| - An emergency is defined as unexpected serious occurrence that may cause injuries that require immediate medical attention. - Time becomes critical in an emergency situation. THE EMERGENCY PLAN - The prime concern of emergency aid is to maintain cardiovascular function and, indirectly, central nervous system function. 1. Phones should be readily accessible. (Money to pay phone and map to local hospital is important) 2. Community-based emergency health care delivery plan, including existing communication and transportation policies. (The person designated by procedure policy is responsible for calling ambulance in an emergency) a. Type of emergency situation b. Type of suspected injury c. Present condition of the athlete d. Current assistance being given (e.g., cardiopulmonary resuscitation) e. Location of telephone being used f. Exact location of emergency (give names of streets and cross streets) and how to enter facility 3. Keys to gates or padlocks must be easily accessible. 4. Separate emergency plans should be developed for each sport’s fields, courts, or gymnasiums. 5. The athletic trainer should inform all coaches, athletic directors, school nurses, & maintenance personnel of the emergency plan at a meeting held annually before the beginning of school year. Each individual must know his or her responsibilities should an emergency occur. 6. Someone should be assigned to accompany the injured athlete to the hospital. Cooperation between emergency Care Providers - Individuals providing emergency care to the injured athlete must cooperate and act professionally. - The athletic trainer is usually the first individual to deal with the emergency situation and more training and experience in moving and transporting an injured athlete than the physician. - An advanced-life-support unit of EMS unit will be dispatched if all units are equally dose Parent Notification - If the injured athlete is a minor (U-18), the athletic trainer should try to obtain consent from the parent to treat the athlete during an emergency. - Consent may be given in writing either before or during an emergency. - Implied consent (no informed consent exists) on the part of the athlete to save athlete’s life takes precedence. PRINCIPLES OF ON-THE-FIELD INJURY ASSESSMENT - The athletic trainer cannot deliver appropriate acute medical care to the injured athlete until some systematic assessment of the situation has been made on the playing field or court where the injury occurs. - On-the-field Assessment · Primary survey; determines the existence of potentially life-threatening situations (ABCs & shock) · Secondary survey; systematically assesses vital signs and symptoms, and allows for a more detailed evaluation of the injury. Dealing with the Unconscious Athlete - Unconsciousness may be defined as a state of insensibility in which the athlete exhibits a lack of conscious awareness. (Resulting from blow to either head or solar plexus, or general shock). 1. Immediately note the body position and determine the level of consciousness and unresponsiveness. 2. Airway, breathing, and circulation should be established immediately. 3. Injury to the neck and spine should always be considered a possibility in the unconscious athlete. 4. If the athlete is wearing a helmet, it should never be removed until neck and spine injury have been unequivocally ruled out. However, the face mask must be cut away and removed to allow for cardiopulmonary resuscitation (CPR). 5. If the athlete is supine and not breathing, airway, breathing, and circulation (ABC) should be established immediately. 6. If the athlete is supine and breathing, nothing should be done until consciousness returns. 7. If the athlete is prone and not breathing, he or she should be logrolled carefully to the supine position and ABC should be established immediately. 8. If the athlete is prone and breathing, nothing should be done until consciousness returns, then the athlete should be carefully logrolled onto a spine board because CPR could be necessary at any time. 9. Life support for the unconscious athlete should be monitored and maintained until emergency medical personnel arrive. 