General Management

Analgesia


There is a degree of crossover between analgesia and anesthesia.


Analgesia can be defined as “loss of the sensation of pain without loss of consciousness.”


Anesthesia can be defined as “loss of the sensation of pain either locally or generally with or without the loss of consciousness.”


The distinction can therefore appear slightly blurred and consideration should be given to whether the condition of any player in pain will benefit from either or possibly from both treatments.


It is vital to ensure that simple measures are not overlooked. Oral administration of simple analgesics such as paracetamol is often disregarded because it is perceived to be an inferior pain killer, primarily because it is readily and cheaply available over the counter, without a prescription. However, the pain relief that can result from administering paracetamol should not be underestimated. It may need to be given in conjunction with another oral or intravenous (IV) analgesic, but even by itself it provides good pain relief and should not be overlooked ( ▶ Table 5.1).




















Table 5.1 Paracetamol

Use


Mild to moderate pain


Dose


1 g for adults or 15–20 mg/kg as a loading dose in children


Pros


Readily available and cheap; easy to administer


Cons


Significant liver and renal damage in overdose


Analgesia can be given orally, rectally, intramuscularly (IM), or IV.


We will focus on the oral and IV routes as there is very little indication to administer analgesia by the IM route and most people with a Glasgow Coma Scale (GCS) of 15 will not tolerate medications per rectum (PR) when there are other options open to them.


Co-codamol 8/500 is not recommended as it provides no better analgesia than paracetamol alone but has a more significant side effect profile. ( ▶ Table 5.2).




















Table 5.2 Co-codamol (30/500)

Use


Moderate pain


Dose


1 g for adults; not recommended in children


Pros


Very few over paracetamol alone; 30/500 (30-mg codeine phosphate and 500-mg paracetamol) will provide better analgesia than paracetamol alone


Cons


Significant side-effect profile—nausea, vomiting, dizziness constipation, and respiratory distress; possibility of dependence if overused.


Nonsteroidal Anti—Inflammatory Drugs


This family of medications provides analgesic, antipyretic, and, at higher doses, anti-inflammatory properties (see, e.g., ibuprofen; ▶ Table 5.3).




















Table 5.3 Ibuprofen

Use


Mild to moderate pain


Dose


400–600 mg up to max of 2.4 g/d (short-term use)


Pros


Comparatively safe side-effect profile; cheap and readily available


Cons


Side-effect profile increases with increasing dose as does anti-inflammatory action


The side-effect profile is not insignificant and a careful history should be taken to ensure there are no contraindications such as peptic ulcer disease, renal disease, or asthma. Previous sensitivity is an absolute contraindication.


Nonsteroidal anti—inflammatory Drugs (NSAIDs) work by blocking the cyclooxygenase enzymes Cox-1 and Cox-2. These enzymes produce prostaglandins that promote pain, inflammation, and pyrexia. Cox-1 also produces prostaglandins that protect the gastric mucosa and support platelet function. When blocked, all these effects are inhibited, resulting in a decrease in inflammation, pain, and temperature. Unfortunately, they also cause an increase in gastric irritation and ulceration as well as prolonged clotting.


There is ongoing controversy about the longer-term effects that inhibiting the inflammatory process may have on the rate of healing of tissues such as muscle, ligament, and tendon. It is up to each clinician to make a personal decision based on their own experience and the available evidence, and to decide whether to prescribe these medications for athletes with acute injury.


NSAIDs can also be administered PR, IM, topically, or even IV if diluted in a significant volume of at least 500 mL for IV infusion.


The topical route is well marketed and appears to provide some analgesia although this does not appear comparable to the oral (PO) route. The side-effect profile is the same for both routes.


IM administration can be problematic and cause sterile abscesses, so it is best avoided if at all possible.


Opiates


The opiate family should be used to provide analgesia to players suffering from severe pain. The significant side-effect profile of all methods of administration of opiates should mean its use is reserved only for such patients.


Opiates can be given orally, topically, IM, or IV. In terms of management of a sporting injury, opiate administration should really be limited to the IV route, as by definition the injury will be such that control of pain is paramount and time critical. The IM route is not appropriate due to the time taken and the variability of absorption.


