Kearsarge Department of Athletics

Winter 2020 Athletics COVID-19 Guidelines

Updated: November 5, 2020

Preface The following plan was developed by the Kearsarge Athletics Department, in order to have a safe environment for student athletes, coaches, and staff to participate in the various athletic programs available under the approved district reopening plan.

Logistics of Return to Play for Kearsarge Athletics Return to Training The pandemic has created a lot of changes for athletes and it is assumed that one of these changes is the potential lack of adequate physical activity or deconditioning. Also within this framework, is the time it may take for student-athletes to acclimate to wearing a mask during physical activity. Workouts and practices should reflect that; they should have lower work to rest ratios, more frequent breaks, and can progress safely on a weekly basis. Athlete & Coach Acknowledgement of Risk Participation in Kearsarge athletics is voluntary and so, all athletes and coaches that will be participating must complete the COVID-19 Acknowledgement of Risk form in addition to all other athletic paperwork. With keeping safety in mind, athletes and coaches that may be considered at risk will also be asked to provide documentation from their Primary Care Physician. Kearsarge Athletics would like to ensure that in the current pandemic state, all participants are doing so safely. The CDC identifies the following conditions as those that may increase the risk of severe illness from COVID-19 for participants of any age:

● Chronic lung diseases ● Moderate to severe asthma ● Serious heart conditions ● Immunocompromised individuals (including cancer treatment, smoking, bone marrow or organ

transplant, immune deficiencies, and prolonged use of corticosteroids or other immune weakening medications)

● Severe obesity ● Diabetes ● Chronic kidney disease (undergoing dialysis) ● Liver disease

Athletes and coaches that may fall into one of the above categories will be asked to obtain written confirmation from their Primary Care Physician to be kept on file in the athletics department prior to participation in Kearsarge Athletics. Form Can be Found in Appendix A.

Prescreening & Check-In Procedures If possible, it is asked that athletes and coaches arriving on campus at the time of practice shower prior to arrival and the check-in procedures. Upon arrival, athletes and coaches will be screened and checked in following all social distancing and safety measures. Social distancing will be maintained by all individuals and masks will be worn at all times during the check-in process. If an athlete or coach does not arrive with a mask, they will be asked to leave or come back with a mask if one is not available on-site for them. Prior to practices or events, coaches will complete a self assessment and temperature check. Coaches will then use the provided form to record the temperatures of their athletes as well as several other questions including:

● Temperature on arrival ● If they have any signs or symptoms of COVID-19 ● If they have traveled outside of New England in the last 14 days ● How they arrived and who they came with (I.E. did they carpool?)

Screening forms and information obtained during the screening will be recorded and maintained according to HIPAA guidelines in the athletics department. Any athlete or coach that has a positive symptom check and/or a fever (100.0 or greater) will be sent home immediately. Any athlete or coach that is sent home will need to complete one of the following:

● Return after 10 days from the onset of symptoms and be 24 hour fever free without and medication

● Get COVID-19 tested, quarantine until results return. Negative tests, with written documentation from a Primary Care Physician only, will be allowed to return.

The certified athletic trainer will follow district protocols for reporting a potential COVID-19 case and treat it as such until proven otherwise. Kearsarge Athletics Expectations of Student Athletes

1. Volunteer to be screened prior to practice, workouts, or events. 2. Volunteer to participate in temperature screening. 3. Athletes are expected to arrive at their screening location at their scheduled time, no more

than 15 minutes early. 4. Athletes are responsible for bringing their own equipment for each practice or event and are

responsible for the sanitization of this equipment frequently. 5. All athletes are required to bring their own water bottle and it must be filled. The athletics

department will NOT be able to provide water for athletes due to current pandemic conditions.

Coaches & Staff Education The Kearsarge Athletics department wants to ensure that all staff are educated on proper disinfection, hygiene, and safety protocols during this pandemic. All coaches are required to attend the pre-season coaches meeting where expectations and procedures for the season will be outlined in detail. The NFHS offers an educational course for said personnel regarding COVID-19 specifically and how to deal with this in the safest way possible during our athletic seasons. This course is free and should be completed by all staff to ensure the safety of our Student Athletes. Contingency Planning & Schedule Changes While it is our intention to participate in athletic events, it is under the discretion of the district, high school and / or athletic department to cancel or change games and practices. Depending on potential outbreaks or a positive test occurring within the athletics population at Kearsarge, the athletic department reserves the right to cancel any contest or season for a team should that be necessary. Equipment As previously mentioned, all student athletes are responsible for providing their own personal equipment. It is not allowed, under any circumstances, for athletes to be sharing equipment at this time and it is expected that each athlete will show up prepared to participate. Any athlete without proper equipment will need to sit out at the coach’s discretion. It is also expected that all equipment should be sanitized and washed at the end of each practice or game. This includes soccer balls, field hockey balls, clothing, etc. Coaches will be responsible for daily equipment sanitization and should educate the athletes on appropriate use of equipment to prevent the spread of any contagions. All cleaning sessions on campus will follow appropriate guidelines and protocols adhered to by the Kearsarge Regional School District. Face Coverings All coaches and student athletes will be required to arrive with a face covering and use the face covering at all times. For indoor sports, masks may only be removed in an athlete’s designated area for a water break, or to enter the pool for swimming. Facilities & Cleaning As always, it is expected that our student athletes and coaches will leave all athletic facilities in good standing and cleaner than when they arrived. This will be expected at home venues, during transportation, and at away venues. Additionally, athletic facilities will be following the following guidelines for cleanliness:

● An appropriate cleaning schedule will be adhered according to district guidelines to mitigate any communicable diseases.

● Hard surfaces should be wiped down and sanitized prior to the arrival of any group (I.e. team benches, athletic training rooms, etc.).

● Individuals are asked to wash their hands for 30 seconds with soap and warm water prior to their arrival at any athletic facility or participation in any event.

● Hand sanitizer will be available to all individuals within the school and at each practice and game site as they transition from school day to after school activities.

● Students and coaches are encouraged to shower prior to their arrival on campus (on remote learning days) and should both shower and wash any workout attire/gear immediately upon returning home.

First Aid Kits Typically, our coaches travel to every athletic event with their own personal first aid kit, provided by the athletic trainer. In order to help mitigate any disease transmission, first aid kits will be distributed by the athletic trainer to any team leaving campus. This will allow for appropriate disinfection after use and minimize disease transmission. To help with quick first aid needs during practices, a first aid station will be set-up outside the athletic training room where student athletes can help themselves in a safe setting and without having to wait to see the athletic trainer. Game Day Procedures

● Kearsarge coaching staff will report to the athletic trainer, while wearing a mask, prior to the student athlete arrival time for pre-screening questionnaires and temperature checks by the athletic trainer.

● Student athletes will arrive at their pre-screening location on time and wearing their masks, so they can be screened by their coaching staff or athletic trainer when coaches are unavailable.

● Coaches and student athletes will keep their masks on at all times. ● Student athletes will be encouraged to arrive at the athletic facilities dressed in uniform as the

locker rooms will NOT be available for use. ● At this time, it is not possible for the athletics department to invite fans into the athletic venues

to watch any athletic events. There will be alternative options for viewing until it is safe for us to welcome fans on campus again.

● Without any fans on campus, it is also noted that the concessions stand will not open for the season.

● Equipment used for games will be sanitized according to district protocols prior to the start of each game and at half time. Equipment will also be disinfected immediately before being stored to prevent disease transmission.

● Officials will have assigned parking on campus and an assigned area where they will be pre-screened prior to entering any athletic facility.

● Officials will be required to wear masks at all times on campus, including during competition. ● Visiting athletes will be directed to an isolation zone. This will be their area to organize and

gather (social distancing considered) prior to entering the athletic venue together and being directed to their respective team area.

● All visiting athletes are required to wear masks.

Away Games ● Coaches and athletes are expected to follow all district policies and guidelines for social

distancing measures while preparing to travel for competition. ● Student athletes will be dismissed 15 minutes prior to bus departure time. ● All student athletes and coaches will be pre-screened and temperature checked prior to

gaining access to the bus for travel. ● Any coach or athlete with a positive screening or temperature exceeding 100.0 degrees will not

be allowed onto the bus and will be immediately sent home. ● Coaches and student athletes will wear their masks at all times when preparing for departure,

during transportation to away venue, and during games. ● Coaches and athletes will disinfect gear prior to getting back onto the bus to come back to

Kearsarge campus to help mitigate disease transmission. ● Coaches and student athletes will wear masks after the competition has ended, while getting

onto the bus, during travel back to Kearsarge campus, and until they have been picked up or get into their own vehicle.

● There will be no stopping on the way back from away contests for food. Buses will stop for emergencies only.

Hydration According to CDC and NHIAA guidelines, at this time it is not appropriate for the athletics department to provide communal water for student athletes. Public hydration will not be available during after school activities and so student athletes and coaches must bring sufficient water or hydration solutions for their athletic activities. A minimum of 1 gallon of water is HIGHLY recommended for after school use only and this should be labeled accordingly. It is not allowable for athletes to SHARE water or sports drinks of any kind during these times. Any student athlete that is not prepared will not be allowed to participate. Restrooms / Changing The restrooms in the main lobby will be available at the end of the day for students that are not able to go home and come back for practices or games. One student will be allowed to change in the restroom at a time. Once practices and games have started, athletes will not be able to re-enter the school. The athletic training room will be available for emergencies and injuries. There will be a designated bathroom to use for each practice and game site. Medical Services & Athletic Trainer As always, the school district Certified Athletic Trainer will be present for on campus practices and scheduled events. Coaches and student athletes will have the ability to access assistance from the athletic trainer during the school day by appointment (not during class time) virtually or in person if necessary. Any appointment that can be done virtually during the school day will be recommended as the after school hours in the athletic training room can be very time constrained.

A first aid station will be set up outside the athletic training room with hand sanitizer for safe communal use of student athletes that may need a simple fix (i.e. bandaid, triple antibiotic, gauze, etc.). Due to the size of the athletic training room, only one student athlete will be permitted inside with the athletic trainer at a time. After all patients are seen, the athletic trainer will be available around campus for events and practices per usual. Any injury that cannot be reported or seen by the athletic trainer immediately (i.e. away venue or home offsite) should be texted or called in to the athletic trainer immediately so that appropriate care and documentation can be taken care of as soon as possible. Any questions or concerns can be directed to the current athletic trainer, Molly Quigley, regarding coverage or athletic training concerns. Mouthguards & Other Activities For sanitary purposes, the NHIAA has allowed some sports to participate without mouthguards for the time being. During practices and competitions, mouthguards will be used according to the guidelines for each specific sport. When mouthguards are required, it is expected that student athletes should wash their hands or use hand sanitizer before and after touching the mouthguards. Mouthguards should be left in the mouth as much as possible to help reduce the number of times a student athlete puts their hand near their face and to help mitigate disease transmission. Other common activities including gum chewing, spitting, chewing/spitting sunflower seeds, licking fingers, etc. are no longer acceptable due to the increased risk of disease transmission. Practices Practices will follow the up to date guidelines from the NHIAA and other governing bodies to ensure the safety of the student athletes:

● When possible, practices should be planned to be executed with a minimum of 6 feet between each participant, coach, or staff member.

● Student athletes should wear masks at all times. ● Individual sports bags should be placed 6 feet apart, in a designated area, so that student

athletes are able to maintain social distancing measures during water breaks. ● During all athletic events, close-contact and non-athletic activities should be avoided (i.e.

handshakes, huddles, etc.). ● At the end of each athletic event, all coaches and student athletes will wash or sanitize their

hands, follow equipment sanitation procedures, and exit the athletic venue in a controlled and socially distanced manner.

Post Events There should not be any handshake lines with opponents or officials at the conclusion of the game. Student athletes will leave all athletic events and go immediately to their vehicle and will not congregate with other students or athletes. If an athlete is waiting for their ride to get them, they will wait in a socially distant spot, away from other people or frequently used walkway until their ride arrives. We ask that all parents do their best to arrive on time to pick up their athletes to avoid unnecessary waiting time. It is important that all coaches and student athletes get home as quickly as possible to shower and clean all athletic equipment to help mitigate disease transmission. Coaching staff will ensure the athletic venues are picked up, disinfected, and restored to original order prior to leaving campus. Coaches are also responsible for ensuring that each of their athletes is picked up prior to their own dismissal. Scrimmages Any scrimmages on campus will be treated just as a game day. All game day protocols previously mentioned will be in effect and completely adhered to by coaches, staff, and student athletes. Supervision It is required that student athletes are supervised at all times during after school activities and for athletics this falls to the Head Coach for each team (or the district approved coach / volunteer assigned by the Head Coach). Student athletes should not be left unsupervised during any form of scheduled activity including all pre/in/post activities, film sessions, and waiting for rides after practice. Transportation

● All transportation for athletics will adhere to social distancing and safety guidelines as determined by the school district policies.

● Students are permitted to drive themselves or be dropped off for home practices and games. ● Carpooling is not encouraged at this time. ● Late bus will be available in the afternoon ● For away games, athletes will arrive 15 minutes before bus departure for their pre-screening

and temperature check. ● Windows on the bus will be open, weather permitting, to allow for better airflow. ● Student athletes and coaches will wear masks at all times while being transported to an away

facility or venue. Heat Related Illness Policy Due to the deconditioning of student athletes over the last four to five months during the pandemic, it will be important to consider the inherent and increased risk of heat related illnesses. The athletic trainer will follow the same protocols for heat related illness with minor stipulations for the current

climate. The ice bath tub will be set up outside the athletic training room daily but will be for emergency use only. This means ice baths will not be available for student athletes daily due to the risk of disease spread. This tub will be sanitized daily: no one will touch or enter the tub unless it is an emergent situation according to the athletic trainer. The remainder of the heat illness policy (Appendix B) will remain entirely the same. Lightning Strike Policy The potential for inclement weather is always a factor for athletic events and will remain to be one this year as well. This policy will continue to follow all appropriate NHIAA guidelines during this time. The only change will be the location for shelter during athletic events due to social distancing requirements. In the event of inclement weather, each team will have a designated area / classroom (or two for social distancing needs) where they can congregate safely during the time it is unsafe to be outdoors. For the fall season, the athletic teams should report to the following locations (if room is available) and make sure they are seated with their mask on (similar to being in class): Boys Soccer: Gym Girls Soccer: Gym Field Hockey: Room 11 & 13 Tennis: Room 5 Cross Country: Cafeteria Golf: Clubhouse at Golf Course Football Alternative: Room 7 & 9 The remainder of this policy will remain the same and can be found in Appendix B. For more information on athletic guidelines and the references for this policy:

1. National Federation of State High School Associations: https://www.nhfs.org/articles/ https://www.nhfslearn.com/courses/covid-19-for-coaches-and-administrators

2. Centers for Disease Control and Prevention: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/reopening-schools.html

3. Covid-19 Reopening Guidance: Governor’s Economic Reopening Taskforce 4. New Hampshire Interscholastic Athletics Association

http://www.nhiaa.org/ckfinder/userfiles/files/NHIAAReopeningSportsActivitiesSummerGuidance.pdf

5. National Athletic Trainers’ Association https://www.nata.org/sites/default/files/covid_19_return-to-sport_considerations_for_secondary_school_ats_1.pdf

6. Kingswood Return to Play - School Board Proposal

Appendix A: Parent & Athlete Form

Kearsarge Regional School District COVID-19 Waiver of Liability for Athletics

COVID-19: The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. It is believed that an individual can be infected with COVID-19 without their knowledge and be asymptomatic. Participation in a Kearsarge Regional School District athletic sports program, related event, or activity, as a student-athlete or staff member, could increase the risk of you contracting or transmitting COVID-19.

The Kearsarge Regional School District has installed rules and guidelines for all individuals who wish to participate in athletics to reduce the spread of COVID-19. However, Kearsarge Regional School District cannot guarantee that you will not become infected with COVID-19 and will not spread COVID-19 to your family, relatives, or friends,

I understand and acknowledge that while participating in Kearsarge Athletics that I could be at risk of acquiring or transmitting COVID-19 which may result in personal injury, illness, permanent disability, and death to myself, my spouse, other children, unborn child, or relatives.

I have considered these risks and dangers and relying on my own judgment, I am voluntarily participating in the athletic program.

In consideration for the opportunity to participate in Kearsarge School District Athletics and any related transportation to and from athletic events, I UNDERSTAND AND VOLUNTARILY ACCEPT AND ASSUME ALL the risks related to COVID-19 and accept sole responsibility for any injury or illness that may occur. Further, I UNDERSTAND AND AGREE that this waiver and release includes any and all claims based on the actions, omissions, or negligence of Kearsarge Regional School District, it’s employees, agents, representatives and volunteers (the “releasees”), whether a COVID-19 infection occurs before, during, or after participation in any Kearsarge Regional School District sports program, related event, or activity. I, also UNDERSTAND AND AGREE for myself, my spouse, and child/ward to release, defend, indemnify, and hold harmless the releasees from and any all claims and liabilities which may result or arise from or are incident to my presence or participation in these activities as provided above, EVEN IF ARISING FROM THE RELEASEES NEGLIGENCE, to the fullest extent provided by law.

This is to certify that I understand and accept these risks and responsibilities. The invalidity of any portion of this Agreement shall not affect any other provision.

