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On-the-Field Acute Care and Emergency Procedures.

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Presentation on theme: "On-the-Field Acute Care and Emergency Procedures."— Presentation transcript:

1 On-the-Field Acute Care and Emergency Procedures

2 Most injuries are not life-threatening, but do require prompt careMost injuries are not life-threatening, but do require prompt care Emergencies require immediate attentionEmergencies require immediate attention Time is a critical factorTime is a critical factor Mistakes in initial injury management canMistakes in initial injury management can –Prolong the length of time for rehabilitation –Cause life-threatening complications –Permanent disability

3 Emergency Action Plan Primary concernPrimary concern –Cardiovascular function –CNS function Key to emergency aidKey to emergency aid –Initial evaluation of the injured athlete –Prearranged plan that can be implemented on a moments notice The sports medicine team must at all times act reasonably and prudentlyThe sports medicine team must at all times act reasonably and prudently

4 Separate plans should be developed for each facilitySeparate plans should be developed for each facility Outline personnelOutline personnel –Athletic trainer –Coaches –Athletic training interns –Administrators –Security Emergency Action Plan

5 Roles for personnelRoles for personnel –Contacting EMS –Provide EMS with the following information Type of emergencyType of emergency Location of emergencyLocation of emergency Suspected injurySuspected injury Present condition of injured athletePresent condition of injured athlete Current medical care being providedCurrent medical care being provided Location of phone being usedLocation of phone being used Hang up last!!!Hang up last!!! –Opening of gates and facility access –Going to hospital with athlete –Parental notification –Health insurance notification –Press releases Emergency Action Plan

6 Identify necessary equipmentIdentify necessary equipment –Spine board/stretchers –Splints –Airway management/oxygen –Tools for equipment or helmet removal –Policies and procedures for helmet or equipment removal

7 Cooperation between Emergency Care Providers Cooperation and professionalismCooperation and professionalism –Certified Athletic Trainer Generally first to arrive on scene of emergencyGenerally first to arrive on scene of emergency Has more training and experience transporting athlete than physicianHas more training and experience transporting athlete than physician –EMT has final say in transportation –Athletic trainer assumes assistive role All individuals involved in plan should practice to familiarize themselves with all procedures (including equipment management)All individuals involved in plan should practice to familiarize themselves with all procedures (including equipment management)

8 Parental Notification ATC should try to obtain consent from parent prior to emergency treatment for athletes who are minorsATC should try to obtain consent from parent prior to emergency treatment for athletes who are minors Consent indicates that parent is aware of situation, is aware of what the ATC wants to do, and parental permission is granted to treat specific conditionConsent indicates that parent is aware of situation, is aware of what the ATC wants to do, and parental permission is granted to treat specific condition When unobtainable, predetermined wishes of parent (provided at start of school year) are enactedWhen unobtainable, predetermined wishes of parent (provided at start of school year) are enacted With no informed consent, consent implied on part of athlete to save athlete’s lifeWith no informed consent, consent implied on part of athlete to save athlete’s life

9 Principles of On-the-Field Injury Assessment Appropriate acute care cannot be provided without a systematic assessment occurring on the playing field firstAppropriate acute care cannot be provided without a systematic assessment occurring on the playing field first On-field assessmentOn-field assessment –Determine nature of injury –Provides information regarding direction of treatment –Divided into primary and secondary survey

10 Establish presence of life-threatening condition/injuryEstablish presence of life-threatening condition/injury –Injuries requiring cardiopulmonary resuscitation Evaluate to determine needEvaluate to determine need Should be certifiedShould be certified –American Heart Association –American Red Cross –National Safety Council –Airway –Breathing –Circulation –Injuries with severe profuse bleeding –Shock Used to correct life-threatening conditionsUsed to correct life-threatening conditions Primary Survey

