Management of the critically injured athlete: packaging of head and cervical spine injuries.Annotation 1. (programming, compiler) annotation - Extra information associated with a particular point in a document or program. Annotations may be added either by a compiler or by the programmer. : Initially all sports medicine sports medicine, branch of medicine concerned with physical fitness and with the treatment and prevention of injuries and other disorders related to sports. Knee, leg, back, and shoulder injuries; stiffness and pain in joints; tendinitis; "tennis elbow"; and providers will encounter potential or real injury in collision and/or individual sports. Proper training and equipment must be available, and all involved must be ready to package and transport effectively when that injury occurs. Head and neck injuries can be catastrophic. This article points to the absolute necessity for a ready and organized response sports medicine team, good equipment, educated and practiced athletic trainer An athletic trainer is an allied (non-physician) health care provider capable of performing immediate and emergency injury management, injury assessment, and rehabilitation. (ATC ATC Air Traffic Control ATC Average Total Cost ATC Certified Athletic Trainer ATC At the Center (Hartford, Maine retreat center) ATC Applied Technology Council ATC All Things Considered ) and physician (MD) personnel, and emergency medical resources available. ********** Injuries to the spinal column spinal column, bony column forming the main structural support of the skeleton of humans and other vertebrates, also known as the vertebral column or backbone. It consists of segments known as vertebrae linked by intervertebral disks and held together by ligaments. are relatively rare in athletics. However, when they do occur, they must be treated promptly and correctly. Athletic trainers must know which procedures to use in these situations. They must have the necessary equipment readily available and be proficient in its use. The regular practice of immobilization Immobilization Definition Immobilization refers to the process of holding a joint or bone in place with a splint, cast, or brace. This is done to prevent an injured area from moving while it heals. of athletes with potential cervical spine injuries cervical spine injury Orthopedics A posttraumatic injury to the cervical spine, resulting in vertebra displacement; horizontal displacement of > 3.5 mm; rotation > 11° is an absolute contraindication to future participation in contact sports–eg, is a must for athletic trainers who expect to perform these important tasks in an actual emergency. Care of the injured in·jure tr.v. in·jured, in·jur·ing, in·jures 1. To cause physical harm to; hurt. 2. To cause damage to; impair. 3. athlete should follow a carefully designed protocol. (1) The athlete's airway airway /air·way/ (-wa) 1. the passage by which air enters and leaves the lungs. 2. a device for securing unobstructed respiration. , breathing and circulation, neurologic neurologic /neu·ro·log·ic/ (-loj´ik) pertaining to neurology or to the nervous system. Neurologic Having to do with the nervous system. status and level of consciousness should all be assessed, and the emergency medical services An Emergency medical service (abbreviated to initialism "EMS" in many countries) is a service providing out-of-hospital acute care and transport to definitive care, to patients with illnesses and injuries which the patient believes constitutes a medical emergency. system should be activated. Since unconscious individuals are unable to speak, they are unable to tell the rescuer if they have a spine injury. Therefore, all unconscious athletes with a mechanism that may have included a collision or a fall, and conscious athletes with any sign or symptoms suggesting cervical spine trauma cervical spine trauma Orthopedics A traumatic event, especially common in contact sports, resulting in cervical spine injury, see there , must be treated as if they have a cervical spine injury. Any athlete suspected of having a head or spinal injury should not be moved and should be managed as though a spinal injury exists. The athlete should not be moved unless it is absolutely essential to maintain airway, breathing, and circulation. If the athlete must be moved to maintain airway, breathing, and circulation, the athlete should be placed in a supine position The supine position is a position of the body; lying down with the face up, as opposed to the prone position, which is face down. Using terms defined in the anatomical position, the posterior is down and anterior is up. while maintaining spinal immobilization. In the conscious athlete, a possible cervical spine injury must be identified