“what every hockey, football, soccer mom and dad in … · “what every hockey, football, soccer...

“What Every Hockey, Football,“What Every Hockey, Football,Soccer Mom and Dad in Health Care Should Know!”

John Boulay B.Sc., CAT(C), EMT, DO(Q)Certified Athletic Therapist, EMT, Osteopath

Sports First Responder / EMR Instructor-Trainer Concordia University – Part-time faculty AT program

Conflict of Interest Disclosure

“I do not or have had in past two years,

an affiliation with /or financial interest

of any nature in a business corporation,

ITC Montreal Sept 26 2014 John Boulay

of any nature in a business corporation,

or I receive remuneration, royalties or

research grants from a business corporation”

Preamble• Health care workers who are parents of

young active athletes are sometimes called upon to render assistance on the field of play.play.

• Not all may be comfortable with responding to suspected spinal injuries or cerebral concussions on the playing field.


Objectives

• To provide an update on pre-hospital sports trauma management principles:

1. ERP - Emergency Response Plan 1. ERP - Emergency Response Plan

2. Primary Survey in Sport

3. Managing Sports Equipment Extrication

4. Spinals

5. mTBI / Sport ConcussionITC Montreal Sept 26 2014 John Boulay

1. Emergency Response Plan

1. The home team is responsible for ensuring that an operational ERP- Emergency Response Plan is in place, tested and periodically revised as necessary.

2. The home team should inform the visiting team about the emergency response plan prior to the start of the game. emergency response plan prior to the start of the game. This should include info about available equipment, resources, roles of each member of the ERP and theirlocation during the event. Each members’ presence should be confirmed prior to the start of the game as well as whether an ambulance was hired for the event/game.


3. Should the visiting team not have a designated person

responsible for injuries/illness, someone from host

team should be pre-determined to respond to on-field

injuries/emergencies.

4. The home team must always be available to give support

when requested by pre-determined signal/ request for


when requested by pre-determined signal/ request for

assistance.

5. Direct access communication (cell phone) from sideline of

playing surface is optimal to ensure immediate activation of

EMS as required.

.

6. Direct verbal communication with on-field charge person

will ensure adequate information is obtained before

activating EMS system. Hand signals may be used when

emergency situation appears obvious, but must be

confirmed by repetition of signal by call person and

verbal confirmation after call is made.

7. Access routes and exact site location information must

be posted/available to the call person. Call person then

ensures that EMS access if facilitated through contact

with facility security and/or delegated EMS greeters at a

designated entrance or intersection.


8. Information regarding local walk-in services should

be available for non-urgent referrals/ minor

emergencies.

9. At the end of the game the home team should inform

the visiting team when they are no longer available to

assist and that they are to call 911 directly should the assist and that they are to call 911 directly should the

need arise.

An ERP should be prepared for every sports venue no

matter what the level / intensity of physical/sports activity.


2. Primary Survey in Sport • Primary survey may be modified in sports setting.

• Different agencies use order of care pertinent to their area

of concern. Sports milieu has its own particular nuances…


AIRWAY ACCESSMOUTH GUARD OXYGEN DEBT

On-Field Intervention1. Determine MOI (mechanism of injury)

2. Spinal precautions in effect (manually stabilize head-neck)

3. Primary Survey UABCd/CABd

UABCd / UCABd

Primary Survey- ILCOR-ECC 2010 (adapted for sport) Primary Survey- ILCOR-ECC 2010 (adapted for sport)

U unresponsiveness AVPU/Glasgow (initiate ERP)

ASSESSMENT TREATMENT

A airway C circulation

B breathing A airway

C circulation B breathing

d defib d defib


ASSESS: ABC simultaneously assessed in order of “ABC” for max 10 sec.

A open airway,

B breathing: Look/Listen/Feel,

C pulse: drop one hand down on same side to take carotid pulse

TREAT: CAB C if pulse absent, commence 30 compressions right away

A airway is opened (if accesible)

B breaths are given (given once airway is open/accessible)

If pulse present, breathing absent, 1 breath every 5-6 sec.


