On the Field Emergency
Management
Emily Carter, ATC
Michelle Johnson, ATC
Megan Lawrence, ATC Teresa Pritchett, ATC
Jonathan Vieira, ATC
Kim Walter, ATC
Fractures/Dislocations
•
David, Tal MD. “Missed Upper Extremity Fractures in Athletes”.
(Current Sports Medical Reports)
– Evaluate ABC’s
– Understand Mechanism
– Immediate reduction techniques
– Knowledge of common complications
– Plan for aftercare
– When in doubt…IMMOBOLIZE
Fractures/Dislocations
•
-
Padua, R. “Surgical versus conservative treatment for acute firsttime anterior shoulder dislocation: the evidence”. (Journal of
Orthopaedics and Traumatology)
96% of shoulders dislocations occur anterior and are acute.
High rate of recurrence within 1st year.
Management: restore range of motion, reduce recurrence, and
improve quality of life
Fractures/Dislocations
•
Cox, C.L. and J.E. Kuhn. “Operative versus Non-operative
Treatment of Acute Shoulder Dislocation in the Athlete”. (Current
Sports Medicine Report)
– 24 discussed reduction techniques, be familiar with several
techniques
– Advantages and Disadvantages of each technique
– May take several attempts to reduce
– Cause no harm, immobilize and refer if necessary
Action plan for Shoulder Dislocation
Determine if shoulder dislocation is present
 Evaluate neurovascular status (before and after)
 Visually inspect and palpate for deformity
 Check Range of Motion
 If dislocated/subluxed prepare for reduction
Instruct athlete what is about to happen
Use technique most familiar with
Action plan for Shoulder Dislocation
Example Techniques: attempt only once
 External Rotation- Place athlete on their back with the affected arm
abducted to about 90 degrees, using one hand to maintain the adducted
position and other hand to guide the arm through slow external rotation with
constant axial rotation
 Spaso- Place athlete on their back with the affected arm forward flexed 90
degrees and gentle longitudinal traction and external rotation are applied
After Reduction:
 Immobilize with sling
 Recheck neurovascular status
 Refer athlete to Emergency Department if NOT reduced
 Refer to team physician if reduced
Action Plan for Patella Dislocation
Presentation:
 Patella displaced laterally
 Knee flexed
Reduction:
 Simply extending the knee is often all that is necessary
 Next apply medially directed pressure onto patella.
Aftercare:
 Check Neurovascular status
 Immobilize in extension for referral to ED or team physician
Action Plan for Finger Dislocation
Presentation:
 PIP – A dorsal dislocation presents with middle phalanx dorsal in relation to proximal
phalanx. A volar dislocation has a lateral displacement in addition to volar.
Reduction:
 Dorsal DIP/PIP – traction, mild hyperextension & direct pressure on base of the more
distal phalanx then bring into flexion flexion
 Volar PIP – Hold MP joint in flexion to relax lateral bands, provide traction and then
flexion and bring them into extension. Often difficult to reduce.
 MP – NO TRACTION—NO HYPEREXTENSION hold wrist in flexed position,
apply steady pressure in a distal and volar direction. Difficult to reduce.
Aftercare:
 Check Neurovascular status
 Splint/Tape and refer to ED if not able to reduce
 Splint/Tape and refer to team physician if reduced
Cervical Spine Injuries
•
Research– Kleiner, DM et. Al. Prehospital Care of the Spine Injured
Athlete: A document from the Inter-Association Task Force
for the Appropriate Care of the Spine Injured Athlete (NATA)
• Always have a designed protocol for the care of the spine
injured athletes
• Always treat unconscious athlete as a cervical spine injury
• Protocol was developed from this article
Cervical Spine Injuries
– Del Rossi et. Al. The 6-Person Lift Transfer Technique
compared with other methods of Spine Boarding. (Journal of
Athletic Training)
• 6-plus person lift generated significantly less axial
rotation, lateral flexion/and medial lateral translation than
the log roll but not significantly less than the lift and slide
technique.
Cervical Spine Injuries
– Waninge, Kevin N. Management of the Helmeted Athlete with
Suspected Cervical Spine Injury. (AJSM Lit. Review)
• Helmets and shoulder pads should not be removed in
prehospital management of the football player with
potential spine injury unless absolutely necessary.
Cervical Spine Injuries
•
Gehron, T et. Al. Cervical Spine Alignment in Youth Football
Athlete: recommendations for Emergency Transportation (Amer.J.
Spt Med)
– No significant difference when a healthy athlete was x-rayed
with full pads on vs. no pads
– There was significant lordosis when x-rayed with only
shoulder pads and no helmet vs. no pads
Cervical Spine Injuries
•
Bailes, JE et al. Management of Cervical Spine injuries in Athletes.
(JAT)
– ATC’s should be prepared to handle and recognize cervical
spine injuries.
– Utilize proper tools and techniques for cutting off masks and
spine boarding (log roll, 6 man lift)
Action Plan for Cervical Spine injury
Stabilize the Head AND Neck
Do Not Move Athlete
 *unless absolutely necessary to do primary survey*
 *Log roll patient if lying prone*
Primary Survey
 Check airway, breathing, and circulation