11 Establish UnresponsivenessEstablish Unresponsiveness –Gently shake and ask athlete “Are you okay?” –If no response EMS should be activatedEMS should be activated Positioning of body should be notedPositioning of body should be noted Adjust position of body in the event CPR is necessaryAdjust position of body in the event CPR is necessary Equipment ConsiderationsEquipment Considerations –Equipment may compromise lifesaving efforts –Removal of equipment may compromised situation further –Facemask should be removed with appropriate loop strap cutters Anvil PrunerAnvil Pruner Trainer’s AngelTrainer’s Angel FM ExtractorFM Extractor –Pocket mask/barrier mandated by OSHA during CPR to avoid exposure to bloodborne pathogens Primary Survey

12 Life-threatening condition ruled outLife-threatening condition ruled out Gather specific information about injuryGather specific information about injury Assess vital signsAssess vital signs Perform more detailed evaluationPerform more detailed evaluation –Non life-threatening injuries/conditions Secondary Survey

13 Unconscious Athlete Must be considered to have life-threatening conditionMust be considered to have life-threatening condition –Note body position –Establish level of consciousness –Check and establish airway, breathing, circulation (ABC) –Assume neck and spine injury –Remove helmet only after neck and spine injury is ruled out (facemask removal will be required in the event of CPR)

14 –Athlete is not breathing –ABC’s should be established immediately –Athlete is breathing, nothing should be done until consciousness resumes –Life support monitored and maintained until EMS arrivesmonitored and maintained until EMS arrives –Once stabilized, a secondary survey should be performed Supine Unconscious Athlete

15 –Athlete is not breathing Log rollLog roll Establish ABC’sEstablish ABC’s –Athlete is breathing Nothing should be done until consciousness resumesNothing should be done until consciousness resumes After consciousness returnsAfter consciousness returns –Carefully log roll –Continue to monitor ABC’s –Life support should be monitored and maintained until EMS arrives –Once stabilized, a secondary survey should be performed Prone Unconscious Athlete

16 Opening the Airway Head-tilt, chin lift methodHead-tilt, chin lift method Push down on the foreheadPush down on the forehead Lifting the jawLifting the jaw Moves tongue away from the back of the throatMoves tongue away from the back of the throat Modified jaw thrustModified jaw thrust Use with suspected neck injuryUse with suspected neck injury

17 Establishing Breathing LookLook ListenListen FeelFeel If not breathing initiate CPRIf not breathing initiate CPR

18 Airway Management Tools

19 Establishing Circulation Locate carotid arteryLocate carotid artery Palpate pulse while maintaining head tilt positionPalpate pulse while maintaining head tilt position

20 Establishing Circulation Locate femoral artery in femoral triangleLocate femoral artery in femoral triangle Palpate pulsePalpate pulse

21 If no pulse initiate chest compressionsIf no pulse initiate chest compressions Compress chest ” (15 times per 2 breaths)Compress chest ” (15 times per 2 breaths) After 4 cycles reassess pulse (if not present continue cycle)After 4 cycles reassess pulse (if not present continue cycle) Anatomical Landmarks for Chest Compressions

22 Obstructed Airway Management Choking is a possibility in many activitiesChoking is a possibility in many activities Causes of chocking in athleticsCauses of chocking in athletics –Mouth pieces –Broken dental work –Tongue injury –Gum –Blood clots from head and facial trauma –Vomit Obstructed individualObstructed individual –Cannot breath, speak, or cough –May become cyanotic Perform appropriate measures for chokingPerform appropriate measures for choking

23 Automatic External Defibrillators (AED) Device that evaluates heart rhythms of victims experiencing cardiac arrestDevice that evaluates heart rhythms of victims experiencing cardiac arrest Can deliver electrical charge to the heartCan deliver electrical charge to the heart Fully automated - minimal training requiredFully automated - minimal training required Electrodes are placed at the left apex and right base of chest - when turned on, machine indicates if and when defibrillation necessaryElectrodes are placed at the left apex and right base of chest - when turned on, machine indicates if and when defibrillation necessary Maintenance is minimal for unitMaintenance is minimal for unit

