All right, good afternoon, everybody. Bobby, thanks for having me on to kind of share this information that I think particularly at this time of year is so valuable. In the interest of time, we'll try to move through things pretty quickly. I've outlined this in a series of cases in which we'll talk through the initial stabilization, evaluation, management, some of the more common sideline emergencies you'll see as you go out into covering sports throughout your fellowship year. So again, our primary goal is just to review the evaluation, emergency stabilization, and diagnostic considerations for any sideline management for the most catastrophic injuries that are frequently encountered in athletes. So we have a high school football player, stands with helmet to helmet, hit, immediately complains of headache and blurred vision, no LOC, but he is amnestic to the event. So we'll talk about closed head injuries with the understanding that the popular thing to focus on is concussions, but the more worrisome things tend to be intracranial bleeds. And so we'll kind of go through how you evaluate that and some of the diagnostic considerations you'll make as well. So head injuries are the leading cause of traumatic deaths in sports. It's estimated that 300,000 sports-related brain injuries occur annually, with 250,000 occurring in high school football players. Concussions aren't the most likely, but you also have to consider these potentially life-threatening events. So your classic epidural hematoma here, a subarachnoid and, I'm sorry, subdural and subarachnoid hemorrhage here. Concussions are caused by direct or indirect transmitted forces, primarily due to rotation, but also due to acceleration and deceleration forces. And you may have heard the term coup-contrecoup. This is one where you see the athlete kind of fall back, strike their head on the turf, and they kind of bounce back. It produces cellular damage and changes that can have long-standing impact. As most of you probably are well aware, a concussion is a clinical diagnosis. There is no single diagnostic test. Imaging does not help you diagnose a concussion. The other thing to keep in mind is that sometimes these symptoms are delayed in onset, and so you'll have multiple categories, physical symptoms, mental, sleep, emotional, et cetera. And a big part of understanding concussions, particularly at the high school level, is giving anticipatory guidance to the families so that they know what to watch for. The thing that you'll want to know is obviously when to remove an athlete from the field of play and when to refer to an ER for a more emergent workup and evaluation. So if you see somebody and they're suspected of having a head injury, immediately remove them from the field of play. If they're conscious, do your ABCs, so airway, breathing, circulation, followed by a C-spine evaluation, as Dr. Kloskowski was talking about in his previous talk. Your Glasgow Coma Scale will be an adjunct to your thorough neurological assessment, but in essence, it's a way that you can quickly and methodically assess what is this patient or this athlete's level of neurological function, taking note of their eye movements, their speech, and their motor function. Any unconscious player should be assumed to have a C-spine injury and immediately stabilize, as we said, in a hard collar, but also on a spine board. The two big things to be mindful of are when to refer them to an ED. If there's any focal neurological deficit or if they have any worsening clinical status, you need to send them in. The classic one where you hear tragically about athletes, particularly high school athletes that die, is with these epidural hematomas. They sustain an injury. They may have a brief loss of consciousness, get on the sidelines, perhaps for a while. They have this lucid interval where they're functioning, and nothing seems to be wrong, and they compensate quickly. And in that moment, you've kind of lost your window. You worry about brain and uncle herniation, and eventually they arrest from a respiratory standpoint. But to prevent that, if you send them to ER, you're basically doing that to get imaging of both their CT and classically their C-spine. And we use a set of diagnostic guidelines and criteria to help with that on the back end. You're Canadian, or you're new on this head CT rule. As we talked about through Glasgow Coma Scale, again, a quick way to screen what their level of alertness is, looking at eye, verbal, and motor responses. I won't go through those in detail this way, save you time. The Canadian head CT rule. It's important to recognize what your inclusion and exclusion criteria are. And so if somebody has a DCS less than 13, this doesn't apply, and they need to be shipped anyway. But what you're looking for is in high-risk conditions that may require neurosurgical intervention, whether that's a bone hole, whether that's decompression. And so if they have a DCS score of less than 15 at two hours after the injury, suspected open or depressed skull fracture, any sign of a basal skull fracture, that may be hemotympanum when you look in the ear, battle signs behind the ear, raccoon eyes around the eyes, representative of intracranial bleed, you're seeing a basal skull fracture. If they have multiple repeated episodes of vomiting, the age grade of 65 won't apply as much, but then these lower risk, but still relatively significant, amnesia, dangerous mechanism, et cetera. If any of these things are present, then you should get a head CT. New Orleans head CT rules are a different set of guidelines, maybe not quite as relevant for your athletic population, but it's good to know how these decisions are made either way. So all symptomatic players should not allow to return. Once you're getting off the sideline, you're putting