 Remove Mouthpiece
 Call 911 (EMS)
 If stable move on to Secondary Survey
 If not breathing proceed with facemask removal
Action Plan for Cervical Spine injury
Facemask Removal
 Remove facemask completely (all clips from facemask via screwdriver,
pruning shears, or trainer’s angel)
 LEAVE HELMET AND SHOULDER PADS ON
 Re-check ABC’s
Secondary Survey – Head to Toe
 Neurological screening
 Assess motor and sensory function in extremities
 Cranial nerve assessment as complete as possible
Transport
 Maintain control of the head during spine board process
 Secure helmet to spine board with tape or EMS straps
Acute Asthma Attacks
 Research:
 Miller, Michael G., et al. National Athletic Trainers’
Association Position Statement: Management of Asthma in
Athletes. (NATA, 2005)
 All existing emergency action plans should include an
asthma action plan.
 If an athlete is experiencing any degree of respiratory they
should be referred rapidly to emergency department or
personal physician.
 Athletes should place inhaler at or in front of lips and
slowly inhale at the same time they are activating the
inhaler. Hold breath for approximately 10 seconds.
 Athletes who have difficulty coordinating MDI generally
benefit from the use of a spacer.
Acute Asthma Attacks
•
Research:
– Houglum, Joe E. Asthma Medications: Basic Pharmacology
and Use in the Athlete. (JAT, 2000)
• Typical adult dosage of Albuterol (B2 agonist) is 2 puffs
tid to qid prn.
• It is important for athletes to be using inhaler devices
properly, including a spacer if good inhalation technique
is not being achieved with MID
Acute Asthma Attacks
 Research:
 Allen, Thomas W. DO. Sideline Management of Asthma.
(Current Allergy and Asthma Reports, 2006)
 Any athlete who demonstrates symptoms of airway
hyperactivity must be removed from activity and provided
emergency treatment.
 If symptoms do not resolve when athlete is removed from
play administer two puffs of short-acting B2 agonist
(Albuterol) via MDI.
 The use of a spacer attached to the inhaler will improve
the delivery of the drug.
 If symptoms have not resolved in five minutes a second
dose of two puffs should be administered.
Action Plan for Acute Asthma Attacks
If athlete is experiencing any symptoms of asthma (SOB, wheezing, retraction)
initiate asthma action plan:
Initial Treatment (With Spacer)
 Use rescue inhaler, 1-2 puffs, up to 3 treatments in 1 hour
 Shake inhaler
 Have athlete exhale, then place inhaler with spacer on lips. Dispense
medicine into spacer, then inhale. Hold breath for 10 seconds before
exhaling.
Initial Treatment (No Spacer)
 Use rescue inhaler, 1-2 puffs, up to 3 treatments in 1 hour
 Shake inhaler
 Have athlete exhale, then place mouth over inhaler. Dispense medicine
while inhaling slowly. Hold breath for 10 seconds before exhaling
Action Plan for Acute Asthma Attacks
If response is good within 5 minutes:
 May continue to participate and use inhaler/spacer as needed
If symptoms are still present after 5 minutes but improving:
 2 more puffs of rescue inhaler/spacer
 Do not return to participation
 Instruct athlete to follow-up with physician
If athlete shows no improvement:
 Repeat use of rescue inhaler as needed
 Call 911 to transport athlete to emergency room
* Activate EMS immediately if athlete is exhibiting signs of impending
respiratory failure (weak respiratory efforts, weak breath sounds,
unconsciousness, or hypoxic seizures, grunting).
Concussions
•
•
We utilized the last year’s concussion focus team information to
develop protocol
We also utilized the SCAT card
Action Plan for Concussions
Cranial Nerve Testing
I
II
III
IV
V
VI
VII
VIII
Nerve
Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducent
Facial
Vestibulocochlear
S/M
S
S
M
M
B
M
B
S
IX
X
XI
XII
Glossopharyngeal
Vagus
Spinal Accessory
Hypoglossal
B
B
M
M
Test
Identify familiar odors applied to each nostril
Identify # of fingers held or read from paper
Pupil reaction to light
Follow finger without moving head
Identify where touch is applied to face
Lateral eye movements
Smile, wink, identify tastes
Identify sounds in both ears, touch finger to
nose, walk, touch knee to heal
Say “ah”, swallow, test for gag reflex
Test for gag reflex
Resistive shoulder shrugging and turning head
Tongue movements, resist w/ tongue
depressor
Action Plan for Concussions
Upper Extremity Neurologic Exam
C5
MOTOR
Shoulder Abduction
Elbow Flexion
SENSORY
Lateral Arm
REFLEX
Biceps
C6
Wrist Extension
Lat. Forearm
Thumb, Index
Brachioradialis
C7
Elbow Extension
Wrist Flexion
Digit Extension
Middle Finger
(Variable)
Triceps
C8
Digit Extension
Medial Forearm
Ring/Small Digit
None
T1
Finger Adduction
Finger Abduction
Medial Arm
None
Action Plan for Concussions
Concussion Assessment
1) Orientation
Time
Date
Place
Surroundings
Recall injury event
2) Immediate Memory
Item Recall
Ball
Sailboat
Computer
Honesty
Purple
3) Concentration
repeat series of digits backward,
progress with level of difficulty
4-9-3
3-8-1-4
6-2-9-7-1
months in reverse order
4) Delayed Recall
recall items given earlier
Ball
Sailboat
Computer
Honesty
Purple
Action Plan for Concussions
Concussions- Physician Referral Checklist







