AT 359
Chapter 12 - On-the-Field Acute Care & Emergency Procedures

Emergency Action Plan
-every athletic program should have an EAP in place
-purpose of EAP is to make sure that in any emergency situation, the victim has immediate and appropriate help
-an EAP should be made for every facility/practice field
-each EAP should be introduced to at an annual meeting so everyone is aware and familiar with it
-each EAP should be practiced yearly
-components of an EAP include:
        1)Personnel/Duties
                    -need to determine what personnel will be available at each site and assign duties to each
        2)Emergency Equipment
                    -need to determine what emergency equipment will be available to each sport at each site
        3)Protocols for Certain Emergencies
                    -ex: helmet/shoulder pad removal
                    -should be coordinated with local EMS
        4)Phones
                    -should be readily accessible
                    -cellular phones are great to have, but you should have another phone besides cellular because
                      there might not be a signal
        5)Local EMS Cooperation
                    -you should be familiar with the local ambulances and hospitals and their policies/protocols
                    -whoever is assigned to make the 911 call should know what information that the operator will ask for
                    -someone should accompany the athlete to the hospital and have medical/insurance information available
        6)Keys
                    -personnel should have easy access to keys of gates/doors to expedite emergency care
                    -you should know which key opens which door
       
Dealing with Minors
-when dealing with anyone under age 18, parental consent must be obtained before treatment is given
        -exception to this is when the victim is unconscious or the injury is immediately life-threatening - in that case, you have implied
          consent

PRINCIPLES OF ON-THE-FIELD INJURY ASSESSMENT
-the on-the-field assessment provides you with the nature of the injury and direction in the decision-making process
-the primary survey is utilized to assess life-threatening conditions
            -if athlete is conscious and stable, there is no need to do a primary survey
-the secondary survey is utilized to assess any non-life threatening injuries sustained to athlete
            -the secondary survey is a lot more in detail

PRIMARY SURVEY - it is very important that you do these in the specified order!!!
1)determine consciousness
            -use tap and shout method to determine if unconscious
                    -if someone is unconscious, EMS should be alerted
                    -if someone is unconscious and on their back and breathing, then leave them in that position until EMS arrives
2)open airway
            -always suspect a head/neck fx unless you saw the injury and can rule it out - utilize the jaw thrust maneuver to open airway
3)check for breathing
            -check for breathing for 5 -10 seconds
            -if not breathing, give them 2 breaths
                    -if breaths do not go in, re-tilt head and try again
                            -if breaths still do not go in, start choking procedures
                    -if breaths do go in, go to next step and check circulation
4)check for circulation
            -assess circulation by taking carotid pulse at neck
            -always check side of neck closest to you
            -check for pulse for 5 -10 seconds
            -if victim is not breathing and has no pulse, start CPR

* When dealing with football, the facemask may pose some potential problems
    -you cannot give breaths to someone wearing a facemask; you must cut it off
    -you need to have a screwdriver and a cutting tool such as a trainer's angel on hand
    -facemask removal should not take any longer than 30 seconds
 

AED's - Automated External Defibrillators
-should be available at every facility --will be limited by financial restraints
-studies show that early use of AED with cardiac emergencies decrease the mortality rates dramatically
-can be utilized with CPR

Supplemental Oxygen
-whenever there is a breathing or cardiac emergency, oxygen(O2) should be utilized if available
-a person breathes in about 21% O2 from the air
-a person breathes out about 16% O2 in their air
-additional oxygen provides a lot more than 16%

Control of Bleeding
-external bleeding
        -gloves should be utilized first and foremost
        -apply direct pressure
        -then elevate body part if needed
        -then apply pressure to arterial pressure points (femoral and brachial)  if needed
-internal hemorrhage
        -hard to determine if there is internal bleeding or not
        -s/s include: abdominal rigidity, shock, decreased BP, fast and weak pulse, bruising, pale/clammy skin

SHOCK
-an injury can cause shock; severe bleeding and fractures will more likely cause shock
-different types of shock:
        -hypovolemic - decrease blood loss; this means a decrease of O2 to the tissues/organs; ex: dehydration
        -respiratory - cannot supply enough O2 to the bloodstream; ex: pneumothorax
        -neurogenic - caused by dilation of blood vessels within the cardiovascular system; not enough O2
        -psychogenic - temporary blood loss; ex: syncope (fainting)
        -cardiogenic - heart cannot pump enough blood to the body; ex: heart attack
        -septic - severe bacterial infection can cause blood vessels to dilate
        -anaphylactic - severe allergic reaction; cause vasodilation
        -metabolic - severe illness goes untreated; ex: diabetes, diarrhea
-s/s of shock:
        -moist, pale, clammy skin
        -weak/rapid pulse
        -rapid/shallow breathing
        -decreased blood pressure (BP)
-management
        -maintain body temperature
                -apply blankets if needed
        -elevate legs about a foot
                -do not elevate legs if there is a suspected fx or head/neck injury

