1. Sideline Preparedness: On Field Management of Athletic Emergencies Sideline Preparedness: On Field Management of Athletic Emergencies Jim Ellis, MD, FACEP September 19, 2011 Steadman Hawkins Clinic of the Carolinas Sports Medicine Fellowship Program

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 AirwayBreathingCardiacCirculation Cervical Spine ConcussionConditions/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. Surgical Airway Unsuccessful endotracheal intubation Mandibular fracture Anterior neck trauma Laryngeal fracture Stridor

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

19. 2002 Super Bowl Kurt Warner played with a laryngeal fracture – sideline cricothyrotomy kit

20. 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

22. 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

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

25. 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

27. 2008 Lauren Chang Cheerleader accidently kicked in the chest Had collapsed lungs - bilateral Died from tension pneumothorax

29. 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)

30. 2001 Rashidi Wheeler Northwestern football player Died secondary to asthma Known asthmatic in difficult workout ?Complicated by ephedra use

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

34. HCM Many athletic deaths from HCM Sometimes is resistant to defib Hypothermia as treatment protocol Small study but great results Neuro protective properties Keep cooled IVF’s just in case

35. 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!

36. 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

38. 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

40. 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

42. 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

44. 2011 Dan Cochran at Syracuse Commotio Cordis at a lacrosse tryout Immediate CPR AED on site and delivered shock Return of vitals by EMS arrival Patient was discharged neuro intact Experienced ATC with an EAP

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 2011 – Armen Gilliam(BB) CAD?

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 - 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 37-40 degrees F should drop temp to around 95. Ideal temp between 92-94. 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 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. Concussion High grade concussion could cause severe decreased level of consciousness and impair the athlete’s ability to protect their airway – rare Second impact syndrome – 3 NC deaths recently ImPact other cognitive based testing Balance testing NFL standardizing the sideline exam

65. 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

68. 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

70. 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

71. Conditions/Environment Lightning – approximately 100-120 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)!

72. 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

74. Be Prepared for Worst Case Scenario At the end of the Packers-Broncos Super Bowl both a DB and WR were down and we weren’t prepared to immobilize both With the Falcons we now have double set ups Last year Falcons-Eagles both a DB and WR went down with head injuries

76. 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

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

78. 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!

79. 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

80. 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

82. 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-differs by state but if you need an airway expert get a paramedic

87. 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