Download Management of Medical Illnesses and Non

Management of Medical Illnesses
and Non-Orthopaedic Injuries on the
Field and in the Training Room
Jim Ellis, MD, FACEP
Faculty, Sports Medicine
Fellowship - Steadman Hawkins
Clinic of the Carolinas
Assistant Team Physician
Atlanta Falcons
Objectives
Preventative measures for medical
illnesses and non-orthopaedic
injuries
Case Presentations – focusing on
differential diagnosis, diagnosis and
treatment
Return to play
Panel Discussion and Questions
Case Presentations
Heat Illness
Cardiac Arrest
Abdominal Injuries and Problems
Seizure
Concussion
Cervical Spine Injury
Prevention of Heat Illness
Practice time
WBGT
Water breaks
Helmets>shoulder pads>full gear (5d)
Pre-hydration
Ice tubs
Rectal temps
Temperature pill monitors
Risk Factors for Heat Illness
Poor acclimatization
Poor conditioning
Poor hydration
Sickle cell trait
Any acute illness (fever, vomiting)
Medications (Bactrim, ephedra,
antidepressants, alcohol, ecstasy)
Body weight loss >3%
Heat Illness Case Study
Kurt Wagner, ATC
Steadman Hawkins Clinic of the
Carolinas
Hillcrest High School
Case Presentation of Heat Illness
16 y/o male football player
History of muscle cramps
Incident occurred during football
training camp
Heat Illness
Practice ended at 11:30 AM
Temp: 88 deg
RH: 60%
Given electrolyte tablets prior to
practice
Given Gatorade during football
practice
Heat Illness
Began c/o muscle cramps on both legs
after he returned to the locker room after
practice
Removed football equipment/clothing
Given fluids and ice was applied to legs
Skin temp was warm and pt. was sweating
Muscle Cramps were getting worse
– More intense/more frequent in legs
– Muscle cramps in torso
Heat Illness
Put into cold water immersion
EMS activated
Began to have full body muscle
cramps
Shortness of Breath
Remained in CWI for 10-15 minutes
Heat Illness
Given IV fluids at ED
EKG was normal
Vital signs
– BP: 133/79
– Pulse: 88
– Temp: 95.3
Specific Gravity of Urine 1.030
Heat Illness
CPK: 9470 IU/liter (reference range 60 –
294)
Serum Creatinine: 1.2 mg/dL (reference
range 0.7 – 1.2)
Diagnosis: rhabdomyolysis, dehydration
Admitted to hospital
– Discharged 4 days later
– CPK decreased to 4684 IU/liter at
discharge
– Serum Creatinine decreased to 1.0
mg/dL
Heat Illness
After discharge
– No activity
– Increased fluid intake
– Monitored time in heat
2 months later
– CPK: 405 IU/liter
– Serum Creatinine 1.2 mg/dL
– Specific Gravity: 1.020
– Had no muscle cramps since discharge
Heat Illness
Return to Play
– Began with light activity
– Slowly increased activity for 2-3 weeks
– Able to return to return to football
games at end of season
More labs were scheduled and
referral to pediatric neurologist to
determine if there is underlying
muscle disease
Differential Diagnosis
Heat Cramps
Heat Exhaustion
Exertional Heat Stroke
Sickle Cell Trait
Underlying viral illness with fever
Gastroenteritis
Return to Play
Heat cramps that day is possible
Heat exhaustion 1-2 days
Exertional heat stroke much longer
Well hydrated
Acclimatized
Good physical conditioning
Usually 2-3 weeks depending on
severity
Prevention of Cardiac Arrest
Pre-participation physical
Murmur detection
ECG
Echocardiogram
Cardiology consult
Disqualification of an athlete
Importance of AED
Cardiac Arrest Case Study
Joni Canter, MBA, ATC, SCAT
Steadman Hawkins Clinic of the
Carolinas
South Carolina School for the
Deaf and the Blind
Cardiac Arrest Case Study