If breathing present, unconscious, maintain airway, further care

Unresponsiveness

Application of GLASGOW in sportNon-scored GCS performed during determination of “U” Unconscious portion of primary survey.

AVPU vs Glasgow “EVM-456”

Glasgow is part of SCAT 3 (Concussion Tool)

UNRESPONSIVENESSAsk: What happened? -Do eyes open if they were closed?

-Do they respond verbally or move?Ask: Open your eyes! -Do they open their eyes? Move? If some response, continue …Ask: Where does it hurt? -Do they respond verbally?Tell: Move your fingers! -Do they move their fingers?


-


3. Managing Sports Equipment Extrication

Old Dilema SolvedSports Equipment Removal Guidelines

“Keep Equipment On? vs. Take Equipment Off!”

ISSUES


ISSUES

-Airway Access

-Chest Access

-Spinal Transfer Issues

• 2010 PIC TAP Tech 13 Sport Equipment Removal Guidelines

• On-going studies to review effective evidence-based techniques * ALL PROTECTIVE SPORTS EQUIPMENT TO BE REMOVED BEFORE TRANSPORT

Sport Equipment Removal Guidelines

• Helmet/Pad removal on-site vs hospital?

• Keeping equipment on prudent?

• Guidelines more effective with UABC/UCAB approach

• Trained/rehearsed in extrication of equipment “ideally” within

30 days before start of season.

• Equipment should be removed sooner than later depending • Equipment should be removed sooner than later depending

on available resources.

• If only one trained rescuer, provide care as required, do not

consider full equipment removal until arrival of paramedic

team.

• Follow priorities of care (principle and preference).

• Should be competent in your designated sport.ITC Montreal Sept 26 2014 John Boulay

Football: Jersey/Pad cut

RIP KORD- Latest shoulder pad removal system


Montreal Children’s Hospital – Trauma Rounds Sept 2011


Football: Quick Release/Unscrew/Cut

1

*VISOR may have to be modified to allow face mask to swivel upITC Montreal Sept 26 2014 John Boulay

2

3

• The football faceguard (facemask) should always be removed with a suspected spinal.

• Research has shown there is less movement of the head/neck during helmet removal when the facemask is removed first.

• Long face masks also present a challenge with pads still in place and helmet rotation needed to clear face is limited.

• Football helmet and pads always removed as unit


• Football helmet and pads always removed as unit

• In arrest situations, do not interrupt first 10 minutes of CPR / first 5 analyses/shock for equipment removal if ALS (mtl) has not arrived

• Hockey is not like football.

• Should be competent in your designated sport.

4. Suspected Spinal

-Spinals: Over vs. Under Immobilized?

http://www.youtube.com/watch?v=808_rxRmRco&sns=em

-Spinal Board vs Vacuum Mattress?

-Tech 13 Sports Equipment Removal


-Tech 13 Sports Equipment Removal

-Sports medicine setting offers better opportunities for

applying optimal spinal transfer techniques due to:

- practice

- personnel

- sports specificity/expertise

Spinal Injury Care - Skill SetsHead stabilization�Head Hold (head squeeze),

�Trap Hold (trap squeeze)

Cervical Collar-sizing/application�supine, standing, seated,

Prone Emergency Log Roll �Emerg LR-1(c-spine,code 99)

�Emerg LR-2(c-spine,code 99)

Supine Lift & Slide� technique of choice,

�better than log roll: L&S-8, L&S-6, �supine, standing, seated,

�seated, four-point

�*avoid over-size collar

(Internal decapitation-Baylor)

Supine Emergency Log Roll �Emerg LR-1 (c-spine,

aspir.risk)

�Emerg LR-2 (c-spine, aspir.

risk)

�better than log roll: L&S-8, L&S-6,



8-person Lift & Slide

Supine Log Roll�More movement than lift &

slide (L&S)

�Requires fewer rescuers:

