© Sports Medicine Concepts, Inc.  All Rights Reserved.

SPORTS MEDICINE CONCEPTS’

Primary Objectives Critical Care Triangle™

AS THE ORGANIZATIONAL FOUNDATION FOR THE

COMPREHENSIVE BEST-PRACTICE EMERGENCY ACTION PLAN

This comprehensive  emergency action plan has been developed as a guide to help the  medical team comply with best-practice emergency action plan standards.  While this document does provide specific details regarding venue-specific summaries, protocols for specific conditions/illnesses of particular concern in athletics, and documentation relating to the medical team’s readiness to execute all aspect of best-practice emergency response, it is intended only a guide.  This document does not replace the need for autonomous medical decision-making based on the unique demands of each and every injury scenario. 

 

 

TABLE OF CONTENTS

PREAMBLE
FOUNDATION OF BEST-PRACTICE EMERGENCY ACTION PLANNING

Execution Strategy

Standing Orders Operating Protocol
HIPPA and FERPA
Preparation and Readiness
Posted Placard
Communications
Review of Sentinel Event
Annual Rehearsal

ESSENTIAL ELEMENTS OF A BEST-PRACTICE EMERGENCY ACTION PLAN

Venue Specific Emergency Action Plan Summary

Venue Details

Injury Spotting Surveillance Plan
Surveillance Zones
Zone Coverage
Total Coverage
Back-Up Coverage
Zone Emergency Response

Stationing of Spotters
Elevated Stations
Ground level stations
Roving Stations
Floating Stations (Rescue Watercraft)

Response Time and Stationing

EAP Principals

Emergency Medical Roaster

Initiation of the EAP

Emergency Response Information

Receiving Facilities

Response Principals

Sharing Venue Specific EAPs

The Pre-Event Medical Team Meeting

The Critical Care Triangle™ Approach

Emergency Response Personnel

Athletic Training Staff
Physicians
Emergency Medical Services
Operations
Lifeguards

Injury Response

Initiating The Emergency Action Plan
Advanced Life-Support
Basic Life-Support

Receiving Facilities

Appropriate Trauma Facilities
Nearest Appropriate Hospitals
Urgent Care Facilities

ADVANCED CARDIAC LIFE SUPPORT

Sudden Cardiac Arrest Overview

Defibrillation
AED Policy
Sudden Cardiac Arrest Protocol Algorithm

Airway Management Overview

BLS Airway Adjuncts
ALS Airway Adjuncts
Airway Management Protocol
Airway Management Protocol Algorithm

CONDITIONAL PROTOCOLS

Allergic Reactions

Anaphylaxis

Epinepherine

Epinephrine Auto-Injectors

Epinephrine Auto Injector Comparison Chart

Asthma

Antihistamine

Metered Dose Inhaler (MDI)

Spacing Chambers

Positive Pressure Nebulizer

Pre-Hospital Care

Environmental Considerations

Environmental Cold Conditions/Illnesses

Environmental Heat Conditions/Illnesses

Lightning/Severe Weather

General Medical/Sudden Illness

Hypoglycemia

Glucagon Injection

Insulin Injections and Insulin Pumps

Travel Considerations

Trauma

Head Trauma

Pneumothorax

SAFE HANDLING PROTOCOLS AND TECHNIQUES

Repositioning

SMC’s Progressive Spine Injury Assessment Algorithm

Equipment Removal

Non-Life-Threatening Equipment Removal

Life-Threatening Equipment Removal

Face Mask Removal

Helmet Removal

Flat-Torso Technique

Torso-Lift Technique

Transfer

From Supine

From Prone

Scoop Stretcher

Neurological Injury

Non-Neurological Injury

SPECIAL VENUE CONSIDERATIONS

Aquatic Facilities

Open Water Venues (in review)

DOCUMENTATION AND REPORTING

Annual Rehearsal Report Forms

Post-Transport Report Form

Review of Sentinel Event

REFERENCES
 

© Sports Medicine Concepts, Inc.  All Rights Reserved.

PREAMBLE

Best practice emergency action plans (EAP) must represents a collaborative agreement between the athletic trainers, team physicians, local emergency medical services, administrative officials, and other appropriate medical professionals, referred to from here as “The Medical Team”.  The TeamEMSoft© Comprehensive EAP Document has been developed as a general emergency response reference guide, organized as resource medical teams may use to enhance cognitive understanding of emergency procedures, to aid in on-going development of emergency response psychomotor skills, and reflect on when developing specific protocols and procedures.

The policies and procedures detailed in this EAP document are intended to serve only as guidelines.  These guidelines are not intended to be a substitution for prudent autonomous medical decision-making required during actual emergency management.  This EAP details policies and procedures as they pertain to communication, on-field response, activation/coordination of BLS and ALS, and development of training along the entire continuum of care.  Implementation of any should be provided for in all physician standing orders.

The policies and procedures are presented using an evidence-based review that is based on the Strength of Recommendation Taxonomy (SORT) criterion scale proposed by the American Academy of Family Physicians (Table 1).¹ Each recommendation is awarded a grade of A, B, or C based upon patient-oriented or disease-oriented outcomes. The SORT emphasizes outcomes-based treatments (ie, randomized controlled clinical trials).   With respect to emergency management recommendations, good-quality outcomes-based research is limited by the ethical constraints of implementing an experimental design that would preclude an at-risk group from being exposed to various treatment measures. The medical team should recognize and consider these limitations when assessing specific recommendations related to planning considerations, education, and emergency management throughout the entire continuum of care.  Clinically relevant works referenced in this document are provided in the reference section which has been organized to correspond works cited in each section of this document.

Table 1.

Strength of Recommendation / Evidence Category Definition
Category A Recommendation based on consistent and good-quality patient-oriented evidence. a
Category B Recommendation based on inconsistent or limited-quality patient-oriented evidence. a
Category C Recommendation based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening. b
a Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life.
Disease-oriented evidence measures intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes (eg. Blood pressure, blood chemistry, physiologic function, pathologic findings).

 

© Sports Medicine Concepts, Inc.  All Rights Reserved.

FOUNDATION OF A BEST-PRACTICE EMERGENCY ACTION PLAN

Standing Orders and Operating Protocol

Dr. Lynette Carlson,  DHS, ACT, Contributing author

Athletic trainers render professional services under the direction of, and in collaboration with, an overseeing physician. Current legal and best practice standards call for athletic trainers to have standing orders and operating protocols, or an established written set of guidelines, rules, and regulations that define an agreement between the overseeing physician and athletic trainer, and under which the athletic trainer provides services within their training, state statutes, rule, and regulations.  Some states provide a definition of standing orders and provide clear examples of written protocol, but it is ultimately the responsibility of all ATs to know their state’s practice act and to abide by them.1,2,3 Although standing orders clearly define a relationship between an overseeing physician and athletic trainer, standing orders should not be an impediment in allowing AT’s to practice to the full scope of their practice act.4

Best practice standing orders include specific language pertaining to all potential scenarios ATs treat under their state’s scope of practice and legal authority.  This includes, but is not limited to, acute, subacute, and chronic injury and illnesses and any potentially catastrophic injury. Standing orders do not take the place of Emergency Action Plans (EAPs) or individual management plans, but are in concert with them. As with EAPs, standing orders should be written to allow for clinical decision making, defined as a contextual, continuous and evolving process, where data are gathered, interpreted and evaluated in order to select an evidence-based choice of action.5  Language that is too precise can create a potential malpractice problem.   Therefore, standing orders should be based on a minimum safe level and not the maximum level aimed at ideal care.6  Like other written medical protocols and procedures standing orders should be updated and reviewed annually to ensure they are evidence-based and represent current legal and best practice standards.

The Standing Orders Operating Protocol is available under the Compliance and Reports and Forms section of the TeamEMSoft® Hub Page7,8Evidence Category C

HIPPA and FERPA Considerations

The “Administrative Simplification” clause found under Title II Part C of the Health Insurance Portability and Accountability Act (HIPPA) is commonly referred to as the Privacy Rule.   The intent of this provision was to establish a set of national standards for the protection of personal health information.  The extent to which this clause applies to sports medicine departments is an area of ongoing debate.  The debate centers on HIPPAs operational definition of a “covered” entity.  Under HIPPA “covered” entities must take certain steps to guard against improper disclosure of personal health information, including taking steps to ensure that “non-covered” entities that they routinely deal with will safeguard shared private health information.  The operational definition of a HIPPA “covered: entity seems to center on transmission of health information in the course of securing payment for services, which would seem to exclude most sports medicine departments9,10.

Sports medicine departments that deal with high school athletes also have the Family Educational Rights and Privacy Act, or FERPA, to contend with.  FERPA governs access to student records, and in many cases supersedes HIPPA.  FERPA protects against the transmission or dissemination of any personally identifiable student information, including any and all medical records.  It is generally agreed upon the FERPA permits sports medicine department personnel to discuss any student-athlete medical information with those who are integral in the on-going care of the student-athlete.

Although it can be argued that FERPA provisions provide for the ability of sports medicine department to discuss a student-athlete’s private medical records with appropriate personnel, and that sports medicine departments are not HIPPA “covered” entities- and are thus able to transmit personal health information accordingly-  it can also be argued to the contrary.  If it were determined that a sports medicine department was in violation of HIPPA or FERPA, the consequences would mostly involve the Department of Health and Human Services (HHS) seeking voluntary compliance, but there are provisions for civil and criminal penalties.  If found in violation of HIPPA or FERPA regulations, a sports medicine department would most likely have to develop a consent and authorization form that specifically grants the department permission to share personal information for specific reasons.

Since there is such controversy and variation in interpretation of HIPPA and FERPA, it is suggested that sports medicine departments opt to develop a signed consent and authorization form to ensure they are in compliance rather than risk the potential administrative, civil, and criminal penalties incurred for violating FERPA and HIPPA. Evidence Category: C

Sports medicine departments opting for a policy including a signed consent and authorization should ensure their forms are in compliance with all HIPPA and FERPA requirements.  Authorization forms should contain a statement that clearly identifies whom the information will be shared with and for how long the information will be shared.  The authorization form should also:

  • have an expiration date;
  • specify who may disclose information;
  • specify what information may be disclosed;
  • specify who may receive information;
  • explain that the athlete cannot be denied care for not signing the form;
  • explain that if information is disclosed to a non-covered entity, the information may no longer be protected;
  • explain that an athlete has the right to revoke authorization at any time.11,12

Click here to view the TeamEMSoft® sample HIPPA/FERPA Authorization form.  This document is also available under the Compliance and Reports and Forms section of your TeamEMSoft® Hub Page7,8Evidence Category C

EXECUTION STRATEGY

Execution of the emergency action plan is an on-going endeavor.  The process of executing the EAP begins with development of venue specific EAP summaries that provide essential information required to respond to a potential emergency.   Venue specific EAP summary posting placards are permanently placed conspicuously throughout all venues.  Preparation and readiness for specific contests and events begins in the days leading up to the event.  In the days prior to an event the medical team will share the venue specific EAP summary with all appropriate visiting team medical personnel.  The venue specific EAP summary is shared to provide visiting team medical personnel with essential information regarding assets and procedures to aid in caring for a critically injured or ill athlete during their visit.  Sharing the venue specific EAP summary also allows medical personnel to identify any athletes, coaches, or officials with medical conditions that may predispose them to onset of specific conditions or illnesses.  Identifying potential predisposing medical conditions provides medical teams opportunity to review conditional protocols.  Conditional protocols are procedures develop for specific medical conditions to prevent the onset of conditions or illnesses and to ensure that medical teams are properly prepared to manage at risk individuals.

The days leading up to a specific event will be used to ensure that all medical personnel are prepared by:

  • Identifying at risk individuals;
  • Checking emergency kits contents to ensure all necessary equipment is present, is operational, is not expired, and is deployment ready;
  • Seal emergency kits with Ready Tags™;
  • Developing the venue/event surveillance plan;
  • Ensuring that posted placards and venue specific EAP summaries are up to date, accurate, and properly placed;
  • Ensure that the venue specific EAP summary has been shared with all appropriate medical personnel.

A pre-event medical meeting will be conducted prior to the start of any event.  Should the EAP be activated during a contest a medical team or other representative will communicate all necessary information to the injured/ill individual’s family and provide them with information about the receiving facility to which their family member was transported as soon as it is possible to do so.  Following conclusion of an event the medical team will conduct a complete sentinel event review.

Venue Specific EAP Summaries

Venue specific EAP summaries include only the vital information required for medical personnel to conduct a medical time out and to communicate during management of a critically injured/ill individual.  The EAP summary does not list all the medical personnel or assets that may be available to a team as this would result in a lengthy document that is too difficult to efficient navigate in an emergency.  Rather, the EAP summary is a simple document that provides for quick access to information that facilitates communication and emergency response.  The EAP summary includes the following:

  • A map to highlight EMS access routes, rendezvous locations, nearest intersections, and access points;
  • Surveillance plan;
  • Communication signals and instructions for activating the EAP;
  • Emergency response equipment and field locations;
  • Receiving facilities, including directions and phone numbers;
  • Emergency contacts, their field location and hotline phone numbers;
  • Overview of procedural and protocol tendencies

Surveillance Planning and Proper Medical Coverage

The EAP Summary will provide details of the venue specific zone-based surveillance plan. 

Posted Placards

A venue-specific Emergency Action Plan Summary Placard shall be posted conspicuously throughout each venue.   A copy of the venue-specific Emergency Action Plan Summary Placard shall also be posted in all visiting team locker rooms.  Evidence Category: C

Communication

After proper care and management of a critically injured/ill individual is underway and it is appropriate to do so a medical team representative or other designated team official will contact the individual’s representative and family members to communicate important information regarding the individual’s condition, the receiving facility to which they were transported, and any other critical information.

Review of Sentinel Events

Within the days following an event requiring activation of the EAP the medical team will conduct a sentinel event review.  This review will include documented discussion regarding the reasons for activating the EAP, the outcome of the event, and any recommended EAP changes.  More about the sentinel event review process is covered in the Documentation section.

Annual rehearsal and Training

To ensure cognitive retention and effective choreography of multi-disciplined psychomotor skills this EAP will be reviewed and practiced a total of 15 hours annually.  This will be accomplished via formal preseason EAP training session that emphasize cognitive review, live simulated testing, and performance bench-marking.14-26. This EAP session will be overseen by an appropriate independent expert who  is qualified to certify that the EAP meets best practice standards and that all personnel demonstrate necessary critical care skills.  A follow-up EAP review will be conducted by the medical staff to ensure an appropriate level of preparedness is maintained at all venues.

Aquatic facilities used during competition, rehabilitation, and athlete conditioning will account for a minimum of 4 hours of in-service training per month for all members of the lifeguard corps and appropriate medical team personnel.  This training will address issues such as surveillance and recognition, water and land rescue skills, specific water rescue and emergency response drills, decision-making protocols, facility rules, regulations, emergency action planning, records and reports, and appropriate physical conditioning.29 .

Training will be conducted at all venues and include venue specific training for all appropriate members of the medical team, emergency medical services responding to the venue, and receiving facilities. Evidence Category: A

 

© Sports Medicine Concepts, Inc.  All Rights Reserved.

ESSENTIAL ELEMENTS OF A BEST-PRACTICE EMERGENCY ACTION PLAN

Effective pre-hospital care and management of medical emergencies depends upon advanced life support (ALS) interventions that build upon the basic life-support (BLS) fundamental principles of early recognition and activation of EMS, early CPR, rapid defibrillation, drug therapy, advanced airway management, on-going monitoring, and coordinated safe-handling throughout the entire continuum of care.1  Perhaps in no other out-of-hospital environment do medical providers have such a unique opportunity to improve outcomes by preparing to provide effective BLS and ALS interventions than in the athletic environment.  The athletic environment is a controlled environment, relative to other out-of-hospital settings.  Medical teams in the athletic environment have the luxury of knowing that should a critical injury happen, it will happen to one of the athletes, officials or coaches; within the borders of the athletic venue; and within the confines of the game clock.  There is, therefore, no excuse for the medical team to be anything but ultimately prepared to provide effective management and the safest handling throughout the entire continuum of care.

Hence, the athletic training staff and other first responders shall acquire and maintain all necessary psychomotor skills and be prepared to carry out the fundamental principles of BLS until ALS can be provided.  Evidence Category C

THE CRITICAL CARE TRIANGLE™ APPROACH

An effective EAP will be overseen by a multi-disciplined medical team organized to respond as a Critical Care Triangle™. 2  The role of the Critical Care Triangle™ is to provide appropriate first-aid and basic life-support, and to activate EMS.  The Critical Care Triangle™ is formed by an A-Man at the athlete’s head, and two additional rescuers positioned on either side of the athlete’s thoraces, labeled B and C man.   The efforts of Critical Care Triangle™ are overseen and managed by a designated Code Runner who is charged with ensuring the medical team’s actions are guided, first and foremost, by the status of the patient’s Circulation, Breathing, and Airway; while the medical team simultaneously protects neurological status, and provides for the safest handling of the patient.  This strategy approach is referred to as the Primary Objectives Approach™.

During practices and scrimmages, members of the Critical Care triangle™ may be dispersed throughout the practice fields.  Generally, the A-Man will be the first to arrive to aid the injured player. The remaining position within the Critical Care Triangle™ will be filled in as other medical team members arrive.  Critical care triangle personnel do not leave their position unless a more qualified medical professional arrives to perform a specialized critical care task.

The athletic trainer will designate a specific Critical Care Triangle™ comprised of appropriate medical personnel.  The athletic trainer may designate specifically trained coaches to perform Critical Care Triangle™ tasks in the absence of medical team personnel.  Critical care triangle personnel are responsible for:

  1. signaling to initiate appropriate component of the emergency action plan;
  2. activating EMS;
  3. providing immediate care of the injured or ill athlete;
  4. escort injured/ill athlete to ED to ensure continuity of care.

The Critical Care Triangle™ will be supported by personnel specifically responsible for ensuring that the emergency equipment and personnel needs of the Critical Care Triangle™ are met.  Support personnel should be responsible for the following:

  1. retrieval, delivery, and preparation of emergency equipment / medicine required by critical care triangle personnel.

The Critical Care Triangle will also be supported by personnel specifically responsible for securing the perimeter of the injury scene. Perimeter support personnel are responsible for the following:

  1. keeping the injury scene clear of unnecessary distraction;
  2. calling 911 when prompted by critical care triangle (provide name, address, telephone number, condition of athlete, first aid treatment, specific directions, other information as requested);
  3. meeting EMS at rendezvous;
  4. directing EMS to appropriate on-field location;
  5. scene control: limit scene to first aid providers and move teammates/coaches/bystanders away from area;
  6. initiating phone tree.

Evidence Category: C

 EMERGENCY RESPONSE PERSONNEL

Athletic Training Staff

Director of Sports Medicine

Email:
Hotline:
Office:
Home:

Head Athletic Trainer

Email:
Hotline:
Office:
Home:

 

Assistant Athletic Trainer

Email:
Hotline:
Office:
Home:
Assistant Athletic Trainer

Email:
Hotline:
Office:
Home:
Assistant Athletic Trainer

Email:
Hotline:
Office:
Home:
Assistant Athletic Trainer

Email:
Hotline:
Office:
Home:
Home Team Injury Spotter

Email:
Hotline:
Office:
Home:
Visiting Team Injury Spotter

Email:
Hotline:
Office:
Home:
Seasonal Intern

Email:
Hotline:
Office:
Home:
Seasonal Intern

Email:
Hotline:
Office:
Home:

Team Physicians

   
 

Medical Director

Email:

Hotline:
Office:
Home:

 
Lead Orthopedic

Email:

Hotline:

Office:
Home:
Lead Internist

Email:
Hotline:
Office:
Home:
Lead Neurosurgeon

Email:
Hotline:
Office:
Home:
Team Physician –

Email:
Hotline:
Office:
Home:

Unaffiliated Neuro Consultants – UNC

Home Team UNC

Email:
Hotline:  
Office Phone:  
Home Phone:  

Visiting Team UNC

Email:
Hotline:  
Office Phone:  
Home Phone:  
Replay UNC

Email:
Hotline:  
Office Phone:  
Home Phone:  

Airway Management Physicians (AMP) and Visiting Team Medical Liaison (VTML)

AMP

Email:
Hotline:  
Office Phone:  
Home Phone:  

AMP

Email:
Hotline:  
Office Phone:  
Home Phone:  
VTML

Email:
Hotline:  
Office Phone:  
Home Phone:  

Emergency Medical Services

   
 

EMS Director

Email:
Hotline Phone:
Office Phone:  
Home Phone:  

 
Home Team Paramedic

Email:
Hotline:
Office Phone:  
Home Phone:  
Visiting Team Paramedic

Email:
Hotline:
Office Phone:  
Home Phone:  

Operations

Director of Security

Email:
Hotline:
Office:
Home:
Player Personnel Representative

Email:
Hotline:
Office:
Home:

 

 

The following section describes the general procedures for initiating basic life-support, activation of EMS, coordinati on of advanced life-support, and safe-handling practices during management of an injured or sick athlete.

INJURY RESPONSE

When approaching a down athlete, the medical team’s designated Critical Care Triangle™ will begin by securing the scene and establishing control of the athlete. Completion of critical care tasks by the Critical Care Triangle™  shall be dictated by the Primary Objectives Approach™ detailed in this document’s introduction.

When an injured athlete is found in the prone position the medical team will assess the mechanism of injury and the athlete’s levels of consciousness (LOC).  If, in caring for the primary objectives, the medical team deems it necessary to take spine injury precautions, the athlete shall be repositioned to supine using either a logroll or logroll-push technique.  The logroll and logroll-push maneuvers are described in the Safe Handling Protocols and Techniques section of this document.  Once the athlete is supine the A-Man shall reposition the athlete into neutral cervical position, unless contraindicated.  Contraindications to moving the athlete into neutral cervical position include athlete apprehension, increased or onset of midline cervical pain, increased or onset of neurological signs and symptoms, or resistance to movement.1  Evidence Category: B

With the athlete supine, the medical team will begin a primary survey by checking LOC, cardiac, airway, breathing, and neurological status.

During instances requiring face mask removal, shoulder pad manipulation to expose the chest, and removal of protective athletic equipment, the medical team will employ the technique deemed most appropriate given the status of the athlete and other environmental factors.  The various current best practice standard equipment removal techniques are described in the Safe Handling Protocols and Techniques section of this document.  A designated code runner shall oversee the medical team’s response.  The designated code runner may be the Critical care triangle™ A-Man or another designated medical team member. Evidence Category: C

Initiating The Emergency Action Plan

In the event of an emergency involving a player, the Critical Care Triangle™ will immediately evaluate, render appropriate first-aid, provide basic life-support, and activate EMS as indicated.

In the event of an injury to a visiting team player, the medical team will make themselves visible to visiting team medical personnel by standing on the field of play, between the injury scene and the home team sideline.  Should the visiting team medical staff require assistance they should signal to the medical staff using the communication signals reviewed during the medical time out.  If medical support is requested by visiting team medical personnel, the medical staff will stand ready to assist and provide any assets required of visiting team medical personnel during completion of their specific adopted protocols and procedures.

If the visiting team does not have medical personnel with them, the visiting team coaching staff may summon help using the communications signals reviewed during the medical time out.  When help is requested of the visiting team coaching staff and no visiting team medical personnel are available, the injured athlete will be cared for in accordance with the adopted policies and procedures.

Should it be necessary to call EMS dispatch to activate EMS, the designated Critical Care Triangle™ support person will contact EMS dispatch and will convey all requested information using the phone number and information communicated during the medical time out as well as real time information provided by Critical Care Triangle™ personnel.  Critical Care Triangle™ personnel will maintain continuous contact with EMS dispatch until EMS arrives on scene and the call is terminated by EMS dispatch.  When EMS is providing on-site service, the appropriate communication signals provided during the medical time out will be used to summon EMS to the injury scene.

Upon activation of EMS, security will be immediately alerted to ensure that the rendezvous location and path to the injury scene are clear for all emergency response vehicles.  Evidence Category: C

Advanced Life-Support

Advanced life-support equipment shall be provided by on-site or on-call EMS as needed.  When appropriate, all EMS equipment shall be rated for oversized individuals, and be capable of handling an oversized equipment-laden athlete.  ALS equipment will include, but not be limited to:

  • ALS airway management supplies
  • Appropriate immobilization and transfer equipment
  • Emergency medications

Evidence Category: C

Basic Life-Support

Appropriate basic life-support sideline emergency kits shall be available at all times.  Basic life-support sideline emergency kit will contain, but are not limited to, the following BLS supplies:

  • Athlete Health History / Emergency Contact Information
  • Airway Management Protocol Supplies:
    • Power screwdriver
    • Quick-Release / Quarter-Turn Tools
    • FMxtractor™
    • Pack-n-fill towels
  • Supplemental Oxygen
    • Oxygen Tank
    • Regulator and Wrench
    • Non-rebreather mask
    • Nasal CannulaAirway Lubricant
    • OPA / NPA
    • Bite stick
    • BVM
    • Airway Suctioning Unit
    • Heart Rate Monitor
    • Blood Pressure Monitor
    • Pulse Oximeter
  • Cardiac Emergency Supplies
    • Automated external defibrillator
    • AED ready supplies, including latex free gloves, absorbent towel, and razor
  • Emergency Medications
    • Appropriate initial and second dose Epinephrine auto-injectors
    • Glucagon injector
  • Splints/Immobilizers
    • Arm Immobilizer
    • Leg Immobilizer
    • Full Lower Extremity Immobilizer
    • Knee Immobilizer
    • Shoulder Immobilizer
    • Wrist Immobilizer

Evidence Category: C

Advanced Life Support Equipment

Advanced life-support equipment shall be provided by on-site or on-call EMS as needed.  When appropriate, all EMS equipment shall be rated for oversized individuals, and be capable of handling an oversized equipment-laden athlete.  ALS equipment will include, but not be limited to:

  • Airway Management Protocol Supplies
    • Supplemental Oxygen
      • Oxygen Tank
      • Regulator and Wrench
      • Non-rebreather mask
      • Nasal Cannula
    • Magill forceps
    • Airway lubricant
    • Oral Tracheal Intubation
      • Endotracheal Tube (ET)
      • Cuffed ET
      • Stylet
      • ET Holder
      • Conventional Laryngoscope
      • Video Laryngoscope
      • Supraglottic Devices
      • Esophageal-Tracheal Tube (ETT or Combitube)
      • Laryngeal Tube (King LT)
      • Laryngeal Mask Airway (LMA)
    • Airway Suctioning Unit
    • Waveform capnography
    • Exhaled CO2 detector device
    • RSI formularies
    • Emergency Medications
    • CPR Protocol Supplies
    • Appropriate immobilization and transfer equipment

Evidence Category: C

Receiving Facilities

The medical team, in conjunction with local EMS policy, will decide the most appropriate receiving facility to transport an injured athlete. Evidence Category: C

Appropriate Trauma Facilities

An appropriate Level I trauma center, or other appropriate medical facility shall be identified for each venue.  Consideration for transport to Level I trauma shall be given to life-threatening injuries, neurological injuries, and unstable patients.  Evidence Category: C

Nearest Appropriate Hospitals

A nearest appropriate hospital shall be identified for each venue.  Consideration for transport to the nearest appropriate hospital shall be given to non-life-threatening injuries, non-neurological injuries, and stable patients.  Additional hospitals may be identified as appropriate for specific conditions such as cardiac arrest or orthopedic injuries as deemed appropriate by the medical team.  Evidence Category: C

After Hours Care Facilities

An appropriate after hours care facility shall be identified for each venue.  Consideration for referral to the designated urgent care facility shall be stable athletes that require timely physician assessment for non-life-threatening, non-neurological conditions.  Evidence Category: C

 

© Sports Medicine Concepts, Inc.  All Rights Reserved.

 

Advanced Cardiac Life Support

SUDDEN CARDIAC ARREST OVERVIEW

Sudden Cardiac Arrest Protocol Algorithm

The overall rate of catastrophic injury during athletic competition is less than 1 in 100,000.  Per the National Center for Catastrophic Sports Injury Research (NCCSIR), 42% of the 92 captured catastrophic injuries/illnesses reported from July 1, 2014 to July 30, 2015 were due to sudden cardiac arrest (SCA) and other cardiac related conditions.1  The leading causes of SCA in athletics are hypertrophic cardiomyopathy (25%), commotio cordis (20%), and coronary artery anomalies (14%).   While early interventions to prevent cardiac arrest would be ideal, efforts to effectively screen for predisposing factors remain limited.  In 55% to 80% of SCA cases in athletics, the athlete is asymptomatic until the onset of the cardiac event, with the underlying cause being identified only after death.2,3 The survival rate following SCA in young athletes is disconcertingly lower than expected, and may be significantly lower than survival rates in older persons. 4

The rate of SCA in persons 35 years or older has been estimated to be 1 in 1000 persons.5 Jones et al reported a 2.1% annual probability of a SCA on high school campuses when factoring in older persons, such as employees, spectators, officials, coaches, and visitors.6  Even when considering young athletes and older persons, the risk of a SCA remains low.  Unfortunately, the reality is that the majority of resuscitation efforts following SCA will not result in a return of spontaneous circulation (ROSC) and ultimate survival.7  This is particularly true when cardiac arrest is due to blunt trauma.8 However, the single most influential factor affecting survival from an out-of-hospital SCA in any population, and for any reason, is the initiation of high-quality CPR, early defibrillation, and subsequent ACLS intervention.  Studies examining trained lay-rescuers providing effective CPR and rapid defibrillation within 3-5 minutes have demonstrated survival rates of 41% to 74%.9-18  Therefore, an effective strategy to ensure early recognition of cardiac arrest, immediate initiation, continuation and monitoring of high-quality CPR, timely defibrillation, and diagnosis and treatment of reversible underlying causes of cardiac arrest is essential to improving the survival rate in young athletes and non-athletes alike.  Evidence Category: A

According the AHA, essential elements of high-quality CPR include:7

  • Pushing hard and fast to deliver compressions at a depth ≥2 in at a rate of ≥100/min while allowing the chest to fully recoil between compressions;
  • Minimizing interruptions in compressions;
  • Avoid excessive ventilation;
  • Rotate compressions provider every 2 min;
  • If no advanced airway, provide compression-ventilation rate of 30:2;
  • If advanced airway, provide continuous compressions and 1 breath every 6-8 seconds (8-10 breaths/min);
  • Quantitative waveform capnography:
    • If PETCO, <10 mm Hg, attempt to improve quality of CPR
  • Intra-arterial pressure
    • If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve quality of CPR

Aside from high-quality CPR, defibrillation of ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT) is the only rhythm-specific intervention that has been demonstrated to increase survival.  Therefore, other ACLS interventions such as vascular access, drug therapy and advanced airway placement are recommended considerations only if they can be performed without interruption of on-going delivery of high-quality CPR.  The AHA recommends the following shock energy for defibrillation of VF/pulseless VT:

  • Biphasic: Manufacturer recommendations (eg, initial dose of 120-200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher dose may be considered.
  • Monophasic: 360 J

If an athlete, or other patient, is observed to collapse or is found unconscious, it should be assumed they are in cardiac arrest until cardiac arrest is otherwise ruled out.  The first provider to aid the victim should immediately initiate high-quality CPR by beginning chest compressions.  The second provider should retrieve and begin setting up a defibrillator by placing the pads, and turning on the unit to check the rhythm.  Pads should be placed on the exposed chest in an anterior-lateral position.  Anterior-posterior, anterior-left infrascapular, and anterior-right infrascapular are acceptable alternative pad placement locations.    If an organized rhythm is detected, a pulse check should be performed.  If the victim presents as pulseless, high-quality CPR should resume immediately with chest compressions.7  Evidence Category: A

The diagnostic accuracy of provider pulse checks has been questioned.  In 1996 Eberle, et al reported that in 10% of cases subjects failed to recognize an absent pulse as pulessness, while in 45% of cases subjects failed to identify a pulse despite there being a systolic blood pressure ≥80 mm Hg.19  Accuracy of AEDs are much more impressive.  In 81% of cases an AED will advise a shock for patients who have a shockable rhythm.  Operator error (eg. moving the patient during analysis) is attributed to much of the 19% error.  With respect to delivering a shock when there is an actual shockable rhythm, an AED may be as accurate as 99.9%.20,21,22  It is common for vital signs and arrest rhythm to evolve during management of a critical injury.  Since rhythms evolve during the course of care and the accuracy of AEDs appear to be more sensitive and specific than provider pulse checks in determining the appropriateness of initiating high-quality CPR, medical teams should consider placement of an AED or cardiac monitor early in the management of injuries/illnesses that result in unstable vital signs or that are known reversible causes of cardiac arrest.  This may help providers more quickly identify the onset of cardiac arrest and the need to initiate high-quality CPR.  Evidence Category:B

Diagnosis and treatment of reversible causes of cardiac arrest is essential to ROSC and ultimate survival.  Upon completion of the first 2 min cycle of high-quality CPR the medical team should begin assessing for and treating any known reversible causes of cardiac arrest.  Common conditions that are known reversible causes of cardiac arrest include:7

  • Hypovolemia
  • Hypoxia
  • Hydrogen ion (acidosis)
  • Hypo-/Hyperkalemia
  • Hypothermia
  • Tension pneumothorax
  • Tamponades, cardiac
  • Toxins
  • Thrombosis, pulmonary
  • Thrombosis, coronary

Best-practice emergency action plans in the athletic environment will have a combined BLS and ACLS out-of-hospital approach.  This approach may be implemented by 1) ensuring that properly trained BLS providers are available during all events, with a designated plan for initiating high-quality CPR within 3-5min and activation of the EMS system to transfer care to a team providing ACLS, or 2) having both BLS and ACLS providers available during events with the ability to provide immediate ACLS and transport to appropriate receiving facilities.  Evidence Category C

In a combined BLS and ACLS system termination of resuscitative efforts is guided by the AHA guidelines for BLS termination of resuscitative efforts which states that rescuers who start BLS should continue resuscitation until one of the following occurs:23

  • Restoration of effective, spontaneous circulation
  • Care is transferred to a team providing advanced life support
  • The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy
  • Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met.

The AHA’s “BLS termination of resuscitation rule” states that all 3 of the following criteria must be present before moving a patient to an ambulance for transport or terminating resuscitative efforts:

  1. arrest was not witnessed by EMS provider or first responder;
  2. no return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis; and
  3. no AED shocks were delivered.

Once care has been transferred to ACLS providers, a different set of criteria may be considered in determining the appropriateness of terminating resuscitative efforts.  The National Association of EMS Physicians (NAEMSP) suggests that terminating resuscitative efforts may be appropriate in patients with witnessed arrest who do not respond to at least 15 min of ACLS care.8  Although literature suggests that expeditated transport is essential, patients suffering traumatic cardiac arrest seem to benefit from ACLS interventions, such as advanced airway placement and insertion of IV lines, as long as they do not delay or interrupt delivery of the first 2 min of high-quality CPR.7  This is particularly relevant to the sports medicine team because most arrests in athletics will result from blunt trauma or a known reversible cause, rather than a penetrating injury.  Therefore, in the management of SCA, sports medicine teams should plan to provide 2 min of uninterrupted high-quality CPR before initiating other ACLS intervention, and continue ACLS for 15 min before deciding to move the patient to an ambulance for transport to the nearest appropriate receiving facility. Evidence Category: A

Ancillary Content

Checking Pulse Checks Sports Emergency Care White Paper

The following information is an excerpt from a comprehensive educational resource regarding the science of defibrillation provided by Resuscitation Central.  The complete discussion can be accessed at the Resuscitation Central Website. Resuscitation Central is sponsored by an educational grant from ZOLL Medical Corporation.

DEFIBRILLATION BASICS

Defibrillation is based upon the understanding that contraction of the heart, and the resulting circulation, is under the control of the electrical conduction system of the heart.

The sinoatrial node, (SAN) located within the wall of the right atrium, normally generates electrical impulses that are carried by special conducting tissue to the atrioventricular node
(AVN).

