Jeffery A. May
Loren A. Crown
Michael C. Gaertner
Although most sports injuries are nonemergent and musculoskeletal in nature, there are certain life- and limb-threatening injuries that the field-side physician (FSP) must be prepared to handle immediately. The most important step in the management of on-field and field-side emergencies is preparation, and depending on the setting of the event and the level of competition, resources may be limited. The FSP must at a minimum have ready access to appropriate health care personnel to assist in an emergency, appropriate medical supplies and emergency equipment, immediate access to a telephone, and the ability to transport an athlete to a medical facility. It would also be advisable to be certified in basic life support (BLS) and have a working knowledge of advanced cardiac life support (ACLS), advanced trauma life support (ATLS), and the common and uncommon injuries specific to the event being covered.
GENERAL APPROACH TO THE FALLEN ATHLETE
When approaching the collapsed athlete, the field-side evaluation should be both rapid and focused. The “primary survey” should follow the “ABCDE” approach taught by ATLS (7) and should occur where the athlete is found. The athlete should initially be left in that position unless the athlete is prone and unconscious or there is a problem performing the “ABCs” (3), in which case the athlete should be logrolled to a supine position.
The logroll should ideally be a four-person technique in which the team leader is at the victim’s head maintaining inline immobilization of the head and neck, while the other three members of the team control the torso, hips, and legs. The athlete should be turned in the direction of the three assistants according to the count of the leader and then onto a spine board placed under the athlete.
If an athlete is wearing an appropriately fitted helmet, neither the helmet nor its chin strap should be removed. Padding or sandbags should be placed around the helmet and the shoulders with the hips and legs immobilized. The face guard can easily be removed by prying or cutting it off for access to the airway. The helmet and shoulder pads should be considered a single unit — the removal of either one necessitates the removal of the other, as leaving only one of them in place forces the neck out of a neutral position (13). If the athlete is not wearing a helmet, a rigid cervical collar should be applied with in-line immobilization of the spine.
After the primary survey is complete and the patient is stabilized, a more detailed secondary survey should be performed either on the field or on the sideline, depending on the status of the athlete and the environmental conditions.
The factors to be considered while evaluating the fallen athlete include whether the injury was witnessed or traumatic. The age, general conditioning, and specific medical conditions of the athlete should be considered, as well as the general characteristics of the sport, such as the amount of contact (i.e., collision, limited contact, and noncontact), the degree of speed involved, and the duration of the event. Finally, the environmental conditions must be considered as both a potential causative and/or exacerbating factor in the injury.
After the initial examination of the patient is completed, the FSP should identify any problem areas and categorize them as being of either an immediate or potential life-threatening/disabling nature and treat accordingly. Frequent reevaluation of the injured athlete is a must.
IMMEDIATE LIFE-THREATENING INJURIES
Upper Airway Obstruction
Although rare in organized sports, respiratory arrest can result from upper airway obstruction (UAO). Signs include respiratory distress with little or no air movement, significant accessory muscle use, and stridorous, wheezing, or snoring breath sounds. If the athlete is unconscious, the airway should be opened with a jaw-thrust maneuver to keep the tongue from occluding the airway, and an oral or nasal airway should be inserted as necessary. In-line repositioning of the head and neck may be necessary to establish airway patency. The oropharynx should be inspected for foreign
bodies, which should be removed if visualized; however, blind finger sweeps are not recommended in either children or adults. Significant facial or mandibular trauma with resultant loss of support of the tongue or with blood, secretions, and loose teeth in the pharynx can produce UAO, particularly in the unconscious athlete who has lost protective airway reflexes. Other causes of UAO, such as airway edema from anaphylaxis, inhalation burn injuries, or an expanding neck or retropharyngeal hematoma from neck trauma should be considered, with early intubation a priority. Surgical airway capability is a is a legitimate concern, and a cricothyrotomy kit might be prudent.
