A COLLABORATIVE REQUEST FOR REVIEW OF CURRENT EMSA PROTOCOL REGARDING THE MANAGEMENT OF THE EQUIPMENT-LADEN ATHLETE

 On behalf of the following:  Central States Orthopedic Specialists  Eastern Oklahoma Orthopedic Center  Tulsa Bone and Joint  The Spine and Orthopedic Center  Oklahoma Athletic Trainers’ Association Thank you.

 To determine and implement a research-based, peer-reviewed, national standard of care regarding the best practice available for the management of the cervical spine injured equipment-laden athlete.

 “The role of all intervening care givers, ranging from a passing good Samaritan to the receiving surgeon, will be to prevent and minimize secondary injury.”  Belanger and Levi, Spinal Cord Injury, Journal of American College of Surgeons, 2000.

 Discussion of Current EMSA Protocol and Recommendations  Current Research Regarding Equipment Removal  Current Research Regarding Equipment Management in the Field  Documentation of the National Standard of Care  Educational Partnership in Sports Medicine

 Synopsis per Dr. Goodloe:  In an athlete with a suspected cervical spine injury, the helmet and shoulder pads are to be removed prior to spine-board immobilization for transport due to:  1) Inadequate didactic training of emergency physicians in this procedure  2) Highly sufficient training of emergency medical technicians in this procedure

 Standardized Tool for Face Mask Removal:  Eliminates the usage of knives  The design of some facemask clips cannot be cut using pruning shears. (Riddell Revolution)  Provides for the assumptions that all tools, other than a regular screwdriver, are equal  Provides for the introduction of another facemask removal tool

 “ The SD”(cordless screw driver) “and QR” (quick release) “generally allowed for faster retraction of the face mask with less force and torque applied to the helmet than the cutting tools, TA and FM. ”  “Removal Tools are Faster and Produce Less Force and Torque on the Helmet Than Cutting Tools During Face-Mask Retraction” Journal of Athletic Training, 2002

“The cordless screwdriver is more efficient than the FM Extractor and Trainer’s Angel.” “Football Equipment Design Affects Face Mask Removal Efficiency” AJSM, 2005

“Combining the cordless screwdriver and cutting tool provided a fast and reliable means of on-field FM removal.” The ”cordless screwdriver, is faster, easier to use, and creates less torque and motion at the head than many of the cutting tools commonly use to remove the face mask.” The Combined Tool Approach for Face Mask Removal During On-Field Conditions. Gale, S. et al…, Journal of Athletic Training, 2008.

“ Before helmet removal, cervical spine stabilization should be transferred from the rescuer at the head to another rescuer, who assumes cervical spine control from the front. ” “National Athletic Trainers’ Association Position Statement: Acute Management of the Cervical Spine-Injured Athlete, 2009

“this maneuver serves to tighten the helmet at the occiput and the forehead.” “Management of the Helmeted Athlete With Suspected Cervical Spine Injury, AJSM, 2004.

“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.” Helmet and Shoulder Pad Removal From a Player with Suspected Cervical Spine Injury: A Cadaveric Model Donaldson III, W et. Al, Spine, 1998.

“In the lower cervical spine (C5-C6),  Helmet removal causes flexion of 9.32°, and during shoulder pad removal the neck extends 8.95°, a total of approximately 18°.  Disc height changes from 1.24 mm of distraction to 1.06 mm of compression during helmet removal and shoulder pad removal for a total 2.3-mm change.  Translation…is greater at C5-C6 during shoulder pad removal.” Helmet and Shoulder Pad Removal From a Player with Suspected Cervical Spine Injury: A Cadaveric Model Donaldson III, W et. Al, Spine, 1998.

“Because of the motion observed in the unstable spine, helmet and shoulder pad removal should be performed in a carefully monitored setting. “ Helmet and Shoulder Pad Removal From a Player with Suspected Cervical Spine Injury: A Cadaveric Model Donaldson III, W et. Al, Spine, 1998.

“Only after radiographs have been taken should the helmet and shoulder pads be removed in a controlled environment…initial workup of the helmeted athlete has shown CT films with helmet and shoulder pads in place were adequate for initial diagnosis and triage. “ Management of the Helmeted Athlete with Suspected Cervical Spine Injury Waniger, K., et. Al, The American Journal of Sports Medicine, 2004.

