ERA Course Flashcards
Airway and breathing steps?
- If unresponsive, open airway and check 5-10 seconds
- Check pulse and look for breathing
- Perform rescue breaths vs. CPR
Types of shock
Cardiogenic, neurogenic, anaphylactic, psychological
Signs/Symptoms of hypoperfusion/shock
- Pale, cool grey skin
- Dizzy/lightheaded
- Decreased BP
- Increased HR
- Anxiety
- Loss of consciousness
- Shallow breathing
What is hypoperfusion/shock
Lack of blood flow to vital organs. Your body tries to compensate by shunting of blood from extremities to organs
Treatment for Shock/hypoperfusion
- Keep patient temperate
- No oral fluids
- Elevate legs
- Emergency oxygen
- Treat injuries (bleeding/fractures)
- Monitor vitals
- Advanced care
Ask these questions during secondary assessment?
SAMPLE
1. Signs/symptoms
2. Allergies
3. Medications (including OTC’s)
4. Pertinent medical history
5. Last oral intake
6. Events leading up to incident
Vitals needing taken?
At a minimum: pulse and RR. Want BP and O2 if possible.
What is in the head to toe exam?
DCAPBLTS
1. Deformity
2. Contusion
3. Avulsion
4. Penetration
5. Burn
6. Tenderness
7. Laceration
8. Swelling
Areas of concern during secondary exam?
- Head/Skull: CSF, bleeding, skull fracture
- Neck: point tenderness, pain with movement
- Chest: Bruising, deformity, asymmetry
- Abdomen: 4 quadrants
- Back: Tenderness
- Pelvis: Tenderness
- Genitals: Swelling, incontinence
- Extremities: Soft tissue or skeletal injury
When to assess Cranial Nerves and How?
If athlete sustained head injury, blow to face, or neuro signs.
Olfactory: Smell
Optic: Vision
Oculomotor: Pupil reaction
Trochlear: Lateral and inferior eye movement
Trigeminal: Mastication and facial sensation
Abducens: Lateral eye movement
Facial: Taste, expression
Vestibulocochlear: Hearing, equilibrium
Glossopharyngeal: Swallow, gag, tongue sensation
Vagus: Speech, swallowing
Accessory: Trap/SCM innervation
Hypoglossal: tongue movement
How often should you reassess athletes?
5 minutes or less for unstable athlete, 15 minutes if stable
Potential symptoms of asthma
Labored breathing, audible wheezing (may be on inspiration and expiration or expiration alone), chest tightness, and persistent coughing. Low systolic BP and rapid breathing. Respiratory distress can occur (O2 Sat <90%)
O2 sat levels that are concerning? What is O2 sat measuring?
Anything below 95. Measures the percentage of oxyhemoglobin in blood pulsating through capillaries.
How much oxygen do you give?
15 L/min tolerated well by most athletes unless by nasal cannula, then only 6 L/min.
How will athlete hold arm with shoulder injuries?
Anterior dislocation = holding arm in abd and ER
Clavicular fracture = holding arm across body.
AC separation = supporting arm under the elbow.
Guidelines for Splinting
- Splint for pain relief or to move an athlete
- Remove jewelry or restrictive clothing
- Clean and bandage any open wounds before splinting
- Do not cause more pain
- Check pulse and sensation before and after splinting
- If joint injured, immobilize bone proximal and distal to joint
- If bone is injured immobilize joints proximal and distal to bone
- Pad areas of bony prominences before tying on splint
- Do not tie any securing straps directly over the fracture site
Physeal closure during development
Growth centers close beginning at the distal extremities and moving proximally. Clavicle last to close in early 20’s. Complete closure of growth plates occur about 18-24 months after start of menarche. Appearance of beard/mustache in males indicative of joint closure.
Diagnostics for Young Patients With Back Pain
Most spinal disorders in skelletaly immature should have plain radiographs.
Grades of spondylolisthesis and when to stop participating in sports?
1 = 0-25%
2 = 25-50%
3 = 50-75%
4 = >75%
Shouldn’t participate in sports with grades 3-4.
Little league shoulder
Stress reaction or fracture of the proximal humeral physis (salter type 1). Overuse injury. Clinical exam shows painful physis and plain films may be negative.
