Irrespective of cause, the initial assessment of any “critical” patient utilizes the same ABC system. The assessment, recognition, and treatment of life-threatening conditions must take place in a structured manner. The only variance between medical and trauma emergencies is the need in trauma to control the cervical spine while dealing with the airway. Unless specifically ruled out, such as in an observed, witnessed collapse without trauma, the cervical spine should always be assumed to be injured. The mechanism of injury provides us with vital information as to the likely extent of injury to the player: Two footballers clashing heads and then falling to the ground clearly raises the possibility of a cervical spine injury as well as a head injury. A player who rises to make a header, clashes with the goalkeeper, and flips over, landing on their back or side, may sustain life-threatening chest, abdominal, or pelvic injuries as well as potential spine and head injuries. Two players who collide while sliding in for a 50:50 tackle may sustain multiple and differing traumatic forces, such as direct impact in addition to rotational twisting forces to the limbs. Injury may occur anywhere from the foot to the head. In these quickly occurring clashes, the actual mechanism may be unclear to the medic watching at pitchside, so a cervical spine injury should again be assumed until a structured assessment has been completed. In many cases, this may be achieved by simply questioning the player, followed by palpation and then gentle movement of the cervical spine. In others (especially where there is a “distracting injury”), full immobilization may be necessary and assessment deferred until the player has been completely removed from the field. Regardless of the injury, each aspect of the framework ( ▶ Fig. 1.1) must be considered, assessed, and, if necessary, treated before moving on to the next. It may seem unnecessary to consider assessing the airway in a player who has twisted his ankle, but it should be an automatic response and the first question asked when dealing with any player on the pitch should be: “Were you hurt in any other way when you fell?” Similarly, it is highly dangerous to focus on the nuances of the neurophysiological assessment of a footballer who has sustained a head injury if you do not give due consideration to the assessment of his potential cervical spine injury. Put simply, as long as you always consider the possibility of more significant problems and are not immediately distracted by the gaping head wound or the ankle pointing the wrong way, then you are unlikely to miss more significant pathology. We shall take each step of the framework and break it down in terms of assessment, potential problems to be looked for, and management. The entire focus of the initial assessment is to keep things simple, not complicated. It could be argued that the only two items of kit required by a team doctor running onto a football pitch are gauze swabs and gloves. Simple maneuvers will allow you to treat the airway, protect the cervical spine, and assess breathing, circulation, and disability. Direct pressure via swabs will stop the vast majority of bleeding. Everything else can be addressed in the dressing room, or in an ambulance if necessary. The player’s well-being must be the number one priority, as difficult as it may be to convey this to the manager who needs to know whether to substitute the player or not. Fig. 1.1 Aspects of the framework for initial assessment, in the order they should be performed. The airway can become compromised due to either primary or secondary trauma. Primary Trauma Trauma to the face, head, or neck can result in bleeding, bruising, or swelling that can make it physically difficult to shift air through the nasopharynx or oropharynx, the laryngopharynx, and into the lungs. Secondary Trauma Injury resulting in a decreased conscious level (usually assessed by either the Alert, Verbal, Pain, Unresponsive [AVPU] or Glasgow Coma Scale [GCS] scoring systems described on page 11) can seriously compromise the airway via an obtundation of the airway reflexes. In this situation, the anatomical structures of the airway may not be directly affected. However, the combination of a direct or primary injury to the airway (e.g., broken teeth or mandible) in association with a decreased GCS score significantly increases the risks of airway compromise and requires immediate action. The airway is best assessed by asking the simple question: “Are you ok?” As basic as this may seem, the information conveyed lets you know immediately that the player has a patent airway with which to shift air in and out to answer you. The rate at which they speak may suggest whether their breathing is affected or not. It indicates that blood pressure (BP) is sufficient to perfuse their brain, and it may also give an indication of the verbal and motor components of their GCS. If the player does not respond, or the answer is