10. Once the athlete is stabilized, the athletic trainer should begin a secondary survey. THE PRIMARY SURVEY Treatment of Life-Threatening Injuries - Situation that are considered life-threatening include those that require cardiopulmonary resuscitation (ABC), profuse bleeding, and shock. Overview of Emergency Cardiopulmonary Resuscitation - Certified by American Red Cross, the American Heart Association, or the National Safety Council. - First, “Are you OK?” establish unresponsiveness of the athlete by tapping or gently shaking his shoulder (not for suspected neck injury) and shouting. - 911 (emergency medical system – EMS) if the athlete is unresponsive. Equipment Considerations - Removing the facemask should be the first step. - Anvil Pruner and the Trainer’s Angel are devices to cut the plastic clips - AT must be proficient in removing the face mask within 30 seconds - Occupational Safety and Health Administration (OSHA) mandated the use of a barrier device or pocket mask to protect the athletic trainer from transmission of bloodborne pathogens during CPR. Begin CPR within five to ten seconds without removing the facemask The ABCs of CPR A – airway opened B – breathing restored C – circulation restored Opening the airway - Head tilt-chin lift method - Modified jaw thrust maneuver (if suspected head or neck injuries) Establishing breathing 1. Maintain the open airway and check breathing 2. Give two slow, full breaths at a rate of 1½ to 2 seconds per inflation If an obstruction is in the mouth, give five abdominal thrusts - Remove face-mask of head-neck injury patient when patient has difficulty breathing Establishing circulation 1. Check pulse (carotid artery (five to ten seconds) - The carotid pulse is palpated in the groove between the larynx and sternocleidomastoid muscle 2. Maintain airway. 3. Place middle finger on xiphoid notch (where meet the sternum) 4. Place hand above the index finger (xiphoid notch) 5. 15 chest compression and 2 full breaths X 4 cycles / one minutes - 1½ to 2 inches (4~5 cm) - When performing two-person CPR, the correct compression to breath ratio is five compression to one breath (5;1) 6. Recheck pulse (Carotid artery) · All coaches and athletic trainers must have current CPR certification. - Brain damage is most likely to occur if the brain is deprived of oxygen for approximately 4 to 6 minutes (Irreversible brain damage occurs 10 minutes of oxygen deprivation) - You can stop giving CPR for 15 seconds to move the patient - An athlete is obviously dead, but other people are concerned because you have not started resuscitation efforts. You should start resuscitation efforts Obstructed Airway Management Chocking (chock on a mouth guard, a broken bit of dental work, chewing gum, or a chaw of tobacco) - Heimlich maneuver (subdiaphragmatic abdominal thrusts) · Method A; Standing (hug) position for conscious athlete · Method B; 5 abdominal thrusts on ground for unconscious athlete - Finger sweeping - Mouth-to-nose ventilation is given when there are severe mouth injury Using a Defibrillator - Automated external defibrillator (AED) is used in situation in which the victim has no pulse. Control of Hemorrhage - An abnormal discharge of blood is called a hemorrhage. (Cause swelling immediately after injury) - Venous blood = dark red with a continuous flow - Capillary bleeding exudes from tissue and is a reddish color - Arterial bleeding flows in spurts and is bright red - The proper position for an impaled object, always leave the object in place and apply a bulky bandage around it to control bleeding and stabilize the object - Applying pressure will minimize the bleeding. Keep the area clean with sterile saline or hydrogen peroxide, apply steri-strips for temporary closure, and use ice and a compressive dressing to minimize further bleeding. Refer the athlete to the physician for sutures if necessary External Bleeding - Direct pressure; - Elevation; reduce hydrostatic blood pressure and facilitates venous and lymphatic drainage - Pressure points; Brachial artery in the upper limb and the femoral artery in the lower limb Internal Hemorrhage - Bleeding within a body cavity such as the skull, thorax, or abdomen is dangerous!! - Even if the athlete shows no outward indication of shock, he should be kept quite and body heat should be maintained at a constant and suitable temperature. Shock - Shock occurs when a diminished amount of blood is available to the circulatory system, that is, when the vascular system loses it s capacity to hold the fluid portion of the blood within its system because of dilation of the blood vessels within the body and disruption of the osmotic fluid balance. - Hypovolemic shock stems from trauma in which there is blood loss. - Respiratory shock occurs when the lungs are unable to supply enough oxygen to the circulating blood. (Pneumothorax) - Neurogenic shock is caused by the general dilation of blood vessels within the cardiovascular system. - Psychogenic shock (fainting = syncope) is caused by a temporary dilation of blood vessels that reduces the normal amount of blood in the brain. - Cardiogenic shock = the inability of the heart to pump enough blood to the body - Septic shock occurs from a severe (bacterial) infection. - Anaphylactic shock = allergic reaction caused by foods, insect stings, or drugs. o Anaphylactic shock is caused by a severe allergic reaction to a foreign protein or drug. There is a contraction of smooth muscle fibers and increased capillary permeability causing Dyspnea, cyanosis, convulsions, unconsciousness and, if untreated, death - Metabolic shock caused by severe illness (diabetes goes untreated) & extreme loss of bodily fluid. Symptoms and Signs - Blood pressure is low - Systolic pressure is usually below 90 mm Hg - Pulse is rapid and weak - Athlete may be drowsy and appear sluggish - Respiration is shallow and extremely rapid - Skin is pale, cool, and clammy Management 1. Maintain body temperature as close to normal as possible. 