Well, welcome everybody to the National Fellows Online Lecture Series. This is the first lecture for the 2022-23 academic year. I'm Ravi Bowers, and along with Siobhan Statuto, we're the co-chairs of the AMSSM Online Fellows Education Subcommittee for 22-23. Glad that you're joining us for this first lecture with one of the founding creators of this lecture series, who's the brainchild of Will Dinh, and he helped to make this what it is now, and it's been a great success so far and much due to Will's efforts. We're pleased to have him as our speaker today. Before we get started with today's lecture, I just want to plug the next lecture, and that's going to be next Wednesday, August 10th at 8.30. Again, it's going to be on heat illness. The speaker will be Seth Smith and be moderated by Nate Nye. Now, this year may be a bit different. We're trying to make things a little bit more standard, so you know when the lectures are going to be. In general, the first three Wednesdays of every month at 8.30 PM, is when these lectures will be. Everyone, you can put it on your calendar. First three Wednesdays of the month, 8.30 PM, we'll have a lecture. We definitely have some good lectures and great speakers lined up for the first quarter of this year. As I mentioned before, tonight, we have Dr. Will Dinh from University of Arizona, speaking on sideline of urgencies. Again, I'm Robbie Bowers from Emory Sports Medicine, Atlanta, Georgia. Before we get started, just some background housekeeping information. This series is supposed to be an adjunct for your individual fellowship programs, educational programming. It's not supposed to take the place of anything. It's supposed to be an adjunct and really help with fellows education, as well as to assist them in CAQ exam preparation. Also to give you access to a wide variety of AMSSM members. Housekeeping, just keep your camera off, mute your device. Put any questions that you have into the chat function. Then at the end of the lecture, I'll ask Will the questions and we'll go through. Please feel free to put your questions in there and put your name and the program that you're with. That'd be helpful as well. Then please, we'll post a link to the evaluation in the chat function as well. If you would go to that link and fill it out, that'd be very helpful to us as well. Without further ado, Dr. Will Den from the University of Arizona, who is dual boarded in emergency medicine and sports medicine. He's going to be speaking tonight on sideline emergencies, so we'll take it away. Awesome. Thanks so much, Robbie. That was a very generous introduction. I can certainly appreciate that. Welcome everyone. Thank you for coming tonight. Today, we're going to be talking about sideline emergencies, the collapsed athlete. Can you guys all see this okay? Hopefully you can. Awesome. We're talking about sideline emergencies, the collapsed athlete. I was given a very broad topic. I think that this is something that we could probably cover over the course of 10 lectures. I'm going to do my best. I try to focus today's talk on the collapsed athlete, but again, more than happy to entertain any questions as I'm sure you guys have quite a few. To start off, these are my disclosures, but in actuality, I don't have any actual conflicts of interest, financial or otherwise. Any of the opinions presented today are strictly my own and do not present those of any group that I'm affiliated with. Again, this is not a comprehensive lecture on sideline emergencies. You have to read, you got to watch lectures, ask questions, run and rerun and rerun scenarios in your head of things that could happen on the sideline to you and to the athletes and to the team. Make sure also to watch Jeremy Whitley's lecture. I think Robbie, you actually moderated that talk last year as well on sideline emergencies. I try not to cross any lines to maximize your guys' learning tonight, but make sure you check out his lecture as well on AMSSM's YouTube channel. Here are our objectives today, to put it in short. We're going to primarily discuss the approach and care of the collapsed athlete. I sincerely hope that this talk generates more questions than answers because the topic of sideline emergencies is just so broad. This talk is really intended to spark your interest about some very real issues that could happen to you the next time you are covering on the sidelines or even during practice. We're going to analyze an EAP, carry out the elements, and you should be able to carry out the elements of an EAP when you're done with this. You should be able to understand what's in a sideline medical bag, or at the very least, what's important in a sideline medical bag when it comes to an emergency. And then identify and manage a neurologic, respiratory, cardiac, traumatic, environmental emergency. I bolded manage because really, we don't have enough time to talk about all of the signs and symptoms of an emergency. It's once you've recognized the emergency, how do you manage it? And hopefully, you walk away today with a pearl that may help you save a life. So, Andy, if you could pull up the first poll question. Let's ask people if you feel comfortable or not with sideline emergencies. Because I know that we've got a lot of people from all walks of different medical fields, of different training levels even. And so, I'd love to kind of see where we're at in terms of our baseline knowledge and comfort sideline emergencies. And nobody's going to judge you. Don't worry about that. Okay, so 19% of you guys said yes. 81% of you said no. That's totally okay. Hopefully, that number changes at the end of the lecture. But if not, I won't feel offended by any means. But that's awesome to see. Thanks so much, Andy. Move on to the next. Let's talk about sideline philosophy before we really get into the meat and potatoes of what an emergency is. And so, this is kind of my sideline philosophy when I'm on the sidelines, and I'm thinking about all the emergent situations that can happen. To me, being on the sideline means that you're triage plus. And this is what I mean by that. You're not in the clinic. You're not inpatient. You're not in the ED. You are on the sideline. So, this is sideline medicine where you're going to get there. Your job first is to figure out whether or not they're sick or not sick, because that's going to determine whether or not they can play or not play. And that's kind of the most important thing when it comes to the athlete and the team. And that will determine your recommendations to the athlete and the coach. So, to play or not to play is always the question the coach is going to ask you and probably the athlete. Is the athlete able to return without immediate or delayed risk that would otherwise be detrimental to their health and goals? That's a question you want to ask yourself. And at times, an athlete's health and goals can be contrary to that. So, as a physician, you have your own duty of ethics and principles that will prioritize their health over their goals. Works best when you work with the team beforehand so you have a shared mental model and so that you can align those two issues. Concussion is a great example of that. It's becoming more and more accepted on the sidelines, something that's often overlooked during a high-stakes game. But now, with more research, education, awareness, you know, this disease is being taken more seriously. So, when you're approaching the athlete, especially if you're asked to approach them on the field, are they sick, are they not sick, or they may be sick? And if they're sick, obviously they're not playing. It's an emergent or urgent matter or an injury that precludes them from play or that further play that would be detrimental to their health and goals. If they're not sick, they're okay to play. You can patch them up. Their treatment can be delayed. And then the potential to be sick. Maybe they're sick. Maybe they're okay to play if they're able to return to play with serial exams or close follow-up at the end of the quarter or halftime, et cetera. But just remember that every athlete is different. They come all with their own individual pre-diseases, preclusions for potential disease. So, you want to kind of give individualized plans based off their health status. Resources are probably the most important thing when it comes to the sideline because you're not a walking hospital. So, you have to ask yourself, what do you have available to you? Can you end point treat the athlete with the resources you have available, or do you need to send them to a higher level of care like the emergency