LR-5, LR-4. LR-2

Supine Straddle-Lift

Standing Take Down�Collar, patient brought down

on board

�2 rescuers. 1 spotter

�Not advised on ice

Spinal Skill Sets

Supine Straddle-Lift�Application in tight spaces,

uneven surfaces: SL-5. SL-4,

Prone Log Roll �Rescuers on board, lunge

back, roll onto board

�On ice: use wet towel under

board

Seated Take Down�Collar first, patient brought

down on board with 3-5

rescuers



5 person straddle lift

Four-Point Take Down�Prone: collar first, patient

lowered down with 3

rescuers, then rolled

�Lateral: collar first, patient

lowered laterally with 3


� ITLS: Torso-2 straps cross,

pelvis-2 straps cross, legs-1

strap horz

Re-positioning Board�PHTLS: lateral then vertical

� ITLS: V-slide

Spinal Skill Sets


Strapping�PHTLS: Torso-2 straps cross,

ASIS-1 strap horz., mis-

femur-1 dtrap horz., pelvis-2

straps cross



-Log-roll athlete and sled together into supine position.

-Once helmet removed and assessment performed,

apply cervical collar and transfer to spine board

Re-Positioning on Board

• ITLS: V-Slide in 2 steps

-less shear

-a practiced skill)

• PHTLS: Separate vertical / lateral slides • PHTLS: Separate vertical / lateral slides

-easier to perform, better on ice

-may cause shear if not careful

Both techniques effective & have advantages



V-Slide (ITLS)

1. Slide down and diagonally

2. Slide up and towards center of board


Track evacuation of immobilized athlete on spine board

placed within litter stretcher.

5. mTBI / Sport ConcussionmTBI under reported vs. over-treated?

Guidelines- which?

Baselines- necessary?


Mayhem- media?

Dr Craton- Re-think Zurich Guidelines?

Marketing/Profiteering?

Professional sport concussion

http://ctsq.qc.ca/wp-content/uploads/2013/08/CTSQ-Final-

version-21-aout-2014.pdf


Concussion- Acute Care

The on-field and sideline management of

concussions is one of the most difficult sport-

related injuries to manage..

Each athlete may respond differently to head Each athlete may respond differently to head

trauma and it is difficult to find one protocol that

will be applicable in every case.

Responders must make an informed decision on

concussion management with the tools available

and treat with utmost care..ITC Montreal Sept 26 2014 John Boulay

CONCUSSION SUSPECTED ?

ON-FIELD

-Mechanism of injury?

-Emergency management/ First aid issues?

If the primary and secondary surveys show presence of serious issues,

activate the Emergency Response Plan (ERP).

Use the SCAT3 as part of the screening tools to help determine Use the SCAT3 as part of the screening tools to help determine

“Recognize & Remove” concussion signs.

-Glasgow Score?

-Maddocks?

IF concussion suspected- Urgent care? (urgent referral ER)

board/stretcher

or non-urgent care? (assess more on sideline)

walk-off with assist


On-Field: Secondary Survey

Secondary Survey includes:

SAMPLE, full body-scan, vitals, GCS baseline score

Determine if concussion signs present?

Somatic? Cognitive? Emotional? Behavioural changes?

(LOC, balance/motor coordination issues, disorientation,

confusion, memory loss, blank vacant stare, visible facial injury?)confusion, memory loss, blank vacant stare, visible facial injury?)

Cranial nerves easily assessed on field:II. Optic - visual acuity

III. Oculomotor - pupil reaction

IV. Trochlear - eye movements

VII. Facial – smile, grimace


SIDELINEIf the athlete is conscious, alert, and has no red flags indicating serious head injury or need for spinal immobilization, the athlete can make their own way off the field, then the concussion assessment may continue on sideline.

Further assessment to determine management choice:

MD referral? SAME DAY POST-CONCUSSION (3-7 days)POST-CONCUSSION (3-7 days)

BackgroundFollowing tests done after 10 minutes post activity (resting state)Symptom Severity Cognitive (SAC)Neck ExamBalanceCoordinationSAC Delayed recall

Cranial nerves testedITC Montreal Sept 26 2014 John Boulay

Initial Concussion ManagementDocument SCAT3 findings at time of injury and compare with baseline if available.

