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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 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

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Hotline:
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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:
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Visiting Team Injury Spotter

Email:
Hotline:
Office:
Home:
Seasonal Intern

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Seasonal Intern

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Hotline:
Office:
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Team Physicians

   
 

Medical Director

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Lead Orthopedic

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Hotline:

Office:
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Lead Internist

Email:
Hotline:
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Lead Neurosurgeon

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Hotline:
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Team Physician –

Email:
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Unaffiliated Neuro Consultants – UNC

Home Team UNC

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Hotline:  
Office Phone:  
Home Phone:  

Visiting Team UNC

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

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Hotline:  
Office Phone:  
Home Phone:  

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

AMP

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Office Phone:  
Home Phone:  

AMP

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Office Phone:  
Home Phone:  
VTML

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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

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Hotline:
Office:
Home:
Player Personnel Representative

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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:

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

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