early. Athletes who cannot execute gentle movement of the head should be suspected of having significant cervical spine trauma and should be treated accordingly. (2) Cervical spine injuries are usually orthopaedic in nature and may or may not have immediately observable neurologic sequelae sequelae Clinical medicine The consequences of a particular condition or therapeutic intervention . Athletes with no neurologic signs or symptoms and no findings suggesting trauma to the cervical spine cervical spine Clinical anatomy The region of the vertebral column encompassing C1 through C7 can be safely moved to a more suitable site for further evaluation. But remember, if there is any question as to medical status, it's best to err on the side of safety and treat the injury as if it were a significant cervical spine injury. When it becomes necessary to transport the athlete, the head and trunk should be moved as a unit. One accepted technique is to manually splint splint, rigid or semiflexible device for the immobilization of displaced or fractured parts of the body. Most commonly employed for fractures of bones, a splint may be a first-aid measure that allows the patient to be moved without displacing the injured part, or it the head to the trunk. It takes at least four people to move an injured athlete correctly. One rescuer must stabilize the athlete's head and cervical spine. As a general rule this should be the most qualified and experienced person on the scene. It is imperative that this rescuer maintain cervical alignment throughout the procedure, until the athlete is completely immobilized on a suitable device. Following a Plan Injuries to the head and neck are difficult to evaluate and treat in the athletic environment. To adequately prepare for these and other critical injuries to athletes, athletic trainers must develop an emergency action plan. They must make sure to have proper equipment readily available and in good working order. (1) The sports medicine team must be prepared for any emergency. Preparation includes education and training, maintenance of appropriate emergency equipment and supplies, utilization of appropriate personnel (including certified athletic trainers [CTAs]), and the formation and implementation of an emergency plan. Emergency plans should be comprehensive and practical, yet be flexible enough to adapt to any emergency situation. The emergency plan must be established, approved, revised, and rehearsed on a regular basis. (3) Each emergency plan may vary, but should include information on education, emergency equipment, personnel, communication, and a rehearsal schedule. The emergency plan should also address equipment issues, which are particularly important in managing and packaging suspected head or cervical spine injuries. Each member of the emergency team should be knowledgeable and practiced in the function and operation of emergency equipment. It would be helpful for each member of the sports medicine team to be multi-skilled and cross-trained in the use of all emergency equipment. For example, it is common for CTAs to know how to remove a football helmet face mask Face mask The simplest way of delivering a high level of oxygen to patients with ARDS or other low-oxygen conditions. Mentioned in: Adult Respiratory Distress Syndrome , while physicians and emergency medical technicians e·mer·gen·cy medical technician n. Abbr. EMT A person trained and certified to appraise and initiate the administration of emergency care for victims of trauma or acute illness before or during transportation of victims to a health care (EMTs) may not. Likewise, EMTs are more practiced in packaging an individual for transportation than are athletic trainers. (4) It has been suggested that practice with the tools required for face mask removal of the catastrophically injured football player is essential. While it is not the purpose of this article to discuss the emergency plan, it is important to emphasize that following an organized plan is critical to the emergency management of an athlete with a suspected head or cervical spine injury. Furthermore, the emergency plan should address equipment issues specific to the management and packaging of suspected head or cervical spine injuries. The Athlete's Equipment When to remove the face mask Any athlete wearing protective shoulder pads This article is about football protective equipment. For shoulder pads in fashion, see Shoulder pads (fashion). Shoulder pads are a piece of protective equipment used in American and Canadian football. and helmet, who has suspected cervical spine injury, should be treated with their equipment left in place to minimize risk of further trauma secondary to cervical spine motion. The face mask