From the Field to the Gurney: Preparing the Potentially Spine Injured Athlete for Transport

1. St. Elizabeth Sports & Physical Therapy Darcie Christensen, PT, ATC From the Field to the Gurney:Preparing the Potentially Spine Injured Athlete for Transport

2. Today’s Objectives • Identify the key components of Emergency Action Plans (EAP’s) • Identify members and describe roles of the emergency response team • Recognize when it is appropriate to employ the use of a spine board • Discuss basic technique for placing an individual on a spine board • Review the current research about equipment issues and the spine injured athlete and discuss the document Pre-hospital Care of the Spine Injured Athlete

3. Emergency Action Plan • Athletic health care providers review prior to the start of each sport covered or new field • Determines the role and location of each person present (ie. AT, EMT, MD) • Establish how communication will occur (primary and backup) • What emergency equipment is present? Where is it located? NATA Official Statement on Athletic Health Care Provider “Time Outs” Before Athletic Events, 2012

4. Emergency Action Plan • Where is the ambulance located? Is it dedicated or on stand-by? If not on site, what is mechanism for calling one? • In the event of transport, what is the designated hospital? • Are there any issues that could potentially impact the EAP? NATA Official Statement on Athletic Health Care Provider “Time Outs” Before Athletic Events, 2012

5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681208/pdf/attr-44-03-306.pdfhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681208/pdf/attr-44-03-306.pdf

6. Teamwork • A variety of healthcare professionals may be involved in on-field management of suspected head and/or spine injury • Development of guidelines is imperative • When dealing with a potential life threatening situation, the scene of the injury is not the time nor the place for healthcare professionals to decide on appropriate treatment on such a potentially controversial area.

7. Pre-hospital Care of the Spine-Injured Athlete Developed by the Inter-Association Task Force

8. Guidelines for National Standard of Care Released in 2001 • Prehospital Care of the Spine-Injured Athlete • Developed by the Inter-Association Task Force • Task force was created by the National Athletic Trainers’ Association in 1998 • Document released in 2001 Free download at www.nata.org

9. Organizations represented on the Inter-Assocation Task Force

10. Participating Authors/Organizations of Interest • National Association of EMT’s • National Athletic Trainer’s Association • Professional Football Athletic Trainer’s Society • American Association of Neurological Surgeons • American College of Emergency Physicians • National Registry of EMTs

11. On-Field Management • Initial Assessment • Primary Survey • Level of Consciousness • Neurologic Screening • EAP Activation • Transportation • Equipment Removal

12. On-Field Management • Initial Assessment- Organized process to quickly obtain information vital to care. • Primary Survey- LOC-ABC • Provide Immediate basic life support measures as needed. • Quickly make decision regarding transport • Secondary Survey performed either on-site or during transport

13. On-Field Management • Neurologic Assessment should be performed before and after full body immobilization • Pulse • Motor • Sensation • Capillary Refill/Circulation

14. Neck Evaluation Flow Chart

15. EAP Activation and Spine Boarding

16. Basics • Body Substance Isolation • Establish mechanism of Injury • Head person establishes C-spine • once established it is not relinquished • person at the head gives ALL commands/counts • Every emergency situation is different • Individual circumstances must dictate appropriate actions.

17. Spine Boarding • C-Spine established • Place/Maintain head in neutral in-line position • Assess consciousness of the athlete • Calm the athlete, ask questions • Assess PSMC Function • Pulse, Sensory, Motor, Capillary Refill/Circulation • When do we activate EMS?

