The Rugby Doctor and Immediate Trauma Care in Sport © BBC

The Rugby Doctor and Immediate Trauma

Care in Sport

© BBC

John MorganGP Partner (Wigan)

Clinical Director Bucket and Sponge Medical Services

GPSI Sports Medicine (North West)

Member of Joint Consultative Forum for Exercise Referral

GP Tutor Manchester University Medical School

Field Placement Supervisor Salford University Sports Rehab & Physiotherapy

Chief Medical Officer Ireland Rugby League

Key Note Lecture BASRaT 2012

Duties of Team Doctor

• coordinating pre-participation screening, examination, and evaluation

• field-side assessment and triage

• managing injuries on the field

• providing for medical management of injury and illness

• coordinating rehabilitation and return to participation

• integrate medical expertise with other health care providers

• provide appropriate education and counselling regarding nutrition, strength and conditioning, ergonomic aids, substance abuse, and other medical problems that could affect the player

• develop and maintain a current , appropriate knowledge base of the sport, understanding current techniques for managing sport injuries

Code of Ethics For The Team Doctor

The Team Doctor must:

• Be primarily responsible for the safety and well-being of the athlete

• Abide by the guiding regulations of the medical profession

• Abide by the rules of the sport governing body

• Must seek other medical opinions when in doubt, and then integrate this expertise as provided

• Preserve confidentiality in all circumstances

• Must not seek secondary gain from commercial interests that in any way would alter that which is in the best interest of the athlete

Immediate Medical Management on the Field of Play (IMMOFP)

• Mandatory qualification required by RFL for medical personnel entering the field of play

• Must be a currently registered medical practitioner or a Chartered and State registered Physiotherapist with a degree in Physiotherapy

• Qualification is valid for two years

• Renewal of qualification must be achieved within two months of expiry or you are prohibited from entering the field of play

Medical Personnel

Super League Requirements

For home and away matches:

• Physiotherapist – CSP and HPC registered with a degree in physiotherapy and current IMMOFP qualification

• Doctor – Qualified, registered with GMC and practicing with current IMMOFP qualification

Source: Medical Standards – 2011 provided by RFL

Medical PersonnelChampionship Requirements

For home matches:-



The Doctor is to remain for at least 15 minutes following the end of the match and to check with the away team physio (if they do not have a Doctor present) to confirm his/her services are not required before leaving the dressing room area.

For away matches:-



Medical PersonnelAcademy,U20s, U23s and Scholarship Requirements

For home matches:-



Where a qualified medical practitioner is unavailable, as a last resort the club may hire a qualified paramedic, operating through a private paramedic company who is on duty and fully equipt by that company. For the avoidance of doubt it is still the responsibility of the home club to provide the Mandatory Medical Equipment. If a paramedic is being used then the visiting club should be informed in advance. The RFL Operations Department must be informed of the name of the company concerned.

For away matches:-



Mandatory Medical Equipment

• Spinal Board and Trained Stretcher Bearers

• Cervical Stiff neck Collar(s)

• Splints

• Airways including a selection of ALL of the following:-

Oropharyngeal airway (assorted sizes)

Nasopharyngeal airway (assorted sizes)

Pocket Mask (1 way valve)

• Automated External Defibrillator

• Portable Suction

• Oxygen

The following equipment must be in the dressing room at least 1 hour before kick-off:-

Mandatory Medical Equipment• Emergency Drug Box containing:-

Adrenaline 1:1000 1ml vial

2 vials Hydrocortisone 100mg for IV administration (200mg dose)

Chlorpheniramine (Piriton) 10mg in 1ml vial for IV/IM use

10mls water for injection

Diazepam IV IM injection 10mg in 2ml vial

Salbutamol UDV 5mg per 2 mls

300mg Aspirin

IV fluids 500ml Sodium chloride 0.9%

IV giving set

Venflon – one of each

Green/Blue/Orange needles (3 of each)

1ml, 2ml, 5ml, 10ml syringes (2 of each)

Mandatory Medical Equipment

• Foil blanket and Ambulance blanket

• Sharps Bin and Clinical Waste Bag

• Bleach Solution and Disposable Gloves

Highly Recommended but not Mandatory Equipment

• Entonox

• Emergency Cricothyotomy Device and/or needle Cricothyotomy Equipment

• Crutches

• Penlight Torch

Additonal Recommended Equipment

• Various ET tubes

• Laryngoscope

• Stethoscope

• Sphygmomanometer

• Various needles, syringes – in addition to those in drug box

• Adrenalin 1:10,000 plus additional 1,000 or epipen

• Suture Kit

• Eye irrigation materials

• Emergency cricothyroidotomy kit

• Anti-inflammatories (tablets/IM)

