Emergency in Sport Medicine

Dr. Andre Triadi Desnantyo SpOT(K)

Departement of Orthopaedic & Traumatology
Sport Clinic
Dr. Soetomo General Hospital Surabaya
Indonesia

2018
 Case 1 (hospital scene)
• Male, 29 y.o,
athlete pro,
fell down after
downhill biking, alert,
very painful
on his right knee,
unable to stand up
no open wound,
only multiple
excoriation, swollen,
hematoma around his
left knee
 Scenario Alogarithm
Recognizing 
• Dx?
• Mechanism of injury ? (severity level)
• Next (possible) complication ?
• Plan?
 Strategies
• Dx : s. Fracture of right proximal lower leg or
Fracture around the right knee
• Plan :
✓ medical analyze: artery pulse, neurologic
function
✓ secure: splinting bandaging –> re-evaluate
neurovascular
✓ transport
X-ray at local clinic
 Strategies ?
• Dx : Closed Fracture of right tibial plateau
• Severity level : high energy trauma
• Possible complication : vascular compromised,
compartment syndrome
• Plan :
✓ medical analyze: Primary survey (CAB), artery pulse,
neurologic function
✓ secure: splinting bandaging–> re-evaluate
neurovascular, elevation (TOTAPS, do RICE-no HARM)
✓ transport, communicate for refferal if need it 
URGENT !!!
 Clinical picture
• After 24 hours abandoned medical treatment

“Compartment syndrome”
Q: Is “compartment syndrome’ one of
emergency case?
A: Yes/ No
Q: Why?
Compartment syndrome : “Limb Threatening”
 Emergency case

Recognize 5P :
Pain, Paresthesia, Paralysis, Pale, Pulseless
 Learning objectives

• Able to recognize
• Able to manage
• Able to maintain

• Able to prepare
WELL Learning objectives
Well prepare

Well recognize

Well manage

Well maintain

Well result
 Emergency Action Planning (EAP)

What is EAP?
• A written document that defines the standard of
care for the management of emergencies.
• Provides an outline of the policies and
procedures well in advance of an emergency to
establish protocols and avoid debate/confusion
about critical decisions during the emergency.
• Helps facilitate a prompt, efficient, coordinated
response in a medical emergency.
 EAP components
• Emergency Personnel – Describe the emergency team involved when
the EAP is activated and the roles of each person.
• Emergency Communication – What communication devices are
available, where, what number to call in an emergency, specific
information and directions to the venue to provide to EMS response team.
• Emergency Equipment – Location of equipment should be quickly
accessible and clearly listed. Equipment needs to be maintained on a
regular basis.
• Medical Emergency Transportation – Describe options and
estimated response times for emergency transportation.
• Venue Directions with a Map – (should be specific to the venue, and
provide instructions for easy access to venue)
• Roles of First Responders – Establish scene safety and immediate care
of the athlete, activation of EMS, equipment retrieval, direction of EMS to
the scene
 MOST COMMON CAUSES OF DEATH
OR CATASTROPHIC INJURY
• Medical Conditions
• Environmental
– Sudden Cardiac Arrest
– Asthma
Conditions
– Diabetes – Lightning
– etc – Exertional heat stroke

• Traumatic Injury • Behavioral

– Catastrophic brain injuries – Exertional hyponatremia
– Cervical spine injuries
– Suicide
– Musculoskeletal injuries
– Abdominal injuries
– Chest injuries
 DIFFICULTY OF EAP
• Multiple individuals involved
– School and local EMS staff
• Rare events
– Will never happen to me!
– What do I do now?
• Multiple venues
– Must be venue specific
• Constant turnover in personnel
– AD’s, coaches, AT’s
• Takes preparation time and practice
BUILD THE EMERGENCY ACTION PLAN
1. Develop the Emergency Action Plan

2. Disseminate the Emergency Action Plan

3. Practice the Emergency Action Plan

4. Review the Emergency Action Plan

 Main Goal of treatment
• Provide structured
framework to handle • Life saving
all emergency
situations (under • Limb saving
pressure)
• Organ saving
• Not to miss any life-
threatening situations • “ stop any bad
• Not to cause progress,
additional damage to stabilize and re-
the injured or unwell
sportsman vitalized”
“ANYONE CAN SAVE A LIFE”
 Kind of threats
• Trauma emergency
• Medical emergency
• Enviromental
• Behaviour
• Other
 SUDDEN CARDIAC ARREST (SCA)
• Iceberg phenomenon
 SCA
• It can happen to
anybody-anytime-
anywhere
American College of Cardiology
SCA during sport activity
 Incidence of Sudden Death
The risk of SD is dependent on:
• gender (in about 90% of cases the athletes
affected are men)
• age (most common in 40- to 50-year-olds)
exercise intensity (higher risk at higher exercise
intensities).

The incidence of SD in young athletes

0.5 to 3 per 100,000 per year and this rises from the age
35 onwards.
 Causes of SCA/SD in sports
Under 35 years of age:
• Hypertrophic cardiomyopathy
(HCM)
• Coronary anomalies
• Myocarditis
• Arrhythmogenic right
ventricular cardiomyopathy
(ARVC).

