Chapter 7: Handling Emergency Situations and Injury Assessment When injuries occur, while generally not life-threatening, they require prompt care

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Chapter 7: Handling Emergency Situations and Injury Assessment

When injuries occur, while generally not life-threatening, they require prompt care

  • When injuries occur, while generally not life-threatening, they require prompt care
  • Emergencies are unexpected occurrences that require immediate attention - time is a factor
  • Mistakes in initial injury management can prolong the length of time required for rehabilitation or cause life-threatening situations to arise
  • All fitness professional, coaches, and others in related areas should be CPR, AED and First Aid trained

Emergency Action Plan

  • Primary concern is maintaining cardiovascular and CNS functioning
  • Key to emergency aid is the initial evaluation of the injured athlete

Emergency Action Plans

  • Emergency Action Plans
    • Separate plans should be developed for each facility
      • Outline personnel and role
      • Identify necessary equipment
      • All involved personnel should know the location of the AED
    • Established equipment and helmet removal policies and procedures
    • Availability of phones and access to 911
      • Must be aware of cell phone calling area issues
    • All staff should be familiar with community based emergency health care delivery plan
      • Be aware of communication, transportation, treatment policies

Community based care (continued)

    • Community based care (continued)
      • Individual calling medical personnel must relay the following: 1) type of emergency 2) suspected injury 3) present condition 4) current assistance 5) location of phone being used and 6) location of emergency
    • Keys to gates/locks must be easily accessible
    • Key facility and school administrators must be aware of emergency action plans and be aware of specific roles
    • Individual should be assigned to accompany athlete to hospital

Cooperation between Emergency Care Providers

  • Cooperation and professionalism is a must
    • Athletic trainer generally first to arrive on scene of emergency, has more training and experience transporting athlete than physician
    • EMT has final say in transportation, athletic trainer assumes assistive role
  • To avoid problems, all individuals involved in plan should practice to familiarize themselves with all procedures (including equipment management)

Parent Notification

  • When athlete is a minor, ATC should try to obtain consent from parent prior to emergency treatment (based on HIPAA)
  • Consent indicates that parent is aware of situation, is aware of what the ATC wants to do, and parental permission is granted to treat specific condition
  • When unobtainable, predetermined wishes of parent (provided at start of school year) are enacted
  • With no informed consent, consent implied on part of athlete to save athlete’s life

Principles of Assessment

  • Appropriate acute care cannot be provided without a systematic assessment occurring on the playing field first
  • On-field assessment
    • Determine nature of injury
    • Provides information regarding direction of treatment
    • Divided into primary and secondary survey

Primary survey

  • Primary survey
    • Performed initially to establish presence of life-threatening condition
    • Airway, breathing, circulation, shock and severe bleeding
    • Used to correct life-threatening conditions
  • Secondary survey
    • Assess vital signs and perform more detailed evaluation of conditions that do not pose life-threatening consequences
    • Used to identify additional problems in other parts of the body not necessarily associated with the injury

Primary Survey

  • Life threatening injuries take precedents
  • Life threatening injuries include
    • Those injuries requiring cardiopulmonary resuscitation
    • Profuse bleeding
    • Shock
  • Rescue squad should always be contacted in these situations

The Unconscious Athlete

  • Provides great dilemma relative to treatment
    • When acting alone, should contact EMS first
  • Must be considered to have life-threatening condition
    • Note body position and level of consciousness
    • Check and establish airway, breathing, circulation (ABC)
    • Assume neck and spine injury
    • Remove helmet only after neck and spine injury is ruled out (facemask removal will be required in the event of CPR)

With athlete supine and not breathing, ABC’s should be established immediately

    • With athlete supine and not breathing, ABC’s should be established immediately
    • If athlete unconscious and breathing, nothing should be done until consciousness resumes
    • If prone and not breathing, log roll and begin CPR
    • If prone and breathing, nothing should be done until consciousness resumes --then carefully log roll and continue to monitor ABC’s
    • Life support should be monitored and maintained until emergency personnel arrive
    • Once stabilized, a secondary survey should be performed

Overview of Emergency Cardiopulmonary Rescucitation

  • Emergency Cardiopulmonary Resuscitation
    • Evaluate to determine need
    • Should be certified through American Heart Association, American Red Cross or National Safety Council
  • CPR for the adult and child (ages 1-12) use the same sequence with only minor differences in technique

