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.