It is vital that a player is never left unattended once they have had an IV dose of morphine and their observations should be assessed regularly.


Respiratory and neurological depression can occur as well as hypotension and these features should be looked for and treated if they arise. More common side effects include nausea and vomiting, and an antiemetic may be required in association.


Caution should be exercised in any player with an injury requiring morphine and an associated head injury, as their conscious level may be affected and their pupils become very small (pinpoint) as a result of the drug. If administering morphine, you must have access to equipment to allow you to treat the potential complications, as well as naloxone to treat respiratory arrest.


Entonox


Nitrous oxide in a 50:50 concentration may be used to allow analgesia and sedation for procedures such as the reduction of a fracture or dislocation.


Caution should be exercised in anyone with a chest or head injury as the nitrous will preferentially diffuse into air containing spaces, resulting in worsening of a pneumothorax or pneumocranium.


It is self-administered and although the player should be monitored, including their oxygen saturations, relatively few complications are encountered.


5.1.2 Anesthesia


Local anesthesia is beneficial in allowing assessment and treatment of wounds. Simple nerve blocks may also provide effective pain relief for injuries such as fractures of the femur or even of the digits. Again, having an understanding of the properties of such medications will enable you to choose the correct drug and the most appropriate method of administering it in any given situation.


Lignocaine (Lidocaine)


This is the most commonly used local anesthetic agent. It has a short time of onset and duration of action, so if used as a nerve block, you may need to consider the addition of a longer-lasting agent such as bupivacaine. If large volumes are required, then the addition of adrenaline can double the quantity used.


Dose is 2 to 3 mL/kg of 1% solution. Therefore, in a 70-kg adult, the maximum dose would be about 200 mg, which equals 20 mL of 1%. The addition of adrenaline allows a maximum of 7 mL/kg to be administered. It is less painful if injected slowly and with a small caliber needle. Warming the solution also helps decrease the pain of injection. Lignocaine does not work well when injected into or around infected wounds.


All local anesthetics are potentially cardiotoxic and neurotoxic, and you should look out for signs of toxicity such as light-headedness, dizziness, abnormal taste, tinnitus, slurred speech, or twitching progressing to seizures. The player may not know to tell you this unless you specifically ask them.


Cardiovascular signs will vary depending on whether or not the solution has had adrenaline added. If it has, the player may develop tachycardia and hypertension. If no adrenaline is used then bradycardia with associated hypotension is more likely. Cardiovascular effects are a consequence of the anesthetic directly acting on the myocardium.


Treatment of local anesthetic toxicity is symptom dependent. Treat according to the ABCs. If the player is fitting, then use either diazepam or lorazepam to control.


Bupivacaine


This has not only a longer time of onset, but also a longer duration of action (approximately 5 hours or so), making it good for blocks. It is more cardiotoxic than lignocaine.


The dose is the same with or without adrenaline (2 mg/kg). In a 70-kg man, administer approximately 150 mg, which is 30 mL of 0.5%.


Topical Anesthetics


These are of limited value in the pitchside setting, with the exception of amethocaine in the context of corneal abrasions. This treatment will provide almost instant pain relief, allowing assessment of the eye. It is a one-off dose as it will delay epithelial healing if used repeatedly. Effects will wear off after about 30 minutes.


5.1.3 Nerve Blocks


Femoral Nerve Block


This technique is worth noting as it will allow analgesia for anyone with a femoral fracture. It will not provide analgesia for lower-leg fractures. The block can facilitate movement of the player and application of a splint.


Dose Dose is 10 to 15 mL of lignocaine 1% or 5 mL of lignocaine 1% + 5 mL of bupivacaine 0.5%.


Anatomy The femoral nerve (L2–L4) is the largest branch of the lumbar plexus. It descends to the midpoint of the inguinal ligament, at which point it passes deep into the ligament and enters the femoral triangle lateral to the femoral artery, which is the most important clinical landmark. It supplies the anterior thigh muscles and the hip and knee joints, as well as providing sensation to the anteromedial thigh.


