Sideline Preparedness: Sideline Preparedness: On Field ManagementOn Field Management

of Athletic Emergencies of Athletic Emergencies

Jim Ellis, MD, FACEPJim Ellis, MD, FACEP

September 19, 2011September 19, 2011

Steadman Hawkins Clinic of Steadman Hawkins Clinic of the Carolinas Sports Medicine the Carolinas Sports Medicine

Fellowship ProgramFellowship Program

Why we do what we do Why we do what we do

On October 24, 1971 Chuck Hughes On October 24, 1971 Chuck Hughes of the Detroit Lions went across the of the Detroit Lions went across the middle on a pass play and collapsed. middle on a pass play and collapsed. Legendary LB Dick Butkus frantically Legendary LB Dick Butkus frantically waved to the sideline for help. waved to the sideline for help. Despite the efforts of the training Despite the efforts of the training staff, he died of a “heart attack” and staff, he died of a “heart attack” and remains the only on field death in the remains the only on field death in the history of the NFL.history of the NFL.

ObjectivesObjectivesKnow the risks of the sport you cover Know the risks of the sport you cover

Know your specific role/responsibilityKnow your specific role/responsibility

Know your players’ illnessesKnow your players’ illnesses

Know what equipment to haveKnow what equipment to have

Know the Emergency Action PlanKnow the Emergency Action Plan

ATLS, ACLS, “ASLS”ATLS, ACLS, “ASLS”Advanced Sports Life SupportAdvanced Sports Life Support

AirwayAirwayBreathingBreathingCardiacCardiacCirculationCirculationCervical SpineCervical SpineConcussionConcussionConditions/EnvironmentConditions/EnvironmentCrisis Management/DisasterCrisis Management/DisasterDiabetesDiabetes

Airway ProblemsAirway Problems

Direct TraumaDirect Trauma– Anterior neck trauma Anterior neck trauma

Indirect TraumaIndirect Trauma– Severe concussion can lead to Severe concussion can lead to

unprotected airwayunprotected airway– High cervical spine injuryHigh cervical spine injury

Airway EvaluationAirway Evaluation

Is the player talking?Is the player talking?

Is he tachypneic or agonal?Is he tachypneic or agonal?

What is the pulse ox?What is the pulse ox?

EMS bring pulse ox!EMS bring pulse ox!

Airway - MaintainableAirway - Maintainable

Supplemental oxygenSupplemental oxygen

Chin lift or jaw thrust (for c-spine)Chin lift or jaw thrust (for c-spine)

Nasal or oral airwayNasal or oral airway

Bag-valve-mask/pocket mask/barrier Bag-valve-mask/pocket mask/barrier

Airway EvaluationAirway EvaluationUnmaintainableUnmaintainable– Airway is inadequate with basic Airway is inadequate with basic

supportsupport– Procedural intervention is requiredProcedural intervention is required– Must remove facemask to have Must remove facemask to have

unencumbered access to the unencumbered access to the airway on anyone immobilizedairway on anyone immobilized

– Need Need Advanced Life SupportAdvanced Life Support EMS EMS unit at high risk eventsunit at high risk events

Endotracheal IntubationEndotracheal Intubation

The right personThe right person

The right equipmentThe right equipment

The right drugsThe right drugs

The right plan for the difficult airwayThe right plan for the difficult airway

AnatomyAnatomy

Airway AdjunctsAirway Adjuncts

Intubating StyletIntubating Stylet

Lighted StyletLighted Stylet

LMA *great tool for the airway noviceLMA *great tool for the airway novice

Intubating LMAIntubating LMA

Levitan Fiberoptic ScopeLevitan Fiberoptic Scope

Surgical AirwaySurgical Airway

Unsuccessful endotracheal intubationUnsuccessful endotracheal intubation

Mandibular fractureMandibular fracture

Anterior neck traumaAnterior neck trauma

Laryngeal fractureLaryngeal fracture

StridorStridor

Surgical AirwaySurgical Airway

Know the anatomyKnow the anatomy

Know the equipmentKnow the equipment

Know the procedureKnow the procedure

2002 Super Bowl2002 Super Bowl

Kurt Warner played with a laryngeal Kurt Warner played with a laryngeal fracture – sideline cricothyrotomy kitfracture – sideline cricothyrotomy kit