I/WE HAVE READ, UNDERSTAND, AND AGREE TO RELEASE AND INDEMNIFY THE RELEASEES

Print Parent Name: _____________________________ Parent Signature: __________________________________

Print Student Name: _____________________________ Student Signature: _________________________________

Date:

Appendix B:

Kearsarge Regional High School Athletic Training Room Policies & Procedures

457 North Road North Sutton, NH 03260

603.927.4261 - 603.927.4453 (fax) www.kearsarge.org

Created By: Molly Quigley, ATC NH-LAT Office Phone: 603.927.2383

Email: mquigley@kearsarge.org

Updated: November 5, 2020

Table of Contents

Mission Statement 3 Inherent Risk of Participation 3 Requirements to Participate 4 Athletic Health Care Team 5 Athletic Health Care Team Roles/Descriptions 6 Coaches Training 6 AED Equipment Maintenance Policy 6-7 Playing Surface Maintenance Policy 7 Playing Equipment Maintenance & Fitting Policy 7-8 Emergency Action Plans & Review Policy 8-28 Return to Play Decisions, Requirements, & Rules Policy 28-29 Concussion Protocol 29-33 Heat Related Illness Policy 33-41 Cold Stress Policy 41-48 Lightning Strike Policy 48-51 Communicable Diseases Policy 51-57 Preventing Sudden Death in Sports Policy 57-66 Psychosocial Awareness and Referral Policies 66-66 Related Forms 67

Mission Statement

Along with the Kearsarge Regional High School Statement of Core Values and Beliefs, the mission and purpose of Athletics at Kearsarge is to enhance the educational experience using interscholastic competition to teach life lessons such as sportsmanship, communication, commitment, hard work, sacrifice, time management, determination, accountability, tolerance, focus, patience and making sound decisions.

Inherent Risk of Participation

By its very nature, competitive athletics may put students in situations in which SERIOUS, CATASTROPHIC and perhaps FATAL ACCIDENTS may occur. Students and parents must assess the risks involved in such participation and make their choice to participate in spite of those risks. No amount of instruction, precaution or supervision will totally eliminate all risk of injury. Just as driving an automobile involves choice of risk; athletic participation by high school students also may be inherently dangerous. The obligation of parents and students in making this choice to participate cannot be overstated. There have been accidents resulting in death, paraplegia, quadriplegia and other very serious permanent physical impairment as a result of athletic competition. By granting permission for your student to participate in athletic competition, you, the parent or guardian, acknowledge that such risk exists. By choosing to participate, you, the student, acknowledge that such risk exists.

Requirements to Participate

Student-athletes and their parents/guardians are required to complete two forms and a test in order to be considered eligible to participate in Kearsarge athletics. Prior to the FIRST day of practice every athlete is required to have a current physical on file with the school nurse. This must be completed in their first year of high school, including the summer prior to freshmen year. A physical that is completed in the spring of their 8th grade year will be accepted as long as another appointment is confirmed for some point during their freshmen year. If this form is not on file prior to the first day of their season than the athlete will not be allowed to participate until the form is turned in to the school nurse or athletic trainer. Student-athletes are only required to have ONE physical in their four years at Kearsarge Regional High school however, if another one has been completed it will gladly be accepted and kept on file for reference. Student-athletes and/or parents/guardians must also fill out the athletics emergency contact form (not the same as the school’s emergency form). This must be COMPLETELY filled out so that coaches and appropriate medical personnel will have all pertinent information regarding the athlete’s health, current conditions, PCP, and insurance information. This form will go with the athlete to the ER should that be necessary. This form must be completed and SIGNED by the parent/guardian and given to the athletic trainer or coach prior to the beginning of the second day of practice. The first day of practice is a “freebie” day and no athlete will be sat

because of not having this form in. If the form is not in before the BEGINNING of the second day of practice then the athlete will be sat out until the form is turned into the athletic trainer. There are NO exceptions. This form is good for ONE school year. If you participate in a fall sport, it will carry through to each coach until your spring season. At the end of each year the forms are disposed of and then requires each student-athlete to bring a new one for the next school year. The final requirement for participation is an ImPACT test. This test is completed every two years (freshmen and junior year) and is kept on file. This test must be completed prior to the first outside opponent scrimmage or within the first 10 days (school days) of the season. The athletic trainer will have a schedule of available times to take the test and will often schedule an entire team together. There is, as a last resort, a final make-up test date at the end of the testing window. All testing must be done by the final testing date! Once the student-athlete has completed all of these requirements the athletic trainer will notify the athlete’s coach that they are eligible for participation. Should any issue arise, please contact the athletic trainer with questions and concerns. The appropriate physical and emergency contact form can be located at the end of this handbook as well as on the KRHS athletics webpage under the forms tab on the left.

Athletic Health Care Team

Kearsarge Regional High School has an extensive Athletic Health Care Team that centers around the full-time athletic trainer that coordinates appropriate communication and treatment for all of the student-athletes. This team consists of a Team Physician, School Nurse, Nurse’s Assistant (LNA), Athletic Director, School Administration, School Psychologist, Game Administrator, Concussion Specialist, and local Primary Care Physicians and Physical Therapists. Each member plays a vital role in making sure that student-athletes can participate safely and will return to play when it is safe for them to do so. The goal for this team is to keep kids healthy and active for as long as possible.

Athletic Health Care Team Roles/Descriptions

Team Physician: The team physician is the signing physician over the certified athletic trainer. These two members work together to decide the best course of treatment for athletes outside the predetermined guidelines. The team physician also plays a key role in getting athletes in to see specialists as quickly as possible when necessary and reporting back to the athletic trainer with updated information. School Nurse: The school nurse plays a vital role in injury/illness evaluation at the school during the hours of the day when the athletic trainer is not available. The nurse keeps track of any athletes that require attention during the day and meets with the athletic trainer daily to maintain good communication about the overall health of our athletes. The nurse also assists with concussion tracking and maintenance when athletes are required to be on concussion protocols. The nurse and the athletic trainer also work together during in school emergencies when possible. Assistant School Nurse: Acts as an assistant to the school nurse and plays a very similar role with taking care of the athletes. The assistant also plays a vital role during in-school emergencies.

Coaches: Coaches are all certified in first aid, CPR, and AED use and therefore act as first responders when the athletic trainer is not available. They make sure that all athletes are practicing and playing sports safely. They report any and all possible injuries to the athletic trainer and follow all rules and guidelines that the athletic trainer gives them regarding an athlete’s participation status. Coaches also assist with emergency situations in games and practices when the athletic trainer asks them to do so. Some of these tasks may include calling 911, assisting with CPR, helping rescuers find our location, etc. Coaches are responsible for knowing the emergency action plan for their practice and game locations so that they may be helpful in emergency situations. Athletic Director: The athletic director is responsible for making sure that there is good communication between the members of the athletic health care team. They make sure that all playing facilities are suitable and safe for athletes to use and assist with any issues that arise. They are first aid, CPR and AED certified in order to assist with any emergencies that may occur while they are present and act as a go between if issues arise with members of the athletic health care team and athletes. School Principal: The school principal oversees many athletic events and assists in emergencies when available. Game Administrator: The game administrator assists with making sure that all athletic facilities are safe for athletes to participate on and assists with emergencies when available. The game administrator is also responsible for knowing and practicing all emergency action plans so that they may assist in multiple ways during an emergency. School Psychologist: The school psychologist is a resource for any athlete that any member of the athletic health care team thinks may need more help. Members of the athletic health care team are able to speak with a guidance counselor and fill out appropriate forms in order to help get athletes the help that they may need. The school psychologist is also knowledgeable of local resources for athletes and is well educated in the emotional and developmental needs of growing adolescents. Guidance Counselors: The school guidance counselors assist the athletic trainer and athletic director when it comes to questions concerning an athlete’s grades when it comes to eligibility and health matters. They also assist with psychologist referrals and act as a great resource for athletes that may need someone to speak with. They also assist with resources for athletes that may miss large amounts of school due to illness or injury. Athletic Trainer: The athletic trainer acts as a go between for all members of the athletic health care team in order to ensure that all aspects of an athlete’s health are taken into consideration. They provide game day and practice coverage throughout the school day and throughout the week. They facilitate conversations between parents, primary care physicians, and specialists to ensure that the appropriate forms and rules are followed, while advocating for the best treatment for the athletes.

Coaches Training

All coaches at Kearsarge are required to be first aid, CPR, and AED trained. They are also educated about concussions, communicable diseases, emergency action plans, and specific policies that are to be followed within the season.

Coaches are required to be CPR, AED, and first aid trained in order to provide quick medical attention to athletes should the athletic trainer not be on the sidelines or be available. They are educated about appropriate medical equipment for them to use as well as where said equipment can be located in the school. They are well versed in the emergency action plans for their practice and game field and practice those plans annually to ensure they are efficient.

AED Equipment Maintenance Policy

There are two AEDs located within Kearsarge Regional High School. One AED is at a fixed location on the wall of the front lobby, when this AED case is opened the fire/police departments are notified thus activating any emergency action plan. The second AED is a portable AED that is kept with the athletic trainer at all times; when this AED is used the police/fire departments are NOT immediately notified thus it is important for another member of the athletic health care team to contact them immediately as outlined in every emergency action plan. Maintenance for both AED’s is done by both the school nurse and the athletic trainer. Each AED is checked daily to ensure that both battery packs are functioning appropriately. Each AED has a test done monthly to ensure they are properly functioning and with each test the expiration dates on the pads is checked to ensure that they are within date and that new ones are ordered when necessary. Maintenance logs are kept with both AED’s.

Playing Surface Maintenance Policy

The athletic trainer walks each playing surface weekly to check for any objects, defects, or potential hazards that would make the surface unfit for participation. During set-up and take down for each event the athletic trainer and game administrator make sure that there are no changes or hazards made on each surface as well.

Playing Equipment Maintenance & Fitting Policy

It is required of all student-athletes to use appropriate equipment for their respective sports that is fitted properly. This helps to ensure the safety of each and every athlete on the field. Coaches are responsible for checking that each athlete is properly equipped and for certain sports, that the equipment is refurbished and fitted properly to each individual athletes (more on this later). Coaches are aware of each governing agency that creates the rules and regulations for equipment used for their sport. This includes, but is not limited to, mouthguards, shin guards, helmets, and all forms of padding. Should a coach or athlete have questions about their equipment or any uncommon issue they should contact the athletic trainer or athletic director in order to get more information about appropriate alternatives and solutions. For football and lacrosse, all equipment is sent out for refurbishing that meets the manufacturer’s requirements and regulations. That equipment is then distributed to the athletes (football) and is appropriately fitted by the

coach and/or the athletic trainer. Lacrosse equipment that is personal should be approved by the coach and/or the athletic trainer as well to ensure all regulations are followed. Football equipment and helmets will undergo weekly cleanings conducted by each athlete and monitored by the coach and/or the athletic trainer to help prevent the spread of communicable diseases. This will also present an opportunity to do air-checks in the helmets and ensure they still fit appropriately. Athletes may ALWAYS ask either the coach or the athletic trainer to check their helmet or pads and make sure they fit. There is always an helmet pump on the sidelines of practices and games to assist with fitting as well. Kearsarge Athletics General Emergency Action Plan: Physical Address: 457 North Road, North Sutton, NH 03260

1. Contact ATC (603) 731-8075 2. Administer first aid to the injured student 3. Call Emergency Medical Personnel (911) 4. Notify Parents/Guardians Promptly 5. If Injured athlete does not require transportation by EMS, the student should only be released to a parent or

guardian. Notify ATC of incident as soon as possible (if notification was not made in Step 1). 6. Notify Athletic Director if injured athlete is transported via EMS. 7. Complete Accident Report.

Emergency Telephone Numbers: EMS 9-1-1 New London Hospital 603-526-2911 Concord Hospital 603-228-7200 Dartmouth Hitchcock Medical Center 603-650-5000 Emergency Action Plans (Addition Items) By Location: A Field (Football, Soccer, Cross Country, Lacrosse, Cheer) Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest. Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care. Automated External Defibrillator (AED) Closest Locations: In the front lobby of the high school Sideline with the Athletic Trainer (if available)

If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Address (457 North Road, North Sutton NH 03257) ● Number of People Injured ● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS Address: 457 North Road, North Sutton NH 03260 The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene. Enter the A Field in the parking lot to the right of the field through the gate, across the track, and onto the field if necessary. Someone should be instructed to meet EMS at the gate to the field and direct them to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision. When possible, someone should ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department. Please notify the Athletic Department at 927-2305 if EMS has been contacted. B Field (Soccer, Lacrosse) Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest. Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care.

Automated External Defibrillator (AED) Closest Locations: In the front lobby of the high school Sideline with the Athletic Trainer (if available) If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Address (457 North Road, North Sutton NH 03260) ● Number of People Injured ● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS Address: 457 North Road, North Sutton NH 03260 The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene. Enter the B Field through the B parking lot located between the A and B fields. Someone should be instructed to meet EMS at the parking lot to the right of the field and direct them to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision. When possible, someone should ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department. Please notify the Athletic Department at 927-2305 if EMS has been contacted. Baseball / Field Hockey Field / C Field (Practice Field) Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest.

Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care. Automated External Defibrillator (AED) Closest Locations: In the front lobby of the high school Sideline with the Athletic Trainer (if available) If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Address (457 North Road, North Sutton NH 03260) ● Number of People Injured ● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS Address: 457 North Road, North Sutton NH 03260 The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene. Enter through the gate at the bottom of the hill. Drive up the hill, to the left for Baseball / Field Hockey, to the right for the C Field (Practice Field) and onto the field if necessary. Someone should be instructed to meet EMS at the gate to the field and direct them to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision. When possible, someone should ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department. Please notify the Athletic Department at 927-2305 if EMS has been contacted.

Carl D. Hill Gymnasium at KRHS (Basketball, Wrestling, Dance, Indoor Track) Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest. Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care. Automated External Defibrillator (AED) Closest Locations: In the front lobby of the high school Sideline with the Athletic Trainer (if available) If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Address (457 North Road, North Sutton NH 03260) ● Number of People Injured ● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS Address: 457 North Road, North Sutton NH 03260 The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene. Enter the gymnasium through the double doors at the back of the building.Someone should be instructed to meet EMS at the double doors closest to the Athletic Training Office and direct them to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision. When possible, someone should ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department. Please notify the Athletic Department at 927-2305 if EMS has been contacted.

Plymouth State University Ice Hockey Arena

Catastrophic Injuries This is defined as any condition in which an individual’s life is threatened or the person risks permanent impairment. Examples include, but are not limited to, respiratory or cardiac arrest, spine injuries and possible fractures.

Emergency Procedures A certified athletic trainer (AT) should be notified immediately and the supervising athletic trainer or an athletic training student should stabilize the head and neck as needed, calm the patient, and do a primary survey. If needed, life-saving techniques are initiated after the AT conducts an evaluation and makes any necessary decisions regarding patient care.

Automated External Defibrillator (AED) closest locations: In the Welcome Center lobby, next to the copy machine In the Skate Rental office If an Athletic Trainer is Unavailable The responding individual should make every reasonable attempt to contact an athletic trainer. If EMS is needed, instruct another student, coach, manager, or bystander to call 9-1-1. A second person should be sent to retrieve any necessary equipment, including, but not limited to, an AED. Be sure to have the following information:

● Name, address (129 Route 175A, Holderness, NH), telephone number of caller ● Number of persons injured ● Condition of patient(s) ● First aid initiated by first responder ● Specific directions to emergency scene

Ambulance/EMS Enter ice arena through garage door. Someone should be instructed to meet EMS to direct to proper location. The 9-1-1 caller must HANG UP LAST then go to help direct EMS to the scene.

If possible, send someone with the patient’s emergency contact and insurance information to ride with the patient to the ER. Do not leave a practice or event unattended. When possible, someone should ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department.

(Taken from PSU AT Handbook)

Proctor Ski Hill (Nordic) Emergency Personnel: Coaches trained in first aid and cpr, licensed athletic trainer(s) and student athletic trainer(s) are available upon request by calling Molly Quigley at 603-731-8075. During the winter when ski hill is open the Ski Patrol is available at the base of the lodge. Emergency Communication: Personal cell phone Emergency Equipment: supplies in first aid kits issued to each team or upon arrival of licensed athletic trainer (first aid kit, trauma kit, splint kit, AED) maintained with athletic trainer. AED available during events in Fall and Spring, and full time with Ski Patrol during winter. Roles of First Responder:

1. Immediate care of the injured or ill student-athlete. 2. Activation of athletic training department, call 603-731-8075 3. Emergency equipment retrieval 4. Activation of emergency medical system (EMS) 5. 911 call (provide name, address, number of individuals injured or ill, condition of injured/ill person(s),

first aid treatment given, specific directions, and stay on line to answer any other questions as needed) 6. Direction of EMS to scene upon their arrival

a. Designate individual to “flag down” EMS and direct to scene b. Scene control: limit scene to first aid responders and move bystanders away from area

Venue Directions Direct ambulance to 60 Blackwater Lane, first aid station is in ground floor on back side of Yarrow’s Lodge *Taken from the Proctor Academy EAP Handout- Chris Young ATC Proctor Academy - Teddy Maloney Hockey Rink (hockey, turf use) Emergency Personnel: Coaches trained in first aid and cpr, licensed athletic trainer(s) and student athletic trainer(s) are available upon request by cell phone *MOLLY QUIGLEY 603-731-8075 Emergency Communication: a) personal cell phone or b) fixed landline located in northwest corner of Farrell Fieldhouse Emergency Equipment: supplies in first aid kits issued to each team or upon arrival of licensed athletic trainer (first aid kit, trauma kit, splint kit, AED) maintained in athletic training room. Closest fixed AED is located in lobby of the rink also one in the fieldhouse located outside the athletic training room. Roles of First Responder:

1. Immediate care of the injured or ill student-athlete. 2. Activation of athletic training department 3. Emergency equipment retrieval 4. Activation of emergency medical system (EMS) 5. 911 call (provide name, address, number of individuals injured or ill, condition of injured/ill person(s),

first aid treatment given, specific directions, and stay on line to answer any other questions as needed) 6. Direction of EMS to scene upon their arrival

a. Designate individual to “flag down” EMS and direct to scene b. Scene control: limit scene to first aid responders and move bystanders away from area

*Taken from the Proctor Academy EAP Handout- Chris Young ATC

Holderness School Ice Rink (Hockey) Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest. Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care. Automated External Defibrillator (AED) Closest Locations: In the Athletics Lobby next to the doors to the weight room Sideline with the Athletic Trainer (if available) If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Address (19 Mount Prospect Road, Holderness NH) ● Number of People Injured ● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS Address: 19 Mount Prospect Road, Holderness NH) The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene. Entrance to the rink is located at the South-East corner of the rink which is closest to the parking lot entrance. A rink attendant will have to unlock that door! Someone should be directed to greet the EMS at the entrance to the rink and direct them to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision. When possible, someone should

ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department. Please notify the Athletic Department at 927-2305 if EMS has been contacted. Softball Field Emergency Action Plan (Softball) Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest. Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care. Automated External Defibrillator (AED) Closest Locations: In the front lobby of the high school Sideline with the Athletic Trainer (if available) If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Address (457 North Road, North Sutton NH 03260) ● Number of People Injured ● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS Address: 457 North Road, North Sutton NH 03260 The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene.