2. Elevate the feet and legs 8 to 12 inches for most situations. (Except neck and head injury and leg fracture). - Athlete is instructed to lie down and avoid viewing the injury. THE SECONDARY SURVEY Recognizing Vital Signs - Pulse; 60 to 80 bpm (adult) / 80 to 100 bpm (children) · Rapid and weak pulse indicates shock, bleeding, diabetic coma, or heat exhaustion. · Rapid and strong pulse may indicate heatstroke or severe fright · Strong and slow pulse could indicate a skull fracture or stroke - Respiration; 12 breaths (adult) / 20 to 25 breaths (children) · Shallow indicate shock · Irregular or gasping indicate cardiac involvement · Frothy blood being coughed up indicates a chest injury (rib fracture) - Blood pressure (by sphygmomanometer and a stethoscope) · Systolic blood pressure (when the left ventricle contracts) = 115 to 120 mm Hg (110 mm Hg is too low / 135 mm Hg is too high) · Diastolic blood pressure (The residual pressure when the heart is between beats) = 75 to 80 mm Hg - Lowered blood pressure could indicate hemorrhage, shock heart attack, or internal organ injury. - Temperature; 98.6º F (37º C) · Hot, dry skin may indicate disease, infection, or overexposure to environmental heat · Cool, clammy skin may reflect trauma, shock, or heat exhaustion · Cool, dry skin is possibly the result of overexposure to cold - Skin color · Red skin color may indicate heatstroke, high blood pressure or elevated temperature · Pale, ashen, or white skin may indicate insufficient circulation, shock, fright, hemorrhage, heat exhaustion, or insulin shock · Bluish color (cyanotic) may indicate an airway obstruction or respiratory insufficiency. - Pupils · Some athletes normally have irregular and unequal pupils. · A constricted pupil may indicate using a central nervous system depressant drug. · If one or both pupils are dilated, the athlete may have sustained head injury; may be experiencing shock, heatstroke, or hemorrhage; or may have ingested a stimulant drug. · If one or both pupils fail to accommodate to light, there may be brain injury or alcohol or drug poising. - State of consciousness · Head injury, heatstroke, and diabetic coma can alter the athlete’s level of consciousness. - Movement · The inability to move a body part can indicate a serious central nervous system injury that has involved the motor system. · An inability to move one side of the body (hemiplegia) could be caused by a head injury or cerebrovascular accident (stroke). · Bilateral tingling and numbness or sensory or motor deficits of the upper extremity may indicate a cervical spine injury. · Weakness or inability to move the lower extremities could mean an injury below the neck, and pressure on the spinal cord could lead to limited use of the limbs. - Abnormal nerve response · Numbness or tingling in limb with or without movement can indicate nerve or cold damage. · Blocking of main artery can produce severe pain, loss of sensation, or lack of pulse in limb. · A complete lack of pain or of awareness of serious but obvious injury may be caused by shock, hysteria, drug usage, or a spinal cord injury. Musculoskeletal Assessment - Major signs that reveal the site, nature, and above all, severity of injury. - Mechanism of injury - Uncommon sounds as grating or harsh rubbing may indicate fracture. - Joint sounds may indicate either arthritis or internal derangement - Snap, crack, or pop at the moment of injury often indicate bone fracture or injury to ligaments or tendon. - Visual examination = obvious deformity, swelling, and skin discoloration Assessment Decisions 1. Seriousness of injury 2. Type of first aid required (immobilization) 3. Whether injury warrants physical referral 4. Type of transportation needed Immediate Treatment - First aid immediately to control hemorrhage and associated swelling. - Rest; Minor injury should rest for approximately seventy-two hours before rehab - Ice (cold application); Decrease pain (analgesic effect) and promote local constriction of the vessels (vasoconstriction), thus controlling hemorrhage and edema. · Cold applied to acute injury will lower metabolism and tissue demands for oxygen and will reduce