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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 medical team, first responders, and other support personnel will 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

VENUE SPECIFIC EMERGENCY ACTION PLAN SUMMARY

Comprehensive emergency action plans provide a detailed systematic review of emergency policy and procedure for the purpose of planning, documentation, education, and discussion during annual review.  When it comes time to execute the emergency action plan the cognitive information expressed in the comprehensive document should be ingrained, the psychomotor skills acquired, and the execution strategy practiced.  A venue specific Emergency Action Plan Summary will be borne from the principles described in the Comprehensive Document.  The EAP Summary will provide only EAP information that is critical to executing the emergency action plan within a given venue.  The venue specific EAP Summary is succinct and organized to provide a venue overview prior to the initiation of an event, including:

Venue Details
The EAP Summary will provide the venue name, location, and navigation to the venue.

Surveillance Plans and Injury Spotting
The EAP Summary will provide details of the venue specific zone-based injury spotting surveillance plan.  The medical team will designate surveillance zones and assign appropriate spotters to continuously scan each zone for evidence of emergency situations.  Surveillance zones will be designated such that:

Surveillance Zones
Surveillance zones may change throughout the day and season, depending on the number of patrons, type and variety of activities, time of day, and environmental conditions. The following are three appropriate types of zone surveillance coverage schemes that the medical team will consider when deciding upon an appropriate surveillance plan for an event:

Stationing of Spotters
The American Red Cross identifies use of elevated stations, ground level stations, roving stations, and floating stations for appropriate placement of lifeguards providing pool patron surveillance.1 This concept can be applied to all venues.

When providing supplemental floating stations in calm areas the medical team will decide on the appropriate use of a rescue board, kayak or flat-bottom rowboat.  Lifeguards providing floating surveillance will keep a rescue tube or buoy strapped across their chest or attached to the watercraft. In rough water, rowboats might be used. Powerboats, inflatable boats and personal watercraft may also be considered for use in surveillance and rescue watercraft. If stationed on watercraft in water with a current, the medical team will consider employing a second lifeguard to help row or paddle to keep the watercraft in position, or the use of a special quick release anchor line.   When larger watercraft are used or when there is a large number of patrons taking part in open water activities, the medical team will consider assigning multiple lifeguards such that the watercraft is appropriately manned to maintain position, provide multi-directional surveillance, and rescue.

Use of some watercraft for floating surveillance may require specialized training, particularly for larger watercraft, navigation of active water, or currents.  The medical team will provide for any specialized training required by local laws or that is in the best interest of safety before assigning lifeguards to floating stations using watercraft.

Response Time and Stationing
Immediate cardiopulmonary resuscitation (CPR) and early defibrillation, has been shown to increase a victim’s chance of survival.1,2 There is a 7-10% decline in the chance of survival for every minute that passes without CPR and defibrillation.Perhaps in no other out-of-hospital environment do medical professionals have the ability to plan for emergencies than in the athletic environment.  In athletics, medical personnel have the benefit of knowing when an emergency might take place (within the confines of the event), who the emergency might effect (players, staff, and officials), and where the emergency might happen (within the confines of the venue playing surface or sidelines).  This foresight allows for a fantastic opportunity to plan to have all the necessary assets available within the timeframe that provides the injured with their best chance of surviving an emergency.  According to the American Heart Association a person receiving defibrillation within 4 minutes has a better chance of survival.  Sports Medicine Concepts, Inc., In 2Min or Less!® Sports Emergency Care Curriculum advocates planning and training for emergencies in athletic such that early defibrillation and all other emergency response be carried out within 2 minutes.  Training to provide emergency care within 2 minutes leaves the remaining 2 minutes to deal with situations that arise and complicate emergency care.3  Sports Medicine Concepts, Inc., suggests the 10/20 rule to strategically plan appropriate medical coverage to attain the goal of completing the American Heart Association Chain of Survival within 2 minutes.

The 10/20 rule suggests that spotters must be able to scan their zone of coverage in 10 seconds and alert the medical team to respond to persons in need within the next 20 seconds.  The 10/20 standard is controversial as a standard for effectively scanning zones and providing appropriate care, but it is generally accepted as a guideline for creating surveillance zones and assigning and positioning responders such that care can be provided in 30 seconds.4  This approach is supported by the American Red Cross which suggests that lifeguards be assigned surveillance zones such that they are able to provide care within 30 seconds.5 Evidence Category C.