them through computerized neuropsychological testing, so there's an impact. But that said, the SCAT find remains the standard of care in most settings, particularly acutely. Prevention revolves around screening, technique modification, and protective equipment. So we'll move to our second case. We've got an amateur road racer here in Atlanta. We do the Peachtree Road Race every 4th of July. It's incredibly hot. It's 95 degrees, 80% humidity. There's a show in front of Piedmont Hospital that every year there seems to be some sort of heat-induced event. And so this particular athlete, his calf's cramped, he falls to the pavement. So we're talking about exertional heat illness. Incidence varies between sports, but it is directly related to workout intensity, temperature, and humidity. And one thing to kind of help guide you with this is you'll have those ultra-endurance athletes, the recreational athletes that do these road races, and then your padded players who are doing field sports, so lacrosse, football. This is a time of year when you have to be very mindful of those. They're broadly broken down into three categories, heat stroke being the truly emergent condition, heat exhaustion, and chronic cramp. You may also see exercise and do type one atremia and things like that. We won't focus on that as much now, because again, the primary focus of this talk is to just be cognizant and aware of what could happen and act accordingly and swiftly. If left untreated, this is a particular source of morbidity and mortality. It's the most common cause of death in young athletes. So it's something we need to take very seriously. Here in Georgia, especially I grew up down here, it seemed like every year there was some sort of tragic scenario where an athlete died or had significant morbidity that could have been avoided. Your wet bulb glow temp will be of paramount importance. And the formulas here, we won't get into the specifics of them in essence. It is a way of taking in the air temperature as well as the humidity to help give guidance about should you continue an activity? What is the risk associated with it? And if the risk is too high, what should you do from a modification standpoint? There's a curve that we'll put on this slide, but this gives kind of a low-level view of what you're looking at. So green, yellow, red, black, black means extreme or hazardous. You may need to consider rescheduling with the lightning event until the conditions have improved. Signs and symptoms are relatively nonspecific. So you need to maintain a high index of suspicion. People can feel nauseous. They can have cramping. They can just feel malaise or fatigue. Some of this stuff you may see just by virtue of them participating in the event, but you always have to be mindful of, are there any CNS manifestations? So gait instability, ataxia, altered mental status, confusion, et cetera. Your gold standard for temperature assessment is a rectal temp. Now I say this with the understanding that you may not always have a rectal probe available. You may not always have a place where you can privately assess that. And so if there's any concern that a patient has CNS manifestations and they may be overheated to the point they're not sweating, then go ahead and send them to the ER so they can be evaluated formally. The severity of multi-organ failure directly relates to the amount of time that athlete stays in a hypothermic state. So again, you don't want to necessarily be fumbling around trying to find equipment if you don't have it. If you don't, as an ER provider from our work in the hospital setting, we would much rather you err on the side of caution and send them in, as opposed to delaying definitive care. That said, management equals immediate cooling. You want to transport the athlete to a cooler shaded area. Ice water immersion therapy, if you have this, or a cold tub. If you don't, water mixed with cooling fans that are evaporative cooling is really how humans cool themselves anyway. When you simply get so hot, the athletes lose the ability to do that. We're basically recreating that for them. Ice water soaked towels or cold hats to the neck or the shoulder joint. This will help decrease your core temperature faster than placing it elsewhere. You may read or hear about IV management and things like that. In essence, you don't have to do that. That's when you're getting into a controlled environment where we may be cooling through bladder irrigation, things like that. But again, immediately, you just want to immerse them, cool them, and infect their temperature. The goal is to cool their core temp no more than 0.5 degrees Fahrenheit every minute with initial target of 100 degrees Fahrenheit. You'll be frequently reassessing them. It's not somebody that you evaluate, diagnose, or leave by themselves. You'll constantly be coming back to the reassessing technology. The key to all of this is preparation and prevention. So appropriately acclimatizing the athletes. This summer, we're seeing a lot of this, right? Guys and girls haven't been playing sports for a long period of time. They're trying to get back into it, trying to accelerate season. But you can't overstate how important it is to gradually acclimatize them from a temperature standpoint, making sure they're adequately hydrated. When we get to the point of the event itself, making sure that you have reasonable emergency action protocols in place. This one we produced here is what we use for the public marathon and half marathon here in Atlanta in the past. And it just shows you kind of how you progress through this algorithm, at what point you transfer. And so every event that you're covering should have something like this. And again, the record time is the gold standard. And so if you have access to that, that's great. But if you don't, for whatever reason, don't delay definitive care by trying to kind of walk around that. If there's a reasonable high, reasonably high specialty concern, you wanna go ahead and send them. An ice hockey player skating towards an open goal, he finally checks into that wall by an opposing player, falls to the ice and obviously clutches his left side. So it's something that we don't often talk about because we're not dealing with musculoskeletal care as much, but direct abdominal trauma is pretty prevalent. It's the most common in deceleration and contact sports. That represents just under 1.5% of chest injuries in sports. Rib fractures are the most common, spontaneous pneumothoracies, restraining of exercise and weight lifting. That percentage increases when you start talking about abdominal injuries. 