Upon reaching the AVN, located between the atria and ventricles, the electrical impulse is relayed down conducting tissue (bundle of HIS) that branches into pathways that supply the right and left ventricles. These paths are called the right bundle branch (RBBB) and left bundle branch (LBBB), respectively. The left bundle branch further divides into two sub branches
(called fascicles).

Electrical impulses generated in the SAN cause the right and left atria to contract first. Depolarization (heart muscle contraction caused by electrical stimulation) occurs nearly simultaneously in the right and left ventricles 1­2 tenths of a second after atrial depolarization. The entire sequence of depolarization, from beginning to end (for one heart beat), takes 2­3 tenths of a second.

The SAN is known as the “heart’s pacemaker” because electrical impulses are normally generated here. At rest, the SAN usually produces 60­70 signals a minute. It is the SAN that increases its rate due to stimuli such as exercise, stimulant drugs, or fever.

Should the SAN fail to produce impulses the AVN can take over. The resting rate of the AVN is slower, generating 40­60 beats a minute. The AVN and remaining parts of the conducting system are less capable of increasing heart rate, due to stimuli previously mentioned, than the SAN.

Problems with signal conduction, due to disease or abnormalities of the conducting system, can occur any place along the heart’s conduction pathway. Abnormally conducted signals, or arrhythmias, result in alterations of the heart’s normal beating. This is visualized on the electrocardiogram (EKG).

Ventricular Fibrillation

Ventricular fibrillation is the most common electrical mechanism in cardiac arrest. Fibrillation is the manifestation of chaotic electrical excitation of the chambers of the heart. The consequence is the loss of coordinated contraction of the myocytes around the chambers so that the heart no longer pumps blood adequately or at all.
VF begins as a quasiperiodic reentrant pattern of excitation in the ventricles, with resulting poorly synchronized and inadequate myocardial contractions. Multiple foci within the ventricles are firing rapidly and independently. As the initial reentrant pattern of excitation breaks up into multiple smaller wavelets, the level of disorganization increases. There is no coordinated mechanical activity of the ventricles and, thus, no effective ventricular contraction.

The sudden loss of cardiac output with the subsequent tissue hypo­ perfusion creates global tissue ischemia. The brain and the myocardium itself are most susceptible to the loss of oxygenation, and tissue death begins within minutes.

The Etiology of Ventricular Fibrillation (VF)

The etiology of VF is not completely understood. It often occurs in the setting of acute cardiac ischemia or acute myocardial infarction (MI). It is diagnosed in up to half of sudden­death survivors.

Abnormal rapid stimulation of the ventricles (ventricular tachycardia, or V­tach) can lead to fibrillation. Severe left ventricular dysfunction, a variety of cardiomyopathies and acquired or idiopathic long QT syndrome also increase the risk of fibrillation.

Pathophysiology of VF

Sudden cardiac death can be viewed as a continuum of electromechanical states of the heart:

• Ventricular Tachycardia (VT)
• Ventricular Fibrillation (VF)
• Asystole or pulseless electrical activity (PEA)

VF/VT is the most common initial state, and due to insufficient perfusion of vital cardiac tissues, it degenerates to asystole if left untreated.

VF begins as a coarse, irregular deflection on the ECG, then degenerates to a fine, irregular pattern, and eventually becomes asystole. See Figure 1 below. At the onset of VF, the QRS complexes are regular, widened and of tall amplitude, suggesting a more organized ventricular tachyarrhythmia. Over a brief period of time, though, the rhythm becomes more disorganized, with high amplitude fibrillatory waves – this is coarse VF. After a longer period of time, the fibrillatory waves become finer, culminating in asystole.

Figure 1. Degeneration of VF

Course VF Fine VF Asystole

Principle of Defibrillation

Defibrillation is the definitive treatment for the life-threatening cardiac arrhythmias ventricular fibrillation and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator. This depolarizes a critical mass of the heart muscle, terminates the arrhythmia and allows normal sinus rhythm to be re­established by the sinoatrial node.
Defibrillators can be external, wearable or implanted, depending on the type of device used, but all operate on the same principle. A ventricular arrhythmia is detected by the monitoring circuit of the device. A capacitor is charged with an appropriate level of voltage for the device (either by an operator or automatically) and upon initiation of the shock (automatically or upon the press of a button) current is delivered directly to the heart to interrupt the arrhythmia and restore normal conduction. When the current is delivered via an internal defibrillator far less is required as there is not a lot of resistance in the circuit. External defibrillators, however, have to be able to deliver sufficient current to reach the heart through the mass of skin, hair and tissue.

Until recently, most external defibrillation shocks were delivered via paddles placed upon the patient’s chest and the waveform was monophasic: Current traveled in one direction through the heart (monophasic waveform). Two major changes have occurred in the past decade. Today in the US, the majority of defibrillation shocks are delivered through defibrillation electrodes, pads that are placed directly on the patient’s skin. These defibrillation pads are safer for rescuers, and because they conform to the chest are generally able to deliver the current more effectively.

The second major change in defibrillation is the use of biphasic waveform to deliver the current to the heart. With a biphasic waveform, current is delivered to the heart in two vectors. Because of the two­vector approach, the peak current required to convert the arrhythmia is reduced, and the efficacy of the shock is greatly enhanced. It is generally accepted that biphasic defibrillation results in less myocardial damage from the shock itself.

Understanding Defibrillation Waveforms

Before we start, let’s define a few terms:

Energy: Energy in a defibrillator is expressed in joules. A joule is the unit of work associated with one amp of current passed through one ohm of resistance for one second.

When we express it in a formula, it is generally stated as follows: Joules (Energy) = Voltage X Current X Time
Joules have become a surrogate for current in modern defibrillator language.

Current: Current is what actually defibrillates the heart. It is also expressed as Voltage/Impedance (resistance).

Impedance: Resistance to Flow; there is resistance in the electrical circuit itself as well as in the patient. The amount of impedance in a patient is difficult to determine as it relates to body mass, temperature, diaphoresis quality of the contact with paddles or pads. Impedance is expressed in ohms.

Monophasic Waveforms: A type of defibrillation waveform where a shock is delivered to the heart from one vector as shown below. It is shown graphically as current vs. time.

In this waveform, there is no ability to adjust for patient impedance, and it is generally recommended that all monophasic defibrillators deliver 360J of energy in adult patients to insure maximum current is delivered in the face of an inability to detect patient impedance.

Biphasic Waveforms: A type of defibrillation waveform where a shock is delivered to the heart via two vectors. Biphasic waveforms were initially developed for use in implantable defibrillators and have since become the standard in external defibrillators.

While all biphasic waveforms have been shown to allow termination of VF at lower current than monophasic defibrillators, there are two types of waveforms used in external defibrillators.  These are shown below.

Defibrillator manufacturers have approached biphasic defibrillation differently.

Both Physio Control and Philips use the biphasic truncated exponential (BTE) waveform originally developed for internal defibrillators, though they use different energy settings with the waveform. Physio Control uses what they term a “high energy” biphasic waveform, which they term ADAPTIV™ Biphasic. Physio Control energy settings go up to 360 joules of energy and they essentially distribute the voltage and current available over a wider range of energy settings. Additionally they vary the voltage and extend the duration of the shock in higher impedance patients.

Therefore, with a Physio Control BTE Waveform, you might see the following differences in the waveform when patient impedance differs:

Philips Medical also uses the biphasic truncated exponential waveform in their SMART Biphasic device, but in this case, they distribute the voltage and current available over a more narrow range of energy with the maximum current delivered at 200J, roughly equivalent to that delivered by the Physio Control device at 360J.

The Rectilinear Biphasic Waveform (RBW) is used by ZOLL Medical, and it differs from both of the BTE waveform devices. ZOLL fixes voltage at the maximum and varies resistance in order to deliver constant current across the broad range of patients. Like Philips, 200 Joules is the maximum setting on the defibrillator, however this maximum represents more voltage on the capacitor than either Physio Control or Philips has available. Additionally, the duration of the ZOLL RBE waveform is fixed at 10 msec based upon work by Gliner et al.1 which indicates that the defibrillation threshold decreases with increasing time up to a point around 10­12 msec, after which is begins to increase. As there is concern in the literature about the effects of current on myocardial stunning, ZOLL chooses not to go beyond that threshold.2
The ZOLL RBW defibrillator actually divides impedance into two components: equipment­based impedance and patient­based impedance. Rather than adjusting the secondary variables, such as voltage and time, the ZOLL RBW adjusts the equipment­based impedance, and adds or subtracts resistors in the equipment as required to control for an essentially “constant” current during the course of the first phase.

For example, for a 200J energy setting, the ZOLL RBW charges the capacitor to the maximum voltage regardless of patient impedance. In the case of a patient with 50 ohms of impedance, the defibrillator controller adds ohms of resistance to effectively “dampen” the amount of current being delivered to the patient. For a patient with 150 ohms of impedance, no equipment­based resistors are added, and the full amount of current is delivered to the patient. In laboratory bench tests, at 200J, ZOLL delivered 27.8A peak current and 24.0A average current to a 50 ohm resistor, and 14.8A peak current and 12.5A average current to a 150 ohm resistor. At energy settings less than 200J, the difference between peak and average current is even less, typically a maximum of 1A.

Note:

It is really not a good idea to try to compare manufacturers’ biphasic waveforms as each is appropriate for the device in which it is found and none has been shown to be superior to others despite a number of clinical trials.

Types of Defibrillators

There are four major categories of defibrillators:

Advanced Life Support (ALS) Units
ALS defibrillators, used by healthcare professionals in hospitals and ambulances, allow professionals to monitor the patient rhythm and manually intervene if it is determined that a shock is required. In addition, most of these units offer an Advisory or AED function, in which waveform analysis and shock recommendations are made based upon sophisticated algorithms contained within the device.

ALS units can be used with either paddles or electrodes, though the trend today is to use the defibrillation electrode as it is much safer for the rescuer and delivers the shock more uniformly and effectively.

Parameters

Beyond the ability to deliver a shock, ALS defibrillators are often outfitted with a number of parameters to aid rescuers.

Most in­hospital ALS units will have an external pacing capability to allow external pacing of bradycardias.  Many will also offer SPO2, a means to monitor the oxygenation level of the patient via an external sensor, and non­invasive blood pressure (NIBP) units to automatically measure the patient’s blood pressure via a cuff.

Invasive Blood Pressure (IBP) used mainly with advanced transport units where patients with invasive lines can be managed during transport, either within the hospital or via ambulance or aircraft.
Temperature to monitor patient temperature.

Widely used by paramedics in the field is 12­lead EKG, which allows for rapid identification and classification of myocardial infarction. The EKG reading can be transmitted to receiving hospitals and alert cardiology teams that a patient requiring intervention is on the way.
CPR support:

A growing number of ALS defibrillators now also provide support for cardiac compressions. It has become exceedingly clear that good CPR is vital to improving resuscitation outcomes; it has also been determined that delivering good consistent CPR is difficult – even for highly trained professionals. Therefore, there is growing acceptance of the need for defibrillation products to not only be capable of delivering a shock, but also capable of assisting with delivery of optimal circulatory support

Automatic External Defibrillators (AEDs)
These units are designed for use by laypersons and basic life support­ trained personnel. They are widely available in airports, schools, casinos and other public areas. They guide users through the application of the electrodes and automatically analyze the patient’s rhythm and either tell the rescuer to deliver a shock, or actually deliver the shock automatically. Many will also tell bystanders to start CPR, but only one AED, the ZOLL AED Plus currently coaches rescuers to deliver the correct rate and depth of compressions via the use of an accelerometer
built into the electrode pad. As the importance of CPR delivery is increasingly realized to be a critical part of a successful rescue, this capability will most likely expand to other manufacturers.

Implantable Cardioverter Defibrillators (ICDs)
These units are implanted directly into the patient’s chest and designed to protect those patients at high risk of sudden death. Generally, these are patients who have either a known medical condition that puts them at risk, or have actually experienced an episode of VF/VT. These products are beyond the scope of this website, and an in­depth discussion of these products can be found at the manufacturers’ websites highlighted in the links to the right.

Wearable Defibrillators
These are an intermediate care option for patients with a short­term known risk of sudden death or who are not candidates for an implantable device.

Section Citations

1. Gliner et al. Circulation 1995;92:1634­45

2. Tang et al. Journal of American College of Cardiology 1999;34:815­822.

AED Policy

This policy has been developed by the medical staff to provide guidance in the management or administration of a the medical team’s AED program.

Sudden Cardiac Arrest (SCA) is a condition that occurs when the electrical impulses of the human heart malfunction causing a disturbance in the heart’s electrical rhythm called ventricular fibrillation (VF). This erratic and ineffective electrical heart rhythm causes complete cessation of the heart’s normal function of pumping blood resulting in sudden death. The most effective treatment for this condition is the administration of an electrical current to the heart by a defibrillator, delivered within a short time of the onset of VF. An AED is used to treat victims who experience SCA. It is only to be applied to victims who are unconscious, without pulse, signs of circulation and normal breathing. The AED will analyze the heart rhythm and advise the operator if a shockable rhythm is detected. If a shockable rhythm is detected, the AED will charge to the appropriate energy level and advise the operator to deliver a shock.

PROGRAM OVERSIGHT

Program Coordinator (e.g. team or school physician, nurse, health care coordinator, athletic trainer, athletic director)

The medical advisor of the AED program is

Responsibilities

  • Selection of employees for AED training and distribution of AED-trained employee lists as required;
  • Coordination of training for emergency responders;
  • Coordinating equipment and accessory maintenance;
  • Maintain on file a specifications/technical information sheet for each assigned approved AED model;
  • Revision of this procedure as required
  • Monitoring the effectiveness of this system
  • Communication with medical director on issues related to medical emergency response program including post-event reviews

Applicable Documents (examples)

  • General safety and health standard
  • County/State AED Guidelines
  • Medical emergency action plan
  • Infection control procedure for universal precautions
  • State immunity from liability exclusion
  • AED Procedure

MEDICAL CONTROL

The medical advisor of the AED program is , M.D. The medical advisor of the AED program has ongoing responsibility for:

  • Proving medical direction for use of AEDs
  • Writing a prescription for AEDs
  • Reviewing and approving guidelines for emergency procedures related to use of AEDs and CPR
  • Evaluation of post-event review forms and digital files downloaded from the AED

Authorized AED Users

The AED may be used by:

  • Employees including: administrators, nurses, athletic/activities director, athletic trainers and office staff.
  • Additional staff as identified by administration. Examples: teachers, coaches, field/game managers and security staff.
  • Any trained volunteer responder who has successfully completed an approved CPR/AED training program within the last two years and has a current successful course completion card.

AED-Trained Employee Responsibilities

  • Activating internal emergency response system and providing prompt basic life support including AED and first aid according to training and experience
  • Understanding and complying with requirements of this policy
  • Following the more detailed procedures and guidelines for the AED program

Volunteer Responder Responsibilities

  • Anyone can, at their discretion, provide voluntary assistance to victims of medical emergencies. The extent to which these individuals respond shall be appropriate to their training and experience. These responders are encouraged to contribute to emergency response only to the extent they are comfortable. The emergency medical response of these individuals may include CPR, AED or medical first aid.

Designated Central Office Responsibilities

Designated office staff shall be responsible for:

  • Receiving emergency medical calls from internal locations
  • Using an established 9-1-1 checklist to assess emergency and determine appropriate level of response
  • Contacting the external community 9-1-1 response team (EMS) if required
  • Deploying AED-trained employees to emergency location
  • Assigning someone to meet responding EMS aid vehicle and direct EMS personnel to site of medical emergency

EQUIPMENT

Approved equipment

The AEDs approved for this program conform to the state/county standards.

  • The AED and first-aid emergency care kit will be brought to all medical emergencies.
  • The AED should be used on any person who is at least 8 years of age and displays ALL the symptoms of cardiac arrest. The AED will be placed only after the following symptoms are confirmed:
    • Victim is unresponsive
    • Victim is not breathing, or is breathing ineffectively
    • Victim has no signs of circulation such as pulse and coughing, or movement

NOTE: If AED program includes the treatment of children under eight years old or under 25 Kg. (55 lbs), equip AEDs with Infant/Child Reduced Energy Defibrillation Electrode Starter Kit (includes one pair of electrodes, storage pouch and appropriate safety instructions and labels).

Location of AEDs

During regular hours, the AED will be at designated locations. These locations shall be specific to each school but should allow the device to be easily seen by staff. The locations should allow staff members to retrieve the device outside of normal school hours.

After school hours, the AED may be moved from its designated location by an AED-trained athletic trainer to support athletic department activities on a voluntary basis. A trained volunteer would have to be available and willing to support this effort during non–school hours. A visible sign must be left in the place of the AED, with the phone number of the athletic trainer, clearly indicating they have possession of the AED.

Contracted and other community activities are not guaranteed access to the AED as part of standard rental contracts.

Location of AEDs:

Athletic Program AED Locations:

Administrative AED Locations:

Additional Resuscitation Equipment

Each AED will have one set of defibrillation electrodes connected to the device and one spare set of electrodes with the AED. One resuscitation kit will be connected to the handle of the AED. This kit contains two pair latex-free gloves, one razor, one set of trauma shears, and one facemask barrier device.

Equipment Maintenance

All equipment and accessories necessary for support of medical emergency response shall be maintained in a state of readiness. Specific maintenance requirements include:

  • The main school office shall be informed of changes in availability of emergency medical response equipment. If equipment is withdrawn from service, the main school office shall be informed and then notified when equipment is returned to service.
  • The main school office shall be responsible for informing response teams of changes to availability of emergency medical equipment.
  • The AED Program Coordinator or designee shall be responsible for having regular equipment maintenance performed. All maintenance tasks shall be performed according to equipment maintenance procedures as outlined in the operating instructions.
  • Following use of emergency response equipment, all equipment shall be cleaned and/or decontaminated as required. If contamination includes body fluids, the equipment shall be disinfected according to procedure #_________________.

Routine Maintenance

  • The AED will perform a self-diagnostic test every 24 hours that includes a check of battery strength and an evaluation of the internal components.
  • A volunteer, assigned by the AED Program Coordinator or designee, will perform a daily AED check following the procedure checklist. The procedure checklist will be initialed at the completion of the daily check. The procedure checklist will be posted with the AED.
  • If the OK icon is NOT present on the readiness display, contact the AED Program Coordinator or designee immediately.
    • If the battery icon is visible, the battery or charging unit needs to be replaced. You may continue to use the AED if needed.
    • If the wrench icon is visible, the AED needs service. You may attempt to use the AED if needed. If the message CALL SERVICE appears, the AED is not usable. Continue to provide CPR until another AED is brought to the victim or EMS arrives to take over care.
  • If the expiration date on the electrode is near, notify the AED Program Coordinator or designee immediately.

TRAINING

Trained Employees

  • Must complete training adequate to provide basic first-aid, CPR and AED that will be provided on site. AED training must be a course approved by the state. Trained employees will also be trained in universal precautions against bloodborne pathogens. The trained employees shall be offered hepatitis B vaccination free of charge. The school office shall maintain training records for the trained employees. NOTE: If AED program includes the treatment of children under eight years old or under 25 Kg. (55 lbs), training should include infant/child CPR/FBAO since techniques differ from adult CPR/FBAO.

Volunteer Responders

  • These responders will possess various amounts of training in emergency medical response and their training may be supplied by sources outside of the company. Volunteer responders can assist in emergencies, but must only participate to the extent allowed by their training and experience. Volunteer responders may have training adequate to administer first aid, CPR and use the AEDs deployed throughout the campus. Any volunteer wishing to potentially use one of the AEDs deployed on the campus should have successfully completed a state approved AED course including CPR within the last two years. The school will not maintain training records for the volunteer responders.

Refresher Training

  • Trained employees will renew first-aid and AED training every two years.
  • AED-trained employees will refresh AED skills using computer-based training. Each AED-trained employee will have access to AED Challenge™ interactive training software. Every six months each will perform a three-scenario test that will be reviewed by the AED Program Coordinator or designee.
  • Volunteer responders should obtain documented renewal training at least once every two years. Volunteer responders are encouraged to periodically refresh their AED skills. This can be accomplished through the use of AED Challenge interactive training software. A copy of AED Challenge software has been placed on the computer in the library. All trained volunteer responders are encouraged to practice anytime.

MEDICAL RESPONSE DOCUMENTATION

Internal Post-Event Documentation

It is important to document each use of the medical emergency response system. The following forms shall be sent to the AED Program Coordinator or designee within 24 hours of a medical event:

  • An accident report form shall be completed by a responding employee for each accident requiring first-aid of any type.
  • The AED-trained employee or volunteer responder shall complete a medical event form (9-1-1 form) whenever an AED is used.

External Post-Event Documentation

A copy of AED use information shall be presented within 48 hours of the emergency to the following:

  • Medical director of the AED program
  • Local EMS, county, state officials as designated in state AED requirements and local regulations
  • At a minimum, event information supplied shall include any recorded data, and all electronic files captured by the AED.

Post-Event Review

Following each deployment of the response team member, or if a volunteer responder uses an AED, a review shall be conducted to learn from the experience. The AED Program Coordinator or designee shall conduct and document the post-event review. All key participants in the event shall participate in the review. Included in the review shall be the identification of actions that went well and the collection of opportunities for improvement as well as critical incident stress debriefing. A summary of the post-event review shall be sent to the environmental health and safety committee. The environmental health and safety coordinator according to the record retention policy shall maintain a copy of the post-event review summary.

System Verification and Review

The medical emergency response system is ultimately successful if necessary medical assistance is provided to victims in a timely and safe manner. Since actual use of this system procedure is expected to be very infrequent, other measures of effectiveness are required.

Annual System Assessment

Once each calendar year, the AED Program Coordinator or designee shall conduct and document a system readiness review. This review shall include review of the following elements:

  • Training records
  • Equipment operation and maintenance records

Approvals

Medical Director


Signature
Date

Program Coordinator


Signature
Date

AIRWAY MANAGEMENT OVERVIEW

Under normal breathing, the lungs inflate under a slight vacuum when the chest wall muscles and diaphragm expand; causing air to enter and inflate the lungs under a gentle vacuum. Chest compressions performed during CPR result in passive-oxygen delivery as oxygen is forced out of the lungs during chest compression and drawn into the lungs during chest recoil.  Systemic and pulmonary perfusion is reduced during CPR resulting in minimal ventilation required to maintain adequate perfusion.  Thus, passive oxygen delivery resulting from chest compressions on a patient with a patent airway may be sufficient for the first several minutes of CPR.  Using various manual resuscitation methods during CPR results in positive-pressure ventilation.  During positive-pressure ventilation the lungs are force-inflated with pressurized air or oxygen. This inherently leads to risk of various complications, many of which depend on whether the manual resuscitator is being used with a face mask or ET tube. Complications are related to over-inflating or over-pressurizing the patient, resulting in gastric insufflation, volutrauma, and/or barotrauma.  Recently, it has been suggested that positive pressure ventilation may also interfere with circulation during CPR.  Overall, rescue breathing is less important than chest compression during the first several minutes of CPR because blood flow, rather than arterial oxygen content, is the limiting factor in oxygen delivery to the heart and brain during cardiac arrest.  Therefore, rescue breathing and oral tracheal intubation (OTI) should not delay or interrupt initial CPR and defibrillation during care of a patient in cardiac arrest.  Current recommendations suggest that if OTI will interrupt chest compressions for more than 10 seconds, ALS providers should consider using a supraglottic device (SGD) or defer placement until the patient fails to respond to initial CPR and defibrillation attempts. 1

Airway emergencies resulting from trauma to the larynx are uncommon.  Major medical centers report that only 8% of trauma involves the larynx; and of those, only 10% are attributable to athletics.  Laryngeal injuries resulting from athletics most often result from blunt trauma resulting from being hit by a ball or puck, from a direct blow, such as a punch or close lining, or from contact with other environmental hazards such as goal posts. 2 However, there is an apparent relationship between head and neck injury and laryngeal injuries that cannot be overlooked.  When evaluating athletes for potential head and neck injuries, sports medicine teams should have a high index of suspicion of corresponding laryngeal injury to ensure that a distracting head or neck injury does not result in overlooking injury to the larynx that may result in latent airway complications. 3  Therefore, sports medicine teams should include a systematic evaluation of the larynx in their head and neck injury assessment algorithm.3

Injury to the larynx has no clear presentation pattern.  However, the onset of hoarseness, dyspnea, difficulty swallowing, stridor, and subcutaneous emphysema is indicative of potential acute or latent airway complications.  The onset of airway complications secondary to trauma warrants immediate transport because traditional prehospital airway management techniques, including adjunct airways, may be ineffective or even contraindicated with severe injury to the larynx.  Traditional prehospital airway management techniques may be ineffective when there is trauma to the larynx because they do not bypass the larynx or may be contraindicated during instances where injury to the larynx has resulted in cartilaginous fracture or separation.2,3

Airway emergencies in athletics secondary to laryngeal injury are uncommon.  The more likely cause of an airway emergency in athletics is an upper airway obstruction.  Upper airway obstructions may be caused by a foreign object or may be tongue-based.  Foreign object upper airway obstructions in athletics are likely to be caused by an athlete’s mouth guard.  Tongue-based upper airway obstructions are common when an athlete is rendered unconscious allowing the tongue to fall back against the posterior pharyngeal wall.  Other medical conditions, such as anaphylaxis or laryngospasm, may also result in an upper airway obstruction.2,3

The onset of an upper airway obstruction or injury to the larynx will require the medical team to initiate airway management techniques to establish and maintain a patent airway.  The techniques used to establish, support, and maintain a patent airway will differ based on the qualifications of the medical staff present.  Athletic trainers are qualified to provide airway management using BLS airway adjuncts, including oropharyngeal and nasopharyngeal airways, bag ventilation mask, oxygen, and suction.  Airway management physicians and paramedics are qualified to use more advanced airway management techniques, including intubation using an endotrachial tube (ET), oesophageal tracheal combitube (OTC) laryngeal tube (LT), laryngeal tube with integrated suction tube (LTS), laryngeal mask airways (LMA), ProSeal laryngeal mask airways (PLMA), video laryngoscopes, and rapid sequence intubation (RSI).

Currently, the LMA, LT, and the OTC are the best evaluated and most commonly used advanced airway devices in the pre-hospital athletic environment.  The standard LMA and the PLMA have been shown to be effective during emergency airway management.  However, of concern with the LMA is the lack of reliable protection against aspiration.  The effectiveness of the inflatable LMA to provide reliable protection against aspiration has yet to be determined.  The OTC, though advocated for during prehospital emergency airway management, is limited by high airway morbidity and possible serious complications. 4,5

Stomach Inflation / Lung Aspiration

During positive-pressure ventilation, the intent is for the force-delivered air or oxygen to inflate the lungs.   However, air entering the patient also has access to the stomach via the esophagus.  If the resuscitator is squeezed too hard or too fast, the airflow may be too rapid for the lungs to absorb, resulting in the excess air being diverted to the stomach.   The resulting gastric inflation can lead to vomiting and subsequent aspiration of stomach contents into the lungs.  When stomach inflation leads to vomiting of highly acidic stomach acids, delivery of subsequent breaths can force these caustic acids down into the lungs where they cause life-threatening or fatal lung injuries.

Lung Injury and Air Embolism

When an endotracheal (ET) is placed, one of the key advantages is that a direct air-tight passageway is provided from the output of the manual resuscitator to the lungs, thus eliminating the possibilities of inadvertent stomach inflation or lung injuries from gastric acid aspiration. However, this places the lungs at increased risk from separate lung injury patterns caused by accidental forced over-inflation, called volutrauma and/or barotrauma. Sponge-like lung tissue is delicate, and over-stretching can lead to adult respiratory distress syndrome.  Lung volutrauma, may also result in pneumothorax

BLS Airway Adjuncts


Magill Forceps

When a larger foreign object results in an upper airway obstruction, the foreign object must be cleared from the airway to establish a patent airway.  Blind finger sweeps are no longer recommended by the American Heart Association as they may result in driving the foreign object further into the airway.  Current recommendations from the AHA recommend that the patient’s mouth be opened to allow the rescuer to look for a foreign object.  If a foreign object is visible, the rescuer may reach in with a gloved hand and retrieve the foreign object.6 More advanced medical teams will use a bite stick to open a patient’s airway and retrieve a foreign object with a pair of Magill Forceps.  Evidence Category C

Suction Units
Suction units provide a means for removing blood, fluid, pulmonary secretions, and small foreign particles from an injured or ill patient’s airway.  Suction units may be mounted or portable, but neither is appropriate for removal of large or solid objects such as teeth, large foreign bodies, or food particles.  Portable suction devices are easily carried on-field and may be effective in helping athletic trainers maintaining a patent airway until EMS arrives.  Effective suction units will generate a negative vacuum suction pressure of 300 mm Hg and be powerful enough to provide airflow greater than 40 L/min at the end of the suction tubing.7

Suction is indicated when a gurgling sound is heard during breathing or during positive pressure ventilation, when ventilation is ineffective due to vomitus, blood, bodily fluids, respiratory secretions, and/or when small particles block the airway.  Use of suction to maintain a patent airway during management of the potentially spine injured patient may prevent the need to log roll the patient to clear the airway.  A soft suction tip catheter is indicated for suctioning fluids.   When a patient is unresponsive, or requires suctioning of vomit or thick secretions, use of a rigid suction tip is indicated.

The following procedure is suggested when suctioning is indicated:

1.       Open the patient’s mouth using a bite stick;

2.       Observe body substance isolation precautions;

3.       Remove solid foreign material using Magill forceps;

4.       Measure the distance of insertion of the suction tip from the patient’s ear lobe to the corner of the mouth;

5.       Insert the suction tip into the throat using the measurement from above as a guide. Do not insert the suction tip deeper than the base of the tongue or further than what can be visualized;

6.       Suction from the back of throat outward, use a circular method, and avoid losing sight of the tip. Suction an adult no longer than 15 seconds and 10 seconds in a pediatric patient;

7.       Monitor the patient’s response to suctioning and provide necessary interventions such as positive pressure ventilations using a bag-valve. If the patient begins to gag, withdraw the suction tip until they stop gagging and then resume suctioning.  Evidence Category C.

Bag Mask Ventilation
A bag valve mask (BVM) is a hand-held device commonly used to provide positive-pressure ventilation to patients who are not breathing or not breathing adequately.   The principal type of manual resuscitator used in the pre-hospital setting is one that is self-filling with air, although additional oxygen (O2) can be added, it is not necessary for the device to function.  When used alone, a BMV can deliver oxygen concentrations of 21% as the device draws in room air.  Connecting supplemental oxygen at a rate of 10 to 15 L/min to the inlet valve of a BVM without the use of a reservoir bag increase the oxygen concentration delivered to the athlete to 40 % – 60%.  Using a BMV with a reservoir bag and supplemental oxygen at a rate of 10 to 15 L/min will result in an oxygen concentration of 90% or more being delivered to an injured athlete. 8,9  Therefore, medical teams should be prepared to provide supplemental oxygen during BVM use in the pre-hospital setting.

Figure 1 depicts the various components of a typical BVM.  Part 1 depicts the flexible face mask that seals over the patient’s face.    A filter and valve prevent back flow into the bag itself to prevent patient deprivation and bag contamination (Part 2).  The soft bag element (Part 3) is squeezed to expel air to the patient.

When the face mask is properly applied and the “bag” is squeezed, the device forces air through the trachea and bronchus and into the patient’s lungs.  The bag self-inflates upon release by drawing in either ambient air or low pressure oxygen supplied by a regulated cylinder during which time the patient’s lungs deflate to the ambient environment (not the bag) through the one way valve.  When used without supplemental oxygen a BVM will provide ambient air (21% oxygen) to the patient, however when connected to supplemental oxygen the amount of oxygen delivered to the patient to nearly 100%.8,9 A BVM may also also be attached to an alternate airway adjunct, such as a endotracheal tube (ET) or laryngeal mask airway (LMA).

BVM come in different sizes.   Most BVM are disposable and therefore single use, while others are designed to be cleaned and reused.  For patients with a lot of facial hair or when it is difficult to get a proper seal with a traditional flexible mask, the medical team may consider an easy seal mask (Figure 2).

Method of operation
Manual resuscitators cause the gas inside the inflatable bag portion to be force-fed to the patient via a one-way valve when compressed by the rescuer; the gas is then ideally delivered through a mask and into the patient’s trachea, bronchus and into the lungs. To be effective, a bag valve mask must deliver between 500 and 800 milliliters of air to a normal male adult patient’s lungs, but if supplemental oxygen is provided 400 ml may still be adequate.  Squeezing the bag once every 5–6 seconds for an adult or once every 3 seconds for an infant or child provides an adequate respiratory rate (10–12 respirations per minute in an adult and 20 per minute in a child or infant).

Professional rescuers are taught to ensure that the mask portion of the BVM is properly sealed around the patient’s face to ensure adequate pressure needed to force-inflate the lungs and to avoid leaking oxygen into the ambient environment.   During two-rescuer CPR the BVM is the preferred means of providing ventilations for a patient with a patent airway.  During two-rescuer rescue breathing one rescuer secures the mask to the patient’s face with both hands and focus entirely on maintaining a leak-proof mask seal, while the other rescuer squeezes the bag and focuses on breath (or tidal volume) and timing.  Ventilation via a BVM is difficult when a single rescuer attempts to maintain a face mask seal with one hand while squeezing the bag with the other as depicted in Figure 3. Current practice standards suggest lone rescuers provide rescue breathing via mouth-to-mouth or mouth-to-mask.1

To decrease the risk of gastric inflation, rescuers should deliver each breath from the BVM over a 1 second interval, resulting in a visible chest rise and delivering a tidal volume of 500-600 mL2 at a rate of 10 to 12 breaths per minute with a expiratory time greater than 1:2 (inspiration:expiration).8

Oropharyngeal Airways (OPA)

An oropharyngeal airway (OPA) is an airway adjunct used to maintain or open a patient’s airway. It does this by preventing the tongue from covering the epiglottis, which could prevent the person from breathing. When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway.

OPAs come in a variety of sizes, from infant to adult, and are used commonly in pre-hospital emergency care and for short term airway management post anesthetic or when manual methods are inadequate to maintain an open airway.  The OPA is indicated when tracheal intubation is either not available, not advisable, or the need for airway assistance is of short term duration.  The Guedal style OPA has a hollow cavity that allows the use of a flexible suction catheter to facilitate clearing the airway of secretions.  The Berman style OPA does not have a hollow to permit use of a flexible suction catheter.  OPAs are indicated only in unconscious patients due to likelihood that the device will stimulate a gag reflex in conscious or semi-conscious patients, resulting in vomiting and resulting airway obstruction.

OPAs need to be sized and inserted correctly to maximize effectiveness and minimize possible complications, such as oral trauma.  The OPA is sized by measuring from the center of the mouth to the angle of the jaw, or from the corner of the mouth to the earlobe.  Traditionally, the mouth is opened using the “crossed or scissors” finger technique, but more experienced medical teams will consider use of a bite stick. Evidence Category C

The OPA airway is inserted into the person’s mouth upside down. Once contact is made with the back of the throat, the OPA is rotated 180 degrees, allowing for easy insertion, and assuring that the tongue is secured.  An alternative method for insertion, the method that is recommended for OPA use in children and infants, involves holding the tongue forward with a bite stick and inserting the airway right side up.  An OPA is removed when the person regains a gag-reflex and can protect their own airway, or it is substituted for an advanced airway. It is removed simply by pulling on it without rotation.