18. Any of the following warrant the activation of EMS/EAP • Loss of Consciousness or altered level of consciousness. • Bilateral neurologic findings or complaints. • Significant midline spine pain • Obvious deformity

19. Other Clinical Pearls that should increase suspicion of possible cervical spine injury. • Point Tenderness over the cervical spine with or without deformity • Unrelenting neck pain or muscle spasm in the cervical region with or without palpation • Presence of muscular weakness in extremities • Loss of coordinated movement • Paralysis or inability to move a body part • Abnormal Sensations in the head, neck, trunk, or extremities • Absent or weak reflexes • Loss of bladder or bowel control • Suspicious mechanism • Athletes inability or unwillingness to move the neck • Priapism • Respiratory Distress • Neurogenic Shock • Decreased Blood Pressure • Increased Pulse • A “Gut” feeling

20. Neutral Alignment • Current recommendations for the acute treatment are to immobilize the head and neck in neutral alignment prior to transfer to minimize motion that occurs during this process. Unless… • Movement causes or increases pain, neurologic sx, or muscle spasm. • Movement compromises airway. • It is physically difficult to perform the movement • Resistance is encountered • The patient expresses apprehension

21. Spine Boarding /Prepare for Transport • Apply Cervical collar (if possible) • Position Assistants • Person at the head gives the commands • Log Roll (only option in prone patient) • Six person lift • Feed and Pull method to center on the board. • Secure athlete to spine board with appropriate straps, blocks, towels, etc. • Re-Check P-S-M-C

22. Should the equipmentbe removed? Review of research used in the development of Prehospital Care of the Spine Injured Athlete and current research conducted since that time.

23. Helmet and Shoulder Pad Removal From a Player with Suspected Cervical Spine Injury: A Cadaveric ModelDonaldson III, W et. al, Spine, 1998. “Helmet and shoulder pad removal in the unstable cervical spine is a complex maneuver.” “In the unstable C1-C2 segment, helmet removal causes more angulation in flexion, more distraction, and more narrowing of the space available for the cord.”

24. Impact of cord movement on a spine injured athlete “Abnormal intervertebral motion, even as little as 1mm, may cause significant neurologic damage. This is especially true in the subaxial spine. In this region, the cord demonstrates an exceptional intolerance of even small amounts… and can lead to further neurologic injury in the athlete in whom the spinal cord and osseoligamentous structures are already compromised.” Palumbo M., et. al., The American Journal of Sports Medicine, 1996. Emergency Care and Transportation of the Sick and Injured, American Academy of Orthopedic Surgeons, 1987. McLain, R., Aretakis A., & Moseley, T.A., The Spine Journal, 1994. Owen, J., Naito, M., & Bridwell, K.H., The Spine Journal, 1990. Towbin, A., Archives of Pathology, 1964.

25. Equipment Removal? • WHEN TO REMOVE • When equipment prevents access to the airway or chest for primary life support measures. • If the equipment does not maintain cervical spine or provide adequate immobilization of the head.

26. Equipment Management • Face Mask • When to Remove • Anytime spinal injury is suspected • As soon as decision is made to transport • Prior to transportation regardless of current respiratory status • Combined Tool Approach • Tools should be readily available • Cordless screw driver, FM Extractor, Anvil Pruning Sheers, Screw Drive, Trainers Angel.

27. Most common face mask removal tools • FMS Extractor • Trainer’s Angels • Pruning shears • Cordless screwdriver • Handheld screwdriver • Dremel

28. Facemask Removal • Be familiar with all types of equipment used. • Do not “flip” the mask • Studies show increased movement from torque involved in rotating facemask

29. Facemask Removal and Oxygen Administration • Prior to facemask removal, pocket mask may be positioned through facemask for ventilatory assistance • Following removal, BVM may be used. • Utilize Oxygen if available

30. What did the Inter-Association Task Force make as their recommendation based upon the previously discussed research and what is still in place today? • “The Inter-Association Task Force recommends that neither the football helmet nor the shoulder pads be removed before transportation.” • “The Inter-Association Task Force recommends the face mask be removed as quickly as possible any time a player is suspected of having a spinal injury, even if the player is still conscious.”

31. How to prepare an athletefor transport

32. Access the Airway With the face mask removed, you have access to the airway

33. Hyperextension when helmet is removed

34. Spine boarding the equipment ladden athlete • Six-plus – person lift • preferred if enough personnel available • Log Roll • ½ log roll, position spine board, complete log roll • Responders need to be trained • Avoid the lay person if possible • Person at the head is in charge!

