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

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
• 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 athlete
• 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 and 6) location of emergency
– 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
– Individual should be assigned to accompany
athlete to hospital
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 athlete is a minor, ATC should try to obtain
consent from parent prior to emergency treatment
• Consent indicates that parent is aware of
situation, is aware of what the ATC 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 athlete to save athlete’s 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
• Primary survey
– Performed initially to establish presence of lifethreatening 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 lifethreatening consequences
Dealing with Unconscious Athlete
• 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 athlete supine and not breathing, ABC’s
should be established immediately
– If athlete unconscious and breathing, nothing
should be done until consciousness resumes
– If prone and not breathing, log roll and
establish ABC’s
– 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
Primary Survey
• Life threatening injuries take precedents
– Those injuries requiring cardiopulmonary
resuscitation, profuse bleeding and shock
• Emergency Cardiopulmonary Resuscitation
– Evaluate to determine need
– Should be certified through American Heart
Association, American Red Cross or National
Safety Council
• Establish Unresponsiveness
– Gently shake and ask athlete “Are you okay?”
– If no response, EMS should be activated and
positioning of body should be noted and
adjusted in the event CPR is necessary
• Equipment Considerations
– Equipment may compromise lifesaving efforts
but removal may compromised situation further
– Facemask should be removed appropriate 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
• ABC’s of CPR
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–
–
A - airway opened
B - breathing restored
C - circulation restored
Generally when A is restored B & C will follow
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
• Modified
technique can be
used when neck
injury is
suspected
• Modified jaw
thrust maneuver
Establishing Breathing
• Look, listen and feel
• While maintaining
pressure on forehead,
pinch nose, hold head
back
• Take deep breath, and
create seal around lips
and perform 2 slow
breaths (raise chest
1.5- 2”
• If breath does not go in, re-tilt and ventilate or
airway is obstructed perform finger sweep
Means of Artificial Respiration
Establishing Circulation
• Locate carotid
artery and
palpate pulse
while
maintaining
head tilt
position
• Locate margin of
ribs and xiphoid
process of sternum
• Two fingers width
above xiphoid
process, place heal
of hand on lower
portion of sternum
• Place other hand on
top with fingers
parallel of
interlocked
• Keep elbows
locked with
shoulders directly
above patient
• Compress chest
1.5-2” (15 times
per 2 breaths)
• After 4 cycles
reassess pulse (if
not present
continue cycle)
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 can be used to
clear the airway
• Stand behind athlete
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
• If athlete becomes unconscious, open airway and
attempt to ventilate.
• If airway still obstructed, re-tilt and re-ventilate
• If not ventilation, perform 15 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
• Index finger should
be inserted in
mouth along cheek
• Using hooking
maneuver, pull
across to free
impediment
• Attempt to
ventilate after each
sweep until athlete
is breathing
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
• Electrodes are placed at the left apex and
right base of chest - when turned on,
machine indicates if and when defibrillation
necessary
• Maintenance is minimal for unit
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
• INSERT Oxygen
administration photo
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
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 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
– Eleven points on either side of body where
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
• 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
athlete 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
• Management
– Maintain core body temperature
– Elevate feet and legs 8-12” above heart
– Positioning may need to be modified due to
injury
– Keep athlete calm as psychological factors
could lead to or compound reaction to life
threatening condition
– Limit onlookers and spectators
– Reassure the athlete
– Do not give anything by mouth until instructed
by physician
Secondary Survey
• Once athlete 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
– Respiration - 12 breaths per minute or 20-25 for
children
•
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•
•
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/ s 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 135 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
– 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
• 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
– 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
– 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
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•
•
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
• For additional information refer to Chapter 15
– 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
– Half-ring splint
• Used for femoral fractures
• Requires extensive practice
• Open fractures must be dressed appropriately to
avoid contamination
– Splint where athlete 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
Moving and Transporting Injured
Athletes
• 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 Athlete 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
– 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 require 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 athlete is a football player, helmet must stay
in place with face mask removed
– Head and neck are stabilized by strapping
– Trunk and limbs are secured
– If athlete 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 athlete, halves of stretcher are placed at
each side of prone athlete, and slid together until
hinges lock, scooping athlete onto stretcher
• No log roll necessary
• 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
– Complete and even support should be provided on
both sides by individuals of equal height when
providing ambulatory aid
– Arms of athlete are draped over shoulders of
assistants, with their arms encircling his/her back
• Manual Conveyance
– Used to move mildly injured athlete a greater
distance than could be walked with ease
– Carrying the athlete 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 athlete is lifted and
placed gently on stretcher
– Careful examination is required is stretcher needed
– May be necessary if athlete can’t be transported
comfortably in seated position
• Pool Extraction
– Requires special consideration
• When athlete does not have injuries to head or neck,
instruct athlete to roll to back and then with crosschest technique, pool athlete to side of pool
• If athlete not breathing, single rescuer should get
athlete out of pool quickly and perform CPR
• With 2 rescuers, resuscitation should begin in water
immediately
– (One supports head and shoulders, other provides rescue
breathing)
– Athlete with suspected head or neck injury
requires special consideration
• Must be approached in the water slowly not to
disrupt water
– Head-chin support method should be used
• Forearms stabilize chest and upper back, hands used
to stabilize head and neck
• Roll athlete to the back and maintain horizontal
position in water
– Athlete should be secured to spine board in
water while stabilization is maintained
– Once on board, athlete should be stabilized and
when removed from the pool, it should occur
head first
Proper Fit and Use of Crutch or
Cane
• 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 athlete
– Athlete 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
– 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 affected side
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