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SIDELINE ATHLETICS

SIDELINE ATHLETICS. Cyprian Enweani MD. Introduction. Focus in literature is quite academic and medico-legal Guidelines suggest sideline physician should be up to date with ATLS & ACLS while comfortable with emergency procedures (ie intubation) This would exclude many GP’s/FP’s.

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SIDELINE ATHLETICS

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  1. SIDELINE ATHLETICS Cyprian Enweani MD

  2. Introduction • Focus in literature is quite academic and medico-legal • Guidelines suggest sideline physician should be up to date with ATLS & ACLS while comfortable with emergency procedures (ie intubation) • This would exclude many GP’s/FP’s

  3. Introduction • Objective today – keep it simple • Assume most physicians are not in the ER • Target to the “mother”&”father” family physician who is volunteering

  4. If in doubt keep out • At a minimum safety • Sideline physicians main responsibility is to protect the athlete from further injury , re-injury , & permanent disability • The pressure will be to let the athlete continue and not delay the game • Don’t rush • If in doubt keep out

  5. ABC’S • Rarely needed but ABC’s still essential • Know how you will activate EMS • If an athlete collapses –don’t move them –log roll to there back (c-spine protection) –then ABC • Airway / C-spine –is the airway clear –am I protecting the neck • Breathing –is the athlete breathing • Circulation –is there a pulse (usually carotid)

  6. The Bag • CASM – full bag with airway supplies, resus meds ,IV’s etc for those interested • Mom &Dad could bring no equipment to the sideline but will be very stressful as really limits what you can do to help • Suggest at minimum a small “black bag”

  7. The Black BagAIRWAY/BREATHING • Cell phone -activate EMS • One-way mask-mouth to mouth • Oral airway –keep tongue forward • 14 gauge cathlon-surgical airway • Stethoscope • Tongue depressor • Pen light • Ventolin inhaler &spacer -asthma

  8. The Black Bag CIRCULATION • Epipen/Twinject- anaphylaxis • Automated BP cuff-useful in heat stroke-concussion etc • Digital thermometer –heat exhaution/stroke • Suture kit (optional)

  9. Suture kit Stopping bleeding /repairing laceration is one area physician can have a significant impact on immediate return to play Disposable suture tray Lidocaine 4-0 /6-0 novafil 22guage 3cc syringe 30 gauge needle Cleaning solution/saline Plastic bottle for sharps

  10. The Black BagOther Equipment • Tuning fork • assess for fractures • Gauze 2x2’s 4x4’s • Tape • Screw driver/allen-wrench/bolt cutter • for face mask removal • Gloves –sterile/non sterile

  11. GENERAL ASSESSMENTTriage • to hospital • finished for the day; clinic f/u • ok to return

  12. INITIAL ASSESSMENTAirway & C-Spine • unconscious/minimally responsive; assume neck injury • may have to take face mask off • log roll

  13. INITIAL ASSESSMENT Breathing • breathing ? • stridor/hoarseness? • suggest laryngeal injury present • Pneumothorax? • deviated trachea, SOB, ↓ breath sounds, subcutaneous emphysema

  14. INITIAL ASSESSMENT Circulation • carotid pulse

  15. INITIAL ASSESSMENT Disability • Brief survey • Neurologic deficit?

  16. INITIAL ASSESSMENT Exposure • Check extremities

  17. Airway • Unconscious/minimally responsive assume neck injury • Activate EMS • Ensure airway - log roll to back; remove face mask • Remove mouth guard; teeth; vomit • Jaw thrust; oral airway

  18. Airway • If anterior neck injury consider laryngeal fracture or edema • stridor/difficulty speaking • Consider needle cricothyroidotomy with 14 gauge needle in the cricothyroid membrane between thyroid cartilage and cricoid cartilage.

