© 2011 McGraw-Hill Higher Education. All rights reserved. Chapter 12: On-the-Field Acute Care and...

© 2011 McGraw-Hill Higher Education. All rights reserved.

Chapter 12: On-the-Field Acute Care and Emergency

Procedures

• When injuries occur, while generally not life-threatening, they require prompt care

• Emergencies are unexpected occurrences that require immediate attention - time is a factor– First hour (“Golden hour”) is critical

• Mistakes in initial injury management can prolong the length of time required for rehabilitation or cause life-threatening situations to arise


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


• Issues plan should address– Separate plans should be developed for each

facility• Outline personnel and role• Identify necessary equipment

– Established equipment and helmet removal policies and procedures

– Availability of phones and access to 911– Athletic trainer should be familiar with

community based emergency health care delivery plan

• Be aware of communication, transportation, treatment policies


– Community based care (continued)• 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 and 7) building limitations

– Keys to gates/locks must be easily accessible– Key facility and school administrators must be

aware of emergency action plans and be aware of specific roles – should be rehearsed

– Individual should be assigned to accompany patient to hospital

– Plans should also be in place for other game personnel (coaches, referees, spectators)



EMERGENCY ACTION PLAN (EAP)

• Athletic trainers in clinic, hospital or industrial settings should also have EAP’s in place– In hospital setting it is likely that a plan is

established – should be familiar with it– In clinic and corporate settings protocols

similar to aforementioned should be followed.


Cooperation between Emergency Care Providers

• Cooperation and professionalism is a must– Athletic trainer generally first to arrive on

scene of emergency, has more training and experience transporting athlete than physician

– EMT has final say in transportation, athletic trainer assumes assistive role

• To avoid problems, all individuals involved in plan should practice to familiarize themselves with all procedures (including equipment management)


Parent Notification• When patient is a minor, athletic trainer should

try to obtain consent from parent prior to emergency treatment

• Consent indicates that parent is aware of situation, is aware of what the athletic trainer wants to do, and parental permission is granted to treat specific condition

• When unobtainable, predetermined wishes of parent (provided at start of school year) are enacted

• With no informed consent, consent implied on part of patient to save life


Principles of On-the-Field Injury Assessment

• Appropriate acute care cannot be provided without a systematic assessment occurring on the playing field first

• On-field assessment– Determine nature of injury– Provides information regarding direction of

treatment– Divided into primary and secondary survey


Figure 12-1


• Primary survey– Performed initially to establish presence of

life-threatening condition– Airway, breathing, circulation, shock and

severe bleeding – Used to correct life-threatening conditions

• 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


Primary Survey

• Life threatening injuries take precedents– Those injuries requiring cardiopulmonary

resuscitation, profuse bleeding and shock– Level of consciousness must also be assessed

• Emergency Cardiopulmonary Resuscitation– Evaluate to determine need– Should be certified through American Heart

Association, American Red Cross or National Safety Council


Dealing with Unconscious Patient

• Provides great dilemma relative to treatment

• 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– Remove helmet only after neck and spine injury

is ruled out (facemask removal will be required in the event of CPR)


– With patient supine and not breathing, ABC’s should be established immediately

– If patient unconscious and breathing, nothing should be done until consciousness resumes

– If prone and not breathing, log roll and begin CPR immediately

– If prone and breathing, nothing should be done until consciousness resumes --then carefully log roll and continue to monitor ABC’s

– Life support should be monitored and maintained until emergency personnel arrive

– Once stabilized, a secondary survey should be performed


Overview of Emergency Cardiopulmonary Resuscitation


• A careful evaluation should be performed to determine if CPR is necessary

• Individuals should be certified/recertified routinely in CPR – American Heart Association, American Red

Cross, National Safety Council


• Check-Call-Care– Check the scene;

identify others to assist

– Call 911– Care should be

initiated

– Time is critical for the patient needing CPR

• Equipment Considerations– Equipment may compromise lifesaving efforts but

removal may compromise situation further– Facemask should be removed w/ a combination

of electric screwdriver and clip cutters (Anvil Pruner, Trainer’s Angel, FM Extractor)

– Use of pocket mask/barrier mandated by OSHA during CPR to avoid exposure to bloodborne pathogens

