Transcript Emergency Action Planning for GHS ATC’s and SHCC

On Field Management:
Athletic Emergencies
Jim Ellis, MD, FACEP
Faculty, Primary Care Sports
Medicine Fellowship Program
Steadman Hawkins Clinic of
the Carolinas
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.
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
ATLS, ACLS, “ASLS”
Advanced Sports Life Support
Airway
Breathing
Cardiac
Circulation
Cervical Spine
Concussion
Conditions/Environment
Crisis Management/Disaster
Diabetes
Airway Problems
Direct Trauma
–Anterior neck trauma
Indirect Trauma
–Severe concussion can lead to
unprotected airway
–High cervical spine injury
Airway Evaluation
Is the player talking?
Is he tachypneic or agonal?
What is the pulse ox?
EMS bring pulse ox!
Airway - Maintainable
Supplemental oxygen
Chin lift or jaw thrust (for c-spine)
Nasal or oral airway
Bag-valve-mask/pocket mask/barrier
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
Endotracheal Intubation
The
The
The
The
right
right
right
right
person
equipment
drugs
plan for the difficult airway
Anatomy
Airway Adjuncts
Intubating Stylet
Lighted Stylet
LMA *great tool for the airway novice
Intubating LMA
Levitan Fiberoptic Scope
LMA and Intubating LMA
Surgical Airway
Unsuccessful endotracheal intubation
Mandibular fracture
Anterior neck trauma
Laryngeal fracture
Stridor
Surgical Airway
Know the anatomy
Know the equipment
Know the procedure
2002 Super Bowl
Kurt Warner played with a laryngeal
fracture – sideline cricothyrotomy kit
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
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
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!
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
2008 Lauren Chang
Cheerleader accidently kicked in the
chest
Had collapsed lungs - bilateral
Died from tension pneumothorax
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)
2001 Rashidi Wheeler
Northwestern football player
Died secondary to asthma
Known asthmatic in difficult workout
?Complicated by ephedra use
Cardiac Problems
Cardiac Etiology
–Sudden cardiac death
–Arrhythmia of unknown etiology
–Hypertrophic cardiomyopathy
–Commotio cordis/cardiac
concussion (hockey and baseball)
–Coronary artery disease in coaches
and referees*
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!
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
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
1996 Polish Chef de Mission
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
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
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
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
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)
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)
1989 Clint Malarchuk
NHL goalie with skate to the neck
Life threatening hemorrhage
Direct pressure and rapid transport
Went directly to OR for vascular
surgery and survived
Circulation Problems
Sickle Cell Trait
- easy to diagnosis with a simple
screening blood test
- 10 known deaths since 2000
- 8-10% of black population
- NATA policy statement
- NCAA ?mandatory testing
Circulation Problems
Sickle Cell Trait
- Identify high risk activities
- common in off- or pre-season
- monitor first few workouts
- ease into preseason conditioning
- SCT muscle pain and weakness
- dehydration cramps/”locking up”
2008 Ereck Plancher
Collegiate athlete with known sickle
cell trait
Off-season program
Strenuous workout
Exhibited difficulty
Died on the field
Sickle Cell Trait - deaths
Preston Birdsong –TTU 2000
DeVaughn Darling – FSU 2001
Aaron Richardson – BGU 2004
Aaron O’Neal – Missouri 2005
Dale Lloyd – Rice 2006
Chad Wiley – NC A&T 2008
Ja'Quayvin Smalls – 2009 WCU
Bennie Abram – 2010 Ole Miss
Cervical Spine Injury
Cervical Spine Immobilization
Clinical decision
Standardize approach and procedure
Have unencumbered airway access
Don’t assume that EMS knows what
to do – you teach them how you
want it done and practice before the
season (NATA video)
Spinal Cord Injury Treatment
“Options”
High dose steroids –
methylprednisolone 30 mg/kg bolus
Maintenance dose – 5.4 mg/kg/hr
(needs to be started at hospital
within 3-8 hours)
Hypothermia – 30 cc/kg of LR cooled
to 37-40 degrees F should drop temp
to around 95. Ideal temp between
92-94.
Kevin Everett case
2007 Kevin Everett
Made a tackle on the kickoff with his
head down
Received cold IV fluids and steroids
The real key to his recovery was
going to the appropriate hospital and
being in surgery within 2 hours
Concussion
Dr. Sease concussion update
Clinical judgment determines if
severity of head injury negates the
validity of the c-spine exam
Always fear the concussion when
paired with the C1/C2 fracture –
axial load with flexion
If immobilizing, remove the
facemask even if awake and talking
2006 and 2007 Trent Green
Concussions while playing with
Chiefs (2006) and Dolphins (2007)
Both were significant and had
prolonged recovery periods
Was able to return to play after
evaluation and clearance
2000 Blaine Bishop
Titans DB in Super Bowl
Brief LOC / neck pain / L arm
numbness
Spinal immobilization
Transport to hospital
Final diagnosis – concussion/cervical
strain
Comprehensive pregame planning
Conditions/Environment
Heat illness
Heat cramps/exhaustion/stroke
33 heat related deaths in football
since 1995
Korey Stringer of the Minnesota
Vikings
Steve Belcher of the Baltimore
Orioles
Conditions/Environment
Lightning – approximately 100-120
people die per year in the US from
lightning
In 2006, 5 people died at one event
during a storm (softball)
Rosbin Yuman and Lester Marrioquin
soccer players killed in 2001
Tend to the unconscious first – they
usually need more electricity (AED)!
Crisis Management/Disaster
Planning
Know the disaster plan/EAP
Have a written Emergency Action Plan for
every venue including practice
Practice the EAP – docs, ATC’s, coaches
Is there an evacuation plan?
Be familiar with the Rally Point
Take care of the visiting team
Have a roster for roll call
Diabetes
Know your athletes
Either high or low when they are sick
Urine dipstick is quick and easy
High – dipstick + for glucose and maybe
ketones if DKA (Rx with NS)
Low – dipstick may have ketones from
starvation but not spilling glucose (Rx with
D50W or glucagon emergency kit)
Usually need to call EMS in either situation
Diabetic Athletes
Jay Cutler
Arthur Ashe
Ty Cobb
Scott Verplank
Jackie Robinson
Joe Frazier
Billie Jean King
Joe Gibbs
What EMS should have:
Airway equipment and supplies
Portable pulse oximeter
End tidal CO2 detector
Manual defibrillator/cardiac monitor
ACLS drugs
RSI drugs if trained MD or state allows
EMS to use
Steroids if you use them for SCI
?Oversize backboard for football
Don’t assume that they have things!
What you should have
Airway plan – LMA, #11 blade, curved
hemostats
Breathing plan – 14 gauge angiocath,
extra inhaler, Flow Meter, Epi(1:1000)
Cardiac plan – know how to use AED
Disaster plan – be familiar with EAP
Procedure plan – know who should and
who can do what procedure
Transport plan – appropriate facility
EMS Relationship
Work closely with them
Preseason practice of scenarios
Let them know what is expected of
them, when to come out, what to do
Demand consistency in staffing
Require their best trained personnel
Who should do what
Paramedics can intubate
Only physicians can do surgical airway
Only physicians can needle decompress
tension pneumothorax
ATC’s, MD’s, coaches, anyone with
training can use AED
EMT-Basic has limited training and
experience in the life threatening
situations
Questions
Life threatening athlete situations
exist in almost every sport
Always know who is in charge
Always know who is best trained for
a particular incident
Always be prepared and be
resourceful if unusual situations arise