should be removed as quickly as possible any time a football player is suspected of having a head or neck injury, even if the football player is still conscious. The face mask should be removed before transportation, regardless of current respiratory status. The face mask will need to be removed anyway for evaluation of vital signs, transportation, and/or intubation intubation /in·tu·ba·tion/ (in?too-ba´shun) the insertion of a tube into a body canal or hollow organ, as into the trachea. endotracheal intubation in the event that the football player stops breathing. It is suggested the emergency medical provider not wait until the football player stops breathing to begin the task of face mask removal. How to remove the face mask The face mask of the football helmet is secured to the helmet with four plastic loop straps which can be cut, or removed, thus allowing the face mask to be retracted re·tract v. re·tract·ed, re·tract·ing, re·tracts v.tr. 1. To take back; disavow: refused to retract the statement. 2. or removed. When the two lateral loop traps are cut or removed, the face mask can be retracted or "swung-away" using the two anterior loop straps as a hinge. This procedure enables medical personnel to gain access to the airway and vital areas of the face for examination, and to administer prehospital care to the football player without having to remove the helmet. This procedure of face mask retraction In the law of Defamation, a formal recanting of the libelous or slanderous material. Retraction is not a defense to defamation, but under certain circumstances, it is admissible in Mitigation of Damages. Cross-references Libel and Slander. is currently accepted as the preferred protocol in sports medicine. However, recent data has reported that more head and neck movement occurs while the face mask is being retracted, and not while the straps are being cut. (5) Therefore, these preliminary data suggest that all four straps should be cut and the face mask should be removed, rather than being retracted. Reducing movement of the football player's head and neck is of primary importance since it is believed that any additional movement that occurs during face mask retraction can cause secondary damage to the football player with an injury to the cervical spine. A recommendation is to use a sharp knife, scalpel, or box cutter to cut the loop straps. However, today's loop straps are made of harder plastics and are more difficult to cut. (6) There have also been reports during research studies of subjects (rescuers) injuring themselves when the knife slips while trying to cut through the loop straps. (6) DuraShears, or EMT See Efficient markets theory. scissors scissors Cutting instrument or tool consisting of a pair of opposed metal blades that meet and cut when the handles at their ends are brought together. Modern scissors are of two types: the more usual pivoted blades have a rivet or screw connection between the cutting ends , are a popular tool in the field for cutting seat belts, clothing, etc., but are not recommended for cutting loop straps. One research study evaluated these scissors with both CTAs and EMTs as subjects. The times that it took to remove the face mask with the DuraShears were judged unacceptable, with most being greater than 8 minutes, and one EMT taking as long as 35 minutes. (6) Currently, the most popular and widely used tool for face mask retraction is the Trainer's Angel, (6) and is the only tool currently available specifically designed to cut the loop straps that secure the face mask to the helmet. However, when compared during scientific investigations, the Trainer's Angel was found to produce greater amounts of head movement than the other tools studied. The task of face mask removal should be accomplished as quickly as possible, and with as little movement of the head and neck as possible. So the best tool used for face mask removal should be efficient with regards to both time and movement. (6) Those involved in the prehospital care of injured football players should have tools for face mask removal readily available. When to remove the helmet Only the face mask should be removed from the helmet. The helmet itself should not be removed unless the rescuer is unable to access the airway by all other means. Furthermore, by removing only the face mask and not the entire helmet, the spine will remain in a neutral position. If the helmet were removed, the athlete's head would hyperextend hy·per·ex·ten·sion n. Extension of a bodily joint beyond its normal range of motion. hy  per·ex·tend ,
particularly when the athlete is wearing shoulder pads. Unless the
shoulder pads were removed first, it would be very difficult to maintain
in-line neutral stabilization.