Use of an OPA does not remove the need for the recovery position and ongoing assessment of the airway and it does not prevent obstruction by liquids (blood, saliva, food, cerebrospinal fluid) or the closing of the glottis. It can, however, facilitate ventilation during CPR. 1,7,8

The main risks of its use are:

●      if the person has a gag-reflex they may vomit

●      when it is too large, it can close the glottis and thus close the airway

●      improper sizing can cause bleeding in the airway

The following protocol shall be used to place an OPA when indicated:

1.       Activate the emergency action plan and ensure that ALS is dispatched by communicating the EMS dispatch that the patient is in respiratory distress;

2.       Attempt ventilations using a BVM;

3.       If unable to ventilate a patient who is not at risk of chocking with the BVM; prepare to place an OPA;

4.       Determine the proper size OPA by measuring from the patient’s ear to the mouth;

5.       Position the patient in cervical neutral position;

6.       Lubricate the OPA with a water-based lubricant;

7.       Open the patient’s mouth using a bite-stick;

8.       Place the OPA by slinging along the roof or side of the patient’s mouth until the OPA reaches the base of the throat; rotate the OPA into place;

9.       Ventilate using a BVM;

10.    Monitor and support vital signs until ALS arrives;

11.    If the patient begins to vomit, suction shall be used to maintain a patent airway. A log roll technique may be employed to clear the airway of vomit if suction is not able to clear the airway of vomit.

Nasopharyngeal Airway (NPA)
A nasopharyngeal airway (NPA) is a tube that is designed to be inserted into the nasal passageway to secure an open airway.  These devices are used by emergency care professionals in situations where an artificial form of airway maintenance is necessary, but tracheal intubation is impossible, inadvisable, or outside the practitioner’s scope of practice. An NPA is often used in conscious patients where an OPA would trigger the gag reflex.

The correct size airway is chosen by measuring the device on the patient.  The device should reach from the patient’s nostril to the earlobe or the angle of the jaw. Ensure that the diameter of the NPA is not larger than the nostril.  The outside of the tube is lubricated with a water-based lubricant so that it enters the nose more easily. The device is inserted until the flared end rests against the nostril. Some tubes contain a safety pin to prevent inserting the tube too deeply. Care must be taken to ensure the pin does not stick into the nostril. If a pin is not available, you may also stop insertion just short of the natural gag reflex and tape the remaining exposed portion of the NPA to the surrounding facial tissue. 1,7,8

Insertion of an NPA is absolutely contraindicated in patients with severe head or facial injuries, or have evidence of a basilar skull fracture (Battle’s sign, raccoon eyes, cerebrospinal fluid/blood from ears, etc.) due to the possibility of direct intrusion into brain tissue. 1,7,8,9,10

The following protocol will be used to place an NPA:

1.       Activate the emergency action plan and ensure that ALS is dispatched by communicating the EMS dispatch that the patient is in respiratory distress;

2.       Determine the appropriate length NPA to be placed by measuring from the tip of the ear to the jaw line;

3.       Determine the proper NPA diameter by referencing the patient’s little finger;

4.       Lubricate the NPA with a water-based lubricant;

5.       Place the NPA with the bevel side toward the septum;

6.       In conscious patients, connect a non-rebreather mask to the oxygen tank and place non-rebreather on the patient and administer oxygen at rate of 15 L/min;

7.       Check the inspiratory and expiratory valves of the non-rebreather to ensure they are working properly;

8.       In unconscious patients begin ventilations using a BVM;

9.       Monitor and support the patient’s vital signs;

10.    If the patient begins to vomit, suction shall be used to maintain a patent airway. A log roll technique may be employed to clear the airway of vomit if suction is not able to clear the airway of vomit.

Supplemental Oxygen
Normal room (ambient) air oxygen concentrations of 21% are more than adequate to sustain life in healthy athletes.  However, traumatic injury or illness may result in higher oxygen concentrations in order ensure adequate perfusion and prevent hypoxia when normal body system function is compromised.  Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level.  Hypoxia can lead to cardiac arrhythmia, tissue and cell damage, renal damage, and eventual cerebral damage.  Significant hypoxia lasting more than 4 to 6 minutes may result in cardiopulmonary arrest and irreversible brain and vital organ damage. 7 Sign and symptoms of hypoxia include, but are limited to:

·         Altered mental status;

·         Neurological compromise;

·         Tachycardia;

·         Angina;

·         Dyspnea, tachypnea, or hypoventilation;

·         Cyanosis;

·         Headache, nausea, vomiting;

·         Restlessness, anxiety, agitation.

The use of supplemental oxygen during management of an injured athlete demonstrating signs and symptoms of hypoxia increases the amount of oxygen being delivered to body tissues and may increase the athlete’s chance of survival. 7,8   Indications for use of supplemental oxygen include, but are limited to:

·         Altered mental status;

·         Cardiac arrest or angina;

·         Drug overdose;

·         Internal trauma;

·         Fractures;

·         Respiratory arrest;

·         Respiratory distress;

·         Shock;

·         Stroke.

There are no absolute contraindications to the use of supplemental oxygen in the athletic setting.  Therefore, medical teams need not wait for the specific signs and symptoms of hypoxia to become evident.  Supplemental oxygen should be administered when an athlete presents with dyspnea or respiratory distress to prevent the onset of hypoxia. 7  However, administration of supplemental oxygen should not interfere with completion of chest compressions during CPR .1

Nasal Cannula
The nasal cannula (NC) is a device used to deliver supplemental oxygen or increased airflow to a patient in need of respiratory help. The NC consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows. The other end of the tube is connected to an oxygen supply. The cannula is generally attached to the patient by way of the tube hooking around the patient’s ears or by elastic head band. Generally, the common adult nasal cannula carries 1–5 liters of oxygen per minute.  Supplemental oxygen via nasal cannula at 4-6L/min delivers 36-44% oxygen, ideal for administering supplemental oxygen for most medical emergencies when the athlete is breathing on their own. 7,8,9

A nasal cannula is generally used wherever small amounts of supplemental oxygen are required, without rigid control of respiration, such as in oxygen therapy. Most cannulae can only provide oxygen at low flow rates—up to 5 liters per minute (L/min)—delivering an oxygen concentration of 28–44%. Rates above 5 L/min can result in discomfort to the patient, drying of the nasal passages, and possibly nose bleeds (epistaxis). Also with flow rates above 6 L/min, the laminar flow becomes turbulent and the oxygen therapy being delivered is only as effective as delivering 5-6 L/min. 7,8

Non-Rebreather Oxygen Mask
A non-rebreather mask (NRB, non-rebreather, non-rebreather facemask, etc.) is a device used in medicine to assist in the delivery of oxygen therapy. An NRB requires that the patient can breathe unassisted, but unlike low flow nasal cannula, the NRB allows for the delivery of higher concentrations of oxygen.

The non-rebreather mask covers both the nose and mouth of the patient and attaches with the use of an elastic cord around the patient’s head. The NRB has an attached reservoir bag, typically 1 liter, that connects to an external oxygen supply. Before an NRB is placed on the patient, the reservoir bag is inflated to greater than two-thirds full of oxygen, at a rate of 6-15 liters per minute (lpm). 8 Approximately ¹⁄₃ of the air from the reservoir is depleted as the patient inhales, and it is then replaced by the flow from the O2 supply.   If the bag becomes completely deflated, the patient will no longer have a source of air to breathe.  Generally, delivery of 10 L/min is standard practice for delivery of supplemental oxygen through a NRB in the prehospital setting. 8

Exhaled air is directed through a one-way valve in the mask, which prevents the inhalation of room air and the re-inhalation of exhaled air. The valve, along with a sufficient seal around the patient’s nose and mouth, allows for the administration of high concentrations of oxygen, approximately 60% – 80% O2.8 The patient must partially deflate the reservoir bag during inspiration or the high oxygen concentration will not be achieved, and the mask will provide only the liter flow rate setting on the flowmeter.

The non-rebreather mask is utilized for athlete with physical trauma or who require high-concentration oxygen, but do not require breathing assistance. Patients uncomfortable with having a mask on their face, such as those with claustrophobia, or patients with injuries to the mouth are more likely to benefit from a nasal cannula, or passive blow-by oxygen.  Patients who are unable to breathe on their own would require invasive or noninvasive mechanical ventilation.

BLS Airway Adjunct Considerations
Placement of an OPA only requires that a patient be lacking a gag reflex and in neutral cervical position.  Therefore, airway management for the potentially spine injured athlete can be facilitated by use of the OPA when maintaining in-line stabilization is desired.  However, use of an OPA is contraindicated when there is a potential airway obstruction.  In athletics, an airway obstruction would likely be caused by swallowing a mouth guard or chewing gum.  Therefore, when there appears to be an airway obstruction, the medical team will complete a visual inspection of the patient’s mouth.  If an obstruction is visible, the medical team will attempt to remove the obstruction using forceps.  If the obstruction cannot be removed, the OPA is contraindicated and the medical team will attempt airway management via the NPA or other appropriate advanced airway management technique.

Suction may be used to remove fluids from the airway to facilitate breathing.   Should the need for airway management be deemed necessary by the athletic training staff prior to the availability of prehospital ALS, the athletic training staff will determine the patient’s level of consciousness.  If the patient is alert and responsive, but in need of airway assistance, an NPA shall be used to provide airway support.  An NPA shall also be indicated for airway support in patients for whom an airway obstruction cannot be ruled out.

BLS Emergency Airway Management Supplies List

  • AED
  • BVM ventilator
  • Seal Quick™ resuscitator
  • Magill forcepts
  • OPA kit
  • NPA kit
  • Manual suction pump
  • Oxygen
  • Non-rebreather mnask

Ancillary Content

OPA Demonstration NPA Demonstration Airway Management Considerations

ALS Airway Adjuncts

Endotracheal Tube

A tracheal tube (ET) is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide.  Most endotracheal tubes today are constructed of polyvinyl chloride, but specialty tubes constructed of silicone rubber, latex rubber, or stainless steel are also widely available. Most tubes have an inflatable cuff to seal the trachea and bronchial tree against air leakage and aspiration of gastric contents, blood, secretions, and other fluids. Uncuffed tubes are also available, though their use is limited mostly to pediatric patients.

The ET maintains a paten airway, facilitates suctioning of airway secretions, enables delivery of oxygen in higher concentrations than ambient air, permits delivery of a prescribed tidal volume, and provides an alternate route for delivery of some medications.  Cuffed ET may also protect the airway from aspiration.  Use of an ET is indicated in when providers are unable to ventilate effectively with a BVM and when the airway protective reflexes are absent.  Although placement of an ET tube can be accomplished during on-going chest compressions during CPR, intubation is generally associated with considerable interruption of chest compressions.  The interruption of chest compressions from ET placement can minimized when ALS providers prepare in advance to begin placement as soon the provider performing compressions pauses during normal CPR protocol.  Compressions should resume as soon as the ET passes through the vocal cords.  The ALS provider with a preference for ET intubation should plan to be able to complete ET intubation in less than 10 seconds, or consider airway management using a supraglottic devices or deferring advanced airway placement until the patient fails to respond to initial CPR attempts.1

ET use is associated with a 6%-25% incident of misplacement or displacement.  In addition, the risk of a properly placed ET becoming displaced is considerable, particularly during movement of the patient.  Therefore, ALS providers should always plan to use a combination of clinical assessment and CO2 monitoring, such as waveform capnography or an exhaled CO2 esophageal detector device, to verify initial placement and ensure that the ET does not become displaced during care. 1

Laryngoscopy

Laryngoscopy is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during general anaesthesia or cardiopulmonary resuscitation or for surgical procedures on the larynx or other parts of the upper tracheobronchial tree.

Direct laryngoscopy

Direct laryngoscopy is typically carried out with the patient lying on his or her back; the laryngoscope is inserted into the mouth on the right side and flipped to the left to trap and move the tongue out of the line of sight.  Depending on the type of blade used, the laryngoscope is inserted either anterior or posterior to the epiglottis and then lifted with an upwards and forward motion, away from the provider and towards the roof of the patient’s mouth. This move makes a view of the glottis possible.

Indirect laryngoscopy

Indirect laryngoscopy is performed whenever the provider visualizes the patient’s vocal cords by a means other than obtaining a direct line of sight. For the purpose of intubation, this is facilitated by fiberoptic bronchoscopes, video laryngoscopes, fiberoptic stylets and mirror or prism optically-enhanced laryngoscopes.

Conventional laryngoscope

The vast majority of tracheal intubations involve the use of a viewing instrument of one type or another. Since its introduction by Kirstein in 1895, the conventional laryngoscope has been the most popular device used for this purpose. Today, the conventional laryngoscope consists of a handle containing batteries with a light source, and a set of interchangeable blades.

Early laryngoscopes used a straight “Magill Blade”, and this design is still the standard pattern veterinary laryngoscopes are based upon; however the blade is difficult to control in adult humans and can cause pressure on the vagus nerve, which can cause unexpected cardiac arrhythmias to spontaneously occur in adults.

Two basic styles of laryngoscope blade are currently commercially available: the curved blade and the straight blade. The Macintosh blade is the most widely used of the curved laryngoscope blades, while the Miller blade is the most popular style of straight blade.  Both Miller and Macintosh laryngoscope blades are available in sizes 0 (neonatal) through 4 (large adult). There are many other styles of curved and straight blades (e.g., Phillips, Robertshaw, Sykes, Wisconsin, Wis-Hipple, etc.) with accessories such as mirrors for enlarging the field of view and even ports for the administration of oxygen. These specialty blades are primarily designed for use by anesthetists, most commonly in the operating room.   Additionally, paramedics are trained to use direct laryngoscopy to assist with intubation in the field.

The Macintosh blade is positioned in the vallecula, anterior to the epiglottis, lifting it out of the visual pathway, while the Miller blade is positioned posterior to the epiglottis, trapping it while exposing the glottis and vocal folds. Incorrect usage can cause trauma to the front incisors; the correct technique is to displace the chin upwards and forward at the same time, not to use the blade as a lever with the teeth serving as the fulcrum.

The Miller, Wisconsin, Wis-Hipple, and Robertshaw blades are commonly used for infants. It is easier to visualize the glottis using these blades than the Macintosh blade in infants, due to the larger size of the epiglottis relative to that of the glottis.

Fiberoptic laryngoscopes

Besides the conventional laryngoscopes, many other devices have been developed as alternatives to direct laryngoscopy. These include a number of indirect fiberoptic viewing laryngoscopes such as the flexible fiberoptic bronchoscope. The flexible fiberoptic bronchoscope or rhinoscope can be used for office-based diagnostics or for tracheal intubation. The patient can remain conscious during the procedure, so that thevocal folds can be observed during phonation. Surgical instruments passed through the scope can be used for performing procedures such as biopsies of suspicious masses. These instruments have become indispensable within the otolaryngology, pulmonology and anesthesia communities.

Other available fiberoptic devices include the Bullard scope, UpsherScope,  and the WuScope.  These devices are widely employed for tracheal intubation, especially in the setting of the difficult intubation.

Video laryngoscope

The conventional direct laryngoscope uses a line of sight provided by a rigid viewing instrument with a light on the blade or intra-oral portion which requires a direct view of the target larynx; this view is clearly seen in 80-90% of attempts. The frequent failure of direct laryngoscopy to provide an adequate view for tracheal intubation led to the development of alternative devices such as the lighted stylet, and several indirect fiberoptic viewing laryngoscopes, such as the fiberscope, Bullard scope, Upsher scope, and the WuScope. Though these devices can be effective alternatives to direct laryngoscopy, they each have certain limitations, and none of them is effective under all circumstances. One important limitation commonly associated with these devices is fogging of the lens.  To address some of these limitations, Dr. Jon Berall, a New York City internist and emergency medicine physician, designed the camera screen straight video laryngoscope in 1998. The first true video laryngoscope  glidescope was produced in 1999 and a production version with 60-degree angle, an onboard heater, and a custom screen was first sold in 2000. The true video laryngoscope has a camera on the blade with no intervening fiberoptic components. The concept is important because it is simpler to produce and handle the resultant images from CMOS cameras. The integrated camera leads to a series of low cost variants that are not possible with the hybrid Fiberoptic units.

Several manufacturers have developed video laryngoscopes which employ digital technology to generate a view of the glottis so that the trachea may be intubated. The KARL STORZ C-MAC Video Laryngoscope and the Glidescope video laryngoscope are examples of such devices. Other examples include the McGrath laryngoscope, Daiken Medical Coopdech C-scope vlp-100, the Storz V-MAC DCI Video Laryngoscope and the Pentax AWS laryngoscopes.

Supraglottic airways

Use of a supraglottic airway device (SGD)is an acceptable alternative to an ET, particularly during CPR as SGD may be placed without interrupting chest compressions.1


Esophageal-Tracheal Tube

The esophageal-tracheal tube (ETT or Combitube), is a blind insertion double-lumen airway (BIAD) used in the pre-hospital and emergency setting to facilitate the mechanical ventilation of a patient in respiratory distress.

The Combitube consists of a cuffed, double-lumen tube that is inserted through the patient’s mouth to secure an airway and enable ventilation.   Generally, the distal tube (tube #2), enters the esophagus, where the cuff is inflated.  Ventilation is provided through the proximal tube (tube #1) which opens at the level of the larynx.   In the rare instance where the distal tube intubates the trachea, ventilation is provided through the distal tube.   Inflation of the cuff in the esophagus allows a level of protection against aspiration of gastric content.  The Combitube is available in two sizes.  A size 37 Fr is used for patients 4 to 6 ft or 122 to 183 cm tall while a 41 Fr is used for patients more than 5 ft or 152 cm tall. 1,11,12,13

The simplicity of placement is the main advantage of the Combitube over endotracheal intubation.  When intubating with a traditional endotracheal tube, care must be taken to visually ensure that the tube has been placed in the trachea while the dual-lumen design of the Combitube allows for ventilation to proceed regardless of esophageal or tracheal placement.1, 11, 12,13

A device called the Positube allows for esophageal intubation detection.  The Postitube can be used on tube #2 to rule out the intubation of the Combitube in the trachea.  The Positube checks for air flow resistance on tube #2 and is very helpful in checking proper Combitube placement when intubation is performed in noisy environment’s.

The Combitube’s ease of use makes it an option for use in the pre-hospital, emergency setting when advanced level providers capable of placing an endotracheal tube are not immediately available. The drawbacks of Combitubes are evidenced by reports of serious complications such as aspiration, esophagus perforation and facial nerve dysfunction associated with their use.  Ventilation and oxygenation with the Combitube are favorable to the ET.1

While it has been suggested as an option by the American Heart Association and European Resuscitation Council for situations where intubation attempts are unsuccessful since the year 2000, it is seldom used outside of the pre-hospital, emergency setting, as it does not allow for long term airway control.   SGD alternatives to the Combitube include the laryngeal mask airway and the laryngeal tube.


Laryngeal Mask Airway

A laryngeal mask airway, or LMA, is a supraglottic airway management device composed of an airway tube that connects to an elliptical mask with a cuff which is inserted through the patient’s mouth to form an airtight seal on top the glottis.  Unlike endotracheal tubes which pass through the glottis, the LMA forms an airtight seal as it sits atop the glottis.   The LMA cuff can be either self-sealing or inflatable.   Once correctly placed the mask conforms to the anatomy with the bowl of the mask facing the space between the vocal cords.   After correct placement, the tip of the laryngeal mask sits in the throat against the muscular valve that is located at the upper portion of the esophagus.  LMA devices may be particularly advantageous when there is the possibility of unstable cervical spine injury as these devices are blind inserted airway devices (BIAD) that can be placed without the movement associated with intubation. 1,11,12,13


Laryngeal Tube

The laryngeal tube, or King LT, is an airway management device that can be inserted blindly through the oropharynx into the hypopharynx to create and maintain a patent airway.   In its standard version, the laryngeal tube is made up of a tube with a larger balloon cuff in the middle (oropharyngeal cuff) and a smaller balloon cuff at the end (oesophageal cuff).   The tube is kinked at an angle of 30-45° in the middle; the kink is located in the larger cuff. There are two apertures, located between the two cuffs, through which ventilation takes place. Both cuffs are inflated through a single small lumen line and pilot balloon. The cuffs are high-volume, low-pressure cuffs with inflating volume ranging from 10 ml (size 0) to 90 ml (size 5). A large bore syringe, which is marked with the required volume for each size, is used to inflate the cuffs. A cuff inflator can also be used, in which case the cuffs should be inflated to a pressure of 60 cm H2O. Three black lines on the tube indicate the depth of insertion when aligned with the teeth. 1, 11,12,13

Various studies have shown that insertion and use of the standard tracheal tube is easy, providing a clear airway in most cases. Comparative studies indicate that the standard laryngeal tube is generally as effective as the LMA, while some studies indicate that an inflatable LMA may be more effective than the standard laryngeal tube under controlled ventilation conditions in general anaesthesia.4,5 Several studies describe the usefulness of the device in securing a difficult airway, even in cases where insertion of the LMA had failed.  The laryngeal tube is also recommended for medical personnel not experienced in tracheal intubation, and as a rescue device when intubation has failed in adults.  According to the manufacturer the use of Laryngeal tubes is contraindicated in people with an intact gag reflex, known oesophageal disease, and people who have ingested caustic substances.

Ancillary Content

Combitube Demonstration LMA Demonstration King LT Demonstration

 

Airway Management Protocol

Airway Management Protocol Algorithm

If the athlete presents with pulselessnes, the medical team will assume cardiac arrest and immediately initiate the CPR Protocol.   If an athlete presents with a pulse, the medical team will open the airway using either the head-tilt/chin-lift or modified jaw thrust maneuver.  If the medical team cannot rule out the possibility of cervical spine injury, the modified jaw thrust maneuver is the preferred method for opening the airway.  If protective athletic equipment is a barrier to completion of maneuvers to open the airway, the medical team will initiate the appropriate equipment removal protocol.

Upon opening the airway, the medical team will assess for breathing for 5-10 seconds.  If the athlete presents with agonal breathing, the medical team will assume cardiac arrest and initiate CPR Protocols, until cardiac arrest is otherwise ruled out.  If it is determined that the athlete is not breathing spontaneously, the medical team will immediately activate the EMS system using the team’s designated primary communication system and backup hand signal.

If the athlete does not begin spontaneous respirations after 5-10s, a bag valve mask (BVM) will be used to provide artificial respiration in accordance with local regulations and as directed by medical standing orders.  With the initiation of BVM ventilation, the medical team will begin a double set-up procedure to prepare to initiate more advanced airway management procedures should they be required.  Simultaneously, the medical team will expose the chest using the appropriate Equipment Removal Protocol. Once the chest has been exposed the medical team will connect an automated external defibrillator (AED) or ALS defibrillator accordance with the CPR Protocol.  If an AED is connected, the unit will not be started unless the athlete becomes pulseless.  Once the airway has been secured and the defibrillator has been placed, the medical team will apply appropriate BLS or ALS monitors, including a blood pressure monitor, heart rate monitor, pulse oximeter, and CO2 detector device.  Effectiveness of ventilatory efforts and cardiac status will be continually evaluated based on feedback provided by on-going clinical assessment and monitoring devices applied to the athlete.

If ventilation is unsuccessful using the BVM, the medical team will assess for an airway obstruction.  If there is a foreign-body airway obstruction, forceps will be used to remove the object from the athlete’s airway.  If there is a tongue-based airway obstruction, the medical team may assess the appropriateness of placing an airway adjunct.  If the athlete is unconscious and without a gag-reflex, the medical team may consider placing an OPA.  If the athlete presents with a gag-reflex, the medical team may consider placing an NPA.  If the medical team can successfully ventilate after placement of either the OPA or NPA, the medical team will continue with appropriate respiratory support and clinical assessment.  If, after placement of an NPA, ventilation is unsuccessful, the medical team may consider the appropriateness of rapid sequence intubation when the athlete is in respiratory distress, but has a gag-reflex.  If ventilation is unsuccessful after placement of an OPA, the medical team may consider the appropriateness of an advanced airway device when an appropriately trained ALS provider is available

Although oral tracheal intubation (OTI) is the definitive airway management technique, the ease of use and effectiveness of SGD make them an appropriate alternative in the pre-hospital setting.  If ALS providers prefer a SGD to OTI or are not adequately trained in OTI, the medical team may consider the use of a SGD.  If OTI during CPR is likely to disrupt compressions longer than 10s, the medical team may consider placement of an SGD or consider delaying all further airway management until the athlete fails to respond to initial CPR attempts.

If the medical team is unable to ventilate the athlete after placement of a SGD, the medical team will consider the appropriateness of OTI.  If 3 or more attempts at OTI by an experienced operator fail to result in confirmed placement of an ET, the medical team will consider the condition a difficult airway and may elect to use a video laryngoscope to aid OTI.14,15

Upon establishing a patent airway, the medical team will provide on-going care in accordance with established advanced cardiac life support (ACLS) procedures.  When an ALS provider is not available the medical team will continue to provide care in accordance with BLS standards until too exhausted to continue or until ALS providers arrive to take over scene management.  When ALS personnel deem the athlete stable enough for transport the medical team shall remove the protective equipment from the athlete using the appropriate Equipment Removal Protocol. The athlete shall then be transferred using the appropriate Transfer Protocol, and secured to an EMS gurney using the appropriate Package For Transport Protocol.  Once properly packaged for transport the athlete will be transported to the appropriate medical facility with appropriate medical team escorts.

© Sports Medicine Concepts, Inc.  All Rights Reserved.

CONDITIONAL PROTOCOLS

Each injury situation is unique, requiring the medical team to have an array of psychomotor skills and a cognitive ability to determine what management strategy is most appropriate for any given scenario.  Conditional protocols in this document represent an organizational approach to common emergency conditions/illnesses in athletics that provides for autonomous medical decision-making regarding appropriate strategies for ensuring safe handling of injured/ill athletes.  Although certain medical conditions require specific management, emergencies in general require that the medical team consider, first and foremost, the Primary Objectives, which include the athlete’s cardiac, airway, breathing, and neurological status.

If an athlete collapses or is found unconscious, it will be assumed that they are in cardiac arrest until the medical team can establish otherwise. If an injured athlete is found to be without a carotid pulse, the medical team will immediately activate the EMS system using the team’s designated emergency response radio call and backup hand signal. The medical team will immediately implement CPR/AED protocols.  When managing a critically injured equipment-laden athlete, the most appropriate equipment removal procedures detailed in the the Safe Handling Protocols and Techniques section of this document will be implemented. Simultaneously, the medical team will establish a patent airway using the most appropriate Airway Management Protocol.

Upon establishing a patent airway, the medical team will provide on-going care in accordance with regional policies and established advanced cardiac life support (ACLS) procedures. The athletic training staff shall continue to provide care in accordance with professional practice standards until too exhausted to continue or until more qualified medical professionals arrive to take over scene management. When a team paramedic is available, the medical team shall continue to provide on-going care until the team paramedic deems the athlete stable enough for transport, at which time the medical team shall remove the protective equipment from the athlete using the most appropriate Equipment Removal Protocol. The athlete shall then be transferred and packaged for transport using the most appropriate protocol. Once properly packaged for transport the athlete will be transported to an appropriate medical facility with a designated athletic training, paramedic, and EMT escort.

The equipment required to carry out all ACLS procedures, equipment preparation and removal, transfer, and package for transport protocols shall be kept with the team’s advanced life support (ALS) equipment as indicated in the Emergency Response Equipment section of this document.

© Sports Medicine Concepts, Inc.  All Rights Reserved.

ANAPHYLAXIS

OVERVIEW

An allergen is a substance capable of producing an immediate hypersensitivity or allergic reaction in an individual. Many different substances can cause an allergic reaction. Allergic reactions begin when a susceptible person eats, drinks or touches the allergen, or gets it into their eyes, nose, or mouth. Initial exposure may create no symptoms and go unnoticed. Reactions can occur in minutes or take hours after ingestion or exposure. Symptoms can be mild to life-threatening depending on the location in the body in which the response occurs. An allergic response may be magnified in certain individuals, such as those with:

⦁ heart disease or high blood pressure
⦁ have diabetes
⦁ have thyroid conditions
⦁ have asthma
⦁ have depression or other mental disease
⦁ have Parkinson’s disease
⦁ are pregnant
⦁ are allergic to any of the ingredients in epinephrine auto-injector (EAI)1

Common allergens include foods, venom from insect stings, plants, medications, latex, glue, soaps, and other over the counter products. Foods, including peanuts, shellfish, fish, treenuts (i.e., pecan, walnut, cashes, etc.), eggs, milk, soy, and wheat, are the most common allergens.1,2
Anaphylaxis is a potentially life-threatening medical condition occurring in allergic individuals after exposure to an allergen. Symptoms of anaphylaxis include, but are not limited to breathing difficulties, drop in blood pressure and or shock, all of which may be fatal. Therefore, immediate recognition and intervention is needed.1-4
Identification of individuals with known allergens is vital to early recognition and intervention. Anaphylaxis often mimics an asthma attack. Therefore, it is important to have medical history information for each individual readily available.1,10

Recognition
Signs and symptoms of an allergic reaction usually appear within minutes. However, signs and symptoms of an allergic reaction may occur up to 2 hours after exposure to an allergen. Individuals may also experience a rebound effect in signs and symptoms whereby the signs and symptoms resurface following a period of perceived resolution.

F.A.S.T is a common acronym used to remember the signs and symptoms of an allergic reaction that may require immediate medical intervention:

⦁ Face: redness, itching or swelling of lips tongue or face;
⦁ Airway: trouble breathing, swallowing, or talking;
⦁ Stomach: pain, cramps, vomiting, diarrhea;
⦁ Total Body: hives, itchiness, swelling, paleness, fainting/dizziness, sense of doom.

Other signs and symptoms may include: wheezing, shortness of breath, throat tightness, cough, hoarse voice, chest pain/tightness, trouble swallowing, itchy mouth/throat, nasal stuffiness/congestion, pale/blue color, low pulse, dizziness, lightheadedness/passing out, low blood pressure, shock, loss of consciousness, chest pain, tachycardia.1,5-11

Management
The correct steps to take for emergency treatment of suspected anaphylaxis are to:

  1. Check status of Primary Objectives® (Cardiac, Airway, Breathing);
  2. Assess FAST signs and symptoms;
  3. Remove from environment containing triggers/allergens;
  4. Administer epinephrine as indicated;
  5. Activate Emergency Medical Services (EMS);
  6. Notify the designated EAI official if available;
  7. Place individual on their back with lower extremities elevated above the level of the heart;
  8. Monitor and support vital signs until EMS arrives;
  9. Send Epi-pen with EMS;
  10. Notify parents/guardians and designated administration;
  11. Document time, suspected allergen if known and response steps taken to activate EMS;
  12. Follow local EMS transport protocols;
  13. Report administration to appropriate EAP personnel.1

Epinephrine
Epinephrine, also known as Adrenalin, is a drug used in the treatment of anaphylaxis. Epinephrine constricts blood vessels thereby raising blood pressure. Epinephrine also opens airways to improve breathing, stimulate the heart, and works to reverse hives and swelling secondary to an allergic reaction. The effects of epinephrine are short acting, generally lasting about 10-20min. Therefore, signs and symptoms of anaphylaxis may return as the drug wears off. A second dose of epinephrine may be indicated if advanced medical care is delayed following administration of the first dose of epinephrine.1

Epinephrine Auto-Injectors
An epinephrine auto-injector (EAI), is a disposable, prefilled automatic injection device which is designed to deliver a single pediatric dose of 0.15 or an adult dose 0.30mg of epinephrine to someone showing signs or complaining of symptoms of anaphylaxis. There are 4 types of EAI each with specific directions for use. A comparison chart and video demonstration of each is provided in the EAI Comparison Chart.

Common EAIs

AdrenaclickAdrenaclick
Auvi-Q
Auvi-Q
Epi-Pen / Epi-Pen Jr.Epi-Pen / Epi-Pen Jr.
USP Auto-Injector (Authorized Adrenaclick Generic)
USP Auto-Injector
(Authorized Adrenaclick Generic)

Storage And Stability Of Epinephrine In An EAI

Replace expired or compromised EAIs

There is very little evidence-based literature regarding the stability of epinephrine in an automatic epinephrine injector. However, in accordance with recommendations from the American Academy of Allergy Asthma & Immunology (AAAAI) EAIs shall be stored in the carrier provided by the manufacturer, out of sunlight, and at 25°C (77°F); with excursion permitted to 15° – 30°C (59 ° – 86°F). In practice, patients may be forced to use their EAIs in temperature ranges outside of the advised range. An EAI shall be replaced if the epinephrine in the EAI has frozen (and requires re-thawing), has expired, or if the solution in the EAI does not appear clear and free of particulates.12,13

Indications/Contraindication For Use Of An EAI
EAI are indicated for use when an individual shows signs or complains of symptoms of anaphylaxis. Anaphylaxis should be suspected when any of the three following criteria are met:

  • Acute onset of signs and symptoms involving the skin, mucosal tissue or both in conjunction with at least one of the following:
  1. Airway or breathing complication (respiration > 30 breaths/min);
  2. Hypotension;
  3. Acute onset of two or more of the following after exposure to a potential allergen;
  4. Any of the aforementioned signs and symptoms;
  5. Persistent gastrointestinal symptoms;
  6. Hypotension.

There are no contraindications to the use of epinephrine in a life-threatening allergic reaction or severe asthma. However, precautions should be taken with elderly patients or patients with heart disease or hypertension.

The most common side effects may include increase in heart rate, stronger or irregular heartbeat, chest pain, sweating, nausea and vomiting, difficulty breathing, paleness, dizziness, weakness or shakiness, headache, apprehension, nervousness or anxiety. These side effects usually go away quickly, especially with rest. Individuals with certain medical conditions, or who take certain medicines, may get more side effects from an EAI, or the side effects may last longer. This includes individuals who take certain types of medicines for asthma, allergies, depression, hyperthyroidism, high blood pressure, and heart disease. Individuals with heart disease may feel chest pain (angina). Individuals with mental disease or Parkinson’s disease may have worsening symptoms of their illness. The risk of death from untreated anaphylaxis outweighs the risk of adverse side effects from using epinephrine. In the event that a pediatric dose EAI is indicated, but not available, an adult dose EAI can administered.12,13

After use of an EAI the remaining liquid that is left after this fixed dose cannot be further administered and should be discarded. Put the EAI, needle first, into the carrying case. Replace the safety cap over the non-needle end of the EAI and close the case. Do NOT throw away in a regular trash can. EAI shall be disposed of in a sharps container in accordance with standard universal precaution procedures.1

The correct sequence of steps to administer an EAI includes:

  1. Have the person sit or lie down;
  2. Check EAI unit to make sure the liquid is clear, and/or the unit has not expired;
  3. Pull off the safety cap. Do not touch the administration end which is clearly identified;
  4. Place the tip or end of the unit against the outer thigh at a 90 degree angle;
  5. Press hard into the victims thigh until auto-injector mechanism clicks or a verbal prompt is heard;
  6. Hold in place for 3 seconds;14
  7. Remove EAI and massage the injection area for 5-10 seconds depending on the brand;
  8. Discard the used auto-injector as indicated by the district plan. Do not throw away in a regular trashcan.1

Reassessment
Following the administration of epinephrine ongoing assessment of and support for airway, breathing and circulation is required. Declining mental status, decreasing blood pressure and increasing difficulty in breathing indicate the allergic reaction or severe asthma is worsening. If the condition is worsening, the medical team will:

⦁ consider a second dose of epinephrine;
⦁ provide emergency care for shock;
⦁ administer positive pressure ventilation with supplemental oxygen if breathing becomes inadequate;
⦁ be prepared to initiate high-quality CPR.

