Resuscitation of the Athlete
Content
Resuscitation
IMPORTANT NOTICE: On March 30, 2008, the American Heart Association broke away from the ILCOR position and stated that COMPRESSION-ONLY CPR WORKS AS WELL AS , AND SOMETIMES BETTER THAN, TRADITIONAL CPR. The method of delivering chest compressions remains the same, as does the rate (100 per minute), but the rescuer delivers only the compression element which, the University of Arizona claims, keeps the bloodflow moving without the interruption caused by MTM respiration. It has been claimed that the use of compression only delivery increases the chances of lay person delivering CPR (REF Wikipedia, accessed 26/9/08. http://en.wikipedia.org/wiki/CPR)
· · · · ·
Introduction Sick and injured athletes The collapsed athlete Early CPR The seriously injured
Introduction
The number that are life-threatening is probably low. The risk of these injuries or illnesses amongst athletes depends upon factors, such as the type and level of sport (amateur versus professional), and the athlete’s previous illness or injury and level of fitness. Use a simple approach for cases of potential life-threatening injury (Fig. 1) or illness as confusion or doubt can be lethal.. Sick and Injured Athletes Resuscitating patients falls into two basis groups: non-trauma related or trauma related (Fig. 2). Various treatment algorithms have been designed for each group (Australian Resuscitation Council, American Heart Association, Early Management of Severe Trauma, Advanced Trauma Life Support). For athletes requiring resuscitation it is essential to determine from the onset of first aid, if there has been any trauma present. If there is uncertainty about the presence or absence of trauma,
assume trauma is involved and treat accordingly (Fig. 3). 1 Figure 1
Field Approach to Injury Injuries can be: Action 1. Minor cuts/abrasions/sprains/cramps Return to game 2. Moderate sprains (swelling, pain, ▼ ROM) Treat on site/later refer 3. Severe severe pain, swelling, deformity Expert medical care (severe sprains, fractures, dislocations) 4. Life stroke, head/neck injury, heart attack Resuscitate threatening Use: A airway B breathing C circulation History: Brief talk to athlete or witness/details of accident/extent pain/assess severity. Examine:
Check for: swelling/deformity/tenderness/ROM and classify (as above). Treat.
Figure 2
Basic differences between nontrauma related and trauma related illness in athletes Examples Airway Management Circulation Management Nontrauma Related Dehydration Exertional heat illness (heat stroke) Cardiac disease (eg angina, heart attack, or arrhythmia) Exercise induced acute asthma Epilepsy Diabetic hypoglycaemia Standard Basic Life Support (see below) Standard Basic Life Support (see below) Trauma Relates Contact sports spear tackle (rugby) boxing Motor sports Water sports neardrowning diving into shallow water Falls rock climbing Must protect the neck and prevent head movement Require early intravenous therapy Obvious external bleeding must be stopped pressure bandage Do not use tourniquets
Care of the Collapsed or Seriously Ill Athlete
The basic principles of the resuscitation of collapsed or seriously ill patients are outlined (Fig. 4). The steps in this Chain of Survival are: 1.Early Access to emergency medical services. This “call for help” allows the rapid delivery of care in the field by ambulance services to commence early stabilisation and delivery of the patient to a hospital for definitive care. 2. Early commencing of bystander CPR (cardiopulmonary resuscitation), when required. This will buy time for the arrival of ambulance personnel, particularly in the setting of cardiac arrest, where early defibrillation is the most important factor determining survival. 3. Early Defibrillation is the most important factor in determining survival in cardiac arrest due to either ventricular fibrillation or pulseless ventricular tachycardia. 4. Early Advanced Care implies the rapid delivery of the seriously ill patient to hospital. In the non-trauma related illness this allows the early administration of advanced medical care. 3 Early Access to Emergency Medical Services
