On the Field Emergency Management Emily Carter, ATC Michelle Johnson, ATC

1. On the Field Emergency Management Emily Carter, ATC Michelle Johnson, ATC Megan Lawrence, ATC Teresa Pritchett, ATC Jonathan Vieira, ATC Kim Walter, ATC

2. Fractures/Dislocations • David, Tal MD. “Missed Upper Extremity Fractures in Athletes”. (Current Sports Medical Reports) • Evaluate ABC’s • Understand Mechanism • Immediate reduction techniques • Knowledge of common complications • Plan for aftercare • When in doubt…IMMOBOLIZE

3. Fractures/Dislocations • Padua, R. “Surgical versus conservative treatment for acute first-time anterior shoulder dislocation: the evidence”. (Journal of Orthopaedics and Traumatology) • 96% of shoulders dislocations occur anterior and are acute. • High rate of recurrence within 1st year. • Management: restore range of motion, reduce recurrence, and improve quality of life

4. Fractures/Dislocations • Cox, C.L. and J.E. Kuhn. “Operative versus Non-operative Treatment of Acute Shoulder Dislocation in the Athlete”. (Current Sports Medicine Report) • 24 discussed reduction techniques, be familiar with several techniques • Advantages and Disadvantages of each technique • May take several attempts to reduce • Cause no harm, immobilize and refer if necessary

5. Action plan for Shoulder Dislocation Determine if shoulder dislocation is present • Evaluate neurovascular status (before and after) • Visually inspect and palpate for deformity • Check Range of Motion • If dislocated/subluxed prepare for reduction Instruct athlete what is about to happen Use technique most familiar with

6. Action plan for Shoulder Dislocation Example Techniques: attempt only once • External Rotation- Place athlete on their back with the affected arm abducted to about 90 degrees, using one hand to maintain the adducted position and other hand to guide the arm through slow external rotation with constant axial rotation • Spaso- Place athlete on their back with the affected arm forward flexed 90 degrees and gentle longitudinal traction and external rotation are applied After Reduction: • Immobilize with sling • Recheck neurovascular status • Refer athlete to Emergency Department if NOT reduced • Refer to team physician if reduced

7. Action Plan for Patella Dislocation Presentation: • Patella displaced laterally • Knee flexed Reduction: • Simply extending the knee is often all that is necessary • Next apply medially directed pressure onto patella. Aftercare: • Check Neurovascular status • Immobilize in extension for referral to ED or team physician

8. Action Plan for Finger Dislocation Presentation: • PIP – A dorsal dislocation presents with middle phalanx dorsal in relation to proximal phalanx. A volar dislocation has a lateral displacement in addition to volar. Reduction: • Dorsal DIP/PIP – traction, mild hyperextension & direct pressure on base of the more distal phalanx then bring into flexion flexion • Volar PIP – Hold MP joint in flexion to relax lateral bands, provide traction and then flexion and bring them into extension. Often difficult to reduce. • MP – NO TRACTION—NO HYPEREXTENSION hold wrist in flexed position, apply steady pressure in a distal and volar direction. Difficult to reduce. Aftercare: • Check Neurovascular status • Splint/Tape and refer to ED if not able to reduce • Splint/Tape and refer to team physician if reduced

9. Cervical Spine Injuries • Research- • Kleiner, DM et. Al. Prehospital Care of the Spine Injured Athlete: A document from the Inter-Association Task Force for the Appropriate Care of the Spine Injured Athlete (NATA) • Always have a designed protocol for the care of the spine injured athletes • Always treat unconscious athlete as a cervical spine injury • Protocol was developed from this article

10. Cervical Spine Injuries • Del Rossi et. Al. The 6-Person Lift Transfer Technique compared with other methods of Spine Boarding. (Journal of Athletic Training) • 6-plus person lift generated significantly less axial rotation, lateral flexion/and medial lateral translation than the log roll but not significantly less than the lift and slide technique.

11. Cervical Spine Injuries • Waninge, Kevin N. Management of the Helmeted Athlete with Suspected Cervical Spine Injury. (AJSM Lit. Review) • Helmets and shoulder pads should not be removed in prehospital management of the football player with potential spine injury unless absolutely necessary.