department? So, resources don't just include what's in your medical bag. It includes your skill set. It includes your team skill set. It includes your emergency response team. It includes whether or not you have the time to reassess an athlete, whether or not you have time to monitor an athlete. And socioeconomics. This is something that I wish I had more time to talk about, but you may be covering a school with lower resources, a poorer county that doesn't have access to the same medical care off the field as others may have the privilege of receiving. Some of you may encounter some difficulty of wanting to send a patient or an athlete for a workup or management they can't afford to receive. So, health disparity is a whole other topic. It's a super important topic and issue that this lecture just really isn't geared for, but a really important one that you should be aware of and seek more info on to kind of help affect change. So, let's get into a case scenario. I love case scenarios. It's talked about the collapsed athlete now that we've covered our sideline philosophy. All pathologies today are going to fall under that kind of sick category because we're talking about emergencies. So, the scenario is your first high school football game. You're there as a fellow. Clock is winding down to the half. You see a player collapse on the field. Crowd suddenly becomes quiet. You've got hush murmurs rippling throughout the stands. What do you do? And thank you, Andy, for pointing that out. Remember, no judgment. We're just all here to learn and kind of figure things out together. Do you run onto the field? Do you watch your ATC run onto the field? Do you assess for scene safety? Do you follow your EAP? Awesome, so we got a mixed bag and I was hoping for a mixed bag because almost all these answers are right. It really depends on your EAP, but assessing scene safety is almost always number one. So let's talk a little bit about this. Thank you, Andy for pulling that up. So we want to expect the unexpected. So before this event even occurred, before the athlete collapsed on the field, you should already be prepared for it. You should have done a PPE to screen for abnormalities, and you should have already reviewed your EAP to prepare for certain emergencies. So an EAP consists of key personnel, equipment, communication methods, facilities around you, certain scenarios, such as lightning strike, like we'll talk about that, transportation methods, other resources, and it all kind of comes out here. So you'll see a photo here that I took. It is an EAP of an event. You're going to see all different types of styles and methods of EAPs, but they should contain those key features, and you need to review them. And the answer is to drill, baby, drill. You want to practice or simulate all elements of your EAP so you can have that shared mental model so that when this happens, when that collapsed athlete is on the field, you know who's going to be out there first. The answer still should be yes, assess for scene safety before anyone runs out there, and then based off your EAP, somebody is going to run out there first, and then you need to know your communication method if you need more help for that collapsed athlete. Know your resources. So you have to not, when we talked about skill sets, who's your athletic trainer or PT? What's their background? What's your communication method? Where are you? What kind of response do you have from your hospital system? Where's EMS? What's in your bag? What's in their bag? And what can you do with the resources you have available? And then the answer, the question should also be what should you do with what you have available? Just because you have a crike kit doesn't mean you should cut open everyone's throats, right? So let's talk a little bit more about the different emergencies, but just because you have it available to you in that bag does not necessarily mean that you should use it. It really depends on a lot of factors, including time, available resources, and athlete condition. So a lot of elements may be in the EAP, but ultimately each athlete is individual. Each circumstance is individual, and the details will be determined by a medical team, which is you, your trainer, and the rest of your medical support staff. Practice will make perfect, so that when you run into a scenario you're not used to yet, you will at least have the fundamentals ready. Let's talk a little bit about understanding what it is to be, what it is to have an EMS on standby, or at the very least understanding what your EMS level of response may be. Because just because you have an EMS crew available to you, it doesn't mean that that EMS crew is going to be at the same level as the next EMS crew. So knowing the capabilities of EMS crew is super key. A lot of states have already transitioned their levels to match the scope of practice guidelines released on the federal level, the national EMS education standards. It's EMR, EMT, advanced EMT, and paramedic. For example, EMRs will be like your firefighters, law enforcement, community responders, lifeguards. And then paramedics are able to provide advanced level of care. They make medical decisions based off their exam. They engage in risk-first benefit analysis. They use diagnostic equipment approved by the EMS medical director. But you should all know that these education standards aren't mandatory. They're just guidelines. And so their names may also change by state, and their level of training may change by state. And so, for example, Alaska, you've got EMT 1, 2, 3, AEMT to match those four levels, as you see above. And in Florida, you just got EMT and paramedic. So highly encourage you to figure out what exactly your EMS crew is available, how they're available, and then what sort of skill sets they actually have. You should also know what trauma center you have next to you. What sort of hospital do you have next to you? What's the difference between a level 1 and a level 5? So level 1 is comprehensive coverage. They're very familiar with removing safety pads, helmets. They have all of the specialties available. All the way down to level 5, where the ATLS capabilities are available, and you're going to have physician and nurse available on patient arrival with transfer agreements to level 1 and level 2. But you don't have any sort of specialty. You don't have any sort of necessarily even emergency medicine. And you might not have any sort of surgery or anesthesia available. You might not even have 24-hour labs. So just know that. Know what sort of level trauma center you're sending your athlete to, and just understand that your mileage may vary regardless of what credentialing level they have. And so understanding your hospital system is also very key. So let's get back to the scenario. Your trainer runs over to the unmoving athlete, gives you the signal as you've communicated in your EAP. As you run over with your bag, you've got a lot of things going through your head. Crowd's becoming more unsettled. It's hard to hear your own thoughts. Heart's pounding. You feel a lot of pressure from the crowd. So what do you do? Scene safety. So 49% of you answered scene safety, and I think that's right. Scene safety is the most important thing. If you are at risk for injury, then who on earth is going to take care of you? So you really want to make sure that you are safe. And then when you realize that play has stopped, nobody's going to run you over. No cart is going to run you over. The rig isn't going to run you over. You can run over there, and there are three things you need to ask yourself when you arrive to the patient, and that's CAB. It used to be ABCs. Now we focus a lot more on circulation. Do they have a pulse? Do they have an airway? Are they responsive? And are they breathing? So take a deep breath. Clear your mind. You can think about the mechanism, and you're thinking about your CAB, but don't rely too much on your recall because there is such thing as recall bias. You might make a wrong assumption. The best thing to do is to do your CAB simultaneously, and you've got about 10 seconds to figure it out, as you can see on this BLS algorithm for healthcare providers. And that is your quick assessment. If you determine that there is no pulse, that they're not breathing, then you should begin compressions. The most experienced person should begin the compressions, and I'll explain why. And then you should ask your trainer to get the AED, activate EMS, and closed-loop communication is the key. You need verbal confirmation from your team member that's carrying out an order. So