & conditioning coach, by an experienced athlete (senior). If this accident could happen at USC…

17. LIFE-THREATENING EMERGENCIES: RESPIRATORY PROBLEMS SOFT TISSUE INJURIES TO THE NECK • Blunt trauma to the front of the neck can injure the larynx and/or trachea, resulting in acute airway obstruction. • Symptoms: • Shortness of breath • Coughing • Pain in the throat • Difficulty speaking and swallowing • Apprehension • If faced with a similar injury (or suspicion of such an injury), notify EMS immediately.

18. LIFE-THREATENING EMERGENCIES: RESPIRATORY PROBLEMS ASTHMA • Definition: Chronic inflammatory disorder of the airways characterized by variable airway obstruction and bronchial hyper-responsiveness.

19. LIFE-THREATENING EMERGENCIES: RESPIRATORY PROBLEMS SIGNS OF RESPIRATORY DISTRESS FROM ASTHMA • Significant increase in wheezing • Chest tightness • Respiratory rate >25 breaths/minute • Inability to speak in full sentences • Uncontrolled cough • Significantly prolonged expirations • Nasal flaring • Paradoxic abdominal movement When these are present → rapid referral to ER. [Miller et al., 2005]

20. LIFE-THREATENING EMERGENCIES: RESPIRATORY PROBLEMS NONPHARMACOLOGIC TREATMENT OF ASTHMA • Increase physical conditioning. • Warm-up for ~10 minutes before hard exercise commences (may lead to a refractory period of as long as 2 hours). • Cover mouth/nose with scarf or mask during cold weather. • Exercise in warm, humidified environment—if possible. • Gradually lower exercise intensity before stopping. • Wait at least 2 hours after meal before exercising (to avoid GE reflux, which exacerbates asthma). [Miller et al., 2005]

21. LIFE-THREATENING EMERGENCIES: RESPIRATORY PROBLEMS EXERCISE-INDUCED ASTHMA: DIAGNOSTIC CRITERIA • Symptoms 5-8 minutes after intense exercise starts: • Dyspnea • Coughing • Chest tightness (or chest pain in children) • Wheezing • Decreased exercise tolerance • Drop in FEV1 of 10-15% after 6-8 minutes of exercise at 80% (or more) of maximum heart rateand methacholinechallenge test.

22. EXERCISE-INDUCED ASTHMA

23. REFERENCES ON RESPIRATORY PROBLEMS Miller MG, Weiler JM, Baker R, Collins J, D’Alonzo. National Athletic Trainers’ Association Position Statement: Management of Asthma in Athletes. Journal of Athletic Training. 2005; 40(3): 224-245. Sinha T, David AK. Recognition and management of exercise-induced bronchospasm. American Family Physician. 2003; 67: 769-774, 776. http://www.nata.org/statements/position/asthma.pdf

24. LIFE-THREATENING EMERGENCIES: INSECT STING-INDUCED REACTIONS • Non-allergic symptoms from an insect sting: • Redness • Swelling • Itching at the site of the sting • Symptoms of a true allergic reaction: • Generalized itching and hives • Swelling in the throat or tongue • Difficulty breathing • Dizziness • Stomach cramps/nausea/diarrhea

25. LIFE-THREATENING EMERGENCIES: INSECT STING-INDUCED REACTIONS INSECT STING-INDUCED ANAPHYLAXIS • Anaphylaxis is a life-threatening medical emergency & should prompt activation of EMS. • Once stung: Remain calm → remove stinger → use injectable epinephrine (EPI pen). • Go to emergency room immediately! (Epinephrine is a rescue drug & should not be used as definitive treatment without follow-up medical attention.)