– Shoulder pads and helmet must either both come off or both remain in place

– Removal should occur if:• 1) Head is not secure, 2) airway can’t be controlled, 3)

facemask can’t be removed in reasonable amount of time, 4)helmet prevents immobilization



Figure 12-3 & 4

• Establish Unresponsiveness– Ask athlete “Are you okay?” and gently tap – If no response, EMS should be activated and

positioning of body should be noted and adjusted in the event CPR is necessary

– A patient that is breathing in a prone or side lying position should be placed in a recovery position

– If in a position other than supine the patient should be carefully log rolled as a unit to limit cervical motion


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


• Modified technique can be used when neck injury is suspected

• Modified jaw thrust maneuver

• Not always effective and should be utilized by trained personnel

Figure 12-7B


Establishing Breathing

• Look, listen and feel• While maintaining

pressure on forehead, pinch nose, hold head back

• OSHA has mandated use of barrier shield by AT’s to minimize transmission of bloodborne pathogens

• Take deep breath, and create seal around lips and perform 2 slow breaths (raise chest 1.5 - 2”)


Figure 12-8


• If breath does not go in, re-tilt and ventilate • If airway continues to be obstructed, perform 30

chest compression and look for object• Repeat until ventilation occurs• If available, use bag/valve mask for respiration

Figure 12-9

Administering Supplemental Oxygen

• May prove to be critical in treating severe injury or illness

• Requires the use of bag-valve mask and pressurized container of oxygen

• Canister is green with yellow oxygen label• Training is required• Provides patient with a significantly high

concentration of oxygen (up to 90%)• Deliver at a rate of 10-15 liters/minute



Figure 12-10

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 chest compressions should be given after 2 rescue breaths

• Maintain an open airway• Place heel of hand, closest to head on

sternum between the nipples


• Place other hand on top with fingers parallel

• Keep elbows locked with shoulders directly above patient

• Compress chest 2-2.5” (30 times per 2 breaths)

• After 5 cycles reassess pulse (if not present continue)


Figure 12-11 & 12

• Compressions should occur at a rate of 100 per minute• In children, compressions should occur to depth of 1.5-

2”

• In 2008, American Heart Association proposed Hands-Only CPR in instances where individual collapses unexpectedly, is unresponsive and is not breathing– Rescuer calls 911 and begins compressions– Continues until rescuers with AED arrive


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


• Most can be trained to use AED in an hour

• Requires trained individual to follow instructions regarding breaths and chest compression

• Electrodes are placed at the left apex and right base of chest - when turned on, machine indicates if and when defibrillation necessary

• Patient should not be on metal or wet surface during use


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


• Give 5 back blows with the palm of the hand between the shoulder blades

• Stand behind patient with one fist against the body and other over top just below the xiphoid process

• Provide forceful thrusts to abdomen (up and in) until obstruction is clear


Figure 12-14

• If patient becomes unconscious, assist to the ground, open airway and attempt to ventilate.

• If airway remains obstructed, re-tilt and re-ventilate• If ventilation fails, perform 30 chest compressions

and finger sweep to clear obstruction– Be sure not to push object in further with sweep

• Repeat cycle until air goes in• When athlete begins to breath on own, place in

comfortable recovery position while lying on their side


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


External Bleeding• Stems from skin wounds, abrasions, incisions,

lacerations, punctures, avulsions or amputations• 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– Points on either side of body where direct pressure is

applied to slow bleeding



Figure 12-17

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


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

• Several types of shock– Hypovolemic - decreased blood volume

resulting in poor oxygen transport– Respiratory - lungs unable to supply enough

oxygen to circulating blood (may be the result of pneumothorax)

– 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


– Psychogenic - syncope or fainting caused by temporary dilation of vessels reducing blood flow to the brain

– Septic - result of bacterial infection where toxins cause smaller vessels to dilate

– Anaphylactic - result of severe allergic reaction

– Metabolic - occurs when illness goes untreated (diabetes) or when extensive fluid loss occurs

• Signs and Symptoms– 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


• Management– 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


Secondary Survey• Once patient is deemed stable secondary survey can

begin• Assessment of vital signs

– 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


– State of Consciousness• Must always be assessed• 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 assesses the following areas

– Alertness, verbal (responding to voice), pain (responds to painful stimulus), unresponsive (no response to pain)

