Examples EMERGENCY SITUATIONS IN SPORTS

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Examples EMERGENCY SITUATIONS IN SPORTS Dr Kaspar Rõivassepp Orthopedic surgeon (North Estonian Medical Centre, Estonian Football Association) 23.08.

1 Examples EMERGENCY SITUATIONS IN SPORTS Dr Kaspar Rõivassepp Orthopedic surgeon (North Estonian Medical Centre, Estonian Football Association) IX Baltic Sports Medicine Conference The most serious injuries in my practice M 20 Todays topics A. Emergency situations in sports and initial assessment Clash with heads B. Sudden cardiac arrest - Fracture of right maxilla and zygomatic bone (tripod fracture) C. Head injuries

The most serious injuries in my practice 06.02.

the halftime, where retro- and anterograde amnesia was found) The most serious

$2006 M 27 Tackle from the side - Open fracture of the right ankle (Webber C) Emergency$ injury Musculosceletal injury Health related conditions Syncope Epilepsy Hypoglycaemia

injury Musculosceletal injury Health related conditions Syncope Epilepsy Hypoglycaemia

2 The most serious injuries in my practice M 35 Clash with heads - Concussion (trauma on 10th min, continued playing until the halftime, where retro- and anterograde amnesia was found) The most serious injuries in my practice M 27 Tackle from the side - Open fracture of the right ankle (Webber C) Emergency situations in sports Traumatic injuries Head and neck injury Chest injury Abdominal injury Musculosceletal injury Health related conditions Syncope Epilepsy Hypoglycaemia Heart problems - NB! sudden cardiac arrest The most serious injuries in my practice M29 Head to the body contact and hit to the ground - Concussion (time of unconsciousness 5 min)

spine and head injury Provide structured framework to handle

life-threatening situations Not to cause additional damage

INITIAL ASSESSMENT Clash with the goalkeeper - Possibility

3 What happened? PURPOSE Head to head collision - possibility of cervical spine and head injury Provide structured framework to handle all emergency situations (under pressure) Not to miss any life-threatening situations Not to cause additional damage to the injured or unwell sportsman NB! Cervical spine injury! What happened? INITIAL ASSESSMENT Clash with the goalkeeper - Possibility of lifethreatening chest, abdominal or pelvic injuries as well as potential spine and head injuries

sliding tackle - Injury may occur anywhere from the foot to the

The initial assessment of any critical patient (traumatic,

4 What happened? What happened? Non-contact situation Non-traumatic situation Player collapsed on the field!!! Syncope Epileptic seizure Sudden cardiac arrest sliding tackle - Injury may occur anywhere from the foot to the head ABC system What happened? The initial assessment of any critical patient (traumatic, nontraumatic) is based on the same ABC system A - Airway B Breathing C Circulation Non-contact situations Traumatic Protection of cervical spine is very important in all traumatic condition

5 A-Airway Secondary Injuries to the head can result in decreased conscious level and can seriously compromise the airway through depression of airway reflexes and muscle activity. It seems unreasonable to assess breathing (A, B) or circulation (C) in athlete with an ankle injury. But if you think and act the same in all situations you will never miss underlying lifethreatening conditions it helps you to stay calm and take right decisions while being under the pressure. AIRWAY (A) ASSESSMENT AND MANAGEMENT Starts from the questions: What happened?, Are you ok?, Where does it hurt? If you get an voiced answer, you will know that the airways are patent enough to let oxygen in and out and further manoeuvres to open airways are not needed. A-Airway Primary trauma to the face, head or neck can result in bleeding, bruising or swelling that can make it physically difficult to shift air through the naso- or oropharynx, the laryngopharynx and into the lungs. If the player does not respond, or the answer is inappropriate or confused, it is essential that both the airways and the cervical spine are assessed and protected.

Assessment of airway Airway opening manoeuvres FEEL!

6 Assessment of airway Airway opening manoeuvres FEEL! Jaw thrust (lets you hold cervical spine under control) Head tilt and shin lift (NB! It is contraindicated in trauma situations) LISTEN! LOOK! If the airway cannot be controlled, i.e. remains obstructed, airway adjuncts will be required. Oropharyngeal airway (Guedel, S-tube)

stable LATERAL POSITION (except if there is a suspicion for

7 Adjuncts Endotracheal intubation UNCONSCIOUS, but normally breathing patient (in your opinion) should be put into stable LATERAL POSITION (except if there is a suspicion for neck injury)! Nasopharyngeal airway Adjuncts Laryngeal mask airway

8 If there is possibility for neck injury, patient may be turned into lateral position only for vomiting or bleeding from the mouth. CAN IT BE NECK INJURY? That question should be always asked! The level of concern about a neck injury is directly related to the severity of the mechanism by which the injury was sustained. WHEN SHOULD NECK INJURY BE SUSPECTED? Existing concern over the mechanism of injury In all severe trauma cases GCS <15 (loss of consciousness) Existing symptoms of neck injury (tenderness and stiffness in the neck) or signs of neurological deficiencies (numbness, weakness or tingling sensation in toes and fingers) Abnormal breathing after trauma. Erection Stable lateral position (recovery position) Should allow vomit, blood or other secretes to flow out Should hold airways open Should be stable Should not cause worsening of any existing injuries (NB! cervical spine injuries!) Should avoid excessive pressure to the chest, which can impair breathing.