This rare injury occurs after direct trauma to the anterior neck. Signs include stridor, hoarseness, subcutaneous emphysema, and perhaps bony crepitus and a palpable fracture. Although airway obstruction may not be immediate, it can rapidly progress to this stage because of resultant edema, and as with other causes of obstruction, early intubation is a priority; surgical airway capability is again a necessity.
A simple pneumothorax may be spontaneous (i.e., rupture of a bleb) or traumatic, with spontaneous pneumothoraces occurring more often in sports that involve changes in intrathoracic pressure (e.g., scuba diving and weightlifting) and traumatic pneumothoraces occurring secondary to rib fractures. Symptoms may include unilateral chest pain, dyspnea, and cough. Immediate treatment is rarely needed unless the patient is severely dyspneic or the pneumothorax is open or under tension. Those with a stable simple pneumothorax should be given oxygen and transported to a medical facility for further evaluation and management.
This is defined as a pneumothorax accompanied by an open wound to the chest (sucking chest wound). Treatment consists of placing an occlusive dressing over the open wound and taping it down on three sides to create a one-way valve that allows air to exit without reentering until a definitive thoracostomy tube can be placed.
This occurs when a pneumothorax is accompanied by progressive accumulation of air in the pleural space with the resultant increase in intrathoracic pressure causing a shift of mediastinal structures away from the pneumothorax as well as a decrease in venous return and cardiac output. In addition to the previously listed symptoms, these athletes may have tracheal deviation away from the affected side with jugular venous distention and hypotension. This is a true medical emergency that requires immediate treatment by needle decompression of the chest with a large (14-16 gauge) needle or catheter inserted in the anterior chest wall in the second intercostal space at the midclavicular line, followed by placement of a thoracostomy tube.
Although devastating when it occurs in a young athlete, a cardiac sudden death is extremely rare, with incidence varying depending on the age of the athlete and the sporting event (17,23). The most common cause of sudden cardiac death in young athletes is congenital cardiovascular structural abnormalities, with hypertrophic cardiomyopathy leading the list, followed by coronary artery anomalies. The most common cause in middle-aged athletes is atherosclerotic heart disease causing acute ischemic events.
The field-side treatment of any cause of cardiac arrest should follow ACLS guidelines with attention to early cardiopulmonary resuscitation (CPR) and defibrillation as indicated. An equally important task for the FSP is to identify those athletes who have warning signs of cardiac disease and dysrhythmias, such as sudden unexplained syncope or collapse, exertional syncope, early fatigue, or anginal chest pain during or immediately following exertion, as well as a family history of early sudden cardiac demise. Strong consideration should be given to withholding these athletes from further competition until a thorough evaluation is performed (17,23).
Commotio cordis is a rare event caused by relatively low-energy chest trauma and results in a dysrhythmia very often unresponsive to treatment. With a huge proportion of cases being fatal, the most successful intervention has been immediate CPR and application of an automated external defibrillator (AED) to treat ventricular fibrillation, the predominant arrhythmia. Better protection from direct blows to the chest may be the best way to prevent this rare but often lethal injury.
Anaphylactic reactions are acute systemic hypersensitivity reactions that can be idiopathic, exercise-induced, or allergen-induced, and although rare, they can progress very rapidly and prove fatal if unrecognized. Insect stings (especially Hymenoptera) may be a cause of sports-related anaphylaxis; inhalation of such insects is another possible cause in athletes.
The symptoms of anaphylaxis may include urticaria or angioedema, upper airway edema, dyspnea, wheezing, flushing of skin, dizziness, hypotension, syncope, gastrointestinal symptoms, rhinitis, and headache (2). Symptom onset is typically rapid (within 5-30 minutes of exposure), and in its most severe form, anaphylaxis can progress to severe bronchospasm, airway edema, and fatal cardiovascular collapse.