Enter the field through the gate in left field..Someone should be instructed to meet EMS at the gate in left field and direct them to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision. When possible, someone should ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department. Please notify the Athletic Department at 927-2305 if EMS has been contacted. Tennis Courts (Tennis) Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest. Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care. Automated External Defibrillator (AED) Closest Locations: In the front lobby of the high school Sideline with the Athletic Trainer (if available) If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Address (457 North Road, North Sutton NH 03260) ● Number of People Injured ● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS Address: 457 North Road, North Sutton NH 03260 The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene. Enter the tennis court through the gate on the parking lot side of the courts. Someone should be waiting courtside to direct them to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision.When possible, someone should ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department. Please notify the Athletic Department at 927-2305 if EMS has been contacted. Cafeteria Emergency Action Plan (Wrestling, Dance, Cheer) Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest. Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care. Automated External Defibrillator (AED) Closest Locations: In the front lobby of the high school Sideline with the Athletic Trainer (if available) If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Address (457 North Road, North Sutton NH 03260) ● Number of People Injured

● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS Address: 457 North Road, North Sutton NH 03260 The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene. Enter the cafeteria through the double doors between the softball field and the tennis courts.Someone should be instructed to meet EMS at the double doors and direct them to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision. When possible, someone should ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department. Please notify the Athletic Department at 927-2305 if EMS has been contacted. Colby-Sawyer College Sports Medicine Emergency Action Plan

The following is a guide for those involved in the care of Colby-Sawyer College student-athletes, visiting student-athletes, spectators, and staff needing emergency medical services at one of the Colby-Sawyer College Athletics Facilities. Included is information specific to each venue, such as the location of AEDs or landline telephones.

The importance of expedient action cannot be overstated when emergency care becomes necessary. Proficiently caring for and transporting injured individuals can only be achieved by frequent review and regular practice of existing emergency protocols by the Athletic Trainers, Athletic Training Students, Coaches, Event Management, Campus Safety, and other Athletic Management personnel.

Three major components of our emergency action plan include: the emergency team, means of communication, and equipment. This plan will be reviewed and revised as appropriate on an annual basis by the Colby-Sawyer College Sports Medicine Staff.

Emergency Communication After emergency care has been provided, including the activation of local EMS, the responsible individual (ie: Head Coach) should notify Colby-Sawyer College Campus Safety at (603) 526-3300 as well as the certified

athletic trainer responsible for your team - CONTACT MOLLY QUIGLEY @ 603-731-8075

Important Emergency Information

AMBULANCE: Call 911

Name Title Phone Number CSC Safety 603-526-3300

Emergency Equipment

Emergency equipment includes, but is not limited to: Automated External Defibrillators (AEDs), CPR masks, vacuum splint kit, spine board, cervical collars, ice, and other supplies needed. All emergency equipment is located in the Stock Sports Medicine Clinic (athletic training room) on the first floor of the Hogan Sports Center. Colby-Sawyer College’s athletic training department is responsible for two portable Automated External Defibrillators (AED) located with the certified athletic trainer providing event coverage. Campus safety is responsible for one additional portable AED.

Location of AEDs on Campus

Please refer to the attached map which offers a pictorial representation of AED locations, landline emergency telephones, and ambulance routes to venues.

The two portable sports medicine AEDs will be available at athletic events on the golf cart or Gator® with the sports medicine representative on site. Campus safety maintains an additional AED which is located either in their patrol vehicle or their office in Colgate Hall. AEDs are also located on the second floor of Hogan Sports Center just outside the fitness center, Ware Campus Center adjacent to Wheeler Hall, Baird Health and Counseling Center, Mercer Hall near room 103 (1st Floor hallway).

Site Specific Information

Mercer Gymnasium Emergency Phone Location: 1st Floor near entrance to the Ray Climbing Wall Stationary AED Location: 1st Floor hallway near room 103 Ambulance Route: Enter campus from Seamans Road between the Sawyer Center and Baird Health and Counseling Center, continue past campus quad and enter Mercer from upper southeast entrance.

Mercer Field (includes Rooke Field) Emergency Phone Location: Blue light call box in K Lot Static AED Location: 1st Floor hallway in Mercer Hall, near room 103 Ambulance Route: Enter field directly off of Seamans Road onto field surface

Kelsey Fields Emergency Phone Location: Call box on side of facilities shed or blue light call box in K Lot Static AED Location: No static AED available at this facility, the nearest is 1st Floor hallway in Mercer Hall, near room 103 Ambulance Route: Enter complex directly off of Seamans Road

NH Poison Control 1-800-222-1222 New London Fire Department 603-526-6073 New London Police Department 603-526-2626 New London Hospital 603-526-2911 Dartmouth-Hitchcock Medical Center 603-650-5000

Ivey Field Emergency Phone Location: Call box on door to Colby-Farm or blue light call box in M lot Static AED Location: Athletic training room in Hogan Ambulance Route: Enter via the dirt road directly from Main Street (just east of library)

Hogan Sports Center (includes Knight Natatorium, Coffin Field House, and Van Cise fitness center) Emergency Phone Location: Hogan front desk Static AED Location: Second floor hallway, left of Van Cise fitness center entrance Ambulance Route: Enter campus from Seamans Road between the Sawyer Center and Baird Health and Counseling Center, continue past campus quad and enter Hogan through main entrance.

*Taken from Colby Sawyer Athletic Training Handbook - Scott Roy, ATC & TJ Smith, ATC

Dartmouth College Sports Medicine

Emergency Action Plan LEVERONE FIELD HOUSE

*Taken from Dartmouth Sports Medicine Handbook, Bethanie Brann, ATC

In the event of an EMERGENCY: 1. Call 911

· Location: 26 South Park Street (direct to appropriate entrance) · Be prepared to provide the following information to the 911 operator:

· Your name, phone # calling from and specific location/address · Condition of injured individual:

· Age, consciousness, breathing, body part & injuries, · First aid/treatment being provided · Answer any questions & stay on the line until operator has hung up

2. Send bystander to get AED unit: located outside men’s restroom 3. Call Safety & Security: 646-4000 (automatic if calling 911 from landline phone) 4. Flag down and direct EMS to scene

Country Club of New Hampshire Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest. Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care. Automated External Defibrillator (AED) Closest Locations: Sideline with the Athletic Trainer (if available) If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Address (Kearsarge Valley Road, North Sutton NH 03260) ● Number of People Injured ● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS Address: Kearsarge Valley Road, North Sutton NH 03260 The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene. Enter the field via the gate at the bottom of the access road. Turn to the right at the top of the hill and drive onto the field if necessary.Someone should be instructed to meet EMS at the gate to the access road and direct them to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision. When possible, someone should ride with the athlete to the hospital. The best option would be a coach, athletic trainer, or member of the athletics department. Please notify the Athletic Department at 927-2305 if EMS has been contacted.

Mount Sunapee Ski Area *CONTACT SKI PATROL VIA 763-3500 Catastrophic Injuries A catastrophic injury is defined as a condition which threatens the life and/or permanent damage to the individual. This may include, but is not limited too, severe fractures, spinal/cervical injuries, and cardiac or respiratory arrest. Emergency Procedures In the event of an emergency the certified Athletic Trainer (ATC) on site should be notified immediately. The ATC or athletic training student (ATS) will stabilize c-spine if necessary, perform a primary assessment, and keep the patient calm. The ATC or ATS will initiate life-saving techniques if the conducted evaluation deems it necessary and will make all decisions necessary regarding patient stabilization and further care. Automated External Defibrillator (AED) Closest Locations: With Ski Patrol If an AT is Unavailable: The first responder to the patient will be responsible to make every attempt to contact the on-site ATC. If it is necessary to call EMS, the first responder should instruct another responsible individual to call 9-1-1. A different individual should be sent to retrieve any necessary emergency equipment including, but not limited to, the AED, Splints, etc. Please be ready to give EMS the following information:

● Your Name ● Number of People Injured ● Condition of the Patients ● First Aid Already Given to Patients ● Specific Directions to Emergency Scene (Indicated Below)

Ambulance/EMS The individual on the phone with EMS should stay on the line until the dispatcher tells you it is okay to hang up. You MUST HANG UP LAST and then return to the emergency scene. If possible, someone should ride with the patient to the ER with the patient’s emergency contact form. Please do NOT leave your practice or event unattended by appropriate supervision. Another athlete, assistant coach, or manager would be ideal to travel with an injured student-athlete. Please notify the Athletic Department at 927-2305 if EMS has been contacted.

Return to Play Decisions & Referrals Policy

The athletic trainer will follow a specific set of guidelines to return athletes to participation after illness or injury. These guidelines are as follows:

A. Any athlete that is under the care of a licensed physician, physician extender, physical therapist, or other medical professional must provide written documentation from that licensed provider to the certified athletic trainer in order to return to practice and/or competition. This documentation may contain guidelines for use by the athletic trainer to determine readiness to return to practice and/or competition.

B. For all non-referred injuries and conditions, the athletic trainer may at his/her discretion return an athlete to competition after a full physical is completed and documented.

Any athlete who has been referred for treatment MUST provide documentation in order to participate in the next practice or competition. If there is not a note the athlete may contact their referrals office to see if they will fax a note but the athlete may not begin participation until a note is on file with the athletic trainer. The appropriate fax number is 603-927-4453, with attention to the athletic trainer. In the case that injury or illness requires specialist attention or a referral the athletic trainer will make a decision regarding who the athlete should be referred to. If the athlete is referred to a primary care physician then the return to play note should also come from the same physician. The athletic trainer follows a set of guidelines in order to determine who should or should not be referred. These guidelines are as follows:

A. Head: a. Any loss of consciousness, seizure/posturing activity. b. Deterioration, rather than improvement, of neurological signs and symptoms. c. Post concussion symptoms that do not improve, worsen, or begin to interfere with the athlete’s

daily activities (e.g., sleep disturbances or cognitive difficulties) B. Spine:

a. All suspected serious neck or spine injuries including but not limited to fractures, dislocations, sprains, strains, etc. with or without neurological compromise.

b. Extended neurological compromise associated with brachial plexus injuries (motor weakness or abnormal nerve function)

C. Extremities: a. All suspected fractures and dislocations. b. All suspected third degree sprains or strains.

D. Other injury or illness conditions: a. Exertion or sport related syncope. b. Significant respiratory difficulty uncontrolled by existing pharmacological intervention or in

athletes previously undiagnosed with respiratory pathology. At any point, if the athletic trainer finds an injury that does not fit these guidelines appropriately the team physician will be contacted for a second opinion and the two will agree on an appropriate treatment plan for that athlete. If parents/guardians have any issues with a diagnosis or would like a second opinion they are more than welcome to do so, however, they must bring a note from that physician regarding return to play and diagnosis decisions.

Kearsarge Regional High School Concussion Protocol:

Medical management of sports related concussion is evolving. In recent years there has been a significant amount of research into sports-related concussion in high school athletes. Kearsarge Regional High School has established this protocol to provide education about concussion for athletic department staff, school personnel, athletes, and parents. This protocol outlines procedures for staff to follow in managing head injuries, and outlines school policy as it pertains to participation in athletics after concussion. Kearsarge Regional High School seeks to provide a safe return to activity for all athletes after injury, particularly after a concussion. In order to effectively and consistently manage these injuries, procedures have been developed to aid in ensuring that concussed athletes are identified, treated, referred appropriately, and receive appropriate follow-up medical care. In addition to recent research, two primary documents were consulted in developing this protocol. The “Consensus statement on concussion in sport-The 3rd International Conference on Concussion in Sport, held in Zurich, November 2008”(referred to in this document as the Zurich statement), and the “National Athletic Trainers’ Association Position Statement: Management of Sport Related Concussion” (referred to in this document as the NATA Statement). Contents: 1. Recognize Remove Refer 2. Initial Assessment 3. Concussion Vital Signs - neuropsychological requirements 4. ATC procedures 5. Return to Play 6. Additional Information 1. Recognize, remove, refer a. Recognize Concussion All Coaches should become familiar with the signs, symptoms, and mechanism of concussion. The following signs and symptoms are indicative of a probable concussion. Other causes for symptoms should also be considered.

Signs (Observed by others) Symptoms (reported by the athlete)

Athlete appears dazed or stunned Headache

Confusion (about assignments, play, etc.) Fatigue

Forgets Plays Nausea or Vomiting

Unsure about game, score, opponent Double vision, blurry vision

Moved clumsily (altered coordination) Sensitivity to light or noise

Balance Problems Feels sluggish

Personality Changes Feels ‘foggy

Very basic cognitive testing should be performed to determine cognitive deficits b. Remove from Activity

i. In accordance with NH SB 402 any coach, official, licensed Athletic Trainer, or health care provider who suspects that a student-athlete has sustained a concussion or head injury in a practice or a game shall remove the student-athlete immediately until evaluated medically by a Certified Athletic Trainer or health care provider. c. Refer the Athlete for Medical Evaluation Coaches should report all head injuries to the Certified Athletic Trainer as soon as possible for medical assessment, management, and coordination of home instructions and follow up care with their primary care provider. 2. Initial Assessment (when available) a. The Certified Athletic Trainer will assess the injury, or provide the guidance to the coach if unavailable to personally attend to the athlete.

i. Modified-Sport Concussion Assessment Tool General cognitive status can be determined by simple sideline cognitive testing. The Certified Athletic Trainer will utilize a modified SCAT5 for serial sideline assessment as recommended by the NATA and Zurich Statements. b. The SCAT 5 is most effective immediately after an injury and can be less effective after 12+ hours post injury. The Certified Athletic Trainer will make all possible attempts to perform this testing in the appropriate window. 3. Concussion Vital Signs testing requirements. a. Concussion Vital Signs is a computer test that evaluates multiple aspects of neurocognitive function, including memory, attention, and brain processing speed, reaction time, and post-concussion symptoms. Neuropsychological testing is utilized to help determine recovery after a concussion. b. All KRHS athletes are required to take a baseline Concussion Vital Sign test prior to participation in sports. Athletes must have “Valid” results as determined by the testing service in order to participate in sports. Re-testing may occur in order to achieve this status. c. Athletes are required to establish a “new” Concussion Vital Signs baseline score prior to participation in athletics during their junior year. 4. Procedures for ATC a. The ATC will assess the injury, or provide guidance to the coach if unable to personally attend to the athlete. Immediate referral to a health care provider when medically appropriate. The ATC will perform serial assessments following the recommendations in the NATA Statement, and utilize a modified SCAT5 as the

Responds slowly to questions Problems concentrating

Forgets events prior to the hit Problems remembering

Forgets events after the hit Sensitivity to light

Loss of consciousness (any duration) Sensitivity to noise

concussion assessment tool. The ATC will notify the athlete's parents or guardians and provide written and/or verbal instructions. b. The ATC will refer ALL athletes that experience a high symptom score, loss of consciousness, altered cranial nerve assessment, seizure, or posturing activity related to the injury to the emergency department for immediate assessment. Athletes may be referred later in this process if symptoms or condition deteriorate in the following 24 hours. c. All athletes will be referred to their primary care physician for official clearance purposes. It is important to let the Certified Athletic Trainer know before you see the physician so that testing data and appropriate forms can be faxed to the office for signing and clearance purposes. ALL athletes must have a PRIMARY CARE PHYSICIAN (or specialist in neuropsychology) sign the official paperwork before they can RETURN TO SPORTS. d. Prior to the next school day the ATC will notify the School Nurse of the injury. The School Nurse can initiate appropriate in-school follow up including teacher and guidance counselor notification. It is recommended that parents contact their child’s primary care physician to notify them of the injury though they may not be seen by their primary care physician immediately (besides above requests). e. The initial post-injury test will be administered within 48-72 hours post injury, whenever possible. Repeat post-concussion tests will be given at appropriate intervals, depending on clinical presentation. f. The ATC will review post-injury concussion test data with the athlete and the athlete’s parents when available. g. The ATC will forward the post injury testing results and the sideline modified SCAT5 to the athlete’s treating health care provider. h. The ATC will determine if the athlete should be seen by their health care provider or if an appointment can wait until the beginning of the return to play protocol. If the ATC determines there are findings that should be evaluated by a specialist they will make this decision with the athlete’s health care provider. i. The ATC will monitor the athlete, and keep the school nurse informed of the individuals symptomatology and neurocognitive status. This is to aid in the purpose of developing or modification of an appropriate health care plan for the Student-Athlete. j. When the athlete has been symptom free for a MINIMUM of 24 hours the ATC will conduct an additional Concussion Vital Signs post injury test. This data will be compared to the baseline and subsequent tests for the determination of return to play. All test scores should be back to baseline or, at a minimum, within 5% of baseline scores. Any discrepancies may be discussed with the athlete’s health care provider for clarification. k. The ATC is responsible for monitoring recovery and coordinating the appropriate return to play activity progression, in accordance with NH SB 402. l. The ATC will maintain appropriate documentation regarding assessment and management of the injury. 5. Return to Participation Procedures after concussion a. Returning to participation on the same day of the injury. As previously discussed in this protocol, an athlete who exhibits signs or symptoms of a concussion or has abnormal cognitive testing will not be permitted to return to play on the

day of the injury. Any athlete who denies symptoms but has abnormal sideline cognitive testing will be held out of activity for at least that day.