2004 Al Lucas2004 Al Lucas

Arena League player went down Arena League player went down headfirst on a kick-offheadfirst on a kick-off

Evaluated by MD and ATC on FOPEvaluated by MD and ATC on FOP

While being loaded into the While being loaded into the ambulance, stopped breathing (within ambulance, stopped breathing (within 10 minutes of injury)10 minutes of injury)

Died from airway compromise due to Died from airway compromise due to C1/C2 fracture and concussion despite C1/C2 fracture and concussion despite using an LMA for airwayusing an LMA for airway

1997 Reggie Brown1997 Reggie Brown

Lions linebacker injured vs JetsLions linebacker injured vs Jets

C1/C2 fracture with CHIC1/C2 fracture with CHI

Airway compromise from aboveAirway compromise from above

On field mouth to mouth and BVMOn field mouth to mouth and BVM

Response saved his life and had Response saved his life and had remarkable post op recoveryremarkable post op recovery

Breathing ProblemsBreathing Problems

Massive HemothoraxMassive Hemothorax– Load and Go!Load and Go!

Tension PneumothoraxTension Pneumothorax– Use pulse oximetry for helpUse pulse oximetry for help– Large bore IV catheter(14 gauge)Large bore IV catheter(14 gauge)– 22ndnd intercostal space, midclavicular intercostal space, midclavicular

lineline– LEAVE IT IN!LEAVE IT IN!

2001 Drew Bledsoe2001 Drew Bledsoe

Patriots QB was driven into the Patriots QB was driven into the ground on the sidelineground on the sideline

Was short of breath after the gameWas short of breath after the game

Taken to Mass General Hospital and Taken to Mass General Hospital and had a chest tube inserted to reinflate had a chest tube inserted to reinflate his lung and an autotransfusionhis lung and an autotransfusion

Tom Brady became the starterTom Brady became the starter

2008 Lauren Chang2008 Lauren Chang

Cheerleader accidently kicked in the Cheerleader accidently kicked in the chestchest

Had collapsed lungs - bilateralHad collapsed lungs - bilateral

Died from tension pneumothoraxDied from tension pneumothorax

Breathing ProblemsBreathing ProblemsAsthmaAsthma– Know your playersKnow your players– Nebulizer vs inhaler (use a spacer)Nebulizer vs inhaler (use a spacer)– Keep an extra MDI (inhaler)Keep an extra MDI (inhaler)– Make sure EMS gives the right Epi dose Make sure EMS gives the right Epi dose

SQ/IM (1:1000) vs IV (1:10,000)SQ/IM (1:1000) vs IV (1:10,000)– Can use Epi-Pen if needed (same dose Can use Epi-Pen if needed (same dose

as allergic reaction 0.3cc)as allergic reaction 0.3cc)– Peak Flow Meter (know their baseline)Peak Flow Meter (know their baseline)

2001 Rashidi Wheeler2001 Rashidi Wheeler

Northwestern football playerNorthwestern football player

Died secondary to asthmaDied secondary to asthma

Known asthmatic in difficult workoutKnown asthmatic in difficult workout

?Complicated by ephedra use?Complicated by ephedra use

Cardiac ProblemsCardiac Problems

Cardiac EtiologyCardiac Etiology– Sudden cardiac deathSudden cardiac death– Arrhythmia of unknown etiologyArrhythmia of unknown etiology– Hypertrophic cardiomyopathyHypertrophic cardiomyopathy– Commotio cordis/cardiac Commotio cordis/cardiac

concussion (hockey, lacrosse and concussion (hockey, lacrosse and baseball)baseball)