inappropriate, vague, or confused, it is essential that both the airway and the cervical spine are assessed and protected. The easiest way to do this is to kneel beside the player and gently support the head in a neutral position in relation to the neck. The head should be held so that it is neither flexed nor extended upon the cervical spine. Assessment of the airway and breathing should be done almost as one. If the player does not respond to the initial “Are you ok?”, an airway-opening maneuver should be used and airway adjuncts administered as necessary. The look, listen, and feel approach is then applied as described in more detail under the Breathing section later in the chapter. Management of the airway can be divided into four sections: Airway-opening maneuvers. Basic airway adjuncts. Advanced airway adjuncts. Surgical airways. The jaw thrust should be used in any patient who has an obstructed airway when an injury to the cervical spine cannot be excluded. In trauma, this is the best method to relieve an airway obstruction because it can be carried out while still maintaining control over the cervical spine. In an obtunded player, the tongue can fall backward causing a soft-tissue obstruction to the oropharynx. Technique By simply placing the index finger of each hand directly under the angle of the mandible and lifting directly upward, the tongue is moved anteriorly away from the posterior pharynx, allowing airflow to be restored ( ▶ Fig. 1.2). Fig. 1.2 Jaw thrust. Note that even with two people, the jaw thrust is the preferred technique to open the airway in a trauma situation. The head tilt and chin lift can only be used in a patient who has an obstructed airway once an injury to the cervical spine has definitely been excluded. This technique is contraindicated in trauma as it requires movement of the head from a neutral position with the possible result of overflexion or extension of the neck and worsening of any spinal injury. Technique One hand is placed on the player’s forehead. The other hand is placed with the thumb resting just below the lower lip and the index and middle fingers underneath the chin in the midline. The head is gently extended (so that the player is looking upward) and the chin is gently pulled forward in an anterior direction. Again, the tongue is moved anteriorly away from the posterior pharynx to allow increased airflow ( ▶ Fig. 1.3). Fig. 1.3 Head tilt and chin lift. These techniques should be sufficient in the majority of cases to open the airway and allow you to assess breathing. If the airway cannot be controlled, i.e., it remains obstructed, airway adjuncts will be required. This firm plastic device is designed to fit into the airway and assist in helping to pull the tongue forward from the posterior pharyngeal wall. The advantages of this kit are that it is cheap, readily available, portable, and can in most cases be used relatively easily. However, if it is wrongly sized, or care is not taken when placing it, it may stimulate the gag reflex and cause the player to vomit. The Guedel comes in a range of sizes and is usually sized by measuring from the angle of the mandible to the front incisors ( ▶ Fig. 1.4a). Fig. 1.4 (a) Guedel airway. (b) Sizing a Guedel airway. It is placed upside down into the mouth and then rotated 180 degrees to lie with the plastic flange at the lips. If it keeps protruding from the lips after you have placed it, then consider resizing ( ▶ Fig. 1.4b). The nasopharyngeal airway (NPA) is another adjunct commonly used to help airflow through the pharynx. It is made of soft plastic and can be used either in isolation or in conjunction with the Guedel airway. In principle, it should not be used when treating head injuries where there is a risk or signs suggestive of a base of skull fracture, as it may be incorrectly placed and find its way through the fracture and into the skull base. This is a recognized complication, though exceptionally rare. If it is the only airway adjunct available to you and you require one to support the airway as all other measures have failed, the NPA can be considered, though caution should be exercised. Head injury is thus a relative contraindication to the use of an NPA. The method of placement is to first size the diameter of the NPA directly against the size of the nasal opening. The correct size should allow the lubricated tip of the NPA to fit snuggly into the nose ( ▶ Fig. 1.5a). The tip should be gently rotated in a twisting motion and aimed directly backward, not upward. If there is resistance to passing the NPA, do not force it: try the other nostril instead. If there is resistance using the other nostril, consider a smaller NPA. Fig. 1.5 (a) Nasopharyngeal airway. (b) Demonstration. The main complication of this airway is iatrogenic trauma resulting in blood passing into the player’s airway from the nose ( ▶ Fig. 1.5b). While advanced airway adjuncts are very useful, it is far more important to do the basics well than