Emergency medical services are able to achieve two major goals: the early resuscitation and stabilisation of the seriously ill patient, and the rapid delivery of the patient to definitive care. This is bet achieved when bystanders “call for help: as the initial step in the caring for the seriously ill patient. If two or more bystanders are present, one person should dial the Emergency telephone number, while other commence CPR. When doing this it is important to relate clear information regarding the location of the patient, and any other information requested by the operator. For the infant or child, in arrest, the most likely cause is an airway problem. In this setting it is best to commence CPR, then call for help. “Call for help” also implies gaining assistance at the scene, before the ambulance arrives. Even for people experienced in resuscitation, CPR is always easier with 2 or more people lending help. Do not hesitate seeking help. Commencing Early CPR ( SEE ABOVE)
The window of opportunity for survival from cardiac arrest is small. As such the aim of bystander CPR is to increase the time before death occurs, allowing emergency medical services the opportunity to deliver earl defibrillation, and other advanced care techniques. After assessing the person’s responsiveness, the steps in bystander CPR or basic life support for the collapsed patient are as follows (Fig. 5):
1. Secure the airway
To do this requires 2 actions, firstly clearing the airway, and then opening the airway. Clearing the airway removes any foreign bodies from the airway including dentures, broken teeth, food, vomit or blood. It is achieved by the finger sweep, although care must be taken not to dislodge any loose teeth, especially in young children. When available a suction device should be used. After clearing the airway, it may need to be opened by a combination of extending the head, chin lift and jaw thrust (Fig. 6). Various devices such as oropharyngeal airways or Guedel’s airway (Fig. 7) should be used if available. 2. Assess and ensure breathing (rescue breathing or expired air resuscitation). To assess the presence or absence of breathing one must look for movement of the chest with inhalation and exhalation, feel for chest movement and listen for the movement of air. This can be easily achieved by using the technique shown in Fig. 8. If there is no evidence of breathing, rescue breathing should be commenced immediately. This is commenced with 2 slow breaths, by the mouth-to-mouth technique, ensuring that the chest rises (Fig. 9). If a mouth to mask device is available (Fig. 10), this may be used, reducing any risk of infection. The rates and ratios of external cardiac compression and rescue breathing are shown in Fig. 10. 4 Figure 11
Ratios of breath to chest compressions for cardiopulmonary resuscitation
Ventilation One Rescuer Two Rescuers 15 breaths/min 15 breaths/min 80 to 100/min 80 to 100/min 15 to 2 5 to 1 Chest Compressions Ratio
3.
Assess and maintain circulation (external cardiac compression)
To assess the circulation the rescuer feels for the carotid pulse, in the neck at the angle of the jaw. If the pulse is present, but the patient is not breathing spontaneously, continue
rescue breathing at a rate of 15 breaths per minute, until either help arrives or spontaneous breathing commenced. If there is o detectable carotid pulse< commence external cardiac compression (ECC) immediately. The hands are placed on the lower third of the sternum, with the arms locked at the elbows and the rescuer kneeling over the patient (Fig. 12). Compressions are approximately 5 cm deep in the adult, at a rate of between 80 to 100 compressions per minute. This is tiring work, if continued for a prolonged period, so do not hesitate in getting help from other bystanders, changing every few minutes. To determine the adequacy of ECC, the carotid pulse should be felt for, and after every 2 minutes of full CPR, a check should be made for the return of spontaneous breathing and circulation. Full CPR should be continued until either help arrives, or there is return of a spontaneous circulation. 4.
