Download Airway Breathing Circulation

On-the-Field Acute Care
and
Emergency Procedures
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Most injuries are not life-threatening, but do require prompt care
Emergencies require immediate attention
Time is a critical factor
Mistakes in initial injury management can
– Prolong the length of time for rehabilitation
– Cause life-threatening complications
– Permanent disability
Emergency Action Plan
• Primary concern
– Cardiovascular function
– CNS function
• Key to emergency aid
– Initial evaluation of the injured athlete
– Prearranged plan that can be implemented on a moments notice
• The sports medicine team must at all times act reasonably
and prudently
Emergency Action Plan
• Separate plans should be developed for each facility
• Outline personnel
– Athletic trainer
– Coaches
– Athletic training interns
– Administrators
– Security
Emergency Action Plan
• Roles for personnel
– Contacting EMS
– Provide EMS with the following information
• Type of emergency
• Location of emergency
• Suspected injury
• Present condition of injured athlete
• Current medical care being provided
• Location of phone being used
• Hang up last!!!
– Opening of gates and facility access
– Going to hospital with athlete
– Parental notification
– Health insurance notification
– Press releases
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Identify necessary equipment
– Spine board/stretchers
– Splints
– Airway management/oxygen
– Tools for equipment or helmet removal
– Policies and procedures for helmet or equipment removal
Cooperation between Emergency Care Providers
• Cooperation and professionalism
– Certified 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
• All individuals involved in plan should practice to familiarize themselves with
all procedures (including equipment management)
Parental Notification
• ATC should try to obtain consent from parent prior to emergency treatment
for athletes who are minors
• 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
• Establish presence of life-threatening condition/injury
– Injuries requiring cardiopulmonary resuscitation
• Evaluate to determine need
• Should be certified
– American Heart Association
– American Red Cross
– National Safety Council
– Airway
– Breathing
– Circulation
– Injuries with severe profuse bleeding
– Shock
• Used to correct life-threatening conditions
Primary Survey
• Establish Unresponsiveness
– Gently shake and ask athlete “Are you okay?”
– If no response
• EMS should be activated
• Positioning of body should be noted
• Adjust position of body in the event CPR is necessary
• Equipment Considerations
– Equipment may compromise lifesaving efforts
– Removal of equipment may compromised situation further
– Facemask should be removed with appropriate loop strap cutters
• Anvil Pruner
• Trainer’s Angel
• FM Extractor
– Pocket mask/barrier mandated by OSHA during CPR to avoid exposure to
bloodborne pathogens
Secondary Survey
• Life-threatening condition ruled out
• Gather specific information about injury
• Assess vital signs
• Perform more detailed evaluation
– Non life-threatening injuries/conditions
Unconscious Athlete
• Must be considered to have life-threatening condition
– Note body position
– Establish 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)
Supine Unconscious Athlete
– Athlete is not breathing
– ABC’s should be established immediately
– Athlete is breathing, nothing should be done until
consciousness resumes
– Life support
• monitored and maintained until EMS arrives
– Once stabilized, a secondary survey should be performed
Prone Unconscious Athlete
– Athlete is not breathing
• Log roll
• Establish ABC’s
– Athlete is breathing
• Nothing should be done until consciousness resumes
• After consciousness returns
– Carefully log roll
– Continue to monitor ABC’s
– Life support should be monitored and maintained until EMS
arrives
– Once stabilized, a secondary survey should be performed
Opening the Airway
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Head-tilt, chin lift method
Push down on the forehead
Lifting the jaw
Moves tongue away from the back of the throat
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Modified jaw thrust
Use with suspected neck injury
Establishing Breathing
• Look
• Listen
• Feel
• If not breathing initiate CPR
Airway Management Tools
Establishing Circulation
• Locate carotid artery
• Palpate pulse while maintaining head tilt position
Establishing Circulation
• Locate femoral artery in femoral triangle
• Palpate pulse
Anatomical Landmarks for
Chest Compressions
• If no pulse initiate chest compressions
• 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
• Causes of chocking in athletics
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Mouth pieces
Broken dental work
Tongue injury
Gum
Blood clots from head and facial trauma
Vomit
• Obstructed individual
– Cannot breath, speak, or cough
– May become cyanotic
• Perform appropriate measures for choking
Automatic
External
Defibrillators
(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
Supplemental
Oxygen
• May 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
Universal Medical Precautions
Biohazardous Waste Management
QuickTi me™ and a
TIFF ( LZW) decompressor
are needed to see thi s pi ctur e.