– Coronary artery disease in coaches Coronary artery disease in coaches and referees*and referees*

HCM

Many athletic deaths from HCMSometimes is resistant to defibHypothermia as treatment protocolSmall study but great resultsNeuro protective propertiesKeep cooled IVF’s just in case

Cardiac InterventionsCardiac Interventions

CPR if AED is not right thereCPR if AED is not right there

AED – know where it is at all times AED – know where it is at all times and have nearby at eventsand have nearby at events

Practice run getting the AEDPractice run getting the AED

Trauma scissorsTrauma scissors

Manual defibrillator (EMS)Manual defibrillator (EMS)

Time to shock is critical!Time to shock is critical!

Cardiac InterventionsCardiac Interventions

Every minute that passes, there is a Every minute that passes, there is a 10% decrease in chance of survival.10% decrease in chance of survival.– 90% chance of survival at 1 minute90% chance of survival at 1 minute– 50% chance at 5 minutes50% chance at 5 minutes– 10% chance of survival if the initial 10% chance of survival if the initial

shock is delivered 9 minutes after shock is delivered 9 minutes after the cardiac arrest occurredthe cardiac arrest occurred

– Don’t wait for EMS Don’t wait for EMS

2005 Jiri Fisher2005 Jiri Fisher

Collapsed on the iceCollapsed on the ice

Saved with CPR and AEDSaved with CPR and AED

Key was a rapid response to a true Key was a rapid response to a true life threatening emergencylife threatening emergency

Etiology was underlying arrhythmiaEtiology was underlying arrhythmia

19961996 PolishPolish ChefChef dede MissionMission

Opening Ceremony 1996 Olympic Opening Ceremony 1996 Olympic GamesGames

Cardiac arrest on the field of play Cardiac arrest on the field of play

10,000 athletes / worldwide TV 10,000 athletes / worldwide TV audienceaudience

Defibrillated on the FOP and intubatedDefibrillated on the FOP and intubated

Transported with return of vital signsTransported with return of vital signs

Subsequent death in the hospitalSubsequent death in the hospital

2011 Al Schmidt at UGA2011 Al Schmidt at UGA

Mississippi State track officialMississippi State track official

Known CADKnown CAD

At SEC Track meet on UGA campusAt SEC Track meet on UGA campus

Witnessed cardiac arrestWitnessed cardiac arrest

Well practiced EAPWell practiced EAP

AED on site in 2 minutesAED on site in 2 minutes

Survived to discharge neuro intactSurvived to discharge neuro intact

2011 Dan Cochran at Syracuse

Commotio Cordis at a lacrosse tryoutImmediate CPRAED on site and delivered shockReturn of vitals by EMS arrivalPatient was discharged neuro intactExperienced ATC with an EAP

Other serious cardiac eventsOther serious cardiac events1988 – Pete Maravich(NBA) 1988 – Pete Maravich(NBA) congenital coronary arterycongenital coronary artery1990 – Hank Gathers(NCAA) HCM1990 – Hank Gathers(NCAA) HCM1993 – Reggie Lewis(NBA) HCM 1993 – Reggie Lewis(NBA) HCM 1998 – Chris Pronger(NHL) commotio1998 – Chris Pronger(NHL) commotio2003 – Marc Vivien-Foe(soccer) SCD2003 – Marc Vivien-Foe(soccer) SCD2004 – Sergei Zholtok(NHL) HCM2004 – Sergei Zholtok(NHL) HCM

Other serious cardiac eventsOther serious cardiac events2005 – Jaxon Logan(NCAA) commotio2005 – Jaxon Logan(NCAA) commotio2005 – Thomas Herrion(NFL) 2005 – Thomas Herrion(NFL) HCM/CADHCM/CAD2007 – Damien Nash(NFL) 2007 – Damien Nash(NFL) arrhythmia of unknown etiologyarrhythmia of unknown etiology2007 – Antonio Puerta(soccer) SCD2007 – Antonio Puerta(soccer) SCD2011 – Wes Leonard(BB) SCD/?HCM2011 – Wes Leonard(BB) SCD/?HCM2011 – Armen Gilliam(BB) CAD? 2011 – Armen Gilliam(BB) CAD?

