2014 JMSP Symposium Trauma in the ER

1. 2014 JMSP SymposiumTrauma in the ER Dr. Jim Kyle, FACSM Team Physician, Concord University Sports Medicine Director Beckley ARH Hospital West Virginia EMS Regional Medical Director Marshall University School of Medicine Associate Clinical Professor

2. Sports Trauma in the ED Hand and Wrist Mallet finger Coach’s finger Skiers thumb Scaphoid Fx TFCC injury Elbow and Shoulder Tennis elbow Radial head Fx Rotator cuff strain Impingement syndrome A-C separation Low Back, Pelvis, Hip Spondylolysis Apophyseal Avulsions Femoral neck Stress Fx SCFE Knee Injuries Meniscal Tears Anterior Cruciate Ligament Medial Collateral Ligament Adolescent knee Ankle Injuries Lateral sprain Deltoid sprain High-Ankle sprain Jones Fx Head, Heart, Lung, Kidneys Concussion Syncope – HCM, SVT EIA, Rib Fx, Pulmonary Contusion Heat Stress, Rhabdo, ECAST

3. International Symposia on Concussion in Sport • First ISC Vienna 2001 • Second ISC Prague 2005 Simple vs Complex, SCAT2 sideline tool • Third ISC Zurich 2008 Removed Simple vs Complex grading, RTP based on progression • Fourth ISC Zurich 2012 – SCAT3, Baseline NP, BESS, enhanced MRI, mTBI vs Concussion FIFA, IOC, IIHA

4. 2014 RTP Guidelines ED discharge instructions: • Physician follow-up in 72 hrs for repeat exam • Graded Symptom Checklist at D/C • No date for return to contact • Neuro-Cognitive Testing • Sports medicine team should provide protocol for gradual return to activity

5. VT Sub Concussive Research • Helmets with accelerometer • Sideline Box with recordings • Many Hits with + 40g • Physician Beeper set @ 50g • Average 4 + 80g Hits Season • # Hits position specific • 5 concussions in 2013 season

6. ED Discharge: Rhomberg Test Balance Error Scoring SystemBESS

7. BARH ED “Best Practice”Youth Concussion • Emergency Room: Head, C-spine evaluation- ?CT BESS Testing, 72hr GSC at D/C • Pediatrician: Review Graded Symptom Checklist ImPACT testing • School/ Coach: Equipment check, 5 day progession Consult Physician RTP

8. Collegiate Strength and Conditioning Coach • BIGGER • STRONGER • FASTER

9. Rhabdomyolysis Medical Trauma Sports - Exertional SCT – Fulminant Ischemic “Explosive” Rhabdo

10. Rhabdomyolysis in Athletes • January 2011 • University of Iowa • Football players required to perform 100 squats with weight = 50% of prior max

11. Rhabdomyolysis in Athletes 13 cases of Rhabdo first day of conditioning drills after Holiday break Cold day in Iowa City

12. Rhabdomyolysis TRIAD of: 1. Muscle Weakness 2. Myalgia 3. Dark Urine

13. Exertional Rhabdo • Modest elevation of CPK • Basic Training Military Recruits • Common in August Football • Marathon runners 10% > 3,000 • Recent increased awareness 2011

14. CPK in Exertional Rhabdo • 4-5x high normal consider diagnosis • peak in 24-36, fall 30%/day • Less than 20,000 unlikely ARF • May peak at levels > 100,000 • ^ LDH, ^SGOT – 25%

15. Rhabdo Complications • ARF • Hyperkalemia • Hypocalcemia • ^ LFT • DIC

16. ARF in Rhabdo • CPK less than 20,000 – rare • Early treatment • Mortality approaches 20%

17. Sodium Bicarbinate in Rhabdo Use recommended in cases of: 1. Acidemia 2. Dehydration 3. Underlying Renal Disease 1 amp in 1 L NS @ 100cc/hr

18. Exertional Rhabdo

19. Rhabdomyolysis Medical Trauma Sports - Exertional SCT – Fulminant Ischemic “Explosive” Rhabdo

20. Case Study ECAST Dale Lloyd II September 2006 Rice 5’9” 190lb defensive back Struggling during sprints Teammates attempted to asisst, coaches leave alone, unaware of SCT

21. Workout Program • 4:00 – weight lifting • 4:30 - Outside sprints • 16 sprints 100yards • Rest 1 min first 4, 2 min next 4 1 min last 8.