Individuals involved in emergent situation should be aware of Good Samaritan Law

  • Individuals involved in emergent situation should be aware of Good Samaritan Law
    • Provides legal protection to individual willing to provide emergency care
  • Ideally should obtain consent from victim prior to rendering first aid
    • When unconscious, consent is implied
  • Rescuer should use the following steps
    • Check – survey the scene
    • Call – activate EMS
    • Care – initiate care for victim

In 2008, the American Heart Association simplified CPR for those that are not certified

  • In 2008, the American Heart Association simplified CPR for those that are not certified
    • Hands-only CPR
    • Following activation of 911, perform uninterrupted CPR (100 compression/min) until EMS arrives or an AED is present
    • Should be used for those adults that unexpectedly collapse, stop breathing or are unresponsive

CPR Flowchart

Equipment Considerations

  • Equipment Considerations
    • Equipment may compromise lifesaving efforts but removal may compromised situation further
    • Facemask should be removed with appropriate clip cutters (Anvil Pruner, Trainer’s Angel, FM Extractor)
    • Recent recommendations suggest using a combination of electric screwdrivers and clip cutters
    • Use of pocket mask/barrier mandated by OSHA during CPR to avoid exposure to blood-borne pathogens

Establish Unresponsiveness

  • Establish Unresponsiveness
    • Gently shake and ask athlete “Are you okay?”
    • If no response, EMS should be activated, positioning of body should be noted and adjusted in the event CPR is necessary, AED should be retrieved

Opening the Airway

  • Head-tilt, chin lift method
  • Push down on the forehead and lifting the jaw moves the tongue from the back of the throat
  • In cases where cervical injury is suspected, the rescuer should use the jaw-thrust maneuver
    • Rescuer hooks the index finger around the curve of the jaw and draws the jaw forward, pulling the tongue from the back of the throat

Establishing Breathing

  • Look, listen and feel
  • While maintaining pressure on forehead, pinch nose, hold head back
  • Take deep breath, and create seal around lips and perform 2 slow breaths (1 per second)
  • If breath does not go in, re-tilt and ventilate
  • If airway is obstructed perform 30 chest compressions, look for the object and perform a finger sweep

Means of Artificial Respiration

Establishing Circulation

  • Locate carotid artery and palpate pulse while maintaining head tilt position
  • If AED is available – should be used as soon as possible
  • If no AED is present and no signs of circulation chest compressions should begin after 2 rescue breaths

Position the heel of hand between the nipples

  • Position the heel of hand between the nipples
  • Place other hand on top with fingers parallel and directed away from athletic trainer
  • Keep elbows locked with shoulders directly above patient
  • Compress chest 1.5-2” (30 times per 2 breaths)

30:2 ratio should be maintained for all victims (infant to adult

  • 30:2 ratio should be maintained for all victims (infant to adult
  • After 5 cycles reassess pulse (if not present continue cycle)

Using an Automatic External Defibrillator (AED)

  • Device that evaluates heart rhythms of victims experiencing cardiac arrest
  • Can deliver electrical charge to the heart
  • Fully automated - minimal training required
  • Electrodes are placed at the left apex and right base of chest - when turned on, machine indicates if and when defibrillation or additional compressions necessary
  • Maintenance is minimal for unit

Obstructed Airway Management

  • Choking is a possibility in many activities
  • Mouth pieces, broken dental work, tongue, gum, blood clots from head and facial trauma, and vomit can obstruct the airway
  • When obstructed individual cannot breath, speak, or cough and may become cyanotic
  • The standing abdominal thrust technique can be used to clear the airway

Obtain consent

  • Obtain consent
  • Deliver 5 back blows initially
  • Next, stand behind athlete with one fist against the body and other over top just below the xiphoid process
  • Provide forceful thrusts to abdomen (up and in) until obstruction is clear

If athlete becomes unconscious, open airway and attempt to ventilate.

  • If athlete becomes unconscious, open airway and attempt to ventilate.
  • If airway still obstructed, re-tilt and re-ventilate
  • If no ventilation, look and perform a finger sweep
    • Be sure not to push object in further with sweep
  • Follow with 30 chest compressions
  • Repeat cycle until air goes in
  • When athlete begins to breath on own, place in comfortable recovery position while lying on their side
  • Recovery Position
  • Finger Sweep

Controlling Bleeding

  • Abnormal discharge of blood
  • Arterial, venous, capillary, internal or external bleeding
    • Venous - dark red with continuous flow
    • Capillary - exudes from tissue and is reddish
    • Arterial - flows in spurts and is bright red
  • Universal precautions must be taken to reduce risk of bloodborne pathogens exposure