Surveillance Rotations
When appropriate spotters will rotate stations to combat monotony and fatigue that have been identified as two challenges to effective surveillance.29 Spotter rotations include moving from one station to another as well as breaks from surveillance duty. During long duration events spotters will receive regular breaks from surveillance duty to help stay alert and decrease fatigue. Spotters will provide patron surveillance for 20 or 30 minutes at one station, rotate to another station for 20 or 30 minutes, and then rotate off of patron surveillance duty to perform other duties or take a break for 20 or 30 minutes. An emergency back-up coverage “station” is included as a part of the rotation. The location of the back-up coverage station will be designated accordingly.  The spotter(s) at this station is are not responsible for patron surveillance, but is/are expected to be able to immediately respond to the EAP signal in an emergency.

EAP Principals
The EAP Summary will identify individuals critical to EAP program oversight such that they can readily identified and contacted in the event of activation of the EAP or in the event their is an issue with any EAP component.

Emergency Medical Roaster
The EAP summary will provide a list of athlete’s with previous medical history or conditions that may pre-dispose them to injury.  The EAP Summary will also provide a means of easily identifying the individual, what their condition is, access to any special medications required, and any special instructions/guidelines for care in the event of an injury or episode.  Upon identifying individuals with a pre-disposing condition, the medical team will review appropriate care and management practices.

Initiation of the EAP
The EAP Summary will identify the means by which the medical team will communicate.  This will include specific life-threatening and non-life-threatening radio calls when radio communication is appropriate.  The EAP Summary will also identify back-up hand signals to convey life-threatening and non-life-threatening injuries when radio communication is not appropriate or unavailable.  The EAP Summary will provide specific information regarding EMS, including primary and secondary means of establishing communication with EMS Dispatch and the approximate time for arrival of EMS once activated.

Emergency Response Information
The EAP Summary will provide the following response details:

Receiving Facilities
The EAP Summary will provide specific information pertaining to hospitals that will received injured patients transported from the venue, including:

Response Principals
The EAP Summary must be clear and concise.  Therefore, only those individuals critical to the initial care and management of critical injuries will be detailed on the EAP Summary.  In the event that further medical consult is required after the patient is stabilized, the emergency contacts will identify the appropriate medical professionals and contact them directly.  All response principals must maintain all necessary and appropriate credentials, be in good standing with their respective governing organization, and have their critical care response skills verified through psychomotor skills testing during annual EAP review and training.  Physicians must have documented privileges at venue receiving facilities. Response Principals include:

SHARING VENUE SPECIFIC EMERGENCY ACTION PLAN INFORMATION

In the days prior to the start of any official team activity the  athletic trainer will review the appropriate venue specific emergency action plan (EAP) information to ensure accuracy and completeness.  Once the venue EAP information has been verified the information will be shared with the visiting medical team and coaching staff.  The visiting medical team and coaching staff will be encouraged to review the EAP summary and provide any information regarding at risk athletes they may have competing during the upcoming contest. 

THE PRE-EVENT MEDICAL TEAM MEETING

Prior to the initiation of any official team activities, the medical team will conduct a Pre-Event Medical Team Meeting using the venue specific EAP Summary.  The pre-event medical team meeting is a meeting of all medical personnel during which all questions or concerns regarding emergency procedures are resolved.  Performance of a pre-event medical team meeting is a common hospital practice prior to the initiation of any surgical procedure, and is part of The Join Commission Universal Protocol for preventing wrong site, wrong procedure, and wrong person surgery. 6  The National Athletic Trainers’ Association suggests that a similar philosophy applied by medical teams covering athletic events will help improve on-field emergency response during care and management of a critically injured athlete.7,8

Prior to the initiation of any official team activities, the athletic trainer will complete a pre-event medical team meeting. When a visiting team has medical personnel with them, the pre-event medical team meeting shall consist of the  athletic trainer meeting, either individually or as a group, with all visiting and home team medical personnel, EMS, contest officials, and other essential EAP personnel.  The pre-event medical team meeting shall be used to provide personnel introductions, identify at risk athletes and discuss their specific management plan, review communications and initiation of the EAP, presence and location of emergency response equipment, venue EMS access points, local receiving facilities, identify members of each team’s Critical Care Triangle™, and review procedure and protocol tendencies.  In addition, pre-event medical team meeting shall be used by medical personnel to specifically identify and reconcile any potential critical injury management protocol differences, and discuss how each can facilitate efficient delivery of any pre-hospital care and management required by either medical team.

