First Aid for Volunteer Coaches

1. First Aid for Volunteer Coaches Understanding the Basics Swedish Medical Center Thursday, March 18, 2010 Seattle, WA

2. Introduction Terrence Cronin, MD Pediatric Sports Medicine Swedish Pediatric Specialty Care Seattle/Bellevue/Issaquah

3. Introduction • When to call for help • ABC’s • Head Injuries • Cervical/Neck Injuries • Heat Illness

4. ABC’s - The Important Stuff • A is for Airway: Is the player able to move air, or is there a blockage? • B is for Breathing: Is the player breathing on his/her own? • C is for Circulation: Does the player have a pulse?

5. Commotio Cordis • Direct blow to the heart, causing it to stop • “R on T” phenomenon • Player takes direct hit of baseball or Lacrosse ball to the chest, and collapses immediately • Very Rare, 188 from 1996-2007, half during sports • USE AED IF AVAILABLE • Call 911 and do CPR until one arrives

6. Head Injuries • Importance? Brain cells die when injured (and they don’t grow back) • Bad Signs: • Prolonged loss of consciousness > 1 min • Severe/worsening headaches (1st 6 hours) • Visual changes • Unusual bumps or depressions on the head • Bleeding from ears/nose (both ears or nostrils) • Something is “not right”

7. Types of Head Injuries • Brain Issues • Concussions • Sub-dural/epi-dural Hematoma • Scalp Lacerations (blooooooooody!!!) • Skull Fractures • Battle Signs - bruising behind the ears • Raccoon eyes

8. Concussions • May be caused by a direct blow to the head, face, neck, or elsewhere, with an “impulsive” force transmitted to the head • Results in a rapid onset of neurologic function impairment that resolves spontaneously • Largely a functional disturbance, rather than a structural injury • Conventional imaging is normal • Consensus Statement on Concussion in Sport; 3rd International Conference on Concussion in Sport: Zurich, November 2008

9. Concussions • A concussion is a brain injury • All brain injuries are serious • Functional disturbance • Injured brain requires more sugar • Body limits blood flow (and sugar supply) to reduce swelling • No more grading, simple or complex • Severity of concussion depends on how long it takes for athlete to recover

10. Signs - what you look for • Appears dazed, stunned, or vacant expression • Is confused about assignment or position • Forgets sports plays • Is unsure of game, score, or opponent • Moves clumsily • Answers questions slowly or with slurred speech • Loses consciousness (even briefly) or has seizures or convulsions • Shows behavior or personality changes • Can’t recall events before or after hit or fall

11. Symptoms - what they say • Headache or “pressure” in head • Nausea or vomiting • Confusion/Does not “feel right” • Blurry or double vision • Balance problems or dizziness • Feeling foggy, groggy, or sluggish • Sensitivity to light or noise • Concentration or memory problems

12. HB 1824 • “Zachary Lystedt Law” • Signed into law Thursday, May 14, 2009 • Effective July 26, 2009 • Youth who is suspected of having a concussion or head injury be removed from practice or play • Cannot return without written clearance from a “licensed healthcare provider, trained in the management of concussions”

13. What should you do? • Remove player if a concussion is suspected • Look for signs or symptoms of concussion • If found, do not let player return to play • Inform family that player needs to be evaluated • Give them a concussion fact sheet • Do not let player return until written clearance is provided

14. Licensed Medical Professionals • Medical Doctors (MD)/Doctor of Osteopathy (DO) • Pediatrician, Family doctor, or Sports Medicine physician • Neurologist/Neurosurgeon - difficult to get it quickly • Advanced Registered Nurse Practitioner (ARNP)/Physicians Assistant (PA) • At doctor’s office • Licensed Certified Athletic Trainers (ATC) • At some high schools

15. Treatment

16. Treatment • Rest! • Rest! • Rest!

17. Treatment • Cognitive rest • No video games/texting until no symptoms • Homework 30 min at a time • Rest if symptoms come on • Consider no school x 24-48 hrs • Physical Rest • No Practice or exertion until no symptoms at rest