Technique Clean the skin around the groin, then palpate the femoral artery just below the inguinal ligament. Using a green needle, inject about 1 cm lateral to the femoral artery pulse. Aspirate to ensure you do not enter the artery. If the player complains of paresthesia, withdraw the needle slightly and then inject. (It is important not to inject directly into the nerve.) If there is no paresthesia, then penetrate the skin to a depth of approximately 2 to 3 cm and start to inject at this point.


From this depth (1 cm lateral to the artery and 2- to 3-cm deep), inject the local anesthetic and then aim the needle slightly laterally and inject more. Ensure you continue to inject local anesthetic more superficially as you withdraw the needle.


Remember the mnemonic NAVY: from lateral to medial, Nerve, Artery, Vein, Y-fronts.


Digital Nerve Block


This is equally applicable to fingers and toes. It will provide analgesia for phalangeal fractures and dislocations and allow manipulation if necessary. It is also useful in nail and nail-bed injuries.


Dose Dose is 1 to 2 mL of 1% lignocaine.


Anatomy The fingers have dorsal and palmar digital nerves, while the toes have the dorsal and plantar digital nerves. The nerves can be blocked either between the metacarpals or at the proximal phalanx.


Technique Using a 23- or 25-gauge needle, identify the bony proximal phalanx. Use a dorsal approach to inject, aiming to penetrate the skin just lateral to the bone and coming slightly medially under the bone. Aspirate to ensure no intravascular injection. Inject 0.5 to 1 mL of 1% lignocaine. Repeat on the medial side of the finger. Inject a further 0.5 mL across the dorsal aspect of the finger to ensure the dorsal nerves have been caught.


5.2 Wound Management


Wounds occur commonly in sport and their immediate management can be difficult due to the time constraints placed on the clinician to get the player back onto the field of play as soon as possible.


The initial management of all wounds should be to ensure optimum healing. This involves an adequate assessment of the depth and length of the wound, the underlying structures, and tissues affected, and the presence of debris.


Remember: If you do not look for it, you will not find it.


Good basic management involves thorough wound cleaning, usually including wound irrigation. This is far more important than the administration of antibiotics, which should rarely if ever be used as prophylaxis for infection.


5.2.1 History


How was the wound sustained? In a scalp laceration, attention should initially be paid to the cervical spine. Once the initial assessments have been made, the wound can be properly assessed.


A laceration over the knuckle with or without an underlying fracture is a common site for a fight-bite injury. It is highly prone to infection, so an honest history is vital from the player.


Tetanus status is not of great importance in the initial assessment of a player you are trying to return to the field of play but a vital medicolegal question you must document in your notes. Be aware of the immunization status of all your players.


5.2.2 Examination




  • What type of wound is it? Most wounds will be lacerations, i.e., ragged edges caused by shearing and splitting of the tissues from blunt trauma (compare with an incised wound caused by a sharp object such as a knife). A breach of the skin overlying a fracture suggests a compound fracture.



  • What is the location of the wound? A wound sustained over the forehead or supraorbital ridge may cause significant issues for a footballer as they are required to head the ball. An identically sized wound in the same person but over the occiput may be managed differently as it is less likely to receive further trauma during the match.



  • What are the dimensions (length and depth) of the wound? Depth is very important as some full-thickness wounds (i.e., fully through the skin) may need to be closed in layers to ensure healing and minimize collections.



  • Are there any associated musculotendinous or neurovascular complications?



  • Is there any foreign body contamination? This is an exceptionally easy thing to overlook, especially in wounds that are rushed when assessed. Contaminants may come in the form of impregnated clothing such as a sock in the wound, or soil, grass, bone, or tooth.


5.2.3 Immediate Management


The best possible treatment for all but the smallest and most superficial of wounds is removal of the player from the field, ideally to an appropriately stocked treatment room. Ensure that you bring another member of staff with you if at all possible. They can then update the manager on whether you can sort the wound quickly enough to return the player or let the manager know that the player is unable to return to play.


The wound must be cleaned and explored thoroughly. The wound edges should be gently opened to allow a depth assessment to be made. This may need to be done under local anesthetic, so ensure you have documented normal sensation distal to the wound before you instil the agent.