if you say, Michael, the trainer, get the AED, then Michael needs to respond with, okay, I'm getting the AED, just so that you know that that part is done. You're not wondering whether or not they heard you. You're not wondering whether or not something is going to get carried out the way that you would like to get it carried out. And then you're going to get the athlete off the field. So let's say we get to the athlete. Not only are they unresponsive, they're apneic, and they're pulseless. What do we do? And before we get to that, how do we check for a pulse? What's the best place to check for a pulse? And Andy, can you pull that up in terms of questions? Is it the carotid? Is it the femoral? Is it the popliteal? Or is it the radial? All right, so 79% of you said carotid, 17% said femoral, 3% said radial. Awesome, so the correct answer is carotid. Yilmaz et al found that the sensitivity of a carotid pulse to be higher than a femoral pulse, although their specificities were about equal. And these are only central pulses, carotid and femoral. Don't check anywhere else, radial, popliteal, or elsewhere as they are peripheral pulses, okay? So we find that there is not a carotid pulse. There's no responsiveness. Patient is aptic. What is the diagnosis? I think it's probably the only true emergency, and that is a witness cardiac arrest. We don't have time to discuss an unwitnessed, but since you're on the sidelines, chances are you're gonna be witnessing it, or at least somebody in the stands will be witnessing it. And it is only due to a few things. It's only due to dysrhythmia, asystole, such as from a congenital disease, commotional cortis, myocarditis from COVID, for example, trauma, aortic transection, tension pneumothorax, pulmonary embolus, or heat stroke. And regardless of the etiology, your initial management is the same. So again, what do we do? Pretty simple. It's compressions, compressions, compressions. They're the only thing beyond electrocardioversion that has been shown to change outcomes in patients. And despite the insistence of use of such things as epinephrine by the EHA, there are huge studies ranging in the hundreds of thousands of patients that haven't demonstrated any sort of benefit to the use of epinephrine pre-hospital or even in the hospital during resuscitation. We'll talk later about giving breaths as well, but the standard of care per BLS or a healthcare provider is to provide 30 compressions to two breaths. Another thing to remember is that when you're doing compressions, the only way to do them properly is at a depth of two to 2.4 inches at 100 to 120 BPM. We all remember the staying alive. That'll give you the 100 to 120 BPM. Nobody's taking a tape measure to determine whether or not you've got two to 2.4 inches of depth or not, but practice makes perfect. And there are AEDs such as the Zoll AED that give you a compression feedback. The other thing to know about compressions is this. I don't care how much you've gone to the gym or what your trainer is telling you, how swole you look. You are gonna run out of energy after about two minutes of compressions. So just make sure you have a small contingency of CPR trained staff that are ready to take over every two minutes at the time of pulse check if EMS hasn't arrived yet. And another thing to note about compressions is that you've already made the decision that the benefits outweigh the risks. The patient is technically dead and you may cause rib fractures. You may cause ternal fractures, which may result in a pneumothorax. It may result in pneumomediastinum, but the benefits far outweigh the risks at this point. But you should just know that when you're performing compressions, you may hear a crack here and there. And that's okay. This has happened to me a couple of times in the emergency department. What if the athlete starts to push your hand away? What if the athlete starts to move during compressions? I just wanted to bring this up because this may come up in the event of a resuscitation. If they're doing this, that means your compressions are perfusing the brain. It means you're doing a good job. If the patient or the athlete is actually making meaningful movements, is talking to you, I've had a patient push my hand away and kindly ask me to stop, it's okay to stop as long as they don't fall back and become pulseless again. However, if they're not making any sort of purposeful movement and they're just moaning or they're just groaning, continue compressions until it's time for a pulse check. And speaking of pulse checks, as soon as you start compressions, make sure that someone has a timer going on their watch or their phone and every two minutes calls it out so that the next person can take over for compressions. So let's say you got your AED now and the trainer ran over and got it, what do you do? So the first thing you should have done before you got into the situation is to make sure the AED actually turned on. So go to your assigned school, make sure you know the location of your AED, make sure to check it can even turn on. These things run off of batteries and so they have an estimated lifespan of about five years. But as we all know from our smoke alarms, not all batteries are made the same. So make sure that your AED turns on. You just don't wanna be in a situation where you have to use it. The next step is to place the pads. If they're suspected trauma, you wanna place them in position one. If you have the ability to, you can place them in the anteroposterior approach, which is position two. This diagram is for refractory V-fib. So let's hope that never happens on the field. We can certainly talk about electrical storms after this lecture, but we don't have the time for that. So AEDs, like I had mentioned, are made by companies such as Zoll. I'm not paid by them. They've got compression feedback devices, which will help you get to that two to 2.4 inch depth. So back to our athlete. We do our CABs. We perform BLS or ALS. And the athlete gets to the hospital. Return of spontaneous circulation, or ROSC, is achieved en route. He destabilizes him, admits him to the PICU for further management. He's found to have hypertrophic cardiomyopathy. He survives and is in rehab now. Hypertrophic cardiomyopathy, as a side note, there are many great lectures out on our AMS YouTube channel on cardiac issues and emergencies. Hypertrophic cardiomyopathy is one of the most common reasons for sudden death in young athletes. So cardiac emergencies. This is what the athlete had. They're one of the most common reasons for sudden death in the young athlete. And you can see there the list of some of them. There's a reason why we do PPEs, right? There's a reason why we carefully screen athletes for this. And since our diagnostics aren't perfect and the healthcare system are far from perfect, these will occasionally slip through the cracks. So just remember that if your athlete collapses due to a cardiac emergency, there's only one management path, which is fortunate. It's compressions and AED. Compressions and AED. If you want to know your epinephrine, if you want to give epinephrine, just know your concentrations, one to 1,000, one to 10,000. One to 10,000 is the proper 0.5 to one milligram of one to 10,000 epinephrine is the proper dosing, IV or IO. And then perform BLS and if necessary, ALS until help arrives. The last thing I will say about cardiac emergencies is make sure that you control your environment. That's one thing that you can control. Prevent crowding, prevent people from just bystanding. Organize people in your facility to help out. If they aren't there to help out, they need to get out. Protect the patient's privacy as much as you can. And in the next slide, I'll talk to you about some pearls I picked along the way up in the emergency department. And feel free to ask any sort of questions in the chat like we talked about. So beyond BLS, this is meant to be just a very, very, very small discussion that goes beyond standard guidelines. Just remember that compressions AD are the only two interventions. But beyond AD, studies have shown that minimizing interruption of compression time, AKA maximizing compression time, is what has been shown to change outcomes. So we've done a couple of things here in Tucson and across the nation in certain other areas to reduce compression time. Here, we've demonstrated that if you focus on compressions over giving breaths, instead of taking care of the airway as long as it is patent, we don't do the 30 to two. We administer 15 liters of oxygen by non-breather passive oxygenation for eight minutes. And