Flow chart of emergency procedures (Figure 12-1) page 276

The on-the-field assessment may be divided into a primary survey and a secondary survey.

The primary survey, which is done initially, determines the existence of potentially life-threatening situations, including problems with the airway, breathing, and circulation and with severe bleeding and shock.  The primary survey takes precedence over all other aspects of victim assessment and should be used to correct life-threatening situations.

The secondary survey gathers information about the injury sustained by the athlete, systematically assesses vital signs and symptoms, and allows for a more detailed evaluation of the injury.

The unconscious athlete must always be considered to have a life-threatening injury, which requires an immediate primary survey.

Dealing with an unconscious athlete page 276-278.

External bleeding can be managed through direct pressure, elevation, or pressure points.

SHOCK

Shock occurs when a diminished amount of blood is available to the circulatory system, that is, when the vascular system loses its capacity to hold the fluid portion of blood within its system because of dilation of blood vessels within the body and disruption of the osmotic fluid balance.  When shock occurs, a quantity of only plasma moves from the blood vessels into the tissue spaces of the body, leaving the blood cells within the blood vessels, causing stagnation, and slowing the blood flow.  As a result, not enough oxygen-carrying blood cells are available to the tissues, particularly those of the nervous system.  With this general collapse of the vascular system comes widespread tissue death, which will eventually cause the death of this individual unless treatment if given.

            Certain conditions, such as extreme fatigue, extreme exposure to heat or cold, extreme dehydration of fluids and mineral loss, or illness, predispose an athlete to shock.  In a situation in which there is potential shock condition, there are other signs by which the athletic trainer should assess the possibility of the athletes lapsing into a state of shock as an aftermath of the injury.  The most important clue to potential shock is recognition of a severe injury.  It may happen that none of the usual signs of shock is present.

            The main types of shock are hypovolemic, respiratory, neurogenic, psychogenic, cardiogenic, septic, anaphylactic, and metabolic.

            Hypovolemic shock stems from trauma in which there is blood loss.  Decreased blood volume causes a decrease in blood pressure.  Without enough blood in the circulatory system, organs are not properly supplied with oxygen.

            Respiratory shock occurs when the lungs are unable to supply enough oxygen to the circulating blood.  Trauma that produces a pneumothorax or an injury to the breathing control mechanism can produce respiratory shock.

            Neurogenic shock is caused by the general dilation of blood vessels within the cardiovascular system.  When it occurs, the typical six liters of blood can be no longer supply oxygen to the body.

            Psychogenic shock refers to what is commonly known as fainting (syncope).  It is caused by temporary dilation of blood vessels that reduces the normal amount of blood in the brain.

            Cardiogenic shock refers to the inability of the heart to pump enough blood to the body.

            Septic shock occurs from a severe, usually bacterial, infection.  Toxins liberated from the bacteria cause small blood vessels in the body to dilate.

            Anaphylactic shock is the result of a severe allergic reaction caused by foods, insect stings, or drugs or by inhaling dusts, pollen, or other substances.

            Metabolic shock happens when a severe illness such as diabetes goes untreated.  Another cause is an extreme loss of bodily fluid (e.g. through urination, vomiting, or diarrhea).

Signs of shock

1.  Blood pressure is low

2.  Systolic pressure is usually below 90 mm Hg.

3.  Pulse is rapid and weak

4.  Athlete may be drowsy and appear sluggish

5.  Respiration is shallow and extremely rapid

6.  Skin is pale, cool, and clammy

Management of shock

            Depending on the causative factor of shock, the following emergency care should be given:

1.  Maintain body temperature as close to normal as possible.

2.  Elevate the feet and legs eight to twelve inches for most situations.  However, shock positioning varies according to the type of injury.  For a neck injury, the athlete should be immobilized as found; for a head injury, his or her head and shoulders should be elevated; and for a leg fracture, his or her legs should be kept level and should be raised after splinting.

            Shock can also be compounded or even initially produced by the psychological reaction of the athlete to an injury situation.  Fear or the sudden realization that a serious situation has occurred can result in shock.  In the case of psychological reaction to an injury, the athlete should be instructed to lie down and avoid viewing the injury.  The athlete should be held with patience and gentleness, but firmness as well.  Spectators should be kept away from the injured athlete.  Reassurance is of vital concern to the injured individual.  The person should be given immediate comfort through the loosening of clothing.  Nothing should be given by mouth until a physician has determined that no surgical procedures are indicated.