Stabilisation and Transport
When the patient begins to maintain their own airway and breathing, and has return of a spontaneous circulation, they should be placed in the coma position until help arrives (Fig. 13). Airway patency, adequacy of breathing and circulation, should be frequently reassessed, and any deterioration should be acted upon immediately. Once available, the patient should be transported to hospital, as soon as possible. The Seriously Injured Athlete
The approach to the seriously injured athlete is similar to that of the seriously ill athlete, with a couple of points of note. The system taught in Advanced Trauma Life Support and the Early Management of Severe Trauma courses, is an easy to remember system for dealing with such cases (see Fig. 14). Remember: 1. Remove from danger, in order to prevent further injury. While doing so it is essential to protect the patient’s neck, to prevent any trauma to the cervical spine and spinal cord. Fig. 14 shows how this may be achieved. 2. Airway management includes care of the cervical spine. In the non-injured patient, one of the first airway opening manoeuvres is to extend the neck. This should not be done in the injured patient, especially if unconscious, as it may damage the cervical spine. All airway manoeuvres must be accompanied by in-line cervical immobilization). When available, the neck should be immobilized with a rigid cervical collar (see Fig. 16). 3. In controlling the circulation, control blood loss. This can be achieved over the site of any external bleeding by pressure (Fig. 17). Limb tourniquets should not be used, as they may cause arterial or nerve damage. Any long bone fractures, especially fractures of the femur, should be splinted to reduce blood loss and help control pain (Fig. 18).
4.
In the unconscious, injured athlete always consider severe head
injury. These patients need rapid stabilisation and transfer to a hospital to allow a further assessment for potentially life threatening intracranial bleeding, which will require urgent operation (Fig. 19).
Figure 14
The approach to the severely injured athlete. At the scene, it is important to prevent further injury by removing the patient from any danger. It is essential to care for the patient’s neck whilst doing so. Primary Survey Assess disability (neurologic function) Control environment, and be able to clearly explain the events causing injury If unconscious, assume major head injury and transport to hospital ASAP If unable to move arms or legs, assume spinal cord injury, and prevent further injury by not moving until help arrives Remove from anger Prevent excessive cooling if injured Be clear about the mechanism of injury (events), as this is important in looking for Airway and cervical spine immobilisation Assess and ensure adequate breathing (ventilation) Control bleeding and maintain circulation Immobilise head and neck with inline stabilisation Clear airway Open airway – remember not to extend the neck Commence rescue breathing Apply pressure to external bleeding commence external chest compression, if no pulse
Resuscitation Phase Secondary Survey Stabilisation and Transport Any immediately life threatening problem found in the primary survey is addressed Usually done in hospital head to toe, front to back examination looking for injuries Usually includes xrays and blood tests Reassess ABC, before moving Splint any limb injuries
injuries later System by system examination Thorough history: Allergies Medications, last tetanus Previous illness/surgery Last ate Event – what happened Transport to hospital as soon as possible
7 Legends for Chapter 5 – The Fallen Athlete Figure 1 - On Field Approach to Injury Figure 2 - Some basic differences between non-trauma related and trauma related illness in athletes. Figure 3 - Initial assessment of the sick or injured athlete. Figure 4 - The Chain of Survival (adapted from the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care) Figure 5 - Basic Life Support Figure 6 - Opening the airway. Note how each of the manoeuvres results in moving the tongue from the back of the pharynx. Remember in the injured patient not to use head extension, as this may damage the cervical spine. Figure 7 - An oropharyngeal (Geudel’s) airway. When inserting the airway take care not to dislodge teeth as the airway is rotated into position. This is especially important in young children with primary dentition.
Figure 8 - Assessing the adequacy of breathing. By adopting this position it is easy to look for the chest moving, feel for the chest moving, and listen for the movement of air, while keeping the airway open. Figure 9 - Rescue (Mouth to Mouth) breathing. Note how the rescuer is able to assess the adequacy of rescue breathing by watching the chest move, while maintaining an open airway. Figure 10 - Mouth to mask ventilation. Such devices are portable and reduce the risks to the rescuer due to vomiting and infectious diseases. They should only be used by people adequately trained in their use. Figure 11 - Ratios and rates for CPR. Figure 12 - Technique of CPR> Hands over lower 1/3 of sternum, elbows locked, rescuer kneeling over patient. Figure 13 - The Recovery (coma) position. Placing the patient in this position allows the patient op keep their airway open, and reduces the risk of aspiration of vomitus. Figure 14 - The approach to the severely injured athlete.