Over 35 years of age:

• Coronary artery disease.
• Distribution of causes of death among young US athletes. ARVC indicates
arrhythmogenic right ventricular cardiomyopathy; AS, aortic stenosis; CA,
coronary artery; CAD, coronary artery disease; CM, cardiomyopathy; CV,
cardiovascular; HCM, hypertrophic cardiomyopathy; LAD, left anterior
descending coronary artery; MVP, mitral valve prolapse; and WPW, Wolff-
Parkinson-White. Maron et al. 2006, the American Heart Association.
Medical Plan for Emergency
Recognition

Response

Resuscitation

Remove from the field

 Recognition  Resuscitation
• Collapse athlete always think a SCA until proven otherwise
• Always start assessment from primary survey (CAB)
• Initial SCA rhythm is ventricular fibrillation (VF) – 70% of
cases
• SCA only has 120 seconds to get to the collapsed athlete
(time critical illness for SCA)
• Next 5 minute (max) is clinical death period
• Start to CPR=
Call for help 118, ask some one to get Automated
External Defibrillator (AED)
Push, start to chest compression immediately, continue
until AED and/ or medical rescue (ALS) arrive
Recharge the AED, standby mode, ready to attach
 Must to know!!

Ventilation??

• Chest compressions are much more important

than breathing in the first minutes.
• Do not get mislead by agonal breaths –
abnormal breathing
We lose 10% of change of survival
in every minute of delay!!!
Automated External Defibrillator (AED)
 Successful of SCA Resuscitation

• Don’t delayed start

• Don’t brakes > 5 sec
• Right placement of hands
• Right pace location
• Gentle power strength and depth
• Complications maybe happen : rib fractures
and other injuries
 Case 2
• Male, 20 y.o, soccer
player
• Unconscious !
• After head to head
collision with other
player
• Any wound was not
found
 Strategies?
QUICK :
1. Assess with CAB and
treat stimultaneously
Think that any possibility
of cervical spine and
head injury
2. Think that anything less
than full GCS score of 15 or
AVPU level of A, mandates removal
from the field of play, transport by hard
collar brace and spinal board or immobilize
by 2 hands
 Cervical spine injury

Can be ruled out if:

• Absence of posterior midline cervical spine tenderness

• GCS of 15
• Absence of focal neurological deficit on motor or
sensory testing
• Absence of any distracting injuries
• Ability to achieve active 45-degree lateral neck rotation
in both directions
• No concern over the mechanism of injury.
 Important!!
• If there is possibility for
neck injury, patient may
be turned into lateral
position only for
vomiting or bleeding
from the mouth.
• UNCONSCIOUS, but
normally breathing
patient should be put
into stable LATERAL
POSITION (except if
there is a suspicion for
neck injury)
 Unconscious and not breathing
• Evaluate and control the airway (look, feel,
listen)
• Head tilt and shin lift
(contraindicated in
trauma situations)
• Jaw thrust
(hold cervical spine
under control)
 Airway maneuvres

If the airway cannot be

controlled, i.e. remains
obstructed, airway
adjuncts
will be required.
• Oropharyngeal airway
(Guedel, S-tube)
• Endotracheal
intubation tube,
nasopharyngeal tube,
Laryngeal mask airway
Unconscious-not breathing-no pulse
Opening the airway with jaw thrust
And C-spine control

check breathing-ventilation
FEW SECONDS

Breathing (+) Breathing (-)

Check pulse

Pulse (+) Pulse (-)

Hold the airways opened Call for help to get AED

(airway adjuncts if needed) and start CPR.
 (Others) Musculoskeletal
Emergency & Urgent cases
• Spine injury
• Pelvic fracture (w/o unstable haemodynamic)
• Bone Fracture (open/ close)
• Joint Dislocation
• Neurovascular compromised
Threat:
“LIFE and LIMB”
 DRCAB
(modified ABCDE)
& TOTAPS
 DRCAB regime
• Danger =
if they’re still in any chance of being in danger you must remove that danger
away from them.
• Response =
where you talk to that person – can you hear me? What is your name?
• Compressions =
If there is still no pulse & breathing start CPR. 2 breaths and 30
compressions and call for ambulance.
If they are breathing, place in the recovery position and attend to other
injuries. Bleeding first, then bone.
• Airway =
make sure their airways are clear. If someone is unconscious then they lose
their gag reflex and their tongue can then block their airways. This is a
possibility
in a situation where they’ve cause to vomit or something else is blocking
their airway
• Breathing =
look at the chest and see if the chest is moving up and down and listen to
see if we can hear them breathing. If there is no breathing give 2 rescue
breaths.
TOTAPS regime
• Talk=
the first thing you do is ask
them about the injury. Where is your
pain? What are you feeling?
What happened to give you this
pain? If you get an idea of the
injury and the way it happens, it
leads you more easily towards a
diagnosis.
• Observe =
Look for abnormalities; redness,
bruising or bleeding. Compare
to the side other of the body. If
they’ve broken their leg and it’s
a compound fracture, you’re
going
to see the bone coming through
the skin.
• Touch =
Touch area to check for swelling
and abnormalities as well as
sensitivity to
pain.
“TOTAPS  NON-LIFE THREATENING”
• Active movement =
If the injury isn’t so bad then you can
ask them to move the injured
area. Are they able to move it
without pain?
• Passive movement =
If they’re able to move it without pain
then do some passive
movement so you can over-press and
feel how well the knee is moving.
• Skills =
If the injury doesn’t seem bad, then
get the athlete up and have them walk
first, and then jog. If they’re able to do this
without too much pain, and then you
can test their skills and how well they’re
able to move. It may be possible for
the athlete to continue on with the sport
or they may need to stop immediately,
come off the ground, and you start
your RICE regime.
 Take Home Messages
• Develop specific Emergency Action Planning
(EAP) for any kind event
• Always practise to provide structured framework
to handle all emergency situations (life
threatening, limb threatening) and able to
identify terrible medical complication in
immediately in hours or day
• There is no super person to handle all emergency
situations in sports, always by teamwork, well
knowledge, well prepare and well organize