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Use protective gloves on both hands
Don’t remove gloves until after the wound is bandaged
Protect yourself and the athlete you are treating from infection!
Glove Removal
• Clean to clean
• Dirty to dirty
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Grab left glove in middle of left palm by right gloved hand
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Pull left glove off
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Hold left glove in middle of right palm
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Use one finger of left (ungloved hand) to pull right glove inside out over left glove
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Place both gloves in biohazard container
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Wash or disinfect hands
Control of Hemorrhage
• Abnormal loss of blood
– 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
– Reduce risk of bloodborne pathogens exposure
Hemostasis Techniques
(Control of Bleeding)
• Direct pressure
– Firm pressure (hand and sterile gauze)
– Placed directly over site of injury against the bone
Elevation
• Reduces pressure
• Gravity facilitates venous and lymphatic drainage
Pressure Points
•Eleven points
•Pressure is applied to slow bleeding
Cryotherapy
• Ice Application
– Constricts blood vessels
– Slows blood flow to tissues
– Reduces metabolic needs of tissues (oxygen)
– Prevents secondary tissue death
Internal Hemorrhage
• Invisible unless
– manifested through body opening
– X-ray or other diagnostic techniques
• Non life threatening internal hemorrhage
– Beneath skin (bruise) or contusion
– Intramuscular
– In joints
• Life threatening hemorrhage
– Bleeding within body cavity
– Difficult to detect
– Must be hospitalized for treatment
– Could lead to shock if not treated accordingly
Shock
• Generally occurs with
– Severe bleeding
– Severe fluid loss from
• Vomiting
• Diarrhea
• Dehydration
– Fractures
– Internal injuries
• Decrease in blood available in circulatory system
– Vascular system loses capacity to maintain fluid portion of blood
– Due to vessel dilation
– Disruption of osmotic balance
• Movement of blood cells slows
• Decreasing oxygen transport to the body
Predisposing Conditions
for Shock
• Extreme fatigue
• Exposure to heat or cold
• Illness
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
Types of Shock
• 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 of Shock
• Wet, White,Weak
– Diaphoretic
• Moist clammy skin (excess sweating)
• Pale (decreased blood flow to skin
• Cold (from loss of blood flow
• Vital Signs
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Weak rapid pulse
Increasing shallow respiration
Decreased blood pressure
Systolic below 90mm Hg
Diaphoretic
• Urinary retention and fecal incontinence
• Irritability or excitement,
• Possibly thirsty
Management of Shock
• Maintain core body temperature
• Elevate feet and legs 8-12” above heart
• Positioning may need to be modified due to injury
• Keep athlete calm
– Psychological factors could lead to or compound reaction to life
threatening conditions
• Limit onlookers and spectators
• Reassure the athlete
• Do not give anything by mouth until instructed by physician
Vital Signs
• Secondary survey of vital signs
– Pulse assessment of heart function
• Normal
– Adult 60-80 beats per minute
– Well conditioned athlete’s may be lower 40-60 bpm
– Child’s pulse 80-100 bpm
• Rapid and weak pulse could indicate
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Shock
Bleeding
Diabetic coma
Heat exhaustion
• Rapid and strong could indicate
– Heatstroke
– Fright
• Strong and slow indicates
– Skull fracture
– Stroke
• No pulse = cardiac arrest or death
Secondary Survey
Respiration
– Normal Respiration
• Adult 12 breaths per minute
• Child 20-25 breaths per minute
– Abnormal Respiration
• Shallow - shock
• Irregular or gasping - cardiac compromise
• Frothy w/ blood - chest injury
Secondary Survey
Blood Pressure
• Systolic blood pressure is created by ventricle contraction
• Diastolic pressure is residual pressure
• Measured w/ s sphygmomanometer (blood pressure cuff)
– Inflate cuff (up to 200 mm Hg)