External Bleeding

  • Stems from skin wounds, abrasions, incisions, lacerations, punctures or avulsions
  • Direct pressure
  • Elevation
    • Reduces hydrostatic pressure and facilitates venous and lymphatic drainage - slows bleeding
  • Pressure Points
    • Eleven points on either side of body where direct pressure is applied to slow bleeding

Internal Hemorrhage

  • Invisible unless manifested through body opening, X-ray or other diagnostic techniques
  • Can occur beneath skin (bruise) or contusion, intramuscularly or in joint with little danger
  • Bleeding within body cavity could result in life and death situation
  • Difficult to detect and must be hospitalized for treatment
  • Could lead to shock if not treated accordingly

Managing Shock

  • Generally occurs with severe bleeding, fracture, or internal injuries
  • Result of decrease in blood available in circulatory system
    • Vascular system loses capacity to maintain fluid portion of blood due to vessel dilation, and disruption of osmotic balance
  • Movement of blood cells slows, decreasing oxygen transport to the body

Extreme fatigue, dehydration, exposure to heat or cold and illness could predispose athlete to shock

  • Extreme fatigue, dehydration, exposure to heat or cold and illness could predispose athlete to shock
  • Signs and Symptoms
    • Moist, pale, cold, clammy skin
    • Weak rapid pulse, increasing shallow respiration decreased blood pressure
    • Urinary retention and fecal incontinence
    • Irritability or excitement, and potentially thirst


  • Management
    • Dial 911 to access emergency care
    • Maintain core body temperature
    • Elevate feet and legs 8-12” above heart
    • Positioning may need to be modified due to injury
    • Keep athlete calm as psychological factors could lead to or compound reaction to life threatening condition
    • Limit onlookers and spectators
    • Reassure the athlete
    • Do not give anything by mouth until instructed by physician

Conducting a Secondary Survey

  • Once athlete is deemed stable a secondary survey can begin
  • Recognizing vital signs
    • Heart rate and breathing rate
    • Blood pressure
    • Temperature
    • Skin color
    • Pupils
    • Movement
    • Presence of pain
    • Level of consciousness

On-Field Injury Inspection

  • Initial on-field injury inspection
    • Determine injury severity and transportation from field
  • Must use logical process to adequately evaluate extent of trauma
  • Knowledge of mechanisms of injury and major signs and symptoms are critical

Once the mechanism has been determined, specific information can be gathered concerning the affected area

  • Once the mechanism has been determined, specific information can be gathered concerning the affected area
    • Brief history
    • Visual observations
  • Gently palpate to aid in determining nature of injury
    • Determine extent of point tenderness, irritation and deformity

Decisions can be made with regard to:

  • Decisions can be made with regard to:
    • Seriousness of injury
    • Type of first aid and immobilization
    • Whether condition require immediate referral to physician for further assessment
    • Manner of transportation from injury site to sidelines, training room or hospital
  • Individual performing initial assessments should document findings of exam and actions taken

Off-Field Assessment

  • Performed by athletic trainer, physical therapist or physician once athlete has been removed from site of injury
  • Divided into 4 segments
    • History
    • Observation
    • Physical examination
    • Special tests


  • History
    • Obtain information about injury
    • Listen to athlete and how key questions are answered
  • Visual Observation
    • Inspection of injured and non-injured areas
    • Look for gross deformity, swelling, skin discoloration
  • Palpation
    • Assess bony and soft tissue
    • Systematic evaluation beginning with light pressure and progressing to deeper palpation – beginning away from injured area

Special Test

  • Special Test
    • Designed for every body region for detecting specific pathologies
    • Used to substantiate findings from other testing

Immediate Treatment Following Acute Injury

  • Primary goal is to limit swelling and extent of hemorrhaging
  • If controlled initially, rehabilitation time will be greatly reduced
  • Control via PRICE
    • REST
    • ICE


      • Prevents further injury
      • Immobilization and appropriate forms of transportation will help in protecting an injury from further damage
    • REST
      • Stresses and strains must be removed following injury as healing begins immediately
      • Days of rest differ according to extent of injury
      • Rest should occur 72 hours before rehab begins

ICE (Cold Application)

    • ICE (Cold Application)
      • Initial treatment of acute injuries
      • Used for strains, sprains, contusions, and inflammatory conditions
      • Used to decrease pain, promote vasoconstriction
      • Lowers metabolism, tissue demand for oxygen and hypoxia
      • Ice should be applied initially for 20 minutes and then repeated every 1 - 1 1/2 hours and should continue for at least the first 72 hours of new injury
      • Treatment must last at least 20 minutes to provide adequate tissue cooling and can be continued for several weeks