to attempt a more advanced technique and fail due to lack of experience. The laryngeal mask airway (LMA) is an advanced airway tool that has found great use in the controlled environment of planned, fasted “routine” surgery. It is also a rescue airway tool used where there is a failure to intubate, as it is relatively quick and simple to use and provides a better degree of airway support than an NPA or Guedel. As with all other airway adjuncts, it comes in a range of sizes. On average, a size 4 or 5 is about right for a man and a size 4 for a woman. An LMA is basically a plastic tube attached to a moldable, conforming inflatable end piece that should sit in the laryngopharynx when inflated. When the LMA pack is opened, the moldable end piece should be placed on a flat surface and any remaining air removed using a syringe so that it becomes flat. It is then placed directly into the mouth and as far into the laryngopharynx as possible. Once inflated, the whole airway will rise up a little if it is placed correctly. The player can then be bagged and an oxygen supply attached. There is better protection from secretions than found with an NPA or Guedel, but if the player vomits, then there is still a significant risk of aspiration, which is why an LMA must not be thought of as a definitive airway. The newer i-gel LMA come with a firm gel end piece that does not require inflation and as such is easier to use (see ▶ Fig. 1.6). Because it is preshaped to conform to airway anatomy, it is much less likely to be sited incorrectly. The only potential downside with the i-gel airways is that in extreme cold conditions the gel can start to freeze, making placement of the airway potentially much more difficult. Fig. 1.6 Laryngeal mask airway. Intubation is considered the “gold standard” in airway management, but it is recommended that unless you practice intubation regularly, there is little benefit to you or the player in attempting to perform this technique. Note: Surgical techniques have only been mentioned to allow a familiarity in principle. The methods for performing these are not included and specific training should be undertaken if you intend to perform such techniques. A needle cricothyroidotomy is performed only when there is a proximal airway obstruction resulting in air being unable to flow into the trachea despite all other adjuncts having been attempted. This is incredibly rare because the simple measures previously described will usually result in a player being able to be ventilated. A needle cricothyroidotomy may, however, be required due to significant facial trauma or anaphylaxis. In order to be successful with a needle cricothyroidotomy, it is important that you have equipment with you that can be used to blow air into the trachea (e.g., an oxygen supply and connective tubing). This allows jet insufflation of oxygen into the lungs. Note that this will allow you to oxygenate, though not actually ventilate the player. A needle cricothyroidotomy should not be performed without this equipment as it will not achieve anything. A needle cricothyroidotomy will give you around 30 minutes or so before the levels of carbon dioxide build up in the body, producing a fatal respiratory acidosis. For this reason, a needle cricothyroidotomy is very much a temporizing procedure to be followed by a formal surgical airway that will allow definitive airway control. This technique should only be carried out if: The player has a definite and complete proximal airway obstruction that is unresponsive to all basic interventions described above. The ambulance is delayed or no ambulance is available. You have access to a large caliber venflon, oxygen tubing, and an oxygen supply. Lastly, it must be re-emphasized that this procedure is only performed as a last-ditch effort to oxygenate a player in a highly unusual and uncommon clinical context. Along with endotracheal intubation of the trachea, a formal surgical airway is the only other method of formally “securing” the airway. As mentioned above, the needle cricothyroidotomy is a temporizing measure used when all other methods have failed and there is no one with the expertise to perform a formal surgical airway. The formal surgical airway involves locating the cricothyroid membrane and cutting through this to allow the passage of a specific small-width tube that can be inflated to provide a seal across the trachea. This type of procedure may be carried out using local anesthetic on an awake patient who is in the process of losing their airway due to burns, trauma, anaphylaxis, etc. Note
1.1 Framework for Initial Assessment
1.2 Airway
1.2.1 Airway Assessment and Management
Airway-Opening Maneuvers
Jaw Thrust
Head Tilt and Chin Lift
Basic Airway Adjuncts
Oropharyngeal Airway (Guedel)
Nasopharyngeal Airway
Advanced Airway Adjuncts
Laryngeal Mask Airway
Endotracheal Intubation
Surgical Airways
Needle Cricothyroidotomy
Formal Surgical Airway
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