24 Supplemental Oxygen May be critical in treating severe injury or illnessMay be critical in treating severe injury or illness Requires the use of bag-valve mask and pressurized container of oxygenRequires the use of bag-valve mask and pressurized container of oxygen Canister is green with yellow oxygen labelCanister is green with yellow oxygen label Training is requiredTraining is required Provides patient with a significantly high concentration of oxygenProvides patient with a significantly high concentration of oxygen –Up to 90% –Deliver at a rate of liters/minute

25 Universal Medical Precautions Biohazardous Waste Management Use protective gloves on both handsUse protective gloves on both hands Don’t remove gloves until after the wound is bandagedDon’t remove gloves until after the wound is bandaged Protect yourself and the athlete you are treating from infection!Protect yourself and the athlete you are treating from infection!

26 Glove Removal Grab left glove in middle of left palm by right gloved handGrab left glove in middle of left palm by right gloved hand Pull left glove offPull left glove off Hold left glove in middle of right palmHold left glove in middle of right palm Use one finger of left (ungloved hand) to pull right glove inside out over left gloveUse one finger of left (ungloved hand) to pull right glove inside out over left glove Place both gloves in biohazard containerPlace both gloves in biohazard container Wash or disinfect handsWash or disinfect hands Clean to cleanClean to clean Dirty to dirtyDirty to dirty

27 Control of Hemorrhage Abnormal loss of bloodAbnormal loss of blood –Internal or external bleeding –Venous - dark red with continuous flow –Capillary - exudes from tissue and is reddish –Arterial - flows in spurts and is bright red Universal precautionsUniversal precautions –Reduce risk of bloodborne pathogens exposure

28 Hemostasis Techniques (Control of Bleeding) Direct pressureDirect pressure –Firm pressure (hand and sterile gauze) –Placed directly over site of injury against the bone

29 Elevation Reduces pressureReduces pressure Gravity facilitates venous and lymphatic drainageGravity facilitates venous and lymphatic drainage

30 Pressure Points Eleven pointsEleven points Pressure is applied to slow bleedingPressure is applied to slow bleeding

31 Cryotherapy Ice ApplicationIce Application –Constricts blood vessels –Slows blood flow to tissues –Reduces metabolic needs of tissues (oxygen) –Prevents secondary tissue death

32 Internal Hemorrhage Invisible unlessInvisible unless –manifested through body opening –X-ray or other diagnostic techniques Non life threatening internal hemorrhageNon life threatening internal hemorrhage –Beneath skin (bruise) or contusion –Intramuscular –In joints Life threatening hemorrhageLife threatening hemorrhage –Bleeding within body cavity –Difficult to detect –Must be hospitalized for treatment –Could lead to shock if not treated accordingly

33 Shock Generally occurs withGenerally occurs with –Severe bleeding –Severe fluid loss from VomitingVomiting DiarrheaDiarrhea DehydrationDehydration –Fractures –Internal injuries Decrease in blood available in circulatory systemDecrease in blood available in circulatory system –Vascular system loses capacity to maintain fluid portion of blood –Due to vessel dilation –Disruption of osmotic balance Movement of blood cells slowsMovement of blood cells slows Decreasing oxygen transport to the bodyDecreasing oxygen transport to the body

34 Extreme fatigueExtreme fatigue Exposure to heat or coldExposure to heat or cold IllnessIllness Predisposing Conditions for Shock

35 Hypovolemic - decreased blood volume resulting in poor oxygen transportHypovolemic - decreased blood volume resulting in poor oxygen transport Respiratory - lungs unable to supply enough oxygen to circulating blood (may be the result of pneumothorax)Respiratory - lungs unable to supply enough oxygen to circulating blood (may be the result of pneumothorax) Neurogenic - caused by general vessel dilation which does not allow typical 6 liters of blood to fill system, decreasing oxygen transportNeurogenic - caused by general vessel dilation which does not allow typical 6 liters of blood to fill system, decreasing oxygen transport Cardiogenic - inability of heart to pump enough bloodCardiogenic - inability of heart to pump enough blood Types of Shock