Circulation ProblemsCirculation ProblemsAbdominal Trauma/HemorrhageAbdominal Trauma/Hemorrhage– Splenic or liver injurySplenic or liver injury– Don’t confuse with dehydrationDon’t confuse with dehydration– High index of suspicionHigh index of suspicion– Life/limb threatening hemorrhageLife/limb threatening hemorrhage– Two large bore IV’sTwo large bore IV’s– Load and go (nearest Load and go (nearest appropriateappropriate

facility)facility)

2006 Chris Simms2006 Chris Simms

September game vs PanthersSeptember game vs Panthers

Multiple hard hitsMultiple hard hits

No specific complaint of LUQ painNo specific complaint of LUQ pain

Treated for dehydrationTreated for dehydration

Ruptured spleenRuptured spleen

Surgery at St. Joe’s Hospital (< 1 Surgery at St. Joe’s Hospital (< 1 mile)mile)

1989 Clint Malarchuk1989 Clint Malarchuk

NHL goalie with skate to the neckNHL goalie with skate to the neck

Life threatening hemorrhageLife threatening hemorrhage

Direct pressure and rapid transportDirect pressure and rapid transport

Went directly to OR for vascular Went directly to OR for vascular surgery and survivedsurgery and survived

Circulation ProblemsCirculation ProblemsSickle Cell TraitSickle Cell Trait

- easy to diagnosis with a simple - easy to diagnosis with a simple screening blood test screening blood test - 10 known deaths since 2000- 10 known deaths since 2000- 8-10% of black population- 8-10% of black population- NATA policy statement- NATA policy statement- NCAA ?mandatory testing- NCAA ?mandatory testing

Circulation ProblemsCirculation Problems

Sickle Cell TraitSickle Cell Trait

- Identify high risk activities- Identify high risk activities

- common in off- or pre-season- common in off- or pre-season

- monitor first few workouts- monitor first few workouts

- ease into preseason conditioning- ease into preseason conditioning

- SCT muscle pain and weakness - SCT muscle pain and weakness

- dehydration cramps/”locking up”- dehydration cramps/”locking up”

2008 Ereck Plancher2008 Ereck Plancher

Collegiate athlete with known sickle Collegiate athlete with known sickle cell traitcell trait

Off-season programOff-season program

Strenuous workoutStrenuous workout

Exhibited difficultyExhibited difficulty

Died on the fieldDied on the field

Sickle Cell Trait - deathsSickle Cell Trait - deaths

Preston Birdsong –TTU 2000Preston Birdsong –TTU 2000

DeVaughn Darling – FSU 2001DeVaughn Darling – FSU 2001

Aaron Richardson – BGU 2004Aaron Richardson – BGU 2004

Aaron O’Neal – Missouri 2005Aaron O’Neal – Missouri 2005

Dale Lloyd – Rice 2006Dale Lloyd – Rice 2006

Chad Wiley – NC A&T 2008Chad Wiley – NC A&T 2008

Ja'Quayvin Smalls – 2009 WCUJa'Quayvin Smalls – 2009 WCU

Bennie Abram – 2010 Ole MissBennie Abram – 2010 Ole Miss

Cervical Spine InjuryCervical Spine Injury

CervicalCervical SpineSpine ImmobilizationImmobilization

Clinical decisionClinical decision

Standardize approach and procedureStandardize approach and procedure

Have unencumbered airway accessHave unencumbered airway access

Don’t assume that EMS knows what Don’t assume that EMS knows what to do – you teach them how you want to do – you teach them how you want it done and practice before the it done and practice before the season (NATA video) season (NATA video)