16 yo male, sophomore
Active in Special Olympics, Jump
Rope for Heart, Horseback Riding
and Swimming
2nd year playing football at SC School
for the Deaf and the Blind
Born with hole in heart, surgery at
birth
No Hx of cardiac problems
Cardiac Arrest Case Study
Collapsed during practice on
September 13, 2011
Full contact practice
Tackled below the waist
Stood up and signed “ready” to coach
Cardiac Arrest Case Study
Player fell to the
ground
Coach called for
me on the sideline
attending to 2
other players
Upon arrival, he
was seizing
I sent another
player to the
Health Center to
get the nurse
I sent a coach to
the Welcome
Center to call 911
I directed the other
players to the
sideline and
monitored
Cardiac Arrest Case Study
While he was seizing, he was
breathing
When seizing stopped, I stabilized CSpine and monitored
I asked a coach to cut the jersey and
shoulder pads and t-shirt open
When his belly stopped moving—
called for the other coach to get the
AED
Cardiac Arrest Case Study
Coach didn’t understand me—I
signed “black box” to the student
athletic trainer
Student athletic trainer and coach
opened the AED and began
placement
AED analyzed and advised shock
Delivered a shock and began CPR—
after 2 cycles, gurgling sounds heard
and weak breath felt
Cardiac Arrest Case Study
Weak, rapid carotid pulse and weak,
shallow breathing
Stabilized and monitored until nurse
arrived—checked BP (76/44 and
80/46) and radial pulse was unestablished
EMS arrived---transported to
Spartanburg Regional Medical Center
Cardiac Arrest Case Study
Heart monitor showed a rhythm that
was inconsistent with a 16 yo male
athlete
Taken by helicopter to Greenville
Memorial Hospital—pediatric ICU
Cardiologist and Neurologist
concluded it was a cardiac condition
Defibrillator was implanted 8 days
after event
Cardiac Arrest Case Study
Returned to school 2 weeks following the
event
No clearance for contact sports
Has been cleared for SO: Bocce Ball,
Swimming, Golf, Cheerleading, and
Bowling
He has been chosen as one of the “poster
children” for the American Heart
Association’s Heart Survivor for 20122013
Cardiac Arrest Case Study
Cardiologist could not conclude that
the AED saved his life
Can we conclude the outcome had it
not been used?
Differential Diagnosis
Hypertrophic Cardiomyopathy
Arrhythmia of unknown etiology
Commotio Cordis
Acute MI from coronary artery
anatomical abnormality
Other cardiac genetic anomaly
Return to Play
Depends on diagnosis and sport
Cardiology clearance
Sometimes indwelling pacemakers
and defibrillators are required
Medication can control some
arrhythmias
Prevention of Abdominal Problems
“Kidney” pads
Mono patients held out of sport
High index of suspicion with any
abdominal complaints
CT scan usually the best diagnostic
modality for unknown abdominal
pain or injury
Abdominal Problem Hydronephrosis
Case Study
Katie O’Connor, ATC
Steadman Hawkins Clinic of the
Carolinas
Wade Hampton High School
Who
•
•
17 year old female
Volleyball player
• 4 years high school
• Club athlete
Presentation
•
•
•
Occasional back pain/ tightness
during summer practice
no previous kidney issues
• 1 bladder infection as a child
back pain increased during
preseason tournament (mid august
2010)
Treatment
•
•
•
Morphine didn’t relieve pain
CT scan
Emergency surgery
• Stent placed
•
•
Drained 2 gallons of urine
Cleared for RTP with stent
Surgery Stats
•
•
12” long, 6” wide, 4” thick
5+ pounds
• new world record?