In the management of an injured football player with a suspected spinal injury, both the National Athletic Trainers Association, (7) and the American College of Sports Medicine '''Founded in 1954, the AMERICAN COLLEGE OF SPORTS MEDICINE is the largest sports medicine and exercise science organization in the world. More than 20,000 international, national and regional members are dedicated to advancing and integrating scientific research to provide educational (8) have promoted statements that advise against the removal of football helmets. Reducing the head and neck movement that occurs during helmet removal is very important since unnecessary movement may cause further damage to the football player with a cervical spinal injury. (5) The athletic helmet and chin strap should only be removed if: 1) the helmet and chin strap do not hold the head securely, such that immobilization of the helmet does not also immobilize im·mo·bi·lize v. 1. To render immobile. 2. To fix the position of a joint or fractured limb, as with a splint or cast. im·mo the head; 2) the design of the helmet and chin strap is such that even after removal of the face mask the airway cannot be controlled, or ventilation be provided; 3) the face mask cannot be removed after a reasonable period of time; 4) the helmet prevents immobilization for transportation in an appropriate position. Transfer of the Athlete Log roll of a supine supine /su·pine/ (soo´pin) lying with the face upward, or on the dorsal surface. su·pine adj. 1. Lying on the back; having the face upward. 2. athlete The person at the head (rescuer 1) must maintain the head-spine in a neutral position. A rigid cervical collar cervical collar, n a leaded device positioned over the throat roughly midway between the chin and collarbones. Used because extended exposure of the thyroid gland to radiographs can cause thyroid cancer. See also apron, lead. should be applied. Neutral positioning is maintained by the rescuer at the head until it is completely splinted on the full body splint. The athlete's arms should be maintained at his or her side (palm inward). Rescuers 2 and 3 should roll the athlete onto the arm during the log roll maneuver. The athlete's arm should be kept to the side during the roll unless it is injured. In which case the arm should be raised over his or her head. However, this may be difficult in the presence of shoulder pads. Shoulder pads are not easy to remove, especially if worn with a neck collar; thus they should only be removed in the most extenuating ex·ten·u·ate tr.v. ex·ten·u·at·ed, ex·ten·u·at·ing, ex·ten·u·ates 1. To lessen or attempt to lessen the magnitude or seriousness of, especially by providing partial excuses. See Synonyms at palliate. 2. of circumstances. The body splint should be placed at the athlete's side, and the two additional rescuers should kneel at the athlete's side away from the splint. Rescuers 2 and 3 should be positioned with rescuer 2 at the chest and rescuer 3 at the thigh area. Rescuer 3 is expected to control both legs during the log roll maneuver. Rescuer 1 is in charge, and gives each and every command to move the athlete. Rescuer 1 must continue to maintain neutral positioning of the head and neck complex until the athlete is completely immobilized. To roll, rescuer 1 gives the command "Prepare to roll, roll." The assistants roll the athlete onto his or her side, toward the rescuers. By rolling onto the athlete's arm, the head, shoulders, and pelvis pelvis, bony, basin-shaped structure that supports the organs of the lower abdomen. It receives the weight of the upper body and distributes it to the legs; it also forms the base for numerous muscle attachments. are kept in anatomic alignment. When the athlete is rolled onto his or her side, rescuer 2 should be in position to assess the back for any visible signs of injury. At this point, the splint should be placed into position and held against the athlete's back and held at a 30-degree angle. While the positions are maintained, rescuer 1 gives commands "Prepare to lower, lower," and the athlete is lowered onto the splint. The Log Roll of a Prone Athlete Due to the urgency of oxygen for the athlete, assessment must be made very quickly and efficiently. If the athlete is not breathing, a log roll should be performed immediately. (9) Unless the immobilization device is immediately available, the athlete must be immediately log rolled into a supine position, and then log rolled a second time on to the body splint. Obviously, with each unnecessary movement the chances of a secondary injury increase. Athletes who are vomiting vomiting, ejection of food and other matter from the stomach through the mouth, often preceded by nausea. The process is initiated by stimulation of the vomiting center of the brain by nerve impulses from the gastrointestinal tract or other part of the body. or bleeding from the oral cavity oral cavity n. The part of the mouth behind the teeth and gums that is bounded above by the hard and soft palates and below by the tongue and the mucous membrane connecting it with the inner part of the mandible. must be kept prone, or placed on their side to prevent aspiration of food or vomitus vomitus /vom·i·tus/ (vom´i-tus) [L.] 1. vomiting. 