we've demonstrated in our population that they've had a 26 to 50% survival increase rate because we focused on compressions and not worried about the airway. Big shout out to Dr. Gaither and our EMS crew here in Tucson for leading the charge on this. And the reason being that is that oxygenation, just remember oxygenation is not the issue behind cardiac arrest, unless it's due to a PE. So oxygenation largely is not the problem. It's really the heart's inability to pump blood to vital organs, such as the brain. So passive oxygenation just allows for more focus and minimize interruption of compressions. And then the second thing is stay in play versus scoop and run. Most EMS crews and agencies around the country are opting for a stay in play approach. There is a study by Grinnell. They studied 44,000 patients that show that the probability of survival increased with continued on scene resuscitation. And so what we'll do here is for 20 to 30 minutes, as you can see, we'll actually stay in play, make sure that we maximize compressions because what can happen is if we scoop and run, AKA take them straight to the ED, there's interruptions compression time from transfer onto the gurney. And then when they're doing compressions in the rig, they're doing them the best they can, but then they have to take the athlete off the rig doing one hand compressions or something along those lines. And then they're waiting for a room or they finally get to a room still doing one hand compressions. And that's a lot of minutes of time where the athlete isn't getting proper blood flow to their brain. And so this is something just to kind of think about. I'm not advocating that everyone do this. This should not be a spur of moment decision. Just please discuss this with your medical director if this is something that makes sense or establish this into your EAP before any of these are implemented, but just a small aside. You may have seen or may have used mechanical compression devices for resuscitation. I just want to put a brief aside as well for this. Currently seven RCTs have shown no significant benefit over manual chest compressions. If your crew is really familiar with these devices, the quality of CPR will definitely increase and minimize chest compressions, especially if you opt for a scoop and run approach during transport, but they're very expensive. And if not used regularly or positioned properly, it can actually worsen outcomes. So we talked about cardiac emergencies. We talked about having a serious emergency where you're missing all three on the CAV checklist. And a lot of these pathologies are emergencies in their own right that I have listed here. But in comparison, I would argue that they aren't necessarily as emergent. You probably have 10 to 20 more seconds to handle this. And it requires a little bit more brain power. And so of this list of pathologies, which ones can we actually do something about? Stasysmaticus, anaphylaxis, upper airway, dysrhythmia, hyperthermia, hyperglycemia, grand mal seizure, all the traumas. Surprisingly, maybe not so surprisingly, we can do a fair amount of a lot with what we have on the sidelines. And I would actually argue that dysrhythmia, really fast AFib, SVT, stable VTAC, TBI, hollow viscous injuries are still something that we can do something about. We can recognize that there is an issue and get them to a higher level of care. But the rest of these, as you'll see, we can actually do something about. Unfortunately, I don't have time to include HENT injuries and some MSK injuries into this lecture, but there are definitely urgencies and eventually ophthalmologic, for example, emergencies or orthopedic emergencies that need to be addressed day of. But we're talking about the next 30 seconds for the most part for a lot of these. So we talked about things that we can do for emergencies or urgencies, but we really have to know what's available to us. I'm sorry, this slide is so busy, but this is a list that was put together by some of our most experienced people in our field in a consensus statement. It's up on the AAFP, I put the URL there. I've highlighted a few things in the bag that can help with emergencies. Your large or angiocath, for example, your CRITE kit, your EPI, your mask, your albuterol, your collar spine board, we'll talk more about that, your scalpel, ECLS drugs, equipment, your AED, tourniquet. Some other things that could probably work well in your bag would be a pulse ox, an OPA, NPA, supraglottic airway, which falls under ACLS equipment, D50, glucose gel, atropine, midazolam, perhaps even magnesium. Tape cutter shears are incredibly useful, especially when you wanna access the chest and have to cut the pads. And let's talk about the possibilities now that we know what's in the bag. What can you actually do for the things that we talked about previously on the sidelines? We talked about compressions, we talked about AED. This will be the only slide I talk about, precordial thump. This is really a last resort kind of thing. It's in the event you don't have access to an AED, you don't have access to anything else, and you really, really are highly suspicious for a dysrhythmia that can be taken out of that said dysrhythmia. So a precordial thump is said to generate a very small amount of joules. You aim for the inferior third of the patient's sternum, you strike it with a closed fist, about 20 centimeters away, in the hopes that you take them out of V-fib or unstable V-tach, and you bring them back into a more stable rhythm. There are many complications that come with a precordial thump. You could worsen the dysrhythmia, you could create sternal fractures, thromboembolic stroke, liver hemorrhage, among many others. Again, this is last, last resort. So let's talk about other stuff. BVM, your OPA, NPA, needle thoracostomy, finger thoracostomy for a tension in the thorax, tourniquet for an arterial bleed, IV epi for a code, IM epi for anaphylaxis or status asthmaticus even, Heimlich for an upper airway obstruction, fluids, raising the legs, hypotensive athlete, cold water immersion taco method for hyperthermia, TXA, not ready yet for prime time, but certainly something we'll talk about a little bit for any sort of intra-abdominal bleeding, and then controlling your environment. Too much assistance can be a bad thing, coordinate the transfer, make clear and concise decisions as the team leader, and then preparation. That's probably the biggest thing you can do is prep. run those scenarios in your head. So we'll spend the latter half talking about neurologic, traumatic, and environmental emergencies and respiratory emergencies. In the collapsed athlete with a neurologic emergency, you should always be able to palpate a carotid pulse. However, their breathing may be agonal, they may be apneic due to a large epidural hematoma, for example, as you could see on the right-hand side there, or due to grand mal seizure. In this case, prioritization is for reducing risk for hypoxia. I know previously in the cardiac emergency slide, I said oxygenation isn't necessarily number one, compressions are. In the case of neurologic emergencies, hopefully you're not doing compressions because then something else seriously has gone wrong. You should be focusing on making sure that they have proper oxygenation. And so you wanna reduce risk for hypoxia as the brain is very sensitive to this. And both TBI, it's an epidural hematoma, they're not responsive, they're not breathing well, grand mal seizure, those should all be sent to the emergency department for more definitive management. If you have Valium, you can administer it PR. If it is in a liquid formulation, you can administer it IV or IO, and this is for the grand mal seizure. Seizures can occur after a TBI, especially a bad one that's near the temporal lobe. And we will be talking about neurogenic shock coming up, and we'll talk more about an unstable CTL spine injury as well. The more common neurologic presentation you're going to see on the sidelines will probably be a stinger or a burner. These are brachial plexus unilateral injuries that can present, but transient quadriparesis should give you pause as there's concern for a cervical spine injury as a result. They typically have bilateral extremity symptoms compared to unilateral. There is temporary loss of sensation or motor function. And in football injuries, this is typically due to like a hyperflexion of the C-spine with an axial force. Helmet to helmet is a great example of that. And it's theorized that basically that compression causes a prolonged depolarization of the neural tissue, and