Ohio Dept. of Ed. P.A.S.P. Program: SPORTS MEDICINE EMERGENCIES & OTHER HEALTH CONCERNS

Ohio Dept. of Ed. P.A.S.P. Program:SPORTS MEDICINE EMERGENCIES & OTHER HEALTH CONCERNS Summa Center for Sports Health Tom Bartsokas, MD, MS, FACSM 9318 State Route 14 5655 Hudson Drive Streetsboro, OH 44241 Suite 200 (330) 422-7820 Hudson, OH 44236 iambartmd@gmail.com

OUTLINE OF PRESENTATION Life-threatening injuries/conditions: 1. Airway obstruction 2. Cardiac arrest 3. Respiratory failure (from EIB/Asthma) 4. Exertional sickling in sickle cell trait 5. Concussions 6. Cervical spine injuries 7. Bee sting allergies & anaphylaxis Other health concerns impacting sports: 8. Diabetes 9. Communicable & infectious diseases

Why address cardiac emergenciesat a P.A.S.P. session? “Most sudden cardiac deaths in the young occur during or immediately following school sports, and nearly 90 percent occur in the presence of a teacher or coach.” Charles Berul, MD (Pediatric Cardiologist) Children’s Hospital Boston

APPROACH TO THE DOWNED ATHLETE:PRIMARY SURVEY • Establish responsiveness. • Check Airway, Breathing and Circulation (ABC’s of CPR). • Open airway—if closed. Use head tilt* or jaw thrust.(*Use only jaw thrust in neck injuries.) • Prepare to ventilate. • Check circulation (radial pulse/capillary refill). • Activate EMS if any abnormalities noted.

CARDIAC CRISES • Primary causes of cardiac arrest in individuals < 35 years of age are mainly congenital abnormalities. • Good news is that these conditions are extremely rare.

SPECIFIC CARDIAC CONDITIONS: HYPERTROPHIC CARDIOMYOPATHY • It is the most common genetic malformation of the heart (seen at a rate of 1 in 500 of general population). • Under intense physical stress, patients with HCM are prone to developing fatal arrhythmias. • Hank Gathers (power forward on basketball team at Loyola Marymount University) died in 1990 from ventricular tachycardia, which came on while shooting free throws. He was subsequently found to have HCM.

SPECIFIC CARDIAC CONDITIONS:CORONARY ARTERY ANOMALIES • Apparent cause in 15-35% of sudden deaths in young. • Variety of manifestations can occur, including number of arteries (e.g. single or duplicated), origin (e.g. coronary sinus of Valsalva or pulmonary artery), course, termination (e.g. fistula), & structure (e.g. stenosis, atresia). • “Pistol Pete” Maravich died at age 40 while playing pick-up basketball from a fatal cardiac arrhythmia. Later found to have anomalous origin of left coronary artery from right sinus of Valsalva.

SPECIFIC CARDIAC CONDITIONS:PRIMARY ELECTRICAL DISEASES • Examples of these conditions are: • Wolff-Parkinson-White Syndrome • Long QT Syndrome • Brugada Syndrome • Catecholaminergic Polymorphic Ventricular Tachycardia • Electrocardiogram (EKG) is not always diagnostic. • Depending on the condition, surgery is often the best treatment option.

SPECIFIC CARDIAC CONDITIONS:MYOCARDITIS • Accounts for 5% of sudden, out-of-hospital cardiac deaths in youth. • When present, symptoms are not specific.A “bad cold” is suggested in most cases. • Key to prevention: use the “neck check” when advising athletes about exercising when ill.

SPECIFIC CARDIAC CONDITIONS:MARFAN SYNDROME • Genetic condition seen in 1 in 20,000 live births. • Physical characteristics: tall stature, wing span>height, pectus excavatum, & ocular lens detachment. C-V connective tissue often affected. • Most fatalities result from widening of aortic root with valve dysfunction and/or aortic dissection. • Flo Hyman died in 1986 at age 32 from acute aortic rupture while playing professional volleyball in Japan. Ronalda Pierce died in 2004 at age 19 from acute aortic rupture. (She played basketball at FSU & was on ACC Freshmen All-Conference team previous year.)

SPECIFIC CARDIAC CONDITONS:COMMOTIO CORDIS • Caused by blunt force precordial trauma during a vulnerable period in cardiac cycle. • Commotio cordis most often occurs in males between 4-16 years of age. (Young athletes are at risk due to smaller chest muscle mass.) • Cases have occurred during baseball, softball, hockey, football, & martial arts.