“When in doubt, hold them out” b. Return to play after a concussion The Athlete must meet all of the following criteria in order to progress to activity:

1: Asymptomatic at rest AND exertion. (including mental exertion in school).

AND

2: Post Concussion Vital Signs test scores are within normal range of baseline

AND

3: In accordance with NH SB 402 the Student-Athlete’s health care provider must provide written documentation to provide clearance for progression to activity and subsequent return to play.

AND

4. In accordance with NH SB 402 the Student-Athletes parents must also provide written documentation to acknowledge understanding of the risks involved with return to participation, and acknowledge that their child was evaluated by the health care provider. C. Once the above criteria are met, the athlete will be progressed back to full activity following a stepwise process, (also recommended by both Zurich and NATA statements), under the direct supervision of the ATC. d. Stepwise progression as described in the Zurich Statement: The Athlete will continue to proceed to the next level if asymptomatic at the current level. Each step will take 24 hours so that an athlete would take approximately one week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and physical exertion. If any post-concussion symptoms occur during the stepwise progression, the athlete will drop back to the previous asymptomatic level and attempt to progress from that level after a 24 hour period of rest has passed. 1. Light aerobic activity in a short increment. 2. Light aerobic activity (e.g. Exercise walking, stationary bike) 3. Sport specific training (e.g. skating in hockey, running in soccer) 4. Non-contact training drills. 5. Full-contact training. 6. Game Play. e. Once both the ATC and the athlete’s primary care physician have signed off on clearing the athlete for return to play the coach has the official capacity to determine when it is appropriate to return the athlete to game play.

6. Additional Information The ATC is happy to speak to anyone regarding the concussion protocol. The protocol is monitored by the ATC and not the coaches, it is important that questions during the process are directed to the ATC so they can be addressed. Additionally, there are no current recommendations on the number of concussions that an individual can sustain before they should be removed from participation. This conversation should occur with your child’s primary care physician. The dangers of too many concussions is well documented and this is not a situation that any athlete should be put in. Concussions are very serious injuries classified as mild traumatic brain injuries. Please encourage all athletes to report signs and symptoms and to follow return to play guidelines appropriately.

Heat Related Illness Policy

The KRHS athletics staff recognize and follow the National Athletic Trainers’ Association’s Position statement on Exertional Heat Illnesses. This document provides the appropriate information for the safest treatment, recognition, and prevention of and heat related illness or injury. The following is an excerpt from the above named position statement, to read the entire position statement please go to the National Athletic Trainers’ Association’s website, click on the statements link under the Practice and Patient Care tab at the top of the page, and select the link titled “Exertional Heat Illnesses”. “DEFINITIONS OF EHIs Exercise-Associated Muscle Cramps

Exercise-associated muscle cramps (EAMCs) are sudden or sometimes progressively and noticeably evolving, involuntary, painful contractions of skeletal muscle during or after exercise.4,5 Heat cramps is a popular but technically inappropriate term for a certain category of EAMCs because they are not directly related to an elevated body temperature,5,6 do not readily occur after passive heating at rest, and can present during exercise in warm or even cool6– 8 and temperature-controlled conditions,9 although extensive sweating is typical. The signs and symptoms of incipient EAMCs can be described as tics, twinges, stiffness, tremors, or contractures, but these terms refer to conditions that are typically painless and do not demonstrate muscle activity on electromyography, unlike fullblown EAMCs.10 The cause of EAMCs is not fully confirmed; proposed contributing factors and conditions include dehydration,5 electrolyte imbalances,5,11 altered neuromuscular control,4 fatigue, or any combination of these factors.5–10 Heat Syncope

Heat syncope, or orthostatic dizziness, often occurs in unfit or heat-unacclimatized persons who stand for a long period of time in the heat or during sudden changes in posture in the heat, especially when wearing a uniform or insulated clothing that encourages and eventually leads to maximal skin vasodilation. This condition is often attributed to dehydration, venous pooling of blood, reduced cardiac filling, or low blood pressure with resultant cerebral ischemia.12 Heat syncope usually occurs during the first 5 days of unaccustomed heat exposure (eg, during the preseason), before the blood volume expands and cardiovascular adaptations are complete, and in those with heart disease or taking diuretics.13

Heat Exhaustion Heat exhaustion is the inability to effectively exercise in the heat, secondary to a combination of factors,

including cardiovascular insufficiency, hypotension, energy depletion, and central fatigue.14 This condition is manifested by an elevated core body temperature (usually ,40.58C) and is often associated with a high rate or volume of skin blood flow, heavy sweating, and dehydration.15 It occurs most frequently in hot or humid (or both) conditions, but it can also occur in normal environmental conditions with intense physical activity. Heat exhaustion most often affects heat-unacclimatized or dehydrated individuals with a body mass index .27 kg/m.16 By definition, absent from heat exhaustion are end-organ damage, which would indicate heat injury (eg, renal insufficiency, rhabdomyolysis, or liver injury), and significant central nervous system (CNS) dysfunction with marked temperature elevation (.40.58C [1058F]), which would indicate the possibility of EHS. Exertional Heat Injury

Heat injury is a moderate to severe heat illness characterized by organ (eg, liver, renal) and tissue (eg, gut, muscle) injury associated with sustained high body temperature resulting from strenuous exercise and environmental heat exposure. Body temperature is usually but not always greater than 40.58C (1058F).17,18 Exertional Heat Stroke

Exertional heat stroke is the most severe heat illness. It is characterized by neuropsychiatric impairment and a high core body temperature, typically .40.58C (1058F).16,19 This condition is a product of both metabolic heat production and environmental heat load and occurs when the thermoregulatory system becomes overwhelmed due to excessive heat production (ie, metabolic heat production from the working muscles) or inhibited heat loss (ie, decreased sweating response, decreased ability to evaporate sweat) or both. Although this illness is most likely to occur in hot and humid weather, it can manifest with intense physical activity in the absence of extreme environmental conditions. The first sign of EHS is often CNS dysfunction (eg, collapse, aggressiveness, irritability, confusion, seizures, altered consciousness).19 A medical emergency, EHS can progress to a systemic inflammatory response and multi-organ system failure unless promptly and correctly recognized and treated. The risks of morbidity and mortality increase the longer an individual’s body temperature remains elevated above the critical threshold (.40.58C [1058F]) and are significantly reduced if body temperature is lowered promptly.20 RECOMMENDATIONS

The NATA advocates the following prevention, recognition, and treatment strategies for EHIs. These recommendations are presented to help certified athletic trainers and other health care providers maximize health, safety, and sport performance. However, individual responses to physiologic stimuli and environmental conditions vary widely. Therefore, these recommendations do not guarantee full protection from exertional heat-related illnesses but could mitigate the risks associated with athletic participation and physical activity. These recommendations and prevention strategies should be carefully considered and implemented by certified athletic trainers and the health care team as part of an overall strategy for the prevention and treatment of EHIs. The strength of each recommendation follows the Strength of Recommendation taxonomy (SORT; Table 1).21 Prevention

1. Conduct a thorough, physician-supervised preparticipation medical screening before the start of the season to identify athletes with risk factors for heat illness or a history of heat illness (Table 2).22,23 Strength of recommendation: C

2. Individuals should be acclimatized to the heat gradually over 7 to 14 days.22–26 Heat acclimatization involves progressively increasing the intensity and duration of physical activity and phasing in protective equipment (if Journal of Athletic Training 987 applicable). If heat acclimatization is not maintained, the physiologic benefits provided by this process will decay within 3 weeks.24–26 The first 2–3 weeks of preseason practice typically present the greatest risk of EHI, particularly in equipment-intensive sports.26,27–29 All possible preventive measures should be used during this time to address this high-risk period (Figure 1). Strength of recommendation: B

3. Athletes who are currently sick with a viral infection (eg, upper respiratory tract infection or gastroenteritis) or other illness or have a fever or serious skin rash should not participate until the condition is resolved.16,27,30 Even after symptoms resolve, the athlete may still be susceptible to heat illness and should be observed carefully upon return to exercising in the heat. Strength of recommendation: B

4. Individuals should maintain euhydration and appropriately replace fluids lost through sweat during and after games and practices (see the NATA position statement on fluid replacement in athletes31). Players should have free access to readily available fluids at all times, not just during designated breaks. Instruct them to eat or drink appropriate sodium-containing fluids and foods to help replace sodium losses in sweat and urine and to enhance hydration (ie, water retention and distribution). The aims of fluid consumption or replacement are to prevent a body mass loss of more than 2% (as measured before and after the practice or game) and to keep morning urine light in color.31,32 These strategies may reduce the risk of acute and chronic significant dehydration and decrease the risk of EHI.27,31–34 Strength of recommendation: B

5. The sports medicine staff must educate relevant personnel (ie, coaches, administrators, security guards, emergency medical services [EMS] staff, athletes) on preventing and recognizing EHI and, in particular, EHS.35,36 Signs and symptoms of a medical emergency should be reviewed, and every institution should have and personnel should practice an emergency action plan specific to each practice and game site. Review and rehearsal of the emergency action plan should include all relevant members of the sports medicine team (ie, coaches, athletic trainers, EMS). Strength of recommendation: C

6. Appropriate medical care must be available, and all personnel must be familiar with EHI prevention, recognition, and treatment.35–37 Certified athletic trainers and other health care providers covering practices or events are the primary providers of medical care for athletes who display signs or symptoms of EHI and have the authority to restrict an athlete from participating if EHI is suspected or to refer the athlete for a significant EHI condition. Strength of recommendation: C

7. When environmental conditions warrant, a cold-water or ice tub and ice towels should be available to immerse or soak a patient with a suspected heat illness.33,37 Immediate whole-body cooling is essential for treating EHI and EHS in particular. Onsite facilities are needed for immediate treatment. Strength of recommendation: B

8. The assessment of rectal temperature is the clinical gold standard for obtaining core body temperature of patients with EHS38 and the medical standard of practice and accepted protocol. No other field-expedient methods of obtaining core body temperature (eg, oral, axillary, tympanic, forehead sticker, temporal) are valid or reliable after intense exercise in the heat, and they may lead to inadequate or inappropriate treatment, thereby endangering a patient’s health.38–41 Parents, administrators, coaches, and student-athletes should be educated ahead of time that this procedure will be used for heat-illness emergencies, especially in patients suspected of having heat exhaustion or EHS. Esophageal and gastrointestinal (via ingestible thermistor) measurements may be appropriate alternatives for temperature assessment but require advanced training for the former and careful planning for the latter. Under all circumstances in which EHS is possible, a rectal temperature assessment should be able to be obtained. Strength of recommendation: A

9. Because the effects of heat are cumulative, athletes should be encouraged to sleep at least 7 hours per night in a cool environment; eat a balanced diet; and properly hydrate before, during, and after exercise.16 Individuals should also be advised to rest in a cool environment during periods of inactivity (eg, off days,

between sessions on double-practice days) to maximize recovery. Rest periods should incorporate meal times and allow 2 to 3 hours for food, fluids, electrolytes (primarily sodium and chloride), and other nutrients to be digested and absorbed before the next practice or competition. Strength of recommendation: C

10. To anticipate potential problems, a preseason heat-acclimatization policy should be developed for organized sports and event guidelines formulated for hot, humid weather conditions based on the type of activity and wetbulb globe temperature (WBGT).23,26 In stressful environmental conditions, particularly during the first 2–3 weeks of preseason practice, activity should be delayed or rescheduled or the practice session shortened to reduce the risk to participants. Special attention should be given to practice drills that involve high-intensity activity and full protective equipment worn by players, as these factors may exacerbate the amount of heat stress on the body. Strength of recommendation: B

11. Individuals who may be particularly susceptible to EHI must be identified.42–45 They should be closely monitored during stressful environmental conditions, and preventive steps should be taken.45,46 In addition, emergency supplies and equipment (eg, tubs for cold-water immersion [CWI], rectal thermometer) should be onsite, easily accessible, and in good working order to allow for immediate intervention and treatment if needed. Strength of recommendation: B

12. Rest breaks should be planned and the work-to-rest ratio modified to match the environmental conditions and the intensity of the activity.45–47 Breaks should be in the shade or in a predetermined cooling zone and should allow enough time for all athletes to consume fluids. Additionally, players should be permitted to remove equipment (eg, helmets) during rest periods. Strength of recommendation: B

13. The use of dietary supplements and other substances that have a dehydrating effect, increase metabolism, or affect body temperature and thermoregulation is discouraged.48 Because supplements may increase the risk of EHI, their use should be carefully monitored. Strength of recommendation: C

14. Minimal experimental evidence exists regarding the most effective method of preventing EAMCs due to the variety of causes. Supplemental sodium ingestion and fluid monitoring9 or neuromuscular reeducation49 may help to prevent EAMC recurrences. Clinicians should identify the patient’s unique intrinsic (eg, hydration, acclimatization, biomechanics, training status) and extrinsic (eg, climate conditions, exercise intensity) risk factors that preceded EAMCs before implementing a prevention strategy. Strength of recommendation: C Recognition Exercise-Associated Muscle Cramps.

15. A patient experiencing EAMCs will likely show 1 or more of the following signs and symptoms: visible cramping in part or all of the muscle or muscle groups, localized pain, dehydration, thirst, sweating, or fatigue.4,5,50 Strength of recommendation: C

16. A thorough medical history should be obtained to distinguish muscle cramping as a result of an underlying clinical condition (eg, sickle cell trait) from EAMCs.50 The latter is often preceded by subtle muscle twitching,4 whereas the former is not. Strength of recommendation: C

17. Most EAMCs related to overload or fatigue tend to be short in duration (less than 5 minutes) and mild in Figure 1. National Collegiate Athletic Association heat-acclimatization guidelines. Journal of Athletic Training 989 severity.7,51 However, some EAMCs severely affect athletic performance and as a result, prohibit further exercise; require further medical attention to resolve; or elicit soreness for several days.7,49–51 Strength of recommendation: B Heat Syncope.

18. A patient who experiences a brief episode of fainting associated with dizziness, tunnel vision, pale or sweaty skin, and a decreased pulse rate while standing in the heat or after vigorous exercise (with a relatively low rectal temperature [,398C]) is likely experiencing heat syncope.12 However, responsiveness,

breathing, and pulse must be assessed to rule out a cardiac event, which can present with similar signs and symptoms but is a more serious condition. Strength of recommendation: B

19. A thorough medical history and physical examination should be performed to eliminate any other medical conditions that could cause syncope. Strength of recommendation: C

Exertional Heat Exhaustion.

20. Heat exhaustion may be present if the patient demonstrates excessive fatigue, faints, or collapses with minor cognitive changes (eg, headache, dizziness, confusion) while performing physical activity,15 yet the athletic trainer should assess the patient’s CNS function by noting any bizarre behavior, hallucinations, altered mental status, confusion, disorientation, or coma that may indicate a more serious condition such as EHS. Other signs and symptoms of exertional heat exhaustion may include fatigue, weakness, dizziness, headache, vomiting, nausea, lightheadedness, low blood pressure, and impaired muscle coordination. Strength of recommendation: B

21. It is strongly recommended that a rectal temperature be obtained to differentiate exertional heat exhaustion from the more serious EHS. With heat exhaustion, core body temperature (measured rectally) is usually less than 40.58C (1058F), a key characteristic that differentiates it from EHS. Strength of recommendation: A Exertional Heat Stroke.

22. The 2 main diagnostic criteria for EHS are CNS dysfunction and a core body temperature greater than 40.58C (1058F).16,19,52 However, if a suspected EHS victim exhibits CNS dysfunction even though the rectal temperature is slightly lower (ie, 408C [1048F]), it is prudent to assume the patient is suffering from EHS and begin the appropriate treatment. After initial collapse, recognition is often delayed, and the patient may begin to cool passively, dropping below the 40.58C (1058F) threshold. Rectal temperature thermometry is the only method of obtaining an immediate and accurate measurement of core body temperature. Other devices, such as oral, axillary, aural canal, tympanic, forehead sticker, and temporal artery thermometers, inaccurately assess the body temperature of an exercising person.38–41 A delay in accurately assessing temperature during diagnosis may also explain a body temperature that is lower than expected. Strength of recommendation: A

23. Because immediate treatment is vital in EHS, it is important to not waste time by substituting an invalid method of temperature assessment if rectal thermometry is not available. Instead, the practitioner should rely on other key diagnostic indicators (ie, CNS dysfunction, circumstances of the collapse). If EHS is suspected, CWI (or another rapid cooling mechanism if CWI is not available) should be initiated immediately. Strength of recommendation: C

24. In a patient suspected of having EHS, CNS function should be assessed. Signs and symptoms can include disorientation, confusion, dizziness, loss of balance, staggering, irritability, irrational or unusual behavior, apathy, aggressiveness, hysteria, delirium, collapse, loss of consciousness, and coma. In some cases, a lucid interval may be present; however, if EHS is present, the patient will likely deteriorate quickly. Strength of recommendation: B

25. Other signs and symptoms of EHS that may be present include dehydration, hot and wet skin, hypotension, and hyperventilation. Most patients with EHS have hot, sweaty skin as opposed to those with the classical type of heat stroke (the passive condition that typically affects children and the elderly), who present with dry skin. (Table 3). Strength of recommendation: B

Heat Injury. 26. Heat injury is a moderate to severe heat illness characterized by end-organ damage but the

absence of the profound CNS dysfunction often found with EHS.17,18 Evaluation usually reveals very dark (cola-colored) urine, severe muscle pain, and abnormal blood chemistry levels. Strength of recommendation: B Treatment Exercise-Associated Muscle Cramps.