so you get inhibition of further action potentials. So let's talk a little bit about kind of that apneic agonal patient who is having a neurologic emergency. So often the recovery position is taught to protect the airway as vomiting can happen. Their soft tissues are collapsing as they're kind of laying supine. However, for the athlete on the field, unless you're absolutely certain, you can't rule out trauma because if they're seizing or unresponsive, they can't tell you what symptoms they're having. And so I don't really recommend a recovery position unless you're absolutely positive there isn't any trauma involved. If there is suspected trauma, they're becoming agonal, they're becoming apneic, or you're just hearing sonorous respirations, you wanna perform midline stabilization, make sure that there is no further damage that you can incur by putting them into the recovery position, especially if they might have a spinal injury. You wanna perform a jaw thrust without a head tilt because they could still have a C-spine injury. And I wouldn't recommend attempting a blind finger sweep to make sure that their airway is completely patent, mostly because, especially if they're seizing, it's a good way to lose a finger. So if the athlete isn't able to protect their airway due to a TBI seizure, consider at least an OPA or NPA. Like I said, the soft tissues begin to collapse, therefore necessitating a way to facilitate air to the trachea and the lungs. There is no oxygenation issue in the sense that you don't have a PE, for example, that is preventing proper oxygen transfer across the capillaries. This is an airway issue. And so an OPA or NPA is a great way. If that's not working or that's not your preferred method, an LMA, IGEL, or KING can help. And so placement of both the LMA and KING are easy, but the KING-LT is designed to intubate the esophagus, thereby allowing air to flow towards the only remaining space, which is your vocal cord, trachea, lungs. You should know that the overall success, first-pass success rate ranges for the KING from 53% to 92%. So you can see this is very user-dependent. The LMA is 72% to 96%. IGEL, the modified LMA, is 74% to 97%. And I will say that the only benefit of the air for the LMA and IGEL over the KING, and this is also possible somewhat with the KING, is that in transition of care, you're actually able to intubate and place a more definitive airway with an ET tube through the IGEL or LMA. And we can talk a little bit more on tips and tricks to do that, but certainly not within the scope of this lecture. So for spine immobilization, the traditional framework and dogma for dealing with an unstable CT or L spine injury, the traditional framework is to provide proper immobilization. You want to make sure that if you were to suspect this, and this is, we're talking about the athlete who is able to respond to you, you need to evaluate for things like midline tenderness, signs of trauma, strength, sensation, reflexes, et cetera. We use the Nexus of Canadian C-Spine Decision Rules a lot in the emergency department to determine if further diagnostic imaging is indicated, but this may also help to inform your examination history taking. So providing proper inline stabilization while placing a C collar on can be super helpful. Same should be performed for suspected thoracolumbar injury. Once they're transferred onto a spine board, they can be transported to the ED for further diagnostic imaging or management. And just so you guys know, systematic review in 2012 found that the Canadian C-Spine Decision Rules, the sensitivity range from 90 to 100% and specificity 1% to 77%. Nexus, sensitivity of 83 to 100% and a specificity of two to 46%. So not very specific. So kind of keep that in mind as you are utilizing these clinical decision rules or CDRs. I'll try to provide some pearls again beyond what we consider to be standard of care. Please discuss with your medical director, implement this in your EAP in conjunction with your EMS system before carrying this out to make sure that you all have a shared mental model. So here we'll talk a little bit about why C collars and spine boarding slash log rolling might not be necessarily recommended for every athlete. Dr. Monceau, August 17th, is gonna talk a lot more about C-Spine injuries. So I recommend you to tune into that and hear him talk more about this. All I will say about the C-Spine is that typically there are about four categories of C-Spine injuries. Dr. Oschlag wrote about this. It's the uninjured minor, stable C-Spine, unstable C-Spine without neurodeficit or partial neurodeficit, unstable C-Spine with complete neurodeficit. Based off the evidence, 96% of C-Spine injuries fall into the uninjured minor category. Only 1% fall into the category of unstable fractures that may benefit from immobilization. When a deficit occurs, because the reason why we put a C collar on is to prevent further deficits from occurring, preventing unstable fractures from slipping or becoming worse. Most deficits occur at the time of the injury and only 41 case reports across a systematic review show that deficits occurred later. And those deficits were actually reported and a lot of those deficits were actually reported to develop after application of a C collar. And so a great example for this is in a distractive injury, C collars can actually be harmful by increasing the axial displacement of the C-Spine. And they actually put C collars on volunteers, measured their movements during transport and show that C collars don't actually sufficiently immobilize the C-Spine, they can still wiggle around even doing passive range of motion tests. They can still do those and the C collar didn't really stop that range of motion. They might be too small, they might be too big. And so there's a lot of problems when it comes to C collars. I'm not advocating that every athlete does not need a C collar, but just kind of keep this evidence in mind. They did the same thing when looking at spine boarding, non-immobilized patients or athletes did not have worse neurologic outcomes compared to those that were. In fact, log rolling has been shown to worsen injuries. The only time a log roll should be attempted is if the athlete is prone and can just be pushed directly onto the spine board, don't pull them, you should push them. And speaking of the spine board, like I said, lateral motion is not reduced during transport. They found that a stretcher mattress actually helps. It takes forever to put up a stretcher mattress. So we'll not talk too much about that, but this is just from food for thought and not totally yet standard of care per se. Last thing about C-Spine and T-Spine injuries is a dangerous complication of this is neurogenic shock. So this is loss of sympathetic tone. Therefore creating an unregulated sympathetic tone, typically an injury above T6. The athlete becomes hypotensive bradycardic, which is a key sign to neurogenic shock compared to such things as cardiogenic hypovolemic shock. Those become tachycardic, but because of that unregulated parasympathetic tone, you get hypotension and bradycardia. For those that are familiar with, and for those that want to be familiar with, you can mix and make your own push dose pressors. These are pressors such as epinephrine that are not a full dose for a cardiac arrest, but merely a small amount to help with the hypotension such that you can achieve proper vital organ perfusion, such as for the brain. I'm happy to cover this after the lecture, but we just don't have the time. Just wanted to bring that up. And continue to post questions, we're going to move on to respiratory emergencies for the collapse athlete. This is where they should definitely have a pulse unless we're dealing with a tension pneumothorax. They will most often have an issue with their airway or breathing. And so a tension pneumothorax we talked about, it's a big one. We'll talk about that on the traumatic slide for emergencies but an upper airway obstruction, anaphylaxis, supraglottic swelling, that is an airway problem. Status of the asthmaticus, that's a breathing problem. PE, it's more of a cardiac problem, but early recognition can result in better patient outcomes. Your management options, needle finger thoracoscopy for a tension pneumothorax, IMEPI for anaphylaxis, upper airway obstruction, or sorry, not upper airway obstruction or status asthmaticus. So anaphylaxis or status asthmaticus, Heimlich for upper airway obstruction, Crick as needed for upper airway obstruction or anaphylaxis that's not responding proper to your dosing of epinephrine. And speaking