Head and neck Diafragm Delta and biceps muscle Wrist extensors Triceps muscle Hand Thoracic muscles The higher the injury is, the more dangerous Abdominal muscles it is!

9 If all aforementioned conditions are achieved, only then you can remove the hands supporting and immobilising head and neck. As far as there is an existing concern over the neck injury, the patient may be transported only on the special hard board (spinal board) with head and neck strapped in. Head and neck Diafragm Delta and biceps muscle Wrist extensors Triceps muscle Hand Thoracic muscles The higher the injury is, the more dangerous Abdominal muscles it is! Lower extremity muscles Anal and bladder muscles Sexual function If you don t have a special spinal board, call for an ambulance and wait for help, all the time immobilising head with your hands! Cervical spine injury can be ruled out if all of the following have been achieved: Absence of posterior midline cervical spine tenderness GCS of 15 absence of focal neurological deficit on motor or sensory testing absence of any distracting injuries; ability to achieve active 45-degree lateral neck rotation in both directions no concern over the mechanism of injury.

10 In concern over neck injury the patient can be turned only in one piece (log roll) and at least 2-4 helpers are needed Fitting the neck collar The initial assessment of any critical patient (traumatic, nontraumatic) is based on the same ABC system Protection of cervical spine is very important in all traumatic condition ABC system A - Airway B Breathing C Circulation The neck is not considered fully immobilised if the patient only has a hard collar on Neck is fully immobilised the patient has been placed on a spinal board, a hard collar applied and the forehead taped onto the spinal board OR your hands are placed either side of the head to stop movement (with or without a collar on).

11 Scenario 3 After trauma, the player is combative and confused. Should you still try no matter what fix the head? In that case the best option would be to release the head and neck and then try to calm the player down. If possible, put or hold hard collar on. If the patient is combative and you fix the head it can cause the torsion and tension in the neck which is considered more dangerous. Scenario 1 After trauma, the patient is unconscious and lying on their side. What should be done? Log roll is required to move the player in a supported manner into a supine position (lying on their back). control of ABC transport on spinal board, head and neck immobilised. Scenario 4 Patient collapsed without certain trauma and is not breathing. What should be done? Open airways with head tilt and shin lift, if the patient is still not breathing call for help and start CPR. If the patient starts breathing, he should be put on recovery position and breathing should be continuously controlled. Scenario 2 After trauma, the player is unconscious and vomiting. What should be done? The solution is again to perform a log roll in a supported manner. Not to turn head alone or put the patient to recovery position!

12 There are two main scoring systems used to quickly assess the conscious level AVPU system A-alert V-verbal P-pain U-unresponsive Glascow Coma Scale (GCS) Verbal Eyes Motor Scenario 5 After trauma, patient is unconscious and not breathing. Open airways with jaw thrust. If the patient starts breathing, hold airways opened (airway adjuncts?). In case of vomiting, the patient should be log rolled on the side. Transport must be performed on hard spinal board, head and neck fixed. If after opening the airways the patient is still not breathing, check the pulse. If the pulse is missing, call for help and start CPR. If the pulse is present, hold the airways opened (airway adjuncts?) A Alert AVPU system The patient is fully conscious and responds appropriately. V - Verbal The patient responds to verbal command as a stimulus. P Pain The patient responds to painful stimulus U Unresponsive There is no response to painful stimulus CONSCIOUS LEVEL If vital functions (ABC) are checked, you can assess the conscious level and other existing injuries.

UNCONSCIOUS, but normally breathing patient (in your opinion) should be put into stable LATERAL POSITION (except if there is a suspicion for neck injury)!

13 UNCONSCIOUS, but normally breathing patient (in your opinion) should be put into stable LATERAL POSITION (except if there is a suspicion for neck injury)! In concern over neck injury the patient may be turned only in case of vomiting or bleeding from mouth (log roll)!!! Glasgow Coma Scale (GCS) 3-15 points Verbal 5 Eyes 4 Motor 6 Orientated 5 Open spontaneously Confused 4 Open to verbal command 4 Obeys commands 6 3 Localises to painful stimulus Inappropriate 3 Open to pain 2 Withdraws from painful stimulus Incomprehensible 2 Do not open 1 Flexes to painful stimulus No verbal response 1 Extends to painful stimulus No response to pain Anything less than full GCS score of 15 or AVPU level of A mandates removal from the field of play!!! 52

