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Emergency Procedures

Opening Comments:

Professional Team Chiropractor is part of a Healthcare Team.

Other professionals are more trained / experienced.

Stay out of the way until athlete cleared for chiropractic care.

Opportunity to develop interprofessional relationships.

Potential opportunity to attend emergency training practice which should be ongoing.

Like other elite athletics – Olympics, World Games, Colleges

BUT! What if you’re the only doc on the field at the time?

High School / Middle School / PeeWee / Pop Warner /Clubs

Know your roll – by contract.

“I’ll be your sports doc.”

Know your responsibilities.

Who’s in charge if you are not.

If you accept primary responsibility. Be prepared. Malpractice.

Activating EMS. Location. Entry. Ambulance. 911.

Your job, KNOW when EMS necessary.

In our profession, err on the side of caution – recommended.

Rare occurrences

Our job – recognize rare and dangerous conditions.

Stabilize, manage and, if necessary, transport.

Safely avoid transport saves $$$

Emergency Procedures – unlike other types of healthcare.

No time to consider various alternative actions

No time to research correct procedures – or ask Siri / Google

Requires protocol development and practice.

Scrutiny guaranteed if an incident occurs. Perhaps Deposition.

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Develop written Emergency Action Plan (written & practiced)

Athlete down:

▪ Trauma vs Non-Trauma

▪ Conscious: breathing / dyspnea / communicative / pain

▪ Unconscious: breathing / airway / facemask &/or helmet removal?

▪ AED: document training, maintenance (charge, pad expiration, software updates)▪ Prescriptions?

▪ Exertional Dehydration – Heat Stroke: Fluids available?

▪ Exertional Hyponatremia: Electrolyte replacements available

Facemask Removal – helmet – Steven Rosen – Virginia Tech

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Emergency Response

First Step: “Survey the Scene” vs. “Deep Breath”

In a sea of CHAOS, calm prevails.

Approach the athlete Stabilize the neck, establish communication & cooperation

• Asthma • Catastrophic brain injuries • Cervical spine injuries • Diabetes • Exertional heat stroke • Exertional hyponatremia • Exertional sickling • Head-down contact in football • Sudden cardiac arrest

NATA: Preventing Sudden Death in Sports

Not to be considered comprehensive.

Preparation should include complete sports injury program like CCSP / DACBSP.

Head / Neck Trauma

Helmet to helmet contact. Helmet to ground contact. Etc.

Or just a really hard hit without helmet contact.

▪ Can this cause concussion? How do you know that’s only a concussion?

▪ What other concerns do you have?

Player not moving / Or grasping head or neck, writhing in pain

Healthcare team rushes onto the field

WHAT DO YOU DO?

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Head Trauma Protocol

1. Clear the Cervical Spine

Golden Rule: “Assume cervical fracture until proven otherwise.”

First Contact: Establish communication + cooperation while stabilizing cervical spine.

Athlete unconscious or not communicative

▪ Follow the Golden Rule – stabilize spine and emergency transport

▪ Activate EMS with risk of morbidity & mortality

Head Trauma Protocol

1. Clear the Cervical Spine (continued)

Severe cervical pain or spasm – follow the Golden Rule

Observable deformity - follow the Golden Rule

Upper extremity neuro testing

▪ Any BL positives - follow the Golden Rule

▪ Persistent UL positives - follow the Golden Rule

▪ Discuss Stingers / Burners

Lower extremity neuro testing – any positives - follow the Golden Rule

Head Trauma Protocol

1. Clear the Cervical Spine (continued)

Spinous Process Palpation in 2 stages – follow the Golden Rule

Gentle Isometric Testing – follow the Golden Rule

Assist first movement with cervical stabilization

Cervical Spine is “cleared”. Move to sidelines for further evaluation

Can’t Clear the Cervical Spine:

What does that mean? What do you say to the athlete?

“OMG, you broke your neck” – No! Why?

It doesn’t mean the neck is broken.

Burning Hands Syndrome / Transient Quadraplegia

▪ Probably due to a spinal cord concussion

“We need to make sure it is safe before you move your neck.” Encourage cooperation / you can’t force cooperation.

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Head Trauma Protocol

2. Head / Brain evaluation – Skull Fracture

Helmets protect skull from fracture pretty well.

Regardless, palpate entire skull for severe T2P or depressions.

▪ Include orbit

Observe for fluids from nose or ears. Raccoon eyes. Battle sign.

▪ Halo sign, Hemotympany, Save fluids for lab – Beta -2 transferrin

Extra-ocular ROM – facial fxr.

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Head Trauma Protocol

3. Brain evaluation – concussion / increasing ICP

Infrascan 2000 if you’ve got it.

Repeated vital signs – Red Flag = Increasing Pulse Pressure

Repeated evaluation of brain function over several domains

▪ SCAT3, ImPACT, King Devick, Reaction Time

▪ Expect steady improvement from test training

No return to play that day – “When in doubt, sit them out!”

Period of vulnerability

Prevention Strategies

Value of Cervical Strengthening Exercises

Decreases cervical fracture risk

Decreases concussion risk

Concussion vs. Cervical Proprioceptive Injury

Girls vs. Boys / Relative Testosterone Deficiency / Teens vs. Adults

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SCAT3 and Return to Play Protocols