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On Field Management: On Field Management: Athletic Emergencies Athletic Emergencies
Jim Ellis, MD, FACEPJim Ellis, MD, FACEP
Faculty, Primary Care Sports Faculty, Primary Care Sports Medicine Fellowship ProgramMedicine Fellowship Program
Steadman Hawkins Clinic of Steadman Hawkins Clinic of the Carolinasthe Carolinas
Why we do what we do Why we do what we do
On October 24, 1971 Chuck Hughes On October 24, 1971 Chuck Hughes of the Detroit Lions went across the of the Detroit Lions went across the middle on a pass play and collapsed. middle on a pass play and collapsed. Legendary LB Dick Butkus frantically Legendary LB Dick Butkus frantically waved to the sideline for help. waved to the sideline for help. Despite the efforts of the training Despite the efforts of the training staff, he died of a “heart attack” and staff, he died of a “heart attack” and remains the only on field death in the remains the only on field death in the history of the NFL.history of the NFL.
ObjectivesObjectivesKnow the risks of the sport you cover Know the risks of the sport you cover
Know your specific role/responsibilityKnow your specific role/responsibility
Know your players’ illnessesKnow your players’ illnesses
Know what equipment to haveKnow what equipment to have
Know the Emergency Action PlanKnow the Emergency Action Plan
ATLS, ACLS, “ASLS”ATLS, ACLS, “ASLS”Advanced Sports Life SupportAdvanced Sports Life Support
AirwayAirwayBreathingBreathingCardiacCardiacCirculationCirculationCervical SpineCervical SpineConcussionConcussionConditions/EnvironmentConditions/EnvironmentCrisis Management/DisasterCrisis Management/DisasterDiabetesDiabetes
Airway ProblemsAirway Problems
Direct TraumaDirect Trauma– Anterior neck trauma Anterior neck trauma
Indirect TraumaIndirect Trauma– Severe concussion can lead to Severe concussion can lead to
unprotected airwayunprotected airway– High cervical spine injuryHigh cervical spine injury
Airway EvaluationAirway Evaluation
Is the player talking?Is the player talking?
Is he tachypneic or agonal?Is he tachypneic or agonal?
What is the pulse ox?What is the pulse ox?
EMS bring pulse ox!EMS bring pulse ox!
Airway - MaintainableAirway - Maintainable
Supplemental oxygenSupplemental oxygen
Chin lift or jaw thrust (for c-spine)Chin lift or jaw thrust (for c-spine)
Nasal or oral airwayNasal or oral airway
Bag-valve-mask/pocket mask/barrier Bag-valve-mask/pocket mask/barrier
Airway EvaluationAirway EvaluationUnmaintainableUnmaintainable– Airway is inadequate with basic Airway is inadequate with basic
supportsupport– Procedural intervention is requiredProcedural intervention is required– Must remove facemask to have Must remove facemask to have
unencumbered access to the unencumbered access to the airway on anyone immobilizedairway on anyone immobilized
– Need Need Advanced Life SupportAdvanced Life Support EMS EMS unit at high risk eventsunit at high risk events
Endotracheal IntubationEndotracheal Intubation
The right personThe right person
The right equipmentThe right equipment
The right drugsThe right drugs
The right plan for the difficult airwayThe right plan for the difficult airway
AnatomyAnatomy
Airway AdjunctsAirway Adjuncts
Intubating StyletIntubating Stylet
Lighted StyletLighted Stylet
LMA *great tool for the airway noviceLMA *great tool for the airway novice
Intubating LMAIntubating LMA
Levitan Fiberoptic ScopeLevitan Fiberoptic Scope
LMA and Intubating LMALMA and Intubating LMA
Surgical AirwaySurgical Airway
Unsuccessful endotracheal intubationUnsuccessful endotracheal intubation
Mandibular fractureMandibular fracture
Anterior neck traumaAnterior neck trauma
Laryngeal fractureLaryngeal fracture
StridorStridor
Surgical AirwaySurgical Airway
Know the anatomyKnow the anatomy
Know the equipmentKnow the equipment
Know the procedureKnow the procedure
2002 Super Bowl2002 Super Bowl
Kurt Warner played with a laryngeal Kurt Warner played with a laryngeal fracture – sideline cricothyrotomy kitfracture – sideline cricothyrotomy kit
2004 Al Lucas2004 Al Lucas
Arena League player went down Arena League player went down headfirst on a kick-offheadfirst on a kick-off
Evaluated by MD and ATC on FOPEvaluated by MD and ATC on FOP
While being loaded into the While being loaded into the ambulance, stopped breathing (within ambulance, stopped breathing (within 10 minutes of injury)10 minutes of injury)
Died from airway compromise due to Died from airway compromise due to C1/C2 fracture and concussion despite C1/C2 fracture and concussion despite using an LMA for airwayusing an LMA for airway
1997 Reggie Brown1997 Reggie Brown
Lions linebacker injured vs JetsLions linebacker injured vs Jets
C1/C2 fracture with CHIC1/C2 fracture with CHI
Airway compromise from aboveAirway compromise from above
On field mouth to mouth and BVMOn field mouth to mouth and BVM
Response saved his life and had Response saved his life and had remarkable post op recoveryremarkable post op recovery
Breathing ProblemsBreathing Problems
Massive HemothoraxMassive Hemothorax– Load and Go!Load and Go!