12. Cervical Spine Injuries • Gehron, T et. Al. Cervical Spine Alignment in Youth Football Athlete: recommendations for Emergency Transportation (Amer.J. Spt Med) • No significant difference when a healthy athlete was x-rayed with full pads on vs. no pads • There was significant lordosis when x-rayed with only shoulder pads and no helmet vs. no pads

13. Cervical Spine Injuries • Bailes, JE et al. Management of Cervical Spine injuries in Athletes. (JAT) • ATC’s should be prepared to handle and recognize cervical spine injuries. • Utilize proper tools and techniques for cutting off masks and spine boarding (log roll, 6 man lift)

14. Action Plan for Cervical Spine injury Stabilize the Head AND Neck Do Not Move Athlete • *unless absolutely necessary to do primary survey* • *Log roll patient if lying prone* Primary Survey • Check airway, breathing, and circulation • Remove Mouthpiece • Call 911 (EMS) • If stable move on to Secondary Survey • If not breathing proceed with facemask removal

15. Action Plan for Cervical Spine injury Facemask Removal • Remove facemask completely (all clips from facemask via screwdriver, pruning shears, or trainer’s angel) • LEAVE HELMET AND SHOULDER PADS ON • Re-check ABC’s Secondary Survey – Head to Toe • Neurological screening • Assess motor and sensory function in extremities • Cranial nerve assessment as complete as possible Transport • Maintain control of the head during spine board process • Secure helmet to spine board with tape or EMS straps

16. Acute Asthma Attacks • Research: • Miller, Michael G., et al. National Athletic Trainers’ Association Position Statement: Management of Asthma in Athletes. (NATA, 2005) • All existing emergency action plans should include an asthma action plan. • If an athlete is experiencing any degree of respiratory they should be referred rapidly to emergency department or personal physician. • Athletes should place inhaler at or in front of lips and slowly inhale at the same time they are activating the inhaler. Hold breath for approximately 10 seconds. • Athletes who have difficulty coordinating MDI generally benefit from the use of a spacer.

17. Acute Asthma Attacks • Research: • Houglum, Joe E. Asthma Medications: Basic Pharmacology and Use in the Athlete. (JAT, 2000) • Typical adult dosage of Albuterol (B2 agonist) is 2 puffs tid to qid prn. • It is important for athletes to be using inhaler devices properly, including a spacer if good inhalation technique is not being achieved with MID

18. Acute Asthma Attacks • Research: • Allen, Thomas W. DO. Sideline Management of Asthma. (Current Allergy and Asthma Reports, 2006) • Any athlete who demonstrates symptoms of airway hyperactivity must be removed from activity and provided emergency treatment. • If symptoms do not resolve when athlete is removed from play administer two puffs of short-acting B2 agonist (Albuterol) via MDI. • The use of a spacer attached to the inhaler will improve the delivery of the drug. • If symptoms have not resolved in five minutes a second dose of two puffs should be administered.

19. Action Plan for Acute Asthma Attacks If athlete is experiencing any symptoms of asthma (SOB, wheezing, retraction) initiate asthma action plan: Initial Treatment (With Spacer) • Use rescue inhaler, 1-2 puffs, up to 3 treatments in 1 hour • Shake inhaler • Have athlete exhale, then place inhaler with spacer on lips. Dispense medicine into spacer, then inhale. Hold breath for 10 seconds before exhaling. Initial Treatment (No Spacer) • Use rescue inhaler, 1-2 puffs, up to 3 treatments in 1 hour • Shake inhaler • Have athlete exhale, then place mouth over inhaler. Dispense medicine while inhaling slowly. Hold breath for 10 seconds before exhaling

20. Action Plan for Acute Asthma Attacks If response is good within 5 minutes: • May continue to participate and use inhaler/spacer as needed If symptoms are still present after 5 minutes but improving: • 2 more puffs of rescue inhaler/spacer • Do not return to participation • Instruct athlete to follow-up with physician If athlete shows no improvement: • Repeat use of rescue inhaler as needed • Call 911 to transport athlete to emergency room  * Activate EMS immediately if athlete is exhibiting signs of impending respiratory failure (weak respiratory efforts, weak breath sounds, unconsciousness, or hypoxic seizures, grunting).

