On-Field On-Field Evaluation of Head Evaluation of Head and Neck Injuriesand Neck Injuries

Orthopedic Assessment III Orthopedic Assessment III – Head, Spine, and Trunk – Head, Spine, and Trunk

with Labwith Lab

PET 5609CPET 5609C

On-Field EvaluationOn-Field Evaluation Equipment Equipment

Considerations:Considerations: Suspected spinal injury Suspected spinal injury

→ helmet should → helmet should NOTNOT be be removedremoved

Airway is accessible Airway is accessible (facemask removal)(facemask removal)

Cervical collar can be Cervical collar can be applied with helmet and applied with helmet and shoulder pads onshoulder pads on

Athlete’s head can be Athlete’s head can be secured to spine boardsecured to spine board

Helmet removal without Helmet removal without removing the shoulder removing the shoulder pads → cervical spine pads → cervical spine extensionextension

On-Field EvaluationOn-Field Evaluation

Facemask Removal:Facemask Removal: Facemask is Facemask is

attached to the attached to the helmet by thick helmet by thick plastic fastenersplastic fasteners

Can be cut off or Can be cut off or unscrewedunscrewed

Most helmets have Most helmets have four fastenersfour fasteners

Can cut all four or Can cut all four or cut the bottom two cut the bottom two and retract the and retract the maskmask

On-Field EvaluationOn-Field Evaluation

Facemask Facemask Removal:Removal: Common tools for Common tools for

helmet removal:helmet removal: Hand held Hand held

screwdriverscrewdriver Anvil PrunerAnvil Pruner Trainer’s AngelsTrainer’s Angels FM ExtractorFM Extractor

On-Field EvaluationOn-Field Evaluation

Chest Exposure:Chest Exposure: Shoulder pads and Shoulder pads and

jersey should be left jersey should be left in place along with in place along with the helmet the helmet

To access the chest To access the chest for CPR, cut the for CPR, cut the jersey, shoulder pad jersey, shoulder pad stings and straps, stings and straps, and spread the pads and spread the pads apart so the chest is apart so the chest is exposedexposed

On-Field EvaluationOn-Field Evaluation Initial Inspection:Initial Inspection:

Encumbering Encumbering circumstances:circumstances:

Diver still in the waterDiver still in the water Football player lying on a Football player lying on a

pilepile Movement:Movement:

Note any athlete movementNote any athlete movement Position of athlete:Position of athlete:

Alignment of arms, legs, Alignment of arms, legs, cervical spine relative to cervical spine relative to trunktrunk

Splayed extremities must be Splayed extremities must be aligned prior to spine-aligned prior to spine-boarding or log-rolling the boarding or log-rolling the athleteathlete

Lesion of cervical or thoracic Lesion of cervical or thoracic spinal cordspinal cord

PriapismPriapism

On-Field EvaluationOn-Field Evaluation Initial Action: Cervical Initial Action: Cervical

Spine StabilizationSpine Stabilization Primary goal: Maintain the Primary goal: Maintain the

head and neck in alignment head and neck in alignment with the long axis of the with the long axis of the bodybody

Kept from time of initial Kept from time of initial assessment, through assessment, through transportation, and to the transportation, and to the hospitalhospital

Assign one person whose Assign one person whose only responsibility is to only responsibility is to secure and position the secure and position the head and neckhead and neck

Usually the person with the Usually the person with the most training and experiencemost training and experience

In-control – directs othersIn-control – directs others

On-Field EvaluationOn-Field Evaluation

Initial Action: Primary Survey / LOCInitial Action: Primary Survey / LOC Determine level of consciousness:Determine level of consciousness:

““Can you hear me”Can you hear me” Response to painful stimulusResponse to painful stimulus

Determine ABCs:Determine ABCs: Clear the airway and assess breathingClear the airway and assess breathing

Remove mouthpieceRemove mouthpiece Check CirculationCheck Circulation

Inspect ears and nose:Inspect ears and nose: CSFCSF

Secondary Survey:Secondary Survey: Signs of trauma (fracture, dislocations, bleeding)Signs of trauma (fracture, dislocations, bleeding)