– Above antecubital fossa (crease at elbow)
– Slowly deflate cuff
– Listen with stethoscope for
• First beating sound (systolic)
• Final sound (diastolic)
• Kartokoff sounds (soft sounds)
Secondary Survey
Blood Pressure
Category
Systolic
Diastolic
Optimal
<120
<80
Normal
<130
<85
High Normal
130-139
85-89
Stage 1 HT
140-159
90-99
Stage 2 HT
160-179
100-109
Stage 3 HT
>180
>110
Elevated systolic or diastolic pressure alone is enough to meet the criteria
HT = Hypertension or high blood pressure
Secondary Survey
Temperature
• Normal is 98.6 o F
• Measure with thermometer
– Oral
– Axillary
– Tympanic membrane
– Rectal
– Core temperature is best measured rectally
– Skin temperature
Secondary Survey
Temperature
• Temperature changes can be the result of
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Disease or infection
Cold of heat exposure
Loss of body fluids
Pain, fear, nervousness
• Signs and symptoms of lowered temperature are
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Chills
Teeth chattering
Blue lips
Goose bumps
Pale skin
Secondary Survey
Skin Color
– Can be an indicator of health
– Red
• Elevated temperature
• Heat stroke
• High blood pressure
– Blue (cyanotic)
• Airway obstruction
• Respiratory insufficiency
• Poor circulation
– White
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Insufficient circulation
Shock
Fright
Hemorrhage
Heat exhaustion
Insulin shock
Secondary Survey
Skin Color
– Dark pigmented skin is slightly different in response
• Nail beds, and inside lips and mouth and tongue will be pinkish
• Shock,
– Skin around mouth and nose will have grayish cast
– Mouth and tongue will be bluish
• Hemorrhaging
– Mouth and tongue will become gray
• Fever is indicated by red flush tips of ears
Secondary Survey
Pupils
• Extremely sensitive to situation impacting nervous system
• Most individual’s pupils are regularly shaped
• Abnormal pupil size must be known by the health care provider
– Pre participation exams
• Constricted pupils may indicate
– depressant drug
– Muscle injury to eye
• Dilated pupils may indicate
– Head injury
– Shock
– Use of stimulants
• Failure to accommodate may indicate
– Brain injury
– Alcohol
– Drug poisoning
• Pupil response is more important than size
Secondary Survey
State of Consciousness
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Must always be assessed
Alertness
Awareness of environment,
Response relative to vocal stimulation
Glascow Coma Scale
Conditions altering level of consciousness
– Head injury
– Heat stroke
– Diabetic coma
Musculoskeletal Assessment
• Use logical process to adequately evaluate extent of trauma
• Critical knowledge
– Anatomy/kinesiology
– Mechanisms of injury
– Major signs and symptoms
Secondary Assessment
• Assessment
• History
–Head
• Observation
–Spine
• Palpation
–Trunk
–Abdomen
• Special Tests
–Upper extremities
–Lower extremities
Injury Assessment: Medical History
History
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Describe the events of the injury and those leading up to it
Past Medical History and Present History of Injury
Alphabet of assessment Questions
M Mechanism of injury, medications, meals
N Name of patient, name of examiner
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R
Old injuries to same side or opposite side, Onset
Point tenderness, provocative, palliative
Quantity, Quality
Region of pain, referred pain
S Sounds or sensations
Mechanism of Injury
How Did The Injury Happen?
What position was the joint in?
QuickTi me™ and a
TIFF ( LZW) decompressor
are needed to see thi s pi ctur e.
“M”
Medications
Did the athlete take any medication today
For current injury?
For other injuries?
For medical conditions?
Is the athlete taking any supplements
Is the athlete allergic to any medications?
QuickTi me™ and a
TIFF ( LZW) decompressor
are needed to see thi s pi ctur e.
“M”
Meals
When was the last time the athlete ate any food?
Is the athlete adequately hydrated?
Is the athlete eating a good balanced diet?
“N”
Names
Don’t forget to put athletes name on injury report!
Don’t forget to introduce yourself to the athlete
“O”
Onset
(When did the injury occur?)
Acute
Chronic
Chronic/Acute
Pain?
Swelling
How fast?