Prevention Guidelines
Known at risk individuals shall be counseled in the following prevention measures:

⦁ Ask your doctor how to avoid your allergens and what to do if you have an allergic reaction, especially a severe reaction;
⦁ Tell their health care providers, including your dentist, about all allergies before accepting any medication, especially injections;
⦁ Always remain in your doctor’s office the full amount of time your doctor says after receiving any injection. Report any unusual reaction immediately;
⦁ Wear a Medic Alert bracelet or pendant that lets others know about your allergies;
⦁ If allergic to insect stings, wear protective clothing when outside;
⦁ Avoid shiny clothing or jewelry, which can attract insects, and cover sugary drinks;
⦁ If allergic to any food, be assertive about seeking detailed information from food manufacturers, restaurant staff, and dinner hosts about ingredients;
⦁ Keep two epinephrine injection kits with them at all times and readily available;
⦁ Be sure family, friends, and colleagues know how to use the kit if you have a reaction;
⦁ If the person at risk is a child, make sure the child’s teachers, friends’ parents, and any other caregivers know how to use the child’s kit in an emergency and that the kit is always with the child and readily available at all times;
⦁ Know the symptoms of a severe reaction, and reach for the epinephrine if you think you are beginning to show signs of a having one. Do not hesitate to use your epinephrine if you suspect an anaphylactic reaction. Waiting to take the shot is a key issue in patients who have poor outcomes;
⦁ Ensure that your epinephrine is up to date and has not expired. Epinephrine typically has a one year shelf life;
⦁ Ask an allergist if you can obtain desensitization therapy for the offending allergen. This therapy is available for insect stings and drugs such as penicillin when appropriate.

Readiness supplies
Basic Life Support Supplies

⦁ AED
⦁ BLS airway adjuncts
⦁ Hear rate monitor
⦁ Blood pressure monitor
⦁ Pulse oximeter

Protocol Specific Supplies

⦁ Benadryl
⦁ EAI
⦁ Second dose EAI
⦁ Communication system
⦁ Ice
⦁ Supplemental oxygen

© Sports Medicine Concepts, Inc.  All Rights Reserved

ASTHMA

OVERVIEW
Asthma has been defined as a chronic inflammatory disorder of the airways that is characterized by variable airway obstruction and bronchial hyperresponsiveness that may lead to ongoing bouts of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning.1 Although asthma cannot be cured airflow limitation is often reversible. However, if asthma is left untreated, ongoing asthma symptoms may result in chronic irreversible airway obstruction. For some asthma is a minor nuisance, while others may have problems with daily activities or suffer severe life-threatening asthma attacks. Asthma often changes over time, so it’s important to work with doctors and specialists to track signs and symptoms, and adjust treatment as needed. It isn’t clear why some people get asthma and others don’t, but it’s probably due to a combination of environmental and genetic factors. A number of factors are thought to increase the chances of developing asthma; these include:2

⦁ Having a blood relative (such as a parent or sibling) with asthma
⦁ Having another allergic condition, such as atopic dermatitis or allergic rhinitis (hay fever)
⦁ Being overweight
⦁ Being a smoker
⦁ Exposure to secondhand smoke
⦁ Having a mother who smoked while pregnant
⦁ Exposure to exhaust fumes or other types of pollution
⦁ Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing
⦁ Having some types of bacterial or viral infections
⦁ Exposure to certain germs or parasites

Exposure to various allergens and irritants can trigger signs and symptoms of asthma. Asthma triggers are different from person to person and can include:1-2

⦁ Airborne allergens, such as pollen, animal dander, mold, cockroaches and dust mites
⦁ Respiratory infections, such as the common cold
⦁ Physical activity (exercise-induced asthma)
⦁ Cold air
⦁ Air pollutants and irritants, such as smoke
⦁ Certain medications, including beta blockers, aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve)
⦁ Strong emotions and stress
⦁ Sulfites and preservatives added to some types of foods and beverages, including shrimp, dried fruit, processed potatoes, beer and wine
⦁ Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat
⦁ Menstrual cycle in some women

Asthma symptoms range from minor to severe, and vary from person to person. For some people, asthma symptoms flare up in certain situations, such as:1-2

⦁ During exercise (Exercise-induced asthma), which may be worse when the air is cold and dry
⦁ During work (Occupational asthma), triggered by workplace irritants such as chemical fumes, gases or dust
⦁ When exposed to a specific allergen (Allergy-induced asthma), triggered by particular allergens, such as pet dander, cockroaches or pollen

Others suffering from asthma may have symptoms all the time. Proper treatment of asthma makes a big difference in preventing both short-term and long-term complications caused by asthma, which can include:1-2

⦁ Symptoms that interfere with sleep, work or recreational activities
⦁ Sick days from work or school during asthma flare-ups
⦁ Permanent narrowing of the bronchial tubes (airway remodeling) that affects how well you can breathe
⦁ Emergency room visits and hospitalizations for severe asthma attacks
⦁ Side effects from long-term use of some medications used to stabilize severe asthma

Recognition
Asthma is typically associated with the following signs and symptoms:2

⦁ Shortness of breath
⦁ Chest tightness or pain
⦁ Trouble sleeping caused by shortness of breath, coughing or wheezing
⦁ A whistling or wheezing sound when exhaling
⦁ Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu

Management
Antihistamine
If an individual develops only hives (only skin problems), administration of an antihistamine, shall be considered. A plan for close observation of the athlete for additional symptoms over the next 6hrs shall then be developed, including counseling the athlete, parent/guardian, and coaches in instructions for what to do if symptoms progress.

Metered Dose Inhaler (MDI)
An MDI is an aerosol canister filled with medicine that is housed in a plastic holder with a mouthpiece. To ensure proper function and that medication is available when needed, the medical team shall counsel all athletes with a MDI in the proper care and maintenance of their MDIs. Counseling shall include the following steps for cleaning the MDI and monitoring reliever medication dosages:3,4,6,7

⦁ MDIs with removable canisters should be cleaned weekly by removing the canister and rinsing the plastic holder with warm running water to prevent the holes from getting clogged. Shake the MDI well and allow to air dry completely.
⦁ MDIs which do not have removable canisters shall be cleaned by wiping the mouthpiece with a cloth or cleaning with a cotton swab. Refer to the patient instructions that come with each MDI for specific cleaning instructions.
⦁ It is important to monitor how much medication is left in an MDI. Most inhalers have counting devices built in. Remember to watch the counter and replace the inhaler when the counter is on zero.
⦁ There are a few inhalers that do not have a built-in counter. For these, remaining dosage must be tracked by tallying how many puffs have been administered, including priming puffs. The number of puffs contained in an MDI is printed on the side of the canister. If an MDI is used every day for control of symptoms, the life of the MDI can be calculated by dividing the total number of puffs in the inhaler by the total daily puffs prescribed. For example: 2 puffs x 2 times per day = 4 total puffs per day. If there are 120 puffs, the MDI will last 30 days. If an MDI is used only when needed, keep track of how many times the MDI is sprayed, including priming sprays.

If an athlete presents with signs and symptoms of asthma that include wheezing, the medical team will consider treatment with reliever medication using a MDI. If the athlete is familiar with the use of a MDI and is not in any particular distress that would limit the effective administration of medication via proper use of the MDI, the medical team shall counsel the athlete in proper administer reliever medication via the MDI as follows:5

1. Prime the MDI by spraying one or more puffs into the air before use to make sure that the inhaler is ready to use and will deliver the correct dose of medication. Priming may be different for each medication, so it is important to read the patient instructions that come with your inhaler.
2. Remove the cap from the MDI and shake well for 5 seconds.
3. Breathe out all the way.
4. Keep chin up.
5. Place the mouthpiece of the inhaler between teeth and seal lips tightly around it.
6. Breathe in slowly while simultaneously pressing down on the canister one time.
7. Keep breathing in slowly to completely fill lungs. (It should take about 5 to 7 seconds to completely breathe in.)
8. Hold breath for 10 seconds to allow the medication to reach the airways of the lung.
9. Repeat the above steps for each puff ordered by your doctor. Wait about 1 minute between puffs.
10. Replace the cap on the MDI when finished.

Spacing Chambers
Spacing chambers hold the MDI spray medication, making it easier to use the MDI and can help get the medication into the lungs more effectively for athletes who are having trouble using an MDI. To ensure proper function of a spacing chamber the medical team shall counsel the athlete in proper care and maintenance of their valve holding chamber, including:6

⦁ Clean the chamber about once a week. Remove the soft ring at the end of the chamber. Soak both the chamber and soft ring in warm water with a mild detergent. Carefully clean, rinse in clear water, and shake well. Allow to air dry completely.

If an athlete is in mild distress that may affect his or her ability to effectively deliver reliever medication via a MDI, the medical team may consider use of a spacing chamber. A spacing chamber shall also be used if using a corticosteroid MDI. When administering medication via a spacing chamber, the medical team shall counsel the athlete in proper use as follows:

1. Remove the cap from the MDI and chamber.
2. Shake well for 5 seconds.
3. Insert the MDI into the open end of the chamber (opposite the mouthpiece).
4. Breathe out all the way.
5. Keep chin up.
6. Place the mouthpiece of the chamber between teeth and seal lips tightly around it.
7. Press the canister once.
8. Breathe in slowly through mouth to completely fill lungs. If a “horn-like” sound is heard, the athlete is breathing in too quickly and needs to slow down.
9. Hold breath for 10 seconds (count to 10 slowly) to allow the medication to reach the airways of the lung.
10. Repeat steps 2-8 for each puff ordered by doctor. Wait about 1 minute in between puffs.
11. Replace the cap on the MDI when finished.
12. If using a corticosteroid MDI, rinse mouth and gargle using water or mouthwash after each use.

Positive Pressure Nebulizer
Many medications are available as inhaled treatments. Inhaled methods deliver medication directly to the airway, which is helpful in cases when athletes are unable to self-administer reliever medication using an MDI or an MDI with a holding chamber.

A nebulizer delivery system consists of a nebulizer (small plastic bowl with a screw-top lid) and a source for compressed air. The air flow to the nebulizer changes the medication solution to a mist. When inhaled correctly, the medication has a better chance to reach the small airways. This increases the medication’s effectiveness.

When available the medical team may consider administering reliever medications via a nebulizer. This may require having an appropriate team member escort the athlete to the nurse’s office. To initiate a nebulizer treatment, be sure to refer to manufacturer’s specific instructions for use. General assembly and treatment instructions for a nebulizer and air compressor are as follows:4

1. Place the compressor where it can safely reach its power source and where you can reach the ON/OFF switch.
2. Wash hands prior to preparing each treatment.
3. Use a clean nebulizer.
4. Measure the correct dose of medication and other solutions prescribed and add these to the nebulizer.
5. Connect the air tubing from the compressor to the nebulizer base. Make sure all connections are snug.
6. Attach a mask to the nebulizer.
7. Turn the compressor on and check the nebulizer for misting.
8. If the nebulizer is not misting, check all connection.

The medical team administering reliever medication via a nebulizer shall counsel the athlete in proper use of the nebulizer as follows:

1. Hold the mask to the face so both the nose and mouth are covered. The mask may be secured to the head with an elastic band.
2. Turn the compressor on to start the mist. The head should be held upright. This correctly positions the nebulizer and opens the airway.
3. Assure deep breathing throughout the treatment.
4. Occasionally tapping the side of the nebulizer helps the solution to drop to where it can be misted.
5. Continue the treatment until the onset of inconsistent nebulization, i.e. sputtering.

Follow the manufacturer’s instructions for cleaning the nebulizer equipment. The tubing should be replaced every two weeks because it is difficult to clean. Follow the manufacturer’s instructions for care and cleaning the compressor. Some suggested cleaning guidelines include:

1. Take apart the nebulizer. Wash all parts (except tubing and finger valve) in liquid dish soap and water. Rinse with water.
2. After washing the nebulizer shake off any excess water.
3. Reattach the nebulizer pieces and tubing to the air compressor and turn on the compressor to dry the nebulizer quickly. Make sure the nebulizer is completely dry before storing the nebulizer.

The nebulizer should be sterilized every other treatment day. Boiling the nebulizer components is the preferred method if your nebulizer can be boiled.

1. Boiling Water
2. Wash your hands.
3. Take the nebulizer apart.
4. Put all the parts of the PARI LC JET+ TM except the mask, tubing and interrupter in boiling water for 10 minutes.
5. After boiling the nebulizer shake off any excess water
6. Reattach the nebulizer pieces and tubing to the air compressor and turn on the compressor to dry the nebulizer quickly.
7. Make sure the nebulizer is completely dry before storing the nebulizer.

If boiling nebulizer components is not suggested use a vinegar and water solution to soak all parts as follows:

1. Wash your hands.
2. Soak all parts of the nebulizer (except mask, tubing and interrupter) for 1 hour in a solution of 1 part distilled white vinegar and 3 parts hot water. The solution should be fresh. Remove the parts from the vinegar solution and rinse them in water. Discard the solution.
3. Shake off any excess water.
4. Reattach the nebulizer pieces and tubing to the air compressor and turn on the compressor to dry the nebulizer quickly. Make sure the nebulizer is completely dry before storing the nebulizer.

Pre-Hospital Care Management Of An Acute Asthma Attack
When the medical team has provided for the administration of any reliever medications, including antihistamines, due to the onset of signs and symptoms of asthma, the following steps shall be taken as deemed appropriate:

  1. Issue and review anaphylaxis/asthma warning sheet with athlete and parent/guardian;
  2. Observe closely for additional symptoms over the next 6 hours. Counsel athlete and parent/guardians in signs and symptoms of an asthma emergency, including:
    a. Rapid worsening of shortness of breath or wheezing
    b. No improvement even after using a quick-relief inhaler, such as albuterol
    c. Shortness of breath with minimal physical activity
  3. If the individual develops signs and symptoms of severe reaction (anaphylaxis) or respiratory distress, immediately:
    a. Inject Epinephrine IM: Dose □ 0.15mg (Infant/child Epi-pen Jr.) □ 0.30mg (Adult);
    b. Give additional dose of Diphenhydramine (Benadryl) _____mg by mouth;
    c. Have athlete lie down, feet elevated, monitor vital signs;
    d. Maintain a patent airway;
    e. Be prepared to suction any secretions;
    f. Administer oxygen therapy with non-rebreather device;
    g. Be prepared to assist ventilation with positive pressure ventilation with bag-valve-mask;
    h. Activate EMS for immediate transport to appropriate receiving facility.
    i. Document time, suspected allergen if known, and response steps taken to activate EMS;
    j. Be prepared to administer a second dose Epinephrine IM after 15 minutes if symptoms degrade or recur.
  4. Report administration to appropriate EAP personnel.

Prevention Guidelines
During a pre-participation screen the medical team shall obtain a thorough medical history that includes signs and symptoms indicating the presence of asthma. The medical team shall counsel athletes who suffer frequent coughing or wheezing that last more than a few days, or who demonstrate any other signs and symptoms of asthma to seek advice from their physician. These signs and symptoms include:

⦁ Chest tightness;
⦁ Coughing;
⦁ Shortness of breath;
⦁ Wheezing;
⦁ Unable to catch their breath;
⦁ Exercise-induced symptoms;
⦁ Labored breathing;
⦁ Exacerbation of symptoms when exposed to allergens;
⦁ Family history;
⦁ Hay fever.

Those athletes with known asthma shall be advised to monitor their asthma to keep it under control in order to feel better and prevent a life-threatening asthma attack. Athletes with known asthma shall be further advised to:

1. Contact their physician immediately if asthma symptoms worsen, if medication doesn’t seem to ease symptoms, if there is a more frequent need for quick-relief inhaler use;
2. Not try to solve increased asthma symptoms by taking more medication without consulting your doctor as overusing asthma medication can cause side effects and may make your asthma worse;
3. To review asthma treatment.

Asthma often changes over time. Meet with doctor on a regular basis to discuss symptoms and make any needed treatment adjustments, and to their specialist if signs and symptoms of worsening asthma are observed, including:

a. Asthma signs and symptoms that are more frequent and bothersome;
b. Increasing difficulty breathing;
c. The need to use a quick-relief inhaler more often.

Readiness Supplies
Basic Life Support Supplies
⦁ AED
⦁ BLS airway adjuncts
⦁ Heart rate monitor
⦁ Blood pressure monitor
⦁ Pulse Oximeter

Protocol Specific Supplies
⦁ MDI
⦁ Spacing Chamber
⦁ Nebulizer
⦁ Antihistamine
⦁ 1st and 2nd dose epinephrine auto-injector
⦁ Oxygen
⦁ Non-rebreather mask

© Sports Medicine Concepts, Inc.  All Rights Reserved.

COLD RELATED CONDITIONS AND ILLNESSES

OVERVIEW
Cold injuries are inherent to physical activity outdoors, particularly for sports that have seasons that extend into late fall, early winter, or that begin in early spring.1 The risk of cold injuries increases with dropping temperatures and in environments with wet or windy conditions. According to the NATA position statement, low air or water temperatures and wind are environmental factors that may combine to stress the body’s ability to maintain a normothermic core and surface temperature.2 When exposed to cold air an individual’s body may lose its ability to maintain heat, resulting in various cold-related illnesses and conditions that may be uncomfortable, impair performance, or become life-threatening.1

The mechanisms of heat loss fall into three categories, radiated heat loss, direct heat loss, and heat loss due to wind. Most heat loss is due to heat radiated from unprotected body surfaces. When an individual is in direct contact with something very cold, such as cold water or the cold ground, heat is conducted away from the body. Water is a particularly good heat transfer medium; and therefore, capable of transferring heat from the body at a much faster rate than cold air. Similarly, heat loss from the body is much faster with wet clothing. Wind removes body heat by carrying away the thin layer of warm air at the surface of the skin. Therefore, the wind chill is a critical factor effecting heat loss from the body.

The degree to which an individual is effected by cold exposure may be influenced by a number of non-environmental factors, including prior episodes of cold weather injury, race, geological origin, medications, fatigue, hydration, age, activity, body size/composition, aerobic fitness level, clothing, acclimatization and low caloric intake. Nicotine, alcohol and other drugs may also contribute to how a person adapts to the stresses of cold.1

Early recognition of signs and symptoms of cold stress is important to prevent long-term disability or the on-set of a medical emergency resulting from cold exposure. Shivering is a mechanism through which the body generates heat, and may serve as an early warning sign that an individual is suffering cold stress. As the body continues to lose the ability to maintain heat, shivering many become excessive, leading to fatigue and motor function deficits. Numbness and pain in the extremities or burning sensation of the ears, nose or exposed flesh are also early signs and symptoms that cold stress is overwhelming the body. Continued cold exposure will result in the body drawing blood away from the extremities to protect the core vital organs. Eventually cold exposure will result in a drop in core temperature that will affect the brain, resulting in sluggishness, disorientation, cognitive impairment, and speech impairment. The emergency action plan should be activated immediately if an individual desires to lie down and rest.1,2,3,7,9

General Cold Exposure Risk Factors

  • Extreme cold, precipitation, wind;
  • Existing medical conditions;
  • Prior history of cold exposure injury/condition;
  • Low caloric intake (less than 1200 to 1500 kcal/day);
  • Low body fat and muscle mass;
  • Hypoglycemia;
  • Females are 2x more likely to experience hypothermia compared to their male counter-parts;
    Dehydration;
  • Fatigue;
  • Black individuals may be two to four times more likely to experience cold injuries/conditions;
  • Nicotine, alcohol, and drug use;
  • Insufficient clothing or clothing that does not reduce heat loss.

Recognition and Management of Common Cold Exposure Conditions in Athletics

Hypothermia
Hypothermia is a medical emergency that occurs when an individual’s body loses heat faster than it can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6° F (37° C). Hypothermia occurs when body temperature passes below 95° F (35° C). When body temperature drops, the function of the cardiovascular system, nervous system, and other vital organs becomes impaired. Left untreated, hypothermia can eventually lead to complete failure of the cardiovascular and respiratory system, resulting in death. Hypothermia is most often caused by exposure to cold weather or immersion in a cold body of water. People who develop hypothermia because of exposure to cold weather or cold water are also vulnerable to other cold-related injuries, including frostbite and Gangrene.1-4

Hypothermia can be classified as mild to moderate and severe with specific signs and symptoms associated with each category.
Signs and symptoms of mild hypothermia include:

  • Vigorous shivering;
  • Increased blood pressure;
  • Core body temperature less than 98.6°F(37.6°C) but greater than 95.6°F (35.6°C);
  • Fine motor skill impairment;
  • Lethargy, apathy and mild amnesia.

Signs and symptoms of moderate to severe hypothermia include:

  • Cessation of shivering;
  • Very cold skin;
  • Depressed vital signs;
  • Core body temperature between 90.6°F (32.6°C) and 95.6°F (35.6°C) for moderate hypothermia or below 90.6°F (32.6°C) for severe hypothermia;
  • Impaired mental function;
  • Slurred speech;
  • Gross motor skill impairment;
  • Unconsciousness.

There are a number of factors can increase the risk of developing hypothermia, including:4-6

  • Age: Older adults are more vulnerable to hypothermia as the body’s ability to regulate temperature and to sense cold may lessen with age. Older individuals are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. Children lose heat faster than adults do. Children have a larger surface area-to-weight ratio than adults do, making them more prone to heat loss. Children may also ignore the cold because they’re having too much fun to think about it. And they may not have the judgment to dress properly in cold weather or to get out of the cold when they should. Infants may have a special problem with the cold because they have less efficient mechanisms for generating heat.
  • Mental Illness: Individuals with a mental illness, dementia or another condition that interferes with judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather.
  • Alcohol and Drug Use: Alcohol and drugs may result in an individual feeling warm inside, but it causes your blood vessels to dilate, resulting in more rapid heat loss from the surface of the skin. The body’s natural shivering response is diminished in people who’ve been drinking alcohol. In addition, the use of alcohol or recreational drugs can affect judgment about the need to get inside or wear warm clothes in cold weather conditions. If a person is intoxicated and passes out in cold weather, he or she is likely to develop hypothermia.
  • Health Conditions: Some health disorders affect the body’s ability to regulate body temperature. Examples include hypothyroidism, poor nutrition or anorexia nervosa, stroke, severe arthritis, Parkinson’s disease, trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities, dehydration, and any condition that limits activity or restrains normal blood flow.
  • Medications: A number of drugs, including certain antidepressants, antipsychotics, narcotic pain medications and sedatives, can change the body’s ability to regulate its temperature.

The medical team shall follow the following guidelines when managing an athlete presenting with signs and symptoms of hypothermia:1-6

  • Be gentle. When you’re helping a person with hypothermia, handle him or her gently. Limit movements to only those that are necessary. Don’t massage or rub the person. Excessive, vigorous or jarring movements may trigger cardiac arrest;
  • Move the person out of the cold. Move the person to a warm, dry location if possible. If you’re unable to move the person out of the cold, shield him or her from the cold and wind as much as possible;
  • Remove wet clothing. If the person is wearing wet clothing, remove it. Cut away clothing if necessary to avoid excessive movement;
  • Cover the person with blankets. Use layers of dry blankets or coats to warm the person. Cover the person’s head, leaving only the face exposed;
  • Insulate the person’s body from the cold ground. If you’re outside, lay the person on his or her back on a blanket or other warm surface;
  • Monitor breathing. A person with severe hypothermia may appear unconscious, with no apparent signs of a pulse or breathing. If the person’s breathing has stopped or appears dangerously low or shallow, begin CPR immediately if you’re trained;
  • Share body heat. To warm the person’s body, remove your clothing and lie next to the person, making skin-to-skin contact. Then cover both of your bodies with blankets;
  • Provide warm beverages. If the affected person is alert and able to swallow, provide a warm, sweet, nonalcoholic, non-caffeinated beverage to help warm the body;
  • Use warm, dry compresses. Use a first-aid warm compress (a plastic fluid-filled bag that warms up when squeezed) or a makeshift compress of warm water in a plastic bottle or a dryer-warmed towel. Apply a compress only to the neck, chest wall or groin.  Don’t apply a warm compress to the arms or legs. Heat applied to the arms and legs forces cold blood back toward the heart, lungs and brain, causing the core body temperature to drop. This can be fatal.
  • Don’t apply direct heat. Don’t use hot water, a heating pad or a heating lamp to warm the person. The extreme heat can damage the skin or, even worse, cause irregular heartbeats so severe that they can cause the heart to stop.

Depending on the severity of hypothermia, emergency medical care for hypothermia may include one of the following interventions to raise the body temperature:6

  • Blood rewarming. Blood may be drawn, warmed and recirculated in the body. A common method of warming blood is the use of a hemodialysis machine, which is normally used to filter blood in people with poor kidney function. Heart bypass machines also may need to be used;
  • Warm intravenous fluids. A warmed intravenous solution of salt water may be injected into a vein to help warm the blood;
  • Airway rewarming. The use of humidified oxygen administered with a mask or nasal tube can warm the airways and help raise the temperature of the body;
  • Irrigation. A warm saltwater solution may be used to warm certain areas of the body, such as the area around the lungs (pleura) or the abdominal cavity (peritoneal cavity).

Frostbite
Frostbite is an injury caused by freezing of the skin and underlying tissues. Skin first becomes very cold and red, then numb, hard and pale. Frostbite is most common on the fingers, toes, nose, ears, cheeks and chin. Exposed skin in cold, windy weather is most vulnerable to frostbite. But frostbite can occur on skin covered by gloves or other clothing. Frostbite can also result from direct contact with ice, freezing metals or very cold liquids.1,2,4-6,8,9

Frostbite occurs in three stages. Frostnip or prefreeze is often considered a precursor to superficial frostbite and doesn’t result in permanent skin damage. The onset of the second and third stage, referred to as superficial and deep frostbite respectively, requires medical attention because these stages can damaged skin, tissues, muscle and bones. Due to numbness of the skin an individual may suffer from frostbite and not be aware until having the condition pointed out to them. But it can also be caused by:

  • Wearing clothing that isn’t suitable for current environmental conditions;
  • Staying out in the cold and wind too long. Risk increases as air temperature falls below 5° F (-15° C), even with low wind speeds. In wind chill of -16.6° F (-27° C), frostbite can occur on exposed skin in less than 30 minutes;
  • Touching materials such as ice, cold packs or frozen metal.

Possible complications of severe frostbite include infection and nerve damage. Cold exposure that’s severe enough to cause frostbite can also result in onset of hypothermia. Additional complications may include:

  • Increased sensitivity to cold;
  • Increased risk of developing frostbite again;
  • Long-term numbness in the affected area;
  • Changes in the cartilage between the joints (frostbite arthritis);
  • Growth defects in children, if frostbite damages a bone’s growth plate;
  • Infection;
  • Tetanus;
  • Gangrene.

Specific Signs and Symptoms of associated with the 3 stages of Frostbite include:

Prefreeze or Frostnip

  • Pale or red skin;
  • Skin feels cold;
  • Prickling and numbness in the affected area;
  • Pain and tingling as skin rewarms.

Superficial Frostbite

  • Reddened skin that turns white or pale;
  • Skin may remain soft, but some ice crystals may form in the tissue;
  • Skin begins to feel warm as condition progresses to deep Frostbite;
  • Skin appears mottled, blue, or purple with burning, stinging, and swelling when treated by rewarming.

Deep Frostbite

  • Numbness;
  • Loss of sensation of cold;
  • Pain or discomfort in affected area;
  • Physical impairment of joints and muscles;
  • Blistering with 24-48 hrs following rewarming;
  • Black, hard, necrotic tissue.
Prefreeze/Frostnip Superficial Frostbite Deep Frostbite

A number of factors may increase the chance of developing frostbite, including:

  • Medical conditions that affect the ability to feel or respond to cold, such as dehydration, exhaustion, diabetes and poor blood flow in limbs;
  • Alcohol or drug abuse;
  • Smoking;
  • Fear, panic or mental illness that impairs judgment;
  • Previous frostbite or cold injury;
  • Age. Infants and older adults may have a harder time maintaining body heat;
  • Being at high altitude, which reduces the oxygen supply to your skin.

Very mild cases of frostbite can be cared for with basic first-aid measures, including rewarming the skin. However, medical attention for frostbite is indicated when:

  • An individual exhibits signs and symptoms of superficial or deep frostbite;
  • Increased pain, swelling, redness or discharge in the area that was frostbitten;
  • Fever;
  • New, unexplained symptoms.

Chilblains (CHILL-blayns)

Chilblains, also referred to as perniosis or pernio, is a reaction to cold, non-freezing temperatures that results in painful inflammation of small blood vessels in the skin that occur in response to sudden warming from cold temperatures. Chilblains may result in itching, red patches, swelling and blistering on extremities, such as on your toes, fingers, ears and nose.1,2,14,15

The exact reason chilblains occur is unknown. They may be an abnormal reaction of an individual’s body to cold exposure followed by rewarming. Rewarming of cold skin may result in smaller subcutaneous blood vessels expanding more rapidly than nearby larger blood vessels, resulting in a blood flow volume from the smaller vessels that the larger blood vessels are not prepared to accept. The result is blood leaking into nearby tissues.

Chilblains on Fingers Chilblains on Toes

Signs and Symptoms of Chilblains include:

  • Small, itchy red areas on your skin, often on the feet or hands;
  • Possible blistering;
  • Swelling of your skin;
  • Burning sensation on your skin;
  • Changes in skin color from red to dark blue, accompanied by pain;
  • Possible ulceration.

A number of factors may increase the chance of developing Chilblains, including:

  • Exposing skin to cold, damp conditions;
  • Women tend to be more likely to develop chilblains;
  • Individuals whose weight is 20% less than is expected for their height;
  • Geographic locations with high humidity and low, but not freezing, temperatures, increases the risk of chilblains;
  • The risk of chilblains increases from early winter to spring. Chilblains often disappear completely in the spring when the weather warms;
  • Individuals with poor circulation tend to be more sensitive to changes in temperature, making them more susceptible to chilblains;
  • Individuals diagnosed with Raynaud’s phenomenon, another cold-related condition that affects the extremities, are more susceptible to chilblains. Either condition can result in sores, but Raynaud’s causes different types of color changes on the skin.

Chilblains can be cared for with basic first aid measures including:

  • Warming the area, while avoiding direct heart;
  • Avoid rubbing and scratching;
  • Apply antiseptic and dressing to broken skin to prevent infection;
  • Apply anti-itch or pain relieving topical creams as indicated.

Chilblains generally clear up within one to three weeks with the use of simple over-the-counter topical lotions to treat itchiness and pain. While chilblains don’t usually result in permanent injury, they can lead to infection, which may cause severe damage if left untreated. Medical referral is indicated if:

  • If the pain becomes severe;
  • If the affected skin begins to look as if it might be infected;
  • If skin does not improve after one to two weeks.

Prevention Guidelines
Remember the acronym COLD — cover, overexertion, layers, dry:

  • Cover. Wear a hat or other protective covering to prevent body heat from escaping from the head, face and neck. Cover hands with mittens instead of gloves. Mittens are more effective than gloves because mittens keep fingers in closer contact;
  • Overexertion. Avoid activities that would cause excessive sweating. The combination of wet clothing and cold weather can cause more rapid heat loss;
  • Layers. Wear loose fitting, layered, lightweight clothing. Outer clothing made of tightly woven, water-repellent material is best for wind protection. Wool, silk or polypropylene inner layers hold body heat better than cotton does;
  • Dry. Stay as dry as possible. Get out of wet clothing as soon as possible. Be especially careful to keep hands and feet dry.

Whenever event time weather forecasts indicate the potential for temperatures of 39ºF or below the medical team shall prepare for the upcoming event by reviewing and accounting for the items on the Readiness Supplies Checklist.  Wind Chill shall be checked 1 hour before an event by a medical team member or designated official whenever the temperature is 39° F or lower.  Wind chill shall be assessed using the RealFeel® temperature provided by AccuWeather.com or from the AccuWeather phone app.  If the RealFeel® temperature is 10° F or below, the athletic trainer or designated official shall re‐check the RealFeel® temperature at 20 minute intervals and provide coaches and officials with updates regarding the cold exposure guidelines outlined below.  If the RealFeel® temperature is ‐11° F or lower, the contest will be suspended.

Cold Exposure Guidelines 1-3,9-13,16,1

RealFeel® Temperature Warning Level Guidelines
 ≥ 40° F  All Clear  Full activity without restriction.
 39° F to 20° F  Wind Chill Watch
  •  Notify designated officials that there is a wind chill watch and the potential onset of cold related illnesses.
  • Designated officials shall monitor the RealFeel® temperature every hour during practice or at the midpoint of a contest.
  • Personnel should dress in layers.
  • Stay adequately hydrated.
 19° F to 10° F  Wind Chill Warning
  •  Notify designated officials that there is a wind chill warning and the potential onset of cold related illnesses.
  • Designated officials shall monitor the RealFeel®temperature every hour during practice or at the midpoint of a contest.
  • Personnel should dress in layers.
  • Cover the head and neck to prevent heat loss.
  • Stay adequately hydrated.
 9° F to -10° F  Wind Chill Advisory
  •  Notify designated officials that there is a wind chill advisory and the potential onset of cold related illnesses.
  • Consider postponing competition until the RealFeel®temperature improves.
  • Consider moving practices indoors until the RealFeel®temperature improves.
  • Reduce outdoor practice time.
  • Designated officials shall monitor the RealFeel®temperature every hour during practice or at the midpoint of a contest.
  • Personnel should dress in layers.
  • Cover the head and neck to prevent heat loss.
  • Stay adequately hydrated.
 ≤ -11° F   Wind Chill Alert  No Outside Activity

Readiness Supplies

Basic Life Support Supplies

  • AED
  • BLS airway adjuncts
  • Hear rate monitor
  • Blood pressure monitor
  • Pulse oximeter

Protocol Specific Readiness Supplies:

  • Designated Warming Area;
  • A supply of water or sports drinks for rehydration;
  • Warm fluids to aid in re-warming;
  • Heat packs, blankets, additional clothing, and external heaters;
  • Flexible low-reading rectal thermometer probe;
  • Warm water immersion tub, wading pool, or whirlpool;
  • Topical anti-itch cream;
  • Topical pain relieving cream;
  • Dressings.

© Sports Medicine Concepts, Inc.  All Rights Reserved.

LIGHTNING

Contributed by Pete McCabe, MS, ATC

OVERVIEW

Injuries sustained from lightning have been well documented in recent literature.  It is important to note that if lightning safety procedures are not reviewed and implemented, lightning occurrences can result in  fatal outcomes in the athletic setting.  According to the National Weather Service, 210 fatalities were reported from 2006-2011.  Of the 210 fatalities reported, 51% were engaging in some form of recreational activity.  Peak seasons for thunderstorms seem to correlate with the data placing the physically active population in more danger.  Late spring to early fall historically have seen increases in thunderstorm activity with a high prevalence of thunderstorm activity from afternoon to early evening. 4,5,7 The previously mentioned timing of seasonal thunderstorms makes them a substantial risk for most outdoor practices and competitions in certain areas.  On average, 25 million lightning strikes hit the ground in the United States. 3,8 While certain areas of the United States are more exposed to lightning activity, no location is safe from the potential risk of lightning exposure.  Institutions need to ensure proper lightning procedures are in place, along with educational opportunities for administrators, coaches, players and referees.

Lightning is defined as a transient, high-current electric discharge in the air.1 These high-current discharges’ peak temperatures have been documented to be about 5 times greater than the temperature on the sun.16 Lightning often result in visible flashes that are the result of conduction of electricity between gradient potentials created within positively and negatively charged areas of a cloud.  There are two primary types of lightning, cloud-to-ground and cloud-to-cloud strikes.1  As these gradient potentials increase within a cloud, the negatively charged region of the cloud begins to create a stepped leader that moves toward the ground.  On average, more than 90% of global cloud-to-ground lightning is negative.1

When thunder is heard or a lightning bold is seen, the leading edge of the thunderstorm is close enough to strike the current location with lightning.  It is important for athletic trainers, administrators and coaches to understand the mechanisms of a lightning injury.    Lightning can cause injury or death through 6 potential mechanisms:  direct strike, contact injury, side flash, step voltage, upward leader and concussive. 7,15, 17

  • Direct Strike is the least common mechanism of a lightning strike. A direct strike mechanism occurs when an individual is struck directly.
  • Contact Injury occurs when an individual is touching an object that is in the direct path of the lightning current. Objects such as wired telephones, poles, trees and wired computers are documented as causing contact lightning injuries.
  • Side Flash injuries occur when an object is struck by lightning and an individual is close enough for a portion of the lightning’s energy to “jump” toward them. This mechanism is accounts for approximately 30-35% of lightning injuries.18
  • Step Voltage is documented as being the most common mechanism of a lightning strike, attributed to nearly half of all lightning injuries and deaths.18 This mechanism occurs when an individual near the strike disrupts the path of the lightning’s energy path. Often in this mechanism, the voltage from the strike will travel through the victim’s body via a limb and exit a separate limb in contact, or enroute of, the lightning’s path to the ground.  This mechanism is more prevalent when groups of people are in one area, sometimes resulting in mass injuries or casualties.1
  • Upward Leader mechanisms are lightning strikes that develop from the earth toward a cloud.  Upward leaders are responsible for approximately 10-15% of all lightning encounters.17, 18 Upward leaders that remain disconnected from downward leaders can transfer sufficient energy to injure or kill. 1
  • Concussive mechanisms of injury can cause violent muscular contractions and can sometimes throw victims away from the site of the lightning strike. Sometimes termed, “explosive forces,” concussive mechanisms result from rapid heating and cooling of the lightning current.1 Injuries to the eyes and ears are commonly reported as a result of explosive force lightning strikes.

