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

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


1
Chapter 12 On-the-Field Acute Care and Emergency
Procedures
2
  • 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

3
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

4
  • 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

5
  • 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

6
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)

7
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 athletes life

8
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

9
  • 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

10
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)

11
  • With athlete supine and not breathing, ABCs
    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 ABCs
  • If prone and breathing, nothing should be done
    until consciousness resumes --then carefully log
    roll and continue to monitor ABCs
  • Life support should be monitored and maintained
    until emergency personnel arrive
  • Once stabilized, a secondary survey should be
    performed

12
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

13
  • 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, Trainers Angel, FM
    Extractor)
  • Use of pocket mask/barrier mandated by OSHA
    during CPR to avoid exposure to bloodborne
    pathogens

14
  • ABCs of CPR
  • A - airway opened
  • B - breathing restored
  • C - circulation restored
  • Generally when A is restored B C will follow

15
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

16
  • Modified technique can be used when neck injury
    is suspected
  • Modified jaw thrust maneuver

17
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

18
Means of Artificial Respiration
19
Establishing Circulation
  • Locate carotid artery and palpate pulse while
    maintaining head tilt position

20
  • 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

21
  • 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)

22
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

23
  • 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

24
  • 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

25
  • 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

26
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

27
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

28
  • INSERT Oxygen administration photo

29
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

30
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 direct
    pressure is applied to slow bleeding

31
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32
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

33
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

34
  • 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

35
  • 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

36
  • 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

37
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 (athletes may
    be slightly lower)
  • Childs 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

38
  • Respiration - 12 breaths per minute 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/ 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

39
  • 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

40
  • 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

41
  • 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 individuals pupils are regularly shaped
  • Disparities must be known by the athletic trainer
    in the event that a condition arises

42
  • 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

43
  • 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
    athletes 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

44
  • 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

45
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

46
  • 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

47
  • 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

48
  • 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

49
  • 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

50
  • 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

51
  • 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

52
  • 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

53
  • 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

54
  • 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

55
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

56
  • 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

57
  • 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

58
  • 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

59
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60
  • 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

61
  • 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 cant be transported
    comfortably in seated position

62
  • Pool Extraction
  • Requires special consideration
  • When athlete does not have injuries to head or
    neck, instruct athlete to roll to back and then
    with cross-chest 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

63
  • 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

64
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

65
  • 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

66
  • 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

67
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68
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 persons limitations as real
  • Accept own limitations as provider of first aid
  • Be empathetic and calm, being obvious that
    athletes feelings are understood and accepted
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