21. Concussions • We utilized the last year’s concussion focus team information to develop protocol • We also utilized the SCAT card

22. Action Plan for Concussions Cranial Nerve Testing NerveS/MTest I Olfactory S Identify familiar odors applied to each nostril II Optic S Identify # of fingers held or read from paper III Oculomotor M Pupil reaction to light IV Trochlear M Follow finger without moving head V Trigeminal B Identify where touch is applied to face VI Abducent M Lateral eye movements VII Facial B Smile, wink, identify tastes VIII Vestibulocochlear S Identify sounds in both ears, touch finger to nose, walk, touch knee to heal IX Glossopharyngeal B Say “ah”, swallow, test for gag reflex X Vagus B Test for gag reflex XI Spinal Accessory M Resistive shoulder shrugging and turning head XII Hypoglossal M Tongue movements, resist w/ tongue depressor

23. Action Plan for Concussions Upper Extremity Neurologic Exam MOTORSENSORYREFLEX C5 Shoulder Abduction Lateral Arm Biceps Elbow Flexion C6 Wrist Extension Lat. Forearm Brachioradialis Thumb, Index C7 Elbow Extension Middle Finger Triceps Wrist Flexion (Variable) Digit Extension C8 Digit Extension Medial Forearm None Ring/Small Digit T1 Finger Adduction Medial Arm None Finger Abduction

24. Action Plan for Concussions Concussion Assessment 1) Orientation 3) Concentration Time repeat series of digits backward, Date progress with level of difficulty Place 4-9-3 Surroundings 3-8-1-4 Recall injury event 6-2-9-7-1 months in reverse order 2) Immediate Memory 4) Delayed Recall Item Recall recall items given earlier Ball Ball Sailboat Sailboat Computer Computer Honesty Honesty Purple Purple

25. Action Plan for Concussions Concussions- Physician Referral Checklist Immediate EmergencyDelayed Transport • Loss of consciousness > ?min Vomiting more than once • Decreased level of consciousness Post traumatic confusion lasting • Abnormal neurological function longer than 15 min • Seizure activity Cranial nerve deficits • Mental status changes Increase in blood pressure • lethargy, confusion, agitation Post concussion symptoms that worsen • Decrease of irregularity in respirations or do not improve over time Increase in the number of symptoms • Unequal, dilated, or un-reactive pupils reported over time • Signs or symptoms of associated injuries, spine or skull fracture, • Other considerations: social barriers, parental awareness, length of travel, language barriers

26. Revision of Existing Protocols • We also had enough time to revise several of our existing protocols to fit our new format. They include: • Heat Illness • Heat Index Guidelines • Dental Issues • Epi-Pen Delivery • Lightning • Activating EMS

27. Action Plan for Heat Illness If athlete is experiencing any symptoms of heat illness, initiate action plan: Heat Stress (Mild): S/S: Cramping TX: Remove from sun Dizziness / Light headed Remove clothing and Nausea/Vomiting equipment Rapid Breathing Encourage athlete to drink fluids Apply ice towels to axilla/groin Monitor and record vitals every 3-5 minutes. * Activate EMS immediately if athlete becomes unresponsive at any time

28. Action Plan for Heat Illness Heat Exhaustion (Moderate): S/S: Cramping TX: Activate EMS: • Extreme Exhaustion Treatment same as Heat Stress plus: • Dizziness/ light headed Cool with fans if available • Moist / Pale / Cool skin Elevate legs • Visual Disturbances Notify team physician if present • Altered mental state • Increased body temp (>102) Monitor and record vitals every 3-5 minutes Heat Stroke (Severe): S/S: Staggering TX: Activate EMS • Hot / Dry skin Treat the same as Heat • Altered mental state Exhaustion while waiting for • Severe headache EMS to arrive. • Increased body temp (>104) • Weak pulse • Decreased blood pressure Monitor and record vitals every 3-5 minutes