Injuries sustained by a lightning strike can have long-term effects on the human body.  Research has documented short-term memory problems, attention deficit, difficulty processing new information, and severe headaches resulting from lightning strikes.20,21 Additional injuries such as tympanic membrane damage and superficial burns have also been reported.  In all situations, first responders should be knowledgeable in the mechanisms of lightning strikes and the importance of immediate first aid for the victim(s).

First Aid/Management

A common myth with the first aid/management of a lightning victim is that the person will still hold a charge from the lightning strike.  Touching a lightning victim is safe and first-aid should be provided promptly as long as the rescuer is not putting him or herself in danger from on-going severe weather.1 If possible, lightning victims should be moved to a safe area prior to management and care.  Mortality rate for lightning strikes is quite low, only 8-10% of lightning strike victims will die as a direct result of the strike itself. 13 Most lightning deaths result from secondary acute cardiac or respiratory arrest.  Therefore, an AED and the ability to perform high-quality CPR is a critical link in prevention of deaths resulting from lightning strikes.  In mass strike scenarios, care for lightning victims should be placed on those who appear to be dead first.14,22 Other victims who are moving and breathing should be treated secondarily.

It is recommended that victims of lightning strikes be admitted into a hospital following the lightning event.  Additionally, follow-up care with the victim’s primary care physician is recommended to treat and monitor sighs of concussion, muscle pain, temporary paralysis, deafness or blindness.13,19

Lightning Action Plan

  1. All appropriate personnel will be notified and educated regarding venue specific designated evacuation safe zones.  The primary choice for evacuation should be a fully enclosed building with wiring and plumbing.4,6,7,9,10,11,12,23 If a fully enclosed building is not available, seek shelter within a fully enclosed vehicle with a roof.  Golf carts, ATV’s, gazebos and under trees are not acceptable areas to seek shelter during lightning activity.
  2. If sever weather is forecast, designated personnel will discuss the possibility of suspending, cancelling, or rescheduling the event.
  3. An athletic training staff member or other designated weather watcher at an event will be on the field monitory local weather conditions.  This person will actively watch for signs of threatening weather, monitor local weather forecasts and sever weather alerts, and any lightning detection systems in place.  The weather watcher will notify appropriate personnel when severe weather becomes a threat.
  4. If a storm is expected to occur during a practice or game, the weather watcher will notify coaches, officials, and all other designated personnel of the severe weather threat.
  5. When severe weather is possible, the weather watcher or other designated personnel will provide visiting team personnel with lightning policy information during the medical time out, including evacuation safe zone for their players and personnel.
  6. When severe weather is possible, the weather watcher or other designated personnel will provide spectators with specific severe weather updates, including evacuation safe zones via public address announcements.
  7. The designated weather watcher will notify designated officials of weather threats and has the authority to immediately suspend all play and initiate the evacuation plan.
  8. During games or competitions, the appropriate public address announcements will be made and repeated over the public-address system advising fans of the inclement weather and directing them to evacuate the site to a designated safe zones when play is suspended:

Severe Weather Watch/Warning: “Ladies and Gentlemen, we are now under a severe weather (watch/warning).  Please seek shelter immediately.  The closest shelter is located ___________.  More details will be relayed when it is safe to return to the venue to resume competition.  Thank you.”

Lightning Warning: “Ladies and Gentlemen, we are now under a severe weather/lightning delay.  Please seek shelter or move to your cars immediately.  More details will be relayed when it is safe to return to the venue to resume competition.  Thank you.”

Postponement: “This (game/event) has been postponed due to inclement weather.  We regret and apologize for the inconvenience.  Please follow instructions of ushers, law enforcement and public safety officers in exiting the facility.  Thank you.”

Suspending / Resumption of Activities

  • Any system notifications indicating lightning strikes within 12 miles, audible thunder, or visible lightning will result in suspension of the event and evacuation of all participants and spectators to designated Safe Zones.
  • Once play has been suspended, wait at least 30 minutes after the last system notification, audible thunder, or visible lightning to resume play.
  • Any subsequent thunder or lightning indications after the beginning of the 30 minute count will result in the count clock being reset and another 30 minute count will begin.
  • When using lightning detection systems refer to the National Weather Service guidelines below:
NWS / Monitor System Alerts Risk Level Prevention Measures
No Warning Low Monitor skies for onset of dark clouds and high winds, and 30sec lightning/thunder interval.
Watch
Heads-Up
Moderate Alert personnel to the alert status and potential for alert level upgrade.  Monitor for warning upgrades.
Warning
<30s lightening/thunder interval
High Alert all participants to the risk and evacuate to venue safe zone.  Resume practice in venue safe zone or wait for “All Clear” and warnings to expire before resuming outside activity.
Danger High Alert all participants to the risk and evacuate to venue safe zone.  Resume practice in venue safe zone.
All Clear Low Reassess that lightning or thunder has not been heard of observed for at least 30 min within 15 miles of venue.  If desired, resume outdoor activity.  Monitor for additional severe weather activity.

 

© Sports Medicine Concepts, Inc.  All Rights Reserved.

HYPOGLYCEMIA

OVERVIEW
Normal fasting blood glucose levels range from 60-80 to 100 mg/dl.  Normal postprandial levels are less than 160 mg/dL at 2 hrs post ingestion. Chronic hypoglycemia is associated with long-term damage and dysfunction involving the eyes, kidneys, nerves, and heart.

Diabetes is a chronic endocrine disorder characterized by the onset of hypoglycemia.  There are two types of Diabetes, Type 1 and Type 2.  Type 2 diabetes accounts for 90% of the 20.8 million individuals affected by Diabetes.  Type 2 Diabetes typically occurs in adults 40yrs and older.  However, Type 2 Diabetes is reportedly on the rise in the younger population, particularly among the American Indian, African American, and Hispanic/Latino populations.  Type 1 Diabetes is a rarer form of diabetes, affecting only 10% of the diabetic population.  Type 1 Diabetes typically occurs in children and young adults.  Although Type 1 Diabetes is the rarer form of the disease it is the form of the disease most likely encountered by the sports medicine team as it typically affects individuals within the middle school, secondary school, college, and professional age groups.

Type 1 Diabetes  is an autoimmune disorder resulting in absolute insulin deficiency.  Type 1 diabetes is thought to be the result of genetic predisposition and unknown environmental factors.

Recognition and Management
The signs and symptoms of Type 1 diabetes develop rapidly and are related to hypoglycemia.  The typical signs and symptoms include:

⦁ Frequent urination;
⦁ Thirst;
⦁ Hunger;
⦁ Polyphasia;
⦁ Weight loss;
⦁ Visual disturbances;
⦁ Fatigue;
⦁ Ketosis.

Individuals diagnosed with diabetes are able to resume exercise within weeks of initiating proper insulin therapy, a comprehensive diabetic care treatment plan, and specific exercise guidelines overseen by a management team.  Considering specific recommendations from the American Diabetes Association and American College of Sports Medicine the management team will develop a comprehensive diabetic care plan designed to maintain consistent blood glucose concentrations at a near-normal range without provoking hyperglycemia.  The comprehensive diabetic care plan will provide for the following:

⦁ Blood glucose monitoring, including specific exclusion criteria;
⦁ Insulin therapy guidelines;
⦁ List of and access to all necessary medications and supplies;
⦁ Guidelines for hyper/hypoglycemia;
⦁ Emergency contact information;
⦁ Medic alert identification/tag.

A team approach is critical to the success of a diabetic treatment plan.  The medical support team will include physicians, including the athlete’s primary care and specialists, nurses, coaches, administration, and athletic trainers. Athletic trainers will be central to the comprehensive diabetic care plan, with daily responsibilities, including prevention, recognition, immediate care, exercise nutrition, hydration, exercise monitoring/modifications, and communication.

Glucagon Injection
With the onset of signs and symptoms of severe hypoglycemia, the medical team will activate EMS and prepare to administer appropriate glucagon injections in accordance with injector instructions.  Athletes may experience nausea and vomiting after glucagon injections.  Unconscious athletes should regain consciousness within 15 min following injection.  Athletes treated with glucagon injection may be provided food once conscious and able to swallow.  Athletes who are unable to consume food will be treated according to EMS protocol.
Patients may be in a coma from severe hyperglycemia rather than hypoglycemia.  In such cases, the patient will not respond to glucagon and requires immediate medical attention.
Glucagon kits should be stored at controlled room temperature between 20° to 25°C (68° to 77°F).   Glucagon solution should be used immediately.   Discard any unused portion.  Solutions should be clear and of a water-like consistency at time of use.

Use glucagon to treat insulin coma or insulin reaction resulting from severe hypoglycemia (low blood sugar). Symptoms of severe hypoglycemia include disorientation, unconsciousness, and seizures or convulsions. Give glucagon if (1) the patient is unconscious (2) the patient is unable to eat sugar or a sugar-sweetened product (3) the patient is having a seizure, or (4) repeated administration of sugar or a sugar-sweetened product such as a regular soft drink or fruit juice does not improve the patient’s condition. Milder cases of hypoglycemia should be treated promptly by eating sugar or a sugar-sweetened product. Glucagon is not active when taken orally.

To prepare glucagon for injection:

1. Remove the flip-off seal from the bottle of glucagon. Wipe rubber stopper on bottle with alcohol swab.

2. Remove the needle protector from the syringe, and inject the entire contents of the syringe into the bottle of glucagon. DO NOT REMOVE THE PLASTIC CLIP FROM THE SYRINGE. Remove syringe from the bottle.

3. Swirl bottle gently until glucagon dissolves completely. GLUCAGON SHOULD NOT BE USED UNLESS THE SOLUTION IS CLEAR AND OF A WATER-LIKE CONSISTENCY. TO INJECT GLUCAGON Use Same Technique as for Injecting Insulin

4.  Using the same syringe, hold bottle upside down and, making sure the needle tip remains in solution, gently withdraw all of the solution (1 mg mark on syringe) from bottle. The plastic clip on the syringe will prevent the rubber stopper from being pulled out of the syringe; however, if the plastic plunger rod separates from the rubber stopper, simply reinsert the rod by turning it clockwise. The usual adult dose is 1 mg (1 unit). For children weighing less than 44 lb (20 kg), give 1/2 adult dose (0.5 mg). For children, withdraw 1/2 of the solution from the bottle (0.5 mg mark on syringe). DISCARD UNUSED PORTION.

Glucagon Preparation Steps

 Step 1 Step 2 Step 3 Step 4

Use the following steps to inject glucagon immediately after mixing:

1. Cleanse injection site on buttock, arm, or thigh with alcohol swab;

2.  Insert the needle into the loose tissue under the cleansed injection site, and inject all (or 1/2 for children weighing less than 44 lb) of the glucagon solution. THERE IS NO DANGER OF OVERDOSE. Apply light pressure at the injection site, and withdraw the needle. Press an alcohol swab against the injection site;
3. Turn the patient on his/her side. When an unconscious person awakens, he/she may vomit. Turning the patient on his/her side will prevent him/her from choking;
4. FEED THE PATIENT AS SOON AS HE/SHE AWAKENS AND IS ABLE TO SWALLOW. Give the patient a fast-acting source of sugar (such as a regular soft drink or fruit juice) and a long-acting source of sugar (such as crackers and cheese or a meat sandwich). If the patient does not awaken within 15 minutes, give another dose of glucagon and INFORM A DOCTOR OR EMERGENCY SERVICES IMMEDIATELY;
5. Even if the glucagon revives the patient, his/her doctor should be promptly notified. A doctor should be notified whenever severe hypoglycemic reactions occur;
6. It is important to remember that patients may be in a coma from severe hyperglycemia rather than hypoglycemia.  In such cases, the patient will not respond to glucagon and requires immediate medical attention.

Severe side effects are very rare, although nausea and vomiting may occur occasionally. A few people may be allergic to glucagon or to one of the inactive ingredients in glucagon, or may experience rapid heartbeat for a short while. If you experience any other reactions which are likely to have been caused by glucagon, please contact your doctor.

Hyperglycemia occurs when renal glucose thresholds of 180 mg/dl are exceeded.  Hyperglycemia may result from poor glycemic control, acute care treatment of hypoglycemia or from exercise itself.  Some athletes may purposely train or compete in a hyperglycemia state to avoid hypoglycemia. Hyperglycemia results in ketoacidosis, hepatic glucose production, Catecholamine, FFA and keytone body production, and psychological stresses that are typically offset by counter-regulatory hormones in a normal state.  Hyperglycemia is associated with increased urination production, dehydration, and decreased athletic performance, relative to well-designed glycemic control measures.

Signs and symptoms of hyperglycemia include:

⦁ Rapid breathing;
⦁ Fruity breath;
⦁ Unusual fatigue;
⦁ Sleepiness;
⦁ Inattentiveness;
⦁ Loss of appetite;
⦁ Increased thirst;
⦁ Frequent urination.
To avoid complications associated with hyperglycemia, the medical team will follow current American Diabetic Association guidelines to avoid exercise during period of hyperglycemia, and may consider increasing basil rates or insulin boluses.

Insulin Injections and Insulin Pumps
For athletes using insulin injections to control their blood glucose levels, the medical team shall counsel athletes to avoid intramuscular injections; injecting instead in the subcutaneous tissues of the abdomen, upper thigh, or upper arm.  Heat and cold therapies may be contraindicated for 1-3hrs following injection of fast-acting insulin.  Insulin pump users will be counseled to replace insulin infusion sets every 2-3days.
Ambient temperatures <36 degrees F or >86 degrees F have been associated with reduced insulin action.  During these conditions the medical team may advise checking blood glucose concentrations more frequently.  The medical team may also counsel insulin pump users to replace cartridge and infusion sets with the onset of unusual hypoglycemia readings.

Travel Considerations
When airline travel is required the medical team will refer to Transportation Security Administration (TSA) guidelines concerning all diabetic instruments and medications.  Diabetic medical supplies and prescriptions will be carried with the athlete or a designated agent.  Diabetic medical supplies and prescriptions will not be stored in the cargo hold.  The medical team will advise all diabetic athletes to bring an appropriate prepacked meal or snack.  The medical team will also discuss and counsel appropriate adjustments to insulin therapy when traveling through time zones.

Prevention Guidelines
Prevention measures will be emphasized during the Preparticipation Physical Examination (PPE).  During the PPE the medical team shall counsel the athlete in the following:
1. Self-care skills;
2. Current status of glycemic control;
3. Discussion of how exercise affects blood glucose concentration;
4. Screening for complications;
5. Exclusion thresholds;
6. Bolus adjustments;
7. Acute care guidelines

In addition to the PPE the athlete shall have a regular annual exam with diabetic care specialists who will review:
1. GlycoHemo (HBAc) every 3-4mo
2. Overall glycemic control;
3. Retinopathy;
4. Nephrology
5. Neuropathy;
6. Cardiovascular screening.

Daily prevention of hypoglycemia will include a 3-prong approach that includes blood glucose monitoring, carbohydrate supplementation, and insulin adjustment.  Blood glucose monitoring will be monitored 2-3x at 30 minutes intervals prior to the onset of exercise, at 30 minute intervals during exercise, and every 2hrs for up to 4 hrs post-exercise.  Blood glucose levels will also be tested once before bed, once during the night, and upon awakening.
Athletes who present with pre-exercise blood glucose levels of < 100 mm/dl (5.5 mmmol/dl) will be provided approximately 30 grams of carbohydrates.  This will be accomplished through dietary supplementation, examples of which include, but are not limited to:

1. ½ peanut butter sandwich (1 slice of whole wheat bread + 1 Tbsp peanut butter) and 1 c milk;
2. 6 oz yogurt + ¼ c berries;
3. 1 English muffin + 1 teaspoon low-fat tub margarine

Carbohydrate supplementation may also be indicated for exercise bouts greater than 60min when pre-exercise insulin levels have not been reduced by 50%.  Diabetic athletes will be encouraged to eat a snack or meal shortly after cessation of exercise.

Insulin adjustments may also be indicated, particularly during moderate intensity exercise.  For athletes using insulin pumps the medical team may consider reducing basil rates by to 20-50% 1 to 2 hrs before exercise, reducing the bonus dose up to 50% at preceding meal, suspending or discontinuing pump at start exercise (< 60min). Insulin adjustments for athletes using multiple daily injections may include reducing bonus injections up to 50% at preceding meal.  The medical team may also consider adjusting the evening meal bolus by 50%.
Since prolonged or severe hypoglycemia may result in brain damage or death it is imperative for the medical team to be prepared to recognize and care for hypoglycemia. Signs and symptoms of hypoglycemia will generally present when blood glucose concentrations fall below 70 mg/dl.  These signed and symptoms will likely include:

⦁ Tachycardia;
⦁ Sweating;
⦁ Palpitations;
⦁ Hunger;
⦁ Nervousness;
⦁ Headache:
⦁ Trembling;
⦁ Dizziness.

Since prolonged or severe hypoglycemia may result in brain damage or death it imperative for the medica team to be prepared to recognize and care for hypoglycemia. Signs and symptoms of hypoglycemia will generally present when blood glucose concentrations fall below 70 mg/dl.  These signs and symptoms will likely include:

⦁ Tachycardia;
⦁ Sweating;
⦁ Palpitations;
⦁ Hunger;
⦁ Nervousness;
⦁ Headache:
⦁ Trembling;
⦁ Dizziness.

With the onset of signs and symptoms of mild hypoglycemia the medical team will be prepared to administer 10-15 g of fast acting carbohydrates. This may be accomplished via 4-8 glucose tablets or 2 Tbsp of honey.  Upon ingestion of fast-acting CHO supplement glucose concentrations will be measured.  Blood glucose concentrations will be measured again 15min following ingestion of fast-acting CHO supplement.  If blood glucose concentrations normalize, the athlete will be encouraged to consume a snack while 15min blood glucose serial measures are taken.  If blood glucose measures do not normalize after intention of fast-acting CHO supplement, the medical team may consider administering another 10-15 g of fast-acting CHO supplement.  If blood glucose levels do not normalize following a second round of fast-acting CHO supplementation, the medical team may elect to activate EMS.

As blood glucose concentrations continue to fall below 70 mg/dl athletes may begin to present with neurogenic symptoms indicative of sever hypoglycemia.  These signs and symptoms may include:

⦁ Signs and symptoms of mild hypoglycemia;
⦁ Blurred vision;
⦁ Fatigue;
⦁ Difficulty thinking;
⦁ Loss of motor control;
⦁ Aggressive behavior;
⦁ Seizures;
⦁ Convulsions;
⦁ Loss of consciousness.

Readiness Supplies
Basic Life Support Supplies
⦁ AED
⦁ BLS airway adjuncts
⦁ Hear rate monitor
⦁ Blood pressure monitor
⦁ Pulse oximeter

Protocol Specific Readiness Supplies:
⦁ Copy of the diabetic care plan;
⦁ Blood glucose monitoring equipment;
⦁ Supplies to treat hypoglycemia;
⦁ Supplies for urine or blood keytone testing;
⦁ Sharps container;
⦁ Spare batteries.

© Sports Medicine Concepts, Inc.  All Rights Reserved.

 HEAD TRAUMA

OVERVIEW

The medical team will designate an appropriate head injury assessment location for each venue.  The head injury assessment location shall be a quiet location which will remove the athlete from the chaotic competition environment and permit medical personnel to conduct a thorough head injury assessment without outside distractions. Athletes who present with signs and symptoms consistent with a concussion will be entered into the the team’s concussion protocol.  Athletes entering into the concussion protocol will receive a Head Injury Warning Sheet with specific guidelines for seeking care when not in the presence of team medical personnel.  The Head Injury Warning Sheet will be reviewed with the athlete and also with a family member or designated guardian.  Athletes who present with signs and symptoms inconsistent with a concussion will be assumed to have suffered injury resulting in intracranial hemorrhage and will be immediately transported to an appropriate medical facility by EMS.

Distinguishing Intracranial Hemorrhage (IH) from a sports-related SRC (SRC) has long been a challenge for medical teams during sideline management of athletes having suffered head trauma.  IH and SRC can present with very similar acute signs and symptoms, but each requires very different acute management.  While proper management of both conditions is critical to prevent a catastrophic outcome, failure to identify an acute IH could result in rapid deterioration of the athlete’s health due to life-threatening elevations in intracranial pressure (ICP) 1,2.  Elevated ICP has been shown to result in specific sign and symptom patterns that may be useful in helping athletic trainers distinguish IH from SRC.  Therefore, this section discusses 1) how IH may result in elevated ICP, 2) specific signs and symptoms that evolve as ICP rises, 3) how serial monitoring of specific signs and symptoms may be useful in identifying rising ICP, and 4) a possible sideline assessment protocol using Sports Medicine Concepts’ Mild Traumatic Brain Injury (MTBi) Differential Diagnosis Trending Report (DDTR).  The medical team will use differential diagnosis trending as part of an overall assessment strategy to help determine if an injured athlete should be transported to an appropriate medical facility or be entered into the team’s concussion protocol.

Body’s Response to Rising ICP

The cranial compartment, vertebral canal, and dura form a rigid inelastic container that houses the brain, blood, and cerebral spinal fluid (CSF).  ICP is the pressure inside the cranial compartment.    Under normal conditions autoregulatory processes maintain pressure within the cranial compartment to within 1 mmHg 3.  Rising ICP results from volume changes in the brain, CSF, or blood.  In order to maintain ICP, an increase in the volume of one of the cranial constituents must be offset by a compensatory decrease in volume of another.  For example, an IH resulting in an increase blood volume within the cranial compartment is compensated for by displacement of CSF into the ventricles and spinal canal, and some elasticity properties of the brain.  This compensatory mechanism allows for small increases in cranial volume that do not immediately result in elevated ICP 4,3.

Recognition of Rising ICP

Normal adult ICP is 7-15 mmHg 3.  The body’s compensatory mechanism for controlling small increases in cranial compartment volume will accommodate pressures up to 25 mmHg.    Therefore, initial increases in ICP may not result in any outward signs and symptoms that can be readily observed during acute sideline management.  However, as ICP begins to reach mean arterial pressure (MAP) cerebral perfusion pressure (CPP) falls resulting in decreased blood flow to the brain.  As a result of declining CPP the body’s autoregulatory processes increase systemic blood pressure in an attempt to maintain adequate blood flow to the brain.  In the case of an IH, an increase in systemic blood pressure (BP) will facilitate bleeding into the cranial compartment, initiating a spiraling ICP-CPP-BP cycle that will ultimately result in elevated ICP that leads to ischemia and brain infarction secondary to inadequate blood flow to the brain 1,2,5.

As ICP exceeds the body’s compensatory mechanism an athlete is likely to begin exhibiting an increase in number and severity of signs and symptoms.  Signs and symptoms indicative of rising ICP may include headache, nausea, vomiting without nausea, ocular palsies, altered levels of consciousness, back pain, papilledema, and widened pulse pressure.  In children, bradycardia may be particularly suggestive of high ICP 6. Specific signs and symptoms indicating the presence of an IH include bradycardia, hypotension, hypertension, respiratory depression, systemic vasoconstriction, altered mental status or lucid interval, hyperventilation, sluggish dilated pupils, and widened pulse pressure.  Early recognition of these signs and symptoms is paramount to ensure that injured athletes receive medical treatment before ICP reaches 40-50 mmHg, at which point catastrophic outcomes secondary to brain infarction and brain death become more likely 7.

Catastrophic outcomes may also result secondary to a mid-line shift of the brain within the cranial compartment.  A mid-line shift may result over a period of time as IH results in a growing mass of blood that eventually pushes the brain from mid-line.  If the mid-line shift results secondary to an IH, the on-set of signs and symptoms may develop over a period of time, depending on how long it takes for enough blood to collect in the cranial compartment to result in pushing the brain from mid-line.   Signs and symptoms of a growing mass effect IH may include pupillary dilatation, abducens palsies, increased systemic blood pressure, bradycardia, irregular respiratory patterns, and a widen pulse pressure.  Trauma, itself, may result in a mid-line shift.  If the mid-line shift is a direct result of trauma, dire signs and symptoms may present immediately.  Regardless of a gradual or immediate on-set, a resulting mid-line shift will ultimately lead to brain herniation or brain stem compression resulting in brain infarction and decrease respiratory drive 8.

Sideline Assessment

An injury resulting in rapid increases in ICP or mid-line shift will present with immediately life-threatening outward signs and symptoms indicating the need for immediate transport.  Injury to the brain resulting in more gradual rises in ICP may initially mimic a SRC.    However, observation of certain sign and symptom trends could alert athletic trainers to the possibility of elevated ICP secondary to IH, and thus the need for immediate transport.    Vital signs trending is an assessment strategy that has been used to observe serial measures of heart rate (HR), respirations (R), blood pressure (BP), and temperature (T) at 10min intervals over a 30 minute period.  Vital signs that do not normalize within the 30 minute trending period warrant immediate medical follow-up 9.  In the following section the vital signs trending philosophy is modified and used to observe for the development of specific signs and symptoms indicative of rising ICP secondary to IH, and thus, the need for immediate transport of an injured athlete.   Specifically, the vital signs trending protocol was changed from 10 minute to 5 minute serial measures of certain signs and symptoms over a 30 minute period of time.  This modification is believed to be more sensitive to changes in signs and symptoms.  Many of the signs and symptoms that present themselves in the sideline environment that are the result of an IH, rising ICP, or mid-line shift may be readily observed by trending three specific assessment batteries; the Sport Concussion Assessment Tool (SCAT) Symptoms Severity Score 10, the Sports Medicine Concepts’ Cranial Nerve Assessment Survey (See Appendix A), and Cushing’s Triad, which compares heart rate, respiration, and pulse pressure.  Therefore, these traditional indicators of SRC and elevated ICP were added to the vital signs trending protocol.  A theoretical application of this trending approach is explained in detail below followed by Sports Medicine Concepts’ Mild Traumatic Brain Injury (MTBi) Differential Diagnosis Trending Report that offers a means of more efficiently applying this concept during sideline management. (Evidence Category C)

Symptom Severity Graph

Typical sideline assessment using the SCAT form includes assessment of 22 signs and symptoms for which athletes are instructed to rate their symptom severity at the time of evaluation.  Athletes are given a severity score ranging from 0 points, if they are not experiencing the sign or symptom at all, and 6 points, indicating the sign or symptom is severe.  The total number of signs and symptoms out of a possible 22 is placed on the ICP Symptom Score Trending Graph (See Figure 1).  The symptom severity score is calculated by adding up the severity rating numbers.  This number is plotted on the Symptom Severity Trending Graph (See Figure 2).  If this process were repeated at 5 minute intervals for a total of 30 minutes, general trends indicating the possibility of rising ICP secondary to IH may become evident.  Generally, athletes who may have sustained a head injury resulting in IH may present with an increasing number of signs and symptoms or an increasing symptom severity rating.  A rapid rise in symptoms or symptom severity scores during the trending period may be indicative of rising ICP and the need to transport an athlete prior to the completion of the 30 minute trending period, particularly if the signs and symptoms involved include headache, nausea, or vomiting in the absence of nausea.  Figures 1 and 2 illustrate a theoretical model of general trends in the number and severity of signs and symptoms that might be indicative rising ICP due to IH.

Another significant sign of IH that may be observed using the Symptom Score and Symptom Severity Trending Graphs is a lucid interval. A lucid interval is a period of time during which an athlete reports improvement in signs and symptoms followed by worsening signs and symptoms, including altered mental status (AMS).  Figures 1 and 2 depict potential graphic representations of a lucid interval by illustrating a general trend of improvement followed by worsening severity scores. (Evidence Category C)

 

 

 

Figure 1. Symptom Score Trending Graph Indicating a Possible Hematoma.

Figure 2. Symptom Severity Trending Graph Indicating a Potential Hematoma.

Cranial Nerve Assessment Graph

Although there is some overlap in the cranial nerve assessment survey with the SCAT Symptom Evaluation Form, specific assessment of all 12 cranial nerves is warranted because any rise in ICP could have immediate impact on any of the cranial nerves due to their anatomical location at the base of the brain within the cranial compartment.  Therefore, assess both motor and sensory function for all 12 cranial nerves using SMC’s Cranial Nerve Assessment Survey provided in Table 1.  Calculate the total number of abnormal findings out of a possible 12 and place this number on the Cranial Nerve Trending Graph shown in Figure 3.  Repeat this assessment at 5 minute intervals for a total of 30 minutes.    A general trend indicating a rise in the number of abnormal findings may indicate the presence of rising ICP due to IH, and the need for immediate transport of the injured athlete.  More specifically, rising ICP has been shown to result in ocular palsies, papilledema, pupillary dilatation, and abducens palsies.  These specific conditions may present themselves upon assessment of the Optic (II), Oculomotor (III), Trochlear (IV), and Abducens (VI) nerves. (Evidence Category C)


Table 1. SMC’s Cranial Nerve Assessment Survey.

Nerve Name Function Test for Result
        Normal Abnormal
I Olfactory Smell Have the athlete identify odors w/ each nostril(sports cream, antiseptic, etc)
II Optic Visual acuity Have the athlete identify number of fingers
Visual field Approach the athlete’s eyes from the side using your finger or light pen
III Oculomotor Pupilary reaction Shine pen light in each eye and note pupilary reaction
IV Trochlear Eye movements Have the athlete follow your pen light without moving his/her head
V Trigeminal Facial sensation Have the athlete identify areas of face being touched
Motor Have the athlete hold mouth open against resistance
VI Abducens Motor Check athlete’s lateral eye movements
VII Facial Motor Have the athlete smile, wrinkle forehead, frown, puff cheeks, and wink each eye
Sensory Have the athlete identify familiar tastes (Gatorade)
VIII Acoustic Hearing Have athlete identify sounds in both ears (tuning fork)
Balance Check athlete’s balance (Romberg sign)
IX Glossopharyngeal Swallowing Have the athlete say “ah” and swallow hard
X Vagus Gag reflex Test the gag reflex (tongue depressor)
XI Spinal Neck strength Have athlete complete full AROM,  shoulder shrugs against resistance
XII Hypoglossal Tongue movement and strength Have the athlete stick out his/her tongue and move it around.  Apply resistance with tongue depressor.

Figure 3. Cranial Nerve Trending Graph Indicating a Potential Hematoma.

Cushing’s Triad

Cushing’s Triad is an assessment battery that compares pulse pressure, heart rate, and breathing patterns to indicate the presence of intracranial hemorrhage or edema.  Pulse pressure, or the amount of pressure required to create the feeling of a pulse, is the mathematical difference between the systolic and diastolic pressure.  For example, normal blood pressure is 120mmHg (systolic) / 80mmHg (diastolic), resulting in an normal healthy pulse pressure of P (systolic) – P (diastolic)  = 40 mmHg.  The normal resting pulse pressure of a healthy individual, sitting position, is about 60-80 mmHg 11.   Pulse pressure, heart rate, and respiration rate will increase with exercise, but have all shown to trend towards normal within 10 minutes following the cessation of exercise.  Therefore, an injured athlete presenting with an elevated pulse pressure, heart rate, or respiration rate should be trending towards normal within 10 minutes, and should certainly demonstrate a normal pulse pressure, heart rate, and respiration following a 30 minute trending period. (Evidence Category C)

To assess Cushing’s Triad, use a blood pressure monitor to measure blood pressure and heart rate.  Additionally, assess the athlete’s respirations and respiration rate.  Calculate pulse pressure and place the pulse pressure, heart rate, and respiration rate values on the Cushing’s Triad Trending Graph shown in Figure 4.    Blood pressure of a normal healthy individual should trend toward 120mmHg (systolic) / 80mmHg (diastolic) resulting in a normal pulse pressure of 40-80mmHg.  Respiration rates should trend toward 10-12 breaths per minute.  A more sensitive measure of effective respiration may be obtained by using a simple finger pulse oximeter to measure blood oxygen saturation (SpO2).  Normal range for SpO2 is typically considered from 95%-99%, but may be lower for individuals in high altitude environments 12. A general trend indicating an elevated pulse pressure combined with bradycardia and ineffective respirations might indicate the presence of IH or edema and the need for immediate transport of the injured athlete.  Incidentally, a low pulse pressure may also be problematic in and of itself, indicating the presence of shock or significant blood loss.  A pulse pressure is considered low if it is less than 25% of the systolic value 11.


Figure 4. Cushing’s Triad Trending Graph indicating elevated pulse pressure, bradycardia, and erratic respiration.

SMC MTBi Differential Diagnosis Trending Report (DDTR)

The intent of the prior discussion was to graphically demonstrate how sign and symptom trends indicative of rising ICP secondary to IH may present.  The DDTR is intended to offer athletic trainers an easier mechanism for applying this concept during on-field assessment of a potentially head injured athlete.

In the absence of immediate life-threatening signs and symptoms, begin recording information on the DDTR 10 minutes post-injury and continue to do so at 5 minute intervals.  Clinical signs and symptoms that fail to normalize following the 30min trending period or that worsen significantly during any interval during the trending period may be indicative of rising ICP pressure secondary to IH or cerebral swelling.

Total Number of SCAT Symptoms and Symptom Severity Score
Using the SCAT Symptom Evaluation chart calculate the total number of SRC-like symptoms and the corresponding Symptom Severity Score.  A significant increase in the number of SRC-like symptoms or the symptom severity score may be indicate the need to transport the athlete to the nearest Level 1 trauma center.

Altered Mental Status
Assess the athlete for any variations in level of consciousness or the presence of a lucid interval.  Use “N” to indicate normal or “AB” to indicate abnormal findings.

Cranial Nerves
Using the Sports Medicine Concepts, Inc., Cranial Nerve Assessment Survey record the number of abnormal clinical findings (out of a possible 12).  An increase in the number of abnormal clinical findings during any interval or remaining abnormal findings following the 30 minute trending period may be indicative of the need to transport the athlete from the field to the nearest Level 1 trauma center.

Heart Rate, Blood Pressure, and Pulse-Pressure
Use an appropriate heart rate / blood pressure monitor to record the athlete’s heart rate, blood pressure, and pulse pressure (Systolic-Diastolic) readings.  Persistent heart elevation above 100bpm, hypotension, hypertension, and pulse-pressures above 100 could be indicative of rising intra-cranial pressure, and the need to transport the athlete by EMS to the nearest Level 1 trauma center.

Blood Oxygen Saturation
Using a pulse-oximeter take serial measures of the athlete’s blood oxygen levels.  Abnormal blood oxygen levels may be indicative of the need to transport the athlete by EMS to the nearest Level 1 trauma center.


