Athletic Emergencies: On Field Management

1. Athletic Emergencies: On Field Management Jim Ellis, MD, FACEP Faculty, Primary Care Sports Medicine Fellowship Program Steadman Hawkins Clinic of the Carolinas

2. Why we do what we do • On October 24, 1971 Chuck Hughes of the Detroit Lions went across the middle on a pass play and collapsed. Legendary LB Dick Butkus frantically waved to the sideline for help. Despite the efforts of the training staff, he died of a “heart attack” and remains the only on field death in the history of the NFL.

4. Objectives • Know the risks of the sport you cover • Know your specific role/responsibility • Know your players’ illnesses • Know what equipment to have • Know the Emergency Action Plan

6. ATLS, ACLS, “ASLS”Advanced Sports Life Support • Airway • Breathing • Cardiac • Circulation • Cervical Spine • Concussion • Conditions/Environment • Crisis Management/Disaster • Diabetes

8. Airway Problems • Direct Trauma • Anterior neck trauma • Indirect Trauma • Severe concussion can lead to unprotected airway • High cervical spine injury

10. Airway Evaluation • Is the player talking? • Is he tachypneic or agonal? • What is the pulse ox? • EMS bring pulse ox!

11. Airway - Maintainable • Supplemental oxygen • Chin lift or jaw thrust (for c-spine) • Nasal or oral airway • Bag-valve-mask/pocket mask/barrier

12. Airway Evaluation • Unmaintainable • Airway is inadequate with basic support • Procedural intervention is required • Must remove facemask to have unencumbered access to the airway on anyone immobilized • Need Advanced Life Support EMS unit at high risk events

13. Endotracheal Intubation • The right person • The right equipment • The right drugs • The right plan for the difficult airway

14. Anatomy

15. Airway Adjuncts • Intubating Stylet • Lighted Stylet • LMA *great tool for the airway novice • Intubating LMA • Levitan Fiberoptic Scope

17. LMA and Intubating LMA

19. Surgical Airway • Unsuccessful endotracheal intubation • Mandibular fracture • Anterior neck trauma • Laryngeal fracture • Stridor

20. Surgical Airway • Know the anatomy • Know the equipment • Know the procedure

21. 2002 Super Bowl • Kurt Warner played with a laryngeal fracture – sideline cricothyrotomy kit

22. 2004 Al Lucas • Arena League player went down headfirst on a kick-off • Evaluated by MD and ATC on FOP • While being loaded into the ambulance, stopped breathing (within 10 minutes of injury) • Died from airway compromise due to C1/C2 fracture and concussion despite using an LMA for airway

24. 1997 Reggie Brown • Lions linebacker injured vs Jets • C1/C2 fracture with CHI • Airway compromise from above • On field mouth to mouth and BVM • Response saved his life and had remarkable post op recovery

26. Breathing Problems • Massive Hemothorax • Load and Go! • Tension Pneumothorax • Use pulse oximetry for help • Large bore IV catheter(14 gauge) • 2nd intercostal space, midclavicular line • LEAVE IT IN!

27. 2001 Drew Bledsoe • Patriots QB was driven into the ground on the sideline • Was short of breath after the game • Taken to Mass General Hospital and had a chest tube inserted to reinflate his lung and an autotransfusion • Tom Brady became the starter

29. 2008 Lauren Chang • Cheerleader accidently kicked in the chest • Had collapsed lungs - bilateral • Died from tension pneumothorax

31. Breathing Problems • Asthma • Know your players • Nebulizer vs inhaler (use a spacer) • Keep an extra MDI (inhaler) • Make sure EMS gives the right Epi dose SQ/IM (1:1000) vs IV (1:10,000) • Can use Epi-Pen if needed (same dose as allergic reaction 0.3cc) • Peak Flow Meter (know their baseline)

32. 2001 Rashidi Wheeler • Northwestern football player • Died secondary to asthma • Known asthmatic in difficult workout • ?Complicated by ephedra use

34. Cardiac Problems • Cardiac Etiology • Sudden cardiac death • Arrhythmia of unknown etiology • Hypertrophic cardiomyopathy • Commotio cordis/cardiac concussion (hockey, lacrosse and baseball) • Coronary artery disease in coaches and referees*

36. HCM • Many athletic deaths from HCM • Sometimes is resistant to defib • Hypothermia as treatment protocol • Small study but great results • Neuro protective properties • Keep cooled IVF’s just in case

37. Cardiac Interventions • CPR if AED is not right there • AED – know where it is at all times and have nearby at events • Practice run getting the AED • Trauma scissors • Manual defibrillator (EMS) • Time to shock is critical!

38. Cardiac Interventions • Every minute that passes, there is a 10% decrease in chance of survival. • 90% chance of survival at 1 minute • 50% chance at 5 minutes • 10% chance of survival if the initial shock is delivered 9 minutes after the cardiac arrest occurred • Don’t wait for EMS

40. 2005 Jiri Fisher • Collapsed on the ice • Saved with CPR and AED • Key was a rapid response to a true life threatening emergency • Etiology was underlying arrhythmia

42. 1996PolishChefdeMission • Opening Ceremony 1996 Olympic Games • Cardiac arrest on the field of play • 10,000 athletes / worldwide TV audience • Defibrillated on the FOP and intubated • Transported with return of vital signs • Subsequent death in the hospital

44. 2011 Al Schmidt at UGA • Mississippi State track official • Known CAD • At SEC Track meet on UGA campus • Witnessed cardiac arrest • Well practiced EAP • AED on site in 2 minutes • Survived to discharge neuro intact

46. 2011 Dan Cochran at Syracuse • Commotio Cordis at a lacrosse tryout • Immediate CPR • AED on site and delivered shock • Return of vitals by EMS arrival • Patient was discharged neuro intact • Experienced ATC with an EAP

47. Other serious cardiac events • 1988 – Pete Maravich(NBA) congenital coronary artery • 1990 – Hank Gathers(NCAA) HCM • 1993 – Reggie Lewis(NBA) HCM • 1998 – Chris Pronger(NHL) commotio • 2003 – Marc Vivien-Foe(soccer) SCD • 2004 – Sergei Zholtok(NHL) HCM

48. Other serious cardiac events • 2005 – Jaxon Logan(NCAA) commotio • 2005 – Thomas Herrion(NFL) HCM/CAD • 2007 – Damien Nash(NFL) arrhythmia of unknown etiology • 2007 – Antonio Puerta(soccer) SCD • 2011 – Wes Leonard(BB) SCD/?HCM • 2011 – Armen Gilliam(BB) CAD?

49. Circulation Problems • Abdominal Trauma/Hemorrhage • Splenic or liver injury • Don’t confuse with dehydration • High index of suspicion • Life/limb threatening hemorrhage • Two large bore IV’s • Load and go (nearest appropriate facility)

50. 2006 Chris Simms • September game vs Panthers • Multiple hard hits • No specific complaint of LUQ pain • Treated for dehydration • Ruptured spleen • Surgery at St. Joe’s Hospital (< 1 mile)