IMPORTANT NOTICE: On March 30, 2008, the American Heart Association broke away from the ILCOR position and stated that COMPRESSION-ONLY CPR WORKS AS WELL AS , AND SOMETIMES BETTER THAN, TRADITIONAL CPR. The method of delivering chest compressions remains the same, as does the rate (100 per minute), but the rescuer delivers only the compression element which, the University of Arizona claims, keeps the bloodflow moving without the interruption caused by MTM respiration. It has been claimed that the use of compression only delivery increases the chances of lay person delivering CPR (REF Wikipedia, accessed 26/9/08. http://en.wikipedia.org/wiki/CPR)
· · · · ·
Introduction Sick and injured athletes The collapsed athlete Early CPR The seriously injured
Introduction
The number that are life-threatening is probably low. The risk of these injuries or illnesses amongst athletes depends upon factors, such as the type and level of sport (amateur versus professional), and the athlete’s previous illness or injury and level of fitness. Use a simple approach for cases of potential life-threatening injury (Fig. 1) or illness as confusion or doubt can be lethal.. Sick and Injured Athletes Resuscitating patients falls into two basis groups: non-trauma related or trauma related (Fig. 2). Various treatment algorithms have been designed for each group (Australian Resuscitation Council, American Heart Association, Early Management of Severe Trauma, Advanced Trauma Life Support). For athletes requiring resuscitation it is essential to determine from the onset of first aid, if there has been any trauma present. If there is uncertainty about the presence or absence of trauma,
assume trauma is involved and treat accordingly (Fig. 3). 1 Figure 1
Field Approach to Injury Injuries can be: Action 1. Minor cuts/abrasions/sprains/cramps Return to game 2. Moderate sprains (swelling, pain, ▼ ROM) Treat on site/later refer 3. Severe severe pain, swelling, deformity Expert medical care (severe sprains, fractures, dislocations) 4. Life stroke, head/neck injury, heart attack Resuscitate threatening Use: A airway B breathing C circulation History: Brief talk to athlete or witness/details of accident/extent pain/assess severity. Examine:
Check for: swelling/deformity/tenderness/ROM and classify (as above). Treat.
Figure 2
Basic differences between nontrauma related and trauma related illness in athletes Examples Airway Management Circulation Management Nontrauma Related Dehydration Exertional heat illness (heat stroke) Cardiac disease (eg angina, heart attack, or arrhythmia) Exercise induced acute asthma Epilepsy Diabetic hypoglycaemia Standard Basic Life Support (see below) Standard Basic Life Support (see below) Trauma Relates Contact sports spear tackle (rugby) boxing Motor sports Water sports neardrowning diving into shallow water Falls rock climbing Must protect the neck and prevent head movement Require early intravenous therapy Obvious external bleeding must be stopped pressure bandage Do not use tourniquets
Care of the Collapsed or Seriously Ill Athlete
The basic principles of the resuscitation of collapsed or seriously ill patients are outlined (Fig. 4). The steps in this Chain of Survival are: 1.Early Access to emergency medical services. This “call for help” allows the rapid delivery of care in the field by ambulance services to commence early stabilisation and delivery of the patient to a hospital for definitive care. 2. Early commencing of bystander CPR (cardiopulmonary resuscitation), when required. This will buy time for the arrival of ambulance personnel, particularly in the setting of cardiac arrest, where early defibrillation is the most important factor determining survival. 3. Early Defibrillation is the most important factor in determining survival in cardiac arrest due to either ventricular fibrillation or pulseless ventricular tachycardia. 4. Early Advanced Care implies the rapid delivery of the seriously ill patient to hospital. In the non-trauma related illness this allows the early administration of advanced medical care. 3 Early Access to Emergency Medical Services