36 Psychogenic - syncope or fainting caused by temporary dilation of vessels reducing blood flow to the brainPsychogenic - syncope or fainting caused by temporary dilation of vessels reducing blood flow to the brain Septic - result of bacterial infection where toxins cause smaller vessels to dilateSeptic - result of bacterial infection where toxins cause smaller vessels to dilate Anaphylactic - result of severe allergic reactionAnaphylactic - result of severe allergic reaction Metabolic - occurs when illness goes untreated (diabetes) or when extensive fluid loss occursMetabolic - occurs when illness goes untreated (diabetes) or when extensive fluid loss occurs Types of Shock

37 Wet, White,WeakWet, White,Weak –Diaphoretic Moist clammy skin (excess sweating)Moist clammy skin (excess sweating) Pale (decreased blood flow to skinPale (decreased blood flow to skin Cold (from loss of blood flowCold (from loss of blood flow Vital SignsVital Signs –Weak rapid pulse –Increasing shallow respiration –Decreased blood pressure –Systolic below 90mm Hg –Diaphoretic Urinary retention and fecal incontinenceUrinary retention and fecal incontinence Irritability or excitement,Irritability or excitement, Possibly thirstyPossibly thirsty Signs and Symptoms of Shock

38 Maintain core body temperatureMaintain core body temperature Elevate feet and legs 8-12” above heartElevate feet and legs 8-12” above heart Positioning may need to be modified due to injuryPositioning may need to be modified due to injury Keep athlete calmKeep athlete calm –Psychological factors could lead to or compound reaction to life threatening conditions Limit onlookers and spectatorsLimit onlookers and spectators Reassure the athleteReassure the athlete Do not give anything by mouth until instructed by physicianDo not give anything by mouth until instructed by physician Management of Shock

39 Vital Signs Secondary survey of vital signsSecondary survey of vital signs –Pulse assessment of heart function NormalNormal –Adult beats per minute –Well conditioned athlete’s may be lower bpm –Child’s pulse bpm Rapid and weak pulse could indicateRapid and weak pulse could indicate –Shock –Bleeding –Diabetic coma –Heat exhaustion Rapid and strong could indicateRapid and strong could indicate –Heatstroke –Fright Strong and slow indicatesStrong and slow indicates –Skull fracture –Stroke No pulse = cardiac arrest or deathNo pulse = cardiac arrest or death

40 –Normal Respiration Adult 12 breaths per minuteAdult 12 breaths per minute Child breaths per minuteChild breaths per minute –Abnormal Respiration Shallow - shockShallow - shock Irregular or gasping - cardiac compromiseIrregular or gasping - cardiac compromise Frothy w/ blood - chest injuryFrothy w/ blood - chest injury Secondary Survey Respiration

41 Systolic blood pressure is created by ventricle contractionSystolic blood pressure is created by ventricle contraction Diastolic pressure is residual pressureDiastolic pressure is residual pressure Measured w/ s sphygmomanometer (blood pressure cuff)Measured w/ s sphygmomanometer (blood pressure cuff) –Inflate cuff (up to 200 mm Hg) –Above antecubital fossa (crease at elbow) –Slowly deflate cuff –Listen with stethoscope for First beating sound (systolic)First beating sound (systolic) Final sound (diastolic)Final sound (diastolic) Kartokoff sounds (soft sounds)Kartokoff sounds (soft sounds) Secondary Survey Blood Pressure

42 CategorySystolicDiastolic Optimal<120<80 Normal<130<85 High Normal Stage 1 HT Stage 2 HT Stage 3 HT>180>110 Elevated systolic or diastolic pressure alone is enough to meet the criteria HT = Hypertension or high blood pressure Secondary Survey Blood Pressure

43 Normal is 98.6 o FNormal is 98.6 o F Measure with thermometerMeasure with thermometer –Oral –Axillary –Tympanic membrane –Rectal –Core temperature is best measured rectally –Skin temperature Secondary Survey Temperature

