Management of Acute Pathologies ATTR 322 Krzyzanowicz- Spring ‘13

Objectives Understand the differences between on-the- field examination and clinical assessment Identify conditions that warrant termination of the exam Understand how to implement an Emergency Action Plan

Purpose Purpose of on the field exam is to determine the next course in evaluation or management Immediate emergency care Heart attack, femur fracture Transport to hospital/physicians office for care Sutures, x-ray to r/o fx (non-emergency) Move to sidelines for further evaluation Perform a more thorough evaluation

Immediate Management Ask yourself “Does this situation require emergency management to save patient’s life or extremity” Immediate examination must rule out Lack of ABC’s Life-threatening trauma to head or spinal column Profuse bleeding Fractures Joint dislocation (to a point)

Emergency Planning Emergency Action Plan (EAP) Personnel Physician, EMS Equipment Splints, AED Communication Cell phone, radio Standard procedures Catastrophic event Good to review EAP at least once a year Get together with local EMS as well

Sport Specific Rules Each sport has specific rules about on-field- evaluations Wrestling-3 minutes injury evaluation time Football- unlimited Soccer- must be waved onto field by official Find out from your coach/league, etc

Critical Findings Conditions warranting termination of the evaluation Always err on the side of caution if uncertain Activate the EAP Begin injury management What conditions can we think of?

Primary Survey Are they moving? Conscious Apena? or dyspnea? Activate EMS (if needed) Unconsciouscervical spine trauma Stabilize head and neck Activate EAP & EMS Check ABC’s SeizingCNS trauma

Secondary Survey Identify other serious conditions that require immediate management Bleeding Gross deformity Other signs of trauma Rule out head/spinal trauma Calm athlete Rule out injury other body parts Manage the condition Treat for shock (if indicated)

On-Field History Determine (ask while observing/palpating) Location of pain Peripheral symptoms Mechanism of injury Associated signs and symptoms History of injury **If athlete is unconscious or disoriented seek information from witnesses.

On-Field Inspection

On-Field Palpation Bony alignment Crepitus Joint alignment Swelling Gross deformity Tender to palpation (TTP) Crepitus Joint alignment Palpate along joint line to determine alignment Swelling Disruption to tissue Bursa Tissues with a rich blood supply (eg, face) Painful Areas Tender to palpation Deficit in the muscles or tendons Palpable defect

Joint/Muscle Function AROM Assesses their willingness to move the limb Strength assessment A break test examines the muscle’s ability to sustain contracting (I don’t really do very often on field) PROM Often delayed until clinical evaluation DON’T do if the athlete cannot perform AROM Weight-bearing status (LE injuries) If a fracture has been ruled out and ROM tests have been completed, the athlete may walk off the field with assistance.

Joint Stability Tests Purpose Select the best tests for that pathology Immediately tests the ligaments and capsule involved before swelling and guarding begin Select the best tests for that pathology Suspected ACL injury DO NOT perform all 7 special tests Those with the best sensitivity and specificity Lachman’s, Pivot Shift (difficult), Ant. Drawer Wait until off the field to perform all tests you may want

Neurological Testing Cranial nerve tests Cervical nerve tests (upper quarter screen) Perform on suspected concussions as well as cervical spine injuries (NO strength testing!) Assess motor function distal to injury Don’t move injured bone or joint Eg, Ask an athlete with an anterior GH dislocation to wiggle his or her fingers

Vascular Exam Dislocation or fracture can compromise vascular structures Vascular tests Check distal pulses Capillary refill testing Edema formation distal to injury Blockage of venous return “Normal” injury (i.e. sprained ankle) Do this in off-field clinical assessment

Getting off the field Determine best ambulation Walking, 2 man carry, etc Take all pieces of your puzzle Determine what needs to be done on sidelines If able to r/o injury or further injury Determine if RTP is allowed

Return to Play Consult a physician if necessary Younger athletes vs. older athletes Conservative vs. aggressive management Risk of reinjury? Assessment of function Strength and ROM Pain Proprioception Functional activity progression

Review Practice Sport Patience Everytime you go onto the field with your ACI- watch them-what do they do? What do you want in your bag of tricks. Sport Some sports you need to be quick (football, wrestling) Coach needs to know if the patient can get back in or not Patience Don’t rush a medical emergency Take every precaution not to cause more harm