VITAL SIGNS

Pulse

            Carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsal pedalis

            Normal 60 to 80 beats adults, 80 to 100 beats in children

Respiration

            Normal breathing 12 breaths adults, 20 to 25 breaths in children

Blood pressure

            Systolic blood pressure-the pressure caused by the hearts pumping

            Diastolic blood pressure-the residual pressure when the heart is between beats

            Normal systolic for 15 to 20 y/o is 115 to 120 mm Hg

            Normal diastolic for 15 to 20 y/o is 75 to 80 mm Hg

            Normal blood pressure for females is usually 8 to 10 mm Hg lower than males

Temperature

Skin color

Pupils

State of consciousness

Movement

Abnormal nerve response

Immediate treatment (PRICE)

CHAPTER 13 Off the field Evaluation

EVALUATION OF SPORTS INJURIES

Four distinct evaluation are routinely conducted:  the pre-participation physical examination, done prior to the start of preseason practice; the initial on-the-field assessment, is done immediately after acute injury to determine the immediate course of acute care, necessary first aid, and handling of emergency situations; a more detailed off-the-field injury evaluation is done in the athletic training room, clinic, emergency room, or physicians office after appropriate first aid has been rendered; and a progress evaluation is done periodically throughout the rehabilitative process for determining the progress and effectiveness of a specific treatment regimen.

Athletic trainers recognize and evaluate sports injuries, but by law they cannot make diagnoses.

Terms

Etiology cause of disease

Pathology structural and functional changes that result from an injury

Symptom Symptoms are subjective and are described by the athlete to the coach or athletic trainer, or physician.

Sign an objective, definitive and obvious indicator for a specific condition.

Indication condition, which warrants certain actions

            Example:  an indication for using aspirin is a headache.

Contraindication condition in which certain action would prove harmful

            Example:  a contraindication for taking medication is drinking alcohol.

Off-the-field evaluation (HOPS)

History

            Past

            Present

                        Injury location

                        Pain characteristics

                        Joint responses

                        Determining whether the injury is acute or chronic

Observation

Palpation

            Bony palpation

            Soft-tissue palpation

Special Tests

            Movement assessment

                        AROM, PROM, RROM

                        Goniometric measurements

            Manual muscle testing

            Neurological examination

                        Cerebral function, cranial nerve function, cerebellar function,

sensory testing, reflex testing

            Joint stability

            Functional performance testing

            Postural examination

            Anthropometric measurements (body fat)

            Volumetric measurements

Reflexes

            The term reflex refers to involuntary response to stimulus.  In terms of the neurological examination there are three types of reflexes:  deep tendon (somatic) reflexes, superficial reflexes, and pathological reflexes.

            A deep tendon reflex is caused by stimulation of the stretch reflex and results in an involuntary contraction of muscle because of stretch of its tendon.  Deep tendon reflexes can be elicited at the tendons of the biceps (C5), brachioradialis (C6), triceps (C7), patella (L4), and Achilles (S1).

            Superficial reflexes are elicited by stimulation of the skin at specific sites, which produces a reflex muscle contraction.  Superficial reflexes include upper abdominal (T7, 8, 9), lower abdominal (T11, 12), cremasteric (T12, L1), plantar (S1, 2), and gluteal (L4, S3).  An absence of a superficial reflex is indicative of some lesion in the cerebral cortex of the brain.

            Pathological reflexes are also superficial reflexes.  The presence of a pathological reflex indicates a lesion in the cerebral cortex, an absence indicates integrity.  Babinskis sign, in which stroking of the lateral plantar surface produces extension and splaying of the toes, is an example of a pathological reflex.  Chaddocks, Oppenheims, and Gordons are additional pathological reflexes.

SOAP Notes is the documentation of acute athletic injury findings and a plan of action to be taken.

Subjective

Objective

Assessment

Plan

Subjective

This component includes the subjective statements provided by the injured athlete.  History taking is designed to elicit the subjective impressions of the athlete relative to time, mechanism, and site of injury.  The type and course of the pain and the degree of disability experienced by the athlete are also noteworthy.

Objective

Objective findings result form the athletic trainers visual inspection, palpation, and assessment of active, passive, and resistive motion.  Findings of special testing should also be noted here.  Thus the objective report would include assessment of posture, presence of deformity or swelling, and location of point tenderness.  Also, limitations of active motion and pain arising or disappearing during passive and resistive motion should be noted.  Finally, the results of special tests relative to joint stability or apprehension are also included.

Assessment

Assessment of the injury is the athletic trainers professional judgment with regard to impression and nature of injury.  Although the exact nature of the injury will not always be known initially, information pertaining to suspected site and anatomical structures involved is appropriate.  A judgment of severity may be included but is not essential at the time of acute injury evaluation.

Plan

The plan should include the first aid treatment rendered to the athlete and the sports therapists intentions relative to disposition.  Disposition may include referral for more definitive evaluation or simply, wrap, or crutches and a request to report for reevaluation the next day.  If the injury were chronic, the examiners plan for treatment and therapeutic exercise would be appropriate.  The treatment plan should establish specific short-term goals for the rehabilitation program and should provide criteria-based guidelines for accomplishing these goals.

CHAPTER 14 Bloodborne Pathogens

Bloodborne pathogens are transmitted through contact with blood or other bodily fluids.  Hepatitis, especially the hepatitis B virus (HBV), and human immunodeficiency virus (HIV) are of special concern.