• Painkillers (check WADA Prohibited List) (Tablets/IM)

Additonal Recommended Equipment• Anti-emetics• Anti-fungals • Antibiotics (various)• Medipreps• Gauze Swabs• Scissors• Inhalers - Salbutomol• Jelly Babies/Lucozade Tablets• Other drugs you personally feel necessary to carry out your duties

• Effective means of communication with emergency services

Additionally all medics should have:-

• Sound knowledge of additional medical persons at ground

• Detailed knowledge of treatment room facilities

The Preparticipation Examination: Preventing injury

• Recent development in sports medicine

• Used to:-

Assess overall health

Detect conditions that may cause injury

Detect conditions that may disqualify the player from participating

Assess fitness

Make recommendations for the exercise program

• Completed at start of Pre-Season training

Components of the Pre-participation Examination

• Medical history

• General medical health evaluation

• Cardiac Screening

• Musculoskeletal examination

• Family/Social History

ECG

Echocardiography Report – if required

• Consent

Medical Treatment

Information

• COGSPORT

• 100% ME talk

Rugby League is an ‘international collision sport‘ with an elevated risk of injury, compared with many

other popular international sports. Some investigations have indicated that injury rates in

rugby-league play are as high as 1.4 serious injuries per game, and the frequency of injury in the

sport seems to be increasing rather than decreasing

‘A Prospective Study of Injuries to Élite Australian Rugby Union Players,‘ British Journal of Sports Medicine, Vol. 36, pp. 265-269, 2002

Basic Life Support

Three elements:

Airway – establishment of an airwayHead Tilt / Chin Lift or Jaw ThrustJaw thrust should be used to open the airway if an injury to the C-spine is suspectedAdjuncts should be used if required

Breathing – artificial ventilation of the lungs

Circulation – artificial circulation of blood through the body

Alex Thompson

http://www.roughyeds.co.uk/wp-content/uploads/2011/02/Alex-Thomison.jpg

Scene Safety

• Most Important Person is YOU

• Is Area safe and game stopped?

• No matter how well equipped you are hospital may be the most appropriate place for treatment

• Don’t forget to request an ambulance as early as possible

• Collapse Witnessed?• If not – consider more unusual causes

Aims of Treatment

• Preserve Life• Maintain an Airway• Perform CPR• Stop Bleeding

• Prevent the Situation Deteriorating• Summon Help• Use First-Aiders or Bystanders

• Promote Recovery• Reassure Patient• Wrap in a Blanket

Priorities of Treatment

• In all patients involved in trauma it is important to immobilise the head and neck until a C-spine injury is ruled out

• Treatment of a player and their injuries should be dealt with in the following order:

• If any life threatening problem is found it should be dealt with immediately before moving on to the next stage

• Breathing• Airway – ensure the airway is patent• Breathing – patient is breathing and respirations are adequate• Circulation – the patient has a palpable carotid pulse

• Bleeding – ensure there is no major bleeding

• Bones – Examine the patient for any fractures

Sudden Cardiac Death

7 deaths in Rugby League 1996-2011

Unconsciousness

Causes:

• Head injury

• Skull fracture

• Concussion

• Compression

• Cerebrovascular accident

• Epileptic fits

• Infantile convulsion

• Hysteria

• Poisonous substances and fumes

• Asphyxia

• Fainting

• Extremes of body temperature

• Cardiac arrest

• Hypoglycaemia

• Hyperglycaemia

• Hypothermia

• Blood loss

• Drug overdose

Management of an unconscious patient

• AcBCDE – airway must always take priority

• If in doubt treat as a C-spine injury!

• If YES to any of following, continue with Full Spinal Immobilisation

1. Decreased conscious levels?

2. Any loss of consciousness post incident?

3. Under the influence of drink/drugs (including prescription medication)?

4. SIGNIFICANT neck or back pain?

5. Deformity, tenderness, swelling over the spinal process?

6. Neurological signs and symptoms?

7. Other painful injuries?

8. Significant pain on moving the neck or back?

Levels of Response – AVPU Scale

The casualty is fully alert

Confused

They are responsive and fully orientated (a casualty in this category will usually know what month it is)`

Alert

VoiceThe casualty is not fully orientated but asks and answers your questions

Inappropriate wordsThe patient is able to speak words, but cannot put them together into logical sentences

Utter SoundsThe casualty is not able to speak words but makes noises often in response to painful stimuli