44 Temperature changes can be the result ofTemperature changes can be the result of –Disease or infection –Cold of heat exposure –Loss of body fluids –Pain, fear, nervousness Signs and symptoms of lowered temperature areSigns and symptoms of lowered temperature are – Chills –Teeth chattering –Blue lips –Goose bumps –Pale skin Secondary Survey Temperature

45 –Can be an indicator of health –Red Elevated temperatureElevated temperature Heat strokeHeat stroke High blood pressureHigh blood pressure –Blue (cyanotic) Airway obstructionAirway obstruction Respiratory insufficiencyRespiratory insufficiency Poor circulationPoor circulation Secondary Survey Skin Color –White Insufficient circulationInsufficient circulation ShockShock FrightFright HemorrhageHemorrhage Heat exhaustionHeat exhaustion Insulin shockInsulin shock

46 –Dark pigmented skin is slightly different in response Nail beds, and inside lips and mouth and tongue will be pinkishNail beds, and inside lips and mouth and tongue will be pinkish Shock,Shock, –Skin around mouth and nose will have grayish cast –Mouth and tongue will be bluish HemorrhagingHemorrhaging –Mouth and tongue will become gray Fever is indicated by red flush tips of earsFever is indicated by red flush tips of ears Secondary Survey Skin Color

47 Extremely sensitive to situation impacting nervous systemExtremely sensitive to situation impacting nervous system Most individual’s pupils are regularly shapedMost individual’s pupils are regularly shaped Abnormal pupil size must be known by the health care providerAbnormal pupil size must be known by the health care provider –Pre participation exams Constricted pupils may indicateConstricted pupils may indicate –depressant drug –Muscle injury to eye Dilated pupils may indicateDilated pupils may indicate –Head injury –Shock –Use of stimulants Failure to accommodate may indicateFailure to accommodate may indicate –Brain injury –Alcohol –Drug poisoning Pupil response is more important than sizePupil response is more important than size Secondary Survey Pupils

48 Must always be assessedMust always be assessed AlertnessAlertness Awareness of environment,Awareness of environment, Response relative to vocal stimulationResponse relative to vocal stimulation Glascow Coma ScaleGlascow Coma Scale Conditions altering level of consciousnessConditions altering level of consciousness –Head injury –Heat stroke –Diabetic coma Secondary Survey State of Consciousness

49 Musculoskeletal Assessment Use logical process to adequately evaluate extent of traumaUse logical process to adequately evaluate extent of trauma Critical knowledgeCritical knowledge –Anatomy/kinesiology –Mechanisms of injury –Major signs and symptoms

50 Secondary Assessment H istoryH istory O bservationO bservation P alpationP alpation S pecial TestsS pecial Tests AssessmentAssessment –Head –Spine –Trunk –Abdomen –Upper extremities –Lower extremities

51 Injury Assessment: Medical History History O P S Describe the events of the injury and those leading up to it Past Medical History and Present History of Injury Alphabet of assessment Questions M Mechanism of injury, medications, meals N Name of patient, name of examiner O Old injuries to same side or opposite side, Onset P Point tenderness, provocative, palliative Q Quantity, Quality R Region of pain, referred pain S Sounds or sensations

52 Mechanism of Injury How Did The Injury Happen? What position was the joint in?

53 Did the athlete take any medication today For current injury? For other injuries? For medical conditions? Is the athlete taking any supplements Is the athlete allergic to any medications? “M” Medications

54 “M” When was the last time the athlete ate any food? Is the athlete adequately hydrated? Is the athlete eating a good balanced diet? Meals

55 “N” Don’t forget to put athletes name on injury report! Don’t forget to introduce yourself to the athlete Names

56 “O” Onset (When did the injury occur?) “O” Onset (When did the injury occur?) AcuteChronicChronic/AcutePain?Swelling How fast?

57 “O” Old Injuries “O” Old Injuries Did the athlete ever have a similar injury to the same body part? Opposite (injuries to the contralateral side?) If yes, how severe and when did they occur? If yes, how severe and when did they occur? Did the athlete go to to an MD for the injury? Did the athlete go through a formal rehabilitation program?

