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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

SIDELINE ATHLETICS

Cyprian Enweani MD

introduction
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
introduction1
Introduction
  • Objective today – keep it simple
  • Assume most physicians are not in the ER
  • Target to the “mother”&”father” family physician who is volunteering
if in doubt keep out
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
abc s
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)
the bag
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”
the black bag airway breathing
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
the black bag circulation
The Black Bag CIRCULATION
  • Epipen/Twinject- anaphylaxis
  • Automated BP cuff-useful in heat stroke-concussion etc
  • Digital thermometer –heat exhaution/stroke
  • Suture kit (optional)
suture kit
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

the black bag other equipment
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
general assessment triage
GENERAL ASSESSMENTTriage
  • to hospital
  • finished for the day; clinic f/u
  • ok to return
initial assessment airway c spine
INITIAL ASSESSMENTAirway & C-Spine
  • unconscious/minimally responsive; assume neck injury
    • may have to take face mask off
    • log roll
initial assessment breathing
INITIAL ASSESSMENT Breathing
  • breathing ?
  • stridor/hoarseness?
    • suggest laryngeal injury present
  • Pneumothorax?
    • deviated trachea, SOB, ↓ breath sounds, subcutaneous emphysema
initial assessment disability
INITIAL ASSESSMENT Disability
  • Brief survey
  • Neurologic deficit?
airway
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
airway1
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.
breathing
Breathing
  • Once airway open, often all needed.
  • If not – mouth to mouth/mouth to bag mask.
  • Anaphylaxis – Epinephrine (EpiPen; Twinject)
  • Asthma
    • Ventolin + spacer
    • Epinephrine
breathing1
Breathing
  • Pneumothorax from:
    • penetrating trauma
    • rib #
    • spontaneous
tension pneumothorax
Tension Pneumothorax
  • If compressing rest of lung tissue

- tracheal deviation

- hypotension

- ↓ breath sounds

- distended neck veins

- dyspnea

  • Tx: 14 gauge, 2ndintercostal space, midclavicular line
circulation
Circulation
  • No pulse
  • CPR
  • EMS
  • AED
specific conditions
SPECIFIC CONDITIONS
  • Neck Injury
  • Concussion
  • Stinger/Burner
  • Bony Injury
  • Soft Tissue
  • Teeth
  • Heat Injury
neck injury unconscious
Neck Injury: Unconscious
  • Assume neck injury
  • Activate EMS/support C-spine/ABCs/transport
  • Immobilization in helmet/pads
neck injury conscious
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
concussion recognition
Concussion: Recognition
  • Any head and any neurologic symptoms
  • Review check list – key symptoms/signs

- Amnesia

- Memory testing

- Balance

concussion return to play
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
concussion return to play1
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”
stinger burner
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
bony injury
Bony Injury
  • hard to assess
  • if pretty good, no deformity, no swelling, stable and…
  • tuning fork negative, likely ok to return to play
bony injury major deformity
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
soft tissue
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. ”
teeth complete avulsion entire tooth knocked out
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
teeth complete avulsion entire tooth knocked out1
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.
luxation of tooth in socket but wrong position
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
luxation of tooth in socket but wrong position1
Luxation of tooth(in socket but wrong position)
  • Intuded Tooth – pushed in
    • do nothing
    • after first aid transport to Dentist
fracture tooth
Fracture Tooth
  • if broken tooth, save as for avulsed tooth
  • rinse/moisten/transport to Dentist
  • Stabilize remnant in mouth by biting on gauze/towel
heat injury
Heat Injury
  • Prevented by drinking enough water
  • Cramps – typically calf
  • sodium depletion/dehydration
  • tx fluids/salty drinks
  • local heat to ↑ blood flow
heat exhaustion
Heat Exhaustion
  • ↑ core temp less than 1040F, 400C
  • + sweating
  • flushed
  • orthostatic syncope
  • tx – cool environment/oral hydration
heat stroke
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
conclusion
Conclusion
  • Keep it simple
  • ABCs
  • Have basic tools along
  • IF IN DOUBT SIT OUT!
  • UNSURE, THEN REFER!