27. The immediate treatment for acute EAMCs related to muscle overload or fatigue is rest and passive static stretching of the affected muscle until cramps abate.7,51,53 Icing, massage, or both may also help relieve some of the discomfort after EAMCs.5 For EAMCs related to excessive sweating and a suspected whole-body sodium deficit, the patient must ingest sodium-containing fluids (preferably) or foods (or both) to help return the body to normal fluid, electrolyte, and energy distribution. Strength of recommendation: B

28. Fluid absorption, retention, and distribution are enhanced by beverages that contain sodium and carbohydrates. A high-sodium product (eg, salt packet) may be added to a beverage to help offset sodium lost via exercise-induced sweating. Similarly, small volumes (eg, 1 mL per 1 kg body weight) of a salty solution such as pickle juice may be consumed, if tolerated, without negatively affecting ad libitum water ingestion,54 plasma electrolyte concentrations,55 or thirst or causing nausea or stomach fullness.54 Strength of recommendation: B

29. Patients with EAMCs are normally conscious and responsive and have normal vital signs.50 Thus, clinicians can provide fluids orally to a patient suffering from EAMCs who is compliant and tolerating fluid intake. The use of intravenous fluids should be considered if the patient is noncompliant or unable to tolerate fluids.5 Strength of recommendation: A

30. Patients with recurring EAMCs should undergo a thorough medical screening to rule out more serious 990 Volume 50 Number 9 September 2015 neuromuscular conditions (eg, fatigue, hydration level, improper nutrition).50 Strength of recommendation: C Heat Syncope.

31. The clinician should move the patient to a shaded area, monitor vital signs, elevate the legs above the level of the heart, cool the skin, and rehydrate.12 Strength of recommendation: C Exertional Heat Exhaustion.

32. Removing any excess clothing and equipment increases the evaporative surface of the skin and facilitates cooling. Strength of recommendation: C

33. The patient should be moved to a cool or shaded area. Further body cooling should be accomplished via fans or ice towels if necessary. Strength of recommendation: C

34. While monitoring vital signs, the clinician should place the patient in the supine position with legs elevated above the level of the heart to promote venous return.15,16,56 Strength of recommendation: C

35. If intravenous fluids are needed or if recovery is not rapid (within 30 minutes of initiation of treatment) and uneventful, fluid replacement should begin and the patient’s care transferred to a physician. If the condition worsens during or after treatment, EMS should be activated.15,16 Additionally, rectal temperature should be obtained; if .40.58C (1058F), the patient should be treated for EHS. Strength of recommendation: C Exertional Heat Stroke.

36. For any EHS patient, the goal is to lower core body temperature to less than 38.98C (1028F) within 30 minutes of collapse.20 Body cooling serves 2 purposes: returning blood flow from the skin to the heart and lowering core body temperature by reducing the hypermetabolic state of the organs. The length of time the

core body (and particularly the brain) is above the critical temperature threshold (40.58C [1058F]) dictates morbidity and the risk of death from EHS (Figure 2).57,58 Strength of recommendation: B

37. When EHS is suspected, the patient’s body (trunk and extremities) should be quickly immersed in a pool or tub of cold water. Removing excess clothing and equipment will enhance cooling by maximizing the surface area of the skin. However, because removing excess clothing and equipment can be time consuming, CWI should begin immediately and equipment should be removed while the patient is in the tub (or while temperature is being assessed or the tub is being prepared).59 Rectal temperature and other vital signs should be monitored during cooling every 5 to 10 minutes if a continuous monitoring device is not available.20,60 Strength of recommendation: B

38. Cold-water immersion up to the neck is the most effective cooling modality for patients with EHS.57 The water should be approximately 1.78C (358F) to 158C (598F) and stirred continuously to maximize cooling. The patient should be removed when core body temperature reaches 38.98C (1028F) to prevent overcooling (Table 4).60 Strength of recommendation: A

39. Although cooling rates may vary, the cooling rate for CWI will be approximately 0.28C/min (0.378F/min) or about 18C every 5 minutes (or 18F every 3 minutes) when considering the entire immersion period from postcollapse to 38.98C (1028F).20,57,58 Strength of recommendation: B

40. If full-body CWI is not available, partial-body immersion (ie, torso) with a small pool or tub and other modalities, such as wet ice towels rotated and placed over the entire body or cold-water dousing with or without fanning, may be used but are not as effective as CWI.61,62 Strength of recommendation: B

41. If a physician is onsite (as in a mass medical tent situation) and can manage the EHS, then transportation to a medical facility may not be necessary if cooling occurred immediately (ie, if the duration above 408C [1048F] was less than 30 minutes) and the patient is asymptomatic 1 hour postcooling. If a physician is not present but other medical staff (eg, AT, EMS, nurse) are onsite, aggressive cooling should continue until the patient’s temperature is 398C (102.88F). When medical staff is onsite, all patients with EHS should be cooled first and transported second. However, when medical staff is not present and EHS is suspected, then the coaching staff/supervisors should implement cooling until medical assistance arrives. Strength of recommendation: B

42. Policies and procedures for cooling patients before transport to the hospital must be explicitly stated in an emergency action plan and shared with potential EMS responders so that treatment of EHS by all medical professionals is coordinated (Figure 3). Strength of recommendation: B Return to Activity

43. In cases of EAMCs or heat syncope, the athletic trainer should monitor the patient’s condition until signs and symptoms are no longer present. Strength of recommendation: C

44. In patients with heat exhaustion, same-day return to activity is not recommended and should be avoided.15,56 Strength of recommendation: C

45. Many patients with EHS are cooled effectively and sent home the same day63; they may be able to resume modified activity within 1 month with a physician’s clearance. However, when treatment is delayed (ie, not provided within 30 minutes), patients may experience residual complications for months or years after the event. Strength of recommendation: C

46. Most guidelines suggest that a patient recovering from EHS be asymptomatic with normal blood-work results (renal and hepatic panels, electrolytes, and muscle enzyme levels) before a gradual return to activity is initiated.64 Unfortunately, few evidence-based strategies have been developed to determine recovery of the thermoregulatory system,65 so the medical professional must use clinical cues such as ongoing signs and symptoms, responses to a standard exercise heat-tolerance test, responses to gradually increasing exercise demands, and ability to acclimatize to the heat to make return-toplay decisions. Strength of recommendation: C

47. In all cases of EHS, after the patient has completed a 7- to 21-day rest period, demonstrated normal blood-work results, and obtained physician clearance, he or she may begin a progression of physical

activity, supervised by the athletic trainer or other medical professional with knowledge of EHS treatment and care, from low intensity to high intensity and increasing duration in a temperate environment, with equipment added gradually where indicated. Also, a graded progression of heat acclimatization, while monitoring for signs and symptoms of EHI, should be completed. The ability to progress depends largely on the treatment provided, and in some rare cases, full recovery may not be possible. Rectal temperature and heart rate should be monitored during these activities, and if the patient experiences any side effects or negative symptoms with training, the progression should be slowed, delayed, or stopped.65,66 Strength of recommendation: C

48. Although structured guidelines for return to play after EHS in athletics are lacking, the US military has adopted effective recommendations for the proper progression of return to duty after an episode of EHS. The main considerations are treating any associated sequelae and, if possible, identifying the cause of EHS, so that future episodes can be prevented.65–67 As evidence-based medicine research has advanced, the role of exercise heat-tolerance testing has gained favor as a commonsense approach: a patient who has a poor test result should not increase activity at that point. However, the significance of a normal test result and its relationship with clearance to return to play still need to be refined and evaluated. In either circumstance, monitoring the physiologic response to series of challenging exercise heat exposures is a large step forward in our delivery of health care to the EHS patient who is recovering and working toward a return to physical activity as a laborer, soldier, or athlete. This method has proved effective within the Israeli military68 and the US military and at the Korey Stringer Institute, and it supports many of the considerations put forth by the American College of Sports Medicine and US military.65,67,69 Strength of recommendation: C”

Cold Stress Policy

The KRHS athletics staff recognize and follow the National Athletic Trainers’ Association’s Position statement on Environmental Cold Injuries. This document provides the appropriate information for the safest treatment, recognition, and prevention of and cold related illness or injury. The following is an excerpt from the above named position statement, to read the entire position statement please go to the National Athletic Trainers’ Association’s website, click on the statements link under the Practice and Patient Care tab at the top of the page, and select the link titled “Environmental Cold Injuries”. “DEFINITIONS OF COLD INJURIES

Cold injuries are classified into 3 categories: decreased core temperature (hypothermia), freezing injuries of the extremities, and nonfreezing injuries of the extremities. Each scenario and its characteristic condition(s) will be described. A summary of the signs and symptoms of these injuries and illnesses is found in Table 1, with images of the skin conditions displayed in Figures 1 through 3. Hypothermia

Traditionally, hypothermia is defined as a decrease in core body temperature below 956F (356C). Hypothermia is classified as mild, moderate, or severe, depending upon measured core temperature. Information in the literature varies slightly as to which core temperatures are assigned to which degree of hypothermia, but in this paper, we will use the following definitions. Mild hypothermia is a core temperature of 956F (356C) to 98.66F (376C). Moderate hypothermia is a core temperature of 906F (326C) to 946F (346C). Severe hypothermia is a core temperature below 906F (326C).1,7–9 Each level of hypothermia has characteristic signs and symptoms, although individuals respond differently, and not every hypothermic person exhibits all signs and symptoms. Therefore, a detailed assessment is appropriate in all cases of potential cold injury. Hypothermia is most likely to occur with prolonged exposure to cold, wet, or windy conditions (or a

combination of these) experienced during endurance events, outdoor team sports (eg, soccer, football), mountaineering, hiking, and military maneuvers and in occupations that require long periods outdoors or in unheated spaces (eg, public safety, building trades, transportation). Frostbite and Frostnip

Frostbite is actual freezing of body tissues. It is a localized response to a cold, dry environment, yet moisture from sweating may exacerbate frostbite due to increased tissue cooling. Similar to hypothermia, frostbite has stages, delineated by the depth of tissue freezing and resulting in frostnip, mild frostbite, or severe frostbite.1,8–13 Frostbite develops as a function of the body’s protective mechanisms to maintain core temperature. Warm blood is shunted from cold peripheral tissues to the core by vasoconstriction of arterioles, which supply capillary beds and venules to the extremities and face, especially the nose and ears. Frostbite progresses from distal to proximal and from superficial to deep. As the temperature of these areas continues to decrease, cells begin to freeze. Damage to the frostbitten tissue is due to electrolyte concentration changes within the cells, resulting in water crystallization within the tissue. For cells to freeze, the tissue temperature must be below 286F (226C).8–13

Frostnip, the mildest form of cold injury to the skin, is a precursor to frostbite. It can occur with exposure of the skin to very cold temperatures, often in combination with windy conditions. It can also occur from skin contact with cold surfaces (eg, metal, equipment, liquid). With frostnip, only the superficial skin is frozen; the tissues are not permanently damaged, although they may be more sensitive to cold and more likely, with repeated exposures, to develop frostnip or frostbite.8–13 Mild frostbite involves freezing of the skin and adjacent subcutaneous tissues; extracellular water freezes first, followed by cell freezing. Severe frostbite is freezing of the tissues below the skin and the adjacent tissues, which can include muscle, tendon, and bone.8–13 Chilblain (Pernio)

Chilblain, also known as pernio, is an injury associated with extended exposure (1–5 hours) to cold, wet conditions. Chilblain is an exaggerated or uncharacteristic inflammatory response to cold exposure. Prolonged constriction of the skin blood vessels results in hypoxemia and vessel wall inflammation; edema in the dermis may also be present. Chilblain can occur with or without freezing of the tissue. The hands and feet are most commonly affected, but chilblain of the thighs has also been reported.14 Situations in which this can happen include alpine sports, mountaineering, hiking, endurance sports, and team sports in which footwear and clothing remain wet for prolonged periods due to water exposure or sweating. Chilblain severity is time and temperature related. The higher the temperature of the water (generally ranging from 326F [06C] to 606F [166C]), the longer the duration of exposure required to develop chilblain. Time of exposure is usually measured in hours or even days, rather than the minutes or hours associated with frostbite. Chilblain and immersion foot (see below) occur in similar environments, but the former is a more superficial injury and can develop in a shorter time period than the latter.13,14

Immersion (Trench) Foot. Immersion foot typically occurs with prolonged exposure (12 hours to 4 days) to cold, wet conditions, usually in temperatures ranging from 326F to 656F (06C–186C). This condition affects primarily the soft tissues, including nerves and blood vessels, due to an inflammatory response that results in high levels of extracellular fluid. The most common mechanism for developing immersion foot is the continued wearing of wet socks or footwear (or both).8,14 EVIDENCE CLASSIFICATION

In this position statement, we present recommendations using an evidence-based review and the Strength of Recommendation Taxonomy (SORT) criterion scale (Table 2) proposed by the American Academy of Family Physicians.15 The recommendations are given a grade of A, B, or C based upon evidence using patient or disease oriented outcomes (treatments or practices). Little outcomes-based research using

randomized clinical trials on cold injury has been performed due to ethical constraints regarding standards of care and difficulties procuring large sample groups. These limitations should be weighed when assessing specific recommendations. RECOMMENDATIONS

Recommendations are presented to help ATs and other health care providers minimize risks to the health and safety of physically active individuals exposed to cold environments and provide effective immediate care when needed. Individual responses to cold vary physiologically with combinations of cold, wet, and windy conditions as well as clothing insulation, exposure time, and other non environmental factors. Therefore, these recommendations do not guarantee complete elimination of cold-related injuries but may decrease risk. The National Athletic Trainers’ Association (NATA) promotes the following approaches for prevention, recognition, and treatment of cold-related injuries. Prevention

1. Perform a comprehensive, physician-supervised, preparticipation medical screening to identify athletes with a previous history of cold injury and athletes predisposed to cold injury based upon known risk factors (Table 3). This preparticipation examination should include questions pertaining to a history of cold injury and problems with cold exposure16 and should be performed before planned exposures to conditions that may lead to cold injury. Evidence Category: C

2. Identify participants who present with known risk factors (Table 3) for cold injury and provide increased monitoring of these individuals for signs and symptoms.5 Evidence Category: C

3. Ensure that appropriately trained personnel are available on-site at the event and are familiar with cold injury prevention, recognition, and treatment approaches.5 Evidence Category: C

4. Educate athletes and coaches concerning the prevention, recognition, and treatment of cold injury and the risks associated with activity in cold environments.5 Evidence Category: C

5. Educate and encourage athletes to maintain proper hydration and eat a well-balanced diet. These guidelines are especially imperative for activities exceeding 2 hours.17–19 Consistent fluid intake during low intensity exercise is necessary to maintain hydration in the presence of typical cold-induced diuresis.20–22 Athletes should be encouraged to hydrate even if they are not thirsty, as evidence suggests the normal thirst mechanism is blunted with cold exposure.23 Evidence Category: C

6. Develop event and practice guidelines that include recommendations for managing athletes participating in cold, windy, and wet conditions.24,25 The influence of air temperature and wind speed conditions should be taken into account by using wind-chill guidelines.26,27 Risk management guidelines (Table 3, Figure 4) can be used to make participation decisions based upon the prevailing conditions. Participation decisions depend upon the length of anticipated exposure and availability of facilities and interventions for rewarming if needed. Modify activity in high-risk conditions to prevent cold injury. Monitor athletes for signs and symptoms and be prepared to intervene with basic treatment. Also monitor environmental conditions before and during the activity and adjust activities if weather conditions change or degenerate.28,29 Evidence Category: C

7. Clothing should provide an internal layer that allows evaporation of sweat with minimal absorption, a middle layer that provides insulation, and a removable external layer that is wind and water resistant and allows for evaporation of moisture. Examples of various clothing ensembles are found in Table 4. Toes, fingers, ears, and skin should be protected when wind-chill temperatures are in the range at which frostbite is possible in 30 minutes or less. Remove wet clothing as soon as practical and replace with dry, clean items.30–32 Evidence Category: C

8. Provide the opportunity for athletes to rewarm, as needed, during and after activity using external heaters, a warm indoor environment, or the addition of clothing. After water immersion, rewarming should

begin quickly and the athlete should be monitored for afterdrop, in which the core temperature actually decreases during rewarming.33–35 Evidence Category: C

9. Include the following supplies on the field, in the locker room, or at convenient aid stations for rewarming purposes: N A supply of water or sports drinks for rehydration purposes as well as warm fluids for possible rewarming purposes. Fluids that may freeze during events in subfreezing temperatures may need to be placed in insulated containers or replaced intermittently. N Heat packs, blankets, additional clothing, and external heaters, if feasible, for active rewarming. N Flexible rectal thermometer probe to assess core body temperature. Rectal temperature has been identified as the best combination of practicality and accuracy for assessing core temperature in the field.36 Other measurements (tympanic, aural, and esophageal) are problematic or difficult to obtain. The rectal thermometer used should be a lowreading thermometer (ie, capable of measuring temperatures below 956F [356C]). N Telephone or 2-way radio to communicate with additional medical personnel and to summon emergency medical transportation. N Tub, wading pool, or whirlpool for immersion warming treatments (including a thermometer and additional warm water to maintain required temperatures). Evidence Category: C