26. LIFE-THREATENING EMERGENCIES: SICKLING CRISIS IN SCT • Incidence: • Sickle cell trait prevalence is highest in West Africa, where it affects 25% of the population. • SCT is found in ~8% of African-Americans in the US. In US alone, 2.5 million African-Americans have SCT. • SCT also appears in Mediterranean countries (e.g. Italy, Greece, and Spain), Arabia, the Caribbean, India, and South/Central America. • SCT confers some resistance to malaria parasitization of red blood cells, so that individuals with SCT have a selective advantage in some environments. (SCT does not completely protect a person from infection, but it makes death from malaria less likely.)

27. LIFE-THREATENING EMERGENCIES: SICKLING CRISIS IN SCT • Pathophysiology: • In SCT, strenuous exercise evokes four forces that foster sickling: • Severe hypoxemia, • Metabolic acidosis, • Hyperthermia in muscles, and • Red blood cell dehydration. • When these forces exist → RBC’s become rigid, change to a sickle shape, accumulate in the blood, and obstruct blood flow.

28. LIFE-THREATENING EMERGENCIES: SICKLING CRISIS IN SCT • Pathophysiology (continued): • Further complicating this picture is the fact that muscle breakdown associated with vigorous exertion → ↑ release of myoglobin (which damages renal function) and potassium (which causes cardiac arrhythmias). • Internal organ failure and death may ensue. • From 2000-2007, nine athletes (ages 12-19) died in US as result of exertional sickling.

29. LIFE-THREATENING EMERGENCIES: SICKLING CRISIS IN SCT SICKLING COLLAPSE: MAKING THE DIAGNOSIS • Sickling collapse may be mistaken for cardiac collapse and heat illness collapse. • Unlike sickling collapse, cardiac collapse tends to be instantaneous, has no cramping associated with it, and the athlete stricken with ventricular fibrillation no longer talks after hitting the ground. • Unlike heat illness collapse, sickling collapse often occurs within the first half hour on-field during initial windsprints and core temperature is not greatly elevated.

30. LIFE-THREATENING EMERGENCIES: SICKLING CRISIS IN SCT SICKLING COLLAPSE: MAKING THE DIAGNOSIS • Heat cramping often has a prodrome of muscle twinges, whereas sickling has none. • The pain is different in intensity, with the pain from heat cramping being more excruciating. • What stops the athlete is different, with heat crampers hobbling to a halt with “locked-up” muscles and sickling victims slumping to the ground with weak muscles.

31. LIFE-THREATENING EMERGENCIES: SICKLING CRISIS IN SCT NATA CONSENSUS ON PRECAUTIONS & TREATMENT • Build up slowly in training with paced progressions, allowing longer periods of rest and recovery between repetitions. • Encourage participation in preseason strength and conditioning programs to enhance the preparedness of athletes for performance testing.Athletes with sickle cell trait should be excluded from participation in performance tests such as mile runs, serial sprints, etc. (Several deaths have occurred in this setting.) • Stop activity with onset of symptoms such asmuscle cramping, muscle pain, extremity swelling, weakness, and inability to “catch breath” due to fatigue.

32. LIFE-THREATENING EMERGENCIES: SICKLING CRISIS IN SCT NATA CONSENSUS ON PRECAUTIONS & TREATMENT • Allow sickle cell trait athletes to set their own pace. • Athletes should participate in a year-round, strength and conditioning program consistent with individual needs, goals, abilities, and sport-specific demands. • Athletes with sickle cell trait performing repetitive high speed sprintsand/or interval training should be allowed extended recovery between repetitions, since this type of conditioning poses special risk.

33. LIFE-THREATENING EMERGENCIES: SICKLING CRISIS IN SCT NATA CONSENSUS ON PRECAUTIONS & TREATMENT 7)Ambient heat stress, dehydration, asthma, illness, and altitude predispose athletes with SCT to onset of crisis in physical exertion. • Adjust work/rest cycles to environmental heat stress. • Emphasize hydration. • Control asthma. • Do not allow exercise if athlete with SCT is ill. • Watch athletes with SCT closely when new to altitude training. • Modify training and have supplemental oxygen available for competitions at altitude.