Table 2.  SMC’s MTBi Differential Diagnosis Trending Report (DDTR)

MTBi Signs and Symptoms Time: Status Post-Injury
10min S/P 15min S/P 20min S/P 25min S/P 30min S/P
Total number of SCAT symptoms
SCAT Symptom severity score
AMS
Cranial Nerves
Heart Rate
Blood Pressure
SpO2
Pulse-Pressure

Conclusion

Assessing pulse pressure, heart rate, respirations, abnormal cranial nerve finding, and signs and symptoms of SRC at 5 minutes intervals for a period of 30 minutes may provide medical personnel with a mechanism for sideline identification of head injuries that are more likely to involve rising ICP due to IH, and therefore, the need to immediately transport the injured athlete to an appropriate medical facility.  It is important to note that vital signs trending as a sideline assessment tool is not without significant limitations.  The presence of any of the signs and symptom patterns discussed in this section may suggest an increased potential for IH, but their absence does not rule out the possibility that an IH exists.  Additionally, the trending graph results presented here represent only one example of sign and symptom patterns that result in a graphic form that may indicate the presence of an IH.  Other trending patterns may produce other graphic forms also indicative of an IH.  Therefore, medical personnel will consider this sideline evaluation protocol only as part of a comprehensive head injury management plan that includes a multi-disciplined emergency action plan.  Annual EAP rehearsal will include discussions on the validity and reliability of the ICP Trending Graphs and the SMC DDTR as predictors of hematoma resulting from head trauma in sports.


Ancillary Content

Sample Head Injury Warning Sheet

© Sports Medicine Concepts, Inc.  All Rights Reserved.


PNEUMOTHORAX

Contributed by: Brad Wilson, NRP

OVERVIEW

During respirations, the diaphragm contracts and causes a negative pressure in the plural cavity, causing the lungs to expand and fill with air. When the diaphragm relaxes, a positive pressure is created and allows the lungs to deflate.  During certain traumatic injuries, the lungs can be damaged with punctures, causing the lung to “deflate” and not react to the pressure gradients in the plural cavity. This condition is called a pneumothorax.

A pneumothorax can be either open or closed and is reported to present in roughly 15% – 50% of all reported chest injuries.1 An open pneumothorax, commonly called a sucking chest wound, occurs when the plural cavity is penetrated from outside the body. This release of pressure will cause the lung from the affected side to collapse. Pneumothorax (PTX) can be divided into three different types, spontaneous, traumatic, or tension. In the realm of athletics, a traumatic or spontaneous PTX is most likely to occur. Traumatic PTX can be further subdivided into penetrating or non-penetrating trauma. While rare, traumatic PTX have been reported in sports such as ice hockey, football, rugby, and soccer. For the most part, sports-related PTX are due to blunt chest trauma. Luckily, in athletics, PTX is rare.  Only about 2% of adult pneumothorax injuries are due to athletics.2

Spontaneous Pneumothorax
A spontaneous pneumothorax occurs when air escapes from the lung causing it to collapse. This type of pneumothorax occurs for no apparent reason.

Traumatic Pneumothorax
A traumatic pneumothorax results from a puncture wound to the lung, causing the lung to collapse. This can be life-threatening.

Tension pneumothorax
A tension pneumothorax is a severe pneumothorax that can be life-threatening. The cause of this type of pneumothorax can be a traumatic event, or a severe spontaneous pneumothorax. The lung collapse is usually more than 50%.

Individuals who are young, thin, and tall, such as basketball players, are most susceptible to the development of a primary spontaneous pneumothorax. Individuals in high blunt chest trauma risk sports are also at increased risk when compared to non-contact sports.  At times the plural cavity may fill with blood, do to barotrauma, causing a hemothorax. In very rare instances, an athlete might experience an open penetrating chest wound, causing an open pneumothorax.

One final type of injury that could be caused by trauma to the chest cavity is a hematoma. A hematoma acts just like a pneumothorax, except blood fills the cavity instead of air. Each of the body’s thoracic cavities can accumulate up to 3000ml of blood. A “massive” hemothorax occurs when at least 1500ml of blood accumulates in the plural cavity.

Risk Factors

Risk factors include:

  • Gender. Males are more at risk of a pneumothorax than females
  • Smoking. The risk increases with the length of time and the number of cigarettes smoked, even without emphysema
  • Age. The type of pneumothorax caused by ruptured air blisters is most likely to occur in people between 20 and 40 years old, especially if the person is a very tall and underweight
  • Genetics. Certain types of pneumothorax appear to run in families
  • Lung disease. Having an underlying lung disease — especially chronic obstructive pulmonary disease (COPD) — makes a pneumothorax more likely  
  • Mechanical ventilation. People who need mechanical ventilation to assist their breathing are at higher risk of pneumothorax
  • Previous pneumothorax. Anyone who has had one pneumothorax is at increased risk of another, usually within one to two years of the first

Recognition and Management

Signs and Symptoms

  • Shortness of breath
  • Sharp chest pain while breathing
  • Rapid breathing
  • Increased heart rate
  • Anxiety
  • Subcutaneous emphysema

Late signs of a worsened PTX

  • Tension pneumothorax
  • Tracheal deviation
  • Increased blood pressure
  • Distended neck veins

Acute Care and Management of a pneumothorax

  1. Maintain an open airway.
  2. Give oxygen via a non-rebreather facemask. At 15 l/min
  3. Check lung sounds using a stethoscope.
    1. Make sure to check for breath sounds in all lobes of the lungs (see diagram)
    2. Listen to the lungs both anteriorly and posteriorly.
  4. Check the respiratory rate, rhythm and depth.
  5. Look for equal and bilateral chest expansion during respirations.
  6. Check pulse.
  7. Activate EMS for immediate transport to appropriate receiving facility if the athlete has these signs and symptoms:
    1. Penetrating chest trauma;
    2. Jugular vein distension;
    3. Shallow breathing;
    4. Tachycardia;
    5. Tachypnea;
    6. Decreased breath sounds.

Once EMS arrives, they will determine if there is a pneumothorax present. In the late stages, tracheal deviation will start to happen. The trachea will start to deviate in the direction of the unaffected lung. This occurs because of the pressure from the tension pneumothorax that has developed. This is dangerous to the compression being applied to the other organs. If a tension pneumothorax has developed, EMS well perform a needle decompression, “dart” the chest. This is performed by the provider using a 14g catheter in the second intercostal space mid clavicular. Once the needle is removed from the catheter, air or blood (if a hemothorax) will be observed.  This release of pressure will allow the lung to start to re-inflate.

When the patient arrives to the emergency department, a chest tube may be inserted, depending on how severe the pneumothorax or hemothorax is.

Recommended Equipment List

  • Stethoscope
  • Blood pressure monitor
  • CPR mask/bag-valve mask
  • Supplemental oxygen
  • Emergency Airway Kit
  • Automated external defibrillator (AED)
  • Emergency contact cards

© Sports Medicine Concepts, Inc.  All Rights Reserved.

SAFE HANDLING PROTOCOLS AND TECHNIQUES

REPOSITIONING

Repositioning a prone athlete to supine may be required in order to facilitate medical assessment and care, establish neutral cervical position, or provide access to the athlete’s airway and chest.  The logroll maneuver is the accepted technique used to reposition injured athletes.  The  medical team recognizes that there are variations of the log roll maneuver that may be employed to reposition an injured athlete.  The  will decide which variation is most appropriate based on the team’s expert opinion of how best utilize existing emergency response equipment and personnel to meet the team’s Primary Objectives™ established for each unique injury management scenario.

The various techniques that the medical team may elect to employ are outlined below:

5-Person Log Roll-Push

A-Man
⦁ Maintain manual head stabilization until full immobilization to the long spine board (LSB) is achieved;
⦁ Directs the log roll maneuver;
⦁ Watches the torso turn and maintains neutral in-line support of the head, rotating it exactly with the torso;
⦁ Positions the patient in cervical neutral position and directs B- and C-Man to pack-n-fill as required to maintain proper neutral position.

Step 1
⦁ B- and C-Man clear the area of any extraneous objects or medical equipment;
⦁ If the protective athletic equipment remains in place, B- and C-Man utilize pack-n-fill towels to maintain cervical neutral alignment;
⦁ If the protective athletic equipment has been removed, B- will apply a c-collar on the patient and provide pack-n-fill padding as required to support cervical neutral position;
⦁ B-Man kneels at the patient’s mid-torso, straightens the patient’s arms with the patient’s palms facing in next to the torso. Palm-out may result in elbow joint damage during the roll;
⦁ B-Man then grasps the far side of the patient at the shoulder and just above the elbow;
⦁ C-Man kneels next to B-Man and grasps the patient just above the elbow, crossing over the B-Mans arm;
⦁ C-Man’s lower hand grasps the patient at the mid-thigh;
⦁ C-Man places their lower foot up against the patient’s legs, just below the knees for the patient’s lower legs to roll onto during the log roll, to prevent the patient’s pelvis drooping;
⦁ D-Man kneels next to C-Man and grasps the patient’s mid-thigh with their upper hand by crossing over the C-Man’s arms;
⦁ D-Man grasps the patient with their lower hand at the ankles;
⦁ E-Man kneels on the opposite side of the patient at the patient’s pelvic level;
⦁ E-Man’s upper hand is placed on the patient’s upper arm and the lower hand is placed on the patient’s upper leg.

Step 2
⦁ Under the direction of the A-Man, the patient is carefully log rolled until at a right angle to the ground;
⦁ A-Man watches the patient’s torso turn and maintains manual support of the head, rotating it exactly with the torso:
⦁ C-Man at the patient’s legs assists with rotation of the patient’s torso and takes the weight of the patient’s pelvis, again watching the torso. The patient’s lower legs roll onto B-Man’s lower foot to prevent pelvic drooping;
⦁ E-Man facilitates the efforts of the B-, C-, and D-Man by carefully pushing the patient into proper position.

Step 3
⦁ The A-Man directs the medical team to reposition to complete the log roll.  When in proper position, and under the direction of the A-Man, the log roll is completed by carefully rolling the athlete to a supine position;
⦁ A-Man watches the patient’s torso turn and maintains manual support of the head, rotating it exactly with the torso;
⦁ C-Man at the patient’s legs assists with rotation of the patient’s torso and takes the weight of the patient’s pelvis, again watching the torso. The patient’s lower legs roll onto B-Man’s lower foot to prevent pelvic drooping.
⦁ E-Man facilitates the efforts of the B-, C-, and D-Man by carefully pushing the patient into proper position;
⦁ Upon completion of the log roll, the A-Man positions the patient into cervical neutral position, unless otherwise contraindicated.

4-Person Log Roll-Push

A-Man
⦁ Prepare to log roll the patient in the direction opposite the patient’s face by assuming a start position with the A-Man’s inside knee positioned at the patient’s lower shoulder;
⦁ Place hands on head/helmet with the palms together and thumbs down, and the arm corresponding to the direction of the log roll on top such that the A-Man’s arms are twisted at initiation of the log roll and untwist during the maneuver;
⦁ Maintain manual head stabilization until full immobilization to the long spine board (LSB) is achieved;
⦁ Directs the log roll maneuver;
⦁ Watches the torso turn and maintains neutral in-line support of the head, rotating it exactly with the torso;
⦁ Positions the patient in cervical neutral position and directs B- and C-Man to pack-n-fill as required to maintain proper neutral position.

Step 1
⦁ B- and C-Man clear the area of any extraneous objects or medical equipment;
⦁ If the protective athletic equipment remains in place, B- and C-Man utilize pack-n-fill towels to maintain cervical neutral alignment;
⦁ If the protective athletic equipment has been removed, B- will apply a c-collar on the patient and provide pack-n-fill padding as required to support cervical neutral position;
⦁ B-Man kneels at the patient’s mid-torso, straightens the patient’s arms with the patient’s palms facing in next to the torso. Palm-out may result in elbow joint damage during the roll;
⦁ B-Man then grasps the far side of the patient at the shoulder and just above the elbow;
⦁ C-Man kneels next to B-Man and grasps the patient’s pelvic bone;
⦁ C-Man’s lower hand grasps at the ankles.
⦁ C-Man places their lower foot up against the patient’s legs, just below the knees for the patient’s lower legs to roll onto during the log roll, to prevent the patient’s pelvis drooping;

Step 2
⦁ Under the direction of the A-Man, the patient is carefully log rolled until at a right angle to the ground;
⦁ A-Man watches the patient’s torso turn and maintains manual support of the head, rotating it exactly with the torso:
⦁ C-Man at the patient’s legs assists with rotation of the patient’s torso and takes the weight of the patient’s pelvis, again watching the torso. The patient’s lower legs roll onto B-Man’s lower foot to prevent pelvic drooping.

Step 3
⦁ The A-Man directs the B- and C-Man to reposition to complete the log roll.  When in proper position, and under the direction of the A-Man, the log roll is completed by carefully rolling the athlete to a supine position;
⦁ A-Man watches the patient’s torso turn and maintains manual support of the head, rotating it exactly with the torso;
⦁ C-Man at the patient’s legs assists with rotation of the patient’s torso and takes the weight of the patient’s pelvis, again watching the torso. The patient’s lower legs roll onto B-Man’s lower foot to prevent pelvic drooping.
⦁ D-Man facilitates the efforts of the B- and C-Man by carefully pushing the patient into proper position;
⦁ Upon completion of the log roll, the A-Man positions the patient into cervical neutral position, unless otherwise contraindicated.

2-Person Log Roll

A-Man
⦁ Inform and reassure the conscious and alert patient about the use of the scoop stretcher and what they can expect to experience during the process;
⦁ Maintain manual head stabilization until full immobilization is achieved;
⦁ Watches the torso turn and maintains neutral in-line support of the head, rotating it exactly with the torso.

B-Man
⦁ Clear the area of any extraneous objects or medical equipment;
⦁ If the protective athletic equipment remains in place, utilize pack-n-fill towels to maintain cervical neutral alignment;
⦁ If the protective athletic equipment has been removed, a c-collar will be placed on the patient and padding will be placed under head of patient as needed;
⦁ Kneels at the patient’s mid-torso on the side to which the patient is to be log rolled. The patient’s legs are tied together and the knees bent up to a 90º angle;
⦁ The patient’s arms are extended beside their torso with their palms facing inwards;
⦁ Grasps the far side of the patient at the shoulder;
⦁ Grasp lower arm grasps the patient’s hip just distal of the wrist and runs their arm along the patients upper legs which will help assist with the log roll;
⦁ Position patient’s lower foot so that on log rolling the patient, the patients knees will rest of B-Man’s foot to reduce the patient’s pelvis drooping;
⦁ Carefully log roll patient until they are at right angles to the ground;
⦁ As the B-Man at the patient’s torso will bear most of the patient’s weight during the log roll the B-Man is in charge and sets the pace;
⦁ A folded blanket running the length of the patient’s posterior body (head to feet) can be placed against the patient to improve comfort after the patient is laid back on the spine board.  This will also assist in removing the patient from the spine board;
⦁ Slide the spine board in against the patient’s back and elevate the side of the spine board furthest from the patient at a 45º angle towards the patient’s back. Align the patient’s shoulders level with the shoulder markings on the spine board;
⦁ Lower the patient and elevated side of the spine board down onto the ground together, with the spine board assisting to maintain alignment of the patient, again with B-Man at the patient’s torso setting the pace. The spine board, therefore, acts a body splint for lowering the patient;
⦁ Straighten out the patient’s knees;
⦁ Apply appropriate padding under the patient’s head and lumbar spine to maintain proper alignment of the patient’s spinal column and to improve comfort;
⦁ Immobilize the patient on the spine board.

©Sports Medicine Concepts, Inc.  All Rights Reserved.

 

SMC’s PROGRESSIVE SPINE INJURY ASSESSMENT

SMC Progressive Spine Injury Assessment Algorithm

OVERVIEW
The leading cause of spinal cord injury in athletics is axial loading brought about by spearing, or the using the top of the head to initiate contact. Although spearing is illegal in all sports, at every level, spearing remains prevalent in collision sports, either through the conscious decision to butt of spear another player, or due to a subconscious protective mechanism, or poor tackling technique. Though it is impossible to eliminate all axial loading conditions from collision sports, the medical team will attempt to reduce the incidence of conscious use of the head by counseling those athletes observed to repeatedly use their head to initiate contact to modify their play style. Athlete’s observed to have dangerous tackling techniques may be provided instruction in various safe tackling techniques such as the HUTT™ technique.

Management
Whenever the medical team is called to respond to an injury, the priority will always be to first care and provide support for the injured athlete’s Cardiac, Airway, Breathing, and Neurological needs, or what are referred to as the Primary Objectives™. The process of initial care and management of an injured athlete’s Primary Objectives™ may begin with establishing control of the injury scene. Gaining control of the injury scene may involve ensuring that non-EAP personnel are strictly prohibited from entering the injury scene or otherwise interfering with medical team efforts. The medical team’s Critical Care Triangle™ may secure the safety of the athlete by placing one hand on the mid thorax, and another on the head. This serves to comfort the athlete and reduce the risk of secondary injury due to untimely movement due to over excitement or from altered mental status. Initial scene and athlete security is accomplished with the athlete remaining in the position they are found.

Once an injured athlete has been properly secured, the medical team may conduct a thorough acute injury assessment, beginning with cardiac, airway, and breathing (CAB) status. Fortunately, the majority of injured athletes will not have issues pertaining to cardiac, airway, and breathing complications. However, after determining that CAB are without issue, an injured athlete’s neurological status may remain in question. Instances involving prolonged unconsciousness or altered mental status make it impossible for the medical team to medically clear an athlete of neurological injury, and thus may result in activation of EMS to transport the injured athlete to the nearest appropriate medical receiving facility. Athletes who present with no issues pertaining to CAB, or mental status changes, but who have demonstrated or expressed a mechanism of injury associated with injury to the spine may be medically evaluated to determine if transport is indicated.

On-field medical evaluation of a potentially neurologically injured athlete may begin by first repositioning the injured athlete into cervical neutral position, unless otherwise contraindicated by the presence of increased onset of neurological signs and symptoms, physical resistance to movement, or athlete apprehension with being moved. If repositioning to cervical neutral position is contraindicated, the medical team may activate EMS and transport the athlete to the nearest appropriate medical facility using the medical team’s package and transport protocol.

Repositioning a potentially neurologically injured athlete found in the prone position may require a log roll or log roll-push maneuver. The medical team may determine the most appropriate repositioning maneuver to employ based on the injury conditions presented at the time of injury. Once the athlete is in cervical neutral position, the medical team may medically evaluate the athlete’s neurological status using Sports Medicine Concepts’ Progressive Spine Injury Assessment Algorithm or similar assessment battery that is based on accepted pre-hospital clinical clearance criteria.

The SMC Progressive Spine Injury Assessment Algorithm begins with a subjective inquiry of the athlete’s perceived level and location of neck pain, and the presence of neurological signs and symptoms, including burning, numbness, tingling, and/or radicular signs and symptoms. If the athlete presents with midline cervical pain or bi-lateral subjective neurological signs and symptoms, the medical team may activate EMS, prepare to provide on-going assessment and care for the athlete’s vitals, and transport the injured athlete to the nearest appropriate medical receiving facility. In the presence of unilateral signs and symptoms resulting from lateral bending of the neck with depression of the shoulder, the medical team may consider injury to the brachial plexus. However, the team should remain cognizant of the fact that brachial plexus injuries follow a textbook pattern of mechanism of injury and unilateral symptomatology that does not involve midline cervical pain or point tenderness, or an axial load mechanism of injury. Although it is conceivable to have simultaneous bi-lateral injury to the brachial plexus, it is not likely and is overshadowed by the potential for spinal cord injury.

Athletes who do not complain of midline neck pain or bi-lateral subjective neurological signs and symptoms may be further evaluated through palpation to assess for the presence of midline point tenderness, pain, muscle guarding/spasm, or any obvious deformity. Should the neck examination discover any of these signs and symptoms, the medical team may activate EMS, prepare to provide on-going assessment and care for the athlete’s vitals, and transport the injured athlete to the nearest appropriate medical receiving facility using the medical team’s package and transport protocol.
For athletes who clear the medical team’s neck exam, the medical team may next conduct a modified upper and lower neurological screen. A full upper and lower neurological screen may be contraindicated at this point due to the movement required to complete these tests. Simply conducting bi-lateral myotome and dermatome assessments through grip-strength, plantar flexion, dorsi-flexion and sensation evaluation provides adequate assessment for determining the need for transport. Should the neurological screen identify any deficits, the medical team may activate EMS, prepare to provide on-going assessment and care for the athlete’s vitals, and transport the injured athlete to the nearest appropriate medical receiving facility using the medical team’s package and transport protocol.

Athletes who clear the medical team’s neurological screen may be permitted to complete isometric muscle contractions in all planes of movement. This is accomplished under the direction of the medical team’s instructions to the athlete to only apply enough muscle force to show evidence of muscle contraction. Should the athlete express apprehension about completing the isometric neck examine or if the examination results in onset of signs and symptoms, the medical team may reposition to midline, activate EMS, prepare to provide on-going assessment and care for the athlete’s vitals, and transport the injured athlete to the nearest appropriate medical receiving facility using the medical team’s package and transport protocol..

Athletes who clear the medical team’s isometric neck assessment may be permitted to complete active range of motion in all planes. Should the athlete express apprehension about completing the improvements or if the movement results in onset of signs and symptoms, the medical team may reposition the athlete to cervical neutral, activate EMS, prepare to provide on-going assessment and care for the athlete’s vitals, and transport the injured athlete to the nearest appropriate medical receiving facility using the medical team’s package and transport protocol..

Athletes who clear the medical team’s active range of motion examination may be permitted to assume a seated position with the aid of the medical team. Should the athlete express apprehension about sitting up or if sitting up results in onset of signs and symptoms, the medical team may reposition to supine with the neck in neutral position, activate EMS, prepare to provide on-going assessment and care for the athlete’s vitals, and transport the injured athlete to the nearest appropriate medical receiving facility using the medical team’s package and transport protocol.

With the athlete in the seated position, the medical team may reassess active range of motion in the seated position. Should the athlete express apprehension about completing seated active range of motion tests or if sitting up results in onset of signs and symptoms, the medical team may reposition to supine with the neck in neutral cervical position, activate EMS, prepare to provide on-going assessment and care for the athlete’s vitals, and transport the injured athlete to the nearest appropriate medical receiving facility using the medical team’s package and transport protocol.

For athletes who clear the seated active range of motion tests, the medical team may conduct a cervical axial load compression test. Should the athlete express apprehension about the completion of a compression test or if the compression test is positive, the medical team may reposition to supine with the neck in cervical neutral position, activate EMS, prepare to provide on-going assessment and care for the athlete’s vitals, and transport the injured athlete to the nearest appropriate medical receiving facility using the medical team’s package and transport protocol.

Athletes who clear the compression test may be permitted to assume a standing position and be escorted to the sideline for further medical evaluation.

Readiness Supplies

Basic Life Support Supplies
● AED
● BLS airway adjuncts
● Hear rate monitor
● Blood pressure monitor
● Pulse oximeter

Protocol Specific Readiness Supplies:
▪ Heart rate monitor
▪ Blood pressure monitor
▪ Pulse Oximeter

© Sports Medicine Concepts, Inc.  All Rights Reserved.

EQUIPMENT REMOVAL

OVERVIEW

There is a growing body of evidence-based literature examining the effectiveness of various s equipment removal techniques as well as the appropriate timing of equipment removal from an athlete requiring transport to an appropriate medical facility.  Currently, there is no evidence to suggest that any one removal technique is safer than another.  Nor is there sufficient evidence to suggest the most appropriate time to remove equipment from an injured athlete.  Expert opinion is varied on the subject of equipment removal technique and timing as well.  The reason for such inconclusive evidence and varied expert opinion is likely due to the unpredictable nature of managing injury in the pre-hospital care environment.  Unpredictable factors such as weather conditions, protective equipment variations, and patient sequelae weigh heavily on pre-hospital management.  The mediating factor in all this variation, however, is that the medical team must always provide for the safest handling of the athlete.  This means that the medical team must have the psychomotor skills required to carry out all the various equipment removal techniques while having a firm cognitive understanding of when each techniques is most appropriate.  The appropriateness and timing of equipment removal cannot be dictated by an equipment removal protocol that relies on a single technique for all conditions..  Rather, a best-practice equipment removal protocol will rely on the decision of the medical team to employ the technique that provides for the safest handling of an injured athlete given the current condition.

There are three common conditions during which the medical team will be required to remove protective athletic equipment from an athlete.  The first condition is during a non-life-threatening injury scenario involving an athlete with stable vital signs and no neurological sequalae for whom the medical team has elected to transport to an appropriate medical facility for further evaluation.  The second condition is during management of a non-life-threatening injury scenario involving an athlete who presents with neurological sequalae, but who is otherwise stable.  The third condition is during a life-threatening emergency during which advanced cardiac life support and/or other critical care tasks may be required.

Non-Life-Threatening Equipment Removal

During a non-life-threatening injury scenario there are three leading philosophical approaches to equipment removal.  A point, counterpoint review of each approach is provided below.  These points shall be considered regularly as part of the annual review of safe handling practices.

Trauma Naked Approach

This approach involves removing all equipment on the field prior to transfer and transport.

  • Point 1:  Proponents of on-field equipment removal feel that immediately removing equipment from a potentially seriously injured athlete facilitates safe handling by facilitating repositioning and transfer techniques while also providing immediate and complete access to the athlete in the event that critical care tasks need to be completed at any point throughout the continuum of care.

Counterpoint: In a stable non-life-threatening situation properly fitted equipment facilities safe handling by aiding in maintaining immobilization during repositioning and transfer techniques.  In the event that the athlete’s condition changes, equipment can be removed quickly enough to provide any necessary critical care tasks.

  • Point 2: Proponents of this approach feel that the equipment should be removed by those with the most experience with equipment removal techniques.

Counterpoint: Most prehospital care providers have no specific training in athletic equipment removal techniques.  Athletic trainers are not experts simply because of their credential.  Becoming proficient and remaining proficient in equipment removal techniques requires regular practice that most do not undertake.  The result is equipment removal that is not any more efficient than the different safe handling techniques used by emergency room personnel.  In addition, the grass or turf makes pulling the shoulder pads out from under the athlete more challenging during the flat-torso technique, relative to the flat surface of a spine board.  Finally, removing equipment while on the field is harder because the medical team is not in an ergonomically advantageous position, relative to the raised height of a gearnie or emergency room table.

Primary Objectives Approach

This approach involves dealing only with equipment that hinders care required to rapidly stabilize the athlete while on the playing surface with the goal of quickly transporting them from a very chaotic environment to a more controllable environment.  Proponents of this approach feel that safe handling is ultimately more effective when the athlete is in an environment that can be ultimately controlled.  The field of play has many distractions, including media, other players, coaches, parents, bystanders, and additional stresses associated with being in the public eye.  Typically, proponents of this philosophy will remove the face mask while leaving the jersey and shoulder pads intact prior to transport from the field.  Depending on the signs and symptoms present, medical teams may elect to remove the face mask to gain access to the airway, and cut the jersey and shoulder pads to provide access to the thorax, but leave the helmet and shoulder pads on the athlete during evacuation from the playing surface.  Some teams may elect to transport with the equipment in place or with it prepped, but still on the athlete, while others will ultimately remove all the protective athletic equipment prior to transport to an appropriate medical facility.  In any case proponents of this approach generally perform equipment removal procedures once the athlete has been removed from the field, is in the back of the ambulance, or is in the ED.

  • Point: Proponents of this approach will express that the ergonomics of removing equipment from a raised gurney is preferable to that of on-field removal.

Counterpoint: some transfer techniques, such as the scoop stretcher protocol, have been shown to be complicated by protective athletic equipment, field conditions, and with larger athletes.

ED Philosophy

Proponents of this philosophy generally believe that the emergency room is ultimately the most controlled environment, and ultimately the best place to remove equipment from the athlete.  Proponents of this philosophy will generally transport the athlete one of two ways.

  1. With the facemask removed;
  2. With the face mask removed and the chest exposed by prepping the jersey, shoulder pads, and undergarments.

Counterpoint: Proponents of this approach generally have large medical staffs, including athletic trainers, paramedics, physicians, trauma surgeons, etc.  They often have many more resources available to them that allow the medical team to provide a consistent high level of care throughout the entire continuum of care.  Proponents of this philosophy often will provide an experienced athletic trainer as an escort during transport, all EMS providers will are specifically trained, and a police escort may be provided to expedite transport to an appropriate medical facility.

Life-Threatening Injury Equipment Removal

During a life-threatening injury scenario there are two leading philosophical approaches to equipment removal.  A point, counterpoint review of each approach is provided below.  These points shall be considered regularly as part of the annual review of safe handling practices.

Trauma Naked Approach

Proponents of this philosophy will suggest that if there is a life-threatening condition, they prefer to begin management by removing all of the equipment.  These individuals believe that overall critical care task completion is facilitated with the prior removal of all equipment.  The belief is that the overall improved ability to more effectively administer advanced care throughout the entire continuum of care far outweighs the minimal delay in onset of critical care from first removing the equipment.

Counterpoint: Anecdotally, medical teams that are well practiced and have a choreographed plan for equipment removal can remove equipment from an athlete very quickly.  However, there is some literature to suggest that medical teams can initiate chest compressions and AED application sooner by leaving the helmet and shoulder pads in place, but cutting the jersey, shoulder pad strings, and straps, and cutting any undergarments to expose the chest.  Likewise, research indicates that the airway of an injured athlete can be accessed sooner by removing only the facemask to initiate airway management, relative to complete helmet removal or helmet and shoulder pad removal.

Primary Objective Philosophy

Proponents of the primary objectives philosophy will suggest that the expeditious care of cardiac, airway, and breathing complications is facilitated by only dealing with a particular piece of equipment that is a liability to the medical team’s immediate critical care objectives.  Proponents of this philosophy feel that it is better to leave the equipment in place unless it becomes a liability to the team’s immediate care objectives.  With this approach, complete equipment removal is reserved for after the athlete has been stabilized and is being transferred and prepared for transport.

Counterpoint:  As stated above, others believe that if the equipment is going to have to come off, it should be done so sooner than later to facilitate immediate care and care provided throughout the entire continuum.

Techniques

Face Mask Removal

FMxtractor® Face Mask Removal Video Demonstrations Library    
  Series begins with intro to the FMxtrator® functionality and proceeds through face mask removal techniques for all the various helmets and attachment systems presently in use.
     

In accordance with current practice standards, the  medical staff employs the Combo-Tool Approach to face mask removal when face mask removal is required to provide emergent or non-emergent access to an injured patient’s airway.

Small, low voltage hand held power screwdrivers (PSD) are used to reduce the risk of stripping face mask hardware screws.  The directional buttons of all PSDs are locked and taped in the reverse direction to avoid accidentally tightening helmet hardware to reduce the risk of accidentally tightening or stripping hardware.  A phillips style screw driver bit is glued into the end-effector of all PSDs to avoid having them fall out and lost while being stored in emergency kits.  PSDs are taken out of all emergency kits following each and every event, and are plugged in to ensure they are fully charged.  Each PSD is tested for proper function prior to being packed for event use.  FMx3 functionality is checked prior to each event and the blade lubricated with a silicone based lubricant before each event.

If face mask removal is delayed or complicated to the point of disrupting completion of other primary objective critical care tasks, the A-Man or designated code runner will direct the team to initiate the helmet removal protocol.  Generally, the criteria to abort the face mask removal procedures and initiate the helmet removal protocol is met if face mask removal cannot be completed prior to the start of the second cycle of CPR, or approximately 2 min.  The A-Man or designated code runner will ultimately determine the appropriateness of helmet vs. face mask removal on a case by case basis.

A-Man

  • Begin with the patient pack-n-filled in cervical neutral,
  • Inform and reassure the conscious and alert patient about the use of the various tools that will be used to remove the face mask from the patient’s helmet, and what they can expect to experience during the process;
  • Instruct the conscious and alert patient to close their eyes to avoid injury from fastener remnants and/or fastener hardware that may fall through the face mask during the removal process;
  • Assure that the unconscious athlete’s cardiac needs have been assessed and are actively being supported;
  • Maintain in-line stabilization, being sure to hold in-line stabilization with enough force to counteract external forces resulting from face mask removal procedures;
  • Continue to monitor and assess the patient’s level of consciousness and vital signs;
  • If face mask removal is delayed or complicated to the point of disrupting completion of critical care tasks, the A-Man shall direct the team to initiate the helmet removal protocol.  Generally, the criteria to abort the face mask removal procedures and initiate the helmet removal protocol is met if face mask removal cannot be completed prior to the start of the second cycle of CPR, or approximately 2 min.  The A-Man or other code runner will ultimately determine the appropriateness of helmet vs. face mask removal on a case by case basis.

B- and C-Man

  • Provide appropriate on-going assessment and support of the patient’s cardiac needs;
  • Continue to monitor and assess the patient’s level of consciousness and vital signs;
  • Initiate face mask removal on their respective sides by pushing the release button on the Riddell Quick-Release push-pins using the Riddell Quick-Release Tool or the appropriate FMx3 end-effector for Riddell face masks secured to helmets using the Riddell Quick Release hardware.  Use a standard or phillips screwdriver or appropriate FMx3 end-effector to turn the screw portion of Schutt Quarter-Turn Release push-pin on Schutt face masks secured to helmets using the Schutt Quarter-Turn hardware.  Use power screwdrivers on their respective sides to remove hardware systems using screws;
  • In the event of hardware system failure, use the FMx3 to cut the face mask fasteners to release the face mask from the helmet.

Helmet Removal

Removal Technique Review Videos for Various Modern Helmets

Riddell SpeedFlex    
   
 

Conditions which may warrant removal of the football helmet from an athlete may include, but are not limited to:

  1. Inability to gain access to the injured athlete’s airway with face mask removal;
  2. Inability to perform sufficient injury assessment;
  3. Desire to have access to stable or unstable athlete during transport.

When it is determined that the football helmet should be removed from an athlete, the following removal procedure shall be followed:

  1. The A-Man shall maintain in-line stabilization of the head and neck;
  2. The B- and/or C-Man shall prepare the helmet for removal by cutting the chin-strap and removing the mouth guard. In some helmet models removal of cheek pads, and deflation of air bladders may facilitate helmet removal.  In the event that the B- and C-Man are occupied with completion of other critical care tasks, extended members of the Critical Care Triangle™(CCT) shall be directed to prepare the helmet for removal.
  3. The B- or C-Man shall take control of and maintain in-line stabilization of the athlete’s head and neck by reaching in from the side to wrap hands around the neck such that the thumbs run along the mandible, coming to rest at the temporal-mandibular joint, while the fingers interlock to support the cervical spine posteriorly. Extended members of the CCT may be assigned this task in the event that B- and C-Man are completing other necessary critical care tasks.
  4. Upon securing in-line stabilization B- or C-Man shall iterate to the A-Man that they have sufficient control of in-line stabilization, upon which the B- or C-Man shall count “1-2-3, Release” to officially take control of the in-line stabilization from the A-Man.
  5. The A-Man will begin the helmet removal process by first removing all pack-n-fill towels used to maintain cervical neutral position;
  6. The A-Man will the begin helmet removal by slightly spreading the helmet at the earholes, then will carefully begin pulling the helmet from the athlete until the athlete’s ears are just about to clear the helmet cheek pads, at which point the A-Man shall pause helmet removal;
  7. The A-Man shall next iterate to the team member providing stabilization that the athlete’s ear are about to clear the helmet cheek pads and that helmet removal will resume on the count of “1-2-3, Remove”. This allows the team member providing in-line stabilization ample time to prepare to mediate a rebound force often observed to cause significant movement of the cervical spine when the helmet cheek pads slide over the athlete’s ears during football helmet removal.  Upon the “1-2-3, Remove” command, the A-Man shall resume extraction of the helmet by pulling the helmet while tipping the helmet slightly forward to clear the occiput posteriorly, but being careful to not hit the athlete’s nose when the face mask is still in place.
  8. Once the football helmet has been removed the A-Man shall pack-n-fill the athlete in cervical neutral position and then retake control of in-line stabilization by placing arms along the lateral aspect of the athlete’s head and placing the web space of hands on the athlete’s traps bilaterally with the thumbs on the collar bone, thus securing the head and neck to the torso.
  9. The A-Man shall iterate to the team member presently maintaining in-line stabilization that they properly positioned and are ready to re-take control of in-line stabilization, at which time the A-Man shall count “1-2-3, Release”. The A-Man shall now have control of in-line stabilization.
  10. The CCT will then resume prudent on-going assessment, care, and support of the athlete’s vital signs.