10. Notify area hospital and emergency personnel before large events to inform them of the potential for cold related injuries. Evidence Category: C Recognition and Treatment Hypothermia (Mild)

11. Be aware of the signs and symptoms of hypothermia, which include vigorous shivering, increased blood pressure, rectal temperature less than 98.66F (376C) but greater than 956F (356C), fine motor skill impairment, lethargy, apathy, and mild amnesia (Table 1). Evidence Category: A

12. Rectal temperature obtained using a thermometer (digital or mercury) that can read below 946F (346C) is the preferred method for assessing core temperature in persons suspected of being hypothermic, even though procuring rectal temperature in the field can be a challenge. Using tympanic, axillary, or oral temperatures instead of rectal temperature is faulty due to environmental concerns, such as exposure to air temperatures; however, if either axillary or oral temperature is above 956F (356C), the person is not hypothermic.1,7–9 Figure 5 provides a treatment algorithm for hypothermia. Evidence Category: B

13. Begin by removing wet or damp clothing; insulating the athlete with warm, dry clothing or blankets (including covering the head); and moving the athlete to a warm environment with shelter from the wind and rain. Evidence Category: C

14. When rewarming, apply heat only to the trunk and other areas of heat transfer, including the axilla, chest wall, and groin.37–39 Rewarming the extremities can produce afterdrop, which is caused by dilation of peripheral vessels in the arms and legs when warmed. This dilation sends cold blood, often with a high level of acidity and metabolic byproducts, from the periphery to the core. This blood cools the core, leading to a drop in core temperature, and may result in cardiac arrhythmias and death.40,41 Evidence Category: C

15. Provide warm, nonalcoholic fluids and foods containing 6% to 8% carbohydrates to help sustain shivering and maintain metabolic heat production. Evidence Category: C

16. Avoid applying friction massage to tissues, as this may increase damage if frostbite is present.10 Evidence Category: A Hypothermia (Moderate/Severe)

17. Be aware of the signs and symptoms of moderate and severe hypothermia, which may include cessation of shivering, very cold skin upon palpation, depressed vital signs, rectal temperature between 906F (326C) and 956F (356C) for moderate hypothermia or below 906F (326C) for severe hypothermia, impaired mental function, slurred speech, unconsciousness, and gross motor skill impairment (Table 1).1,7–9 Evidence Category: A

18. If an athlete with suspected hypothermia presents with signs of cardiac arrhythmia, he or she should be 644 Volume 43 N Number 6 N December 2008 moved very gently to avoid causing paroxysmal ventricular fibrillation.7–9 Evidence Category: B

19. Begin with a primary survey to determine the necessity of cardiopulmonary resuscitation (CPR) and activation of the emergency medical system. Remove wet or damp clothing; insulate the athlete with warm, dry clothing or blankets (including covering the head); and move the athlete to a warm environment with shelter from the wind and rain. Evidence Category: C

20. When rewarming, apply heat only to the trunk and other areas of heat transfer, including the axilla, chest wall, and groin.37–39 Evidence Category: C

21. If a physician is not present during the treatment phase, initiate rewarming strategies immediately and continue rewarming during transport and at the hospital. Evidence Category: C

22. During the treatment and/or transport, continually monitor vital signs and be prepared for airway management. A physician may order more aggressive rewarming procedures, including inhalation rewarming, heated intravenous fluids, peritoneal lavage, blood rewarming, and use of antiarrhythmia drugs.41–46 Evidence Category: C

23. When immediate management is complete, monitor for postrewarming complications, including infection and renal failure.47 Evidence Category: A Frostbite (Superficial)

24. Be aware of signs and symptoms of superficial frostbite, which include edema, redness or mottled gray skin appearance, stiffness, and transient tingling or burning (Table 1, Figure 1). Evidence Category: A

25. Rule out the presence of hypothermia by evaluating observable signs and symptoms and measuring core temperature. Evidence Category: C

26. The decision to rewarm an athlete is contingent upon resources available and likelihood of refreezing. Rewarming can occur at room temperature or by placing the affected tissue against another person’s warm skin. Rewarming should be performed slowly, and water temperatures greater than 986F to 1046F (376C–406C) should be avoided. Evidence Category: C

27. If rewarming is not undertaken, protect the affected area from additional damage and further tissue temperature decreases and consult with a physician or transport to a medical facility.48–50 Evidence Category: C

28. Avoid applying friction massage to tissues and leave any vesicles (fluid-filled blisters) intact.48–50 Evidence Category: C

29. Once rewarming has begun, it is imperative that affected tissue not be allowed to refreeze, as tissue necrosis usually results.48–50 Evidence Category: C

30. Athletes should avoid consuming alcohol and using nicotine.5 Evidence Category: B Frostbite (Deep)

31. Be aware of signs and symptoms of deep frostbite, which include edema, mottled or gray skin appearance, tissue that feels hard and does not rebound, vesicles, and numbness or anesthesia (Table 1).10–12 Evidence Category: A

32. Rule out the presence of hypothermia by assessing observable signs and symptoms and measuring core temperature.10–12,48–50 Evidence Category: C

33. To rewarm, the affected tissue should be immersed in a warm (986F–1046F [376C–406C]) water bath. Water temperature should be monitored and maintained. Remove any constrictive clothing and submerge the entire affected area. The water will need to be gently circulated, and the area should be immersed for 15 to 30 minutes. Thawing is complete when the tissue is pliable and color and sensation have returned. Rewarming can result in significant pain, so a physician may prescribe appropriate analgesic medication. Evidence Category: C

34. If rewarming is not undertaken, the affected area should be protected from additional damage and further tissue temperature decreases. Consult with a physician or transport the athlete to a medical facility.48–50 Evidence Category: C

35. Tissue plasminogen activators (tPA) may be administered to improve tissue perfusion. These agents have been shown to limit the need for subsequent amputation due to tissue death.51 Evidence Category: B

36. Do not use dry heat or steam to rewarm affected tissue.48–50 Evidence Category: C 37. Avoid friction massage or vigorous rubbing to the affected tissues and leave any vesicles or

fluid-filled blisters intact. If vesicles rupture, they should be treated to prevent infection.48–50 Evidence Category: C

38. Once rewarming has begun, it is imperative that the affected tissue not be allowed to refreeze, as tissue necrosis usually results. Also, weight bearing should be avoided when feet are affected. If the possibility of refreezing exists, rewarming should be delayed until advanced medical care can be obtained.48–50 Evidence Category: C

39. Athletes should avoid using alcohol and nicotine.48–50 Evidence Category: B 40. If tissue necrosis occurs and tissue sloughs off, debridement and infection control measures are

appropriate.48–50 Evidence Category: B Chilblain 41. Be aware of the signs and symptoms of chilblain, which include exposure to cold, wet conditions for

more than 60 minutes at temperatures less than 506F (166C) and the presence of small erythematous papules, with edema, tenderness, itching, and pain (Table 1, Figure 2). Upon rewarming, the skin may exhibit inflammation, redness, swelling, itching, or burning and increased temperature.14 Evidence Category: A

42. Remove wet or constrictive clothing, wash and dry the area gently, elevate the area, and cover with warm, loose, dry clothing or blankets.14 Evidence Category: C

43. Do not disturb blisters, apply friction massage, apply creams or lotions, use high levels of heat, or allow weight bearing on the affected area.14 Evidence Category: C

44. During treatment, continually monitor the affected area for return of circulation and sensation.14 Evidence Category: C Immersion (Trench) Foot

45. Be aware of the signs and symptoms of immersion (trench) foot, which include exposure to cold, wet environments for 12 hours to 3 or 4 days, burning, tingling or itching, loss of sensation, cyanotic or blotchy skin, swelling, pain or sensitivity, blisters, and skin fissures or maceration (Table 1, Figure 3).8,14 Evidence Category: A

46. To prevent immersion foot, encourage athletes to maintain a dry environment within the footwear, which includes frequent changes of socks or footwear (or both), the use of moisture-wicking sock material, controlling excessive foot perspiration, and allowing the feet to dry if wearing footwear that does not allow moisture evaporation (eg, vinyl, rubber, vapor-barrier shoes or boots).5,8,14 Evidence Category: C

47. For treatment, thoroughly clean and dry the feet, and then treat the affected area by applying warm packs or soaking in warm water (1026F–1106F [396C–436C]) 646 Volume 43 N Number 6 N December 2008 for approximately 5 minutes. Replace wet socks with a clean, dry pair, and rotate footwear or allow footwear to dry before reusing.8,14 Evidence Category: C

48. Use a risk management process that includes strategies for preventing, recognizing, and treating cold injuries during events. These strategies can then be used for preparing and devising risk management protocols and plans when cold injuries may be a possibility. An example of a risk management process is found in Table 3. Evidence Category: C”

Lightning Policy The KRHS athletics staff recognize and follow the National Athletic Trainers’ Association’s Position statement on Lightning Safety for Athletics and Recreation. This document provides the appropriate information for the safest treatment, recognition, and prevention of and cold related illness or injury as well as the safest protocols for getting everyone to a safe area, calling for a cease in activity when in danger, and when to allow play to resume again. The following is an excerpt from the above named position statement, to read the entire position statement please go to the National Athletic Trainers’ Association’s website, click on the statements link under the Practice and Patient Care tab at the top of the page, and select the link titled “Lightning Safety for Athletics and Recreation”. “RECOMMENDATIONS Establish a Lightning-Specific Emergency Action Plan

Formalize and implement a comprehensive proactive emergency action plan (EAP) specific to lightning safety for each venue.1–3,13,19–22 Evidence category: C The plan should have the following components:

1. Promote lightning-safety slogans supported by the National Weather Service.11 a. ‘‘NO Place Outside Is Safe When Thunderstorms Are In The Area!’’ b. ‘‘When Thunder Roars, Go Indoors!’’ c. ‘‘Half An Hour Since Thunder Roars, Now It’s Safe To Go Outdoors!’’

2. Establish a chain of command that identifies a specific person (or role) who is to make the decision to remove individuals from the field or activity. This person must have recognized and unchallengeable authority to suspend activity.13,19 Evidence category: C

3. Use a reliable means of monitoring the local weather. Before the event, identify a specific person (a weather watcher) who is responsible for actively looking for threatening weather and is charged with notifying the chain of command.13,19,23 Evidence category: C

4. Identify safe locations from the lightning hazard in advance of the event for each venue.13,19,23 Evidence category: C

5. Identify specific criteria for suspending and resuming activity in the EAP.13,23 Evidence category: C Lightning and General Weather Awareness

6. Use a designated weather watcher and the National Weather Service to monitor local weather.13,19 Evidence category: C

7. Consider subscribing to a commercial, real-time lightning detection service that has been independently and objectively verified.24–28 Evidence category: C Identify Locations Safe from Lightning

8. For each venue, identify substantial, fully enclosed buildings with wiring and plumbing, such as a school, field house, library, home, or similar habitable (eg, where people live and work) building to serve as a safe place from lightning. Identify these locations before the event, and inform participants of them. Access to these buildings during outdoor activities must be assured.13,14,19,22,23,29,30 Evidence category: A

9. Fully enclosed metal vehicles such as school buses, cars, and vans are also safe locations for evacuation.13,19,23,30,31 Evidence category:

A Identify Locations Unsafe from Lightning

10. Unsafe locations include most places termed shelters, such as picnic, park, sun, bus, and rain nonmetal shelters and storage sheds.10,13,15,29,32 Evidence category: A

11. Locations with open areas, such as tents, dugouts, refreshment stands, gazebos, screened porches, press boxes, and open garages are not safe from a lightning hazard.13,33,34 Evidence category: A

12. Tall objects (eg, trees, poles and towers, and elevated areas) are potential lightning targets and should be avoided. Large bodies of water, including swimming pools, are unsafe areas.19,32,33 Evidence category: A

13. Injuries have been reported to people inside a building who were using plumbing or wiring or were near enough to the structure to receive a side flash from lightning. Close proximity to showers, sinks, locker rooms, indoor pools, appliances, and electronics can be unsafe.1,2,14,22,32,35,36 Evidence category: A Criteria for Postponement and Resumption of Activities

14. Postpone or suspend activities if a thunderstorm appears imminent before or during activity. Watch the skies for locally developing or approaching storms that have not yet produced lightning.1,13,37 Evidence category: A

15. All individuals must be completely within an identified safe location when thunderstorms are already producing lightning and approaching the immediate location and when the distance between the edge of the lightning storm and the location of the outdoor activity reaches 5 nautical miles (nmi; roughly 6 statute miles or 9.26 km; Table 2).14,19,22,38–40 Evidence category: C

16. Allowing time for individuals to evacuate the premises, leave outdoor facilities, and be completely within the designated safe location(s) must be taken into consideration in the lightning-safety plan.1,13,20 Evidence category: C

17. Activities should be suspended until 30 minutes after the last strike of lightning is seen (or at least 5 nmi away) and after the last sound of thunder is heard. This 30-minute clock restarts for each lightning flash within 5 nmi and each time thunder is heard. Consideration must be given to patrons leaving safe locations and returning to the venue.13 Evidence category: A Large-Venue Planning

18. A specific lightning-safety plan for large-scale events should be established and include the components of the EAP for lightning. The National Oceanic and Atmospheric Administration (NOAA) has a tool kit that provides direction for large-venue lightning safety.41 The plan should include the following items20:

a. Use of a reliable weather-monitoring system to determine whether to cancel or postpone activity before the event begins. Continuous monitoring of the weather should occur during the event.

b. Means to prevent spectators from entering an outdoor venue when the event is suspended due to lightning. Spectators should be directed to the nearest safe location.

c. Identification of enough close-proximity substantial buildings and vacant, fully enclosed metal vehicles to hold all individuals affected by the lightning hazard, including participants and spectators.

d. Means to ensure a safe and orderly evacuation from the event, including announcements, signage, safety information in event programs and brochures, assistance from ushers, and entrances that also serve as exits.

e. Consideration for the time it takes to notify and move all individuals so they can be wholly within a safe, substantial building by the time the leading edge of the storm is within 5 nmi of the outdoor activity.22,38 Evidence category: C

First Aid

19. Active thunderstorms can pose an ongoing hazard to rescuers as well as spectators and sport participants. Rescuers and emergency personnel must ensure their own personal safety before venturing into the venue to provide aid.35,42–44 Evidence category: A

20. Activate the emergency management system. Evaluate and treat patients in the following order: (a) Move patient(s) carefully to a safer location if needed. (b) Evaluate and treat for apnea (cessation of breathing) and absence of heartbeat (cardiac arrest). (c) Assess level of consciousness. (d) Evaluate and treat for the possibility of spinal injuries. (e) Evaluate and treat for hypothermia.13,35,42 Evidence category: A

21. Personnel responsible for the well-being of participants should maintain current cardiopulmonary resuscitation (CPR) and first-aid certifications.19 Evidence category: C

22. If an automated external defibrillator (AED) is available, it should be applied on anyone who appears to be unconscious, pulseless, or apneic. However, other firstaid efforts and resuscitation should not be delayed while an AED is being located.13 Evidence category: A Personal Safety and Notification of Participants of Lightning Danger

23. If thunder can be heard, lightning is close enough to be a hazard, and people should go to a safe location immediately.1,11,37 Evidence category: A

24. In the event of impending thunderstorms, those in control of outdoor events should fulfill their obligation to warn participants and guests of the lightning danger.13,20 Evidence category: C

25. All individuals have the right to vacate an outdoor site or unsafe area, without fear of repercussion or penalty, in order to seek a lightning-safe location if they feel in danger from impending lightning activity. Evidence category: C”

Communicable Diseases Policy

The KRHS athletics staff recognize and follow the National Athletic Trainers’ Association’s Position statement on communicable/skin diseases. This document provides the appropriate information for the safest treatment, recognition, and prevention of communicable/skin disease. The following is an excerpt from the above named position statement, to read the entire position statement please go to the National Athletic Trainers’ Association’s website, click on the statements link under the Practice and Patient Care tab at the top of the page, and select the link titled “Skin Diseases”. This section applies heavily to athletes that are required to use equipment that can’t be washed daily (i.e. football, lacrosse, wrestling, etc.). It is very important that these athletes wash all clothing and sanitize all equipment on a regular basis to help prevent the spread of any of the diseases that are mentioned in the following position statement. Coaches and the athletic trainer will be vigilant and assist with the proper schedule for cleaning all equipment and we ask that parents/guardians and athletes take care of washable items on a daily basis.

