On-the-Field Acute Care and Emergency Procedures

1. On-the-Field Acute Care and Emergency Procedures

2. Emergency Action Plan Primary concern is maintaining cardiovascular and CNS functioning Key to emergency aid is the initial evaluation of the injured patient Members of sports medicine team must at all times act reasonably and prudently Must have a prearranged plan that can be implemented on a moments notice

3. EAP • Separate plans should be developed for each facility • Personnel and role • Identify necessary equipment • Availability of phones and access to 911 • Be familiar with community based emergency health care delivery plan

4. EAP • Know communication, transportation, treatment policies • Individual calling medical personnel must relay the following: 1) type of emergency 2) suspected injury 3) present condition 4) current assistance 5) location of phone being used 6) location of emergency 7) building limitations • Keys to gates/locks must be easily accessible • Should be practiced

5. Principles of On-the-Field Injury Assessment On-field assessment Determines nature of injury Provides information regarding direction of treatment Divided into primary and secondary survey

6. Figure 12-1

7. Performed initially to establish presence of life-threatening condition • Airway, breathing, circulation, shock and severe bleeding • Used to correct life-threatening conditions On the Field Assessment Primary Survey Secondary survey • Life-threatening condition ruled out • Gather specific information about injury • Assess vital signs and perform more detailed evaluation of conditions that do not pose life-threatening consequences

8. Primary Survey Life threatening injuries Cardiopulmonary resuscitation Profuse bleeding Shock Level of consciousness must also be assessed

9. Unconscious Patient Must be considered to have life-threatening condition Note body position and level of consciousness Check and establish airway, breathing, circulation (ABC) Assume neck and spine injury

10. Opening the Airway Head-tilt, chin lift method Push down on the forehead and lifting the jaw moves the tongue from the back of the throat Figure 12-7A

11. Opening the Airway • Modified technique can be used when neck injury is suspected • Modified jaw thrust maneuver Figure 12-7B

12. Establishing Breathing Look, listen and feel While maintaining pressure on forehead, pinch nose, hold head back OSHA has mandated use of barrier shield by minimize transmission of bloodborne pathogens Figure 12-8

13. Establishing Circulation Locate carotid artery and palpate pulse while maintaining head tilt position If available, the AED should be used ASAP If no AED is available and there are no signs of circulation begin CPR

14. Using an Automatic External Defibrillator (AED) Device that evaluates heart rhythms of victims experiencing cardiac arrest Can deliver electrical charge to the heart Fully automated - minimal training required Maintenance is minimal for unit True public access defibrillation Anyone with knowledge of AED can utilize Some states require formal training, in others individuals can utilize AED in good faith attempt to save life of victim in cardiac arrest

15. Obstructed Airway Management Choking is a possibility in many activities Mouth pieces, broken dental work, tongue, gum, blood clots from head and facial trauma, and vomit can obstruct the airway When obstructed individual cannot breath, speak, or cough and may become cyanotic The Heimlich maneuver (abdominal thrusts) can be used to clear the airway

16. Control of Hemorrhage Abnormal discharge of blood Arterial, venous, capillary, internal or external bleeding Venous - dark red with continuous flow Capillary - exudes from tissue and is reddish Arterial - flows in spurts and is bright red Universal precautions must be taken to reduce risk of bloodborne pathogens exposure

17. External Bleeding Stems from skin wounds, abrasions, incisions, lacerations, punctures or avulsions Direct pressure Firm pressure (hand and sterile gauze) placed directly over site of injury against the bone Elevation Reduces hydrostatic pressure and facilitates venous and lymphatic drainage - slows bleeding Pressure Points

19. Figure 12-17

20. Internal Hemorrhage Invisible unless manifested through body opening, X-ray or other diagnostic techniques Can occur beneath skin (bruise) or contusion, intramuscularly or in joint with little danger Bleeding within body cavity could result in life and death situation If suspected, monitor blood pressure Difficult to detect and must be hospitalized for treatment Could lead to shock if not treated accordingly

21. Shock Generally occurs with severe bleeding, fracture, or internal injuries Result of decrease in blood available in circulatory system Vascular system loses capacity to maintain fluid portion of blood due to vessel dilation, and disruption of osmotic balance Movement of blood cells slows, decreasing oxygen transport to the body Extreme fatigue, dehydration, exposure to heat or cold and illness could predispose patient to shock

22. Several types of shock (MASHNCPR) • Metabolic - occurs when illness goes untreated (diabetes) or when extensive fluid loss occurs • Anaphylactic - result of severe allergic reaction • Septic - result of bacterial infection where toxins cause smaller vessels to dilate • Hypovolemic - decreased blood volume resulting in poor oxygen transport • Neurogenic - caused by general vessel dilation which does not allow typical 6 liters of blood to fill system, decreasing oxygen transport • Cardiogenic - inability of heart to pump enough blood • Respiratory - lungs unable to supply enough oxygen to circulating blood (may be the result of pneumothorax) • Psychogenic - syncope or fainting caused by temporary dilation of vessels reducing blood flow to the brain

23. Signs and Symptoms of Shock • Moist, pale, cold, clammy skin • Weak rapid pulse, increasing shallow respiration decreased blood pressure • Urinary retention and fecal incontinence • Irritability or excitement, and potentially thirst