Complete GSC at time of injury, 2-3 hours, 24 hours, 48 hours, 72 hours post

concussion.

Provide copies of both SCAT3 and GSC to responsible adult doing home monitoring

and for physician visit.

Urgency of treatment and referral is dependent on athlete condition. Urgency of treatment and referral is dependent on athlete condition.

In all cases, it is highly recommended that athletes with suspected head injury seek

medical attention.

If EMS is called, transfer of care should involve giving the paramedics the original

copy of completed SCAT3 and intervention notes. The AT can take a picture of the

form with their camera for later reference and documentation.

An athlete with suspected concussion can never RTP same day and must follow

currently accepted age-specific RTP guidelines.


911 & Concussions

It is prudent to be over-cautious, but there are realities of the

pre-hospital care system that should be considered.

The current 2013 protocols for the Services Préhospitaliers

d’Urgences du Québec (Quebec Provincial Emergency Medical d’Urgences du Québec (Quebec Provincial Emergency Medical

Services - EMS) indicate use of cervical collar and full spinal

immobilization (including vacuum mattress) for ANY head injury.

The use of urgent referral should be validated before use.

However, if there is any doubt, initiate ERP including 911

ambulance dispatch sooner than later.


Categories of Referral

A physician referral is also required if further

diagnostic testing is indicated, medications prescribed,

or if there are medical forms/letters that must be

completed for school or specialist referral.

There are generally three categories of physician

referrals:

A. Urgent

B. Same-day

C. Post-concussion


Physician Referral

The AT should document all findings of SCAT3/Child

SCAT3 and GSC, for home monitoring, and provide copies

to the EMT during transfers of care.

All concussions should be referred to a physician, ideally All concussions should be referred to a physician, ideally

one who has experience dealing with head injuries for

follow-up investigation. AT’s should remain in contact with

their injured athlete and/or the person monitoring them for

the first 48 hours to ensure appropriate follow-up is made.


A. Urgent Referral

Requires immediate referral to an ER physician by ambulance.

The athlete would be immobilized and then transported urgently to the

nearest trauma hospital.

The following are typical red flags indicating need for an urgent referral:

-Unconsciousness / prolonged loss of consciousness

-Altered or decreasing level of consciousness

-Decreased neurological function

-Decreased or irregularity in pulse

-Unequal / dilated / unreactive pupils-Unequal / dilated / unreactive pupils

-Mental status changes such as lethargy, non-arousal, confusion,

agitation

-Seizure activity, lucid interval, convulsions, etc.

-Vomiting

-Severe or increasing headache

-Visual changes

-Slurred speech

-Any sign / symptoms of associated injuries such as to the spine, possible

skull fracture or cranial bleeding.


B. Same Day Referral

A physician’s office visit is recommended on the same day for

concussion follow-up when there are no urgent red flags

present.

The athlete would not leave the presence of the AT for at least

30 minutes. The athlete would be closely monitored for any

deterioration (especially first 4 hours) until seen that day.

If a same day office/clinic visit is not possible for any reason,it is

recommended that one goes to the ER, however an ambulance

should not be required.


Same day referral criteria includes:

-No loss of consciousness

-Alert, oriented, normal neurological exam

-Minimal symptoms that persist more than 15 minutes

-Minimal symptoms such as mild nausea, mild light/noise

sensitivity, mild memory issues, or any alteration from

baseline (if available) would warrant a same day referral.baseline (if available) would warrant a same day referral.

If headache is:

• the only remaining symptom after 15 minutes

• does not go and come back

• does not increase in intensity

• is not severe


Same day vs. Post Concussion Referral

-If there are no other urgent indicators, and it is possible to monitor

for next four hours … a decision to refer as a same-day or post-

concussion can be made.

-It is important to provide the person monitoring the athlete a -It is important to provide the person monitoring the athlete a

completed copy of SCAT3 that also includes concussion injury advice.

Also give them a copy of GSC form (with initial findings) for home

monitoring.

