Presentation on theme: "On Field Management: Athletic Emergencies"— Presentation transcript:
1On Field Management: Athletic Emergencies Jim Ellis, MD, FACEPFaculty, Primary Care Sports Medicine Fellowship ProgramSteadman Hawkins Clinic of the Carolinas
2Why we do what we doOn 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.
10Airway Evaluation Is the player talking? Is he tachypneic or agonal? What is the pulse ox?EMS bring pulse ox!
11Airway - Maintainable Supplemental oxygen Chin lift or jaw thrust (for c-spine)Nasal or oral airwayBag-valve-mask/pocket mask/barrier
12Airway Evaluation Unmaintainable Airway is inadequate with basic supportProcedural intervention is requiredMust remove facemask to have unencumbered access to the airway on anyone immobilizedNeed Advanced Life Support EMS unit at high risk events
13Endotracheal Intubation The right personThe right equipmentThe right drugsThe right plan for the difficult airway
20Surgical AirwayKnow the anatomyKnow the equipmentKnow the procedure
212002 Super BowlKurt Warner played with a laryngeal fracture – sideline cricothyrotomy kit
222004 Al Lucas Arena League player went down headfirst on a kick-off Evaluated by MD and ATC on FOPWhile 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
26Breathing Problems Massive Hemothorax Tension Pneumothorax Load and Go!Tension PneumothoraxUse pulse oximetry for helpLarge bore IV catheter(14 gauge)2nd intercostal space, midclavicular lineLEAVE IT IN!
272001 Drew BledsoePatriots QB was driven into the ground on the sidelineWas short of breath after the gameTaken to Mass General Hospital and had a chest tube inserted to reinflate his lung and an autotransfusionTom Brady became the starter
31Breathing 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)
322001 Rashidi Wheeler Northwestern football player Died secondary to asthmaKnown asthmatic in difficult workout?Complicated by ephedra use
34Cardiac Problems Cardiac Etiology Sudden cardiac death Arrhythmia of unknown etiologyHypertrophic cardiomyopathyCommotio cordis/cardiac concussion (hockey and baseball)Coronary artery disease in coaches and referees*
36Cardiac Interventions CPR if AED is not right thereAED – know where it is at all times and have nearby at eventsPractice run getting the AEDTrauma scissorsManual defibrillator (EMS)Time to shock is critical!
37Cardiac Interventions Every minute that passes, there is a 10% decrease in chance of survival.90% chance of survival at 1 minute50% chance at 5 minutes10% chance of survival if the initial shock is delivered 9 minutes after the cardiac arrest occurredDon’t wait for EMS
411996 Polish Chef de Mission Opening Ceremony 1996 Olympic Games Cardiac arrest on the field of play10,000 athletes / worldwide TV audienceDefibrillated on the FOP and intubatedTransported with return of vital signsSubsequent death in the hospital
45Other serious cardiac events 1988 – Pete Maravich(NBA) congenital coronary artery1990 – Hank Gathers(NCAA) HCM1993 – Reggie Lewis(NBA) HCM1998 – Chris Pronger(NHL) commotio2003 – Marc Vivien-Foe(soccer) SCD2004 – Sergei Zholtok(NHL) HCM
46Other serious cardiac events 2005 – Jaxon Logan(NCAA) commotio2005 – Thomas Herrion(NFL) HCM/CAD2007 – Damien Nash(NFL) arrhythmia of unknown etiology2007 – Antonio Puerta(soccer) SCD2011 – Wes Leonard(BB) SCD/?HCM
47Circulation Problems Abdominal Trauma/Hemorrhage Splenic or liver injuryDon’t confuse with dehydrationHigh index of suspicionLife/limb threatening hemorrhageTwo large bore IV’sLoad and go (nearest appropriate facility)
482006 Chris Simms September game vs Panthers Multiple hard hits No specific complaint of LUQ painTreated for dehydrationRuptured spleenSurgery at St. Joe’s Hospital (< 1 mile)
52Circulation 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
53Circulation 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”
542008 Ereck Plancher Collegiate athlete with known sickle cell trait Off-season programStrenuous workoutExhibited difficultyDied on the field
57Cervical Spine Immobilization Clinical decisionStandardize approach and procedureHave unencumbered airway accessDon’t assume that EMS knows what to do – you teach them how you want it done and practice before the season (NATA video)
59Spinal 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 betweenKevin Everett case
602007 Kevin Everett Made a tackle on the kickoff with his head down Received cold IV fluids and steroidsThe real key to his recovery was going to the appropriate hospital and being in surgery within 2 hours
62Concussion Dr. Sease concussion update Clinical judgment determines if severity of head injury negates the validity of the c-spine examAlways fear the concussion when paired with the C1/C2 fracture – axial load with flexionIf immobilizing, remove the facemask even if awake and talking
642006 and 2007 Trent GreenConcussions while playing with Chiefs (2006) and Dolphins (2007)Both were significant and had prolonged recovery periodsWas able to return to play after evaluation and clearance
69Conditions/Environment Heat illnessHeat cramps/exhaustion/stroke33 heat related deaths in football since 1995Korey Stringer of the Minnesota VikingsSteve Belcher of the Baltimore Orioles
70Conditions/Environment Lightning – approximately people die per year in the US from lightningIn 2006, 5 people died at one event during a storm (softball)Rosbin Yuman and Lester Marrioquin soccer players killed in 2001Tend to the unconscious first – they usually need more electricity (AED)!
71Crisis Management/Disaster Planning Know the disaster plan/EAPHave a written Emergency Action Plan for every venue including practicePractice the EAP – docs, ATC’s, coachesIs there an evacuation plan?Be familiar with the Rally PointTake care of the visiting teamHave a roster for roll call
73Diabetes Know your athletes Either high or low when they are sick Urine dipstick is quick and easyHigh – 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
74Diabetic Athletes Jay Cutler Arthur Ashe Ty Cobb Scott Verplank Jackie RobinsonJoe FrazierBillie Jean KingJoe Gibbs
75What EMS should have: Airway equipment and supplies Portable pulse oximeterEnd tidal CO2 detectorManual defibrillator/cardiac monitorACLS drugsRSI drugs if trained MD or state allows EMS to useSteroids if you use them for SCI?Oversize backboard for footballDon’t assume that they have things!
77What 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 AEDDisaster plan – be familiar with EAPProcedure plan – know who should and who can do what procedureTransport plan – appropriate facility
78EMS Relationship Work closely with them Preseason practice of scenariosLet them know what is expected of them, when to come out, what to doDemand consistency in staffingRequire their best trained personnel
80Who should do what Paramedics can intubate Only physicians can do surgical airwayOnly physicians can needle decompress tension pneumothoraxATC’s, MD’s, coaches, anyone with training can use AEDEMT-Basic has limited training and experience in the life threatening situations
85QuestionsLife threatening athlete situations exist in almost every sportAlways know who is in chargeAlways know who is best trained for a particular incidentAlways be prepared and be resourceful if unusual situations arise