22. Timeline Athlete Collapse • 4:55:Completes sprints C/O bilateral lower extremity pain and SOB Alert , over next 10 minutes became lethargic • 5:05:Unable to walk , EMS called Cart to Training Room, O2 via BVM • 5:12 :University EMS arrived IV and 100% Oxygen, Fire Department EMS called • 5:28:FD EMS arrival: Patient unresponsive GCS=3, O2Sat =67% room air Nasotracheal intubation, EKG with peaked Twave V2,V3 • 5:52: ED arrival: BP =150/50 Pulse = 126 Temp = 97 O2Sat = 100%

23. Sudden Death SCT • All died under similar distinctive circumstances: non-instantaneous collapse with rapid deterioration (dyspnea, fatigue, weakness and muscle cramping) over 10-45 minutes • Each event occurred during vigorous or exhaustive maximal physical exertion, usually during training (22) • 17 of 23 (74%) Summer or early Autumn • 20 deaths in southern or border states with Temp > 80* • Florida (n = 5) , Texas (n = 4) Maron, BJ, Eichner, ER, et.al. Sickle Cell Trait Associated With Sudden Death in Competitive Athletes. Am J Card: 2012, 110(8)

24. ECAST - On the Field Management • Conditioning Focus • Remove athlete if leg, back pain SOB • Vital Sign with O2 therapy • EMS alert • IV Fluids, Normal Saline Bolus

25. ED Management: Exercise Collapse Associated with SCT (ECAST) • Awareness that ECAST in Diff Dx • ABG monitoring for metabolic acidosis • Aggressive Fluid and Electrolyte Management • Anticipated Explosive Rhabdo • Early Dialysis ^K, to avoid lethal cardiac arrhythmias ( within minutes to hours of syndrome onset )

26. Sports Trauma in the ED Hand and Wrist Mallet finger Coach’s finger Skiers thumb Scaphoid Fx TFCC injury Elbow and Shoulder Tennis elbow Radial head Fx Rotator cuff strain Impingement syndrome A-C separation Low Back, Pelvis, Hip Spondylolysis Apophyseal Avulsions Femoral neck Stress Fx SCFE Knee Injuries Meniscal Tears Anterior Cruciate Ligament Medial Collateral Ligament Adolescent knee Ankle Injuries Lateral sprain Deltoid sprain High-Ankle sprain Jones Fx Head, Heart, Lung, Kidneys Concussion Syncope – HCM, SVT EIA, Rib Fx, Pulmonary Contusion Heat Stress, Rhabdo, ECAST

27. Athletes at Risk for SCA Chief complaint of syncope Chest Pain with or post activity History of palpitations Family History of Sudden death Abnormal EKG

28. Symptoms: HCM Dysneain 90% of symptomatic athlete Syncope during exercise - from inadequate cardiac output or cardiac arrhythmia Chest Pain during exercise Palpitations, Dizziness, Presyncope

29. Athlete SCA : Have We Changed the Playing Field ? Emergency Department • Athlete Collapse – Assume Cardiac Etiology (Sentinel Seizure) • EKG Attention: Delta and Epsilon Waves, LQT • Syncope, Near Syncope, Chest Pain WorkUp: Consider advanced imaging, Cardiac CT, MRI* vs ECHO

30. The Faces of SCA

31. Medical “Time-Out” Prior to Games and Practice • NATA petition to NCAA • EAP Venue specific • On the Field – EMS communication and readiness Head and Neck • Athlete Collapse – EHS , SCA and SCT • Spectator Coverage

32. Sideline ER DoctorBlunt Torso Trauma When to Worry CHEST TRAUMA ABDOMINAL TRAUMA Spleen Injury Renal Contusion Appendicitis • Rib Fracture • Pneumothorax • Pulmonary contusion

33. Chest and Abdomen

34. Rib Fractures • Ribs 4-9 • Most common ribs injured • Ribs 1-2 and Sternum • Great vessel injury • Cardiac contusion • Ribs 9-12 • Injury to spleen, liver or kidney

35. Rib Fractures

36. Thoracic Emergencies Pneumothorax Tension Pneumothorax Flail Chest Diaphragmatic Rupture

38. Wrap or tape Chest • No longer recommended • Leads to pulmonary complications • Decreased ability to take maximal breath during exertion

39. Return to play • 3-6 weeks • Pain permits • Protective padding 6-8 weeks • Stress fracture • 6-8 weeks stopping the inciting repetitive motion

41. What was happening at the hospital • Patient #2: Jacob • 16 years old • California • Pulmonary Contusion

42. Rib Fractures • Ribs 4-9 • Most common ribs injured • Ribs 1-2 and Sternum • Great vessel injury • Cardiac contusion • Ribs 9-12 • Injury to spleen, liver or kidney

43. Abdominal Blunt Trauma

44. Abdominal Blunt Trauma

45. Abdominal Blunt Trauma

46. Sideline Abdominal Exam • LUQ pain • Radiating to L Shoulder • Guarding • Rebound tenderness

47. Abdominal Blunt Trauma Dip the Urine – test for Hematuria

48. Abdominal Blunt Trauma

49. Abdominal Blunt Trauma

50. Abdominal Blunt Trauma