Tension PneumothoraxTension Pneumothorax– Use pulse oximetry for helpUse pulse oximetry for help– Large bore IV catheter(14 gauge)Large bore IV catheter(14 gauge)– 22ndnd intercostal space, midclavicular intercostal space, midclavicular
lineline– LEAVE IT IN!LEAVE IT IN!
2001 Drew Bledsoe2001 Drew Bledsoe
Patriots QB was driven into the Patriots QB was driven into the ground on the sidelineground on the sideline
Was short of breath after the gameWas short of breath after the game
Taken to Mass General Hospital and Taken to Mass General Hospital and had a chest tube inserted to reinflate had a chest tube inserted to reinflate his lung and an autotransfusionhis lung and an autotransfusion
Tom Brady became the starterTom Brady became the starter
2008 Lauren Chang2008 Lauren Chang
Cheerleader accidently kicked in the Cheerleader accidently kicked in the chestchest
Had collapsed lungs - bilateralHad collapsed lungs - bilateral
Died from tension pneumothoraxDied from tension pneumothorax
Breathing ProblemsBreathing ProblemsAsthmaAsthma– Know your playersKnow your players– Nebulizer vs inhaler (use a spacer)Nebulizer vs inhaler (use a spacer)– Keep an extra MDI (inhaler)Keep an extra MDI (inhaler)– Make sure EMS gives the right Epi dose Make sure EMS gives the right Epi dose
SQ/IM (1:1000) vs IV (1:10,000)SQ/IM (1:1000) vs IV (1:10,000)– Can use Epi-Pen if needed (same dose Can use Epi-Pen if needed (same dose
as allergic reaction 0.3cc)as allergic reaction 0.3cc)– Peak Flow Meter (know their baseline)Peak Flow Meter (know their baseline)
2001 Rashidi Wheeler2001 Rashidi Wheeler
Northwestern football playerNorthwestern football player
Died secondary to asthmaDied secondary to asthma
Known asthmatic in difficult workoutKnown asthmatic in difficult workout
?Complicated by ephedra use?Complicated by ephedra use
Cardiac ProblemsCardiac Problems
Cardiac EtiologyCardiac Etiology– Sudden cardiac deathSudden cardiac death– Arrhythmia of unknown etiologyArrhythmia of unknown etiology– Hypertrophic cardiomyopathyHypertrophic cardiomyopathy– Commotio cordis/cardiac Commotio cordis/cardiac
concussion (hockey and baseball)concussion (hockey and baseball)– Coronary artery disease in coaches Coronary artery disease in coaches
and referees*and referees*
Cardiac InterventionsCardiac Interventions
CPR if AED is not right thereCPR if AED is not right there
AED – know where it is at all times AED – know where it is at all times and have nearby at eventsand have nearby at events
Practice run getting the AEDPractice run getting the AED
Trauma scissorsTrauma scissors
Manual defibrillator (EMS)Manual defibrillator (EMS)
Time to shock is critical!Time to shock is critical!
