1. On-Field Evaluation of Head and Neck Injuries SPORTS MEDICINE Instructor: John Hardin

2. On-Field Evaluation Equipment Considerations: Equipment Considerations: Suspected spinal injury → helmet should NOT be removed Suspected spinal injury → helmet should NOT be removed Airway is accessible (facemask removal) Airway is accessible (facemask removal) Cervical collar can be applied with helmet and shoulder pads on Cervical collar can be applied with helmet and shoulder pads on Athlete’s head can be secured to spine board Athlete’s head can be secured to spine board Helmet removal without removing the shoulder pads → cervical spine extension Helmet removal without removing the shoulder pads → cervical spine extension

3. On-Field Evaluation Facemask Removal: Facemask Removal: Facemask is attached to the helmet by thick plastic fasteners Facemask is attached to the helmet by thick plastic fasteners Can be cut off or unscrewed Can be cut off or unscrewed Most helmets have four fasteners Most helmets have four fasteners Can cut all four or cut the bottom two and retract the mask Can cut all four or cut the bottom two and retract the mask

4. On-Field Evaluation Facemask Removal: Facemask Removal: Common tools for helmet removal: Common tools for helmet removal: Hand held screwdriver Hand held screwdriver Anvil Pruner Anvil Pruner Trainer’s Angels Trainer’s Angels FM Extractor FM Extractor

5. On-Field Evaluation Chest Exposure: Chest Exposure: Shoulder pads and jersey should be left in place along with the helmet Shoulder pads and jersey should be left in place along with the helmet To access the chest for CPR, cut the jersey, shoulder pad stings and straps, and spread the pads apart so the chest is exposed To access the chest for CPR, cut the jersey, shoulder pad stings and straps, and spread the pads apart so the chest is exposed

6. On-Field Evaluation Initial Inspection: Initial Inspection: Encumbering circumstances: Encumbering circumstances: Diver still in the water Diver still in the water Football player lying on a pile Football player lying on a pile Movement: Movement: Note any athlete movement Note any athlete movement Position of athlete: Position of athlete: Alignment of arms, legs, cervical spine relative to trunk Alignment of arms, legs, cervical spine relative to trunk Splayed extremities must be aligned prior to spine-boarding or log-rolling the athlete Splayed extremities must be aligned prior to spine-boarding or log-rolling the athlete Lesion of cervical or thoracic spinal cord Lesion of cervical or thoracic spinal cord

7. On-Field Evaluation Initial Action: Cervical Spine Stabilization Initial Action: Cervical Spine Stabilization Primary goal: Maintain the head and neck in alignment with the long axis of the body Primary goal: Maintain the head and neck in alignment with the long axis of the body Kept from time of initial assessment, through transportation, and to the hospital Kept from time of initial assessment, through transportation, and to the hospital Assign one person whose only responsibility is to secure and position the head and neck Assign one person whose only responsibility is to secure and position the head and neck Usually the person with the most training and experience Usually the person with the most training and experience In-control – directs others In-control – directs others

8. On-Field Evaluation Initial Action: Primary Survey / LOC Initial Action: Primary Survey / LOC Determine level of consciousness: Determine level of consciousness: “Can you hear me” “Can you hear me” Response to painful stimulus Response to painful stimulus Determine ABCs: Determine ABCs: Clear the airway and assess breathing Clear the airway and assess breathing Remove mouthpiece Remove mouthpiece Check Circulation Check Circulation Inspect ears and nose: Inspect ears and nose: CSF CSF Secondary Survey: Secondary Survey: Signs of trauma (fracture, dislocations, bleeding) Signs of trauma (fracture, dislocations, bleeding)

9. On-Field Evaluation Management of Unconscious Athlete: Management of Unconscious Athlete: Airway: Airway: Permanent brain damage – within 4 minutes after oxygen deprivation Permanent brain damage – within 4 minutes after oxygen deprivation Assess airway: Assess airway: Look, listen, feel for breathing Look, listen, feel for breathing Emergency Roll: Emergency Roll: No pulse / not breathing and not in supine position No pulse / not breathing and not in supine position Maintain in-line stabilization Maintain in-line stabilization Expose chest Expose chest Remove facemask Remove facemask Jaw thrust to open airway Jaw thrust to open airway 2 quick breaths 2 quick breaths Circulation: Circulation: Carotid pulse Carotid pulse Not breathing with pulse – Rescue breathing Not breathing with pulse – Rescue breathing No pulse – CPR No pulse – CPR

10. On-Field Evaluation Modified Jaw Thrust: Modified Jaw Thrust: Grasp each side of the mandible at the angle and pull upwards Grasp each side of the mandible at the angle and pull upwards Must be careful not to disturb the c-spine Must be careful not to disturb the c-spine May not always open the airway May not always open the airway Should be done by a professional rescuer or athletic trainer Should be done by a professional rescuer or athletic trainer Essentially dislocating the jaw Essentially dislocating the jaw

11. On-Field Evaluation Management of Unconscious but Breathing Athlete: Management of Unconscious but Breathing Athlete: C1 Lesion → Altered brain stem function and cardiac arrest C1 Lesion → Altered brain stem function and cardiac arrest C2 – C4 → phrenic nerve interruption: C2 – C4 → phrenic nerve interruption: Respiratory distress Respiratory distress