18. Return to Play 0. No activity Complete physical and cognitive rest until no symptoms 1. Light aerobics Jogging, swimming or stationary cycling 2. Sport-specific Running, dribbling, throwing drills, avoid head impact (no batting/fielding/heading) 3. Non-contact drills Progression to more complex training drills, limited fielding and batting; may start progressive resistance training, no heading 4. Full practice Participate in normal training activities/heading 5. Return to play Normal game play

19. Concussion Resources • Brain Injury Association of WA State • www.biawa.org • Details of Zack Lystedt law • CDC Heads Up program • www.cdc.gov • Toolkits for Physicians, coaches, parents and athletes

20. Cervical Spine Injuries • Importance: Cords do not regenerate!! • Usually, but not always friend of Mr.. Head Injury • Must be considered with any head injury • If player not alert, assume injury • Stabilize and treat as if one were present

21. Cervical Spine Injuries • Signs: • Acute neck/back pain • midline more worrisome • Tingling/numbness in extremities • especially both • Partial or complete loss of movement of any body part • Hemi (One side of body), Para (legs only), or Quadriplegia (legs and arms) most worrisome

22. Helmets: Remove or not? • Almost always keep Football helmets on • Disrupts alignment if shoulder pads still on • Remove facemask to access airway if needed • Usually can immobilize on spine board with helmet on, use towel rolls/tape/special pads • Indications for removal • Unable to stabilize neck with it on • Inability to maintain ABC’s • How? • Remove faceguard and have someone hold player’s chin • Spread helmet and use inline traction

23. Helmets: Remove or not? • Almost always keep Football helmets on • Disrupts alignment if shoulder pads still on • Remove facemask to access airway if needed • Remove if unable to stabilize neck or maintain ABC’s • Baseball/Lacrosse • Remove if it is causing neck flexion • Leave on if you cannot remove safely • How? • Remove faceguard and have someone hold player’s chin • Spread helmet, rotate gently, use inline traction

24. Fractures of Extremities • Two main types • Open: Break in skin over the fracture (Bad) • Closed: No open wound (Not as Bad) • Signs • Deformity • Swelling • Bruising - may be delayed • Inability to move or partially move (not always true) • Pain - especially “point tenderness” directly over fracture

25. Dislocations • Forces similar to fractures • Ligaments stretch to allow bones at the joint to leave their alignment • Ligaments then retract and trap bones in abnormal position • Signs: • Deformity and pain • Needs post-reduction x-ray to check for fracture

26. Sprains/Strains • Sprain - stretch injury to ligament • Strain - stretch injury to muscle or tendon • Signs: • Pain • Usually still able to partially bear weight • Swelling • Can look like deformity • Decreased range of motion but • usually not as bad as fractures

27. Acute Injury Treatment • Assess distal feeling, pulses and capillary refill • Pinch skin, count seconds until color returns, should be 3 seconds or less • Splint in Position Found • Provides comfort • Prevents further injury (vessels turning from open to closed, nerve compression • If going to Emergency Room, avoid eating and/or drinking as may delay surgery

28. Acute Injury Treatment • R.I.C.E. • Rest: relative rest, NOT total rest • “do what doesn’t hurt” • Ice: use as long as there is pain or swelling • frozen peas/corn, 20 min at a time, with 1-2 hour rest beween icings • avoid blue gel - needs cloth later, can frost burn skin • Compression: wrap ice with Ace bandage to improve cold contact and control swelling • Elevation: above the heart, as long as there is swelling/pain • Try drawer under mattress for ankle/knee injuries

29. Lacerations • Bleeding • Arterial - Pulsatile, hi velocity spray, bright red • Venous - Constant, lower velocity, darker red • Treat the same • PRESSURE and elevation • Stitches? Coming soon to a workshop near you • Gaposis, near a joint (tension), contamination, depth, bleeding, length of time since injury • No tourniquets

30. Heat Injuries • Heat Syncope • Least Serious, recover quickly • Heat Cramps • Not serious and most common • Heat Exhaustion • More serious but not to panic stage • Heat Stroke • Life Threatening Emergency