Family History
•
•
Dad’s Family
Sister
Outcome
• No current health problems
• No activity restrictions
• Very normal college student
Differential Diagnosis
Musculoskeletal back pain
Kidney stone
Pyelonephritis
Appendicitis
Splenic rupture
Traumatic intestinal perforation
Ovarian cyst
Ectopic pregnancy
Return to Play
Depends of diagnosis and sport
Needs clearance of surgeon
Post op laparoscopic appendicitis can
be back in 10-14 days
Athletes with open laparotomy
usually take a month or more to
return
Prevention of Seizures
With seizure disorder make sure
medication is therapeutic
Diabetes maintain tight control of
glucose and eat well especially in
pre-season conditioning workouts
Protect the airway of the seizing
patient to prevent aspiration and
hypoxia
Seizure Case Study
Ashley Raymond MS, ATC, CSCS
Head Athletic Trainer
Riverside High School
Seizures
decerebrateindicates most severe brain injury
Epileptic seizures are the most common
and caused by multiple things ranging
from sleep deprivation, dehydration,
metabolic disturbances, infection, fever,
and stroke, just to list a few that may be
more common in athletics
Case
Female, age 18
She was found lying on her left side and was
seizing, her eyes fluttered but did not respond to
verbal commands.
Maintained current position until we were able to
rule out cervical spine injury and found a pulse.
After 1 minute patient became alert and
responded to questions
– Where are you having pain? Lower abdomen and legs
(legs were very cold)
– Any neck pain? NO (positioned her on her back
supporting head with knees bent)
– Have you eaten or drank anything today? NO
– Did you take any medication? YES but couldn’t tell us
what it was
– Patient was pregnant but confirmed that she no longer
was as of a week ago
Emergency response
Keep calm
Move anything that may case harm away
from the victim
Place a towel or something soft under
their head
Call EMS
Loosen restrictive clothing
Do not give any food or drink
Be sensitive and supportive
Keep an account of the length of seizure
and vital signs
Differential Diagnosis
Seizure disorder
Head trauma
Cardiac etiology
Diabetes
Heat illness
Return to Play
Depends on diagnosis and sport
Neurology clearance
Medication for seizure control – need
a therapeutic level
Break through seizures can be a
problem
Prevention of Concussion
Prevent second impact syndrome
Better detection
Better helmets
Proper fit and chin straps
Mouthpiece
Proper tackling technique
ImPact
Balance testing
Ban “heading” the ball in soccer!?
Concussion Case Study
Colt McCoy
QB of Cleveland Browns
Game last season vs. Steelers
Helmet to helmet hit from James
Harrison
Suffered a hand injury
Medical staff did not see the hit
Concussion Case Study
McCoy only complains about his
injured L hand
Not one of the ATC’s or physicians on
the medical team noted the hit to the
head
McCoy returned to play after
evaluation of the hand injury
Concussion Case Study
Post game evaluation revealed a
concussion
McCoy was out for the final 3 weeks
of the season
There were have been numerous
changes in the NFL over the last few
years with concussion care and this
lead to another
Concussion Case Study
Immediate standardized sideline
evaluation
Take the players helmet
Take the player to the locker room
Sideline monitor for the medical staff
Independent ATC monitor in booth
Independent neurology evaluation
Differential Diagnosis
High index of suspicion
Cervical spine injury
Migraine HA
Other injury masked by the
concussion
CT/MRI rarely needed
Return to Play
ImPact
Balance testing
Progressive symptom free return to
play
Most can return within one week for
minor concussions
? NFL policy for mandatory week off
Neurology consult rarely – make sure
they have experience with sports
Prevention of Cervical Spine Injury
Proper tackling technique
Moving up the kick off
High index of suspicion
Steroids
Therapeutic hypothermia
Rapid transport to the nearest
APPROPRIATE hospital for
decompression
Cervical Spine Injury
Cervical Spine Fracture Case
Study
Kevin Everett
On a kick off for the Buffalo Bills
Poor technique with 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
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
Differential Diagnosis
Cervical spine fracture with or
without paralysis
Spinal stenosis
Cervical disc injury with
radiculopathy
Spinal cord contusion
Return to Play
Depends on diagnosis and sport
Fracture and stenosis are difficult to
get clearance due to risks
If adequate fusion for disk rupture
can be sooner but still difficult
(Peyton Manning)
Lumbar better prognosis and quicker
return (Joe Montana)
Need clearance from surgeon
Panel Discussion
Questions
Comments
Other cases