of dosing of epinephrine, just know your dosing. Like I said, ALS epinephrine is one to 10,000. You give it IVIO, one milligram, 0.5 to one. For anaphylaxis or status asthmaticus, it's one to 1,000 given IM. It's 0.3 milligrams of a 0.3 milligram per 0.3 ML in an EpiPen for adults, 0.15 per 0.15 for EpiPen Junior. It needs to be given IM, blue to the sky, orange to the thigh. That's how you give the EpiPen. And then just make sure that when you're reaching for your Epi, don't accidentally grab like the one to 1,000 and give it IV. That's how you cause cardiac arrest. Let's not do that. And I'll talk a little bit more about tricks and tips actually in the next slide for Epi. So if you only have one EpiPen and you don't have anyone else, make sure you ask around. Even the crowd may have an EpiPen available. But if you really are in dire straits and you only have one EpiPen, you've given the EpiDose and the athlete isn't responding, EMS hasn't arrived, you should just know that in a very last case scenario, there's actually 1.7 CCs left of Epi in that EpiPen. I've posted the YouTube link here. I'm happy to send that out afterwards, but this YouTube link is a great review of how to actually open up the EpiPen and access the remaining 1.7. If you peel the plastic packaging off, you'll notice that there's a kind of a little distinct ridge in the plastic, and then you can use a knife, which is dangerous. Last resort, like I said, you carefully cut along that ridge, you remove the spring, and you can actually see on that picture, there is a full syringe there with a depressor and a needle that had retracted back into the EpiPen device that you can use to administer another 0.3 ML. Just remember, you've got 1.7 left. Don't give all of it in one go. You only give another 0.3 CCs of that 1.7. Happy to talk more about that too afterwards. The traumatic emergency, typically in the collapsed athlete, they will have a pulse. If they do not, you know what to do. Compressions, AED, but, and yes, we can talk more about doing compressions on a traumatic bleed, but that's a discussion for later. But if they do have a pulse and they are breathing and have a protected airway, meaning that this is not necessarily an emergency yet that puts them in the maybe sick category, you've got time. I've listed a couple of potential traumatic, what I would call urgencies that may develop into emergencies. This could be a talk on its own as well. So I won't, I apologize in advance for not covering it in breadth. In a tension pneumo, they typically will be breathing pretty shallow. They'll be able to speak, but they'll report kind of chest wall pain with hypotension. An arterial bleed isn't subtle. Blunt abdominal trauma like a liver lack can result in internal bleeding and you need to have a very high index of suspicion for this. And I do wanna point out the different classes of hemorrhage because I feel that blunt abdominal trauma is one of those things that can escape us. If you look at that class one, vital signs are pretty typical for your pumped up hypercaffeinated athlete who just came off from a play and got hurt. They will probably have pretty normal vital signs and they'll look like any other athlete. So they could have lost 750 CCs of blood and appear just fine. So let's talk a little bit more about blunt abdominal trauma before we talk about management options for the rest of them. So blunt abdominal trauma is that perfect example. Remember we talked about sideline philosophies of an urgent situation that could turn emergent. And so a shoulder dislocation is urgent, for example, but it's highly unlikely to progress to emergent. Blunt abdominal trauma is the exact opposite of that. It's an urgent situation that can definitely turn emergent. They can present to the trainer or to yourself complaining of having the wind knocked out of them, for example, and they can be diagnosed just with a diaphragmatic spasm. But if the pain isn't resolving after they've tucked their knees, they've done some hip flexion, they've removed their safety gear, you wanna maintain a high degree of suspicion for an intra-abdominal injury. It could still be an abdominal wall injury, but as you can see from the previous slide, they could have lost 750 cc's of blood and still look just fine. Splenic injuries are the most common, top periosteum, liver, and kidney. The spleen's capsule is actually a lot thicker than that of the liver, so it can hide a lot of blood. And beyond your standard examination, you might wanna perform serial abdominal examinations. And in fact, you might wanna perform a FAST exam and perhaps serial FAST exams. They're commonly used in the ED, have been so for the past decade or so. You just need to know that they're highly specific, meaning that if you see blood, there probably is blood, but poorly sensitive. So just because you don't see blood doesn't mean that there isn't blood. So if you have a high degree or high index of suspicion, you need to send them to the emergency department for further diagnostic evaluation. I'll briefly touch a little about the FAST. A FAST exam should first be initiated in the right upper quadrant view. The superior aspect of the right pericolic gutter is the most sensitive indicator for free fluid. Left pericolic gutter in the left upper quadrant view is less likely to accumulate fluid due to the phenocolic ligament that blocks fluid movement. And so you're gonna see much more if you perform a right upper quadrant. We don't have time to discuss, sorry again, about performing a proper FAST, but at least you should be aware. And this is something that you can prepare for. This is something you can learn while you're learning more about your MSK ultrasound as well. And this is just Kevin Johnson. He's the CV, or he was CV for the Browns. This rookie tight end dove for a ball and landed on him. And out of this abundance of caution and due to the complaints that he had, the staff actually sent him to the ED. He had to be hospitalized for a liver lack, even though he said that he felt just fine. So kind of just keep that in mind. Future consideration, certainly not standard of practice, certainly not even necessarily ready for prime time, but TXA has fallen into more mainstream use in the trauma centers. I just want to briefly touch on this for just about a minute. It's a reversible competitive inhibitor to the lysine receptor, which prevents plasmin from binding and destabilizing the fibrin matrix. And we've done a lot of trials, crash trials, et cetera. There's one that of 927 patients at risk for hemorrhage that demonstrated that the use of TXA within one hour of the injury reduces 30-day mortality. Patients with severe shock had lower 30-day mortality than compared to placebo. So again, not ready for prime time. FDA has only approved this for things like menorrhagia or short-term prevention in dental procedures for patients with hemophilia. We've used this in the ED off-label many times for uncontrolled epistaxis, dental bleeding, massive hemoptysis, GI bleeds, you'll name it. We probably have used it for bleeding, but just understand that there are adverse effects to TXA. It isn't the perfect drug. It can be prothrombotic. You can get PE, DVT. So caution just needs to be taken, especially in patients with things like factor V Leiden, thrombophilic patients, et cetera. Let's talk about something very important, something that you can do and learn today if you aren't already familiar with, and that can save a life, and that is the arterial bleed. It doesn't take long for somebody to lose all of their blood, and what you can do is to control that bleeding. So make sure you're familiar with the tourniquet that comes with your bag. This is the Stop the Bleed initiative. You want to apply pressure to the wound. You want to place your tourniquet approximately two to three inches proximal to the site of the arterial bleed. Obviously, if this is a carotid bleed, don't use a tourniquet. Apply pressure, please. Make sure that when you fasten the buckle, you can turn. I almost always turn the rod because I don't find the buckle actually helps. Turn the rod to make sure that it's properly fastened and secured. It's going to get very tight, and you should start to see the bleeding slow down, if not stop, and make sure you write down the time on the tourniquet at which you placed the tourniquet. If the bleeding is not controlled, you can place a second tourniquet proximal to the first. I had a situation in a golf game where someone in a golf cart had their carotid partially transected by an unseen line that was hanging a sign, and