On-Field EvaluationOn-Field Evaluation Management of Unconscious Athlete:Management of Unconscious Athlete:

Airway:Airway: Permanent brain damage – within 4 minutes after Permanent brain damage – within 4 minutes after

oxygen deprivationoxygen deprivation Assess airway:Assess airway:

Look, listen, feel for breathingLook, listen, feel for breathing Emergency Roll:Emergency Roll:

No pulse / not breathing and not in supine positionNo pulse / not breathing and not in supine position Maintain in-line stabilizationMaintain in-line stabilization

Expose chestExpose chest Remove facemaskRemove facemask Jaw thrust to open airwayJaw thrust to open airway

2 quick breaths2 quick breaths Circulation:Circulation:

Carotid pulseCarotid pulse Not breathing with pulse – Rescue breathingNot breathing with pulse – Rescue breathing No pulse – CPRNo pulse – CPR

On-Field EvaluationOn-Field Evaluation Modified Jaw Thrust:Modified Jaw Thrust:

Grasp each side of the Grasp each side of the mandible at the angle mandible at the angle and pull upwardsand pull upwards

Must be careful not to Must be careful not to disturb the c-spinedisturb the c-spine

May not always open May not always open the airwaythe airway

Should be done by a Should be done by a professional rescuer professional rescuer or athletic traineror athletic trainer

Essentially dislocating Essentially dislocating the jawthe jaw

On-Field EvaluationOn-Field Evaluation

Management of Management of Unconscious but Unconscious but Breathing Athlete:Breathing Athlete: C1 Lesion → Altered C1 Lesion → Altered

brain stem function brain stem function and cardiac arrestand cardiac arrest

C2 – C4 → phrenic C2 – C4 → phrenic nerve interruption:nerve interruption:

Respiratory Respiratory distressdistress

On-Field EvaluationOn-Field Evaluation Management of Unconscious but Management of Unconscious but

Breathing Athlete:Breathing Athlete: Cervical spine evaluation:Cervical spine evaluation:

Palpate for gross bony deformityPalpate for gross bony deformity Blood pressure:Blood pressure:

Palpation of pulse and minimum Systolic BP:Palpation of pulse and minimum Systolic BP: Carotid artery – 60 mmHgCarotid artery – 60 mmHg Femoral artery – 70 mmHgFemoral artery – 70 mmHg Radial artery – 90 mmHgRadial artery – 90 mmHg

Pupil responsiveness:Pupil responsiveness: Open athlete’s eyelids:Open athlete’s eyelids:

Open eyelids – pupil constrictionOpen eyelids – pupil constriction Absence – brain not receiving oxygen / brain Absence – brain not receiving oxygen / brain

damagedamage Continue monitoring:Continue monitoring:

Every 5 minutesEvery 5 minutes

On-Field EvaluationOn-Field Evaluation

Management of Conscious Athlete: Management of Conscious Athlete: HistoryHistory Loss of consciousness:Loss of consciousness:

Does athlete describe “blacking out” or “seeing Does athlete describe “blacking out” or “seeing stars”stars”

Mechanism of injuryMechanism of injury Symptoms:Symptoms:

Pain in cervical spine Numbness, tingling, burning pain radiating

through upper or lower extremities Sensation of weakness in cervical spine, upper

and/or lower extremities Burning or aching in the chest secondary to

cardiac inhibition

On-Field EvaluationOn-Field Evaluation Management of Conscious Athlete: Management of Conscious Athlete:

Inspection:Inspection: Cervical vertebrae:Cervical vertebrae:

AlignmentAlignment Cervical musculature:Cervical musculature:

Presence of spasmPresence of spasm Palpation:Palpation:

Cervical spine:Cervical spine: Spinous and transverse processes:Spinous and transverse processes:

Alignment, crepitus, tendernessAlignment, crepitus, tenderness Cervical musculature:Cervical musculature:

Spasm in upper trapezius, levator scapulae, SCMSpasm in upper trapezius, levator scapulae, SCM Unilateral spasm – cervical vertebral Unilateral spasm – cervical vertebral

dislocation when skull is rotated and tilted to dislocation when skull is rotated and tilted to opposite sideopposite side

