1. On Field Management: Athletic Emergencies
Jim Ellis, MD, FACEP
Faculty, Primary Care Sports Medicine Fellowship Program
Steadman Hawkins Clinic of the Carolinas

2. Why we do what we do
On October 24, 1971 Chuck Hughes of the Detroit Lions went across the middle on a pass play and collapsed. Legendary LB Dick Butkus frantically waved to the sideline for help. Despite the efforts of the training staff, he died of a “heart attack” and remains the only on field death in the history of the NFL.

4. Objectives Know the risks of the sport you cover
Know your specific role/responsibility
Know your players’ illnesses
Know what equipment to have
Know the Emergency Action Plan

6. ATLS, ACLS, “ASLS” Advanced Sports Life Support
Airway
Breathing
Cardiac
Circulation
Cervical Spine
Concussion
Conditions/Environment
Crisis Management/Disaster
Diabetes

8. Airway Problems Direct Trauma Anterior neck trauma Indirect Trauma
Severe concussion can lead to unprotected airway
High cervical spine injury

10. Airway Evaluation Is the player talking? Is he tachypneic or agonal?
What is the pulse ox?
EMS bring pulse ox!

11. Airway - Maintainable Supplemental oxygen
Chin lift or jaw thrust (for c-spine)
Nasal or oral airway
Bag-valve-mask/pocket mask/barrier

12. Airway Evaluation Unmaintainable
Airway is inadequate with basic support
Procedural intervention is required
Must remove facemask to have unencumbered access to the airway on anyone immobilized
Need Advanced Life Support EMS unit at high risk events

13. Endotracheal Intubation
The right person
The right equipment
The right drugs
The right plan for the difficult airway

14. Anatomy

15. Airway Adjuncts Intubating Stylet Lighted Stylet
LMA *great tool for the airway novice
Intubating LMA
Levitan Fiberoptic Scope

17. LMA and Intubating LMA

19. Surgical Airway Unsuccessful endotracheal intubation
Mandibular fracture
Anterior neck trauma
Laryngeal fracture
Stridor

20. Surgical Airway
Know the anatomy
Know the equipment
Know the procedure

21. 2002 Super Bowl
Kurt Warner played with a laryngeal fracture – sideline cricothyrotomy kit

22. 2004 Al Lucas Arena League player went down headfirst on a kick-off
Evaluated by MD and ATC on FOP
While being loaded into the ambulance, stopped breathing (within 10 minutes of injury)
Died from airway compromise due to C1/C2 fracture and concussion despite using an LMA for airway

24. 1997 Reggie Brown Lions linebacker injured vs Jets
C1/C2 fracture with CHI
Airway compromise from above
On field mouth to mouth and BVM
Response saved his life and had remarkable post op recovery

26. Breathing Problems Massive Hemothorax Tension Pneumothorax
Load and Go!
Tension Pneumothorax
Use pulse oximetry for help
Large bore IV catheter(14 gauge)
2nd intercostal space, midclavicular line
LEAVE IT IN!

27. 2001 Drew Bledsoe
Patriots QB was driven into the ground on the sideline
Was short of breath after the game
Taken to Mass General Hospital and had a chest tube inserted to reinflate his lung and an autotransfusion
Tom Brady became the starter

29. 2008 Lauren Chang Cheerleader accidently kicked in the chest
Had collapsed lungs - bilateral
Died from tension pneumothorax

31. Breathing Problems Asthma Know your players
Nebulizer vs inhaler (use a spacer)
Keep an extra MDI (inhaler)
Make sure EMS gives the right Epi dose SQ/IM (1:1000) vs IV (1:10,000)
Can use Epi-Pen if needed (same dose as allergic reaction 0.3cc)
Peak Flow Meter (know their baseline)

32. 2001 Rashidi Wheeler Northwestern football player
Died secondary to asthma
Known asthmatic in difficult workout
?Complicated by ephedra use

34. Cardiac Problems Cardiac Etiology Sudden cardiac death
Arrhythmia of unknown etiology
Hypertrophic cardiomyopathy
Commotio cordis/cardiac concussion (hockey and baseball)
Coronary artery disease in coaches and referees*

36. Cardiac Interventions
CPR if AED is not right there
AED – know where it is at all times and have nearby at events
Practice run getting the AED
Trauma scissors
Manual defibrillator (EMS)
Time to shock is critical!