hypoxia. - Compression; Decreasing hemorrhage and hematoma formation - Elevation; Reduction in swelling by promoting circulation Emergency Splinting - A suspected fracture must be splinted before the athlete is moved. - Rapid form vacuum immobilizer - Air splint; not useful for deformity - Half-ring splint; fracture of femur - Splinting of lower-limb fractures; immobilize foot and knee for ankle or leg fracture - Splinting of upper-limb fractures; immobilize by a sling and swathe bandage - Splinting of the spine and pelvis; spine board - With a suspected fracture of the knee joint or of the surrounding area, the splint should stabilize all the lower limb joints and one side of the trunk MOVING TRANSPORTING THE INJURED ATHLETE - Great caution must be taken when transporting the injured athlete Placing the Athlete on a Spine Board - In cases of suspected cervical spine injury, the AT should generally access the EMS and wait until the rescue squad arrives before attempting to move the athlete. - The only exception would be if the athlete is not breathing, and logrolling the athlete onto the back is required for CPR - Maintain the head and neck in alignment with the long axis of the body. - Immobilize spine and transport to hospital when an athlete has partial paralysis from head impact 1. Check breath and pulse 2. A spine board is retrieved for moving the athlete 3. If the athlete is lying prone, he must be logrolled onto the back for CPR or to secured to the spine board. 4. Spine board close to the athlete’s side, and logroll him 5. Continue to stabilize his head and neck 6. Remove face guard or lift away from face for possible CPR 7. Head and neck are stabilized on the spine board by a chin strap secured to metal loops Ambulatory Aid - Support or assistance given to injured athlete who is able to walk - The athlete’s arm is draped over the assistants’ shoulders, and their arms encircle his back. - When transporting an athlete with a suspected spinal cord injury, a spine board should be used to stabilize the athlete during transport and additional medical support should be employed Manual Conveyance - Move a mildly injured individual a greater distance than could be walked with ease. Stretcher Carrying - Whenever a serious injury is suspected, the best and safest mode of transportation for a short distance is by stretcher. – Possible ACL tear Pool Extraction 1. Cross-chest technique (except head or neck injury) 2. Rescue breathing should begin in the water. 3. Head-chin support technique in suspected head or neck injury a. Place the spine board under the athlete b. Secure the athlete to the board c. Lift the spine board out of the water PROPER FIT AND USE OD THE CRUTCH OR CANE - Properly fitting a crutch or cane is essential to avoid placing abnormal stresses on the body. Fitting the Athlete A. Crutch tips are placed 6 inches (15 cm) from the outer margin of the shoe and 2 inches (5 cm) in front of the shoe B. The underarm crutch brace is positioned 1 inch (2.5 cm) below the anterior fold of the axilla C. The hand brace is placed even with the athlete’s hand, with the elbow flexed approximately 30 degree - NWB (non-weight bearing) - TDWB (touch down weight bearing - PWB (partial weight bearing - FWB (full weight bearing - Crutches widen the base of support. This allows for the line of gravity to fall within the base of support, increasing stability - Cane fitting; measuring from greater trochanter to the floor with shoes on EMERGENCY EMOTIONAL CARE 1. Accept everyone’s right to personal feelings. Show empathy, not pity 2. Accept the injured person’s limitations as real 3. Accept your own limitations as a provider of first aid OTHER CONSIDERATIONS - During seizure, it is best to keep the area around the athlete clear of objects or spectators and protect the athlete’s head & body from further injury. It is important to turn athlete on his side so if he vomits he will not aspirate. Prolonged seizure is serious medical situation and it is prudent to call for additional medical support - An athlete who is high on a hallucinogenic drug and is exhibiting paranoid behavior refuses to go to hospital. Protect yourself |
| On-the-Field Acute Care and Emergency Procedures |
| Topic Home life Education Activities Drugs Sex Suicide |
| Sample questions Problems with parents or siblings, living arrangements, parents’ drug use? Grade level, grades, enjoy school, future plans? What do you do for fun, extracurricular activities, who are your friends, what are weekends like? Do you or your friends drink alcohol, how much, how often, do you drink until your are drunk, use marijuana, cocaine, inhalants, other drugs? Are you sexually active, use birth control, condoms, sexual preference, number of partners, do you know about risks (pregnancy, STDs, HIV)? Have you ever been depressed, do you feel like you are under too much pressure, thought of or attempted suicide? |