10% of all abdominal injuries are sports-related. Liver, spleen, kidneys are the primary organs needed to blend abdominal trauma. And so we'll go through how you monitor that, how you evaluate that and definitively treat it. I liken taking care of these sorts of injuries to a car accident. And so for me, it immediately shifts to advanced trauma life support. And everything in that is driven by algorithms and being incredibly systematic and consistent every time you evaluate these patients. So you want to engage your primary survey going through your A, B, C, D. So we already talked about A, B, C, airway, breathing, circulation. D is disability. And so that covers your kind of Glasgow-Kona scale. And E, exposure. You want to make sure that you remove the equipment, that you have eyes on potential injury sites that you can feel, that you can touch, because that will clue what you do from a diagnostic level standpoint. You want to identify immediate threats to life. So those in the thorax would include a tensioned pneumothorax, an open pneumothorax, chest or pulmonary contusions, massive hemothorax, cardiac tamponade, et cetera. Now, you may not feel comfortable doing anything about these in the field, but having it on your radar, knowing how to stabilize these patients quickly and then shift them to a trauma center for dependent care is incredibly important. Now, this picture of an angiocast here, a tensioned pneumothorax is one of those that if you have this available and you know your anatomy, you can truly save somebody's life. You do a needle decompression, the second intercostal space in the mid-covicular line, and just kind of perpendicular down. You leave that angiocath in there. You've now decreased that tension pathology, right? So here's a classic example. Somebody sustained a left-sided injury. They've got this fractured rib, punctured the lung. They've got a huge pneumothorax that's creating tension physiology, shifting the mediastinum to the right, or tracheal deviation. If they've got decreased breath sounds or absent breath sounds, hypotension, distended neck veins, that is an indication for this. Know that if you do this, you've got a syndrome, and we eventually will have to convert that to a standard chest tube. But again, if you have access to this and it's something that you just keep with you, a lot of times I keep it just as an omen against bad things happening, but you can actually save lives with it. For the abdomen, it's a little bit more streamlined. Essentially, you're just trying to recognize signs of interabdominal hemorrhage. And we'll go through that in just a second. You're fast, if you have got access to portable ultrasound, can be a helpful adjunct as well. Your secondary therapy, you want to consider the mechanism to this injury. Was this a direct impact or deceleration? And visualize both the anterior and posterior aspects of the thoracic abdomen. Be mindful for signs of acute injury. So this is what we call Turner sign, and where you'll be emblematic of potential pancreatic injury or peritoneal injury. You'll see, I'm blaming the hematoma on the flank as well. This is not typical bruising, right? This is not, oh, I just got an abrasion from being tackled or hit or falling on the turf. This is symptomatic of something more severe and insidious going on beneath the surface. Palpate, so if the athlete has rebounded, or their abdomen is tendered beyond what you would be expected, or if they're paying out the portion to exam, those things to be mindful of. If that abdomen is rigid, if they can't tolerate being moved from one table to another without having excruciating pain, these are all signs that there may be some intra-abdominal hemorrhage, and that they need to be transferred to a higher level of care. So again, we've talked about potential life threats. In emergency medicine training, we learn that you really can only bleed out five different places. It's on the floor, in your head, in your chest, in your belly, and the one that often gets forgotten is in your pelvis. And so certain pelvic fractures, they can bleed and impel a lot of blood, and you may not show that clinically quickly. So again, just having this on your differential diagnosis as you work through your algorithm is key. Hemorrhagic shock is ultimately the thing that you're trying to prevent. It's not a trauma lecture per se, but just so that you understand that obviously the more blood you lose, the more symptomatic you become. But in athletes, they're so well conditioned that you can have a substantial amount of blood loss, particularly in your abdomen and pelvis, without necessarily mounting a response, right? Their blood pressure may already be increased somewhat because they're in the midst of competition. They may already be tachycardic. Their capillaries are only fine, and they'll be maybe a little anxious, but again, these are all things that you might not consider unusual in an athletic setting anyway. The point being that you have to