58 Injury Assessment “P” Provocative: What makes your injury get/feel worse Palliative: What makes your injury get/feel better?

59 Injury Assessment “P” Point Tenderness Where is the pain? Where is the pain? Have the athlete point with one finger where they feel the most pain. Have the athlete point with one finger where they feel the most pain. Does the athlete have point tenderness (pain in one localized area)? Does the athlete have point tenderness (pain in one localized area)?

60 “Q” Quantity (0-10 scale) Quantity (0-10 scale) Quality (describe the pain) Quality (describe the pain) Throbbing Throbbing Stabbing Stabbing Aching Aching Other Other“R” Region (Where is the pain?) Point tenderness Point tenderness Diffuse pain Diffuse pain Referred pain Referred pain

61 “S” Sounds or Sensations Did the athlete feel or hear any sounds or sensations? Pops, Snaps, Crepitus (Grinding), Giving Way or Tearing

62 Injury Assessment Observation of Injuries Discoloration Swelling Deformity HObservationPS

63 Palpation of Anatomical Structures What structures are painful to palpation (touch)? Palpate the area to help determine nature and extent of injury Start away from site of injury Start with gentle pressure, gradually pressing harder until you reach a boney stop Do you feel any Deformities (not apparent visually)? Deformities (not apparent visually)? Lumps, bumps, swelling or defects? Lumps, bumps, swelling or defects? Changes in skin temperature or texture? Changes in skin temperature or texture? HO P alpation S

64 Special Tests HOP

65 Injury Assessment Range of Motion and Flexibility Assessment Did the injury cause any loss on flexibility or range of motion?

66 Injury Assessment Strength Assessment Manual Muscle Testing Machine Testing Isokinetic Testing Did the injury cause a loss in muscle strength?

67 Manual Muscle Testing Grading Strength Grade Against Gravity Full Rom Added Resistance Amount of Strength 5/5 Yes YesYes=/> than other side 5/5 Yes YesYes=/> than other side 4/5 Yes YesYes< than other side 4/5 Yes YesYes< than other side 3/5 Yes Yes No< than other side 3/5 Yes Yes No< than other side 2/5 No YesNo< than other side 2/5 No YesNo< than other side 1/5 No NoNopalpable contraction 1/5 No NoNopalpable contraction 0/5 No NoNono palpable contraction 0/5 No NoNono palpable contraction

68 Injury Assessment Stress Tests Assessment of Joint Stability for Ligamentous Laxity Are the ligaments or the joint capsule torn? Grading Laxity 0 no laxity mm mm 3+ > 10 mm

69 Balance & Proprioception Assessment Balance & Proprioception Assessment Did the athlete suffer a loss of proprioception or balance from their injury?

70 Cardiovascular Assessment Blood pressureBlood pressure Resting Heart Rate (RHR)Resting Heart Rate (RHR) RespirationRespiration AuscultationAuscultation –Heart Sounds –Lung Sounds

71 Neurological Assessment What day is it? Central Nervous System Peripheral Nervous System What’s the score of the game? Do you know where you are? Brain Function Motor Function SensationReflexes

72 DetermineDetermine –Seriousness of injury (What is the return to play status of athlete?) –Type of first aid and immobilization required –Need for medical referral –Type of transportation from field to sideline, training room or hospital All information concerning the evaluation and decisions must be documented All information concerning the evaluation and decisions must be documented Assessment Decisions

73 Return to Play Status When is it okay for an injured athlete to play?When is it okay for an injured athlete to play? What can you do to help the athlete achieve this goal?What can you do to help the athlete achieve this goal? When should you refer the injured athlete to a medical doctor?When should you refer the injured athlete to a medical doctor? StatusStatus –Can continue with no restrictions –Can continue with additional support or protection –Can’t continue. Doesn’t need to see MDDoesn’t need to see MD Needs to be referred to MD in next few daysNeeds to be referred to MD in next few days Needs immediate referral to MDNeeds immediate referral to MD –Can transport self to MD –Needs to be transported (not by EMS) to MD –Needs to be transported by EMS to emergency room


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