| HEADS Topics and Sample Questions for the younger Adolescent |
| Topic Home life Education Activities Depression Safety |
| Sample questions Problems with siblings or parents, living arrangements, adequate diet? Grade level, grades, enjoy school, future plans? What do you do for fun, extracurricular activities, who are your friends, what are weekends like? Ever stressed out or depressed, how do you handle it? Seat belts, helmets, guns in the house or at a friend’s house? |
| ON-FIELD EVALUATION OF ATHLETIC INJURIES The on-field evaluation must rule out; - Inhibition of the cardiovascular and respi9ratory systems - Life-threatening trauma to the head or spinal column - Profuse bleeding - Fractures - Joint dislocation - Peripheral nerve injury - Other soft tissue trauma - In cases of head or spine trauma, one responder is responsible for stabilizing the spine, and the other performs the needed evaluations - For non-catastrophic conditions, one responder conducts the on-field evaluation. The other calms and communicates with the athlete and controls the surrounding scene ON-FIELD HISTORY - Location of the pain - Peripheral symptoms - Mechanism of the injury - Associated sounds and symptoms - History of injury ON-FIELD INSPECTION - Is the athlete moving? o Consciousness, an intact CNS, and cardiovascular function § Moving body normally, holding an injured body part, or writhing in pain o Possible CNS trauma § No signs of movement or seizing § DO NOT move an unconscious athlete unless CPR is to be started - What is the position of the athlete? o If athlete is unconscious and must be moved to begin CPR - Is the athlete conscious? o Level of consciousness - Primary survey o ABC if unconscious - Inspection of the injured area o Fracture, joint dislocation, or swelling - Secondary survey o Bleeding, gross deformity, other trauma ON-FIELD PALPATION Palpation of the Bony Structures - Bony alignment - Crepitus - Joint alignment Palpation of the Soft Tissues - Swelling - Painful areas - Deficit in the muscles or tendons ON-FIELD RANGE OF MOTION TESTING - Active range of motion - Passive range of motion - Resisted range of motion - Weight-bearing status ON-FIELD LIGAMENTOUS TESTING - Only the single-plane tests ON-FIELD NEUROLOGIC TESTING - Cranial nerve and cervical root involvement - After the dislocation of a major joint or the fracture of a large bone, the integrity of the distal neurovascular structures must be determined REMOVAL OF THE ATHLETE FROM THE FIELD - A decision must be made regarding how and when to remove the athlete from the playing area, including the safest manner possible. - If a fracture, dislocation, gross joint instability, or other significant musculoskeletal trauma is suspected, the involved body part must be splinted so the injured area and the joints proximal and distal to it are immobilized |
 |
| HEADS Topics and Sample Questions of the Mature Adolescent |
 |
| When to Summon More Advanced Medical Personnel |
| Condition Unconscious or not easily aroused Difficulty breathing Victim feels short of breath No breathing No pulse Severe bleeding Vomiting blood or passing blood Poisoning Sudden illness requiring assistance Head, neck, or back injuries Possible broken bones |
| Signs and symptoms Victim does not respond to tapping, loud voices, or other attempts to arouse Noisy breathing, such as wheezing or gasping Skin has a flushed, pale, ashen, or bluish appearance You cannot see the victim’s chest rise and fallYou cannot hear and feel air escaping from the nose and mouth You cannot feel the carotid pulse in the neck or the radial and brachial pulses in the arms Victim has persistent pain or pressure in the chest or abdomen that is not relieved by resting or changing positions You can see blood in vomit, urine, or feces Victim shows evidence of swallowed, inhaled, or injected poison, such as presence of drugs, medications, or cleaning agents Victim has seizures, severe headaches, changes in level of consciousness, unusually high or low blood pressure, or a known diabetic problem How the injury happened; for example, a fall, severe blow, or collision suggests a head, neck, or back injuryVictim complains of severe headaches, neck or back pain Victim is unconscious Bleeding, clear fluid, or deformity of the scalp, face, or neck How the injury happened; for example, a fall, severe blow, or collision suggests a fracture Evidence of damage to blood vessels or nerves, for example, slow capillary refill in a child or infant, no pulse below the injury, loss of sensation in the affected partInability to move body part without pain or discomfortPainful, swollen, deformed area |