• ACDU scale =– Alert– Confused– Drowsy– Unresponsive


– Respiration - 12 bpm or 20-25 for children• Shallow - shock• Irregular or gasping - cardiac compromise• Frothy w/ blood - chest injury• Must assess movement of air through mouth and nose

– Blood Pressure• Measured w/ sphygmomanometer indicating arterial

pressure• Systolic blood pressure is pressure created by

ventricle contraction (normal = 115-120 mm Hg)• Diastolic pressure is residual pressure present

between beats (normal = 75-80 mm Hg)• Females are usually 8-10 mm Hg less


• Above 140 mm Hg may be high and below 110 may be low for systolic

• Diastolic Should stay between 60 and 85 mm Hg • 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

– 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© 2011 McGraw-Hill Higher Education. All rights reserved.

• 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

– 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 grayish cast and mouth and tongue will be bluish

– During hemorrhaging, mouth and tongue will become gray

– Fever is indicated by red flush tips of ears

– 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

Figure 12-21


– 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


– Abnormal Nerve Response• 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


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


• 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


• 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


• 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


– REST • Stresses and strains must be removed following injury as healing begins

immediately• Days of rest differ according to extent of injury• Rest should occur 72 hours before rehab begins

– 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 and should continue for at least the first 72 hours of new injury• Treatment must last at least 20 minutes to provide adequate tissue cooling

and can be continued for several weeks


– 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)

• Compression should be maintained daily and throughout the night for at least 72 hours (may be uncomfortable initially due to pressure build-up)

– ELEVATION• Reduces internal bleeding due to forces of gravity• Prevents pooling of blood and aids in drainage • Greater elevation = more effective reduction in

swelling


• Emergency Splinting– Should always splint a suspected fracture before moving– Without proper immobilization increased damage and

hemorrhage can occur (potentially death if handled improperly)

– It is a simple process– New equipment has also been developed– Rapid form immobilizer

• Styrofoam chips sealed in airtight sleeve• Moldable with Velcro straps to secure• Air can be removed to make splint rigid


– Air splint• Clear plastic splint inflated with air around affected part• Can be used for splinting but requires practice• Do not use if it will alter fracture deformity• Provides moderate pressure and can be x-rayed

through

– SAM splint• Thin sheet of pliable aluminum covered with padding

– Half-ring splint• Used for femoral fractures• Requires extensive practice• Open fractures must be dressed appropriately to avoid

contamination

– Splint where patient lies and avoid moving them– Splint one joint above and one below fracture


– Lower Limb Splinting• Fractures of foot and ankle require splinting of foot and knee• Fractures involving knee, thigh, or hip require splinting of whole

leg and one side of trunk

– Upper Limb Splinting• Around shoulder, splinting is difficult but doable with sling and

swathe with upper limb bound to body• Upper arm and elbow should be splinted with arm straight to

lessen bone override• Lower arm and wrist fractures should be splinted in position of

forearm flexion and supported by sling• Hand and finger fractures/dislocations should be splinted with

tongue depressors, roller gauze and/or aluminum splints


• Splinting of the spine and pelvis– Best splinted and

moved with a spine board

– Total body rapid form immobilizers have been developed for dealing with spinal injuries

– Effectiveness has yet to be determined

Figure 12-23 & 34


Moving and Transporting Injured Patient

• Must be executed with techniques that will not result in additional injury

• No excuse for poor handling

• Planning is necessary and practice is essential

• Additional equipment may be required


• Placing Patient on Spine Board– EMS should be contacted if this will be

required– Must maintain head and neck in alignment

of long axis of the body– One person must be responsible for head

and neck at all times– Primary emergency care must be provided

to maintain breathing, treating for shock and maintaining position of athlete

– Permission should be given to transport by physician


• Steps to follow for spine boarding– Examiner stabilizes head & neck

– Perform primary survey & retrieve spine board

– Prone athlete should be log rolled onto back for CPR or secured to spine board

• All extremities should be placed in axial alignment

• Rolling requires 4-5 individuals

• Neck must be maintained in original position as roll occurs

• Place spine board close to athlete

• Each assistant is responsible for a segment

– With board close, captain (at head) gives command to roll onto board


– Head and neck continue to be stabilized once on the board

– If patient is a football player, helmet must stay in place with face mask removed