Treatment consists of prompt attention to the ABCs, followed by treatment with 100% oxygen, epinephrine (1:1,000) 0.3-0.5 mL in adults or 0.01 mg/kg in children (not to exceed 0.30 mg) given subcutaneously and repeated every 10-15 minutes as needed, intravenous (IV) fluids if hypotensive, β-agonists by nebulizer if bronchospasm is present,
antihistamines (H1 and H2 blockers), and glucocorticoids if available. The athlete must be rapidly transported to a medical facility because continued observation will be required (15).
Hemorrhage in the athlete may be the result of lacerations, fractures, vascular disruptions, or visceral organ or muscle disruptions. It can manifest as either massive external bleeding or insidious and occult internal bleeding. Control of external bleeding should follow the basic principles of hemostasis, which include steady direct pressure over the bleeding site and over larger arteries proximal to the site of injury, as well as elevation of the affected body part. Blind clamping of bleeding vessels and tourniquet application (with the possible exception of a traumatic amputation) are not recommended.
Scalp lacerations can cause significant hemorrhage and often go unnoticed if the athlete is lying on his back or is strapped to a spine board.
Occult bleeding may produce delayed signs and symptoms, and what may at first appear to be an atraumatic incident may actually have been caused by recent unnoticed or unwitnessed trauma (3).
Potential injuries that may be major sources of occult blood loss include hemorrhage into the thoracic and abdominal cavities, the soft tissues surrounding major long bone fractures, and the retroperitoneal space secondary to a pelvic fracture, and as a result of penetrating torso injury (7).
Signs and symptoms of hypovolemic shock include altered sensorium; pale and cool extremities with a decreased capillary refill; weak, thready, and rapid pulses; hypotension; tachycardia; and tachypnea.
Treatment should follow ATLS protocol, two large-bore peripheral IVs should be started and oxygen administered. Consideration should be given to starting crystalloid fluids, although there is some debate as to whether or not aggressive fluid resuscitation may actually be more detrimental to patients with certain types of injuries, and one should consider the concept of permissive hypotension when managing hypovolemic shock in the alert patient (11).
POTENTIAL LIFE-THREATENING/DISABLING INJURIES: HEAD, NECK, AND SPINE
Head injuries in sports are quite common and often provoke anxiety and uncertainty. The most common head injury in sports is a concussion, and 90% or more of concussions do not involve a loss of consciousness (LOC) (18,19). The FSP should know how to recognize concussions (which is not always easy) and manage the concussion on the sidelines with a low threshold for transfer to an emergency facility if needed. A search for clues to more serious underlying injury should take place, and finally, a determination of if and when the athlete may return to play must occur (10). In most instances in nonprofessional sports, the player will be removed from play.
When approaching the fallen athlete with a suspected head injury, the FSP should rapidly assess the ABCs and determine the level of consciousness as well as note any spontaneous movement and speech. Assessment for potential spine injury should be done, and once on the sidelines, a focused neurologic examination should be performed, including a more thorough sensory, motor, and cranial nerve examination as well as cognitive functioning and memory testing.
Obvious signs of skull fracture or intracerebral bleeding, such as pupillary asymmetry, postauricular or periorbital ecchymosis, clear otorrhea, rhinorrhea, or hemotympanum, and any depression in the skull should be searched for (epidural hematoma is discussed in more detail later). It must be emphasized that even if the initial examination is completely normal, frequent reassessment is mandatory because victims of head injury may rapidly deteriorate, and many of the previously listed findings may be delayed.
A concussion is generally agreed upon to be a traumainduced alteration in mental status that may or may not involve loss of consciousness. Historically, the most commonly used systems assess severity based on the presence or absence of LOC and/or amnesia, as well as the duration of postconcussive symptoms; however, current guidelines refine decisions to a “yes” or “no” decision regarding concussion.
Despite the multiple differences among the recognized guidelines, most authorities would agree with the following statements:
No athlete should return to play while any symptoms are still present either at rest or with exertion.
No athlete should return to play on the same day.
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