2014 JMSP Symposium
Trauma in the ER
Dr. Jim Kyle, FACSM
Team Physician, Concord University
Sports Medicine Director Beckley ARH Hospital
West Virginia EMS Regional Medical Director
Marshall University School of Medicine
Associate Clinical Professor
Sports Trauma in the ED
 Hand and Wrist
Mallet finger
Coach’s finger
Skiers thumb
Scaphoid Fx
TFCC injury
 Elbow and Shoulder
Tennis elbow
Radial head Fx
Rotator cuff strain
Impingement syndrome
A-C separation
 Low Back, Pelvis, Hip
Spondylolysis
Apophyseal Avulsions
Femoral neck Stress Fx
SCFE
 Knee Injuries
Meniscal Tears
Anterior Cruciate Ligament
Medial Collateral Ligament
Adolescent knee
 Ankle Injuries
Lateral sprain
Deltoid sprain
High-Ankle sprain
Jones Fx
 Head, Heart, Lung, Kidneys
Concussion
Syncope – HCM, SVT
EIA, Rib Fx, Pulmonary Contusion
Heat Stress, Rhabdo, ECAST
International Symposia on
Concussion in Sport
 First ISC Vienna 2001
 Second ISC Prague 2005
Simple vs Complex, SCAT2 sideline tool
 Third ISC Zurich 2008
Removed Simple vs Complex grading,
RTP based on progression
 Fourth ISC Zurich 2012 – SCAT3, Baseline NP,
BESS, enhanced MRI, mTBI vs Concussion
FIFA, IOC, IIHA
2014 RTP Guidelines
ED discharge instructions:
• Physician follow-up in 72 hrs for
repeat exam
• Graded Symptom Checklist at D/C
• No date for return to contact
• Neuro-Cognitive Testing
• Sports medicine team should provide
protocol for gradual return to activity
VT Sub Concussive Research
 Helmets with accelerometer
 Sideline Box with recordings
 Many Hits with + 40g
 Physician Beeper set @ 50g
 Average 4 + 80g Hits Season
 # Hits position specific
 5 concussions in 2013 season
ED Discharge: Rhomberg Test
Balance Error Scoring System
BESS
BARH ED “Best Practice”
Youth Concussion
 Emergency Room: Head, C-spine evaluation- ?CT
BESS Testing, 72hr GSC at D/C
 Pediatrician: Review Graded Symptom Checklist
ImPACT testing
 School/ Coach: Equipment check, 5 day progession
Consult Physician RTP
Collegiate Strength and
Conditioning Coach
• BIGGER
• STRONGER
• FASTER
Rhabdomyolysis
• Medical
• Trauma
• Sports - Exertional
• SCT – Fulminant Ischemic
“Explosive” Rhabdo
Rhabdomyolysis in Athletes
• January 2011
• University of Iowa
• Football players
required to perform
100 squats with
weight = 50% of prior
max
Rhabdomyolysis in Athletes
13 cases of
Rhabdo first day
of conditioning
drills after
Holiday break
Cold day in Iowa City
Rhabdomyolysis
TRIAD of:
1. Muscle Weakness
2. Myalgia
3. Dark Urine
Exertional Rhabdo
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Modest elevation of CPK
Basic Training Military Recruits
Common in August Football
Marathon runners 10% > 3,000
Recent increased awareness 2011
CPK in Exertional Rhabdo
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4-5x high normal consider diagnosis
peak in 24-36, fall 30%/day
Less than 20,000 unlikely ARF
May peak at levels > 100,000
^ LDH, ^SGOT – 25%
Rhabdo Complications
• ARF
• Hyperkalemia
• Hypocalcemia
• ^ LFT
• DIC
ARF in Rhabdo
• CPK less than 20,000 – rare
• Early treatment
• Mortality approaches 20%
Sodium Bicarbinate in Rhabdo
Use recommended in cases of:
1. Acidemia
2. Dehydration
3. Underlying Renal Disease
1 amp in 1 L NS @ 100cc/hr
Exertional Rhabdo
Rhabdomyolysis
• Medical
• Trauma
• Sports - Exertional
• SCT – Fulminant Ischemic
“Explosive” Rhabdo
Case Study ECAST
Dale Lloyd II
September 2006
Rice
5’9” 190lb defensive
back
Struggling during
sprints Teammates
attempted to asisst,
coaches leave alone,
unaware of SCT
Workout Program
• 4:00 – weight lifting
• 4:30 - Outside sprints
• 16 sprints 100yards
• Rest 1 min first 4, 2 min next 4
1 min last 8.