31. Body’s Heat Production • Heat production proportional to body weight • Resting heat production governed by thyroid • Metabolic heat proportional to intensity of exercise and efficiency of movement • Well trained, efficient athletes produce LESS heat for similar activity than poorly trained individuals

32. Body’s Cooling Mechanisms • Evaporation - Sweat/water drying off of skin • 70-80% of cooling in hot weather • Governed by body’s sweat glands • Less effective over 80 oF and 60% humidity • Radiation - Loss of heat by electromagnetic waves • “infra red light” -Next highest cooling mechanism in heat • Blood vessels dilate with increased cardiac output • Brings warm blood from body core to surface • Largest loss of heat in cold weather

33. Body’s Cooling Mechanisms • Conduction • Loss of heat by contact of objects/environment with skin • Low in air • High in water- can lead to hypothermia • Convection • Air movement against skin - hot or cold • Affected by wind and movement • Not the same as evaporation

34. Kids and Cooling • Not as good in either extreme • Slower to acclimatize to environmental conditions • Worse at cooling in the heat • Higher temps before they sweat • Lower sweat volumes • Generally less conditioned • Worse at heating in the cold • Larger surface area so cool fast • Smaller mass so heat less

35. Heat Syncope • Normal body temperature • Transient LOC after exercising in hot weather • Blood pools in the legs, decreasing blood to the brain • Occurs AFTER exercise has stopped • If during exercise or competition, think Heat Exhaustion/Stroke

36. Treatment of Heat Syncope • KEEP MOVING after exercise • “walk it off” best prevention • Lay down in cool place with feet elevated • Oral fluids if dehydrated before event • Gradual return to activity when symptoms resolve

37. Heat Cramps • Normal body temperature • Caused by heavy sweating and water/salt loss • Worsened by fatigue and poor conditioning • Painful cramps of many large muscle groups • Calves, Hamstrings, Quads, Abdominals • Often all at once

38. Treatment of Heat Cramps • Stop Exercise • Rest is cool place • Replace fluids and electrolytes • Passive stretch of muscles, gentle massage • May return when symptoms resolve • Continue fluid/electrolyte replacement

39. Heat Exhaustion • Elevated temperature • but less than 104 oF (40 oC) • Sweaty/moist skin - can be pale or flushed • Headache • Nausea/Vertigo • Dizziness/Syncope • Confusion - troublesome, but transient • Tachycardia

40. Treatment for Heat Exhaustion • Reversible when identified early and prompt care initiated • Remove from activity for remainder of the DAY • Should NOT return for later games at a tournament • Rest in cool place • Replace fluids/electrolytes • Seek medical attention if vomiting or confusion persist

41. Heat Stroke • MEDICAL EMERGENCY!!!!!!! 50 - 70% fatality rate (i.e. This is why you have a cell phone) • Untreated heat exhaustion and prolonged exercise • Core body temperature of 104 oF (40 oC) or more • Red, hot skin (sweating stops in ~ 50% of cases) • Progressive LOC, syncope, seizures, coma • Shallow fast breathing • Rapid weak pulse => Shock/circulatory collapse

42. What to do: • CALL 911 • Move to cool place • Remove heavy clothes/pads • Pack groin/armpits with ice, or place in ice bath (Conduction) • Fluids? • IV fluids if trained personnel/fluids available

43. Prevention • Recognize Environmental Risk • Light colored clothing • Recognize and intervene at Heat Exhaustion stage • Fluids/Electrolytes • Ensure Acclimatization • Proper conditioning • Watch for heavy, poorly conditioned, but motivated players

44. Summary • ABC’s - always start there • Concussions - REST! gradual return, no symptoms, to ER if symptoms getting worse • Immobilize the spine if any doubt of injury • Weight bearing/movement good guide for referral • Anticipate and intervene with heat injury • Especially with pre-teens • Use your gut - if you’re uncomfortable, refer

45. Thanks! Terrence Cronin, MD Pediatric Sports Medicine Swedish Pediatric Specialty Care Seattle/Bellevue/Issaquah