NATA OFFICIAL STATEMENT ON PREVENTION OF COMMOTIO CORDIS • Properly fitted, quality chest protectors recommended to reduce risk of traumatic chest injury to athletes. (Benefit in use of chest protectors is not yet proven.) • Teach athletes how to protect themselves & to avoid being hit in the chest by projectiles such as baseballs, lacrosse balls & hockey pucks. • Do not have athletes step in front of a shot to block it. • Encourage youth baseball & ice hockey organizations to use softer baseballs & pucks. • Maintain even & clean playing surfaces for all athletes.

CARDIAC CRISES:KEYS TO PRIMARY PREVENTION AHA RECOMMENDATIONS FOR PREPARTICIPATION C-V SCREENING OF COMPETITIVE ATHLETES PERSONAL HISTORY: 1) Exertional chest pain/discomfort 2) Unexplained syncope or near syncope 3) Excessive exertional dyspnea or excessive fatigue associated with exercise 4) Prior recognition of heart murmur 5) Elevated systemic blood pressure

CARDIAC CRISES:KEYS TO PRIMARY PREVENTION AHA RECOMMENDATIONS FOR PREPARTICIPATION C-V SCREENING OF COMPETITIVE ATHLETES FAMILY HISTORY: 6) Premature death (sudden and unexpected or otherwise) before age 50 years due to heart disease in equal to or < one relative 7) Disability from heart disease in a close relative < 50 years of age 8) Cardiac conditions in family members:HCM, long QT syndrome, Marfan syndrome or clinically important arrhythmias

CARDIAC CRISES:KEYS TO PRIMARY PREVENTION AHA RECOMMENDATIONS FOR PREPARTICIPATION C-V SCREENING OF COMPETITIVE ATHLETES PHYSICAL EXAMINATION: 9) Heart murmur (especially murmur that gets louder when going from supine to standing, standing to squatting or doing Valsalva maneuver) 10) Femoral pulses (to exclude aortic coarctation) 11) Physical stigmata of Marfan syndrome 12) Brachial artery blood pressure (sitting position)

CARDIAC CRISES:SECONDARY PREVENTION • ASSUME THE WORST INITIALLY. • PROMPT RECOGNITION → QUICK RESPONSE. • IMMEDIATELY INITIATE CPR, IF INDICATED. • EARLY NOTIFICATION OF EMS IS VITAL. • FIND & USE AED, IF POSSIBLE. {ELECTRICITY—WHEN USED—SAVES LIVES!}

CARDIAC CRISES:REFERENCES LIST SUDDEN CARDIAC ARREST http://www.nata.org/statements/consensus/SCA_statement.pdf AED USE IN SCHOOLS http://www.nata.org/statements/official/AEDofficialstatement.pdf COMMOTIO CORDIS http://www.nata.org/statements/official/ASTFstmtCommotioCordisRevised091107(2).pdf

EXERTIONAL SICKLING INSICKLE CELL TRAIT PATIENTS • SCT found in 8% of African-Americans, also found in persons of Mediterranean, Middle Eastern, Indian, Caribbean & Central/South American descent. • In US alone, 2.5 million African-Americans have SCT. • The good news is that all children born in U.S. hospitals are tested for this condition at birth, so those affected should be aware of the condition.

EXERTIONAL SICKLING INSICKLE CELL TRAIT PATIENTS • Extreme physical exertion causes lactic acidosis to occur locally in muscles → deformation of red blood cells in SCT patients. As RBC’s change shape → obstruction of blood flow. • Complicating the picture: muscle breakdown during vigorous exertion →↑ release of myoglobin (damages renal function) & potassium (causes arrhythmias). • Internal organ failure & death may ensue. • Dale Lloyd, II (football player at Rice University) died at age 19 in 2006 after a “light workout” on a Sunday in September.

