(3) Lecture 19: Neck Injuries and On-field Assessment Flashcards
Goals of an Emergency Field Assessment
Primary
- ABC, Roll, Equipment removal, spinal board
Secondary
- history/subjective
- field assessment
- transport
- sideline assessment (what’s wrong? can they play?)
- return to game
What should you be thinking while you are sprinting onto the field?
Is the athlete at risk?
- life vs limb (activate EAP/load + go)
Is the area stable?
Can they continue w/o significant risk (safely + effectively)
How do I get the athlete off the field?
- walk, assist, non-weight bearing? immobilized/boarded
On-Field Assessment
Unconscious vs Conscious
Unconscious - activate EAP immediately
Then primary assessment
- poor result = activate EAP
Primary Survey
Determine existence of potentially life-threatening situations
UABC
U - Responsiveness (Unresponsive? alert? verbal?
Airway
Breathing
Circulation
Check for spinal injury if suspected mechanism
YES to any of those things - “load + go”, activate EAP
NO: secondary Ax (assessment)
Spinal Injury
Supine (on back) - ensure ABC’s and stabilize
Prone (on belly) - may need to reposition to ensure ABC’s
Athlete with suspected neck injury
- Stabilize the C-spine (until neck injury is ruled out)
- Assure athlete and tell them not to move - be firm + assertive
- Get brief history + subjective report
- Begin your palpation + assessment
Subjective spinal
Use 8 questions to help decide course of action
- Can you tell me what happened (MOI)
- Do you have pain in your head?
- Do you have pain in your neck?
- Do you have pain in your back?
- Do you have tingling or numbness in any of your arms or legs? - get specifics
- Do you have pain anywhere else?
- Can you wiggle your toes? - check both sides
- Can you wiggle your fingers? - check both sides
Stinger/Burner Mechanism
best case scenario; risk of injuring brachial plexus
- hits FRONT of player
Mechanism
- nerve traction or compression especially involving C5 and C6
1. Shoulder distracted down from head and neck = stretch
2. Blow to supraclavicular fossa (ex. getting hit by stick/ball) = lax
3. Forced neck extension and rotation to injured side = pinch
Stinger/Burner Signs + Symptoms
- RARELY neck pain (down middle of spinal processes)
- UNILATERAL symptoms
- can be transient (short time)
- SENSORY CHANGES (C5/6) distribution
- motor changes C5/6 (shoulder abduction/external rotation + elbow flexion
Heals quickly often by time they reach the sideline
Neck pain
NOT pain on side of the neck
usually pain down middle of spinal processes
Return to Play for Stinger/Burner
Same game return to play IF
- quick resolution of symptoms (<5mins)
- full ROM
- full strength - able to protect themselves
- ability to complete sport specific skills
- mentally ready
C- spine injury MOI
usually one of two mechanisms:
- Axial load = vertical compression
- burst fracture = everything lined straight up - Compression = flexion injury
- anterior portion compresses and posterior portion elongates
C- spine injury on-field findings
- neck pain
- pain on CENTRAL palpation (spinous process)
- bilateral neural findings (myotomes/dermatomes)
- upper + lower extremity findings
To board or not to board neck injuries
Practice is shifting from blanket immobilisation to a selective approach
Palpation of the injured C-spine athlete
- need to palpate upper back, neck, shoulder, clavicle and sternum
- failure to do this means paralysis or death
- know the order
Dermatomes
go through them
Myotomes
go through them
Canadian C spine Rules
- High-risk factors that mandate RADIOGRAPHY (Yes = X-Ray; No = #2)
- Age > 65 years
- Dangerous mechanism or paraesthesis (tingling) in extremities - Low-risk factors that allow safe assessment of ROM (Yes = #3; No = X-Ray)
- NO midline C-spine tenderness
- Delayed onset of neck pain
- Ambulatory at any time
- Sitting position
- Simple rearend MVC - Able to actively rotate neck? → 45° left and right (able = no X-Ray, unable = X-Ray)
Dangerous mechanisms: fall from elevation, axial load to head (diving). MVC high speed
Stinger/Burner vs Spinal Cord Injury
Stinger/Burner
- unilateral
- rarely involve lower extremities b/c brachial plexus doesn’t innervate there
- transient (can heal quickly)
- sensory (C5/6 dermatome)
- weakness
Spinal cord/C-spine injury
- bilateral
- upper AND lower extremities
- transient or prolonged/permanent
- sensory w/ possible total loss of sensation
- weakness/paralysis
Log Roll
Prior to roll
- make sure helmet is stable
- need to use CROSS ARM technique so arms unwind as roll is performed
Leader uses commands: “PREPARE TO ROLL” and “ROLL” - assistants follow
C- spine immobilization clinical recommendation
when a C-spine injury is suspected, the spine should be immobilized in NEUTRAL position
- can reduce spinal cord compromise
- may facilitate airway management
there are 3 contraindications to moving C-spine to neutral
Contraindications to moving C-spine to neutral
- Movement causes or increases pain, neurologic symptoms or muscle spasm compromising the airway
- there is RESISTANCE to movement
- patient expresses apprehension
Helmet Facemask Removal Tools
Study 1: cordless screwdriver is more efficient than FM extractor
Study 2: cordless screwdriver should be used as primary tool for face mask removal + should have a backup tool
“Don’t Lose Your Head”
Keep them in as much equipment as possible as long as they’re safe and secure
Hockey Helmet Study
looking at alignment of C- spine w/ no equipment, full and partial equipment
- increase of lordosis in sub axial cervical spine alignment
Recommendation: stable ice hockey helmets should NOT be removed from injured players (to eliminate unnecessary motion of the C-spine)
Football Helmet Studies
Study 1
- looked at groups of cadavers using radiograph
- HP had no significant change in cervical lordosis compared to N.