37. Cardiac Interventions
Every minute that passes, there is a 10% decrease in chance of survival.
90% chance of survival at 1 minute
50% chance at 5 minutes
10% chance of survival if the initial shock is delivered 9 minutes after the cardiac arrest occurred
Don’t wait for EMS

39. 2005 Jiri Fisher Collapsed on the ice Saved with CPR and AED
Key was a rapid response to a true life threatening emergency
Etiology was underlying arrhythmia

41. 1996 Polish Chef de Mission Opening Ceremony 1996 Olympic Games
Cardiac arrest on the field of play
10,000 athletes / worldwide TV audience
Defibrillated on the FOP and intubated
Transported with return of vital signs
Subsequent death in the hospital

43. 2011 Al Schmidt at UGA Mississippi State track official Known CAD
At SEC Track meet on UGA campus
Witnessed cardiac arrest
Well practiced EAP
AED on site in 2 minutes
Survived to discharge neuro intact

45. Other serious cardiac events
1988 – Pete Maravich(NBA) congenital coronary artery
1990 – Hank Gathers(NCAA) HCM
1993 – Reggie Lewis(NBA) HCM
1998 – Chris Pronger(NHL) commotio
2003 – Marc Vivien-Foe(soccer) SCD
2004 – Sergei Zholtok(NHL) HCM

46. Other serious cardiac events
2005 – Jaxon Logan(NCAA) commotio
2005 – Thomas Herrion(NFL) HCM/CAD
2007 – Damien Nash(NFL) arrhythmia of unknown etiology
2007 – Antonio Puerta(soccer) SCD
2011 – Wes Leonard(BB) SCD/?HCM

47. Circulation Problems Abdominal Trauma/Hemorrhage
Splenic or liver injury
Don’t confuse with dehydration
High index of suspicion
Life/limb threatening hemorrhage
Two large bore IV’s
Load and go (nearest appropriate facility)

48. 2006 Chris Simms September game vs Panthers Multiple hard hits
No specific complaint of LUQ pain
Treated for dehydration
Ruptured spleen
Surgery at St. Joe’s Hospital (< 1 mile)

50. 1989 Clint Malarchuk NHL goalie with skate to the neck
Life threatening hemorrhage
Direct pressure and rapid transport
Went directly to OR for vascular surgery and survived

52. Circulation Problems Sickle Cell Trait
- easy to diagnosis with a simple screening blood test
- 10 known deaths since 2000
- 8-10% of black population
- NATA policy statement
- NCAA ?mandatory testing

53. Circulation Problems Sickle Cell Trait - Identify high risk activities
- common in off- or pre-season
- monitor first few workouts
- ease into preseason conditioning
- SCT muscle pain and weakness
- dehydration cramps/”locking up”

54. 2008 Ereck Plancher Collegiate athlete with known sickle cell trait
Off-season program
Strenuous workout
Exhibited difficulty
Died on the field

55. Sickle Cell Trait - deaths
Preston Birdsong –TTU 2000
DeVaughn Darling – FSU 2001
Aaron Richardson – BGU 2004
Aaron O’Neal – Missouri 2005
Dale Lloyd – Rice 2006
Chad Wiley – NC A&T 2008
Ja'Quayvin Smalls – 2009 WCU
Bennie Abram – 2010 Ole Miss

56. Cervical Spine Injury

57. Cervical Spine Immobilization
Clinical decision
Standardize approach and procedure
Have unencumbered airway access
Don’t assume that EMS knows what to do – you teach them how you want it done and practice before the season (NATA video)