Spinal Cord Injury Treatment Spinal Cord Injury Treatment ““OptionsOptions””

High dose steroids – High dose steroids – methylprednisolone 30 mg/kg bolus methylprednisolone 30 mg/kg bolus Maintenance dose – 5.4 mg/kg/hr Maintenance dose – 5.4 mg/kg/hr (needs to be started at hospital within (needs to be started at hospital within 3-8 hours)3-8 hours)

Hypothermia – 30 cc/kg of LR cooled to Hypothermia – 30 cc/kg of LR cooled to 37-40 degrees F should drop temp to 37-40 degrees F should drop temp to around 95. Ideal temp between 92-94.around 95. Ideal temp between 92-94.

Kevin Everett case Kevin Everett case

2007 Kevin Everett2007 Kevin Everett

Made a tackle on the kickoff with his Made a tackle on the kickoff with his head downhead down

Received cold IV fluids and steroidsReceived cold IV fluids and steroids

The real key to his recovery was The real key to his recovery was going to the appropriate hospital and going to the appropriate hospital and being in surgery within 2 hours being in surgery within 2 hours

ConcussionConcussion

Clinical judgment determines if Clinical judgment determines if severity of head injury negates the severity of head injury negates the validity of the c-spine examvalidity of the c-spine exam

Always fear the concussion when Always fear the concussion when paired with the C1/C2 fracture – axial paired with the C1/C2 fracture – axial load with flexionload with flexion

If immobilizing, remove the facemask If immobilizing, remove the facemask even if awake and talkingeven if awake and talking

Concussion

High grade concussion could cause severe decreased level of consciousness and impair the athlete’s ability to protect their airway – rareSecond impact syndrome – 3 NC deaths recentlyImPact other cognitive based testingBalance testingNFL standardizing the sideline exam

2006 and 2007 Trent Green2006 and 2007 Trent Green

Concussions while playing with Concussions while playing with Chiefs (2006) and Dolphins (2007)Chiefs (2006) and Dolphins (2007)

Both were significant and had Both were significant and had prolonged recovery periodsprolonged recovery periods

Was able to return to play after Was able to return to play after evaluation and clearanceevaluation and clearance

2000 Blaine Bishop2000 Blaine Bishop

Titans DB in Super BowlTitans DB in Super Bowl

Brief LOC / neck pain / L arm Brief LOC / neck pain / L arm numbnessnumbness

Spinal immobilizationSpinal immobilization

Transport to hospitalTransport to hospital

Final diagnosis – concussion/cervical Final diagnosis – concussion/cervical strainstrain

Comprehensive pregame planning Comprehensive pregame planning

Conditions/EnvironmentConditions/Environment

Heat illnessHeat illness

Heat cramps/exhaustion/strokeHeat cramps/exhaustion/stroke

33 heat related deaths in football 33 heat related deaths in football since 1995since 1995

Korey Stringer of the Minnesota Korey Stringer of the Minnesota VikingsVikings

Steve Belcher of the Baltimore Steve Belcher of the Baltimore OriolesOrioles

Conditions/EnvironmentConditions/EnvironmentLightning – approximately 100-120 Lightning – approximately 100-120 people die per year in the US from people die per year in the US from lightninglightningIn 2006, 5 people died at one event In 2006, 5 people died at one event during a storm (softball)during a storm (softball)Rosbin Yuman and Lester Marrioquin Rosbin Yuman and Lester Marrioquin soccer players killed in 2001soccer players killed in 2001Tend to the unconscious first – they Tend to the unconscious first – they usually need more electricity (AED)! usually need more electricity (AED)!

CrisisCrisis Management/Disaster Management/Disaster PlanningPlanning

Know the disaster plan/EAPKnow the disaster plan/EAP

Have a written Emergency Action Plan for Have a written Emergency Action Plan for every venue including practiceevery venue including practice

Practice the EAP – docs, ATC’s, coachesPractice the EAP – docs, ATC’s, coaches

Is there an evacuation plan?Is there an evacuation plan?