- H v. N - flexion (- degrees); S v. N - extension (+ degrees)
Recommondeation: removal of helmet and pads should be “ALL OR NONE”
Study 2
- looked at live subjects on spine board w/ HP or N via CT
- no significant diff. btwn N and HP
- P only = increased cervical extension
Recommendation: players w/ suspected C-spine be transported w/ helmet and shoulder pads left in place
Lacrosse Study
- assessment of live subjects on spine board wearing personal helmets and shoulder pads (HP) or P only via CT
Results
- HP has greater extension
- P vs. HP = more cervical flexion
- P vs. N = more flexion
Recommendation: players w/ suspected C-spine injury be transported w/ helmet and shoulder pads left in place
Helmet protocol for football and hockey
Helmets must be STABLE
- hockey MUST have chin strap done up tight
Helmet Removal Protocol
Remember to KEEP YOUR HEAD ON - only continue if necessary
- Partner 1 stabilizes helmet w/ ELBOWS ON THE GROUND. Partner 2 (leader) CUTS chin straps - don’t undo
- # 1 maintains grip. #2 unscrews/cuts lateral clip on both sides
- # 1 maintains grip. #2 spreads facemask to release cage from clips and flips facemask toward top of helmet
- # 1 continues grip. #2 removes cheek pads w/ straight edged appliance - AIRWAY ACCESS now achieved
- # 1 attempt to spread sides of helmet. #2 does VICE/ALLIGATOR GRIP to maintain cervical alignment
- # 1 rolls helmet forward on patient’s head towards the chest. #2 maintains vice grip/alligator
if you need airway, take off facemask first and try to keep helmet on
IF HELMET COMES OFF, SHOULDER PADS COME OFF TOO
Helmet and Shoulder pad removal relationship
IF HELMET COMES OFF, SHOULDER PADS COME OFF TOO
Shoulder Pad Removal
- Partner 1 stabilizes patient’s head as before. Partner 2 cuts patient’s jersey up the front, across shoulders and out arms
- # 1 maintains grip. #2 cuts all straps and laces
- # 2 does vice/alligator grip UNDER SHOULDER PADS to achieve cervical stability. #1 grasps both sides of shoulder pad breast plate and bends them bwd. towards patient’s head and slides pad from under patient
- # 1 reestablishes control of head. #2 applies cervical collar to patient
Equipment Removal Guidelines
Helmet should be removed:
- If face mask cannot be removed to gain airway access
- If airway cannot be controlled after removal of facemask due to design
- If helmet and chin straps do NOT hold the head securely
- If helmet prevents immobilization for transport
ALWAYS IF SHOULDER PADS ARE REMOVED
Shoulder pad should be removed in the following situations:
- Multiple injuries requiring full access to shoulder area
- Ill-fitting shoulder pads lead to inability to maintain spinal immobilization
- CPR needs access to thorax
ALWAYS IF HELMET IS REMOVED
Transport to Spine Board
Log Roll vs Vertical Lift
- minimal difference in flexion/ext. btwn LR and VL
- greater axial rotation + lateral flexion w/ log roll
Recommendation: use VERTICAL LIFT when able
Transport to Spinal Board
Vertical Lift
need 8 ppl
- 1 leader immobilizes head + neck)
- 1 person moves board
- 3 ppl on each side at shoulders, hips + knees
Slowly lift vertically together then board is slid under. Then slowly lower athlete
Transport to Spinal Board
Log Roll
- immobilize the head
- use AT LEAST 3 ppl - always roll TOWARDS
- leader/charge always coordinates (head)
- place board against back at 45 degree angle
- may require Z position (slide over + up on an angle) - no straight traction or compression
Securing the athlete with spine board transport
- once on the spine baord, leader must continue to stabilize the head and neck
- assistants secure athlete to the board
BEGIN W/ THORAX, THEN HEAD THEN LOWER BODY
Secondary Ax Goals
non-emergent or extremity
- what is wrong?
- if the sport allows: do they need a more detailed assessment?
- determine if athlete can play or if it is safe to remove from field
- how to transport from the field
Sports rules for assessments
wrestling: 90s
rugby: game keeps going - limited subs; watch your back
football: 2 mins for blood 0 3 plays out for player (make sure they won’t get uo before you go on the field)
soccer: ref calls therapist on field - yellow card
Speed and accuracy are essential
History (Secondary Ax)
Evaluate athlete’s injury
- unique b/c you often see MOI, so pay attention to game/event
- what happened?
- where does it hurt?
- did you hear of feel any pops/grinding?
- have you injured this or the other side before? - comparing to a normal jt?
On-field Secondary Ax
First the 3 questions
1. Life or limb
2. Is area stable? Clear ABCs
THEN
1. clear above and below - squeeze test
2. palpate
3. special tests for stability of bones and joints
Anything grade 2 or above is UNSTABLE
What grade of injury is stable? Unstable?
Anything Grade 2 or above is UNSTABLE
Grade is technically stable
Return to Play after Secondary Ax
Look at ROM, STRENGTH AND FUNCTION
- can athlete participate in the sport safely?
- can athlete play effectively?
- can athlete perform relatively pain free?
Options:
- observe on sideline w/ possible return to play
- removal from play + referral for follow-up
- send to hospital
What do coaches want to know?
During the game
- can they play? yes or no
- are they 100% (if not, what %)
- will they be available this game? minutes, period?
After game
- how are they? what is injured? - LAYMAN’S TERMS
- how long are they out for?
- when will we know about next game?