59. Spinal Cord Injury Treatment “Options”
High dose steroids – methylprednisolone 30 mg/kg bolus Maintenance dose – 5.4 mg/kg/hr (needs to be started at hospital within 3-8 hours)
Hypothermia – 30 cc/kg of LR cooled to degrees F should drop temp to around 95. Ideal temp between
Kevin Everett case

60. 2007 Kevin Everett Made a tackle on the kickoff with his head down
Received cold IV fluids and steroids
The real key to his recovery was going to the appropriate hospital and being in surgery within 2 hours

62. Concussion Dr. Sease concussion update
Clinical judgment determines if severity of head injury negates the validity of the c-spine exam
Always fear the concussion when paired with the C1/C2 fracture – axial load with flexion
If immobilizing, remove the facemask even if awake and talking

64. 2006 and 2007 Trent Green
Concussions while playing with Chiefs (2006) and Dolphins (2007)
Both were significant and had prolonged recovery periods
Was able to return to play after evaluation and clearance

67. 2000 Blaine Bishop Titans DB in Super Bowl
Brief LOC / neck pain / L arm numbness
Spinal immobilization
Transport to hospital
Final diagnosis – concussion/cervical strain
Comprehensive pregame planning

69. Conditions/Environment
Heat illness
Heat cramps/exhaustion/stroke
33 heat related deaths in football since 1995
Korey Stringer of the Minnesota Vikings
Steve Belcher of the Baltimore Orioles

70. Conditions/Environment
Lightning – approximately people die per year in the US from lightning
In 2006, 5 people died at one event during a storm (softball)
Rosbin Yuman and Lester Marrioquin soccer players killed in 2001
Tend to the unconscious first – they usually need more electricity (AED)!

71. Crisis Management/Disaster Planning
Know the disaster plan/EAP
Have a written Emergency Action Plan for every venue including practice
Practice the EAP – docs, ATC’s, coaches
Is there an evacuation plan?
Be familiar with the Rally Point
Take care of the visiting team
Have a roster for roll call

73. Diabetes Know your athletes Either high or low when they are sick
Urine dipstick is quick and easy
High – dipstick + for glucose and maybe ketones if DKA (Rx with NS)
Low – dipstick may have ketones from starvation but not spilling glucose (Rx with D50W or glucagon emergency kit)
Usually need to call EMS in either situation

74. Diabetic Athletes Jay Cutler Arthur Ashe Ty Cobb Scott Verplank
Jackie Robinson
Joe Frazier
Billie Jean King
Joe Gibbs

75. What EMS should have: Airway equipment and supplies
Portable pulse oximeter
End tidal CO2 detector
Manual defibrillator/cardiac monitor
ACLS drugs
RSI drugs if trained MD or state allows EMS to use
Steroids if you use them for SCI
?Oversize backboard for football
Don’t assume that they have things!

77. What you should have Airway plan – LMA, #11 blade, curved hemostats
Breathing plan – 14 gauge angiocath, extra inhaler, Flow Meter, Epi(1:1000)
Cardiac plan – know how to use AED
Disaster plan – be familiar with EAP
Procedure plan – know who should and who can do what procedure
Transport plan – appropriate facility

78. EMS Relationship Work closely with them
Preseason practice of scenarios
Let them know what is expected of them, when to come out, what to do
Demand consistency in staffing
Require their best trained personnel

80. Who should do what Paramedics can intubate
Only physicians can do surgical airway
Only physicians can needle decompress tension pneumothorax
ATC’s, MD’s, coaches, anyone with training can use AED
EMT-Basic has limited training and experience in the life threatening situations

85. Questions
Life threatening athlete situations exist in almost every sport
Always know who is in charge
Always know who is best trained for a particular incident
Always be prepared and be resourceful if unusual situations arise