“RECOMMENDATIONS

Based on the current research and literature, the National Athletic Trainers’ Association (NATA) suggests the following guidelines for prevention, recognition, and management of athletes with skin infections. The recommendations are categorized using the Strength of Recommendation Taxonomy criterion scale proposed by the American Academy of Family Physicians3 on the basis of the level of scientific data found in the literature. Each recommendation is followed by a letter describing the level of evidence found in the literature supporting the recommendation: A means there are well-designed experimental, clinical, or

epidemiologic studies to support the recommendation; B means there are experimental, clinical, or epidemiologic studies that provide a strong theoretical rationale for the recommendation; and C means the recommendation is based largely on anecdotal evidence at this time. The recommendations have been organized into the following categories: prevention, education, and management of the skin infections. The clinical features of the most common skin lesions are presented in Table 1. Prevention 1. Organizational support must be adequate to limit the spread of infectious agents.

a. The administration must provide the necessary fiscal and human resources to maintain infection control.30,31 Evidence Category: B

b. Custodial staffing must be increased to provide the enhanced vigilance required for a comprehensive infection-control plan. Evidence Category: C

c. Adequate hygiene materials must be provided to the athletes, including antimicrobial liquid (not bar) soap in the shower and by all sinks.7,32–35 Evidence Category: B

d. Infection-control policies should be included in an institution’s policies and procedures manuals.22,31,36–38 Evidence Category: C

e. Institutional leadership must hold employees accountable for adherence to recommended infection-control practices.8,30,39–43 Evidence Category: B

f. Athletic departments should contract with a team dermatologist to assist with diagnosis, treatment, and implementation of infection control.44 Evidence Category: C 2. A clean environment must be maintained in the athletic training facility, locker rooms, and all athletic venues.

a. Cleaning and disinfection is primarily important for frequently touched surfaces such as wrestling mats, treatment tables, locker room benches, and floors.9,10,45,46 Evidence Category: A

b. A detailed, documented cleaning schedule must be implemented for all areas within the infection control program, and procedures should be reviewed regularly. Evidence Category: C

c. The type of disinfectant or detergent selected for routine cleaning should be registered with the Environmental Protection Agency, and the manufacturer’s recommendations for amount, dilution, and contact time should be followed.10,31,47 Evidence Category: B 3. Health care practitioners and athletes should follow good hand hygiene practices.31,48

a. When hands are visibly dirty, wash them with an acceptable antimicrobial cleanser from a liquid dispenser.48,49 Evidence Category: A . Correct hand-washing technique must be used, including wetting the hands first, applying the manufacturer’s recommended amount of antimicrobial soap, rubbing the hands together vigorously for at least 15 seconds, rinsing the hands with water, and then drying them thoroughly with a disposable towel.48 Evidence Category: A

b. If hands are not visibly dirty, they can be decontaminated with an alcohol-based hand rub.17,18,41,50,51 Evidence Category: B

c. Hands should be decontaminated before and after touching the exposed skin of an athlete and after removing gloves.52–56 Evidence Category: B 4. Athletes must be encouraged to follow good overall hygiene practices.57–59

a. Athletes must shower after every practice and game with an antimicrobial soap and water over the entire body. It is preferable for the athletes to shower in the locker rooms provided by the athletic department.57 Evidence Category: B

b. Athletes should refrain from cosmetic body shaving.25 Evidence Category: B c. Soiled clothing, including practice gear, undergarments, outerwear, and uniforms, must be laundered

on a daily basis.10 Evidence Category: B

d. Equipment, including knee sleeves and braces, ankle braces, etc, should be disinfected in the manufacturer’s recommended manner on a daily basis.58 Evidence Category: C 5. Athletes must be discouraged from sharing towels, athletic gear, water bottles, disposable razors, and hair clippers.57,59 Evidence Category: A 6. Athletes with open wounds, scrapes, or scratches must avoid whirlpools and common tubs. Evidence Category: C 7. Athletes are encouraged to report all abrasions, cuts, and skin lesions to and to seek attention from an AT for proper cleansing, treatment, and dressing. Evidence Category: C All acute, uninfected wounds (eg, abrasions, blisters, lacerations) should be covered with a semi-occlusive or occlusive dressing (eg, film, foam, hydrogel, or hydrocolloid) until healing is complete to prevent contamination from infected lesions, items, or surfaces. Evidence Category: C Education

The sports medicine staff must educate everyone involved regarding infection-control policies and procedures.7,32–35,60 1. Administrators must be informed of the importance of institutional support to maintaining proper infection control policies.7,32–35,60 Evidence Category: B 2. Coaches must be informed of the importance of being vigilant with their athletes about following infection control policies to minimize the transmission of infectious agents.7,32–35,60 Evidence Category: B 3. Athletes need to be educated on their role in minimizing the spread of infectious diseases.

a. Follow good hygiene practices, including showering with antimicrobial soap and water after practices and games and frequent hand washing.57–59 Evidence Category: B

b. Have all practice and game gear laundered daily.10,17 Evidence Category: B c. Avoid sharing of towels, athletic gear, water bottles, disposable razors, and hair clippers.57,59

Evidence Category: B d. Perform daily surveillance and report all abrasions, cuts, and skin lesions to and seek attention from

the athletic training staff for proper cleansing, treatment, and wound dressing. Evidence Category: C

4. The custodial staff must be included in the educational programs about infectious agents to be able to adequately help in daily disinfection of the facilities.10 Evidence Category: C Management Fungal Infections. 1. Tinea capitis (Figure A)

a. Diagnosis: A culture of lesion scrapings is the most definitive test, but a potassium hydroxide (KOH) preparation gives more immediate results.61 Evidence Category: B

b. Treatment: Most patients have recalcitrant cases and should be treated with systemic antifungal agents: for example, a ‘‘cidal’’ antifungal drug, such as terbinafine, or alternative, such as fluconazole,

itraconazole, or ketoconazole (Table 2). Adjunctive therapy with selenium sulfide shampoo is also recommended.4,57,61,62 Evidence Category: B

c. Criteria for return to competition: Athletes must have a minimum of 2 weeks of systemic antifungal therapy (Table 3).63,64 Evidence Category: B 2. Tinea corporis (Figure B)

a. Diagnosis: A culture of lesion scrapings is the most definitive test, but a KOH preparation gives more immediate results.61 Evidence Category: B

b. Treatment: Topical treatment with a cidal antifungal agent, such as terbinafine, naftifine, ciclopirox, or oxiconazole (or more than one of these), twice a day, is effective for localized lesions. More diffuse inflammatory conditions should be treated with systemic antifungal medication (Table 2).11,57,61,62,65 Evidence Category: B

c. Criteria for return to competition: Athletes must have used the topical fungicide for at least 72 hours, and lesions must be adequately covered with a gas permeable membrane (Table 3).63,64 Evidence Category: B Viral Infections. 1. Herpes simplex (Figure C)

a. Diagnosis: A culture of lesion scrapings is the most definitive test but may take days. A Tzanck smear that identifies herpes-infected giant cells may give more rapid, accurate results.1,57,61,66 Evidence Category: B

b. Treatment: New, active lesions may be treated with an oral antiviral medication, such as valacyclovir, to shorten the duration of the infection and lessen the chance of transmission.57,67–72 Evidence Category: B Fully formed, ruptured, and crusted-over lesions are unaffected by antiviral medication. Evidence Category: B

c. Criteria for return to competition64 i. Athlete must be free of systemic symptoms, such as fever, malaise, etc. Evidence Category: B ii. Athlete must have developed no new blisters for 72 hours. Evidence Category: B iii. All lesions must be surmounted by a firm adherent crust. Evidence Category: B iv. Athlete must have completed a minimum of 120 hours of systemic antiviral therapy. Evidence

Category: B v. Active lesions cannot be covered to allow participation. Evidence Category: B

2. Molluscum contagiosum (MC; Figure D) a. Diagnosis: Clinical findings and microscopic inspection are the basis for diagnosis.73 Evidence

Category: C b. Treatment: Many anecdotal therapies have been suggested, but physical destruction of the lesions

with a sharp curette is recommended.26,64,73–81 Evidence Category: B c. Criteria for return to competition: Lesions should be curetted and covered with a gas-permeable

membrane (Table 3).64 Evidence Category: B Bacterial Infections. 1. Impetigo (Figure E)

a. Diagnosis: The diagnosis of bacterial infections is primarily based on the history and characteristic appearance of the lesions.57 Evidence Category: B Specimens for culture and antimicrobial susceptibility should be obtained from any questionable lesions.57 Evidence Category: B

b. Treatment: Culture and sensitivity of suspicious lesions will dictate treatment for all bacterial infections. Topical mupirocin (Bactroban; GlaxoSmithKline, Middlesex, United Kingdom), fusidic acid (Fucidin

H; Leo Pharma, Ballerup, Denmark), and retapamulin (Altabax; GlaxoSmithKline, Middlesex, United Kingdom) have been shown effective in treating impetigo.1,57,82,83 Evidence Category: B

c. Criteria for return to competition: Any suspicious lesions should be cultured and tested for antimicrobial sensitivity before the athlete returns to competition (Table 3).64 Evidence Category: B i. No new skin lesions for at least 48 hours. Evidence Category: B ii. Completion of a 72-hour course of directed antibiotic therapy. Evidence Category: B iii. No further drainage or exudate from the wound. Evidence Category: B iv. Active infections may not be covered for competition. 2. Folliculitis/furuncles/carbuncles (Figure F and G)

a. Diagnosis: The diagnosis of bacterial infections is primarily based on the history and characteristic appearance of the lesions.57 Evidence Category: B Specimens for culture and antimicrobial susceptibility should be obtained from any questionable lesions.57 Evidence Category: B

b. Treatment: Culture and sensitivity of suspicious lesions dictate treatment for all bacterial infections.57,84,85 i. Athlete must be referred to physician for incision, drainage, and culture. Evidence Category: B ii. Antibiotic therapy must be initiated to control local cellulitis. Evidence Category: B

c. Criteria for return to competition: Any suspicious lesions should be cultured and tested for antimicrobial sensitivity before the athlete returns to competition (Table 3).64 Evidence Category: B i. No new skin lesions for at least 48 hours. Evidence Category: B ii. Completion of a 72-hour course of directed antibiotic therapy. Evidence Category: B iii. No further drainage or exudate from the wound. Evidence Category: B iv. Active infections may not be covered for competition. Evidence Category: B 3. Methicillin-resistant Staphylococcus aureus (MRSA) (Figure H and I)

a. Diagnosis: The diagnosis of bacterial infections is primarily based on the history and characteristic appearance of the lesions. Evidence Category: B i. The differential diagnosis for any potential Staphylococcus lesion must include MRSA.27,84,86,87 Evidence Category: B ii. Reports of ‘‘spider bites’’ should be considered a possible sign for community-associated MRSA (CA-MRSA).84 Evidence Category: B iii. Specimens for culture and antimicrobial susceptibility should be obtained from any questionable lesions.84,86 Evidence Category: B

b. Treatment: Recognition and referral of athletes with suspicious lesions are paramount. Evidence Category: B i. Athletes with suspicious lesions must be isolated from other team members. Evidence Category: B ii. Antibiotic treatment must be guided by local susceptibility data and be determined on a caseby-case basis.23,84,86,88–93 Evidence Category: A

c. Criteria for return to competition: Any suspicious lesions should be cultured and tested for antimicrobial sensitivity before the athlete returns to competition (Table 3).64 Evidence Category: B i. No new skin lesions for at least 48 hours. Evidence Category: B ii. Completion of a 72-hour course of directed antibiotic therapy. Evidence Category: B iii. No further drainage or exudate from the wound. Evidence Category: B iv. Active infections may not be covered for competition. Evidence Category: B Clinical Dermatology: A Color Guide to Diagnosis and Therapy by Habif 94 and Skin Disease: Diagnosis and Treatment by Habif et al95 are excellent references for the recognition, diagnosis, and treatment of skin diseases, as is www.dermnet.com, a Web site that contains more than 23 000 images of skin diseases.”

Preventing Sudden Death in Sports Policy

The KRHS athletics staff recognize and follow the National Athletic Trainers’ Association’s Position statement on Preventing Sudden Death in Sports. This document provides the appropriate information for the safest recognition and prevention of common sudden death injuries. The following is an excerpt from the above named position statement, to read the entire position statement please go to the National Athletic Trainers’ Association’s website, click on the statements link under the Practice and Patient Care tab at the top of the page, and select the link titled “Preventing Sudden Death in Sports”. “ASTHMA Recommendations Prevention and Screening

1. Athletes who may have or are suspected of having asthma should undergo a thorough medical history and physical examination.2 Evidence Category: B

2. Athletes with asthma should participate in a structured warmup protocol before exercise or sport activity to decrease reliance on medications and minimize asthmatic symptoms and exacerbations.3 Evidence Category: B

3. The sports medicine staff should educate athletes with asthma about the use of asthma medications as prophylaxis before exercise, spirometry devices, asthma triggers, recognition of signs and symptoms, and compliance with monitoring the condition and taking medication as prescribed. Evidence Category: C Recognition

4. The sports medicine staff should be aware of the major asthma signs and symptoms (ie, confusion, sweating, drowsiness, forced expiratory volume in the first second [FEVt ] of less than 40%, low level of oxygen saturation, use of accessory muscles for breathing, wheezing, cyanosis, coughing, hypotension, bradycardia or tachycardia, mental status changes, loss of consciousness, inability to lie supine, inability to speak coherently, or agitation) and other conditions (eg, vocal cord dysfunction, allergies, smoking) that can cause exacerbations.4 ,5 Evidence Category: A

5. Spirometry tests at rest and with exercise and a field test (in the sport-specific environment) should be conducted on athletes suspected of having asthma to help diagnose the condition.2,6 Evidence Category: B

6. An increase of 12% or more in the FEVt after administration of an inhaled bronchodilator also indicates reversible airway disease and may be used as a diagnostic criterion for asthma.? Treatment

7. For an acute asthmatic exacerbation, the athlete should use a short-acting ~2-agonist to relieve symptoms. In a severe exacerbation, rapid sequential administrations of a ~2-agonist may be needed. If 3 administrations of medication do not relieve distress, the athlete should be referred promptly to an appropriate health care facility.s Evidence Category: A

8. Inhaled corticosteroids or leukotriene inhibitors can be used for asthma prophylaxis and control. A long-acting ~2-agonist can be combined with other medications to help control asthma.9 Evidence Category: B

9. Supplemental oxygen should be offered to improve the athlete's available oxygenation during asthma attacks.tO Evidence Category: B

10. Lung function should be monitored with a peak flow meter. Values should be compared with baseline lung volume values and should be at least 80% of predicted values before the athlete may participate in activities.ll Evidence Category: B

11. If feasible, the athlete should be removed from an environment with factors (eg, smoke, allergens) that may have caused the asthma attack. Evidence Category: C

12. In the athlete with asthma, physical activity should be initiated at low aerobic levels and exercise intensity gradually increased while monitoring occurs for recurrent asthma symptoms. Evidence Category: C CATASTROPHIC BRAIN INJURIES Recommendations Prevention

1. The AT is responsible for coordinating educational sessions with athletes and coaches to teach the recognition of concussion (ie, specific signs and symptoms), serious nature of traumatic brain injuries in sport, and importance of reporting concussions and not participating while symptomatic. Evidence Category: C

2. The AT should enforce the standard use of certified helmets while also educating athletes, coaches, and parents that although such helmets meet a standard for helping to prevent catastrophic head injuries, they do not prevent cerebral concussions. Evidence Category: B Recognition

3. The AT should incorporate the use of a comprehensive objective concussion assessment battery that includes symptom, cognitive, and balance measures. Each of these represents only one piece of the concussion puzzle and should not be used in isolation to manage concussion. Evidence Category: A Treatment and Management

4. A comprehensive medical management plan for acute care of an athlete with a potential intracranial hemorrhage or diffuse cerebral edema should be implemented. Evidence Category: B

5. If the athlete's symptoms persist or worsen or the level of consciousness deteriorates after a concussion, the patient should be immediately referred to a physician trained in concussion management. Evidence Category: B

6. Oral and written instructions for home care should be given to the athlete and to a responsible adult. Evidence Category: C

7. Returning an athlete to participation after a head injury should follow a graduated progression that begins once the athlete is completely asymptomatic. Evidence Category: C

8. The athlete should be monitored periodically throughout and after these sessions to determine whether any symptoms develop or increase in intensity. Evidence Category: C

CERVICAL SPINE INJURIES Recommendations Prevention

1. Athletic trainers should be familiar with sport-specific causes of catastrophic cervical spine injury and understand the physiologic responses in spinal cord injury. Evidence Category: C

2. Coaches and athletes should be educated about the mechanisms of catastrophic spine injuries and pertinent safety rules enacted for the prevention of cervical spine injuries. Evidence Category: C

3. Corrosion-resistant hardware should be used in helmets, helmets should be regularly maintained throughout a season, and helmets should undergo regular reconditioning and recertification.33 Evidence Category: B

4. Emergency department personnel should become familiar with proper athletic equipment removal, seeking education from sports medicine professionals regarding appropriate methods to minimize motion. Evidence Category: C Recognition

5. During initial assessment, the presence of any of the following, alone or in combination, requires the initiation of the spine injury management protocol: unconsciousness or altered level of consciousness, bilateral neurologic findings or complaints, significant midline spine pain with or without palpation, or obvious spinal column deformity.34-39Evidence Category: A Treatment and Management

6. The cervical spine should be in neutral position, and manual cervical spine stabilization should be applied immediately.40,41Evidence Category: B

7. Traction must not be applied to the cervical spine.42,43 Evidence Category: B 8. Immediate attempts should be made to expose the airway. Evidence Category: C 9. If rescue breathing becomes necessary, the person with the most training and experience should

establish an airway and begin rescue breathing using the safest technique.44,45Evidence Category: B 10. If the spine is not in a neutral position, rescuers should realign the cervical spine.46,47However, the

presence or development of any of the following, alone or in combination, is a contraindication to realignment 45,48: pain caused or increased by movement, neurologic symptoms, muscle spasm, airway compromise, physical difficulty repositioning the spine, encountered resistance, or apprehension expressed by the patient. Evidence Category: B

11. Manual stabilization of the head should be converted to immobilization using external devices such as foam head blocks.47,49Whenever possible, manual stabilization50 is resumed after the application of external devices. Evidence Category: B

12. Athletes should be immobilized with a long spine board or other full-body immobilization device.51,52Evidence Category: B Equipment-Laden Athletes