STRATEGIES TO PREVENT SICKLING INPATIENTS WITH SICKLE CELL TRAIT Dr. Randy Eichner (University of Oklahoma)author of position stand for NATA: • Discourage use of supplements containing high amounts of protein or caffeine. • Avoid use of NSAIDs. • Increase performance levels gradually. • Give longer “breathers” between drills. NATA Consensus Statement: Sickle Cell Trait and the Athlete. June 2007. http://www.nata.org/statements/consensus/sicklecell.pdf

STRATEGIES TO PREVENT SICKLING INPATIENTS WITH SICKLE CELL TRAIT • Do not participate in intensive training methods, such as repeated wind sprints, intense mat drills, fast-paced weight lifting, repeat timed runs, “suicide sprints” & long training runs. • Stay well-hydrated (up to 1 quart fluids/hour). • No training if ill. • Asthma must be well-controlled. NATA Consensus Statement: Sickle Cell Trait and the Athlete. June 2007. http://www.nata.org/statements/consensus/sicklecell.pdf

STRATEGIES TO PREVENT SICKLING INPATIENTS WITH SICKLE CELL TRAIT • Stay fit in the off-season. • Create an environment that encourages the reporting of symptoms immediately. • If muscle cramping, severe pain, weakness, inability to “catch breath” develops, cease training immediately, & seek help. NATA Consensus Statement: Sickle Cell Trait and the Athlete. June 2007. http://www.nata.org/statements/consensus/sicklecell.pdf

RESPIRATORY EMERGENCIES: EXERCISE-INDUCED BRONCHOSPASM • Most frequent pulmonary emergency encountered in sports is EXERCISE-INDUCED BRONCHOSPASM. • Symptoms: Rapid, shallow breathing pattern, wheezing, coughing, complaints of feeling short of breath, chest tightness, & excessive fatigue. • Precipitating factors: Prompt onset of exercise (symptoms must occur during or following exercise of at least 5 minutes’ duration); cold, dry ambient environment (think ice hockey rink)

RESPIRATORY FAILURE:STATUS ASTHMATICUS • Status asthmaticus is a medical emergency in which asthma symptoms are refractory to initial bronchodilator & corticosteroid therapies. • Symptoms: Chest tightness, rapidly progressive shortness of breath, dry cough, use of accessory muscles to breathe, & extreme wheezing. • Key to treatment isprevention of the condition by treating early symptoms promptly & getting help before it is too late. • Treatment of acute dyspnea: Oxygen, use of inhaled medicines (e.g. albuterol), IV fluids, reassure → call EMS. http://www.nata.org/statements/position/asthma.pdf

NONPHARMACOLOGIC TREATMENTSTRATEGIES FOR EIB PREVENTION • Increase physical conditioning. • Warm-up for at least 10 minutes before strenuous exercise commenses. • Cover mouth and nose with scarf/mask during cold weather. • Exercise in warm, humidified environment, if possible. • Avoid aeroallergens & pollutants. • Gradually lower exercise intensity before stopping. • Wait at least 2 hours after meal before exercising. Sinha T, David AK. Recognition and management of exercise-induced bronchospasm. American Family Physician. 2003; 67: 769-774, 776.

SOFT TISSUE INJURIES TO THE NECK& ACUTE AIRWAY COMPROMISE 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 & the bar fell onto his throat. He subsequently underwent 7 hours of surgery to repair a fractured larynx. This unusual injury occurred at one of the country’s most prestigious athletic programs, while being spotted by a strength & conditioning coach, in an experienced athlete (senior), & with a manageable weight. If this accident could happen at USC…

SOFT TISSUE INJURIES TO THE NECK& ACUTE AIRWAY COMPROMISE • 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. (Stafon Johnson was coughing up blood, was still able to breathe on his own, & was extremely apprehensive.) • If faced with a similar injury (or suspicion of such an injury), notify EMS immediately.

CERVICAL SPINEINJURIES • Ask about neck pain. • Palpate midline of neck, check for pain, & spasms. • Neck pain present (or unconscious), assume CERVICAL SPINE INJURY! • Critical to not move injured athlete. • Stabilize head & neck. • Do not remove helmet, chin straps, or shoulder pads when treating a football player for suspected neck injury.

CERVICAL SPINE INJURIES • Determine gross motor function by asking athlete to move fingers & toes, hands & feet, and then arms & legs. • Symptoms/signs that merit call to EMS: • Persistent numbness &/or tingling • Any weakness (unless assoc. with stingers) • Pain radiating down the arm/back/chest • Reduced or absent reflexes • Extreme limitation in active range of motion • Trouble with respiration

CERVICAL SPINE INJURIES • Assign someone to stabilize the head. • If breathing is compromised, use jaw thrust (not head tilt) to assist in ventilation. • Use sandbags, rolled towels, etc. to stabilize the head on a spine board (if available). • Otherwise, just hold athlete’s head still until EMS arrives. • Do not apply traction to the neck while holding the head still.