Use saline-soaked gauze swabs to clean the wound thoroughly under direct vision. Remove and document any contaminants within the wound. A surgical scrubbing brush can be used to loosen any adherent contaminant. Irrigate the wound with sterile solution. This is the best way to ensure the wound has been properly cleaned out. A 20-mL syringe attached to a white needle can be used. After attaching the needle to the syringe, use the protective cover to gently bend the needle back and forth until it breaks at the plastic base. This will now allow a relatively high-pressure jet of sterile solution to be irrigated into the wound. In case of splashing, the operator should wear eye protection if at all possible. Refill the syringe and repeat until the wound is clean.


Bleeding points should be directly compressed for at least a minute and then reassessed. In highly vascular areas such as the scalp, lignocaine and adrenaline may be of use. If a player is bleeding from a scalp wound that cannot be controlled with the methods above, the wound can be oversewn using a large suture such as silk1–0, taking big “bites” to pull the wound together.


Tourniquets are best avoided but can be used for a short time for the assessment of finger injuries. Cut off the small finger of a rubber glove and roll this down the finger as close to the knuckle as possible. Needle holders can then be used to clasp the rubber. Rotating the needle holder will twist the rubber tighter around the finger. Use this technique for a maximum of 15 minutes before releasing and cutting the rubber away.


5.2.4 Wound Closure


Most wounds in a sporting setting are likely to be suitable for primary closure. If a wound is presented to you after more than 12 hours, do not close it; instead leave it open (after thorough cleaning) and arrange for a specialist review (no more than 48 hours later) to allow a decision on whether the wound should undergo delayed primary closure or be granulated (secondary closure). Wounds to the face and scalp may be closed up to 24 hours after they are sustained due to the excellent blood supply, but there is a significant risk of subsequent infection and wound dehiscence.


A number of options are available to close a wound ( ▶ Table 5.4, ▶ Table 5.5, ▶ Table 5.6, ▶ Table 5.7). If you have not learned to suture, then do not attempt it. It is not the remit of this manual or the course to teach this skill. Instead, clean the wound, apply a dressing as best you can, and transfer the patient to the nearest emergency department.



















Table 5.4 Steri-Strips

Pros


Cheap, quick, easily to remove and reapply


Cons


Wound must be dry or the Steri-Strip will just slide off


Uses


Superficial wounds not fully through the skin


Tip


Use in conjunction with skin glue: Steri-Strips to hold wound in place and glue in between, or glue to help stick Steri-Strips onto the skin



















Table 5.5 Tissue adhesive

Pros


Cheap, quick


Cons


You only have one chance to apply, then the tissue is stuck


Uses


Superficial wounds (with or without Steri-Strips)


Tip


Do not use in any wound around the eye



















Table 5.6 Sutures

Pros


Cheap, readily available, good for closing deeper wounds


Cons


Operator dependent (more so than Steri-Strips), take longer to apply, usually needs local anesthetic, may leave poorer long-term cosmetic result compared with glue or Steri-Strips


Uses


Full-thickness wounds


Tip


Start in either the middle of the wound or at the apex



















Table 5.7 Staples

Pros


Quick, can be used without local anesthetic depending on the player


Cons


Operator dependent


Uses


Scalp wounds; do not consider in a frontal injury if returning the athlete to contact sport


Tip


Ensure you have staple remover with you in case you misplace one


Applying Vaseline, gauze swabs, and swathes of bandages to try to tamponade a wound implies that time has not been spent fully assessing the wound. It could be argued, however, that as long as there are no other clinical concerns the same wound can be formally treated at halftime or full time. While this may be appropriate if there is only a short time left to play, it is also a potentially hazardous manner to treat an individual and should not be undertaken routinely.


It could also be argued that to remove a player with a bleeding head with a view to suturing their wound and returning them to the field of play in under 5 minutes is an exceptionally tall order given that an assessment of concussion will have to be made in that time frame as well.


If the player cannot be safely returned to play within 5 minutes, they should probably not be returned at all.


5.2.5 Specific Wounds


Scalp


Scalp wounds can be closed with staples or sutures. Sutures are usually silk 1–0 to 3–0 depending on the site. Blood supply to the scalp is good, so healing time is fast, but bleeding from the wound can be a problem. The same applies to the face; however, ethilon is preferable to silk and staples are not appropriate. The higher the suture value, i.e., the thinner the material, the better the end cosmetic result.