34. LIFE-THREATENING EMERGENCIES: SICKLING CRISIS IN SCT NATA CONSENSUS ON PRECAUTIONS & TREATMENT • Create an environment that encourages athletes with SCT to report any symptoms immediately, such as fatigue, dyspnea, leg/low back pain or cramping. • When extreme symptoms occur → assume sickling crisis and alert 911. • Initial treatments: • Fluids (Oral first, IV if available) • Supplemental oxygen (If available) NATA Consensus Statement: Sickle Cell Trait and the Athlete. June 2007. http://www.nata.org/statements/consensus/sicklecell.pdf

35. CONCUSSIONS IN SPORTS:UPDATE • Discuss the origin of current recommendations (Concussion in Sport Group). • Present consensus opinion of the CISG. • Describe neuropsychologic testing and its value in evaluating & managing concussions. • Outline how to evaluate mild traumatic brain injuries related to sports participation.

36. Establishing an International Treatment Guide for Sports Concussions • 1st International Conference on Concussion inSport Vienna, Austria, Nov. 2001 • 2nd International Conference on Concussion inSport Prague, Czech Republic, Nov. 2004 • 3rd International Conference on Concussion in Sport Zurich, Switzerland, Nov. 2008 Organizing Sports Bodies: Federation Internationale de Football International Ice Hockey Federation International Olympic Committee (International Rugby Board, 3rd Conference only)

37. Establishing an International Treatment Guide for Sports Concussions Summary of Recommendations: “When a player has signs/symptoms of concussion, 1) Player should not be allowed to return to play in the current game or practice.” 2) Player should not be left alone, and regular monitoring for deterioration is essential.” 3) Player should be medically evaluated following an injury.” 4) Return to play must follow a medically supervised, stepwise process.” 5) Neuropsychological (NP) testing was identified as “one of the cornerstones of concussion evaluation.”

38. NEUROPSYCHOLOGIC TESTING: ImPACT™ ImPACT™was first computerized testing system to evaluate concussion severity. ImPACT™is useful screening tool for athletes with history of concussionsneeding pre-participation clearance. ImPACT™is useful management tool forathletes who sustain a concussionduring season to establish safe time for return to play.

39. CONCUSSIONS IN SPORTS: Sideline Evaluation Rule #1 • A force strong enough to cause loss of consciousness may also be strong enough to damage the cervical spine. • Every traumatic event resulting in an unconscious athlete → assume cervical spine injury, until proven otherwise.

40. Loss of consciousness Seizure or convulsion Amnesia Headache “Pressure in head” Neck Pain Nausea or vomiting Dizziness Blurred vision Balance problems Sensitivity to light Sensitivity to noise Feeling slowed down Feeling like “in a fog” “Don’t feel right” Difficulty concentrating Difficulty remembering Fatigue or low energy Confusion Drowsiness More emotional Irritability Sadness Nervous or Anxious CONCUSSIONS IN SPORTS: Sideline Evaluation of Signs & Symptoms

41. CONCUSSIONS IN SPORTS:Sideline Tests of Memory Function Failure to answer all questions correctly may suggest a concussion. • At what venue are we today? • Which half is it now? • Who scored last in this game? • What team did you play last? • Did your team win the last game?

42. CONCUSSIONS IN SPORTS:Sideline Balance Testing Instructions for Tandem Stance Test • Stand heel-to-toe with your non-dominant foot in back. • Weight should be evenly distributed across both feet. • Maintain stability for 20 sec. with hands on hips/eyes closed. • I will be counting number of times you move out of position. • If you stumble out of position, open your eyes and return to the start position and continue balancing. • Testing starts when you are set and have closed your eyes. Observe athlete for 20 seconds. If >5 errors (e.g. lifting hands off hips, opening eyes, lifting forefoot or heel, take a step/stumble/fall or remain out of start position >5 seconds) this may suggest a concussion.