  19. Breathing • Once airway open, often all needed. • If not – mouth to mouth/mouth to bag mask. • Anaphylaxis – Epinephrine (EpiPen; Twinject) • Asthma • Ventolin + spacer • Epinephrine

  20. Breathing • Pneumothorax from: • penetrating trauma • rib # • spontaneous

  21. Tension Pneumothorax • If compressing rest of lung tissue - tracheal deviation - hypotension - ↓ breath sounds - distended neck veins - dyspnea • Tx: 14 gauge, 2ndintercostal space, midclavicular line

  22. Circulation • No pulse • CPR • EMS • AED

  23. SPECIFIC CONDITIONS • Neck Injury • Concussion • Stinger/Burner • Bony Injury • Soft Tissue • Teeth • Heat Injury

  24. Neck Injury: Unconscious • Assume neck injury • Activate EMS/support C-spine/ABCs/transport • Immobilization in helmet/pads

  25. Neck Injury: Conscious • neck pain over C-spine • neurologic symptoms •  no pain, no numbness, no tingling, no weakness can get up • otherwise immobilize and transport

  26. Concussion: Recognition • Any head and any neurologic symptoms • Review check list – key symptoms/signs - Amnesia - Memory testing - Balance

  27. Concussion: Return to play • First Concussion: • Grade I symptoms <15 min – ok • Grade II symptoms >15 min – no until 1 week symptom free at rest and no exertional symptoms • Grade III LOC (other than brief) no until 2 weeks symptom free at rest and no exertional symptoms

  28. Concussion: Return to play • Second concussion double rest period • Third concussion 1 year rest • Some new thought symptoms may not present for 24-36 hours?? • “Any doubt sit out”

  29. Stinger/Burner • usually football • usually a shoulder blow • tingling, numbness, weakness, one arm • if both arms – assume C-spine injury • if symptoms resolve, not recurrent, ok to return to play • wait until no appreciable weakness/numbness • any doubt sit out • EMG can help sort out when resolved

  30. Bony Injury • hard to assess • if pretty good, no deformity, no swelling, stable and… • tuning fork negative, likely ok to return to play

  31. Bony Injury: major deformity • Risk of neurovascular compromise. Try to reduce if delay in transport. • hip dislocations – hospital • could reduce knee if trained • reducing patella, shoulder, elbow, finger will be easier early and decrease pain for patient. • ok to reduce if don’t suspect bony fracture

  32. Soft Tissue • “biggest impact you can likely make for the outcome of a game and safe return to play is to be able to suture a wound and control bleeding. ”

  33. Teeth: complete avulsion(entire tooth knocked out) • completely avulsed teeth can be replanted • ideally within a few minutes • No rough handling • No touching root • rinse teeth in tap water to remove loose debris • re-insert into socket – patient bites on gauze gently to hold in place

  34. Teeth: complete avulsion(entire tooth knocked out) • if can’t re-insert: • keep tooth in patients mouth – buccal vestibule; or Hanks’ Balanced Saline Solution (Save the tooth); milk; saline; tap water as last resort.

  35. Luxation of tooth(in socket but wrong position) • Extruded – hanging down upper or raised lower teeth • reposition with firm pressure • stabilize by biting gently on gauze or towel • Lateral Displacement – pushed back/pulled forward • try to reposition (may need local anesthetic) • stabilize

  36. Luxation of tooth(in socket but wrong position) • Intuded Tooth – pushed in • do nothing • after first aid transport to Dentist

  37. Fracture Tooth • if broken tooth, save as for avulsed tooth • rinse/moisten/transport to Dentist • Stabilize remnant in mouth by biting on gauze/towel

  38. Heat Injury • Prevented by drinking enough water • Cramps – typically calf • sodium depletion/dehydration • tx fluids/salty drinks • local heat to ↑ blood flow

  39. Heat Exhaustion • ↑ core temp less than 1040F, 400C • + sweating • flushed • orthostatic syncope • tx – cool environment/oral hydration

  40. Heat Stroke • ↑ core temp greater than 1040, 400C • Hallmark – CNS changes – mental status; seizures; coma • Often no sweating, hot dry • Eventually multi-symptom organ failure • High morbidity if temp greater than 1070F • Tx – rapid cooling over arteries (neck, axilla, groin); hospital; IV

  41. Conclusion • Keep it simple • ABCs • Have basic tools along • IF IN DOUBT SIT OUT! • UNSURE, THEN REFER!

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