13. The primary acute treatment goals in equipment-laden athletes are to ensure that the cervical spine is immobilized in neutral and vital life functions are accessible. Removal of helmet and shoulder pads in any equipment intensive sport should be deferred53-56until the athlete has been transported to an emergency medical facility except in 3 circumstances57: the helmet is not properly fitted to prevent movement of the head independent of the helmet, the equipment prevents neutral alignment of the cervical spine, or the equipment prevents airway or chest access.53,54,58Evidence Category: C

14. Full face-mask removal using established tools and techniques59-61is executed once the decision has been made to immobilize and transport. Evidence Category: C

15. If possible, a team physician or AT should accompany the athlete to the hospital. Evidence Category: C

16. Remaining protective equipment should be removed by appropriately trained professionals in the emergency department. Evidence Category: C

DIABETES MELLITUS Recommendations Prevention

1. Each athlete with diabetes should have a diabetes care plan that includes blood glucose monitoring and insulin guidelines, treatment guidelines for hypoglycemia and hyperglycemia, and emergency contact information. Evidence Category: C

2. Prevention strategies for hypoglycemia include blood glucose monitoring, carbohydrate supplementation, and insulin adjustments. Evidence Category: B

3. Prevention strategies for hyperglycemia are described by the American Diabetes Association (ADA) and include blood glucose monitoring, insulin adjustments, and urine testing for ketone bodies.67 Evidence Category: C Recognition

4. Hypoglycemia typically presents with tachycardia, sweating, palpitations, hunger, nervousness, headache, trembling, or dizziness; in severe cases, loss of consciousness and death can occur. Evidence Category: C

5. Hyperglycemia can present with or without ketosis. Typical signs and symptoms of hyperglycemia without ketosis include nausea, dehydration, reduced cognitive performance, feelings of sluggishness, and fatigue. Evidence Category: C

6. Hyperglycemia with ketoacidosis may include the signs and symptoms listed earlier as well as Kussmaul breathing (abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis), fruity odor to the breath, unusual fatigue, sleepiness, loss of appetite, increased thirst, and frequent urination. Evidence Category: C Treatment and Management

7. Mild hypoglycemia (ie, the athlete is conscious and able to swallow and follow directions) is treated by administering approximately 10-15 g of carbohydrates (examples include 4-8 glucose tablets or 2 tablespoons of honey) and reassessing blood glucose levels immediately and 15 minutes later. Evidence Category: C

8. Severe hypoglycemia (ie, the athlete is unconscious or unable to swallow or follow directions) is a medical emergency, requiring activation of emergency medical services (EMS) and, if the health care provider is properly trained, administering glucagon. Evidence Category: C

9. Athletic trainers should follow the ADA guidelines for athletes exercising during hyperglycemic periods. Evidence Category: C

10. Physicians should determine a safe blood glucose range to return an athlete to play after an episode of mild hypoglycemia or hyperglycemia. Evidence Category: C

EXERTIONAL HEAT STROKE Recommendations Prevention

1. In conjunction with preseason screening, athletes should be questioned about risk factors for heat illness or a history of heat illness. Evidence Category: C

2. Special considerations and modifications are needed for those wearing protective equipment during periods of high environmental stress. Evidence Category: B

3. Athletes should be acclimatized to the heat gradually over a period of 7 to 14 days. Evidence Category: B

4. Athletes should maintain a consistent level of euhydration and replace fluids lost through sweat during games and practices. Athletes should have free access to readily available fluids at all times, not only during designated breaks. Evidence Category: B

5. The sports medicine staff must educate relevant personnel (eg, coaches, administrators, security guards, EMS staff, athletes) about preventing exertional heat stroke (EHS) and the policies and procedures that are to be followed in the event of an incident. Signs and symptoms of a medical emergency should also be reviewed. Evidence Category: C Recognition

6. The 2 main criteria for diagnosis of EHS are (1) core body temperature of greater than 104° to 105°F (40.0° to 40.5°C) taken via a rectal thermometer soon after collapse and (2) CNS dysfunction (including disorientation, confusion, dizziness, vomiting, diarrhea, loss of balance, staggering, irritability, irrational or unusual behavior, apathy, aggressiveness, hysteria, delirium, collapse, loss of consciousness, and coma). Evidence Category: B

7. Rectal temperature and gastrointestinal temperature (if available) are the only methods proven valid for accurate temperature measurement in a patient with EHS. Inferior temperature assessment devices should not be relied on in the absence of a valid device. Evidence Category: B Treatment

8. Core body temperature must be reduced to less than 102°F (38.9°C) as soon as possible to limit morbidity and mortality. Cold-water immersion is the fastest cooling modality. If that is not available, cold-water dousing or wet ice towel rotation may be used to assist with cooling, but these methods have not been shown to be as effective as cold- water immersion. Athletes should be cooled first and then transported to a hospital unless cooling and proper medical care are unavailable onsite. Evidence Category: B

9. Current suggestions include a period of no activity, an asymptomatic state, and normal blood enzyme levels before the athlete begins a gradual return-to-activity progression under direct medical supervision. This progression should start at low intensity in a cool environment and slowly advance to high-intensity exercise in a warm environment. Evidence Category: C

EXERTIONAL HYPONATREMIA Recommendations Prevention

1. Each physically active person should establish an individualized hydration protocol based on personal sweat rate, sport dynamics (eg, rest breaks, fluid access), environmental factors, acclimatization state, exercise duration, exercise intensity, and individual preferences. Evidence Category: B

2. Athletes should consume adequate dietary sodium at meals when physical activity occurs in hot environments. Evidence Category: B

3. Postexercise rehydration should aim to correct fluid loss accumulated during activity. Evidence Category: B

4. Body weight changes, urine color, and thirst offer cues to the need for rehydration. Evidence Category: A

5. Most cases of exertional hyponatremia (EH) occur in endurance athletes who ingest an excessive amount of hypotonic fluid. Athletes should be educated about proper fluid and sodium replacement during exercise. Evidence Category: C Recognition

6. Athletic trainers should recognize EH signs and symptoms during or after exercise, including overdrinking, nausea, vomiting, dizziness, muscular twitching, peripheral tingling or swelling, headache, disorientation, altered mental status, physical exhaustion, pulmonary edema, seizures, and cerebral edema. Evidence Category: B

7. In severe cases, EH encephalopathy can occur and the athlete may present with confusion, altered CNS function, seizures, and a decreased level of consciousness. Evidence Category: B

8. The AT should include EH in differential diagnoses until confirmed otherwise. Evidence Category: C

Treatment and Management 9. If an athlete's mental status deteriorates or if he or she initially presents with severe symptoms of EH,

IV hypertonic saline (3% to 5%) is indicated. Evidence Category: B 10. Athletes with mild symptoms, normal total body water volume, and a mildly altered blood sodium

level (130 to 135 mEq/L; normal is 135 to 145 mEq/L) should restrict fluids and consume salty foods or a small

volume of oral hypertonic solution (eg, 3 to 5 bouillon cubes dissolved in 240 mL of hot water). Evidence Category: C

11. The athlete with severe EH should be transported to an advanced medical facility during or after treatment. Evidence Category: B

12. Return to activity should be guided by a plan to avoid future EH episodes, specifically an individualized hydration plan, as described earlier. Evidence Category: C

EXERTIONAL SICKLING Recommendations Prevention

1. The AT should educate coaches, athletes, and, as warranted, parents about complications of exertion in the athlete with sickle cell trait (SCT). Evidence Category: C

2. Targeted education and tailored precautions may provide a margin of safety for the athlete with SCT. Evidence Category: C

3. Athletes with known SCT should be allowed longer periods of rest and recovery between conditioning repetitions, be excluded from participation in performance tests such as mile runs and serial sprints, adjust work / rest cycles in the presence of environmental heat stress, emphasize hydration, control asthma (if present), not workout if feeling ill, and have supplemental oxygen available for training or competition when new to a high-altitude environment. Evidence Category: B Recognition

4. Screening for SCT, by self-report, is a standard component of the preparticipation physical evaluation (PPE) monograph. Testing for SCT, when included in the PPE or conducted previously, confirms SCT status. Evidence Category: A

5. The AT should know the signs and symptoms of exertional sickling, which include muscle cramping, pain, swelling, weakness, and tenderness; inability to catch one's breath; and fatigue, and be able to differentiate exertional sickling from other causes of collapse. Evidence Category: C

6. The AT should understand the usual settings for and patterns of exertional sickling. Evidence Category: C Treatment

7. Signs and symptoms of exertional sickling warrant immediate withdrawal from activity. Evidence Category: C

8. High-flow oxygen at 15 Llmin with a nonrebreather face mask should be administered. Evidence Category: C

9. The AT should monitor vital signs and activate the EAP if vital signs decline. Evidence Category: C 10. Sickling collapse should be treated as a medical emergency. Evidence Category: C 11. The AT has a duty to make sure the athlete's treating physicians are aware of the presence of SCT

and prepared to treat the metabolic complications of explosive rhabdomyolysis. Evidence Category: B

HEAD-DOWN CONTACT IN FOOTBALL Recommendations Prevention

1. Axial loading is the primary mechanism for catastrophic cervical spine injury. Head-down contact, defined as initiating contact with the top or crown of the helmet, is the only technique that results in axial loading. Evidence Category: A

2. Spearing is the intentional use of a head-down contact technique. Unintentional head-down contact is the inadvertent dropping of the head just before contact. Both head-down techniques are dangerous and may result in axial loading of the cervical spine and catastrophic injury. Evidence Category: A

3. Football helmets and other standard football equipment do not cause or prevent axial-loading injuries of the cervical spine. Evidence Category: A

4. Injuries that occur as a result of head-down contact are technique related and are preventable to the extent that head-down contact is preventable. Evidence Category: C

5. Making contact with the shoulder or chest while keeping the head up greatly reduces the risk of serious head and neck injury. With the head up, the player can see when and how impact is about to occur and can prepare the neck musculature. Even if head-first contact is inadvertent, the force is absorbed by the neck musculature, the intervertebral discs, and the cervical facet joints. This is the safest contact technique. Evidence Category: C

6. The game can be played as aggressively with the head up and with shoulder contact but with much less risk of serious injury (Figure 2). However, the technique must be learned, and to be learned, it must be practiced extensively. Athletes who continue to drop their heads just before contact need additional coaching and practice time. Evidence Category: C

7. Initiating contact with the face mask is a rule violation and must not be taught. If the athlete uses poor technique by lowering his head, he places himself in the head- Figure 2. Initiating contact with the shoulder while keeping the head up reduces the risk of head and neck injuries. down position and at risk of serious injury. Evidence Category: C

8. The athlete should know, understand, and appreciate the risk of head-down contact, regardless of intent. Formal team education sessions (conducted by the AT, team physician, or both with the support of the coaching staff) should be held at least twice per season. One session should be conducted before contact begins and the other at the midpoint of the season. Recommended topics are mechanisms of head and neck injuries, related rules and penalties, the incidence of catastrophic injury, the severity of and prognosis for these injuries, and the safest contact positions. The use of videos such as Heads Up: Reducing the Risk of Head and Neck Injuries in Football134 and Tackle Progression135 should be mandatory. Parents of high school athletes should be given the opportunity to view these videos. Evidence Category: C Recognition

9. Attempts to determine a player's intent regarding intentional or unintentional head-down contact are subjective. Therefore, coaching, officiating, and playing techniques must focus on decreasing all head-down contact, regardless of intent. Evidence Category: C

10. Officials should enforce existing helmet contact rules to further reduce the incidence of head-down contact. A clear discrepancy has existed between the incidence of head-down or head-first contact and the level of enforcement of the helmet contact penalties. Stricter officiating would bring more awareness to coaches and players about the effects of head-down contact. Evidence Category: B

LIGHTNING SAFETY Recommendations Prevention

1. The most effective means of preventing lightning injury is to reduce the risk of casualties by remaining indoors during lightning activity. When thunder is heard or lightning seen, people should vacate to a previously identified safe location.159-161Evidence Category: A

2. Establish an EAP or policy specific to lightning safety.161,162Evidence Category: C

3. No place outdoors is completely safe from lightning, so alternative safe structures must be identified. Sites that are called "shelters" typically have at least one open side and therefore do not provide sufficient protection from lightning injury. These sites include dugouts; picnic, golf, or rain shelters; tents; and storage sheds.I60,163,164Safe places to be while lightning occurs are structures with 4 substantial walls, a solid roof, plumbing, and electric wiring-structures in which people live or work. 160,164 Evidence Category: B

4. Buses or cars that are fully enclosed and have windows that are completely rolled up and metal roofs can also be safe places during a lightning storm.165Evidence Category: B

5. People should remain entirely inside a safe building or vehicle until at least 30 minutes have passed since the last lightning strike or the last sound of thunder. 166,167 Evidence Category: A

6. People injured by lightning strikes while indoors were touching electric devices or using a landline telephone or plumbing (eg, showering). Garages with open doors and rooms with open windows do not protect from the effects of lightning strikes.159,161,168-170 Evidence Category: B Treatment and Management

7. Victims are safe to touch and treat, but first responders must ensure their own safety by being certain the area is safe from imminent lightning strikes.171,172Evidence Category: A

8. Triage first lightning victims who appear to be dead. Most deaths are due to cardiac arrest.171,173,174 Although those who sustain a cardiac arrest may not survive due to subsequent apnea, aggressive CPR and defibrillation (if indicated) may resuscitate these patients. Evidence Category: A

9. Apply an AED and perform CPR as warranted.174 Evidence Category: A 10. Treat for concussive injuries, fractures, dislocations, and shock.14,164Evidence Category: A

SUDDEN CARDIAC ARREST Recommendations Prevention

1. Access to early defibrillation is essential. A goal of less than 3-5 minutes from the time of collapse to delivery of the first shock is strongly recommended. Evidence Category: B

2. The preparticipation physical examination should include the completion of a standardized history form and attention to episodes of exertional syncope or presyncope, chest pain, a personal or family history of sudden cardiac arrest or a family history of sudden death, and exercise intolerance. Evidence Category: C Recognition

3. Sudden cardiac arrest (SCA) should be suspected in any athlete who has collapsed and is unresponsive. A patient's airway, breathing, circulation, and heart rhythm (using the AED) should be assessed. An AED should be applied as soon as possible for rhythm analysis. Evidence Category: B

4. Myoclonic jerking or seizure-like activity is often present after collapse from SCA and should not be mistaken for a seizure. Occasional or agonal gasping should not be mistaken for normal breathing. Evidence Category: B Management

5. Cardiopulmonary resuscitation should be provided while the AED is being retrieved, and the AED should be applied as soon as possible. Interruptions in chest compressions should be minimized by stopping only for rhythm analysis and defibrillation. Treatment should proceed in accordance with the updated American Heart Association guidelines,182 which recommend that health care professionals follow a sequence of chest compressions (C), airway (A), and breathing (B). Evidence Category: B

Psychosocial Awareness and Referral Policies

All coaches and any member of the Athletics staff should be aware of the various signs and symptoms that are related to psychosocial disorders. If a member of the athletics department sees anything that is worrisome it should be reported to a member of the Athletic Health Care Team. That member will then take the appropriate steps to ensure that the athlete in question is taken care of and gets the appropriate help that they need. Each member of the Athletic Health Care Team will know their role when it comes to psychosocial disorders. The appropriate forms to be filled out can be found on file with the school nurse (who needs to be informed if you are filling one out) and can be filed with her after completion. The school nurse will then work with our school psychologist to determine the appropriate plan of action for the athlete in questions. They will decide if your further involvement in the treatment of the athlete is necessary and will keep you informed when possible. Our Athletics Health Care Team takes the all around well-being of our athletes seriously and thus takes every step possible to ensure that appropriate care is given to them.

Related Forms

All of the forms mentioned in this handbook can be found in several locations. The forms are online on the Kearsarge athletics webpage under the forms link on the left hand side of the page. Student-athletes can also get hard copies from the front office, the athletic director, and the athletic trainer. If there are any questions about these forms please feel free to contact a member of the athletics department for some clarification.

Appendix C:

Athlete & Coach Pre-Screen Responses to screening questions for each person should be recorded and stored so that there is a record of everyone present in case a student or coach develops COVID-19 Name: Date & Time:

Students must have a filled personal water bottle prior to being allowed to participate. Does the student have a personal water bottle? CIRCLE YES OR NO

Any individual (staff or student) who answers yes to any underlying condition or symptom listed below will not be allowed to take part in athletics and should contact their Primary Care Provider.

Any athlete, coach, or staff member living with someone who experiences any of the symptoms of COVID-19, whether they have a positive test or not, should self-isolate for two weeks. If they do not experience any COVID-19 symptoms during that period, they can return. If they experience symptoms, they must self-isolate until the above conditions have been met.

Underlying Conditions (Individual or within household) Circle One

Do you have chronic lung disease or moderate to severe asthma? Yes No

Do you have a serious heart condition? Yes No

Are you immunocompromised (cancer treatment, smoking, bone marrow or organ transplant, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications)?

Yes No

Do you have severe obesity (BMI of 40 or higher)? Yes No

Do you have diabetes? Yes No

Do you have chronic kidney disease undergoing dialysis? Yes No

Do you have liver disease? Yes No

Current Symptoms (Individual or within household) Circle One

Chills or Shaking Yes No

Muscle Pain Yes No

Cough or Sore Throat Yes No

Temperature on Intake: *To be filled out by Kearsarge Athletics Staff *This form will be made into a google form for ease of filling out by students prior to the beginning of the Kearsarge Athletics fall season.

Headache Yes No

Shortness of Breath or Difficulty Breathing Yes No

Loss of Taste or Smell Yes No

Diarrhea Yes No

Known Close Contact with a Person who is Lab Confirmed to have COVID-19 Yes No

Traveled Outside of NH, VT, ME, or MA in the Last 14 Days? Yes No

Have you had a Fever or Cold Symptoms in the Previous 24 Hours? Yes No