SECONDARY SURVEY
Taking Vital Signs
    -Pulse
            -take pulse for 15 seconds and multiply by 4
            -normal range for adults is: 60-80 bpm
    -Respirations
            -count # of respirations for 1 minute
            -normal range for adults is: 12 bpm
    -Blood Pressure
            -systolic pressure - number on top; normal for adult is: 110 - 120 mm Hg
            -diastolic pressure - number on bottom; normal for adult is: 60 - 80 mm Hg
            -females BP is usually 8 -10 points lower than males normally
    -Temperature
            -normal body temp is 98.6 (give or take 1 degree)
            -can be taken orally (mouth), axillary (armpit), tympanic membrane (ear) or anal
            -temperature is more accurate if taken in the rectum or tympanic membrane
    -Skin Color
            -Patriotic distress - red, white, or blue skin coloration signifies a medical emergency
                -red: heat stroke, high BP or elevated temperature
                -white: insufficient circulation, shock, fright, hemorrhage, heat exhaustion or insulin shock
                -blue (cyanotic): airway obstruction or respiratory insufficiency
    -Pupils
            -if one or both pupils are dilated, the athlete may have a head injury, experiencing shock, heatstroke or hemorrhage
            -also check pupil response to light
                    -if pupils fail to respond, there may be a brain injury or alcohol/drug poisoning
            -anisocoria - normal condition where the pupils are unequal in size; small population is born with this

Musculoskeletal Assessment
-a detailed evaluation should be done
-components of evaluation:
        1)History - most important; should have a narrowed down idea of what the injury is after history is taken
        2)Observation - just observing body part and comparing it to the other side; no touching
        3)Palpation - check bony prominences first, then soft-tissue; look/feel for pain, lumps, gaps, etc.
        4)Special Tests - perform muscle/ligament/nerve/vascular tests

Immediate Treatment for Musculoskeletal Injuries
-RICE method
    1)REST - rest body part, not total body rest;  ex: have individual with a sprained ankle do a bicycling routine
    2)ICE - ice body part for 20 minutes every 2 hours
    3)COMPRESSION - apply compression with elastic wrap to help limit/reduce amount of swelling in the joint
    4)ELEVATION - elevate body part above heart level as much as possible

Emergency Splinting
-if fracture/luxation is suspected, always splint body part in position found before moving victim
        -ex: during a game, if an athlete broke their leg you would splint it before carrying them off the field
-types of splints:
        1)rapid form vacuum immobilizer
                -utilizes styrofoam beads and vacuum pressure to stabilize body part
                -easy to use; reusable
                -a total body immobilizer is also available to use instead of a spine board
                -most popular
        2)air splint
                -plastic splint that utilizes air to inflate around fx site
                -should not be used if there is obvious deformity as it will put unwanted pressure on fx
                -rarely used nowdays

MOVING & TRANSPORTING AN INJURED ATHLETE
-Spine Board
        -athlete should be moved as one unit, no bending or twisting
        -ideally, you should have 6 people to put someone on backboard
                -head, two on each side, and foot person
        -can use a scoop stretcher or orthopedic stretcher
                -you can "scoop" the athlete with this type of stretcher
                -you don't have to logroll the athlete to get them on the backboard

-Ambulatory Aid
        -used if injured athlete can still walk but with assistance
        -should be used for mild injuries only!
        -support athlete by walking on both sides and letting them bear weight on your shoulder
        -can also be a cane or crutches

-Manual Conveyance
        -used for greater distances than ambulatory aid is good for
        -can be vehicle (gator), wheelchair, sport chair (looks like a rickshaw) 

-Stretcher Carrying
        -for serious injuries with short distances
        -safest way to move someone with serious injury such as a broken leg (after it has been splinted)


Proper Fitting of a Crutch or Cane
-Cane
        -measure from greater trochanter to the floor for height of cane

-Crutches
        -have athlete stand up as straight as possible
        -place crutch at person's side with bottom tip 6" to the side and in front of shoe
        -the arm rest should be two finger widths from the armpit
        -after arm rest is set in position, have athlete dangle arm to side
        -the hand grip should be right where the wrist joint is
        -you can also measure from a person' fingertip to their elbow with their arms abducted to 90 degrees

Walking with a Crutch or Cane
-Cane
        -the cane (or single crutch) should be used on the opposite side of the injury (opposite of what you think)
        -move the cane/crutch with the good leg using the cane/crutch to bear weight

-Crutches
        -Athlete stands upright with bad leg elevated or partially bearing weight
        -Place crutch tips forward and swing thru
        -Gain balance and repeat

Important Crutch Basics:    
-Going Upstairs/Downstairs
        -remember saying - "Up with the good, and down with the bad!"

-Crutch Palsy
        -make sure and tell athlete not to lean on crutches
        -this puts pressure on axillary nerve which over a period of time can cause irreversible paralysis

-Wet Surfaces
        -crutch tips and wet surfaces do not get along...they will slip/slide
        -be careful on wet surfaces or surfaces that may have been waxed recently

Web Sites for further study/learning:
www.redcross.org/what.html - American Red Cross

www.amhrt.org - American Heart Association

www.trauma.org/spine/cspine-stab.html - Cervical Spine Stabilization

www.nsc.org - National Safety Council

www.parasolemt.com.au - First Aid with Parasol EMT

www.mayohealth.org/mayo/library/htm/firstaid.htm - First Aid

www.ccsd.k12.wy.us/CCHS_web/cramerfirstaider/fstaider.htm - Cramer First Aider

www.medmedia.com/med.htm - Wheeless' Textbook of Orthopedics