            Bloodborne pathogens are pathogenic microorganisms that can potentially cause disease and are present in human blood and other body fluids, including:  semen, vaginal secretions, cerebrospinal fluid, synovial fluid, and other fluid contaminated with blood.  A number of other bloodborne diseases exist, including hepatitis C, hepatitis D, and syphilis.  Hepatitis A virus (HAV) is spread by lack of personal hygiene and can be transmitted during unprotected sexual intercourse, from contact with feces of infected persons, and from shellfish taken from contaminated water.  Good sanitation, personal hygiene, and properly cooking shellfish at high temperatures are essential for prevention.

            Although HIV has been widely addressed in the media, HBV has a higher possibility for spread than HIV, and thus athletic trainers should be more concerned about contracting HBV.  Hepatitis B virus is stronger and more durable than HIV and can be spread more easily via sharp objects, open wounds, and bodily fluids.

HBV is a major cause of viral infection; it results in swelling, soreness, and loss of normal function of the liver.

The signs and symptoms in a person infected with HBV include flu-like symptoms such as fatigue, weakness, nausea, abdominal pain, headache, fever, and possibly jaundice.  It is possible that an individual infected with HBV will exhibit no signs or symptoms, and the virus may go undetected.

            Good hygiene and avoiding high-risk activities is the best way to avoid HBV.  HBV can survive for at least one week in dried blood or on contaminated surfaces and may be transmitted through contact with these surfaces.

            Vaccination against HBV must be made available by the employer at no cost to any individual who may be exposed to blood or other body fluids and may thus be at risk of contracting HBV.  The vaccine is given in 3 doses over a six-month period.

Unlike HBV, there is no vaccine for HIV.

Latex gloves should be worn whenever the athletic trainer handles blood or bodily fluids.  Gloves are always removed carefully and disposed of properly after use.  Hands and skin the comes in contact with blood must be washed immediately. 

Uniforms containing blood must be removed and changed before the athlete can return to competition.

All contaminated surfaces such as treatment tables, taping tables, work areas, and floors should be cleaned immediately with a solution of one part bleach to 10 parts water (1:10) or with a disinfectant approved by the Environmental Protection Agency.

Sharps refers to sharp object used in the athletic training, such as needles, razor blades, and scalpels.  Extreme care should be taken when handling and disposing of sharps to minimize risk of puncturing or cutting the skin.  Whenever needles are used, they should not be recapped, bent, or removed from the syringe.  This extra handling may result in accidental exposure to the sharp surfaces that may contain blood.  Sharps should be disposed of in a leakproof and puncture-resistant container.  The container should be red and labeled as a biohazard.

CHAPTER 15 Using Therapeutic Modalities

Modality- application of anything that affects a person's physiology in a therapeutic way helps to provide an optimal environment for healing.

Modalities help to break the pain-spasm cycle (vicious cycle), reduce secondary hypoxic injury, reduce edema/effusion, and help create an optimal environment for healing.

PRICE - Protection, Rest, Ice, Compression, Elevation

(Elevation must be above the level of the heart to be effective)

Types of Modalities:
Cryotherapy- the application of cold
Thermotherapy- the application of heat
Electrotherapy- any application of electricity
Compression- any application that applies a compressive force to reduce swelling

Cryotherapy:
Physiologic reactions to cold:
Decrease blood flow to area
Decrease muscle spasm
Decrease pain perception
Decrease metabolic rate at which reactions occur
Decrease connective tissue stretchability
Decrease edema/effusion
Increase joint stiffness

Contraindications to cryotherapy - (why not to use)
Not more that 30 mins
Cold allergy
Nerve Palsy

Stages of Cold application
0-3 mins- feels cold
2-7 mins-burns and aches
5-12 mins- numbness
15-30 mins- Hunting Response - increased blood flow to prevent tissue damage from too much cold exposure

Modes of Application:
Ice massage- 5-10 min- good for spasm and tendinitis
Ice immersion- 10-20 min- 48-58 degrees, good for extremities
Ice packs- 15-20 min
Ice towels- towels with Ice and water good for heat illness
***Chemical packs- don't get cold enough, or get too cold.  Possibility of chemical leakage

Thermotherapy:
Physiologic effects:
increase blood flow
decrease muscle spasm
increase metabolic rate
increase connective tissue stretchability
decrease joint stiffness
increase edema (in acute situations)

Contraindications
Never use during acute inflammatory stage
Never use over abdomen of pregnant female
Never use over area of decreased sensation
Never use over genitalia
Never use over eyes
Never use over area of infection

Modes of application
Hydrocollator packs - moist heat, water 140-150 deg
Warm whirlpool - 102-110 deg, 90-100 deg if full body
Infrared - heat lamps, paraffin wax bath 120 degrees
Diathermy - heats tissue through short wave or microwave
Analgesic balm (counter irritant) - does not cause increase in temperature.  Only feels warm because it irritates nerve endings.

Electrical Modalities
Ultrasound- provides heating and micromassage through sound waves.  Can also be used to drive medication across skin barrier.

Electrical stimulation- can be used to block pain, cause muscle to contract, or drive medications across skin barrier.