reassess these patients frequently, because they can be fine, fine, fine, compensating well, and then all of a sudden start to decompensate quickly. And by that point, you're behind the eight ball. A couple of clinical pearls with respect to intra-abdominal injuries. Rapid triage and assessment is key. You want to identify and correct these immediate threats to life. Your abdominal exam is not sensitive or specific, and for that reason, you need to constantly reassess. Go back and top it on the abdomen. Look to see if there's any developing bruising. And if you have a FAST and are trained in how to do that, that can be very helpful. You're simply just looking for evidence of free fluid in the abdomen, which would not be there. And in the setting of trauma, the presumption is that it's blood. If you've got a positive FAST, that is definitely an indication of going to the hospital. If you've got a positive FAST with abnormal vital signs, that's an indication for emergency surgery. Concomitant injuries are often present. So if you have a rib fracture, think about a splenic injury. If there's gross hematuria, think about a kidney injury, and that needs to be sent in as well to get CT imaging. And again, the take-home point here is any clinical decompensation wants to transfer. So lastly, and again, I'll try to get you guys to your respective duties. A couple of athletes here, these you may not recognize as common, but here, Hank Gathers is pretty well-known. His story's pretty tragic. We'll talk about sudden cardiac arrest. This is the one that you always want to know what to do. This is the one that can go south quickly, and you never want to be in a position where you don't have the resources, you aren't prepared to handle it. It takes on particularly increased importance with COVID and the risk of myocarditis and heart-related complications on the back end. But the nice thing is that when you're evaluating this, your approach doesn't change. The overall leading cause of death in high school and college is athletes. It's much more common in males than females. Pathophysiology is wide-ranging. So you have got structural heart disease, counts for a majority of cases, so things like HOCUM, aortic aneurysms, people with morphine-like symptoms, myocarditis, commotional cortis, but the final common pathway is always the same. That's ventricular fibrillation. And so from here on out, I want to shift to, yes, you can do a talk on prevention and screening and exertion protocols and return to play, but this is what do you do when that happens? And so just like with everything else, remember your ABC. Even if it seems unlikely, assume a cardiac etiology and work backwards. The American Heart Association describes four links in the chain of survival, and that's early recognition and activation of EMS, early CPR, early defibrillation, and rapid transit. What you'll see missing from this are all the things that we do on the back end in the hospital, epinephrine, different sources, calcium, things like that that we do in running a code. But the only two things that are proven to increase survival rates that's been studied are early bystander CPR and early defibrillation. Making sure you have an emergency action plan in place, knowing where your defibrillator is, making sure that everybody that's involved in the care of these athletes is familiar with how to use it. A lot of times it makes it pretty straightforward. If you're at a high school and you're covering multiple events in the training, covering multiple events, making sure that they can get to it easily is key. So the BLS algorithms here just kind of simplify, activate the response, start CPR. We don't even really worry about the emergency and rescue breaths anymore. The biggest thing is just doing compressions the right way. So hard, fast, and deep. BLS will tell you to do the 30 compressions and two breaths. But again, if you can't even remember to do that, just do the CPR, 100 compressions a minute, compression depth of at least two inches, allow for a full chest recoil after each compression. Those are the things that really save lives. And then obviously getting the defibrillator in the path of the patient quickly. A quick note on the prevention and preparedness. Ideally, we screen these athletes for fatal conditions, for family and personal history, physical exam findings, so if they have moments of change with positioning. HOCUM, you know, you look for certain EKG findings as well, dagger-like QAs, anterior lead, S and T wave abnormalities, dysregulus. You can spend all day talking about sports cardiology and reading athletic echocardiogram, but just understanding that's part of the process. Again, the most important thing is just having an emergency preparedness plan and being well-equipped to use it. Everything that we do on the sideline and some multidisciplinary approach involves the athlete, the family, coaches, or friends, the sports medicine physician, us, the athletic trainers, the sports staff, governing bodies in school, athletic associations, and then sports cardiologists, right? And so this is, it takes a team effort to keep these athletes safe. So in summary, be systematic in everything that you do, follow your algorithms, maintain a high degree of suspicion at all times, identify and correct the immediate threats to life. And again, this is coming from me, I'd like, if you're at all concerned or doubting yourself, don't be afraid to transfer. We would much rather that you do that in advance of things getting worse than not sending them. Bottom line is, if you plan to fail, if you fail to plan, you plan to fail. Cardi, that's it.

2nd Edition, CASE 52

2nd Edition

Spine

head injuries

exertional heat illness

sudden cardiac arrest

Glasgow Coma Scale

emergency protocols

athlete safety