On-Field EvaluationOn-Field Evaluation

Management of Conscious Management of Conscious Athlete:Athlete: Neurological Testing:Neurological Testing:

Sensory testingSensory testing Motor TestingMotor Testing Active motion:Active motion:

Wiggle toes and fingersWiggle toes and fingers Movement of ankles, wrists, knees, elbows, Movement of ankles, wrists, knees, elbows,

hips, and shoulderships, and shoulders

On-Field EvaluationOn-Field Evaluation

Removing the Removing the Athlete from the Athlete from the Field:Field: Walking athlete off Walking athlete off

the field:the field: Lying → standing: Lying → standing:

↓ BP (risk of ↓ BP (risk of fainting / fainting / unsteadiness)unsteadiness)

Allow athlete to Allow athlete to adjust to position adjust to position changeschanges

On-Field EvaluationOn-Field Evaluation Removing the Athlete from the Removing the Athlete from the

Field:Field: Using a Spine Board: Supine AthleteUsing a Spine Board: Supine Athlete

Place the extremities in axial alignmentPlace the extremities in axial alignment Arm on side toward which athlete rolled abducted Arm on side toward which athlete rolled abducted

to 180to 18000 (if not wearing shoulder pads) (if not wearing shoulder pads) Place the spine board close to the side of Place the spine board close to the side of

the patientthe patient Other responders position along the side of Other responders position along the side of

the athlete, according to the captain’s the athlete, according to the captain’s (person at the head) directions(person at the head) directions

Ideal to have 4 or 5 additional helpers, depending Ideal to have 4 or 5 additional helpers, depending on the size of the patienton the size of the patient

Each person is responsible for one body segment: Each person is responsible for one body segment: trunk, hips, thighs, lower legstrunk, hips, thighs, lower legs

On-Field EvaluationOn-Field Evaluation

Removing the Athlete from the Field:Removing the Athlete from the Field: Using a Spine Board: Supine AthleteUsing a Spine Board: Supine Athlete

No matter how distorted it may appear, the No matter how distorted it may appear, the neck MUST be stabilized in the position it is neck MUST be stabilized in the position it is foundfound

Put the spine board close to the patients sidePut the spine board close to the patients side Roll together on the captains signalRoll together on the captains signal

Ask if anyone has questions before proceedingAsk if anyone has questions before proceeding Example: “we’ll roll on 3. ready 1,2,3”Example: “we’ll roll on 3. ready 1,2,3”

On-Field EvaluationOn-Field Evaluation

On-Field EvaluationOn-Field Evaluation

On-Field EvaluationOn-Field Evaluation

Removing the Athlete Removing the Athlete from the Field:from the Field: Using a Spine Board: Using a Spine Board:

Supine athleteSupine athlete Continue to stabilize head Continue to stabilize head

and neck throughout the and neck throughout the roll and on the spine boardroll and on the spine board

Use chin straps and foam Use chin straps and foam blocks to secure the head blocks to secure the head on the boardon the board

Secure the limbs with Secure the limbs with strapsstraps

Distribute help personnel Distribute help personnel and lift togetherand lift together

On-Field EvaluationOn-Field Evaluation Removing the Athlete from the Field:Removing the Athlete from the Field:

Using a Spine Board: Prone athleteUsing a Spine Board: Prone athlete One person takes charge and immobilizes the One person takes charge and immobilizes the

headhead Hands should be placed so that the head and neck Hands should be placed so that the head and neck

can maintain their position as the body movescan maintain their position as the body moves Assistants kneel and reach across patient’s Assistants kneel and reach across patient’s

bodybody Each person is in charge of a different part, such Each person is in charge of a different part, such

as the trunk, hips, and legsas the trunk, hips, and legs Their arms should cross each other for stability Their arms should cross each other for stability

and synchronizationand synchronization Limbs are placed at athlete’s sidesLimbs are placed at athlete’s sides On the captain’s call, the body is turned in On the captain’s call, the body is turned in

unison onto the boardunison onto the board