2. matter vomited. vom·i·tus n. Vomited matter. vomitus 1. vomiting. 2. vomited material. into the airway. To immobilize the prone athlete, rescuer 1 immobilizes the neck in a neutral position. The hands are placed on the athlete's head with the thumbs pointing to the athlete's face. All athletes should be treated with a rigid cervical collar, unless their equipment prevents such, as would be the case with hockey and football. Next, position the immobilization device next to the injured athlete. Survey the athlete for any additional injuries. Place the splinting splinting /splint·ing/ (splin´ting) 1. application of a splint, or treatment by use of a splint. 2. in dentistry, the application of a fixed restoration to join two or more teeth into a single rigid unit. apparatus on the side of rescuer l's lower hand. If the arm next to the splint device is injured, carefully raise the arm above the athlete's head so he/she does not roll onto the injured arm. Again, this may be difficult if the athlete is wearing protective equipment. Rescuer 2 and 3 should position themselves adjacent to the athlete, opposite the splinting device. Rescuer 2 is located at the chest area and 3 at the level of the thighs. To roll, rescuer 1 gives the command "Prepare to roll, roll". The assistants roll the athlete onto his or her side, toward the rescuers. By rolling onto the athlete's arm, the head, shoulders, and pelvis are kept in anatomic alignment. The splinting device should be positioned at a 30-degree angle. While positions are maintained, rescuer 1 gives the command "Prepare to lower, lower" and the athlete is lowered onto the splint. [ILLUSTRATION OMITTED] Immobilization Equipment Any injured athlete who may have a cervical spine injury should be immobilized on a suitable full-body splint. The equipment used for splinting athletes with head and/or neck injuries will depend on the appliances available as well as the training and know-how of emergency medical personnel. Athletic trainers must know how to use the equipment that is available to them. It is shocking to read reports about sports healthcare professionals not being able to use, in a proper manner, the devices they have purchased for emergency care. Considering that firefighters regularly drill to rehearse the handling of equipment they use frequently, athletic trainers should practice repeatedly with equipment that will be used infrequently. The following discussion focuses on two popular techniques for spinal immobilization: the Miller full-body splint and the standard rigid spine board. Miller full-body splint To use the Miller full-body splint, move the splint next to the athlete. Open the harness and fold all straps onto themselves to prevent entanglement of the Velcro. Log roll the athlete onto the Miller full-body splint. Place the chest straps loosely over the athlete's chest. Place the shoulder strap onto the chest strap. Thread the chest strap through the pins on the Miller full-body splint. Adjust the chest trap, then adjust the shoulder straps. Do not over-tighten either of the straps. Adjust the torso, the leg and ankle straps to secure the athlete to the Miller full-body splint. If athlete is wearing a protective helmet, tape the helmet directly to the Miller full-body splint head piece. Apply the chin strap snugly snug 1 adj. snug·ger, snug·gest 1. Comfortably sheltered; cozy. 2. Small but well arranged: a snug apartment. See Synonyms at comfortable. 3. a. but allowing the mouth to open. Rigid spine board The person at the head should maintain stabilization of the head and neck, including gentle pressure to the head and neck to maintain neutral positioning. Involve a minimum of three assistants for execution of this splinting technique. The person at the head coordinates any movements of the team. For the log roll, the assistants coordinate a pulling action to log roll the athlete toward their legs. Upon the person at the head's command, lower or roll the athlete onto the rigid spine board. Pad the back of the thorax thorax, body division found in certain animals. In humans and other mammals it lies between the neck and abdomen and is also called the chest. The skeletal frame of the thorax is formed by the sternum (breastbone) and ribs in front and the dorsal vertebrae in back. if shoulder pads are removed. This maintains anatomic alignment of the spine with the helmet left in place. Apply blankets, rolled towels, or commercial head immobilizers and strap into position. Secure the helmet to the backboard back·board n. 1. A board placed under or behind something to provide firmness or support. 