2014 JMSP SymposiumTrauma in the ER

Dr. Jim Kyle, FACSMTeam Physician, Concord University

Sports Medicine Director Beckley ARH HospitalWest Virginia EMS Regional Medical Director

Marshall University School of MedicineAssociate 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 GuidelinesED 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

Cold day in Iowa City

13 cases of Rhabdo first day of conditioning drills after Holiday break

Rhabdomyolysis

TRIAD of:

1. Muscle Weakness

2. Myalgia

3. Dark Urine

Exertional Rhabdo

• 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

• 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 IISeptember 2006Rice5’9” 190lb defensive backStruggling 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: non-

instantaneous 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 FocusRemove athlete if leg, back pain SOBVital Sign with O2 therapyEMS alertIV Fluids, Normal Saline Bolus

ED Management: Exercise Collapse Associated with SCT (ECAST)

• 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

• 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 DoctorBlunt Torso Trauma When to Worry

CHEST TRAUMA

Rib FracturePneumothoraxPulmonary contusion

ABDOMINAL TRAUMA

Spleen InjuryRenal ContusionAppendicitis

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

• 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

• 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 AlertMAJOR KNEE

• Mechanism- Downward

Forward

Inward

The Unstable Knee

• High Index Suspicion

• Popiteal Artery

• Sideline ABI < 1