Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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