43. CONCUSSIONS IN SPORTS:Patient Instructions after Acute Injury SIGNS THAT SHOULD LEAD TO ER VISIT: • Headache gets worse with time • Profound drowsiness/can’t be awakened • Unable to recognize people or places • Repeated vomiting (more than 2x) • Behaves unusually, seems confused, gets irritable • Seizures or seizure-like activity • Weakness or numbness in arms or legs • Unsteady on feet • Slurred speech

44. CONCUSSIONS IN SPORTS: Post-Concussion Patient Advice Consult a doctor after having a concussion. OTHER IMPORTANT RECOMMENDATIONS: • Rest and avoid strenuous activity for at least 24 hours. • No alcohol • No sleeping tablets • Use acetaminophen or codeine for headache. • Do not use aspirin or anti-inflammatory drugs. • Do not drive until medically cleared. • Do not train or play sports until medically cleared. • Once symptoms have cleared and ImPACT™ normalizes, Return-to-Play protocol is initiated.

45. CONCUSSIONS IN SPORTS:Graduated Return-to-Play Protocol

46. CONCUSSIONS IN SPORTS:A FEW WORDS ABOUT PREVENTION • The key to prevention is NOT invention of a better helmet. • Difference maker is going to be acceptance of the fact that this serious issue must be addressed by administrators, coaches, AT’s, MD’s, parents, and athletes. • Strict adherence to and enforce- ment of existing rules is the next step. • Widespread application of the recommendations of the CISG is the final measure to minimize risk.

47. REFERENCES ON SPORTS CONCUSSIONS http://www.cdc.gov/NCIPC/tbi/Coaches_Tool_Kit.htm Order: Free information for coaches, parents and athletes http://www.cdc.gov/concussion/HeadsUp/youth.html Download: Fact sheets for coaches, parents and athletes http://www.impacttest.com/ News/Media: PBS The News Hour with Jim Lehrer ESPN Video Clip on Second Impact Syndrome All recent news stories on sports concussions www.neurosurgery.net.au/SCAT2.html See: SCAT2 cards Pocket SCAT2 cards

48. REFERENCES ON SPORTS CONCUSSIONS http://www.amssm.org/Publications.html See: American Medical Society for Sports Medicine’s list of position statements, including information on concussions in sports http://www.nata.org/statements/position/concussion.pdf See: National Athletic Trainers’ Association 2004 stand http://www.klokavskade.no/en/ See: Oslo Sports Trauma Research Center, type “concussion” and hit “search button” http://concussion.orcasinc.com/ See: 20-minute program designed to educate coaches about recognizing & managing sports concussions

49. TYPE 1 DIABETES MELLITUS:TOP 3 THINGS YOU NEED TO KNOW • Hypoglycemia is themost severe complication of intensive insulin therapy in diabetes. Symptoms of hypoglycemia: • Tachycardia • Sweating • Palpitations • Hunger • Nervousness, trembling, and dizziness • Headache Most symptoms occur when serum glucose falls below <70mg/dL, but symptoms of hypoglycemia can be unique to diabetics.As glucose continues to fall, symptoms may include:blurred vision, fatigue, difficulty thinking, loss of motor control, aggressive behavior, seizures, and loss of consciousness. Change in mentation merits activation of EMS by calling 911!

50. TYPE 1 DIABETES MELLITUS:TOP 3 THINGS YOU NEED TO KNOW • Guidelines for treatinghypoglycemia (as long as the athlete is conscious, able to follow directions, and able to swallow): • Administer 10-15 g of fast-acting carbohydrate (e.g. 4-8 glucose tabs or 2 tbsp of honey) and measure [glucose]. • Wait ~15 min. and re-measure [glucose]; if it remains low → administer another 10-15 g of fast-acting CHO. • Recheck [glucose] in ~15 minutes; if it does not return to normal range after second dose of CHO →activate EMS. • Once [glucose] is in normal range, have athlete consume a snack (e.g. sandwich or bagel).