On the Field Emergency Management

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 ABCs
• Understand Mechanism
• Immediate reduction techniques
• Knowledge of common complications
• Plan for aftercare
• When in doubtIMMOBOLIZE

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 TRACTIONNO 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)
• ATCs 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
  trainers angel)
• LEAVE HELMET AND SHOULDER PADS ON
• Re-check ABCs
• 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 years concussion focus team
  information to develop protocol
• We also utilized the SCAT card

22
Action Plan for Concussions

• Cranial Nerve Testing
•  
• Nerve S/M Test
• 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
• MOTOR SENSORY REFLEX
• 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 Emergency Delayed Transport
• Loss of consciousness gt ?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 (gt102)
• 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 (gt104)
• 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 in miles 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

• ACTIVATING EMS
• 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
• Athletes 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