No verbal responseThe casualty makes no noise

Pain Localises pain

The patient is able to localise where painful stimuli is being applied

Responds to (but does not note localise) pain

The patient responds to painful stimuli, but is unable to localise it

Unresponsive Unresponsive

Spinal and Cervical Injuries

Mechanism of Injury

Caused by direct or indirect violence and should always be suspected in all cases where:

• There is a history of accident or injury to the vertebral column

• The patient complains of pain in the back or neck

• A fall from a height and landing on the heels has occurred

• An unconscious patient has been involved in a road traffic accident

• There has been hyper-flexion or whiplash injuries of the neck

• A heavy weight has fallen on the casualty’s shoulders

• There is acceleration or deceleration strains of the neck


Signs and Symptoms of a Spinal Injury

As well as normal signs and symptoms of fracture, there may be other clinical features which are specific to a spinal injury

• Loss of feeling or sensation in the body below the site of the injury

• A hot feeling, or ‘pins and needles’ sensation above the site of the injury

• Fixation of the spinal column at the site of injury

• Paralysis or generalised weakness below the injury site, which may lead to incontinence

• Displacement of the spinal vertebrae felt as an unnatural lump, or depression, from the normal continuity of the spinal column

Spinal and Cervical InjuriesManagement of Spinal Injuries• Ensure an open airway using jaw thrust technique

• Do not move the patient unless there is immediate danger

• Avoid rotation or extension/flexion of the neck

• Spinal injuries can be masked particularly in a patient with multiple injuries. A thorough secondary survey is important to establish the site of the injury

• Manual immobilisation of the patient is paramount. Once applied it should not be released until the patient is firmly strapped to the spinal board and head blocks are applied

• Apply a correctly sized collar, remembering that this will only provide 30% support and manual immobilisation must continue to be applied

• If in doubt as to the presence of a spinal injury, you must immobilise the patient, prevention is better than cure!

• Immobilise the patient to a spinal board using as much help as possible

• The person who is controlling the head must give all the movement commands in a clear and precise way to eliminate the risk of jerky uncoordinated movements

• Waiting for the ambulance service to assist in the movement of this type of patient is usually the best idea


• A soft tissue injury to the cervical spine which is quite common in rugby league

• It is a traction injury occurring with cervical side flexion and simultaneous shoulder depression

Specific to the Cervical Spine on the field of play

• Usually caused by nerve root compression in the upper root of the Brachial plexus (C5/6)

Stinger or Burner

• Symptoms are burning/tingling in the lateral arm, thumb and index finger

• Usually transient and often player can be seen to ‘shake off’ symptoms in his arm and does not require him to be removed from the field of play

• Muscles involved are deltoid, biceps and infraspinatus

• A weakness in any of these muscles on assessment means that the player should be removed and not return to the field of play during that game

Cervical Spine Injuries

• Axial loading

Classification of injuries

• Flexion injury

Harris usefully classified cervical spine injuries according to the mechanism of injury and the subsequently expected pattern of fractures into the following groups:-

It is important to know when and why these injuries must be suspected as well as how to manage them in the field of play

• Flexion + Rotation

all of which may occur in a rugby match

• Hyperextension injury

• Extension + Rotation

• Odontoid peg fractures


• Significant impact above clavicles

Clinical Suspicion

• Immediate neck pain after an injury

Following ATLS guidelines, CSI must be suspected in any of the following circumstances:-

• Increased risk due to predisposing factors (general abnormalities, old age, neck injuries)

• Presence of abnormal neurology

• Multiple trauma

• Presence of step deformity in posterior midline of the neck

• Significant distracting injuries

• Significant MOI

• Unconscious victim


and all of these

Clinical Exclusion

• Not under effects of alcohol or drugs

Before a CSI can be clinically excluded, the patient must satisfy the following criteria:-

• No pain on movement (see Canadian Cervical Spine Rule)

• No pain on palpation

• No abnormal neurology

• No significant distracting injury

• GCS 15/15 on assessment


• No mid-line cervical tenderness on direct palpation

Canadian Cervical Spine Rule

• No focal neurological deficit

Canadian researchers devised an algorithm for selective cervical spine radiology

• No intoxication

• Normal alertness

• No painful distracting injuries

The algorithm classifies the patients as having a low probability of injury (sensitivity 99.6%) if the patient meets the next 5 criteria:-

This helps to eliminate any unnecessary investigations and, therefore reducing cost and wasteful overuse of medical resources at the same time as minimising exposure to unnecessary radiation

PRACTICAL!

Documents

The Rugby Doctor and Immediate Trauma Care in Sport © BBC