2. A board placed beneath the body of a person with an injury to the neck or back, used especially in transporting the person in such a way with adhesive tape. Two straps are positioned through the board at the level of the armpits. Pull the upper end of the straps over the shoulders and across the chest. Lace the straps through the lateral holes at the level of the pelvis. Bring the straps across the lower pelvis and upper legs. Lace through the lateral holes and connect below the knees. Apply the straps snugly so the athlete does not move if moved on his side due to vomiting. Generally, with a helmet and shoulder pad in place, no cervical collar is used, only towels to fill voids. In the event the sports participant was not wearing protective equipment, including helmets and/or shoulder padding Bits or characters that fill up unused portions of a data structure, such as a field, packet or frame. Typically, padding is done at the end of the structure to fill it up with data, with the padding usually consisting of 1 bits, blank characters or null characters. See null and bit stuffing. , a cervical collar would be applied to assist in immobilization of the cervical spine. At any point the athlete requires repositioning repositioning Laparoscopic surgery The changing of a Pt's position during a procedure to improve access or visualization of the operative field, which may be linked to complications, as it changes anatomic planes of operation. Cf Laparoscopic surgery. , lift the athlete vertically. If the athlete is not wearing a helmet, a rigid cervical collar should be utilized to maximize protection of the cervical spine. Leave the chin free to access the athlete's airway. Pad the areas behind the low back and knees to fill all voids between the body and board. Tie the hands and legs together in the event of an unconscious athlete. Once completely stabilized, the person at the head relinquishes his control. Move the athlete on the board to a stretcher stretcher /stretch·er/ (strech´er) a contrivance for carrying the sick or wounded. stretch·er n. and transport to advanced medical facilities. Summary Emergency medical personnel must take extreme caution when evaluating and treating an athlete with a suspected head or spine injury. While head and neck injuries may continue to be life threatening, the proper management of these injuries may prevent further injury from occurring. Accepted May 21, 2004. References 1. Andersen JC CR, Kleiner DM, McLoda TA. National Athletic Trainers Association position statement: emergency planning in athletics. J Athletic Training athletic training Sports medicine The practice of physical conditioning and reconditioning of athletes and prevention of injuries incurred by athletes. See Athlete, Athletic trainer. 2002;37:99-104. 2. Vegso JJ. Field Evaluation and Management of Cervical Spine Injuries, in Athletic Injuries to the Head, Neck, and Face. St. Louis, Mosby-Year Book, 1991. 3. Walters R. Spinal immobilization. Athletic Therapy Today 1996;1:16-20. 4. Kleiner D. Prehospital treatment of catastrophic football injuries. Emerg Med Serv 1998;27:27-32. 5. Kleiner DM. Football helmet face mask removal. Athletic Therapy Today 1996;1:25-37. 6. Kleiner DM. An evaluation of the techniques used by athletic trainers when removing a face mask with the Trainers Angel. J Athletic Training 1995;30:7-12. 7. Kleiner DM, Bailes J, Burruss P, et al. Prehospital care of the spine-injured athlete: a document from the inter-association task force for appropriate care of the spine-injured athlete. March 2001. Located at: National Athletic Trainers Association, Dallas, TX. 8. Kleiner DM, Cantu RC. Football Helmet Removal: A Current Comment. 1996, Indianapolis, IN. 9. Campbell JE. Managing the Airway, in Campbell JE (ed): BTLS BTLS Basic Trauma Life Support BTLS Bubba the Love Sponge (radio personality) BTLS Burns, Tenderness, Lacerations, Swelling : Basic Prehospital Trauma Care. Englewood Cliffs, Brady/Prentice-Hall, 1988, pp 43-58. Rod Walters, DA, ATC From the Athletic Department, University of South Carolina
• • , Columbia, SC. Reprint reprint An individually bound copy of an article in a journal or science communication requests to Rod Walters, DA, ATC, Athletic Department, University of South Carolina, Columbia, SC 29208. Email: rwalters@gwm.sc.edu |
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