Emergency medical services are able to achieve two major goals: the early resuscitation and stabilisation of the seriously ill patient, and the rapid delivery of the patient to definitive care. This is bet achieved when bystanders “call for help: as the initial step in the caring for the seriously ill patient. If two or more bystanders are present, one person should dial the Emergency telephone number, while other commence CPR. When doing this it is important to relate clear information regarding the location of the patient, and any other information requested by the operator. For the infant or child, in arrest, the most likely cause is an airway problem. In this setting it is best to commence CPR, then call for help. “Call for help” also implies gaining assistance at the scene, before the ambulance arrives. Even for people experienced in resuscitation, CPR is always easier with 2 or more people lending help. Do not hesitate seeking help. Commencing Early CPR ( SEE ABOVE)
The window of opportunity for survival from cardiac arrest is small. As such the aim of bystander CPR is to increase the time before death occurs, allowing emergency medical services the opportunity to deliver earl defibrillation, and other advanced care techniques. After assessing the person’s responsiveness, the steps in bystander CPR or basic life support for the collapsed patient are as follows (Fig. 5):
1. Secure the airway
To do this requires 2 actions, firstly clearing the airway, and then opening the airway. Clearing the airway removes any foreign bodies from the airway including dentures, broken teeth, food, vomit or blood. It is achieved by the finger sweep, although care must be taken not to dislodge any loose teeth, especially in young children. When available a suction device should be used. After clearing the airway, it may need to be opened by a combination of extending the head, chin lift and jaw thrust (Fig. 6). Various devices such as oropharyngeal airways or Guedel’s airway (Fig. 7) should be used if available. 2. Assess and ensure breathing (rescue breathing or expired air resuscitation). To assess the presence or absence of breathing one must look for movement of the chest with inhalation and exhalation, feel for chest movement and listen for the movement of air. This can be easily achieved by using the technique shown in Fig. 8. If there is no evidence of breathing, rescue breathing should be commenced immediately. This is commenced with 2 slow breaths, by the mouth-to-mouth technique, ensuring that the chest rises (Fig. 9). If a mouth to mask device is available (Fig. 10), this may be used, reducing any risk of infection. The rates and ratios of external cardiac compression and rescue breathing are shown in Fig. 10. 4 Figure 11
Ratios of breath to chest compressions for cardiopulmonary resuscitation
Ventilation One Rescuer Two Rescuers 15 breaths/min 15 breaths/min 80 to 100/min 80 to 100/min 15 to 2 5 to 1 Chest Compressions Ratio
3.
Assess and maintain circulation (external cardiac compression)
To assess the circulation the rescuer feels for the carotid pulse, in the neck at the angle of the jaw. If the pulse is present, but the patient is not breathing spontaneously, continue
rescue breathing at a rate of 15 breaths per minute, until either help arrives or spontaneous breathing commenced. If there is o detectable carotid pulse< commence external cardiac compression (ECC) immediately. The hands are placed on the lower third of the sternum, with the arms locked at the elbows and the rescuer kneeling over the patient (Fig. 12). Compressions are approximately 5 cm deep in the adult, at a rate of between 80 to 100 compressions per minute. This is tiring work, if continued for a prolonged period, so do not hesitate in getting help from other bystanders, changing every few minutes. To determine the adequacy of ECC, the carotid pulse should be felt for, and after every 2 minutes of full CPR, a check should be made for the return of spontaneous breathing and circulation. Full CPR should be continued until either help arrives, or there is return of a spontaneous circulation. 4.