Immediate Emergency
Loss of consciousness > ?min
Decreased level of consciousness
Abnormal neurological function
Seizure activity
Mental status changes
lethargy, confusion, agitation
Decrease of irregularity in respirations
Delayed Transport
Vomiting more than once
Post traumatic confusion lasting
longer than 15 min
Cranial nerve deficits
Increase in blood pressure
Post concussion symptoms that worsen
or do not improve over time
Increase in the number of symptoms
reported over time


Unequal, dilated, or un-reactive pupils
Signs or symptoms of associated injuries,
spine or skull fracture,

Other considerations:
social barriers, parental awareness, length of travel, language barriers
Revision of Existing Protocols
 We also had enough time to revise several of our existing protocols
to fit our new format. They include:
 Heat Illness
 Heat Index Guidelines
 Dental Issues
 Epi-Pen Delivery
 Lightning
 Activating EMS
Action Plan for Heat Illness
If athlete is experiencing any symptoms of heat illness, initiate action plan:
Heat Stress (Mild):
S/S:
Cramping
Dizziness / Light headed
Nausea/Vomiting
Rapid Breathing
TX:
Remove from sun
Remove clothing and
equipment
Encourage athlete to
drink fluids
Apply ice towels to
axilla/groin
Monitor and record vitals every 3-5 minutes.
* Activate EMS immediately if athlete becomes unresponsive at any
time
Action Plan for Heat Illness
Heat Exhaustion (Moderate):
S/S: Cramping

Extreme Exhaustion

Dizziness/ light headed

Moist / Pale / Cool skin

Visual Disturbances

Altered mental state

Increased body temp (>102)
TX: Activate EMS:
Treatment same as Heat Stress plus:
Cool with fans if available
Elevate legs
Notify team physician if present
Monitor and record vitals every 3-5 minutes
Heat Stroke (Severe):
S/S: Staggering

Hot / Dry skin

Altered mental state

Severe headache

Increased body temp (>104)