When closing a scalp wound, attention must be paid to ensure that the galea has not been involved. The galea is a thick, tough fibrous sheet of tissue that connects the occipitofrontalis muscles. If torn or lacerated, this should be sutured to minimize the potential for infection and also to prevent cosmetic defects caused by asymmetric forehead movement as a result of disruption of the galea anchoring frontalis. This can be done by using a 3–0 suture and taking deep bites through the skin, subcutaneous tissue, and galea all in the one suture.


Hair should be cut or ointment used to pull it out of the way of the wound. It should, however, not be shaved as this increases the risk of wound infection.


Lip


Lip wounds should be assumed to be the result of the player’s tooth being forced through the lip tissue from posterior to anterior. Check the teeth to ensure they are intact and that the patient has not aspirated a tooth or got one stuck in their lip.


The vermillion border must be approximated to with a gap less than 1 mm; otherwise, the resulting defect will be clearly apparent and leave an unsatisfactory cosmetic defect.


Tongue


Very rarely should this be sutured, i.e., only if there is ongoing and uncontrollable hemorrhage. If the wound is anterior, refer to a specialist for closure because of the risk of bifid tongue.


Hand


Consider a human bite in anyone with a wound over the knuckles. This will need to be explored under local anesthetic as a minimum and you should assume there is foreign body contamination (i.e., tooth) and tendinous disruption until proven after wound exploration.


Note: Assess the wound and deeper tissues with the finger in extension through to full flexion at the metacarpophalangeal joint for tendon damage.


Amoxicillin and Metronidazole should be prescribed for anyone with a human bite wound. Make a referral for assessment of hepatitis status.


Pretibial Wounds


In football, these are usually caused by an opponent’s stud from their boot. The tissue in this area is usually thin and is rarely amenable to suturing. Thorough wound cleaning is absolutely vital and thereafter the best plan is usually to either close the wound with Steri-Strips or leave it to heal by secondary intention.


Infected Wounds


Infected wounds can occur despite the best surgical intervention and the highest standards of patient care. However, if you do not spend time assessing and cleaning a wound properly, it will become infected.


Rules of thumb:




  • There is no place for routine antibiotics in the prophylactic treatment of noninfected wounds.



  • You cannot spend too long cleaning or irrigating a wound.



  • If you think a wound is infected, it will be. Remove sutures, Steri-Strips, or staples and accept that the wound is likely to need to heal by secondary intention. Start from scratch and thoroughly clean the wound. Unless the wound involves the face, you are likely to be surprised at how acceptable the end result actually is—however, the length of time it takes to heal can be a source of major frustration for both clinician and player.


5.2.6 Wound Dressings


The best procedure in wound treatment is to use the dressings with which you are most familiar. If you are unsure, do not guess—refer the player to hospital. Otherwise, a simple wound could be converted to a problematic wound purely because of the dressings chosen.


In simplistic terms, silicone nonadherent (silicone N/A) is one of the most useful dressing as it can be used on the vast majority of wounds, from burns through to lacerations and even infected wounds.


5.2.7 Tetanus


Most patients who have received full vaccination (i.e., five doses of tetanus toxoid) will be immune to tetanus.


Rules of thumb:




  • If there is doubt about the player’s vaccination status, refer them to hospital for tetanus toxoid with or without tetanus immunoglobulin (which will be given depending on whether the wound is tetanus prone or not).



  • Also, refer the player to hospital if there is no history of tetanus immunization at all.


5.3 Kit


You must assume that the kit that you take with you will be the only kit you will be able to access. Do not assume that you will have access to other medications or kit if you are traveling away from your local venue.


There is no point taking kit that you do not feel trained or comfortable to use.


It is advisable to have a list of medications and kit and make sure that this is up to date at all times.


Think of items in terms of the following:



You must make sure you have access to your kit at all times. Leaving the stretcher or hard collar on the bus while the team is playing will not help your players should any of them need to be moved. The same applies to your defibrillator ( ▶ Fig. 5.1).



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Fig. 5.1  The doctor must always carry a pitch-side emergency bag with all the necessary equipment.

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May 14, 2018 | Posted by in SPORT MEDICINE | Comments Off on General Management
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