Removal Technique Review Videos for Various Modern Helmets

Helmet and Shoulder Pad Removal

The need to assess status of respiration;Conditions which may warrant removal of both the football helmet and shoulder pads from an athlete may include, but are not limited to:

  1. The need to assess effectiveness of ventilation;
  2. The need to perform CPR;
  3. Proper placement of defibrillator pads;
  4. Inability to perform necessary injury assessment;
  5. The need to perform critical care tasks associated with internal injury
  6. Desire to have access to stable or unstable athlete during transport.

When it is determined that the football helmet and shoulder pads should be removed should be removed from an athlete, the following removal procedures shall be considered:

Flat-Torso Technique

  1. The A-Man shall maintain in-line stabilization of the head and neck;
  2. The B- and/or C-Man shall prepare the helmet for removal by cutting the chin-strap and removing the mouth guard. In some helmet models removal of cheek pads, and deflation of air bladders may facilitate helmet removal.  In the event that the B- and C-Man are occupied with completion of other critical care tasks, extended members of the Critical Care Triangle™(CCT) shall be directed to prepare the helmet and shoulder pads for removal.
  3. The B- and/or C-Man shall prepare the shoulder pads for removal by first cutting the athlete’s jersey with heavy-duty bandage shears, beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs.
  4. Next, in order to reduce the potential onset of a rebound force caused by the release of elastic tension in the shoulder pads straps upon cutting the breast plate strings, the B- and/or C-Man shall cut the shoulder pad elastic straps BEFORE cutting the laces and/or breast plates. In some instances, shoulder pads secured anteriorly with thick plastic plates may be removed without first cutting the plastic breast plate.  This option is more likely in smaller athletes and less likely with larger athletes.  The medical team will be able to assess this option upon observation of shoulder pad fit once the jersey, straps, and strings have been cut.
  5. Next, the B- or C-Man shall cut the athlete’s undergarments with heavy-duty bandage shears by beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs to expose the chest.
  6. The B- or C-Man shall take control of and maintain in-line stabilization of the athlete’s head and neck by reaching in from the side to wrap hands around the neck such that the thumbs run along the mandible, coming to rest at the temporal-mandibular joint, while the fingers interlock to support the cervical spine posteriorly. Extended members of the CCT may be assigned this task in the event that B- and C-Man are completing other necessary critical care tasks.
  7. Upon securing in-line stabilization B- or C-Man shall iterate to the A-Man that they have sufficient control of in-line stabilization, upon which the B- or C-Man shall count “1-2-3, Release” to officially take control of the in-line stabilization from the A-Man.
  8. The A-Man will begin the helmet removal process by first removing all pack-n-fill towels used to maintain cervical neutral position;
  9. The A-Man will the begin helmet removal by slightly spreading the helmet at the ear holes, then will carefully begin pulling the helmet from the athlete until the athlete’s ears are just about to clear the helmet cheek pads, at which point the A-Man shall pause helmet removal;
  10. The A-Man shall next iterate to the team member providing stabilization that the athlete’s ear are about to clear the helmet cheek pads and that helmet removal will resume on the count of “1-2-3, Remove”. This allows the team member providing in-line stabilization ample time to prepare to mediate a rebound force often observed to cause significant movement of the cervical spine when the helmet cheek pads slide over the athlete’s ears during football helmet removal.  Upon the “1-2-3, Remove” command, the A-Man shall resume extraction of the helmet by pulling the helmet while tipping the helmet slightly forward to clear the occiput posteriorly, but being careful to not hit the athlete’s nose when the face mask is still in place.
  11. Once the football helmet has been removed the A-Man shall grasp the shoulder pads and gently pull them from under the athlete. The medical team may elect to perform a torso-lift or flat-lift technique to ease shoulder pad removal.  The medical team may elect to have extended members of the CCT aid in shoulder pad removal by grasping the shoulder pads on either side of the athlete.
  12. Once the football helmet and shoulder pads have been removed the A-Man shall pack-n-fill the athlete in cervical neutral position and then retake control of in-line stabilization by placing arms along the lateral aspect of the athlete’s head and placing the web space of hands on the athlete’s traps bilaterally with the thumbs on the collar bone, thus securing the head and neck to the torso.
  13. The A-Man shall iterate to the team member presently maintaining in-line stabilization that they properly positioned and are ready to re-take control of in-line stabilization, at which time the A-Man shall count “1-2-3, Release”. The A-Man shall now have control of in-line stabilization.
  14. The CCT will then resume prudent on-going assessment, care, and support of the athlete’s vital signs.

Torso-Lift Technique

  1. The A-Man shall maintain in-line stabilization of the head and neck;
  2. The B- and/or C-Man shall prepare the helmet for removal by cutting the chin-strap and removing the mouth guard. In some helmet models removal of cheek pads, and deflation of air bladders may facilitate helmet removal.  In the event that the B- and C-Man are occupied with completion of other critical care tasks, extended members of the Critical Care Triangle™(CCT) shall be directed to prepare the helmet and shoulder pads for removal.
  3. The B- and/or C-Man shall prepare the shoulder pads for removal by first cutting the athlete’s jersey with heavy-duty bandage shears, beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs.
  4. Next, in order to reduce the potential onset of a rebound force caused by the release of elastic tension in the shoulder pads straps upon cutting the breast plate strings, the B- and/or C-Man shall cut the shoulder pad elastic straps BEFORE cutting the laces and/or breast plates. In some instances, shoulder pads secured anteriorly with thick plastic plates may be removed without first cutting the plastic breast plate.  This option is more likely in smaller athletes and less likely with larger athletes.  The medical team will be able to assess this option upon observation of shoulder pad fit once the jersey, straps, and strings have been cut.
  5. Next, the B- or C-Man shall cut the athlete’s undergarments with heavy-duty bandage shears by beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs to expose the chest.
  6. The B- or C-Man shall take control of and maintain in-line stabilization of the athlete’s head and neck by reaching in from the side to wrap hands around the neck such that the thumbs run along the mandible, coming to rest at the temporal-mandibular joint, while the fingers interlock to support the cervical spine posteriorly. Extended members of the CCT may be assigned this task in the event that B- and C-Man are completing other necessary critical care tasks.
  7. Upon securing in-line stabilization B- or C-Man shall iterate to the A-Man that they have sufficient control of in-line stabilization, upon which the B- or C-Man shall count “1-2-3, Release” to officially take control of the in-line stabilization from the A-Man.
  8. The A-Man will begin the helmet removal process by first removing all pack-n-fill towels used to maintain cervical neutral position;
  9. The A-Man will the begin helmet removal by slightly spreading the helmet at the ear holes, then will carefully begin pulling the helmet from the athlete until the athlete’s ears are just about to clear the helmet cheek pads, at which point the A-Man shall pause helmet removal;
  10. The A-Man shall next iterate to the team member providing stabilization that the athlete’s ear are about to clear the helmet cheek pads and that helmet removal will resume on the count of “1-2-3, Remove”. This allows the team member providing in-line stabilization ample time to prepare to mediate a rebound force often observed to cause significant movement of the cervical spine when the helmet cheek pads slide over the athlete’s ears during football helmet removal.  Upon the “1-2-3, Remove” command, the A-Man shall resume extraction of the helmet by pulling the helmet while tipping the helmet slightly forward to clear the occiput posteriorly, but being careful to not hit the athlete’s nose when the face mask is still in place.
  11. Once the football helmet has been removed, an additional responder, or D-Man shall assume the position vacated by the team member who is presently responsible for stabilization.  The D-Man, together with the remaining B- or C-man shall position themselves at each shoulder of the athlete, and place their hands between the athlete’s shoulders and the shoulder pads.  Upon the A-Man command, the responders at the athlete’s shoulders gently lift the athlete to elevate the torso 30º to 40º by bending the athlete at the waist.  The pads are then removed by the A-Man.
  12. After the pads are removed, the A-Man directs the team to lower the athlete to the supine position where the A-Man re-assumes control of the head and neck.  Transfer of stabilization is again done by a “1-2-3 release” command given by the A-Man.  The A-Man then repositions the athlete to cervical neutral position.

Ancillary Content

Current Trends in Equipment Removal White Paper Sessions

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TRANSFER and IMMOBILIZATION TECHNIQUES

Spinal Immobilization vs. Spinal Motion Restriction
Spinal immobilization and spinal motion restriction both relate to preventing movement of the spine.  Spinal immobilization involves the use of cervical immobilization devices such as cervical collars and spine boards to minimize movement of the spine.  Conversely, spinal motion restriction refers to maintaining anatomical alignment of the spine and minimizing movement without the use of such cervical immobilization devices.

Though a long standing practice, the benefit of spinal immobilization in most trauma patients is unproven.  Recent literature indicates that spinal immobilization may actually harm some patients, resulting in agitation, pain, increased radiography, pressure sores, tissue ischemia, aspiration and respiratory compromise. Studies have also suggested that there is no significant difference in movement within the spinal column when comparing patients immobilized to a backboard versus those who were placed on a gurney. Thus, the criteria for the application of spinal precautions though unproven but generally accepted and prudent, should continue to be updated to follow validated, evidence-based indications.1  However, most experts participating in Sports Medicine Concepts’ In 2Min or Less!® sports emergency care curriculum prefer traditional spine immobilization using a cervical collar and spine board when transporting a potentially neurologically injured athlete.  Most experts express that the complications found to be associated with use of spinal immobilization using a spine board result from prolonged immobilization, and that spinal immobilization of patients presenting with mid-line cervical pain, neurological signs and symptoms, or apprehension secondary to an axial load mechanism of injury is warranted in management the neurologically unstable athlete.  Evidence Category C. 

Therefore, spinal immobilization will be considered for patients that have sustained blunt trauma through a high-energy or axial load injury mechanism and present with any of the following:

  • Altered level of consciousness
  • Drug or alcohol intoxication
  • Inability to communicate
  • Spinal column pain and/or tenderness
  • Neurologic complaints (e.g., numbness or motor weakness)
  • Anatomic deformity of the spine
  • Distracting injury (injuries so severely painful that neck examination is unreliable, [e.g., severe thoracic trauma, long bone fractures, crush injuries, large burns])

For these athlete, a cervical collar will be applied and the athlete immobilized to a spine board. 

Spinal motion restriction will be considered when athletes meet NEXUS exclusionary criteria.2

Transferring to a Spine Board
Transferring an athlete to a spine board may be required in order to immobilize an athlete to protect against secondary injury or to facilitate transport to an appropriate medical facility.  The medical team recognizes that there are various accepted techniques employed to transfer an injured athlete to rigid support.  When transfer to rigid support is indicated, The will decide which transfer technique is most appropriate based on the team’s expert opinion of how best to utilize existing emergency response equipment and personnel to meet the team’s Primary Objectives™ established for each unique injury management scenario.

In all transfer techniques the task is completed under the direction of the A-Man.  The A-Man’s primary responsibilities include:

  • Maintain manual head stabilization until full immobilization to the long spine board (LSB) is achieved;
  • Directs the log roll maneuver;
  • Watches the torso turn and maintains neutral in-line support of the head, rotating it exactly with the torso;
  • Positions the patient in cervical neutral position and directs B- and C-Man to pack-n-fill as required to maintain proper neutral position.

Upon completion of any transfer technique, the medical team will likely need to utilize a V-Slide technique to properly position the athlete on the LSB.

A variation of the flat-log techniques described blow would involve log rolling the patient to 45º while the LSB is slid in against the ground with the back of the LSB resting on the thighs of B- and C-Man.  Once in position, A-Man directs the medical team to lower the athlete onto the LSB, then lower the LSB to the ground.

The various techniques that the medical team may elect to employ to transfer an injured athlete to rigid support are outlined below:

From Supine

5-Person Log Roll-Push

A-Man

  • Maintain manual head stabilization until full immobilization to the long spine board (LSB) is achieved;
  • Directs the log roll maneuver;
  • Watches the torso turn and maintains neutral in-line support of the head, rotating it exactly with the torso;
  • Positions the patient in cervical neutral position and directs B- and C-Man to pack-n-fill as required to maintain proper neutral position.

Step 1

  • B- and C-Man clear the area of any extraneous objects or medical equipment;
  • If the protective athletic equipment remains in place, B- and C-Man utilize pack-n-fill towels to maintain cervical neutral alignment;
  • If the protective athletic equipment has been removed, B- will apply a c-collar on the patient and provide pack-n-fill padding as required to support cervical neutral position;
  • B-Man kneels at the patient’s mid-torso, straightens the patient’s arms with the patient’s palms facing in next to the torso. Palm-out may result in elbow joint damage during the roll;
  • B-Man then grasps the far side of the patient at the shoulder and just above the elbow;
  • C-Man kneels next to B-Man and grasps the patient just above the elbow, crossing over the B-Mans arm;
  • C-Man’s lower hand grasps the patient at the mid-thigh;
  • C-Man places their lower foot up against the patient’s legs, just below the knees for the patient’s lower legs to roll onto during the log roll, to prevent the patient’s pelvis drooping;
  • D-Man kneels next to C-Man and grasps the patient’s mid-thigh with their upper hand by crossing over the C-Man’s arms;
  • D-Man grasps the patient with their lower hand at the ankles;
  • E-Man kneels on the opposite side of the patient at the patient’s pelvic level;
  • E-Man’s upper hand is placed on the patient’s upper arm and the lower hand is placed on the patient’s upper leg.

Step 2

  • Under the direction of the A-Man, the patient is carefully log rolled until at a right angle to the ground;
  • A-Man watches the patient’s torso turn and maintains manual support of the head, rotating it exactly with the torso:
  • C-Man at the patient’s legs assists with rotation of the patient’s torso and takes the weight of the patient’s pelvis, again watching the torso. The patient’s lower legs roll onto B-Man’s lower foot to prevent pelvic drooping.
  • D-Man facilitates the efforts of the B- and C-Man by carefully pushing the patient into proper position.

Step 3:  If appropriate, a folded blanket running the length of the patient’s posterior body (head to feet) can be placed against the patient to improve comfort after the patient is laid back on the LSB.  This will also assist in the later removal of the patient off the LSB.

Step 4:  E-Man slides the LSB in against the ground with the edge of the LSB towards the patient’s back. Align the patient’s shoulders level with the shoulder markings on the LSB.

Step 5:  Lower the patient onto the LSB, again with A-Man setting the pace.

Step 6:  Keeping the patient in the neutral in-line position, use a v-slide to gently adjust the patient’s position sideways so that the patient is centered on the LSB.

Step 7:  Apply appropriate padding under the patient’s head and lumbar spine to maintain proper alignment of the spinal column and for comfort;
Immobilize the patient onto the LSB for transport.

4-Person Log Roll-Push

A-Man

  • Prepare to log roll the patient in the direction opposite the patient’s face by assuming a start position with the A-Man’s inside knee positioned at the patient’s lower shoulder;
  • Place hands on head/helmet with the palms together and thumbs down, and the arm corresponding to the direction of the log roll on top such that the A-Man’s arms are twisted at initiation of the log roll and untwist during the maneuver;
  • Maintain manual head stabilization until full immobilization to the long spine board (LSB) is achieved;
  • Directs the log roll maneuver;
  • Watches the torso turn and maintains neutral in-line support of the head, rotating it exactly with the torso;
  • Positions the patient in cervical neutral position and directs B- and C-Man to pack-n-fill as required to maintain proper neutral position.

Step 1

  • B- and C-Man clear the area of any extraneous objects or medical equipment;
  • If the protective athletic equipment remains in place, B- and C-Man utilize pack-n-fill towels to maintain cervical neutral alignment;
  • If the protective athletic equipment has been removed, B- will apply a c-collar on the patient and provide pack-n-fill padding as required to support cervical neutral position;
  • B-Man kneels at the patient’s mid-torso, straightens the patient’s arms with the patient’s palms facing in next to the torso. Palm-out may result in elbow joint damage during the roll;
  • B-Man then grasps the far side of the patient at the shoulder and just above the elbow;
  • C-Man kneels next to B-Man and grasps the patient’s pelvic bone;
  • C-Man’s lower hand grasps at the ankles.
  • C-Man places their lower foot up against the patient’s legs, just below the knees for the patient’s lower legs to roll onto during the log roll, to prevent the patient’s pelvis drooping;

Step 2

  • Under the direction of the A-Man, the patient is carefully log rolled until at a right angle to the ground;
  • A-Man watches the patient’s torso turn and maintains manual support of the head, rotating it exactly with the torso:
  • C-Man at the patient’s legs assists with rotation of the patient’s torso and takes the weight of the patient’s pelvis, again watching the torso. The patient’s lower legs roll onto B-Man’s lower foot to prevent pelvic drooping.

Step 3:  If appropriate, a folded blanket running the length of the patient’s posterior body (head to feet) can be placed against the patient to improve comfort after the patient is laid back on the LSB.  This will also assist in the later removal of the patient off the LSB.

Step 4:  D-Man slides the LSB in against the ground with the edge of the LSB towards the patient’s back. Align the patient’s shoulders level with the shoulder markings on the LSB.

Step 5:  Lower the patient onto the LSB, again with A-Man setting the pace.

Step 6:  Keeping the patient in the neutral in-line position, use a v-slide to gently adjust the patient’s position sideways so that the patient is centered on the LSB.

Step 7:  Apply appropriate padding under the patient’s head and lumbar spine to maintain proper alignment of the spinal column and for comfort;
Immobilize the patient onto the LSB for transport.

2-Person Log Roll

A-Man

  • Inform and reassure the conscious and alert patient about the use of the scoop stretcher and what they can expect to experience during the process;
  • Maintain manual head stabilization until full immobilization is achieved;
  • Watches the torso turn and maintains neutral in-line support of the head, rotating it exactly with the torso.

B-Man

  • Clear the area of any extraneous objects or medical equipment;
  • If the protective athletic equipment remains in place, utilize pack-n-fill towels to maintain cervical neutral alignment;
  • If the protective athletic equipment has been removed, a c-collar will be placed on the patient and padding will be placed under head of patient as needed;
  • Kneels at the patient’s mid-torso on the side to which the patient is to be log rolled. The patient’s legs are tied together and the knees bent up to a 90º angle;
  • The patient’s arms are extended beside their torso with their palms facing inwards;
  • Grasps the far side of the patient at the shoulder;
  • Grasp lower arm grasps the patient’s hip just distal of the wrist and runs their arm along the patients upper legs which will help assist with the log roll;
  • Position patient’s lower foot so that on log rolling the patient, the patients knees will rest of B-Man’s foot to reduce the patient’s pelvis drooping;
  • Carefully log roll patient until they are at right angles to the ground;
  • As the B-Man at the patient’s torso will bear most of the patient’s weight during the log roll the B-Man is in charge and sets the pace;
  • A folded blanket running the length of the patient’s posterior body (head to feet) can be placed against the patient to improve comfort after the patient is laid back on the spine board.  This will also assist in removing the patient from the spine board;
  • Slide the spine board in against the patient’s back and elevate the side of the spine board furthest from the patient at a 45º angle towards the patient’s back. Align the patient’s shoulders level with the shoulder markings on the spine board;
  • Lower the patient and elevated side of the spine board down onto the ground together, with the spine board assisting to maintain alignment of the patient, again with B-Man at the patient’s torso setting the pace. The spine board, therefore, acts a body splint for lowering the patient;
  • Straighten out the patient’s knees;
  • Apply appropriate padding under the patient’s head and lumbar spine to maintain proper alignment of the patient’s spinal column and to improve comfort;
  • Immobilize the patient on the spine board.

6-Person Straddle Lift-Slide

Key Points

  • When lifting, each responder should rest their elbows on their legs to remove the strain from their backs;
  • If applying the LSB, the patient needs to be lifted only 5-6″ off the ground;
  • If using a Scoop or a thick LSB, the patient will need to be lifted slightly higher for the patient to clear the frame;
  • In this procedure, the responder’s limb closest to the patient’s head will be referred to as the responder’s upper limb, and the responder’s limb closest to the patient’s feet will be referred to as the responder’s lower limb.

Step 1: Place the LSB at the patient’s feet and in-line with the patient’s body so that the LSB can be slid under from the patient’s feet.  A-Man positions at the patient’s head and squats down on their knees.  A-Man positions at the patient’s head and squats down on their knees. Manual in-line stabilization of the patient’s head is performed by A-Man with elbows resting on their legs for stability.  A cervical collar is applied in the absence of protective athletic equipment. The manual in-line stabilization is maintained until full spine immobilization is achieved.  B- and C-Man straddle the patient’s torso. B- and C-Man pull the patient’s clothes at the shoulders firmly to the sides with their lower hands to allow their upper hand to easily slide under patients shoulders. DO NOT lift patient’s shoulder upward during this procedure. B- and C-Man’s upper elbow should rest on their upper thigh to avoid strain on the responder’s back during the lift.  B- and C-Man’s lower hand should be placed under the patient’s lumbar spine.  D- and E-Man straddle the patient on either side of the patient’s mid thigh. C- and D-Man pull the patient’s clothes at the patient’s bottom firmly sideways with lower hand to allow their upper hand to slide easily under patient’s bottom. DO NOT lift patients bottom upward. D- and E-Man’s upper elbow should rest on their upper thigh to avoid strain on their back during the lift.  F-Man is positioned above the patient’s head to slide the LSB into place.  Before inserting the LSB, F-Man insert a forearm airsplint on top of the LSB where the patient’s lumbar spine will be positioned.

Step 2:  With A-Man at the patient’s head in-charge, A-E-Man lift the patient only enough for F-Man to slide the LSB under the patient.

Step 3:  F-Man then slides the LSB underneath the patient.   The patient is then immobilized to the Board for transport.

4-Person Straddle-Lift- Slide

Key Points

  • When lifting keep the arms and back straight, and use your quadriceps to do the lift;
  • When applying the LSB, the patient needs to be lifted only 5″ off the ground;
  • If using a Scoop Stretcher or a thick LSB, the patient will need to be lifted slightly higher for the patient to clear the frame.

Step 1:  Place the LSB above the patient’s head and in-line with the patient’s body.   Alternatively, the LSB can be slid under from the patient’s foot end if access above the patient’s head is not possible. A-Man positions at the patient’s head and squats down on their knees with one leg on either side of the LSB so that the LSB can be slid through A-Man’s legs.  Manual in-line stabilization of the patient’s head is performed by A-Man with elbows resting on their legs for stability.   A Cervical Collar is also applied in the absence of protective athletic equipment. The Manual in-line stabilization is maintained until full spine immobilization is achieved.  B-Man 2 is positioned above the patient’s head to slide the LSB into place. Before inserting the LSB, E-Man should place a forearm airsplint on the LSB where the patient’s lumbar spine will be positioned.

Step 2:  C-Man straddles over the patient’s torso and faces side-on to the patient. C-Man then squats down and places their hands underneath the patient’s armpits. C-Man’s arms should rest on their inner legs with their back and arms kept straight. D-Man (at the same time as C-Man) straddles over the patient’s upper legs and faces the same way as C-Man. D-Man then squats down and places their hands underneath the patient’s bottom. D-Man’s arms should rest on their inner legs with their back and arms kept straight.

Step 3:  WithA-Man in charge, A-Man at the head lifts by slightly flexing both their elbows. C-Man at the patient’s chest and D-Man at the patient’s pelvis keep their arms and backs straight and lift the patient approximately 5″ of the ground by flexing their quadriceps only. B-Man then slides the LSB underneath the patient.

2-Person Straddle-Lift-Slide

Key Points

  • When lifting keep the arms and back straight, and use your quadriceps to do the lift;
  • When applying the LSB, the patient needs to be lifted only 5″ off the ground;
  • Padding using blankets is recommended for LSB comfort;

Step 1: A-Man places the LSB above the patient’s head in-line with the patients body and then positions beside the LSB.

Step 2: B-Man straddles the patient’s torso facing A-Man, squatting down and is positioned at the patient’s torso and places a pillow under the patient’s head (if non trauma) or towel (if trauma).  B-Man supports the patient’s head as A-Man slides the LSB under the patient’s head.

Step 3: B-Man now repositions their hands underneath the patient’s armpits. B-Man’s arms should rest on their inner legs, with their back and arms kept straight. B-Man lifts the patient’s torso by slightly flexing their quadriceps, but only enough to slide the LSB underneath the patient’s torso.  A-Man stops sliding the LSB when it touches the patient’s bottom. The curve of the LSB will allow the LSB to slide correctly aligned under the patient.

Step 4: B-Man now moves down to the patient’s pelvis and straddles the patient, squatting down and placing their hands underneath the patient’s bottom.  B-Man’s back and arms are kept straight. B-Man then lifts the patient’s pelvis by slightly flexing quadriceps. A-Man then slides the LSB underneath the patients bottom and legs until the patient’s shoulders are correctly aligned with the shoulder markings on the LSB. The patient is then secured to the LSB for safety during transport.

6-Person Lift-Slide

After careful evaluation of various transfer techniques the  medical team has adopted the following 6-person lift-slide technique as its preferred method of transferring an injured patient to a long spine board (LSB).  However, the medical team may elect to employ any of the other accepted transfer techniques, if deemed by the medical team to be more appropriate to the given situation.

Key Points

  • When lifting, each responder should rest their elbows on their legs to remove the strain from their backs;
  • If applying the LSB, the patient needs to be lifted only 5-6″ off the ground;
  • If using a Scoop or a thick LSB, the patient will need to be lifted slightly higher for the patient to clear the frame;
  • In this procedure, the responder’s limb closest to the patient’s head will be referred to as the responder’s upper limb, and the responder’s limb closest to the patient’s feet will be referred to as the responders lower limb.

Step 1:  Place the LSB at the patient’s feet and in-line with the patient’s body so that the LSB can be slid under from the patient’s feet.  A-Man positions at the patient’s head and squats down on their knees. Manual in-line stabilization of the patient’s head is performed by A-Man with elbows resting on their legs for stability.  A cervical collar is applied in the absence of protective athletic equipment.  Manual in-line stabilization is maintained until full spine immobilization is achieved.  B- and C-Man kneel on either side of the patient’s torso. B- and C-Man pull the patient’s clothes at the shoulders firmly to the sides with their lower hands to allow their upper hand to easily slide under patients shoulders. DO NOT lift patient’s shoulder upward during this procedure. B- and C-Man’s upper elbow should rest on their upper thigh to avoid strain on the responder’s back during the lift.  B- and C-Man’s lower hand should be placed under the patient’s lumbar spine.  D- and E-Man kneel on either side of the patient’s mid thigh.  C- and D-Man pull the patient’s clothes at the patient’s bottom firmly sideways with lower hand to allow their upper hand to slide easily under patient’s bottom. DO NOT lift patients bottom upward. D- and E-Man’s upper elbow should rest on their upper thigh to avoid strain on their back during the lift.  F-Man is positioned above the patient’s head to slide the LSB into place.  Before inserting the LSB, F-Man insert a forearm airsplint on top of the LSB where the patient’s lumbar spine will be positioned.

Step 2:  With A-Man at the patient’s head in-charge, A-E-Man lift the patient by slightly flexing their arms upwards, lifting the patient only enough for F-Man to slide the LSB under the patient.

Step 3:  F-Man then slides the LSB underneath the patient.   The patient is then immobilized to the Board for transport.

Scoop Stretcher

 Scoop Stretcher Football Review  Scoop Stretcher Ice Hockey and Slide Board Review  
 

A-Man

  • Inform and reassure the conscious and alert patient about the use of the scoop stretcher and what they can expect to experience during the process.
  • Maintain manual head stabilization until full immobilization is achieved.

B- and C-Man

  • Clear the area of any extraneous objects or medical equipment;
  • If the protective athletic equipment remains in place, utilize pack-n-fill towels to maintain cervical neutral alignment;
  • If the protective athletic equipment has been removed, a c-collar will be placed on the patient and padding will be placed under head of patient as needed.

Adjust length of Scoop Stretcher

  • Place scoop stretcher beside patient in closed position with shoulders at level of the pin;
  • Loosen leg extension locks and lengthen until heels of feet are level with bottom of foot plate;
  • Re-tighten locks with finger pressure only;
  • Splitting the scoop stretcher in half at both ends;
  • Place one half on each side of the patient;
  • Join head end of scoop stretcher together approximately 3ft from patient’s head with leg section partially spread apart;

Slide scoop stretcher into place

  • Move to head end of patient and kneel down above scoop;
  • Grasp each side of scoop stretcher and slide into place until patient’s head is 2.5″ from locking pin;
  • Reposition until straddling over patient with feet at pelvic level;
  • Grasp patient’s clothes at the shoulders and pull clothes out laterally, while avoiding lifting patient;
  • Kneel at patient’s feet;
  • Grasp foot end of scoop stretcher with hands on top of Scoop on either side of locking mechanism;
  • Slowly bring sides together until plates on each side of patient touch patient’s buttocks;
  • Reposition by maintaining straddle over patient and placing feet at extension poles of scoop stretcher;
  • Squat down and grasp patient’s clothes at buttocks level and pull out laterally, but do not lift patient;
  • Help close the foot end by placing lateral inward pressure on the extension poles with feet;
  • Continue to close scoop stretcher together and lock foot end into place;
  • Hold locking pin up whilst closing;
  • Place a forearm airsplint under patient’s lumber back and inflate until comfortable.

Immobilize or secure patient to scoop stretcher as required by patient’s condition

  • Check to ensure locking pins are secure;
  • Check to see that the patient is reasonably comfortable and that immobilization technique has not resulted in any increased signs and symptoms;
  • Check all distal pulses, myotomes, and dermatomes.  Loosen any immobilization straps accordingly.
  • Check for proper neutral alignment;
  • Check to ensure proper occipital and lumber padding.

From Prone

In athletics, expert opinion suggests that it is generally agreed upon that an athlete should be repositioned from prone to supine before being transferred to rigid support.  This is so because most experts feel that most athlete’s will not ultimately require immobilization on rigid support, or that completion of critical care tasks would be unecessarily delayed by the transfer process.  However, there may be instances where the medical team elects to transfer a prone athlete directly to rigid support.  When transfer from prone to rigid support is required the medical team will employ one of the following accepted techniques:

5-Person 180º- Log Roll

A-Man

  • Inform and reassure the conscious and alert patient about the use of the scoop stretcher and what they can expect to experience during the process;
  • Prepare to log roll the patient in the direction opposite the patient’s face by assuming a start position with the A-Man’s inside knee positioned at the patient’s lower shoulder;
  • Place hands on head/helmet with the palms together and thumbs down, and the arm corresponding to the direction of the log roll on top such that the A-Man’s arms are twisted at initiation of the log roll and untwist during the maneuver;
  • Maintain manual head stabilization until full immobilization to the long spine board (LSB) is achieved;
  • Directs the log roll maneuver;
  • Watches the torso turn and maintains neutral in-line support of the head, rotating it exactly with the torso;
  • Positions the patient in cervical neutral position and directs B- and C-Man to pack-n-fill as required to maintain proper neutral position.

Key Points:

  • The patient is log rolled away from the direction in which the patient’s face initially points;
  • A Cervical Collar is not applied until the patient is in the supine position on the LSB;
  • Remaining in the prone position will limit the patient’s ability to breath due to pressure on the rib cage and prevent proper cervical neutral alignment;
  • Arching of the spine will occur with each of the patient’s breath whilst in the prone position;
  • In this procedure, the responder’s limb closest to the patient’s head will be referred to as the responder’s upper limb, and the responder’s limb closest to the patient’s feet will be referred to as the responder’s lower limb.

Step 1:  A-Man positioned at the patient’s head, positions their arms in anticipation of the full rotation that will occur as described above.  A-Man positions at a 45º angle to the patient, with arms placed so that the elbow to the side the patient will be rolled onto is in line with the patient’s inner shoulder to roll.  B-Man kneels at the patient’s mid-torso, on the other side to which the patient is to be rolled, and extends the patient’s arms down the patients torso. B-Man places their upper hand under the patient’s shoulder and the lower hand under the patient’s abdominal region level with lower ribs. C-Man kneels on the same side as B-Man at the patient’s thigh, slides their upper hand under the patient’s pelvic region, and lower hand under patient’s upper leg.  C-Man also places a rolled up towel against the patient’s leg just below the knees for the lower legs to roll onto during the log roll to prevent pelvic drooping.  D- and E-Man kneel on the side to which the patient is to be rolled. D-Man kneels at the patient’s mid torso grasping the patient’s opposite side shoulders and opposite lower chest. E-Man kneels at the patient’s thigh grasping the patient’s opposite pelvis and opposite mid femur.  A LSB is rested on the knees of D- and E-Man so that the side of the LSB furthest from the patient is elevated at an angle of 45º.  The LSB’s shoulder marking is aligned with the patient’s shoulders.

Step 2:  The patient is carefully log rolled until the patient’s back is placed on the LSB. A-Man at the patient’s head is in charge and sets the pace.  A-Man watches the patient’s torso turn and maintains the current position of the head, rotating it exactly with the patient’s torso. Only after the patient is completely log rolled onto the their back is the patient’s head then slowly re-aligned to the neutral in-line position unless contra-indicated. B- and D Man both assist with rotation of the patient’s torso. C- and E Man both assist with rotation of the patient’s pelvis, ensuring the patient’s pelvis rotates in-line with the patient’s torso.

Step 3:  While rotating the patient, D- and E-Man steadily shuffle backwards until the LSB and patient are flat on the ground. Keeping the patient in the neutral in-line position, use the v-slide technique to gently adjust the patient’s position sideways until centered on the LSB.

Step 4:  A-Man now re-aligns the patients head into the neutral in-line position unless contra-indicated.

Step 5:  Apply appropriate pack-n-fill padding under the patient’s head and lumbar spine to maintain proper alignment of the spinal column.   In the absence of protective athletic equipment, A cervical collar is now applied, and the patient immobilized to the LSB for transport.

References:

  1. National Registry of Emergency Medical Technicians.  National Registry of EMT’s Resource Document on Spinal Motion Restriction/Immobilization.  Accessed 9/2/19.
  2. Hoffman J, Mower W, Wolfson A, Todd K, Zucker M. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. The New England Journal of Medicine. July 13, 2000;343(2):94-99.
 

© Sports Medicine Concepts, Inc., All Rights Reserved.

DOCUMENTATION

ANNUAL REHEARSAL

Game Day Annual Rehearsal Report

Practice Day Annual Rehearsal Report

Training Camp Annual Rehearsal Report

REVIEW OF SENTINEL EVENT

Sentinel Event Review Form

Post-Transport Report Form

Sentinel Event Overview

In order to deliver best practices and design process improvements that enhance the quality of care, medical teams must have an effective reporting system. Sentinel event reporting allows medical teams to know about and understand successes and our failures.

Sentinel event review facilitates the identification of areas that the medical team will focus on for organizational learning and prevention of similar events. It is also a risk management tool that enhances the process of expedited risk control, preservation of factual information and early professional liability intervention if necessary. Identification of best practices through the review process enhances opportunities for implementation of exemplary care institution wide.

Site Medical Director (SMD) and Regional Medical Director (RMD) reviews are an opportunity to make significant contributions to improving the quality and safety of care provided by the medical team. The proposal of solutions to correct system defects will enhance care at the site where the event occurred and have potential to improve all medical care provided by the medical team. Therefore, SMDs and RMDs have ownership in ’s medical team safety record and quality improvement process. As such, there should be no fear in accurate, forthcoming and authentic sentinel event reviews that recognize how human error and system defects may have interacted to result in an event.