Weak pulse

Decreased blood pressure
TX: Activate EMS
Treat the same as Heat
Exhaustion while waiting for
EMS to arrive.
Monitor and record vitals every 3-5 minutes
Action Plan for Dental Issues
Tooth Avulsion (Entire tooth knocked out)
 Avoid additional trauma during handling of tooth. DO NOT handle by root.
Do Not scrub tooth. Do NOT sterilize tooth.
 Gently rinse with water if debris is on tooth.
 If possible, re-implant tooth and stabilize by gently biting down on towel.
 If unable to re-implant, you should do one of the following:
 A. Place tooth in saline solution (Best Option)
 B. Place tooth in cold milk
 C. Wrap tooth in saline soaked gauze
 D. Place tooth in cup of water
 Putting tooth back in socket within 30 minutes gives best chance to save
tooth. Transport to dentist or emergency room immediately
Action Plan for Dental Issues
Tooth Luxation (Tooth in socket, but wrong position)
 Extruded Tooth (tooth is hanging out of gums)
 Reposition tooth in socket using finger pressure
 Stabilize tooth by gently biting on towel
 Transport to dentist or emergency room
 Lateral Displacement (tooth is pushed back or pulled forward)

Reposition tooth using finger pressure.
May require local anesthesia to reposition; if so, stabilize by gently biting down on towel

Transport to dentist or emergency room immediately.
 Intruded Tooth (tooth pushed into gum- looks short)
 DO NOTHING –AVOID REPOSITIONING OF TOOTH
 Transport to dentist or emergency room.
Tooth Fracture (Broken Tooth)
 If tooth is broken in half, save broken portion and transport to dentist. Stabilize portion of tooth left in
mouth.
 Limit contact with other teeth, air, and tongue. Pulp nerve may be exposed, which is extremely
painful to athlete.
 Immediately transport tooth and patient to dentist or emergency room.
Action Plan for Epi-Pen
 Unscrew the cap off of the Epi-Pen carrying case and remove the
Epi-Pen auto-injector from its storage tube. (Do not use Epi-Pen if
it is discolored or a red flag appears in clear window)
 Grasp unit with the black tip pointing downward.
 Form fist around the unit (keeping black tip down)
 With your other hand, pull off the gray safety release
Action Plan for Epi-Pen
 Hold black tip near outer thigh
 Jab firmly into outer thigh until it clicks so that unit is
perpendicular to the thigh
 Hold firmly against thigh for approximately 10 seconds
 Remove unit from thigh and massage injection area for 10 seconds
 Call 911
Action Plan for Lightning Safety
 Flash-to-Bang Method is the easiest and most convenient way to
estimate how far away lightning is occurring.
 Count the seconds in between the first lightning seen with the first
clap of thunder heard.
 Divide the number by five. This will obtain how far away in miles
the lightning is occurring.
 By the time the flash-to-bang count approaches 30 secs (6 miles),
all individuals should be inside a safe structure.
 Once activities have been suspended, wait at least 30 mins
following the last sound of thunder or lightning flash prior to
resuming any activity or returning outdoors.
Action Plan for Lightning Safety
BASIC FIRST AID FOR VICTIM






Survey the scene for safety
Activate local EMS
Lightning victims do not “carry a charge” and are safe to touch.
If necessary, move the victim with care to a safer location.
Evaluate airway, breathing, and circulation. Begin CPR if necessary.
Evaluate and treat for hypothermia, shock, fractures, and/or burns.
SEEK LOWER GROUND AND STAY AWAY FROM TREES
Lightning Safe Position:
crouched on the ground, weight on the balls of the feet, feet together, head
lowered, and ears covered. DO NOT LIE FLAT ON THE GROUND
Action Plan for Activating EMS
ACTIVATING EMS
 If an athletic trainer is not present, coach or administrator should
call 911
 If a police officer present, he/she may call for EMS
INFORMATION TO BE GIVEN TO 911 OPERATOR:
 Your name
 Location (including address and specific directions)
 Phone number calling from
 Athlete’s name, age, and condition
 Care that is being given to athlete
 Stay on line until the operator hangs up
Action Plan for Activating EMS
ROLE OF THE FIRST RESPONDER:
 Immediate care of the injured athlete by the coach if the Athletic Trainer is
not present
 Activate EMS
 Call 911 and provide information on front side of card
 Open any locked gates/doors for EMS access (should be done prior to
event)
 Send someone to meet EMS on arrival to direct them to the site
 Coaches will contact appropriate school officials (AD, principals, etc.)
EMERGENCY PERSONNEL:
Certified Athletic Trainers
Coaches
Administrators
EMS