12. On-Field Evaluation Management of Unconscious but Breathing Athlete: Management of Unconscious but Breathing Athlete: Cervical spine evaluation: Cervical spine evaluation: Palpate for gross bony deformity Palpate for gross bony deformity Blood pressure: Blood pressure: Palpation of pulse and minimum Systolic BP: Palpation of pulse and minimum Systolic BP: Carotid artery – 60 mmHg Carotid artery – 60 mmHg Femoral artery – 70 mmHg Femoral artery – 70 mmHg Radial artery – 90 mmHg Radial artery – 90 mmHg Pupil responsiveness: Pupil responsiveness: Open athlete’s eyelids: Open athlete’s eyelids: Open eyelids – pupil constriction Open eyelids – pupil constriction Absence – brain not receiving oxygen / brain damage Absence – brain not receiving oxygen / brain damage Continue monitoring: Continue monitoring: Every 5 minutes Every 5 minutes

13. On-Field Evaluation Management of Conscious Athlete: History Management of Conscious Athlete: History Loss of consciousness: Loss of consciousness: Does athlete describe “blacking out” or “seeing stars” Does athlete describe “blacking out” or “seeing stars” Mechanism of injury Mechanism of injury Symptoms: Symptoms: Pain in cervical spine Numbness, tingling, burning pain radiating through upper or lower extremities Sensation of weakness in cervical spine, upper and/or lower extremities Burning or aching in the chest secondary to cardiac inhibition

14. On-Field Evaluation Management of Conscious Athlete: Management of Conscious Athlete: Inspection: Inspection: Cervical vertebrae: Cervical vertebrae: Alignment Alignment Cervical musculature: Cervical musculature: Presence of spasm Presence of spasm Palpation: Palpation: Cervical spine: Cervical spine: Spinous and transverse processes: Spinous and transverse processes: Alignment, crepitus, tenderness Alignment, crepitus, tenderness Cervical musculature: Cervical musculature: Spasm in upper trapezius, levator scapulae, SCM Spasm in upper trapezius, levator scapulae, SCM Unilateral spasm – cervical vertebral dislocation when skull is rotated and tilted to opposite side Unilateral spasm – cervical vertebral dislocation when skull is rotated and tilted to opposite side

15. On-Field Evaluation Management of Conscious Athlete: Management of Conscious Athlete: Neurological Testing: Neurological Testing: Sensory testing Sensory testing Motor Testing Motor Testing Active motion: Active motion: Wiggle toes and fingers Wiggle toes and fingers Movement of ankles, wrists, knees, elbows, hips, and shoulders Movement of ankles, wrists, knees, elbows, hips, and shoulders

16. On-Field Evaluation Removing the Athlete from the Field: Removing the Athlete from the Field: Walking athlete off the field: Walking athlete off the field: Lying → standing: ↓ BP (risk of fainting / unsteadiness) Lying → standing: ↓ BP (risk of fainting / unsteadiness) Allow athlete to adjust to position changes Allow athlete to adjust to position changes

17. On-Field Evaluation Removing the Athlete from the Field: Removing the Athlete from the Field: Using a Spine Board: Supine Athlete Using a Spine Board: Supine Athlete Place the extremities in axial alignment Place the extremities in axial alignment Arm on side toward which athlete rolled abducted to 180 0 (if not wearing shoulder pads) Arm on side toward which athlete rolled abducted to 180 0 (if not wearing shoulder pads) Place the spine board close to the side of the patient Place the spine board close to the side of the patient Other responders position along the side of the athlete, according to the captain’s (person at the head) directions Other responders position along the side of the athlete, according to the captain’s (person at the head) directions Ideal to have 4 or 5 additional helpers, depending on the size of the patient Ideal to have 4 or 5 additional helpers, depending on the size of the patient Each person is responsible for one body segment: trunk, hips, thighs, lower legs Each person is responsible for one body segment: trunk, hips, thighs, lower legs

18. On-Field Evaluation Removing the Athlete from the Field: Removing the Athlete from the Field: Using a Spine Board: Supine Athlete Using a Spine Board: Supine Athlete No matter how distorted it may appear, the neck MUST be stabilized in the position it is found No matter how distorted it may appear, the neck MUST be stabilized in the position it is found Put the spine board close to the patients side Put the spine board close to the patients side Roll together on the captains signal Roll together on the captains signal Ask if anyone has questions before proceeding Ask if anyone has questions before proceeding Example: “we’ll roll on 3. ready 1,2,3” Example: “we’ll roll on 3. ready 1,2,3”

19. On-Field Evaluation

21. Removing the Athlete from the Field: Removing the Athlete from the Field: Using a Spine Board: Supine athlete Using a Spine Board: Supine athlete Continue to stabilize head and neck throughout the roll and on the spine board Continue to stabilize head and neck throughout the roll and on the spine board Use chin straps and foam blocks to secure the head on the board Use chin straps and foam blocks to secure the head on the board Secure the limbs with straps Secure the limbs with straps Distribute help personnel and lift together Distribute help personnel and lift together

22. On-Field Evaluation Removing the Athlete from the Field: Removing the Athlete from the Field: Using a Spine Board: Prone athlete Using a Spine Board: Prone athlete One person takes charge and immobilizes the head One person takes charge and immobilizes the head Hands should be placed so that the head and neck can maintain their position as the body moves Hands should be placed so that the head and neck can maintain their position as the body moves Assistants kneel and reach across patient’s body Assistants kneel and reach across patient’s body Each person is in charge of a different part, such as the trunk, hips, and legs Each person is in charge of a different part, such as the trunk, hips, and legs Their arms should cross each other for stability and synchronization Their arms should cross each other for stability and synchronization Limbs are placed at athlete’s sides Limbs are placed at athlete’s sides On the captain’s call, the body is turned in unison onto the board On the captain’s call, the body is turned in unison onto the board