“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.” I. Palumbo M, et al, The American Journal of Sports Medicine, II. Emergency Care and Transportation of the Sick and Injured, American Academy of Orthopedic Surgeons, III. McLain Rf, Aretakis A, Moseley TA, The Spine Journal, IV. Owen, Jh, Naito M, Bridwell KH, The Spine Journal, V. Towbin A, Archives of Pathology, 1964.

“a properly fitted football helmet holds the head in a position of neutral spinal alignment, provided the athlete is wearing shoulder pads.” Feld F., Blanc R., Journal of Emergency Medical Services, “reported similar cervical alignment when comparing full equipment (helmet and shoulder pads) with no equipment” Cantu RC, Clinical Sports Medicine Journal, 1999.

“The tight-fitting football helmet allowed less than 5 degrees of head movement inside the helmet with BTLS immobilization.” Waniger, MD, et al, Clinical Journal of Sports Medicine, “When immobilizing the neck, physicians should avoid movement and maintain proper alignment of the cervical vertebrae. This usually can be done with the helmet and other protective gear (e.g. shoulder pads) in place, and such equipment should not be removed.” Whiteside, American Family Physician, 2006 ”This article exemplifies the AAFP 2006 Annual Clinical Focus on caring for children and adolescents.”

“Any facemask should be rapidly removed to provide adequate airway access..assisted ventilation...is usually performed using a bag-valve device and face mask.” Sideline and Ringside Evaluation for Brain and Spinal Injuries Vincent J. Miele, MD, John A. Norwig, ATC, Julian E. Bailes, MD, Neurosurgery Focus, “The helmet and shoulder pads should remain in place unless removal is required to gain access to the airway.”

Sideline and Ringside Evaluation for Brain and Spinal Injuries Vincent J. Miele, MD, John A. Norwig, ATC, Julian E. Bailes, MD, Neurosurgery Focus, “A solid understanding of the treatment principles discussed in this article will improve the preparedness of a physician to deal with these situations and provide the athlete with the best chance of recovery.” “the front of the shoulder pads can be opened to allow for chest compressions and/or defibrillation.”

 Prehospital Care of the Spine-Injured Athlete:  A Document from the Inter-Association Task Force for Appropriate Care of the Spine- Injured Athlete

 Participating Authors/Organizations of Interest:  National Association of EMT’s  Connie McAdam, MICT, AAS  National Athletic Trainers’ Association  Douglas Kleiner, PhD, ATC, EMT, FACSM (Chair)  Professional Football Athletic Trainers’ Society  T. Pepper Burress, ATC, PT  American Association of Neurological Surgeons  Julian Bailes, MD

“a properly fitted football helmet holds the head in a position of neutral alignment, provided the athlete is wearing shoulder pads. Therefore, the Inter-Association Task Force recommends that neither the football helmet nor the shoulder pads be removed before transportation.”

 Subsequent Publications/Endorsements:  American College of Emergency Physicians

 Subsequent Publications/Endorsements:  North American Spine Society  Emergency Medicine Clinics of North America  Journal Emergency Medical Services  Journal of the American College of Surgeons  American Academy of Pediatrics  Journal of Primary Care  NFL Professional Football Athletic Trainers’ Society  NCAA  USA Football  Texts:  Emergency Care and Transportation of the Sick and Injured  Neurological Sports Medicine: A Guide for Physicians and Athletic Trainers.  Access Emergency Medicine

 Proposal: 1. EMSA MCB Designates a Training Officer for each major hospital in Tulsa and OKC 2. OATA will coordinate and partner ATC’s and Orthopedic Physicians with each Training Officer 3. Annual Fall In-services reviewing a mutually agreed upon standardized protocol for effective equipment removal techniques will be conducted on-site at each hospital location with the most current and up-to-date styles of football equipment.

“Due to the effectiveness of maintaining cervical alignment while leaving the helmet and shoulder pads on, every effort should be made to provide appropriate treatment without removing this equipment.” Hardy, R. et al., Journal of Emergency Medical Services, 2009.