-A physician note should also be obtained stipulating whether a

follow-up MD visit is required before RTP can be done under

guidance of an AT.


C. Post-Concussion Referral

A physician’s office visit is recommended within the next

few days for concussion follow-up in absence of urgent or

same day referral criteria.

The athlete would not leave the presence of the AT for at

least 30 minutes. The athlete would be monitored for any

deterioration (especially first four hours) until seen by

physician in next few days.


Post-concussion referral criteria:

Post-Concussion referral criteria includes:

-Mild headache (as listed under same day criteria) with absence of

red flags

-All other symptoms completely gone within 15 minutes

This visit will ensure medical follow-up, documentation of

condition, completion of forms for insurance or medical notes for

absences and/or academic accommodations.

It is important to provide the person monitoring the athlete a

completed copy of SCAT3 which also includes concussion injury

advice along with a copy of GSC form (within initial findings) for

home monitoring.

A physician note should also be obtained stipulating whether a

follow-up MD visit is required before RTP, or that the RTP can be

done under guidance of an AT.

A physician consult visit should be obtained within 3-7 days. ITC Montreal Sept 26 2014 John Boulay

Home Care and Monitoring

Careful monitoring the first 24-72 hours is critical to identify any

evolving issue.

If the athlete does not need to see a physician same-day, the AT

should provide a structured plan for home care and monitoring.

This includes giving a copy of initial GSC and instructions.

To ensure adequate home monitoring, GSC should be completed

at time of injury, 2-3hrs, 24hrs, 48hrs, and 72hrs post injury.

Any change or deterioration requires an immediate physician

evaluation.


Sleep / Cognitive Rest

As cognitive rest is important, the practice of keeping awake or

waking up the athlete the first night is not advised. This practice

may in fact disrupt sleep pattern, increase symptoms next day

due to combined effects of injury and sleep deprivation.

Sleep is restorative and the athlete should be allowed to sleep.

However, the parent or designated guardian should check in on

the athlete after they are asleep.the athlete after they are asleep.

Suggested monitoring the first night may involve quickly

observing the athlete while they are sleeping to take note of

abnormal breathing patterns, excessive snoring, posturing, or

distress. This can be done 2 and 4 hours after the athlete has

gone to bed. At this point the parent/guardian can also note if the

athlete is not sleeping.


If there is any doubt in athlete’s condition, the athlete

should be woken up to be sure they can be

awakened, there is no amnesia or increase in

symptoms requiring an urgent intervention.

General rules in management usually involve waking

the athlete up only if the athlete had experienced a

…Sleep / Cognitive Rest

the athlete up only if the athlete had experienced a

LOC, prolonged period of amnesia, or still

experiencing significant symptoms.

The completed GSC form should be brought to

subsequent physician / AT visits. Ideally the AT

should see the athlete on daily basis to monitor

symptoms until they resolve and be directing the

RTP. In the first day or two post-injury, a contact by

phone may suffice to check on progress.ITC Montreal Sept 26 2014 John Boulay

Return to Hospital / Worsening Symptoms

It should be understood that during an initial hospital

ER visit, a CT scan may not always be done.

If symptoms worsen or any red flags appear (usually

within first 24-48 hours), the athlete should return to

the same hospital.the same hospital.

Physician discretion would dictate whether imaging

would be of benefit in this situation.

CT scans are used sparingly and only in urgent

situations, especially in the pediatric population.


Vomiting

Vomiting after a head injury may have different

implications depending on the situation. For children (<13

yrs old), persistent vomiting (>3 times) is a more reliable

indicator.

For adults >1 time would be suspect in absence of

migraine/motion sickness history. Some people with migraine/motion sickness history. Some people with

family or personal history of migraines or motion sickness

may be more prone to vomiting after a head injury and

may not be indicative of head injury severity.

Persistent vomiting may be more of an indicator than a

single occurrence post trauma. Approximately 10-15% of

children vomit after a mild traumatic brain injury.


ITC Montreal Sept 26 2014 John BoulayMERCI

“what every hockey, football, soccer mom and dad in … · “what every hockey, football, soccer...

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