The goal of the sentinel event process is NOT to assign blame or take punitive measures against human error. This is not to be construed as a lack of accountability. Disciplinary measures may be taken in cases of willful, conscious disregard for policies and procedures and reckless behavioral choices. A starting place for accountability and “Just Culture” is that:

  • Human error or mistakes are “consoled”
  • At‐Risk Behavior is “coached”
  • Reckless Behavior is “disciplined”

SMD and RMD reviews should focus on:

  • Promptly identifying patient safety issues and corrective actions that address:
  • Care of the affected patient (if necessary)
  • Risk containment
  • Preservation of factual information
  • Objective and authentic retro‐ and introspective review of the care provided
  • Analyzing systems and processes related to the delivery of care and the relationship to human decision‐making
  • Evaluation of skills and knowledge at the site to identify educational and in‐service needs
  • A culture of continuous improvement in clinical outcomes through system and process improvements aimed at decreasing preventable errors and adverse events

The RMD should further consider:

  • Enhancement of the peer review process with timely feedback and “teachable moments”
  • “Cascading audits”: concordance between the SMD/RMD review and Sentinel Event Committee reviews will be part of the peer review process
  • Monitoring of core clinical competencies at site level
  • Maintenance of governing practices related to company philosophies, policies and procedures
  • Improved collaboration between regional and site leadership
  • Providing support and/or debriefing for site staff who may have made mistakes which contributed to the adverse event (“second victim” management)

The SMD will review the medical record and complete the appropriate forms. The RMD will also receive a portion of the medical record (typically 30 days prior to the event) to perform an independent review in accordance with the Policies and Procedures detailed below. The RMD and SMD then discuss the sentinel event together. If regional management includes a Regional Psychiatric Director (RPD), the RMD will involve the RPD in this discussion if the sentinel event is behavioral health related. The SMD will provide the completed review forms to the HSA.

The HSA or designee is responsible for ensuring the medical records and forms are then sent to the appropriate corporate office for review by the ’s Sentinel Event Review Committee.

The Sentinel Event Review Committee is a multi‐disciplinary team that will review events and assign a final category which will lead to information transfer to the Patient Safety Committee and Risk Management as necessary.

The categorizes sentinel events for patient safety improvements as follows:

  • Category 1: Identification of exemplary care
  • Category 2: Indicates that health care was appropriate, following site‐specific policies and procedures.
  • Category 3: Identifies potentially preventable errors of omission/commission associated with opportunities for improvement in systems/processes that were unrelated to the event.
  • Category 4: Identifies potentially preventable errors of omission/commission associated with opportunities for improvement in systems/processes that were directly related to the event.

All Category 3 and 4 events should include specific areas identified that will require Corrective Action Plans (CAPs). The CAP should not just focus on individual performance, but on system and process defects that contributed to the human error. Concluding that events are attributable only to human error or lack of competence is overly simplistic, as errors are systematically connected to the environment and processes.

Human error is not an explanation for failure, but instead demands an explanation as human error is a symptom of trouble rooted inside the system. Stressing what was not done by an individual explains nothing about what actually happened and why. It is imperative to understand why actions made sense at the time and correct factors that contributed to the wrong decisions. This often requires asking questions of the staff who were directly involved with the event. These questions should be asked in a non‐threatening, open‐ended manner i.e., “Could you explain to me in your own words what happened and why?” This helps understand individual behavior by taking into account the environmental context. “Pay more attention”, “remediation”, “be more vigilant”, “try harder” has consistently been shown to retard, rather than advance the understanding of process failures. Meaningful intervention lies in the factors that contribute to error.

Corrective actions plans will be monitored for appropriateness and tracked to completion by the Patient Safety Committee. This provides an opportunity for organizational learning and a company‐wide focus on excellence.

The ’s values related to patient safety include:

  • Quality: never being satisfied with the status quo, always striving to better
  • Patients: treating them with dignity and compassion
  • Integrity: honoring our commitment to do the right thing
  • Sentinel Event reporting and review is the right thing to do. It is a framework for accomplishing the ultimate goal of improving the quality and safety of the healthcare provided by the medical team.

Sentinel Event reporting and review is the right thing to do. It is a framework for accomplishing the ultimate goal of improving the quality and safety of the healthcare provided by the medical team.

Sentinel Event Review Policies and Procedures

 The purpose of the Sentinel Event Review Process is to:

  • Provide information for practice and process improvements to the Patient Safety Committee, with the ultimate goal of improving the quality and safety of patient care provided by the medical team.
  • Facilitate the identification of clinical liabilities for Risk Management POLICY:

A Sentinel Event is defined as an event involving death or serious physical or psychological illness/injury or risk thereof.  Sentinel Events include:

  • All Mortalities
  • Behavioral Health Events
    • All Completed Suicides
    • Suicide Attempts Resulting in Hospitalization
    • Non‐Suicidal Self‐Injurious (NSSI) Behavior*

*Upon request by the Behavioral Health Team on a case by case basis only

  • Non‐Mortality Events
    • Diabetic Ketoacidosis (DKA)
    • Status Asthmaticus
    • Ruptured Viscous
    • MRSA Hospitalizations
    • Acute Myocardial Infarction (MI)
    • Medication Errors Resulting in Patient Harm
  • Non‐Designated Sentinel Events, including but not limited to
    • Loss of limb
    • Visual or hearing impairment/loss
    • Neurological impairment/Paralysis/Brain damage
    • Reproductive organ impairment/loss
  • Pregnancy‐related complications including ruptured ectopic pregnancies, fetal demise and any delivery on‐site
  • High profile events in the media or news
  • Any other events for which it may be alleged that Corizon failed to provide adequate treatment, with errors of omission/commission associated with opportunities for improvement in systems/processes

This Sentinel Event policy and procedure applies to all correctional facilities where the medical team is responsible for providing clinical services: medical, behavioral health, dental or any combination thereof. The Health Services Administrator (HSA) or designee is the ultimate responsible authority for ensuring accurate identification and reporting of events according to this policy and procedure.

The medical team will monitor for accurate reporting of events through Inpatient Census Review, Mortality Attestations, news/media monitoring and an internal reconciliation data base. How events are identified will be reviewed and reported to senior leadership. The majority of sentinel event reports should be voluntarily reported, as opposed to identification through other mechanisms.

Mortality Attestations will be sent quarterly by the medical team designee. The attestations serve as a document of verification for accrediting entities (NCCHC, ACA, etc.) that a mortality review process was completed. The  ’s Sentinel Event Reviews and forms should never be distributed or shared with any non‐ third‐party in any way. Only the attestations may be shared.

The Site Medical Director (SMD) will be responsible for reviewing the event and completing a typed narrative summary and appropriate Sentinel Event Review Form. The Regional Medical Director (RMD) is also responsible for an independent review and collaboration with the SMD.

Certain sentinel events may warrant a Sentinel Event Conference Call (e.g., completed suicides, serious events that will likely be a Category 4). The purpose of a call is to gain further understanding and gather pertinent information. Calls are not meant to name, blame or shame. Calls will be set up by the medical team Designee.  The call may be at the request of the site or other leadership individuals. The Sentinel Event Committee may also request a call. Call attendees may include the Patient Safety Officer, SMD, RMD, HSA, DON, Behavioral Health (when applicable), staff appropriate to the event and other invited guests as necessary. leadership reserves the right to request expedited reviews when necessary.

Procedure:

 The site identifies a Sentinel Event.

The HSA or designee completes the Sentinel Event Notification Form  which is provided to the medical team Designee within 24 hours of the event. Do not place this form in the patient’s medical record.

The HSA or designee is also responsible for notifying appropriate Regional Management within 24 hours of the event. Clients are notified according to contractual requirements; the Sentinel Event Notification Form should NOT be used for client notification or placed in the medical record.

The HSA is responsible for ensuring the integrity of the complete medical record by making a copy to secure in the HSA’s office. Original notification forms and review forms should be kept in a separate locked file.  (Describe how this is done at your site)

It is the Health Services Administrator’s (HSA) or designee’s responsibility to forward the copied (can be copied from the secure copy) and collated medical records to both the SMD and the RMD along with the appropriate review forms. If an electronic medical record is used at the site, copies of documentation stored in the electronic record must be submitted. Refer to the list of requested documents that would otherwise be in the paper record. These copies should be sorted into the proper sequence with the paper portion of the record. All medical records must be collated as outlined below:

  • Master Problem List
  • Intake or Receiving Screening (include booking sheets, TB screen forms, ROIs, other intake related documents)
  • H&P (initial or most recent annual H&P)
  • All Progress Notes, Nursing Evaluations, and Infirmary Notes for 30 days prior to the event

(Chronological from first to last entry, i.e., like reading a book)

  • Sick Call Requests for 30 days prior to the event (Chronological from first to last)
  • Chronic Care Clinic Notes/Flow Sheets (last 2 CCC visits prior to the event, where applicable)
  • Physician’s Orders (30 days prior to the event)
  • MARs (current and month prior to the event)
  • Laboratory and Diagnostic Studies
  • Behavioral Health Notes (Chronological from first to last entry)
  • Dental Notes (Chronological)
  • Utilization Management (Consult requests and authorization letters)
  • Hospital and other off‐site records
  • Any pertinent miscellaneous documents

Any medical records not collated may be returned to the site for sorting.

For mortalities, autopsy reports should be forwarded when available. Reviews should not be delayed in lieu of autopsy results.

The SMD will review the medical records and complete the appropriate form, narrative summary and assign a category (see Sentinel Event Overview for category designations).

The RMD will perform an independent review, assign a category and then discuss the case with the SMD. The SMD should indicate the results of the collaborative discussion in the summary, then forward to the HSA.

The HSA or designee then sends the forms and medical records according to this policy to the appropriate Clinical Services corporate office (see below) within 10 business days of the event.

Upon complete submission of the chart and review forms, the Sentinel Event Committee will review and assign a final category; providing timely feedback to the SMD and RMD. The Sentinel Event Committee may request additional corrective actions.

Identified Corrective Action Plans (CAPs) must be submitted to the Patient Safety Committee and completed by site management. Completion and follow‐through of CAPs will be monitored and tracked.  Incomplete CAPs will be reviewed by leadership regularly.

Sentinel Event Reviews and forms are confidential and protected by both applicable state peer review laws and in some cases attorney‐client privilege. Sentinel Event Reviews are NOT to be distributed to any agency, correctional authorities or non‐ third‐party individuals except by permission of General Counsel. During NCCHC or other audits, Mortality Attestations are acceptable to confirm that a mortality review was conducted. NCCHC or other agency auditors are not permitted to review Sentinel Events.

SMDs and RMDs should shred any copies of patient charts and/or completed forms once the HSA has secured the original copies in a locked file as defined in each site specific procedure for securing original copies.


REFERENCES

PREAMBLE

  1. Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 2004;69(3):548–556.

FOUNDATIONS OF BEST-PRACTICE EMERGENCY ACTION PLANNING

  1. Board of Certification I. BOC standards of professional practice. Version 3.1 – Published October 2017 Implemented January 2018; http://www.bocatc.org/system/document_versions/versions/69/original/boc-standards-of-professional-practice-2018-20171113.pdf?1510606441. Accessed Dec 13, 2017.
  2. Konin JG. Standing orders: What do they mean, and do I need them? Sports Med Legal Dig. 2017;1(1):11-12.
  3. Courson R, Goldenberg M, Adams KG, et al. Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges. Journal of athletic training. 2014;49(1):128-137.
  4. L Cooper BP, D Alosa, C Christy, G Wham, D Grooms, D Newman, K Mathis, L Walker, S Ritter, C Snoody, C Dean, C Wood, A Muscatell. Guidelines for developing a team physician services agreement in the secondary school. 2016.
  5. Tiffen J, Corbridge SJ, Slimmer L. Enhancing clinical decision making: development of a contiguous definition and conceptual framework. Journal of professional nursing : official journal of the American Association of Colleges of Nursing. 2014;30(5):399-405.
  6. Moniz DM. The legal danger of written protocols and standards of practice. The Nurse practitioner. 1992;17(9):58-60.
  7. Board of Certification.  Role Delineation Study/Practice Analysis, Sixth Edition Content Outline Domain Descriptions and Task Statements.  2016.  http://www.bocatc.org/system/document_versions/versions/26/original/boc-rd-pa6-content-outline-20170612.pdf?1497294024.  Accessed 12/13/17.
  8. National Athletic Trainers Association.  Sample standard procedures for injury or illness for licensed athletic trainers.  Available at https://www.nata.org/sites/default/files/Sample_Standing_Orders.pdf.  Accessed 12/20/17.
  9. Handling HIPPA.  Athletic Management.  January 29, 2015.  Available at http://athleticmanagement.com/2007/03/09/handling_hippa/index.php.  Accessed 12/19/17.
  10. Bell R, Ratzlaff SE, Murray SR.  The impact of the HIPPA Privacy Rule on collegiate sport professionals. J Sport, 2008.  Available at http://thesportjournal.org/article/the-impact-of-the-hipaa-privacy-rule-on-collegiate-sport-professionals/.  Accessed 12/19/17.
  11. Hill, D. (2003). A matter of privacy. Athletic Management, 15(2), 37–42.
  12. Department of Health and Human Services.  Notice of Privacy Practices for Protected Health Information.  Available at https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/privacy-practices-for-protected-health-information/index.html
  13. The Universal Joint Commission. Speak Up.
  14. National Athletic Trainers’ Association.  Official Statement on Athletic Health Care Provider “Time Outs” Before Athletic Events.
  15. Anderson JC, Courson RW, Kleiner DM, McLoda TA.  National Athletic Trainers’ Association position statement: emergency action planning in athletics.  J Athl Train.  2001;37(1):99-104.
  16. Kromann CB, Jensen ML, Ringsted C, The testing effect on skills learning might last 6 months. Med Educ, 2009. 43: p. 21-27.
  17. Kuo TM, Investigations of the testing effect. Am J Psychol, 1996. 109: p. 451-64.
  18. Rosenbaum DA, Gilmore RO, Acquisition of intellectual and perceptual motor skills. Annul Rev Psychol, 2001. 52: p. 453-70.
  19. Roediger HL. Test-enhanced learning: taking memory tests improves longterm retention. Psychol Sci, 2006. 17: p. 249-55.
  20. Crocker PR.  Incidental psychomotor learning: the effects of number of movements, practice and rehearsal. J Mot Behav, 1984. 16: p. 61-75.
  21. Ringsted C, Hesselfeldt R, Rasmussen MB, Morgensen SS, Frost T, Jensen ML, Jensen MK, Van derVleuten C, Assessment of Advanced Life-Support competence when combining different test methods-Reliability and validity. Resuscitation, 207. 75(1): p. 153-60.
  22. Aliner G, Gordon R, Determining the value of simulation in nurse education: study design and initial results. Nurs Educ Pract, 2004(4): p. 200-7.
  23. Chopra V, DeJong J et al., Does training on an anesthesia simulator lead to improvement in performance? Br J Anaeth, 1994. 73: p. 293-7.
  24. Gaba, D., Improving anesthesiologists’ performance by simulating reality. J Anesthesia, 1992. 76: p. 491-4.
  25. Medley CF, Gordon R., Using simulation technology for undergraduate nurse education. J Nurs Educ, 2005(44): p. 31-4.
  26. Berden H, Willems F, Hendrick J, Pijls N, Knape J, How frequently should basic cardiopulmonary resuscitation training be repeated to maintain adequate skills? BMJ, 1993. 306: p. 1576-7.
  27. Kromann CB, Jensen ML, Ringsted C. The testing effect on skills learning might last 6 months. Adv Health Sci Edu  2009  [cited 2010 May 4].
  28. Guidelines for Public Access Defibrillation Programs in Federal Facilities. May 23, 2001: Federal register. p. 28495-28511.
  29. American Red Cross.  Surveillance and recognition.  In American Red Cross Lifeguarding Manual.  American Red Cross.  2012.

ESSENTIAL ELEMENTS

  1. Go A, et al. Heart Disease and Stroke Statistics – 2013 Update: A Report From the American Heart Association. Circulation. December 12, 2012.
  2. Zipes DP, Camm AJ, Borggrefe M et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Circulation. 2006;114: 1088-1132.
  3. Cendoma, M. Sports Medicine Concepts, Inc., Triangles of Critical Care Approach to Sports Medicine Team Emergency Action Planning: recommendation based on clinical experience and observations from an evidence-based sports emergency care training program.  Sports Medicine Concepts.
  4. Shawn DeRosaMichael Oostman (2007). A Timing Issue: The 10/20 lifeguarding rule has become a kind of standard in the industry. But is it the right one? Two experts square off on this controversial timing question.  Aquatics International.  Sept 1, 2007.  Accessed 8/27/19.
  5. American Red Cross. Surveillance and recognition.  In American Red Cross Lifeguarding Manual.  American Red Cross. 
  6. Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann EmergMed. 1993;22:1652–1658..
  7. Swartz EE, Boden BP, et al., National Athletic Trainers’ Association position statement: Acute management of the cervical spine-injured athlete.  J Athl Train. 2009;44(3):306-331.
  8. The Universal Joint Commission. Speak Up.
  9. National Athletic Trainers’ Association.  Official Statement on Athletic Health Care Provider “Time Outs” Before Athletic Events.
  10. Swartz EE, Boden BP, et al., National Athletic Trainers’ Association position statement: Acute management of the cervical spine-injured athlete.  J Athl Train. 2009;44(3):306-331.

ADVANCED CARDIAC LIFE SUPPORT

Sudden Cardiac Arrest

  1. Kucera KL, Yau R, Thomas LC, et al. Thirty-third annual report from the National Center for Catastrophic Sport Injury Research.   Available www.nccsir.unc.edu.  Accessed March 1, 2017.
  2. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. JAMA. 1996;276:199–204.
  3. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol. 2000;35:1493–1501.
  4. Drezner JA, Courson RW, Roberts WO, et al. Inter-association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. J Athl Train. 2007;42(1):143-158.
  5. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care, part 4: the automated external defibrillator. Key link in the chain of survival. Circulation. 2000;102(suppl 8):I60–76.
  6. Jones E, Vijan S, Fendrick AM, Deshpande S, Cram P. Automated external defibrillator deployment in high schools and senior centers. Prehosp Emerg Care. 2005;9:382–385.
  7. Neumar RW, Otto CW, Link MS et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122[suppl 8]:S729-S767.
  8. Hopson LR, Hirsh E, Delgado J et al. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. National Association of EMS Physicians position paper. Prehosp Emerg Care. 2003;7(1):141-146.
  9. Weaver WD, Hill D, Fahrenbruch CE, et al. Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med. 1988;319:661–666.
  10. Mosesso VN Jr, Davis EA, Auble TE, Paris PM, Yealy DM. Use of automated external defibrillators by police officers for treatment of out of-hospital cardiac arrest. Ann Emerg Med. 1998;32:200–207.
  11. White RD, Asplin BR, Bugliosi TF, Hankins DG. High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med. 1996;28:480–485.
  12. Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a U.S. airline. N Engl J Med. 2000;343:1210–1216.
  13. Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000;343:1206–1209.
  14. Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators. N Engl J Med. 2002;347:1242–1247.
  15. Myerburg RJ, Fenster J, Velez M, et al. Impact of community-wide police car deployment of automated external defibrillators on survival from outof-hospital cardiac arrest. Circulation. 2002;106:1058–1064.
  16. Hallstrom AP, Ornato JP, Weisfeldt M, et al. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med. 2004;351:637–646.
  17. Drezner JA, Rogers KJ, Zimmer RR, Sennett BJ. Use of automated external defibrillators at NCAA Division I universities. Med Sci Sports Exerc. 2005;37:1487–1492.
  18. White RD, Bunch TJ, Hankins DG. Evolution of a community-wide early defibrillation program experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation. 2005;65:279–283.
  19. Eberle B, Dick WF, et al. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse.   1996;33: 107-116.
  20. Krauthamer V, Gomatam S. Performance aspects and automated rhythm detection capabilities of AEDs. EP Lab Digest.  On-line at http://www.eplabdigest.com/articles/Performance-Aspects-Automated-Rhythm-Detection-Capabilities-AEDs.
  21. Macdonald RD, Swanson JM, et al. Performance and error analysis of AED use in the out-of-hospital setting. Ann Emerg Med.  2001 Sep;38(3):262-7.
  22. Cecchin F, Jorgenson DB et al. Is arrhythmia detection by AED accurate in children?   2001;103:2483-2488.
  23. Morrison LJ, Kierzek G, Diekema DS et al. Part 3: ethics: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. 2010;122[suppl 3]:S665-S675.

Airway Management

Some text is used under the Creative Commons Attribution-ShareAlike License. Wikipedia® is a registered trademark of the Wikimedia Foundation, Inc., a non-profit organization.

1. Neumar RW, Otto CW, Link MS et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S729 –S767.
2. Paluska, SA, Lansford CD. Laryngeal Trauma in Sport. Curr. Sports Med. Rep., 2008;7(1). 16-21.
3. Rejali SD, Bennett JD, Upile T, Rothera MP. Diagnostic pitfalls in sports related laryngeal injury. Br. J Sports Med. 1998; 32: 180-181.
4. Cook, TM, McCormick B, Asai T. Randomized comparison of laryngeal tube with classic laryngeal mask airway for anaesthesia with controlled ventilation. Br J Anaesth. 2003;91(3):373-8.
5. Cook TM, McKinstry C, Hardy R, Twigg S. Randomized crossover comparison of the ProSeal laryngeal mask airway with the Laryngeal Tube during anaesthesia with controlled ventilation. Br J Anaesth. 2003;91(5):678-83.
6. Berg RA, Hemphill R, Abella BS. Part 5: adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S685-S705.
7. Miller MG, Berry DC. Adjunct breathing devices and supplemental oxygen therapy. In Emergency Response Management for Athletic Trainers. 1st ed. Baltimore, MD: Lippincott Williams & Wilkins; 2011: 207-232.
8. Becker DE, Rosenberg MB, Phero JC. Essentials of airway management, oxygenation, and ventilation: part 1: basic equipment and devices. Anesth Prog. 2014 Summer;61(2):78-83.
9. Garcia JA, Gardner D, Vines D, Shelledy D, Wettstein R, Peters J (October 2005). The Oxygen Concentrations Delivered by Different Oxygen Therapy Systems. Chest Meeting 128 (4): 389S–390S.
10. Cairo JM. Mosby’s Respiratory Care Equipment. 9th ed. St Louis, Mo: Elsevier Mosby Inc; 2014:67, 83–88, 150–154.
11. Rosenberg MB, Phero JC, Becker DE. Essentials of airway management, oxygenation, and ventilation: part 2: advanced airway devices: supraglottic airways. Anesth Prog. 2014 Fall;61(3):113-8.
12. Bein B, Scholz J. Supraglottic airway devices. Best Pract Res Clin Anaesthesiol. 2005;19(4):581-93.
13. Limmer D, O’Keefe MF. Emergency Care. 11th ed. Upper Saddle River, NJ: Pearson Education, Inc; 2009.
14. American Society of Anesthsiologists: Practice guidelines for management of the difficult airway. An update report by the American Academy of Anesthsiologists task force on management of the difficult airway. Anesth. 2013;118(2):1-18.
15. Walls R, Murphy MF. Emergency Airway Alogorithms. In Manual of Emergency Management. 3rd ed. Philadelphia. Lippincott Williams & Wilkins; 2008;8-22.

Conditional Protocols

Allergic Reactions

Anaphylaxis

1. New York State Education Department Epinephrine Resources. http://www.schoolhealthny.com/a-zindex.cfm?subpage=151. Accessed 10/20/2016.
2. Schwartz LB. Systemic anaphylaxis, food allergy, and insect sting allergy. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, PA: Saunders Elsevier: 2007.
3. Wasserman SI. Approach to the person with allergic or immunologic disease. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, PA: Saunders Elsevier: 2007.
4. Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, et al. Second symposium on the definition and management of anaphylaxis: summary report: Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium. J Allergy Clin Immunol. 2006;117:391–397
5. Pumphrey RSH. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy.2000;30:1144 –1150.
6. Yeargin SS, Yeargin BE, Anderson JM. Anaphylactic shock, hypothermia, diabetes, and wilderness medicine. In: Casa DJ, ed. Preventing Sudden Death in Sport and Physical Activity.  Sudbury, MA: Jones & Bartlett Learning. 2012:201-231.
7. Korey Stringer Institute. University of Connecticut. On-line at http://ksi.uconn.edu/emergency-conditions/anaphylaxis/. Accessed 10/21/2016.
8. Simons FE, Ardusso LR, Bilo MB, El-Gamal YM et al. World allergy organization guidelines for the assessment and management of anaphylaxis.World Allergy Organ J. 2011;4(2):13-37.
Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2008;121:S402-S407.
10. Worth A, Nurmatov U, Sheikh A. Key components of anaphylaxis management plans: consensus findings from a national electronic Delphi study. JRSM Short Rep. 2010;1(5):43.
11. WebMD.. Understanding anaphylaxis prevention. On-line at http://www.webmd.com/allergies/understanding-anaphylaxis-prevention. Accessed 10/22/16
12. American Academy of Allergy Asthma & Immunology. Storage and stability of automatic epinephrine injectors. On-line at http://www.aaaai.org/ask-the-expert/automatic-epinephrine.aspx. Accessed 10/22/16.
13. EpiPen. Patient information Leaflet. Available at http://www.epipen.com. Accessed 9/19/16.
14. American Heart Association. Update to instructors for use of epinephrine autoinjectors. CPR & Emergency Cardiovascular Care. February 7, 2017.
15. http://www.adrenaclick.com/ Accessed 10/20/2016.
16. https://www.auvi-q.com/ Accessed 10/20/2016.
17. https://www.epipen.com/ Accessed 10/20/2016.
18. http://www.epinephrineautoinject.com/ Accessed 10/20/2016.

Asthma

1. Miller M, Weiler JM, Baker R, Collins J, D’Alonzo GD. National Athletic Trainers’ Association Position Statement: Management of Asthma in Athletes. J Athl Train. 2008. Jul-Sept; 40(3): 224-245.
2. http://www.mayoclinic.org/diseases-conditions/asthma/basics/definition/con-20026992http://www.mayoclinic.org/diseases-conditions/asthma/basics/definition/con-20026992
3. National Lung Health Education Program. 3. Metered-Dose Inhalers (MDIs).  Accessed 10/20/16.
4. American Academy of Allergy Asthma & Immunology. 4. Inhaled Asthma Medications: Tips to Remember.  Accessed 10/20/16.
5. American College of Chest Physicians. Patient Education Guides. 5. Using Your MDI: Closed- Mouth Technique. Accessed 10/20/16.
6. American College of Chest Physicians. Patient Education Guides. 6. Using Your MDI With a Spacer. Accessed 10/20/16.
7. American College of Chest Physicians. Patient Education Guides. 7. Using Your MDI With a Spacer and Mask – Pediatric.  Accessed 10/20/16.

Environmental Emergencies

Cold Related Conditions

1. NCAA Sports Medicine Handbook (2013-2014)
2. Cappaert, T., Stone, J.A., Castellani, J.W., Krause, B.A., Smith, D., and Stephens, B.A. National Athletic Trainers’ Association Position Statement: Environmental Cold Injuries. Journal of Athletic Training. 43(6):640-658. 2008.
3. Prevention of Cold Injuries During Exercise. ACSM Position Stand. Medicine & Science in Sports & Exercise. 2006: 2012-2029.
4. Red Cross: “Frostbite and Hypothermia.
5. CDC: “Winter Weather: Frostbite.”
6. AMA Handbook of First Aid and Emergency Care: “Cold Related Problems: Frostbite.”
7. Young, A.J., Castellani, J.W., O’Brian, C. et al., Exertional fatigue, sleep loss, and negative-energy balance increases susceptibility to hypothermia. Journal of Applied Physiology. 85:1210-1217, 1998.
8. Frey C: Frostbitten feet: Steps to treatment and prevention. The Physician and Sportsmedicine 21(1):67-76, 1992.
9. Street, Scott, Runkle, Debra. Athletic Protective Equipment: Care, Selection, and Fitting. McGraw-Hill, 2001
10. Armstrong, LE: Performing in Extreme Environments. Champaign, IL: Human Kinetics Publishers. 1999.
11. Askew EW: Nutrition for a cold environment. The Physician and Sportsmedicine 17(12):77-89, 1989.
12. Robinson WA: Competing with the cold. The Physician and Sportsmedicine 20(1):61-65, 1992.
13. Thornton JS: Hypothermia shouldn’t freeze out cold-weather athletes. The Physician and Sportsmedicine 18(1): 109-114, 1990.
14. Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/chilblains/basics/definition/con-20033727http://www.mayoclinic.org/diseases-conditions/chilblains/basics/definition/con-20033727
15. http://www.webmd.com/first-aid/tc/chilblains-perniosis-topic-overviewhttp://www.webmd.com/first-aid/tc/chilblains-perniosis-topic-overview
16. http://www.nysphsaa.org/Portals/0/PDF/Safety/WindChillProcedure.pdfhttp://www.nysphsaa.org/Portals/0/PDF/Safety/WindChillProcedure.pdf
17. http:www.accuweather.comhttp://www.accuweather.com

Lightning

  1. Lightning safety awareness statement. American Meteorological Society.     http://www.ametsoc.org/policy/lightningpolicy_2002.htm.  Accessed March 6, 2012.
  2. Lopez RE, Holle RL, Heitkamp TA, Boyson M, Cherington M, Langford, K. The underreporting of lighting injuries and deaths in Colorado.  Bull AM Meteorol Soc. 1993; 74(11):2171-2178.
  3. Holle R, Cummins K. Monthly distributions of U.S. NLDN cloud-to-ground lightning.  Paper presented at:  International Lightning Detection Conference; April 21-22, 2010; Orlando, FL.
  4. Duclos PJ, Sanderson LM. An epidemiological description of lightening-related deaths in the United States.  J Epidemiol.  1990; 19(3):  673-679
  5. Lopez R, Holle R, Heitkamp T.  Lightning casualties and property damage in Colorado from 1950 to 1991 based on Storm Data.    1995; 10(1):  114-126.
  6. Bennett B, Holle R, Lopez R. Lightning safety guidelines.  In:  Klossner D, ed.  National Collegiate Athletic Association Sports Medicine Handbook.  Overland Park, KS:  National Collegiate Association; 2011-2012.
  7. Uman M. All About Lightning.  New York, NY:  Dover Publications; 1986.
  8. Holle R. Lightning fatalities in tropical and subtropical regions.  29th Conference on Hurricanes and Tropical Meteorology.  http://ams.confex.com/ams/29Hurricanes/techprogram/paper_168018.htm.
  9. Bennett BL.  A model lightning safety policy for athletics.  J Athl Train.  1997; 32(3):251-253.
  10. Holle RL, Lopez RE, Howard KW, Vavrek R, Allsopp J.  Safety in the presence of lightning.  Semin Neurol. 1995;15(4)375-380.
  11. Zimmerman C, Cooper MA, Holle RL.  Lightning safety guidelines.  Ann Emerg Med. 2002;39(6):660-664.
  12. Holle RL. Lightning-caused deaths and injuries in and near dwellings and other buildings.  Paper presented at:  4th Conference on the Meteorological Applications of Lightning Data; January 11-15, 2009; Phoenix, AZ.
  13. Cooper MA, Edlich RF, Kulkarni R. Lightning injuries.    http://emedicine.medscape.com/article/770642.  Accessed March 5, 2012.
  14. Cooper MA.  Lightning prognostic signs of death.  Ann Emerg Med.  1980;9(3):  134-138.
  15. Cooper MA, Emergent care of lightning and electrical injuries. Semin Neurol. 1995; 15(3): 268-278.
  16. Rakov VA, Ulman MA. Lightning:  Physics and Effects.  Cambridge, UK:  Cambridge University Press; 2003.
  17. Cooper MA, A fifth mechanism of lightning injury. Acad Emerg Med. 2002;9(2): 172-174.
  18. Cooper, MA, Holle RL. Mechanisms of lightning injury should affect lightning safety messages.  Paper presented at:  3rd International Lightning and Meteorology Conference; April 19-22, 2010:  Orlando, FL.
  19. Gatewood MO, Zane RD. Lightning injuries.  Emerg Med Clin North Am.  2004;22(2):369-403.
  20. Cherington M. Neurological manifestations of lightning strikes.  Neurology.  2003;60(2):182-185.
  21. Duff K, McCaffery RJ. Electrical injury and lightning injury:  a review of their mechanisms and neuropsychological, psychiatric, and neurological sequelae.  Neuropsychol Rev.  2001;11(2):  101-116.
  22. Slesinger TL, Bank M, Drumheller BC, et al. Immediate cardia arrest and subsequent development of cardiogenic shock caused by lightning strike.  J Truama.  2010;68(1): E5-E7.

General Medical/Sudden Illness

Hypoglycemia

1. www. Eli Lilly.com
2. Jimenez CC, Corcoran MH, et. al. National Athletic Trainers’ Association Position Statement: Management of the athlete with Type 1 diabetes mellitus.  J Athl Train. 2007;42(4):536-545.

Trauma

Intracranial Hemmorhage

  1. Orlando Regional Healthcare, Education and Development. Orlando Regional Health Care. [Online] 2004. [Cited: April 27, 2012.] http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf.
  2. S., Dawodu. Traumatic brain injury: definition, epidemiology, pathophysiology. emedicine.com. [Online] 2005. [Cited: April 27, 2012.] www.emedicine.com/med/topic3216.htm.
  3. Steiner LA, Andrews PJ. Monitoring the injured brain: ICP and CBF. British Journal of Anaesthesia. 2006, Vol. 97, 1, pp. 26-38.
  4. B, Mokri. The Monro-Kellie hypothesis in CSF volume depletion. Neurology. June 2001, Vol. 56, 12, pp. 1746-8.
  5. S, Tolias C and Sgouros. Initial evaluation and management of CNS injury. www.emedicine.com. [Online] 2006. [Cited: April 27, 2012.] www.emedicine.com/med/topic3216.htm.
  6. K, Sanders MJ and McKenna. Head and facial trauma. [book auth.] Mosby. Mosby’s paramedic textbook. 2nd revised Ed. s.l. : Mosby, 2001, 22.
  7. A, Singh J and Stock. Head Trauma. emedicine.com. [Online] 2006. [Cited: April 27, 2012.] www.emedicine.com/ped/topic929.htm.
  8. A, Downie. Tutorial: CT in head trauma. www.radiology.co.uk. [Online] 2001. [Cited: April 27, 2012.] www.radiology.co.uk/srs-x/tutors/cttrauma/tutor.htm.
  9. Hart JM, Potter B, Sibold J. Vital Signs Trending and the Rule of 100s. Jul 2012, Vol. 4, 4, p. 152.
  10. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, & Cantu R. Consensus statement on SRC in sport: the 3rd international conference in sport help in Zurich, November 2008. Journal of Athletic Training. 2009, Vol. 44, 4, pp. 434-448.
  11. High Blood Pressure. highbloodpressure.com. [Online] [Cited: April 27, 2012.] http://highbloodpressure.about.com/od/highbloodpressure101/p/pulse_pressure.htm.
  12. ChoiceMMed. OxyWatch Quick Operation Guide. Bristol, PA : ChoiceMMed America Co., 2013.
  13. J, Ghajar. Traumatic brain injury. Lancet. September 2000, Vol. 356, 9233, pp. 923-9.

Pneumothorax

  1. Pollak, MD, FAAOS, Andrew N. Critical Care Transport. Burlington, MA: Jones and Barrlett, 2011.
  2. Putukian, MD, FACSM, Margot. Pneumothorax and pneumomediastinum. Clinics in Sports Medicine Clin Med 23 (2004), 443-454.
  3. Decker, MD, Cameron. “Needle Chest Decompression.” Harris County Emergency Corps. Standing Orders and Emergency Medical Guidelines. 12.7.2015.

Reports and Documentation

Review of Sentinel Event

  1. Patient Safety A Human Factors Approach, Sydney Dekker, CRC Press, 2011
  2. The Patient Safety Handbook, Barbara J. Youngberg, Martin J. Hatlie, Jones and Bartlett, 2004
  3. The Just Culture Community, www.JustCulture.org, 2009

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