Cardiac InterventionsCardiac Interventions
Every minute that passes, there is a Every minute that passes, there is a 10% decrease in chance of survival.10% decrease in chance of survival.– 90% chance of survival at 1 minute90% chance of survival at 1 minute– 50% chance at 5 minutes50% chance at 5 minutes– 10% chance of survival if the initial 10% chance of survival if the initial
shock is delivered 9 minutes after shock is delivered 9 minutes after the cardiac arrest occurredthe cardiac arrest occurred
– Don’t wait for EMS Don’t wait for EMS
2005 Jiri Fisher2005 Jiri Fisher
Collapsed on the iceCollapsed on the ice
Saved with CPR and AEDSaved with CPR and AED
Key was a rapid response to a true Key was a rapid response to a true life threatening emergencylife threatening emergency
Etiology was underlying arrhythmiaEtiology was underlying arrhythmia
19961996 PolishPolish ChefChef dede MissionMission
Opening Ceremony 1996 Olympic Opening Ceremony 1996 Olympic GamesGames
Cardiac arrest on the field of play Cardiac arrest on the field of play
10,000 athletes / worldwide TV 10,000 athletes / worldwide TV audienceaudience
Defibrillated on the FOP and intubatedDefibrillated on the FOP and intubated
Transported with return of vital signsTransported with return of vital signs
Subsequent death in the hospitalSubsequent death in the hospital
2011 Al Schmidt at UGA2011 Al Schmidt at UGA
Mississippi State track officialMississippi State track official
Known CADKnown CAD
At SEC Track meet on UGA campusAt SEC Track meet on UGA campus
Witnessed cardiac arrestWitnessed cardiac arrest
Well practiced EAPWell practiced EAP
AED on site in 2 minutesAED on site in 2 minutes
Survived to discharge neuro intactSurvived to discharge neuro intact
Other serious cardiac eventsOther serious cardiac events1988 – Pete Maravich(NBA) 1988 – Pete Maravich(NBA) congenital coronary arterycongenital coronary artery1990 – Hank Gathers(NCAA) HCM1990 – Hank Gathers(NCAA) HCM1993 – Reggie Lewis(NBA) HCM 1993 – Reggie Lewis(NBA) HCM 1998 – Chris Pronger(NHL) commotio1998 – Chris Pronger(NHL) commotio2003 – Marc Vivien-Foe(soccer) SCD2003 – Marc Vivien-Foe(soccer) SCD2004 – Sergei Zholtok(NHL) HCM2004 – Sergei Zholtok(NHL) HCM
Other serious cardiac eventsOther serious cardiac events2005 – Jaxon Logan(NCAA) commotio2005 – Jaxon Logan(NCAA) commotio2005 – Thomas Herrion(NFL) 2005 – Thomas Herrion(NFL) HCM/CADHCM/CAD2007 – Damien Nash(NFL) 2007 – Damien Nash(NFL) arrhythmia of unknown etiologyarrhythmia of unknown etiology2007 – Antonio Puerta(soccer) SCD2007 – Antonio Puerta(soccer) SCD2011 – Wes Leonard(BB) SCD/?HCM 2011 – Wes Leonard(BB) SCD/?HCM
Circulation ProblemsCirculation ProblemsAbdominal Trauma/HemorrhageAbdominal Trauma/Hemorrhage– Splenic or liver injurySplenic or liver injury– Don’t confuse with dehydrationDon’t confuse with dehydration– High index of suspicionHigh index of suspicion– Life/limb threatening hemorrhageLife/limb threatening hemorrhage– Two large bore IV’sTwo large bore IV’s– Load and go (nearest Load and go (nearest appropriateappropriate
facility)facility)
2006 Chris Simms2006 Chris SimmsSeptember game vs PanthersSeptember game vs PanthersMultiple hard hitsMultiple hard hitsNo specific complaint of LUQ painNo specific complaint of LUQ painTreated for dehydrationTreated for dehydrationRuptured spleenRuptured spleenSurgery at St. Joe’s Hospital (< 1 Surgery at St. Joe’s Hospital (< 1
mile)mile)
1989 Clint Malarchuk1989 Clint MalarchukNHL goalie with skate to the neckNHL goalie with skate to the neckLife threatening hemorrhageLife threatening hemorrhageDirect pressure and rapid transportDirect pressure and rapid transportWent directly to OR for vascular Went directly to OR for vascular
surgery and survivedsurgery and survived
Circulation ProblemsCirculation ProblemsSickle Cell TraitSickle Cell Trait
- easy to diagnosis with a simple - easy to diagnosis with a simple screening blood test screening blood test - 10 known deaths since 2000- 10 known deaths since 2000- 8-10% of black population- 8-10% of black population- NATA policy statement- NATA policy statement- NCAA ?mandatory testing- NCAA ?mandatory testing
Circulation ProblemsCirculation ProblemsSickle Cell TraitSickle Cell Trait
- Identify high risk activities- Identify high risk activities
- common in off- or pre-season- common in off- or pre-season
- monitor first few workouts- monitor first few workouts
- ease into preseason conditioning- ease into preseason conditioning
- SCT muscle pain and weakness - SCT muscle pain and weakness
- dehydration cramps/”locking up”- dehydration cramps/”locking up”