35. Additional equipment situations Other sports offer the same challenges in terms of preparing the spine-injured athlete for transport

36. Unique scenarios - hockey • Working on ice • Helmets and chin straps can be loose • As soon as you lift the mask, it becomes similar to a motorcycle helmet • Shoulder pads vary in thickness/fit • Goalie gear • Differences in gear • regulations

37. Unique scenarios • Larger face masks • Multiple straps • Goalie gear • Rib & kidney protectors • Chin straps in face mask • Differences in gear • regulations

38. Discuss the scenarios before they happen • Familiarize yourself with a variety of equipment and removal tools • Communicate with personnel before the game • Host an in-service • Case by case basis

39. How can our professions work together? Updating protocols, communication, practicing action plans, and other efforts can keep our athletes safe!

40. Communication • Meet each other before the game or event and talk about expectations and roles • Learn about each other’s training and knowledge bases • Familiarize each other with the equipment you have available • Discuss preferences and share stories

41. Example of Spine Boarding Process • http://www.youtube.com/watch?v=GCqtAQ6uslo • Example of Face Mask Removal • http://www.youtube.com/watch?v=bZG3mgTmN-Y • Example of Equipment Removal • http://www.youtube.com/watch?v=OcRNEr32AQ0

42. Special Thanks • Rusty McKune, ATC University of Nebraska Medical Center • Denise Fandel, MBA, CAE Executive Director at Board of Certification(BOC)

43. References • Bailes, et al., Management of Cervical Spine Injuries in Athletes, Journal of Athletic Training, 2007; 42(1): 126–134. • Banerjee, R., Palumbo, M., & Fadale, P., Catastrophic Cervical Spine Injuries in the Collision Sport Athlete, Part 1 : Epidemiology, Functional Anatomy and Diagnosis, American Journal of Sports Medicine, 2004, 32, p. 1077-1086. • Banerjee, R., Palumbo, M., & Fadale, P., Catastrophic Cervical Spine Injuries in the Collision Sport Athlete, Part 2 : Principles of Emergency Care, American Journal of Sports Medicine, 2004, (7), p. 1760-1764. • Barrett, T.W., et. al., Injuries Missed by Limited Computed Tomographic Imaging of Patients with Cervical Spine Injuries, Vol. 47(20, February 2006, p. 129-133. • Belanger, E. & Levi, A., The Acute and Chronic Management of Spinal Cord Injury, Journal of the American College of Surgeons, May 2000: 190 (5), p. 589-604. • Brolinson, P. G., & Cibor, G. M., Editorial: Knowing More than the Score: Providing Sideline Medical Care Coverage for Athletic Competition, Journal of the American Ortohpedic Association, 2011: 101(9), p. 495-496. • Dahl, M., et. al., Helmet and Shoulder Pad Removal in Football Players With Unstable Cervical Spine Injuries, Journal of Applied Biomechanics, 2009, 25, p. 119-132. • Dick, R., et. al., Descriptive Epidemiology of Collegiate Men’s Football Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 Through 2003-2004. • Donaldson, et. al., Helmet and Shoulder Pad Removal From a Player With Suspected Cervical Spine Injury: A Cadaveric Model, Spine 23(16), 1729-1732. • Douglas, K., The Answer is On! A Response to the Initial Lateral Cervical Spine Film for the Athlete with a Suspected Neck Injury: Helmet and Shoulder Pads On or Off?, Clincial Journal of Sports Medicine, 2003: 13(1), p. 57-58. • Feld, F., Management of the Critically Injured Football Player, Journal of Athletic Training, 1993: 28(3), p. 206-212. • Gale, S.D., Decoster, L. C., & Swartz, E. E., The Combined Tool Approach for Face Mask Removal During On-Field Conditions, Journal of Athletic Training, Vol. 43 (1), 2008, p. 14-20. • Frohna, W., Emergency Department Evaluation and Treatment of the Neck and Cervical Spine Injuries, p. 740-793.