Stabilisation and Transport
When the patient begins to maintain their own airway and breathing, and has return of a spontaneous circulation, they should be placed in the coma position until help arrives (Fig. 13). Airway patency, adequacy of breathing and circulation, should be frequently reassessed, and any deterioration should be acted upon immediately. Once available, the patient should be transported to hospital, as soon as possible. The Seriously Injured Athlete
The approach to the seriously injured athlete is similar to that of the seriously ill athlete, with a couple of points of note. The system taught in Advanced Trauma Life Support and the Early Management of Severe Trauma courses, is an easy to remember system for dealing with such cases (see Fig. 14). Remember: 1. Remove from danger, in order to prevent further injury. While doing so it is essential to protect the patient’s neck, to prevent any trauma to the cervical spine and spinal cord. Fig. 14 shows how this may be achieved. 2. Airway management includes care of the cervical spine. In the non-injured patient, one of the first airway opening manoeuvres is to extend the neck. This should not be done in the injured patient, especially if unconscious, as it may damage the cervical spine. All airway manoeuvres must be accompanied by in-line cervical immobilization). When available, the neck should be immobilized with a rigid cervical collar (see Fig. 16). 3. In controlling the circulation, control blood loss. This can be achieved over the site of any external bleeding by pressure (Fig. 17). Limb tourniquets should not be used, as they may cause arterial or nerve damage. Any long bone fractures, especially fractures of the femur, should be splinted to reduce blood loss and help control pain (Fig. 18).
4.
In the unconscious, injured athlete always consider severe head
injury. These patients need rapid stabilisation and transfer to a hospital to allow a further assessment for potentially life threatening intracranial bleeding, which will require urgent operation (Fig. 19).
Figure 14
The approach to the severely injured athlete. At the scene, it is important to prevent further injury by removing the patient from any danger. It is essential to care for the patient’s neck whilst doing so. Primary Survey Assess disability (neurologic function) Control environment, and be able to clearly explain the events causing injury If unconscious, assume major head injury and transport to hospital ASAP If unable to move arms or legs, assume spinal cord injury, and prevent further injury by not moving until help arrives Remove from anger Prevent excessive cooling if injured Be clear about the mechanism of injury (events), as this is important in looking for Airway and cervical spine immobilisation Assess and ensure adequate breathing (ventilation) Control bleeding and maintain circulation Immobilise head and neck with inline stabilisation Clear airway Open airway – remember not to extend the neck Commence rescue breathing Apply pressure to external bleeding commence external chest compression, if no pulse
Resuscitation Phase Secondary Survey Stabilisation and Transport Any immediately life threatening problem found in the primary survey is addressed Usually done in hospital head to toe, front to back examination looking for injuries Usually includes xrays and blood tests Reassess ABC, before moving Splint any limb injuries
injuries later System by system examination Thorough history: Allergies Medications, last tetanus Previous illness/surgery Last ate Event – what happened Transport to hospital as soon as possible
7 Legends for Chapter 5 – The Fallen Athlete Figure 1 - On Field Approach to Injury Figure 2 - Some basic differences between non-trauma related and trauma related illness in athletes. Figure 3 - Initial assessment of the sick or injured athlete. Figure 4 - The Chain of Survival (adapted from the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care) Figure 5 - Basic Life Support Figure 6 - Opening the airway. Note how each of the manoeuvres results in moving the tongue from the back of the pharynx. Remember in the injured patient not to use head extension, as this may damage the cervical spine. Figure 7 - An oropharyngeal (Geudel’s) airway. When inserting the airway take care not to dislodge teeth as the airway is rotated into position. This is especially important in young children with primary dentition.
Figure 8 - Assessing the adequacy of breathing. By adopting this position it is easy to look for the chest moving, feel for the chest moving, and listen for the movement of air, while keeping the airway open. Figure 9 - Rescue (Mouth to Mouth) breathing. Note how the rescuer is able to assess the adequacy of rescue breathing by watching the chest move, while maintaining an open airway. Figure 10 - Mouth to mask ventilation. Such devices are portable and reduce the risks to the rescuer due to vomiting and infectious diseases. They should only be used by people adequately trained in their use. Figure 11 - Ratios and rates for CPR. Figure 12 - Technique of CPR> Hands over lower 1/3 of sternum, elbows locked, rescuer kneeling over patient. Figure 13 - The Recovery (coma) position. Placing the patient in this position allows the patient op keep their airway open, and reduces the risk of aspiration of vomitus. Figure 14 - The approach to the severely injured athlete.