– Head and neck are stabilized with strapping and blocks

– Trunk and limbs are secured

– Rescuers then position themselves so that they can stand with the board on command

– Spine board can then be carried from the field and/or loaded into a transport vehicle



Figure 12-25

• Spine Boarding Supine Patient– If patient is supine, straddle-slide method can be used

• Again requires 4-5 people (captain responsible for head and neck, 2 others for trunk and limbs, and 4th to slide the board)

– Scoop stretcher can be used, although not always considered safe for spinal injuries

• With prone patient, halves of stretcher are placed at each side of supine patient, and slid together until hinges lock, scooping athlete onto stretcher

• No log roll necessary


Alternative Spine Boarding Techniques


Figure 12-26

• Ambulatory Aid– Support or assistance provided to injured individual to walk

– Prior to walking, serious injury should be ruled out along with further injury with walking

– Patient should gradually move from supine, to seated to standing positions

– Complete and even support should be provided on both sides by individuals of equal height when providing ambulatory aid

– Arms of patient are draped over shoulders of assistants, with their arms encircling his/her back


• Manual Conveyance– Used to move mildly injured patient a greater

distance than could be walked with ease

– Carrying the patient can be used following a complete examination

– Convenient carry is performed by two assistants

• Stretcher Carrying– Best and safest mode of transport

– With all segments supported patient is lifted and placed gently on stretcher

– Careful examination is required if stretcher needed

– May be necessary if patient can’t be transported comfortably in seated position


Figure 12-27 & 28


• Pool Extraction– Requires special consideration

• Athletic trainer should be able to swim or have water safety/lifeguard training• Rescue tube should always be available

– Following procedures should be utilized• For minor injuries, with patient close to pools edge, rescue tube can be used• If far from edge entering the water will be necessary

© 2011 McGraw-Hill Higher Education. All rights reserved. Figure 12-30

• When no injuries to head or neck, approach athlete from behind, reach under arm pits and use rescue tube (between swimmer and clinician)

– Tube can be used to help support swimmer

– Must keep swimmer calm while moving towards edge of pool

• Prior to removing swimmer from water you must consider level of assistance, size of swimmer, need for CPR

• If swimmer must come out of the water a spine board should be utilized

– Will require spine board and 2 rescuers


Figure 12-31

– Swimmer with suspected head or neck injury requires special consideration

• Must be approached in the water slowly not to disrupt water

• A single rescuer can stabilize the head and neck– Place the arms of the swimmer overhead and compress against

the head

– Stabilizes the head and neck

• Swimmer should be secured to spine board in water while stabilization is maintained

• Once on board, swimmer should be stabilized and when removed from the pool, it should occur head first



Figure 12-32


Figure 12-33

Emergency Emotional Care

• Emergency care relative to emotional reactions to trauma must also be provided– Accept rights to personal feelings, show

empathy, not pity– Accept injured person’s limitations as real– Accept own limitations as provider of first aid– Be empathetic and calm, being obvious that

athlete’s feelings are understood and accepted


• When lower extremity ambulation is contraindicate a crutch or cane may be required

• Faulty mechanics or improper fitting can result in additional injury or potentially falls

• Fitting patient– Patient should stand with good posture, in flat soled

shoes

– Crutches should be placed 6” from outer margin of shoe and 2” in front


– Crutch base should fall 1” below anterior fold of axilla

– Hand brace should be positioned to place elbow at 30 degrees of flexion

– Cane measurement should be taken from height of greater trochanter

• Walking with Cane or Crutch– Corresponds to walking– Tripod method

• Swing through without injured limb making contact with ground

– Four- point crutch gait• Foot and crutch on same side move forward

simultaneously with weight bearing


– Cane Tripod technique• Used on level surface and modified with stair

climbing• Unaffected support leg moves up one step

while body weight is supported on crutch--followed by transfer of weight to unaffected leg and affected leg is pulled up to step

• Reversed when descending stairs• Must be mindful of wet surfaces

– Crutch walking follows a progression• Non-weight bearing (NWB) to touch down

weight bearing (TDWB) partial (PWB) and full weight bearing (FWB)

– When using cane or one crutch, support should be held on unaffected side



Figure 12-34 & 35

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