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