44. References • Frohna, W., Emergency Department Evaluation and Treatment of the Neck and Cervical Spine Injuries, p. 740-793. • Gatti, J. M., Protective Equipment in the C-spine-injured Athlete, Traumarounds, Winter 2009/2010, p. 4-5. • Ghiselli, G., Schaadt, G., & Mcallister, D., On-the-field evaluation of an athlete with a head or neck injury, Clinics in Sports Medicine, 22 (2003), p. 445–465. • Hardy, et. al., From Sideline to Inline, JEMS, July 2009, p. 72-76. • Jagannathan, J., et. al., Cervical Spine Injuries in Pediatric Athletes: Mechanisms and Management, Neurosurgery Focus, 21(4), 2006, p. 1-5. • Jenkins, et. al., Removal Tools are Faster and Produce Less Force and Torque on the Helmet Than Cutting Tools During Face-Mask Retraction, Journal of Athletic Training, 2002: 37(3), p. 246-251. • LaPrade, R. F., et. al., Cervical Spine Alignment in the Immobilized Ice Hockey Player: A Computed Tomographic Analysis of the Effects of Helmet Removal, American Journal of Sports Medicine, 28(6), 2011, p. 800-803. • LaPrade, R., et. al., An Evaluation of Head Movement in Backboard-Immobilized Helmeted Football, Lacrosse, and Ice Hockey Players, Clinical Journal of Sport Medicine, Vol. 11, p. 82–86. • Miele, Norwig, & Bailes, Sideline and ringside evaluation for brain and spinal injuries, Neurosurg. Focus 21 (4):E8, 2006. • Pre-Hospital Cervical Spinal Immobilization Following Trauma, The Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, September 2001. • Prehospital Care of the Spine-Injured Athlete by the Inter-Association Task Force For Appropriate Care of the Spine-Injured Athlete • Rihn, J.A., et. al., Cervical Spine Injuries in American Football, Sports Medicine, 39(9), 2009, p. 697-708.

45. References • Swartz, E.E., et. al., Football Equipment Design Affects Face Mask Removal Efficiency, The American Journal of Sports Medicine, Vol. 33 (8), 2005, p. 1210-1219. • Swartz, E., et. al., NATA Position Statement: Acute Management of the Cervical Spine– Injured Athlete, Journal of Athletic Training, 2009, 44(3), p. 306–331. • Thomas, B., McCullen, G., & Hansen, A., Cervical Spine Injuries in Football Players, Journal of the American Academy of Orthopaedic Surgeons, Vol. 7 (5), 2004, p. 338-347. • Tierney, R. T., et. al., Head Position and Football Equipment Influence Cervical Spinal-Cord Space During Immobilization, Journal of Athletic Training, 37 (2), 2002, p. 185-189. • Treme, G., et. al., Cervical Spine Alignment in the Youth Football Athlete: Recommendations for Emergency Transportation, American Journal of Sports Medicine, 36(8), 2008, p. 1582-1585. • Veenema, K. et. al., The Initial Lateral Cervical Spine Film for the Athlete with a Suspected Neck Injury: Helmet and Shoulder Pads On or Off?, Clinical Journal of Sports Medicine, 12:123-126. • Waeckerle, J. F. & Kleiner, D. M., Editorial: Protective Athletic Equipment and Cervical Spine Imaging, Annals of Emergency Medicine, 38 (1), July 2001, p. 65-67. • Waninger, K., Management of the Helmeted Athlete With Suspected Cervical Spine Injury, American Journal of Sports Medicine, 2004 (32), p. 1331-1350. • Waninger, K., et. al., An Evaluation of Head Movement in Backboard-Immobilized Helmeted Football, Lacrosse, and Ice Hockey Players, Clinical Journal of Sports Medicine, 11, p. 82-86. • Whiteside, J., Management of Head and Neck Injuries by the Sideline Physician, American Family Physician, 2006: 74(8), p. 1357-1362. • Wieder, B., Cervical Spine Injury in Athletes, CNI Review Medical Journal, 11(1), 2000.

46. Questions? THANK YOU