14 Leading causes of SCA in sports Under 35 years of age: - hypertrophic cardiomyopathy (HCM) - coronary anomalies - myocarditis - arrhythmogenic right ventricular cardiomyopathy (ARVC). Over 35 years of age: - Coronary artery disease. B. SUDDEN CARDIAC ARREST Incidence of SD There are several inherited cardiovascular diseases that can be causes of SCA The majority of athletes don t know they suffer from any underlying cardiovascular conditions Less than 20%, who have these conditions have warning symptoms that allow the conditions to be investigated The incidence of SD in young athletes is 0.5 to 3 per 100,000 per year and this rises from the age 35 onwards. The risk of SD is dependent on: - gender (in about 90% of cases the athletes affected are men) - age (most common in 40- to 50-year-olds) - exercise intensity (higher risk at higher exercise intensities).

seconds to get to the collapsed athlete!

15 What is cardiac arrest? SCA is very infrequent, but we see only the tip of the iceberg Sudden SCA is time critical illness We have only 120 seconds to get to the collapsed athlete!!! It can happen to anybody and in any place of the world!!!

16 Ventricular fibrillation (VF) Why? The clinical death period lasts maximum 5 min In 70% of cases the initial SCA rhythm is ventricular fibrillation (VF) With early defibrillation (first 2 min), the change of survival is 80-90% AED We lose 10% of change of survival in every minute of delay!!!

17 Recognition AED technology If the athlete collapses on the field without a certain trauma, it is a sudden cardiac arrest until it is proven otherwise. Response Endless training and repeated exercising is crucial to respond fast and effectively EMERGENCY MEDICAL PLAN Recognition Response Resuscitation Remove from the field

Resuscitation When you get to the collapsed athlete, you

agonal breaths - abnormal breathing Do not get mislead by

min Call for help (112) Resuscitation Start immediately

18 Resuscitation When you get to the collapsed athlete, you start assessment from ABC as always Do not get mislead by agonal breaths - abnormal breathing Do not get mislead by slow rhythmic seizure-like activity Ambulance within 15 min Call for help (112) Resuscitation Start immediately chest compressions CPR - Call / Push / Recharge!!! Attach AED

19 Correct chest compressions TEE MASSAAŽI ÕIETI! Use your body-weight Compress 5-6 cm Hold your elbows straight Press with the heel of your hands Hold constant contact Hard surface!!! Compression 50% Decompression 50% Rate of compressions: per minute Ratio 30:2 Place your hands in the middle of the chest

The biggest mistakes are: - delayed start - brakes > 5 sec Other

$strength and depth Complications: - rib fractures and other injuries 79$ !! Attach the AED AED gives clear instructions - Do as it says!

20 The biggest mistakes are: - delayed start - brakes > 5 sec Other mistakes: - wrong placement of hands - wrong pace - insufficient strength and depth Complications: - rib fractures and other injuries 79 Ventilation No breathing is needed in the first minutes!!! Attach the AED AED gives clear instructions - Do as it says! Chest compressions are much more important in the first minutes. Switch the AED ON and apply the pads! AED automatically analyses the rhythm and asks you to stop compressions for that. If shock is advised clear the surroundings and PRESS the SHOCK button!

21 Adjuncts for ALS Which drug to use? When? How much? How often? For ventilation you need to open the airways Jaw thrust (lets you hold cervical spine under control) Head tilt and shin lift (NB! It is contraindicated in trauma situations)

22 If the athlete collapses and is unresponsive - call for help! NONE! Open the airways and check for breathing for 10 sec FEEL! LISTEN! LOOK! ERC 2010 AHA 2010

over. If the patient is unresponsive and not breathing normally Send someone or go for AED and call for 112 Until AED is

through constant training and exercising You need to have emergency medical plan The importance of chest compression and

23 How long to resuscitate? Continue until: - the victim starts to wake up: to move, open eyes or breath normally or - ALS unit arrives and takes over. If the patient is unresponsive and not breathing normally Send someone or go for AED and call for 112 Until AED is attached, perform chest compressions Conclusion Cardiac arrest can be treated successfully You will get good results only through constant training and exercising You need to have emergency medical plan The importance of chest compression and early defibrillation has beed proved Don t forget to call for help! If shock is advised press the SHOCK button and continue chest compressions for 2 min If shock is not advised, still continue chest compressions for 2 min.

24 Thank You!

CHANHASSEN FIRE DEPARTMENT MEDICAL / RESCUE SKILLS

CHANHASSEN FIRE DEPARTMENT MEDICAL / RESCUE SKILLS PRACTICAL STATIONS CHANHASSEN FIRE DEPARTMENT MEDICAL / RESCUE SKILLS 1. CARDIAC ARREST MANAGEMENT 2. AIRWAY & RESPIRATORY MANAGEMENT 3. SPINAL IMMOBILIZATION