29. Action Plan for Dental Issues Tooth Avulsion(Entire tooth knocked out) • Avoid additional trauma during handling of tooth. DO NOT handle by root. Do Not scrub tooth. Do NOT sterilize tooth. • Gently rinse with water if debris is on tooth. • If possible, re-implant tooth and stabilize by gently biting down on towel. • If unable to re-implant, you should do one of the following: • A. Place tooth in saline solution (Best Option) • B. Place tooth in cold milk • C. Wrap tooth in saline soaked gauze • D. Place tooth in cup of water • Putting tooth back in socket within 30 minutes gives best chance to save tooth. Transport to dentist or emergency room immediately

30. Action Plan for Dental Issues Tooth Luxation(Tooth in socket, but wrong position) • Extruded Tooth (tooth is hanging out of gums) • Reposition tooth in socket using finger pressure • Stabilize tooth by gently biting on towel • Transport to dentist or emergency room • Lateral Displacement (tooth is pushed back or pulled forward) • Reposition tooth using finger pressure. May require local anesthesia to reposition; if so, stabilize by gently biting down on towel • Transport to dentist or emergency room immediately. • Intruded Tooth (tooth pushed into gum- looks short) • DO NOTHING –AVOID REPOSITIONING OF TOOTH • Transport to dentist or emergency room. Tooth Fracture (Broken Tooth) • If tooth is broken in half, save broken portion and transport to dentist. Stabilize portion of tooth left in mouth. • Limit contact with other teeth, air, and tongue. Pulp nerve may be exposed, which is extremely painful to athlete. • Immediately transport tooth and patient to dentist or emergency room.

31. Action Plan for Epi-Pen • Unscrew the cap off of the Epi-Pen carrying case and remove the Epi-Pen auto-injector from its storage tube. (Do not use Epi-Pen if it is discolored or a red flag appears in clear window) • Grasp unit with the black tip pointing downward. • Form fist around the unit (keeping black tip down) • With your other hand, pull off the gray safety release

32. Action Plan for Epi-Pen • Hold black tip near outer thigh • Jab firmly into outer thigh until it clicks so that unit is perpendicular to the thigh   • Hold firmly against thigh for approximately 10 seconds • Remove unit from thigh and massage injection area for 10 seconds • Call 911

33. Action Plan for Lightning Safety • Flash-to-Bang Method is the easiest and most convenient way to estimate how far away lightning is occurring. • Count the seconds in between the first lightning seen with the first clap of thunder heard. • Divide the number by five. This will obtain how far away inmiles the lightning is occurring. • By the time the flash-to-bang count approaches 30 secs (6 miles), all individuals should be inside a safe structure. • Once activities have been suspended, wait at least 30 mins following the last sound of thunder or lightning flash prior to resuming any activity or returning outdoors.

34. Action Plan for Lightning Safety BASIC FIRST AID FOR VICTIM • Survey the scene for safety • Activate local EMS • Lightning victims do not “carry a charge” and are safe to touch. • If necessary, move the victim with care to a safer location. • Evaluate airway, breathing, and circulation. Begin CPR if necessary. • Evaluate and treat for hypothermia, shock, fractures, and/or burns. SEEK LOWER GROUND AND STAY AWAY FROM TREES Lightning Safe Position: crouched on the ground, weight on the balls of the feet, feet together, head lowered, and ears covered. DO NOT LIE FLAT ON THE GROUND

35. Action Plan for Activating EMS ACTIVATINGEMS • If an athletic trainer is not present, coach or administrator should call 911 • If a police officer present, he/she may call for EMS INFORMATION TO BE GIVEN TO 911 OPERATOR: • Your name • Location (including address and specific directions) • Phone number calling from • Athlete’s name, age, and condition • Care that is being given to athlete • Stay on line until the operator hangs up

36. Action Plan for Activating EMS ROLE OF THE FIRST RESPONDER: • Immediate care of the injured athlete by the coach if the Athletic Trainer is not present • Activate EMS • Call 911 and provide information on front side of card • Open any locked gates/doors for EMS access (should be done prior to event) • Send someone to meet EMS on arrival to direct them to the site • Coaches will contact appropriate school officials (AD, principals, etc.) EMERGENCY PERSONNEL: Certified Athletic Trainers Coaches Administrators EMS