CERVICAL SPINE INJURIES • Move athlete as a single unit when rolling over from face-down position. • Do not remove athlete from field of play before EMS arrives. • Follow the axiom, “Never make it worse than it already is.” • Injudicious movement of the head & neck in unstable spine can cause permanent injury! http://www.nata.org/statements/position/AcuteMgtCervicalSpineInjuredAth.pdf

CONCUSSIONS IN SPORTS:WHAT’S ALL THE FUSS? • In the last two years alone, 8 kids have died; & dozens more have suffered catastrophic injuries after returning to football play too soon following concussions. • Major media outlets are covering this issue with increasing vigor: HBO’s Real Sports with Bryant Gumbel, 9/14/2009 & 1/19/2010 CBS’s 60 Minutes, 10/11/2009 http://www.impacttestoffice.com/ (For list of recent media coverage of sports-related concussions)

CASCADE OF EVENTS ASSOCIATED WITH ACUTE CONCUSSION • Tiny tears in white matter disrupt communication between different parts of brain. • Excitotoxicity results from traumatic depolarization of axonal cells & associated alterations of ion flux across cell membranes. • Excitatory neurotransmitters (primarily glutamate) are released, causing neurons to fire excessively. • Increased need for energy results, which leads to increased glycolysis. This state of hypermetabolism may persist for days & even weeks. • Cerebral vasoconstriction has been shown to follow concussion.

CONCUSSION PATHOPHYSIOLOGY:ETIOLOGYOF POST-INJURY VULNERABILITY The resulting metabolic mismatch between energy demand & energy supply within the brain has been postulated to propagate a cellular vulnerabilityimmediately after injury. For minutes to days after a concussion, the brain is especially vulnerable to changes in intracranial pressure, blood flow, & anoxia. Collins MW, et al. In Current Opinion in Orthopaedics. Philadelphia, PA: Lippincott, Williams & Wilkins, 2004.

CONCUSSIONS IN SPORTS:SECOND IMPACT SYNDROME • Condition in which brain swells after a minor blow to the head. • SISdevelops in people receiving second blow days/weeks after initial concussion (before it has completely resolved).

CONCUSSIONS IN SPORTS:SECOND IMPACT SYNDROME • Increased intracranial pressure puts the cerebellar tonsils at risk for herniation. • If herniation occurs, the brainstem may fail within 5 minutes. • Except for cases from boxing,mostcases of SIS have occurred in athletes < 20 years of age. • 50% of SIS incidents result in death.

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)

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, & 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.”

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

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.

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

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?

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 & continue balancing. • Testing starts when you are set & 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.

CONCUSSIONS IN SPORTS:Patient Instructions after Acute Injury SIGNS THAT SHOULD LEAD TO ER VISIT: • Headache that gets worse with time • Profound drowsiness or 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

CONCUSSIONS IN SPORTS:Post-Concussion Patient Advice Consult a doctor after having a concussion. Other important points: • 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 & ImPACT normalizes, Return-to-Play protocol is initiated. (See next slide.)

CONCUSSIONS IN SPORTS:Graduated Return-to-Play Protocol

CONCUSSIONS IN SPORTS:WHAT IF SYMPTOMS RELAPSE? • If post-concussion symptoms return while an athlete is proceeding through the Return-to-Play protocol or after returning to full play, activity should cease immediately. • Activity may be tried again at the same level where symptoms did not occur—after being symptom-free for 24 hours. • Athletes should be taught to never play with post-concussion symptoms.

CONCUSSIONS IN SPORTS: RECOMMENDATIONS FOR PREVENTION • Insure that all players’ helmets fit properly. • Use only new/regularly refurbished helmets. • Teach/enforce proper tackling techniques. • Encourage football players to “take their heads out” of making contact. • Encourage strengthening of neck/shouldermusculature (especially in off-season).

CONCUSSIONS IN SPORTS:INTERNET RESOURCES 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

CONCUSSIONS IN SPORTS:INTERNET RESOURCES 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

Ohio Dept. of Ed. P.A.S.P. Program: SPORTS MEDICINE EMERGENCIES & OTHER HEALTH CONCERNS