QuickTi me™ and a
TIFF ( LZW) decompressor
are needed to see thi s pi ctur e.
“O”
Old Injuries
QuickTi me™ and a
TIFF ( LZW) decompressor
are needed to see thi s pi ctur e.
Did the athlete ever have a similar injury to the same body part?
Opposite (injuries to the contralateral side?)
If yes, how severe and when did they occur?
Did the athlete go to to an MD for the injury?
Did the athlete go through a formal rehabilitation program?
Injury Assessment
QuickTime™ and a
TIFF (LZ W) decompressor
are needed to see t his picture.
“P”
QuickTi me™ and a
TIFF ( LZW) decompressor
are needed to see thi s pi ctur e.
Provocative:
What makes your injury get/feel worse
Palliative:
What makes your injury get/feel better?
QuickTi me™ and a
TIFF ( LZW) decompressor
are needed to see thi s pi ctur e.
Injury Assessment
“P”
Point Tenderness
•Where is the pain?
•Have the athlete point with one finger where they feel the most pain.
•Does the athlete have point tenderness (pain in one localized area)?
“Q”
•Quantity (0-10 scale)
•Quality (describe the pain)
•Throbbing
•Stabbing
•Aching
•Other
“R”
Region (Where is the pain?)
•Point tenderness
•Diffuse pain
•Referred pain
QuickTime™ and a
TIFF (LZ W) decompressor
are needed to see t his picture.
“S” Sounds or Sensations
Did the athlete feel or hear
any sounds or sensations?
Pops, Snaps, Crepitus (Grinding), Giving Way or Tearing
Injury Assessment
Observation of Injuries
Discoloration
Swelling
Deformity
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Observation
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Palpation of Anatomical Structures
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Palpation
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What structures are painful to palpation (touch)?
Palpate the area to help determine nature and extent of injury
Start away from site of injury
Start with gentle pressure, gradually pressing harder until you reach a boney stop
Do you feel any
Deformities (not apparent visually)?
Lumps, bumps, swelling or defects?
Changes in skin temperature or texture?
Special Tests
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Special Tests
Injury Assessment
Range of Motion and Flexibility
Assessment
Did the injury cause any loss on flexibility or range of motion?
Injury Assessment
Strength Assessment
Did the injury cause a loss in muscle strength?
Machine Testing
Isokinetic Testing
Manual Muscle Testing
Manual Muscle Testing
Grading Strength
Grade
Against Gravity
Full Rom
Added Resistance
Amount of Strength
5/5
Yes
Yes
Yes
=/> than other side
4/5
Yes
Yes
Yes
<
than other side
3/5
Yes
Yes
No
<
than other side
2/5
No
Yes
No
< than other side
1/5
No
No
No
palpable contraction
0/5
No
No
No
no palpable contraction
Injury Assessment
Stress Tests
Grading Laxity
0
no laxity
1+ 0 - 5 mm
2+ 5 -10 mm
3+
> 10 mm
Assessment of Joint Stability for Ligamentous Laxity
Are the ligaments or the joint capsule torn?
Balance & Proprioception Assessment
Did the athlete suffer a loss of
proprioception or balance from
their injury?
Cardiovascular Assessment
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Blood pressure
Resting Heart Rate (RHR)
Respiration
Auscultation
– Heart Sounds
– Lung Sounds
Neurological Assessment
What day is it?
Brain Function
Motor Function
Sensation
Reflexes
Central Nervous System
Peripheral Nervous System
What’s the score of the game?
Do you know where you are?
Assessment Decisions
• Determine
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Seriousness of injury (What is the return to play status of athlete?)
Type of first aid and immobilization required
Need for medical referral
Type of transportation from field to sideline, training room or hospital
• All information concerning the evaluation and decisions must
be documented
Return to Play Status
• Status
– Can continue with no restrictions
– Can continue with additional support or protection
– Can’t continue.
• Doesn’t need to see MD
• Needs to be referred to MD in next few days
• Needs immediate referral to MD
– Can transport self to MD
– Needs to be transported (not by EMS) to MD
– Needs to be transported by EMS to emergency room
• When is it okay for an injured athlete to play?
• What can you do to help the athlete achieve this goal?
• When should you refer the injured athlete to a medical doctor?