so our medic had to stick a finger in the carotid, apply pressure all the way to the operating room where they were able to fix them, and they actually had a decent outcome, but we've also seen this in hockey games, seen this with open fractures, et cetera, so just be prepared. Traumatic emergencies in the tension pneumo situation. Another great example of a pathology that can go from urgent to emergent. This is a blunt injury that turned into a penetrating injury. The blunt trauma to the chest wall can result in rib fractures that then puncture the pleural space. They may start off with just a mild chest wall injury, mild chest pain that then progresses to the point where they're very dyspneic, to the point where they are actually hypotensive, at which point that makes it a tension pneumo. If you have x-rays on the sidelines in very highly resourced games, you can take a photo, but if you do not, there are other ways to take a look, such as our eFAST with the ultrasound. Again, not something that you should do unless you are fully trained for this, but we typically perform this in the ED as part of our eFAST. We take a look at the lungs. Just remember that a pneumo contains air and no fluid, and therefore it's going to rise to the least dependent part of the chest, so if they are supine, then it's going to rise approximately to the second or fourth intercostal spaces along the midclavicular line, and if they are sitting up, then it's going to be in the more apicolateral position. So on ultrasound here, you can see that parietal and visceral pleura are sliding together as that shimmering white line over here. This shimmering white line over here, ribs are on either side, but with a pneumo, it doesn't shimmer, it doesn't move, incredibly static, and so you can use M mode as well, another discussion for later, but think about using your ultrasound as it's becoming more prevalently used on the sidelines, and if you do suspect a tension pneumo, you may have to perform a thoracostomy. So needle thoracostomy is most commonly performed. You may see this ARS decompression needle that comes with your bag. Doesn't matter what brand of needle that's being used, just make sure it's at least 3.25 inches or longer. In our athletic population especially, you may encounter some players with significant anterior chest wall hypertrophy, your tissue that's going to stop at one and a half to two inch, 14 gauge. For this reason, 3.25 is recommended. The traditional approach is the second or third intercostal space at the midclavicular line, the superior rib border, obviously, as your neurovascular runs inferior, but if your chest wall thickness is pretty thick, the anterior axillary is on average much, it's much more superficial, a lot easier to access. This is where we place our chest tubes anyway, and a needle can be placed in the same area. So you just know the risks associated with doing a needle thoracostomy in either area. If you're performing it in that standard area, midclavicular, in that second to third intercostal space, you can strike aorta if you're too medial, you can strike the internal mammary. In the anterior axillary, if you're too low, you could strike the liver. In the event that a needle thoracostomy does not seem to work, you've already introduced something from the outside to the inside. You've actually created a pneumo yourself if you've managed to access the portal space. So slap a chest seal on that because it could cause or worsen a pneumo. Success rate that you guys should know about of needle decompression is about only 60%. So not great, but if you're sure it's a tension pneumo and you have no other alternative, patient's getting more hypotensive, you can perform a finger thoracostomy, making an incision one to two inches at that anterior axillary green spot, curve Kelly's to bluntly dissect the tissue and then pop through. And then you use your finger to kind of make sure that glove finger to make sure that you're actually within plural space. You should hear this audible whoosh with either needle thoracostomy, finger thoracostomy, which should then decompress the pressure the medial stymia has been feeling. And then almost immediately, the athlete starts to regain their blood pressure. Last emergency I'll talk about because I know we're running at the end of this is environmental emergencies. So this quickly is hyperthermia, heat stroke, first heat exhaustion, environmental disaster, lightning strike, management for hyperthermia being cold water immersion. And we'll talk a little bit about MASCAS. This is the heat index, be familiar with it. And we will talk about a little bit about TACO. If you do not have an ice tub full of water, then a tub full of ice water, then the TACO method has been shown to be an alternative approach. It's TARP assisted cooling with oscillation. It's four chests of ice water that are poured on the athlete after being lowered into the TARP. It's been shown to be comparable to CWI, but as you can see, it does require more staffing, a bit more coordination. Seth Smith is talking a lot more about hyperthermia next week. So I'm gonna save this for him. He would be able to speak much better about this anyway. And so please tune in next week for that. Lightning strike and MASCAS triage. This is something that you guys should at least think about. This is why I put this in here. In the setting of an environmental disaster, the first thing again is scene safety. And this is our start triage. This is how we, when there are multiple people who have been devastated by an environmental emergency, let's say your whole football team, typically the start triage is to stop, tag and move on. You give them either a green, black, red, or yellow tag based off of their status. If you've stopped by somebody with no respirations after a head tilt, unfortunately they have deceased. They're a black tag. And then you need to start taking care of the red tagged patients. And the thing that you should know about this is that with a lightning strike, you should not be doing the start triage. You should actually be the reverse because as we all know, if you're struck by lightning, chances are they're in a shockable rhythm. So do not black tag people who do not have respirations after a head tilt. In fact, those are the people you should probably work on the first and then do everything like we talked about with regards to an emergency. Don't have time to talk about safety equipment removal. Just be familiar with the different types of helmets and safety pads. Understand when to use your shears. If there's a quick release, follow your EAP. And then if, unless there is an emergent condition that is requiring it, you don't necessarily need to always remove the safety equipment. A brief reminder, just please learn, relearn standards of care determined by AHA for cardiac emergencies until you feel 100% comfortable for incorporating or applying emerging evidence. Constructively discuss EAPs and protocol standards with your system. And the takeaway point is practice to the point where your mental faculties aren't taken over by things that you could have practiced beforehand. Then you can work on environmental control. You can work on coordinating care and providing individualized assessment and management. And remember that it's all about the team. Your care extends beyond the athlete. Someone might be more likely to collapse from a cardiac event than your athlete. In fact, it might be your coach. That's coach Wendland. He went to a sudden cardiac arrest as they were about to win the game. And two trainers and nurse were able to resuscitate him on scene. And he actually had an awesome outcome at the end of it. So someone next to you that you're not paying attention to may need your help the most. So last question is, I'm sorry this took so long. Do you feel more comfortable with sideline emergencies guys? Thank you for taking a lesson. And we'll get to some questions and some CAQ questions that will be pertinent to your boards coming up. Coming up soon, in about a year. And again, always ask more questions. It's okay if you still don't feel comfortable. But this is certainly something that is very near and dear to my heart. Woo, look at that, 96%. Maybe I spent a whole hour talking about this stuff and you feel a little bit more comfortable now. But 96% of you feel more comfortable with sideline emergencies. For the 4% of those of you that don't, thank you for staying humble. But feel free to ask me questions so we can talk more about how you can be more comfortable with sideline emergencies, but I appreciate that. And