2008 Ereck Plancher2008 Ereck PlancherCollegiate athlete with known sickle Collegiate athlete with known sickle
cell traitcell traitOff-season programOff-season programStrenuous workoutStrenuous workoutExhibited difficultyExhibited difficultyDied on the fieldDied on the field
Sickle Cell Trait - deathsSickle Cell Trait - deathsPreston Birdsong –TTU 2000Preston Birdsong –TTU 2000DeVaughn Darling – FSU 2001DeVaughn Darling – FSU 2001Aaron Richardson – BGU 2004Aaron Richardson – BGU 2004Aaron O’Neal – Missouri 2005Aaron O’Neal – Missouri 2005Dale Lloyd – Rice 2006Dale Lloyd – Rice 2006Chad Wiley – NC A&T 2008Chad Wiley – NC A&T 2008Ja'Quayvin Smalls – 2009 WCUJa'Quayvin Smalls – 2009 WCUBennie Abram – 2010 Ole MissBennie Abram – 2010 Ole Miss
Cervical Spine InjuryCervical Spine Injury
CervicalCervical SpineSpine ImmobilizationImmobilizationClinical decisionClinical decisionStandardize approach and procedureStandardize approach and procedureHave unencumbered airway accessHave unencumbered airway accessDon’t assume that EMS knows what Don’t assume that EMS knows what
to do – you teach them how you want to do – you teach them how you want it done and practice before the it done and practice before the season (NATA video) season (NATA video)
Spinal Cord Injury Treatment Spinal Cord Injury Treatment ““OptionsOptions””
High dose steroids – High dose steroids – methylprednisolone 30 mg/kg bolus methylprednisolone 30 mg/kg bolus Maintenance dose – 5.4 mg/kg/hr Maintenance dose – 5.4 mg/kg/hr (needs to be started at hospital within (needs to be started at hospital within 3-8 hours)3-8 hours)
Hypothermia – 30 cc/kg of LR cooled to Hypothermia – 30 cc/kg of LR cooled to 37-40 degrees F should drop temp to 37-40 degrees F should drop temp to around 95. Ideal temp between 92-94.around 95. Ideal temp between 92-94.
Kevin Everett case Kevin Everett case
2007 Kevin Everett2007 Kevin EverettMade a tackle on the kickoff with his Made a tackle on the kickoff with his
head downhead downReceived cold IV fluids and steroidsReceived cold IV fluids and steroidsThe real key to his recovery was The real key to his recovery was
going to the appropriate hospital and going to the appropriate hospital and being in surgery within 2 hours being in surgery within 2 hours
ConcussionConcussionDr. Sease concussion updateDr. Sease concussion updateClinical judgment determines if Clinical judgment determines if
severity of head injury negates the severity of head injury negates the validity of the c-spine examvalidity of the c-spine exam
Always fear the concussion when Always fear the concussion when paired with the C1/C2 fracture – axial paired with the C1/C2 fracture – axial load with flexionload with flexion
If immobilizing, remove the If immobilizing, remove the facemask even if awake and talkingfacemask even if awake and talking
2006 and 2007 Trent Green2006 and 2007 Trent GreenConcussions while playing with Concussions while playing with
Chiefs (2006) and Dolphins (2007)Chiefs (2006) and Dolphins (2007)Both were significant and had Both were significant and had
prolonged recovery periodsprolonged recovery periodsWas able to return to play after Was able to return to play after
evaluation and clearanceevaluation and clearance
2000 Blaine Bishop2000 Blaine BishopTitans DB in Super BowlTitans DB in Super BowlBrief LOC / neck pain / L arm Brief LOC / neck pain / L arm
numbnessnumbnessSpinal immobilizationSpinal immobilizationTransport to hospitalTransport to hospitalFinal diagnosis – concussion/cervical Final diagnosis – concussion/cervical
strainstrainComprehensive pregame planning Comprehensive pregame planning
Conditions/EnvironmentConditions/EnvironmentHeat illnessHeat illnessHeat cramps/exhaustion/strokeHeat cramps/exhaustion/stroke33 heat related deaths in football 33 heat related deaths in football
since 1995since 1995Korey Stringer of the Minnesota Korey Stringer of the Minnesota
VikingsVikingsSteve Belcher of the Baltimore Steve Belcher of the Baltimore
OriolesOrioles
Conditions/EnvironmentConditions/EnvironmentLightning – approximately 100-120 Lightning – approximately 100-120
people die per year in the US from people die per year in the US from lightninglightning
In 2006, 5 people died at one event In 2006, 5 people died at one event during a storm (softball)during a storm (softball)
Rosbin Yuman and Lester Marrioquin Rosbin Yuman and Lester Marrioquin soccer players killed in 2001soccer players killed in 2001
Tend to the unconscious first – they Tend to the unconscious first – they usually need more electricity (AED)! usually need more electricity (AED)!
