St. Elizabeth Sports & Physical Therapy Darcie Christensen, PT, ATC

 Identify the key components of Emergency Action Plans (EAP’s)  Identify members and describe roles of the emergency response team  Recognize when it is appropriate to employ the use of a spine board  Discuss basic technique for placing an individual on a spine board  Review the current research about equipment issues and the spine injured athlete and discuss the document Pre-hospital Care of the Spine Injured Athlete

 Athletic health care providers review prior to the start of each sport covered or new field  Determines the role and location of each person present (ie. AT, EMT, MD)  Establish how communication will occur (primary and backup)  What emergency equipment is present? Where is it located? NATA Official Statement on Athletic Health Care Provider “Time Outs” Before Athletic Events, 2012

 Where is the ambulance located? Is it dedicated or on stand-by? If not on site, what is mechanism for calling one?  In the event of transport, what is the designated hospital?  Are there any issues that could potentially impact the EAP? NATA Official Statement on Athletic Health Care Provider “Time Outs” Before Athletic Events, 2012

A variety of healthcare professionals may be involved in on-field management of suspected head and/or spine injury Development of guidelines is imperative When dealing with a potential life threatening situation, the scene of the injury is not the time nor the place for healthcare professionals to decide on appropriate treatment on such a potentially controversial area.

Developed by the Inter-Association Task Force

 Prehospital Care of the Spine-Injured Athlete  Developed by the Inter- Association Task Force  Task force was created by the National Athletic Trainers’ Association in 1998  Document released in 2001 Free download at

 National Association of EMT’s  National Athletic Trainer’s Association  Professional Football Athletic Trainer’s Society  American Association of Neurological Surgeons  American College of Emergency Physicians  National Registry of EMTs

Initial Assessment Primary Survey Level of Consciousness Neurologic Screening EAP Activation Transportation Equipment Removal

 Initial Assessment- Organized process to quickly obtain information vital to care.  Primary Survey- LOC-ABC  Provide Immediate basic life support measures as needed.  Quickly make decision regarding transport  Secondary Survey performed either on-site or during transport

 Neurologic Assessment should be performed before and after full body immobilization  Pulse  Motor  Sensation  Capillary Refill/Circulation

Neck Evaluation Flow Chart

 Body Substance Isolation  Establish mechanism of Injury  Head person establishes C-spine  once established it is not relinquished  person at the head gives ALL commands/counts  Every emergency situation is different  Individual circumstances must dictate appropriate actions.

 C-Spine established  Place/Maintain head in neutral in-line position  Assess consciousness of the athlete  Calm the athlete, ask questions  Assess PSMC Function ▪ Pulse, Sensory, Motor, Capillary Refill/Circulation  When do we activate EMS?

 Loss of Consciousness or altered level of consciousness.  Bilateral neurologic findings or complaints.  Significant midline spine pain  Obvious deformity

 Point Tenderness over the cervical spine with or without deformity  Unrelenting neck pain or muscle spasm in the cervical region with or without palpation  Presence of muscular weakness in extremities  Loss of coordinated movement  Paralysis or inability to move a body part  Abnormal Sensations in the head, neck, trunk, or extremities  Absent or weak reflexes  Loss of bladder or bowel control  Suspicious mechanism  Athletes inability or unwillingness to move the neck  Priapism  Respiratory Distress  Neurogenic Shock  Decreased Blood Pressure  Increased Pulse  A “Gut” feeling

 Current recommendations for the acute treatment are to immobilize the head and neck in neutral alignment prior to transfer to minimize motion that occurs during this process. Unless… Movement causes or increases pain, neurologic sx, or muscle spasm. Movement compromises airway. It is physically difficult to perform the movement Resistance is encountered The patient expresses apprehension

 Apply Cervical collar (if possible)  Position Assistants  Person at the head gives the commands ▪ Log Roll (only option in prone patient) ▪ Six person lift ▪ Feed and Pull method to center on the board.  Secure athlete to spine board with appropriate straps, blocks, towels, etc.  Re-Check P-S-M-C

Review of research used in the development of Prehospital Care of the Spine Injured Athlete and current research conducted since that time.

“Helmet and shoulder pad removal in the unstable cervical spine is a complex maneuver.” “In the unstable C1-C2 segment, helmet removal causes more angulation in flexion, more distraction, and more narrowing of the space available for the cord.”

“Abnormal intervertebral motion, even as little as 1mm, may cause significant neurologic damage. This is especially true in the subaxial spine. In this region, the cord demonstrates an exceptional intolerance of even small amounts… and can lead to further neurologic injury in the athlete in whom the spinal cord and osseoligamentous structures are already compromised.” Palumbo M., et. al., The American Journal of Sports Medicine, Emergency Care and Transportation of the Sick and Injured, American Academy of Orthopedic Surgeons, McLain, R., Aretakis A., & Moseley, T.A., The Spine Journal, Owen, J., Naito, M., & Bridwell, K.H., The Spine Journal, Towbin, A., Archives of Pathology, 1964.

 WHEN TO REMOVE 1. When equipment prevents access to the airway or chest for primary life support measures. 2. If the equipment does not maintain cervical spine or provide adequate immobilization of the head.

 Face Mask  When to Remove ▪ Anytime spinal injury is suspected ▪ As soon as decision is made to transport ▪ Prior to transportation regardless of current respiratory status  Combined Tool Approach ▪ Tools should be readily available ▪ Cordless screw driver, FM Extractor, Anvil Pruning Sheers, Screw Drive, Trainers Angel.

 FMS Extractor  Trainer’s Angels  Pruning shears  Cordless screwdriver  Handheld screwdriver  Dremel

 Be familiar with all types of equipment used.  Do not “flip” the mask  Studies show increased movement from torque involved in rotating facemask

 Prior to facemask removal, pocket mask may be positioned through facemask for ventilatory assistance  Following removal, BVM may be used.  Utilize Oxygen if available

 “The Inter-Association Task Force recommends that neither the football helmet nor the shoulder pads be removed before transportation.”  “The Inter-Association Task Force recommends the face mask be removed as quickly as possible any time a player is suspected of having a spinal injury, even if the player is still conscious.”

With the face mask removed, you have access to the airway

 Six-plus – person lift  preferred if enough personnel available  Log Roll  ½ log roll, position spine board, complete log roll  Responders need to be trained  Avoid the lay person if possible  Person at the head is in charge!

Other sports offer the same challenges in terms of preparing the spine-injured athlete for transport

 Working on ice  Helmets and chin straps can be loose  As soon as you lift the mask, it becomes similar to a motorcycle helmet  Shoulder pads vary in thickness/fit  Goalie gear  Differences in gear regulations

 Larger face masks  Multiple straps  Goalie gear  Rib & kidney protectors  Chin straps in face mask  Differences in gear regulations

 Familiarize yourself with a variety of equipment and removal tools  Communicate with personnel before the game  Host an in-service  Case by case basis

Updating protocols, communication, practicing action plans, and other efforts can keep our athletes safe!

 Meet each other before the game or event and talk about expectations and roles  Learn about each other’s training and knowledge bases  Familiarize each other with the equipment you have available  Discuss preferences and share stories

 Example of Spine Boarding Process   Example of Face Mask Removal   Example of Equipment Removal 

 Rusty McKune, ATC University of Nebraska Medical Center  Denise Fandel, MBA, CAE Executive Director at Board of Certification(BOC)

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