Be familiar with the Rally PointBe familiar with the Rally Point

Take care of the visiting teamTake care of the visiting team

Have a roster for roll call Have a roster for roll call

Be Prepared for Worst Case Scenario

At the end of the Packers-Broncos Super Bowl both a DB and WR were down and we weren’t prepared to immobilize bothWith the Falcons we now have double set upsLast year Falcons-Eagles both a DB and WR went down with head injuries

DiabetesDiabetesKnow your athletesKnow your athletes

Either high or low when they are sickEither high or low when they are sick

Urine dipstick is quick and easyUrine dipstick is quick and easy

High – dipstick + for glucose and maybe High – dipstick + for glucose and maybe ketones if DKA (Rx with NS)ketones if DKA (Rx with NS)

Low – dipstick may have ketones from Low – dipstick may have ketones from starvation but not spilling glucose (Rx with starvation but not spilling glucose (Rx with D50W or glucagon emergency kit)D50W or glucagon emergency kit)

Usually need to call EMS in either situationUsually need to call EMS in either situation

Diabetic AthletesDiabetic AthletesJay CutlerJay CutlerArthur AsheArthur AsheTy CobbTy CobbScott VerplankScott VerplankJackie RobinsonJackie RobinsonJoe FrazierJoe FrazierBillie Jean KingBillie Jean KingJoe GibbsJoe Gibbs

What EMS should have:What EMS should have:Airway equipment and suppliesAirway equipment and suppliesPortable pulse oximeterPortable pulse oximeterEnd tidal CO2 detectorEnd tidal CO2 detectorManual defibrillator/cardiac monitorManual defibrillator/cardiac monitorACLS drugsACLS drugsRSI drugs if trained MD or state allows EMS RSI drugs if trained MD or state allows EMS to useto useSteroids if you use them for SCISteroids if you use them for SCI?Oversize backboard for football?Oversize backboard for footballDon’t assume that they have things!Don’t assume that they have things!

What you should haveWhat you should haveAirway plan – LMA, #11 blade, curved Airway plan – LMA, #11 blade, curved hemostatshemostats

Breathing plan – 14 gauge angiocath, Breathing plan – 14 gauge angiocath, extra inhaler, Flow Meter, Epi(1:1000)extra inhaler, Flow Meter, Epi(1:1000)

Cardiac plan – know how to use AEDCardiac plan – know how to use AED

Disaster plan – be familiar with EAPDisaster plan – be familiar with EAP

Procedure plan – know who should and Procedure plan – know who should and who can do what procedurewho can do what procedure

Transport plan – Transport plan – appropriateappropriate facility facility

EMS RelationshipEMS Relationship

Work closely with themWork closely with them

Preseason practice of scenariosPreseason practice of scenarios

Let them know what is expected of Let them know what is expected of them, when to come out, what to dothem, when to come out, what to do

Demand consistency in staffingDemand consistency in staffing

Require their best trained personnelRequire their best trained personnel

Who should do whatWho should do whatParamedics can intubateParamedics can intubateOnly physicians can do surgical Only physicians can do surgical airwayairwayOnly physicians can needle Only physicians can needle decompress tension pneumothoraxdecompress tension pneumothoraxATC’s, MD’s, coaches, anyone with ATC’s, MD’s, coaches, anyone with training can use AEDtraining can use AEDEMT-differs by state but if you need EMT-differs by state but if you need an airway expert get a paramedican airway expert get a paramedic

QuestionsQuestions

Life threatening athlete situations Life threatening athlete situations exist in almost every sportexist in almost every sport

Always know who is in charge Always know who is in charge

Always know who is best trained for Always know who is best trained for a particular incidenta particular incident

Always be prepared and be Always be prepared and be resourceful if unusual situations ariseresourceful if unusual situations arise