    • Compression
      • Decreases space allowed for swelling to accumulate
      • Important adjunct to elevation and cryotherapy and may be most important component
      • A number of means of compression can be utilized (Ace wraps, foam cut to fit specific areas for focal compression)
      • Compression should be maintained daily and throughout the night for at least 72 hours (may be uncomfortable initially due to pressure build-up)
    • Elevation
      • Reduces internal bleeding due to forces of gravity
      • Prevents pooling of blood and aids in drainage
      • Greater elevation = more effective reduction in swelling

Emergency Splinting

  • Should always splint a suspected fracture before moving
    • Without proper immobilization increased damage and hemorrhage can occur (potentially death if handled improperly)
  • It is a simple process
  • New equipment has also been developed
  • Two rules
    • Splint 1 joint above and below fracture
    • Splint injury in position found

Rapid form immobilizer

  • Rapid form immobilizer
  • Air splint
    • Clear plastic splint inflated with air around affected part
    • Can be used for splinting but requires practice
    • Do not use if it will alter fracture deformity
    • Provides moderate pressure and can be x-rayed through

Splinting of Lower Limb Fractures

  • Splinting of Lower Limb Fractures
    • Fractures of foot and ankle require splinting of foot and knee
    • Fractures involving knee, thigh, or hip require splinting of whole leg and one side of trunk
  • Splinting of Upper Limb Fractures
    • Around shoulder, splinting is difficult but doable with sling and swathe with upper limb bound to body
    • Upper arm and elbow should be splinted with arm straight to lessen bone override

Splinting of Upper Limb Fractures (cont.)

  • Splinting of Upper Limb Fractures (cont.)
    • Lower arm and wrist fractures should be splinted in position of forearm flexion and supported by sling
    • Hand and finger fractures/dislocations should be splinted with tongue depressors, roller gauze and/or aluminum splints
  • Splinting of the spine and pelvis
      • Best splinted and moved with a spine board
      • Total body rapid form immobilizers have been developed for dealing with spinal injuries
      • Effectiveness has yet to be determined

Moving and Transporting Injured Athletes

  • Must be executed with techniques that will not result in additional injury
  • No excuse for poor handling
  • Planning is necessary and practice is essential
  • Additional equipment may be required

Suspected Spinal Injury

  • Coach should access EMS immediately and wait for rescue squad before attempting to move athlete
  • Transportation and movement should be left to trained experts
  • Maintain head and neck in alignment with long axis of body

Placing Athlete on Spine Board

  • Placing Athlete on Spine Board
    • EMS should be contacted if this will be required
    • Must maintain head and neck in alignment of long axis of the body
    • One person must be responsible for head and neck at all times
    • Primary emergency care must be provided to maintain breathing, treating for shock and maintaining position of athlete
    • Permission should be given to transport by physician

Ambulatory Aid

  • Ambulatory Aid
    • Support or assistance provided to injured individual to walk
    • Prior to walking, serious injury should be ruled out along with further injury with walking
    • Complete and even support should be provided on both sides by individuals of equal height when providing ambulatory aid
    • Arms of athlete are draped over shoulders of assistants, with their arms encircling his/her back

Manual Conveyance

  • Manual Conveyance
    • Used to move mildly injured athlete a greater distance than could be walked with ease
    • Carrying the athlete can be used following a complete examination
    • Convenient carry is performed by two assistants
  • Stretcher Carrying
    • Best and safest mode of transport
    • With all segments supported/splinted athlete is lifted and placed gently on stretcher
    • Careful examination is required if stretcher is needed
    • Various injuries will require different positioning on stretcher

Proper Fit and Use of Crutch or Cane

  • When lower extremity ambulation is contraindicate a crutch or cane may be required
  • Faulty mechanics or improper fitting can result in additional injury or potentially falls
  • Fitting athlete
    • Athlete should stand with good posture, in flat soled shoes
    • Crutches should be placed 6” from outer margin of shoe and 2” in front

Crutch base should fall 1” below anterior fold of axilla

    • Crutch base should fall 1” below anterior fold of axilla
    • Hand brace should be positioned to place elbow at 30 degrees of flexion
    • Cane measurement should be taken from height of greater trochanter
  • Walking with Cane or Crutch
    • Corresponds to walking
    • Tripod method
      • Swing through without injured limb making contact with ground
    • Four- point crutch gait
      • Foot and crutch on same side move forward simultaneously with weight bearing
  • Stair climbing should be introduced when athlete is able to move effectively on level surface (‘up with the good – down with the bad’)

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