CrisisCrisis Management/Disaster Management/Disaster PlanningPlanning
Know the disaster plan/EAPKnow the disaster plan/EAPHave a written Emergency Action Plan for Have a written Emergency Action Plan for
every venue including practiceevery venue including practicePractice the EAP – docs, ATC’s, coachesPractice the EAP – docs, ATC’s, coachesIs there an evacuation plan?Is there an evacuation plan?Be familiar with the Rally PointBe familiar with the Rally PointTake care of the visiting teamTake care of the visiting teamHave a roster for roll call Have a roster for roll call
DiabetesDiabetesKnow your athletesKnow your athletesEither high or low when they are sickEither high or low when they are sickUrine dipstick is quick and easyUrine dipstick is quick and easyHigh – dipstick + for glucose and maybe High – dipstick + for glucose and maybe
ketones if DKA (Rx with NS)ketones if DKA (Rx with NS)Low – dipstick may have ketones from Low – dipstick may have ketones from
starvation but not spilling glucose (Rx with starvation but not spilling glucose (Rx with D50W or glucagon emergency kit)D50W or glucagon emergency kit)
Usually need to call EMS in either situationUsually need to call EMS in either situation
Diabetic AthletesDiabetic AthletesJay CutlerJay CutlerArthur AsheArthur AsheTy CobbTy CobbScott VerplankScott VerplankJackie RobinsonJackie RobinsonJoe FrazierJoe FrazierBillie Jean KingBillie Jean KingJoe GibbsJoe Gibbs
What EMS should have:What EMS should have:Airway equipment and suppliesAirway equipment and suppliesPortable pulse oximeterPortable pulse oximeterEnd tidal CO2 detectorEnd tidal CO2 detectorManual defibrillator/cardiac monitorManual defibrillator/cardiac monitorACLS drugsACLS drugsRSI drugs if trained MD or state allows EMS RSI drugs if trained MD or state allows EMS
to useto useSteroids if you use them for SCISteroids if you use them for SCI?Oversize backboard for football?Oversize backboard for footballDon’t assume that they have things!Don’t assume that they have things!
What you should haveWhat you should haveAirway plan – LMA, #11 blade, curved Airway plan – LMA, #11 blade, curved
hemostatshemostatsBreathing plan – 14 gauge angiocath, Breathing plan – 14 gauge angiocath,
extra inhaler, Flow Meter, Epi(1:1000)extra inhaler, Flow Meter, Epi(1:1000)Cardiac plan – know how to use AEDCardiac plan – know how to use AEDDisaster plan – be familiar with EAPDisaster plan – be familiar with EAPProcedure plan – know who should and Procedure plan – know who should and
who can do what procedurewho can do what procedureTransport plan – Transport plan – appropriateappropriate facility facility
EMS RelationshipEMS RelationshipWork closely with themWork closely with themPreseason practice of scenariosPreseason practice of scenariosLet them know what is expected of Let them know what is expected of
them, when to come out, what to dothem, when to come out, what to doDemand consistency in staffingDemand consistency in staffingRequire their best trained personnelRequire their best trained personnel
Who should do whatWho should do whatParamedics can intubateParamedics can intubateOnly physicians can do surgical airwayOnly physicians can do surgical airwayOnly physicians can needle decompress Only physicians can needle decompress
tension pneumothoraxtension pneumothoraxATC’s, MD’s, coaches, anyone with training ATC’s, MD’s, coaches, anyone with training
can use AEDcan use AEDEMT-Basic has limited training and EMT-Basic has limited training and
experience in the life threatening experience in the life threatening situationssituations
QuestionsQuestionsLife threatening athlete situations Life threatening athlete situations
exist in almost every sportexist in almost every sportAlways know who is in charge Always know who is in charge Always know who is best trained for Always know who is best trained for
a particular incidenta particular incidentAlways be prepared and be Always be prepared and be
resourceful if unusual situations ariseresourceful if unusual situations arise