Timeline Athlete Collapse
 4:55: Completes sprints
C/O bilateral lower extremity pain and SOB
Alert , over next 10 minutes became lethargic
 5:05: Unable to walk , EMS called
Cart to Training Room, O2 via BVM
 5:12 : University EMS arrived
IV and 100% Oxygen, Fire Department EMS called
 5:28: FD EMS arrival: Patient unresponsive
GCS=3, O2Sat =67% room air
Nasotracheal intubation, EKG with peaked Twave V2,V3
 5:52: ED arrival: BP =150/50 Pulse = 126
Temp = 97 O2Sat = 100%
Sudden Death SCT
 All died under similar distinctive circumstances: noninstantaneous collapse with rapid deterioration (dyspnea,
fatigue, weakness and muscle cramping) over 10-45
minutes
 Each event occurred during vigorous or exhaustive
maximal physical exertion, usually during training (22)
 17 of 23 (74%) Summer or early Autumn
 20 deaths in southern or border states with Temp > 80*
 Florida (n = 5) , Texas (n = 4)
Maron, BJ, Eichner, ER, et.al. Sickle Cell Trait Associated With Sudden Death
in Competitive Athletes. Am J Card: 2012, 110(8)
ECAST - On the Field Management
Conditioning Focus
Remove athlete if leg, back pain SOB
Vital Sign with O2 therapy
EMS alert
IV Fluids, Normal Saline Bolus
ED Management: Exercise Collapse
Associated with SCT (ECAST)
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Awareness that ECAST in Diff Dx
ABG monitoring for metabolic acidosis
Aggressive Fluid and Electrolyte Management
Anticipated Explosive Rhabdo
Early Dialysis ^K, to avoid lethal cardiac
arrhythmias ( within minutes to hours of syndrome
onset )
Sports Trauma in the ED
 Hand and Wrist
Mallet finger
Coach’s finger
Skiers thumb
Scaphoid Fx
TFCC injury
 Elbow and Shoulder
Tennis elbow
Radial head Fx
Rotator cuff strain
Impingement syndrome
A-C separation
 Low Back, Pelvis, Hip
Spondylolysis
Apophyseal Avulsions
Femoral neck Stress Fx
SCFE
 Knee Injuries
Meniscal Tears
Anterior Cruciate Ligament
Medial Collateral Ligament
Adolescent knee
 Ankle Injuries
Lateral sprain
Deltoid sprain
High-Ankle sprain
Jones Fx
 Head, Heart, Lung, Kidneys
Concussion
Syncope – HCM, SVT
EIA, Rib Fx, Pulmonary Contusion
Heat Stress, Rhabdo, ECAST
Athletes at Risk for SCA
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Chief complaint of syncope
Chest Pain with or post activity
History of palpitations
Family History of Sudden death
Abnormal EKG
Symptoms: HCM
• Dysnea in 90% of symptomatic athlete
• Syncope during exercise - from
inadequate cardiac output or cardiac
arrhythmia
• Chest Pain during exercise
• Palpitations, Dizziness, Presyncope
Athlete SCA : Have We
Changed the Playing Field ?
Emergency Department
• Athlete Collapse – Assume Cardiac
Etiology (Sentinel Seizure)
• EKG Attention: Delta and Epsilon Waves,
LQT
• Syncope, Near Syncope, Chest Pain Work
Up: Consider advanced imaging, Cardiac
CT, MRI* vs ECHO
The Faces of SCA
Medical “Time-Out”
Prior to Games and Practice
• NATA petition to NCAA
• EAP Venue specific
• On the Field – EMS communication and
readiness Head and Neck
• Athlete Collapse – EHS , SCA and SCT
• Spectator Coverage
Sideline ER Doctor
Blunt Torso Trauma When to Worry
CHEST TRAUMA
Rib Fracture
Pneumothorax
Pulmonary contusion
ABDOMINAL TRAUMA
Spleen Injury
Renal Contusion
Appendicitis
Chest and Abdomen
Rib Fractures
• Ribs 4-9
– Most common ribs injured
• Ribs 1-2 and Sternum
– Great vessel injury
– Cardiac contusion
• Ribs 9-12
– Injury to spleen, liver or kidney
Rib Fractures
Thoracic Emergencies
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Pneumothorax
Tension Pneumothorax
Flail Chest
Diaphragmatic Rupture
Wrap or tape Chest
• No longer
recommended
• Leads to pulmonary
complications
• Decreased ability to
take maximal breath
during exertion
Return to play
• 3-6 weeks
• Pain permits
• Protective padding 6-8
weeks
• Stress fracture
– 6-8 weeks stopping the
inciting repetitive motion
What was happening at the
hospital
Patient #2: Jacob
• 16 years old
• California
• Pulmonary Contusion
Rib Fractures
• Ribs 4-9
– Most common ribs injured
• Ribs 1-2 and Sternum
– Great vessel injury
– Cardiac contusion
• Ribs 9-12
– Injury to spleen, liver or kidney
Abdominal Blunt Trauma
Abdominal Blunt Trauma
Abdominal Blunt Trauma
Sideline Abdominal Exam
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LUQ pain
Radiating to L Shoulder
Guarding
Rebound tenderness
Abdominal Blunt Trauma
Dip the Urine – test for Hematuria
Abdominal Blunt Trauma
Abdominal Blunt Trauma
Abdominal Blunt Trauma
Abdominal Blunt Trauma
Sideline Alert
MAJOR KNEE
• MechanismDownward
Forward
Inward
The Unstable Knee
• High Index Suspicion
• Popiteal Artery
• Sideline ABI < 1