When a visiting team does not have medical personnel, the athletic trainer shall include the visiting team’s coaching staff in the pre-event medical team meeting procedures.   When the athletic trainer is responsible for all event coverage, and EMS is provided on an on-call basis, the athletic trainer will review specific emergency procedures with each team’s coaching staff and contest officials, either individually or as a group.  This pre-event medical team meeting shall include personnel introductions, general emergency action plan information as well as procedures to follow when injuries occur to visiting players.

The pre-event medical team meeting will also be used to identify at risk individuals or environmental conditions that may put individuals at risk of onset of medical conditions/illness.  Should at risk individuals or conditions be identified the medical team will review appropriate conditional protocols to aid in orchestration of appropriate prevention, care, and management strategies.

The pre-event medical team meeting will be completed using the specific sport and venue EAP Summary.  Evidence Category: C

THE CRITICAL CARE TRIANGLE™ APPROACH

This EAP will be executed by a multi-disciplined medical team organized to respond as a Critical Care Triangle™ (CCT).3  The role of the CCT™ is to provide appropriate first-aid and basic life-support, and to activate EMS.  The CCT™ 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 the CCT™ are guided, primarily, by the need to care for any deficiencies in the athlete’s Circulation, Airway, or Breathing that may be or may become life-threatening, while simultaneously protecting the neurological status of the injured athlete.  Collectively, the primary vital signs include circulation, airway, breathing, and neurological status are referred to in this document as the CABiN™ (Cardiact, Airway, Breathing, Neurological).  The approach by which the efforts of the CCT™ is guided by caring for primary vital signs or CABiN™ is referred to in this document as the Primary Objectives Approach™.

The CCT™ is made up of 3 key positions, positions A-, B-, and C.  The positions within the CCT™ should be filled by the most qualified individuals available at the time of injury.    Position A is likely to be the first person to arrive at the injury scene.  Personnel holding position A are responsible for stabilization of the head and neck during potential head and neck injuries.  Position A is also responsible for initial assessment, gaining control of the injured athlete, activating the EAP, and directing response of personnel during assessment and delivery of critical care.  Positions B and C within the CCT™ are designated for roles pertaining to the primary and secondary surveys, completion of critical care tasks, and support of vital signs.  Positions in the CCT™ are vital.  Therefore, planning to ensure the availability of properly trained personnel to maintain the CCT™ is essential.

The CCT™ is a fluid triangle.  Personnel holding positions within the CCT™ can be replaced as more qualified personnel arrive on-scene.  Therefore, the roles of the CCT™ can be performed initially by first responders whose training may be limited to the use of AEDs, CRP, and first-aid. Personnel for consideration as first responders might include athletic trainers, team physicians, and coaches,   The CCT™ should be designed to quickly integrate specially trained health care professionals by replacing the first responders when appropriate.

The CCT™ is supported by direct support personnel specifically responsible for ensuring that the emergency equipment and personnel needs of the CCT™ are met.  The roles of the direct support personnel include retrieval, delivery, and preparation of emergency equipment / medicine required by critical care triangle personnel.  Perimeter support personnel are also critical to the function of the CCT™.  Perimeter support responsibilities include:

  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.

Perhaps the most important perimeter support role is that of the Medical Team Facilitator or MTF.  It is very common for members of the CCT™ to become so focused on completion of their specific critical care task that the medical team loses site of the immediate primary objective.  It is the role of the MTF to ensure that the CCT™ stays centered on delivery of care based on the immediate primary objectives and in concert with best practice standards, and local and state regulations.  The MTF may be the most qualified health care provider present who steps back away from the CCT™ in order to direct all others in delivery of care.  Alternately, the MTF may be someone knowledgeable in pre-hospital care protocols who guides and manages the care directives given by more qualified medical personnel providing the care directly.  In either case, the conscious decision to include a MTF has been shown to routinely improve delivery of critical care, even for veteran medical teams.  Evidence Category: C

INJURY RESPONSE

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

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.10  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:

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:

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:

Evidence Category: C