24. Management of a Patient in Shock • Maintain core body temperature • Elevate feet and legs 8-12” above heart • Positioning may need to be modified due to injury • Keep patient calm as psychological factors could lead to or compound reaction to life threatening condition • Limit onlookers and spectators • Reassure the patient • Do not give anything by mouth until instructed by physician

25. Secondary Survey Once patient is deemed stable secondary survey can begin Assessment of vital signs Pulse Level of Consciousness Blood Pressure Temperature Skin Pupils

26. Pulse • Pulse - direct extension of heart function • Normal is 60-80 beats per minute (athlete’s may be slightly lower) • Child’s pulse is generally 80-100 bpm • Rapid and weak could indicate shock, bleeding, diabetic coma or heat exhaustion • Rapid and strong could indicate heatstroke, fright • Strong and slow indicates skull fx or stroke • No pulse = cardiac arrest or death

27. Consciousness • Alertness and awareness of environment, as well as response relative to vocal stimulation • Head injury, heat stroke, diabetic coma can alter athlete’s level of consciousness • Can be assessed using a variety of scales • AVPU scale • Alertness, verbal (responding to voice), pain (responds to painful stimulus), unresponsive (no response to pain) • Glasgow Coma scale

28. Blood Pressure • Above 140 mm Hg may be high and below 110 may be low for systolic • Should stay between 60 and 85 mm Hg for diastolic • Must inflate cuff above antecubital fossa (up to 200 mm Hg) • Slowly deflate cuff listening for first beating sound (systolic) and final sound (diastolic) with stethoscope

29. Temperature • Normal is 98.6 o F • Measure with thermometer in mouth, under armpit, against tympanic membrane • Core temperature is best measured rectally • Changes in temperature can be reflected in skin temperature • Digital oral thermometers are also reasonably accurate • Temperature changes can be the result of disease, cold exposure, pain, fear, nervousness • Lowered temperature is often accompanied by chills, teeth chattering, blue lips, goose bumps and pale skin

30. Movement • Inability to move may indicate serious CNS deficits impacting motor control • Hemiplegia (inability to move one side) may be the result of brain trauma or stroke • Bilateral upper extremity sensory motor deficits could indicate cervical spine injury • Pressure on spine or injury below the neck could result in compromised function of lower limbs

31. Pallor • Skin Color • Can be an indicator of health • Red - Elevated temp, heat stroke, or high blood pressure • White - insufficient circulation, shock, fright, hemorrhage, heat exhaustion, or insulin shock • Blue (cyanotic) - airway obstruction or respiratory insufficiency • Dark pigmented skin is slightly different in response • Nail beds, and inside lips and mouth and tongue will be pinkish • With shock, skin around mouth and nose will have greyish cast and mouth and tongue will be bluish • During hemorrhaging, mouth and tongue will become grey • Fever is indicated by red flush tips of ears

32. Pupils • Extremely sensitive to situation impacting nervous system • Most individual’s pupils are regularly shaped • Disparities must be known by the athletic trainer in the event that a condition arises • Constricted pupils may indicate use of a depressant drug • Dilated pupils may indicate head injury, shock, use of stimulant • Failure to accommodate may indicate brain injury, alcohol or drug poisoning • Pupil response is more important than size

33. Nerve Response • Abnormal • Response to adverse stimuli can provide important information • Numbness and tingling in limb w/ or w/out movement could indicate nerve or cold damage • Blocked blood vessel could cause severe pain, lack of pulse, loss of sensation, • Total loss of pain sensation may be caused my hysteria, shock, drug use or spinal cord injury • Generalized local pain is an indicator that spinal injury is not present

34. Musculoskeletal Assessment Must use logical process to adequately evaluate extent of trauma Knowledge of mechanisms of injury and major signs and symptoms are critical Once the mechanism has been determined, specific information can be gathered concerning the affected area

35. Musculoskeletal Assessment • History should be taken • Describe events of injury and those leading up to it • Past history, previous injuries and treatment used • Sounds (snaps, cracks, pops = bone, ligament or tendon), grating, crepitus or rubbing, during or following the injury • Visual Observation • Inspection of injured and non-injured areas • Look for gross deformity, swelling, skin discoloration

36. Musculoskeletal Assessment • Palpation • Palpate the area to help determine nature of injury (start away from site of injury) • Determine extent of point tenderness, affected structures and other deformities (not apparent visually) • Assessment Decisions • Determine 1) seriousness of injury, 2) type of first aid and immobilization required, 3) need for immediate referral, 4) type of transportation from field to sideline, training room or hospital • All information concerning the evaluation and decisions must be documented

37. What now? • Immediate Treatment • Primary goal is to limit swelling and extent of hemorrhaging • If controlled initially, rehabilitation time will be greatly reduced • Control via RICE • REST • ICE • COMPRESSION • ELEVATION

38. RICE? • REST • Days of rest differ according to extent of injury • ICE • Initial treatment of acute injuries • Used for strains, sprains, contusions, and inflammatory conditions • Ice should be applied initially for 20 minutes and then repeated every 1 - 1 1/2 hours (thaw completely) and should continue for at least the first 72 hours of new injury

39. RICE? • COMPRESSION • Decreases space allowed for swelling to accumulate • Important adjunct to elevation and cryotherapy and may be most important component • A number of means of compression can be utilized (Ace wraps, foam cut to fit specific areas for focal compression) • ELEVATION • Reduces internal bleeding due to forces of gravity • Prevents pooling of blood and aids in drainage • Greater elevation = more effective reduction in swelling