1. Cyprian Enweani MD

2. Introduction Focus in literature is quite academic and medico-legal Guidelines suggest sideline physician should be up to date with ATLS & ACLS while comfortable with emergency procedures (ie intubation) This would exclude many GP’s/FP’s

3. Introduction Objective today – keep it simple Assume most physicians are not in the ER Target to the “mother”&”father” family physician who is volunteering

4. If in doubt keep out At a minimum safety Sideline physicians main responsibility is to protect the athlete from further injury, re-injury, & permanent disability The pressure will be to let the athlete continue and not delay the game Don’t rush If in doubt keep out

5. ABC’S Rarely needed but ABC’s still essential Know how you will activate EMS If an athlete collapses –don’t move them –log roll to there back (c-spine protection) –then ABC Airway / C-spine –is the airway clear –am I protecting the neck Breathing –is the athlete breathing Circulation –is there a pulse (usually carotid)

6. The Bag CASM – full bag with airway supplies, resus meds,IV’s etc for those interested Mom &Dad could bring no equipment to the sideline but will be very stressful as really limits what you can do to help Suggest at minimum a small “black bag”

7. The Black Bag AIRWAY/BREATHING Cell phone -activate EMS One-way mask-mouth to mouth Oral airway –keep tongue forward 14 gauge cathlon-surgical airway Stethoscope Tongue depressor Pen light Ventolin inhaler &spacer -asthma

8. The Black Bag CIRCULATION Epipen/Twinject- anaphylaxis Automated BP cuff-useful in heat stroke-concussion etc Digital thermometer –heat exhaution/stroke Suture kit (optional)

9. Suture kit Stopping bleeding /repairing laceration is one area physician can have a significant impact on immediate return to play Disposable suture tray Lidocaine 4-0 /6-0 novafil 22guage 3cc syringe 30 gauge needle Cleaning solution/saline Plastic bottle for sharps

10. The Black Bag Other Equipment Tuning fork assess for fractures Gauze 2x2’s 4x4’s Tape Screw driver/allen-wrench/bolt cutter for face mask removal Gloves –sterile/non sterile

11. GENERAL ASSESSMENT Triage to hospital finished for the day; clinic f/u ok to return

12. INITIAL ASSESSMENT Airway & C-Spine unconscious/minimally responsive; assume neck injury may have to take face mask off log roll

18. INITIAL ASSESSMENT Breathing breathing ? stridor/hoarseness? suggest laryngeal injury present Pneumothorax? deviated trachea, SOB, ↓ breath sounds, subcutaneous emphysema

19. INITIAL ASSESSMENT Circulation carotid pulse

20. INITIAL ASSESSMENT Disability Brief survey Neurologic deficit?

21. INITIAL ASSESSMENT Exposure Check extremities

22. Airway Unconscious/minimally responsive assume neck injury Activate EMS Ensure airway- log roll to back; remove face mask Remove mouth guard; teeth; vomit Jaw thrust; oral airway

23. Airway If anterior neck injury consider laryngeal fracture or edema stridor/difficulty speaking Consider needle cricothyroidotomy with 14 gauge needle in the cricothyroid membrane between thyroid cartilage and cricoid cartilage.

25. Breathing Once airway open, often all needed. If not – mouth to mouth/mouth to bag mask. Anaphylaxis – Epinephrine (EpiPen; Twinject) Asthma Ventolin + spacer Epinephrine

26. Breathing Pneumothorax from: penetrating trauma rib # spontaneous

27. Tension Pneumothorax If compressing rest of lung tissue - tracheal deviation - hypotension - ↓ breath sounds - distended neck veins - dyspnea Tx: 14 gauge, 2 nd intercostal space, midclavicular line

28. Circulation No pulse CPR EMS AED

29. SPECIFIC CONDITIONS Neck Injury Concussion Stinger/Burner Bony Injury Soft Tissue Teeth Heat Injury

30. Neck Injury: Unconscious Assume neck injury Activate EMS/support C-spine/ABCs/transport Immobilization in helmet/pads

31. Neck Injury: Conscious neck pain over C-spine neurologic symptoms no pain, no numbness, no tingling, no weakness can get up otherwise immobilize and transport

32. Concussion: Recognition Any head and any neurologic symptoms Review check list – key symptoms/signs - Amnesia - Memory testing - Balance

34. Concussion: Return to play First Concussion: Grade I symptoms <15 min – ok Grade II symptoms >15 min – no until 1 week symptom free at rest and no exertional symptoms Grade III LOC (other than brief) no until 2 weeks symptom free at rest and no exertional symptoms

35. Concussion: Return to play Second concussion double rest period Third concussion 1 year rest Some new thought symptoms may not present for 24- 36 hours?? “Any doubt sit out”

36. Stinger/Burner usually football usually a shoulder blow tingling, numbness, weakness, one arm if both arms – assume C-spine injury if symptoms resolve, not recurrent, ok to return to play wait until no appreciable weakness/numbness any doubt sit out EMG can help sort out when resolved

37. Bony Injury hard to assess if pretty good, no deformity, no swelling, stable and… tuning fork negative, likely ok to return to play

38. Bony Injury: major deformity Risk of neurovascular compromise. Try to reduce if delay in transport. hip dislocations – hospital could reduce knee if trained reducing patella, shoulder, elbow, finger will be easier early and decrease pain for patient. ok to reduce if don’t suspect bony fracture

39. Soft Tissue “biggest impact you can likely make for the outcome of a game and safe return to play is to be able to suture a wound and control bleeding. ”

40. Teeth: complete avulsion (entire tooth knocked out) completely avulsed teeth can be replanted ideally within a few minutes No rough handling No touching root rinse teeth in tap water to remove loose debris re-insert into socket – patient bites on gauze gently to hold in place

41. Teeth: complete avulsion (entire tooth knocked out) if can’t re-insert: keep tooth in patients mouth – buccal vestibule; or Hanks’ Balanced Saline Solution (Save the tooth); milk; saline; tap water as last resort.

42. Luxation of tooth (in socket but wrong position) Extruded – hanging down upper or raised lower teeth reposition with firm pressure stabilize by biting gently on gauze or towel Lateral Displacement – pushed back/pulled forward try to reposition (may need local anesthetic) stabilize

43. Luxation of tooth (in socket but wrong position) Intuded Tooth – pushed in do nothing after first aid transport to Dentist

44. Fracture Tooth if broken tooth, save as for avulsed tooth rinse/moisten/transport to Dentist Stabilize remnant in mouth by biting on gauze/towel

45. Heat Injury Prevented by drinking enough water Cramps – typically calf sodium depletion/dehydration tx fluids/salty drinks local heat to ↑ blood flow

46. Heat Exhaustion ↑ core temp less than 104 0 F, 40 0 C + sweating flushed orthostatic syncope tx – cool environment/oral hydration

47. Heat Stroke ↑ core temp greater than 104 0, 40 0 C Hallmark – CNS changes – mental status; seizures; coma Often no sweating, hot dry Eventually multi-symptom organ failure High morbidity if temp greater than 107 0 F Tx – rapid cooling over arteries (neck, axilla, groin); hospital; IV

48. Conclusion Keep it simple ABCs Have basic tools along IF IN DOUBT SIT OUT! UNSURE, THEN REFER!