we'll pause there before we get to the CAQ questions just so that in the interest of time, we can answer some stuff. So thank you for listening. Great, thanks Will. I actually think that for the fellows that are on, if you go back and onto the AMSSM YouTube page. Any questions in the chat? Do you guys wanna go through the CAQ questions? Robbie, any sort of things you wanted to ask or talk? Yeah, can you hear me? Can you not hear me? Awesome. I can hear you, Robbie. Muted my thing for a second. You can? Sorry, go ahead. Okay, can you hear me now? I can hear you now. That's my bad. Okay, all right. Okay, I was saying something and then you came on. So as I was telling the fellows is, if they go back and watch Jeremy Willey's talk from August of 2020 on the AMSSM YouTube page, I think your talk fits in very nicely with that one. I think there was very little overlap and they kind of fit together. I'm sure you kind of meant to do it that way. So from a sideline emergency standpoint, I think they go very well together. So thanks for doing that. And then let's see here. Yeah, let's go ahead and do, so what we're gonna try to do this year with these lectures is have CAQ questions at the end of all of them. So Will, why don't you go ahead and run the CAQ questions and then we'll take any chat questions after that. Awesome. Yep, go ahead, Andy, throw them on up. So when planning medical coverage for an event, which of the following is true regarding communication issues? Is it one, small events in which you, maybe the only medical provider, you don't need communications plan. Who needs them? Cellular phones are the preferred method of communication for events. Walkie-talkies are preferred method of communication or special hand signals may be useful to help with communication. And I wanna give a shout out to, this is straight from the CAQ review book. So if you don't have it, get it because it helped me a lot on my boards. These are questions that you will likely see on your boards. Yeah. I'm sorry, Robbie, for interrupting. I actually muted because things were popping up. Awesome. So 20% of you said two, 23% of you said three and 57% of you said four. The answer is D, special hand signals. It sounds weird, but regardless of how small an event is, communications plan is still very necessary. I'm glad that a lot of you didn't, none of you put A. You do not need to communicate with any other medical facilities per se, but you have to be able to communicate at least with your support staff, EMS, coaches, family members. So cell phones are often avoided because there are voids in connection, especially in urban environments or crowded environments where signals get jammed. For example, I ran for help to run an event of 300,000 and no cell phone signals could come out because all the networks got jammed. Walkie talkies, they need a direct line of sight to work. They can be overheard by anyone on the same channel. So for purposes of patient privacy, we try to avoid those if possible. Special hand signals do help for communication in noisy environments, as long as they're clear and specific. Don't just randomly wave about. Make sure that there is a very specific communication signal that you can use, that a trainer might use to, for example, look at their physician onto the side of the athlete on the field. So great job, guys. The next question is this, go ahead and throw that one up, Andy. So as you can see here, you are the team physician for a college football team attending first practice during fall camp when the team has their full pads on. It's a warm and humid day with the heat index and the caution zone. One of your linebackers collapses to the ground. You've got an AED presence, but no other diagnostic equipment. Athlete has a decreased level of consciousness, but is able to be aroused by loud voice and moderate shaking. He's very confused, skin is hot, covered with sweat. He's tachycardic. His femoral pulse is weak and rapid. Respirations are 20. What's your next best step? Bye-bye. All right, good. So the majority of you got the answer correct. The answer is early cooling. That decreased level of consciousness and confusion suggests the player is in heat stroke. C and D actively delay cooling. And the AD is not entirely wrong, but doesn't address the most probable cause, which is heat stroke in this case. But again, AD wouldn't be wrong. Just make sure that you actively cool them. And there's no issue with hooking that up if you really need to, even in the tub. Last CAQ question. 20 year old male basketball player dies during a recreational basketball game. He had played T1 before, was evaluated by a physician and cleared. No cardiac problems. The only family history is that his grandfather was tall and died of heart problems in his sixties. What is the most likely cause of death in this case? All right, good, yeah. So I can see why aortic dissection was a concern because he's tall, grandfather was also tall. And so we're thinking about Marfan's for example, but the most likely still is the highest cause of cardiac exercise related sudden death, which is hypertrophic cardiomyopathy. All their possibilities are still possible, but from a straight statistical standpoint, it's gonna be hypertrophic cardiomyopathy no matter how you look at it. Thank you guys again for taking a listen to the lecture. I'm more than happy to entertain any sort of questions at this point in time. But again, appreciate you guys coming out. Thanks for having me. Thanks again, Will. So nothing in the chat for now. So I'm gonna give everyone a minute or so to put some questions in the chat. If you have any before we wrap up. Awesome. There's so many more things to talk about, but only got so much time. Right. Okay. Yeah, the specifics of what I was mentioning before, I think, you know, Jeremy, we went through some different pathologies that you didn't touch on that I think would, you know, certainly are emergencies, but didn't hit as much on the procedural aspect of things that you talked about that I think we all need to be aware of. So well done there. Okay, so here's a question from Melissa Snell. She said, when you said that most trained person on the field should start compressions, do you mean yourself or other than yourself? So it really depends on your comfort level. If you know ahead of time and you've talked to your trainer, you're like, hey, what sort of comfort level do you have with performing compressions? And they're like, I just practiced, I just passed my, let's just say they got ALS trained, for example. And you yourself haven't really gotten there yet, then maybe they should start their compressions. But if you feel that you are the most comfortable, I typically, especially during BLS scenarios will be the one to start compressions because you want to kind of set an example for everyone else who's following you. And so everyone's going to be watching you perform these compressions. If you feel the most comfortable, you should absolutely do them first and help run the rest of it. If you have enough people and you want to be the brain of the operations, take yourself and remove yourself from any sort of procedural aspects, including compressions and direct everyone. So it really depends on your situation. That's a great question. Great, thanks. Maybe another 30 seconds or so to see if we get another question. And if not, we will wrap up. Awesome. Yeah, I watched all of Jeremy's lecture back in 2020 and I reviewed it again. And so I just wanted to make sure there wasn't any sort of overlap. Hopefully we can do more sideline emergency lectures and keep building on the body of what we have available on the YouTube channel. Yeah, exactly right. I think that's a great question. Yeah, exactly right. I think in the reasoning for doing this every couple of years, certainly at the beginning of the year is with football season starting and the fellows just starting, it could be a point of a little bit of anxiety. So great to cover this stuff before football season. So no other questions have popped up in the chat. Thanks again to everyone that joined. Thanks again, Will, for a great lecture and thanks to Andy Meyer at the AMSSM for running the show. And again, just to plug next week's lecture on heat illness with Dr. Seth Smith. And we'll wrap up. So good night, everyone. Have a great night, guys.

3rd Edition, CASE 53

3rd Edition

Spine

AMSSM

sideline emergencies

collapsed athletes

sports medicine

Emergency Action Plan

cardiovascular emergencies

airway management

spinal injuries

traumatic emergencies

preparation drills

teamwork