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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