Treatment of little league shoulder
Minimum 6 weeks without throwing. Start with gentle stretching to posterior shoulder and core strength. After 2-3 weeks and pain-free ROM, begin RTC strengthening.
Recommended ages for pitches
Pitchers should not throw breaking pitches in competition until bones have matured (typically 13)
Supracondylar fracture
Most common seen in ED for children 3-14. About 1/2 need surgery. Commonly the anterior interosseous branch of median nerve becomes compromised (inability to flex thumb at IP join and give OK sign)
Immobilization after elbow dislocation
Cast immobilization for 2-3 weeks
Types of forearm fractures
Monteggia - fracture of ulna with dislocation of radial head
Nightstick - transverse fractures of ulna
Galeazzi - fracture of distal radius with disruption of distal radioulnar joint
Smith Fracture: Radius goes towards palm
Collies Fracture: Distal radius goes dorsal
Barton Fracture: collies fracture plus dislocation of radiocarpal joint
Signs/Symptoms With Medial Epicondyle Apophysitis
Usually 8-14 and pitchers or tennis players. May have up to 15 degrees flexion contracture of elbow. Pain with wrist flexion and pronation.
Osteochondritis Dessicans vs AVN vs Osteochondrosis.
OCD is where a piece of cartilage, along with a thin layer of bone separates from end of bone because of inadequate blood supply. AVN is where bone dies due to decreased blood supply. Osteochondrosis is derangement of normal bone growth where there is interruption of blood supply to epiphysis in adolescents.
Panner’s Disease Progression Down the Road and Prognosis
Blood supply returns and capitellum reshapes after 1-2 years. Early detection is key, surgery usually not indicated. Full return to sports the next season.
Buckle (Torus) Fracture
From FOOSH. Occurs at diaphyseal-metaphyseal junction where stronger diaphysis compress metaphysis. Treatment usually 3 weeks in cast. Radiograph shows bump on edge of bone.
X-rays needed for hip in youth athlete
AP, lateral, and frog.
Major sites for apophysitis in hip/pelvis.
6 sites:
1. Iliac crest (common and pain with rotation due to obliques)
2. ASIS
3. AIIS
4. Ischial physis
5. GT
6. Lesser Trochanter
Diagnosis and prognosis for LQ avulsion?
Diagnose with radiographs. Need surgery for displacement >3 cm.
Rehab protocol for non-surgical avulsion fracture
Week 1: Rest, protected WB
Weeks 1-3: protected gait and gentle AROM/PROM
Week 3: light resistance
Month 1-2: return to sport activity
Month 2-3: returns o play
SCFE
Slippage of the metaphysis relative to the epiphysis. Most commonly seen in adolescent obese males (males 2x more likely). Diagnosis made with radiographs. Ages 10-16 most common (during puberty). About 25% of time is bilateral. Treatment is pin fixation. Metaphysis translates anteriorly and externally rotates. Mostly atraumatic, pain usually present several months. Pain in hip most common but can often have knee pain and lead to missed diagnosis. Patient usually prefers to sit in a chair with affected leg crossed over other. Usually antalgic gait with ER’d leg or trendelenburg. Loss of hip IR, abd, and flex.
Legg-Calve-Perthes Disease
Occurs between 3 and 13 (most often 5-7). Boys 3-5x more than girls. Avascular necrosis of femoral head. Treatment usually observation for those under 8, femoral and/or pelvic osteotomy in those over 8. Male:Female is 5:1. Limping. Pain in groin, thigh, or knee. Loss of IR and abduction. Presence of hip flexor contracture. Positive log roll test. Try to protect this area and facilitate remodeling, surgery required if conservative measures fail.
Tibial Spine Avulsion Fracture
Usually children 8-14. Looks like ACL tear but tibial spine fails instead of ACL. Usually pain, effusion, and reduced WB. Best seen on lateral radiograph. Try to cast these individuals to heal but if significant displacement or lack of reduction can use surgery.
Distal Femoral Physeal Fracture
During valgus stress the distal femur at physis is weakest and will fail. If Salter-Harris type 1 radiographs will be negative. Medial knee pain and pain at physis with palpation, also TTP at MCL. Can immobilize for type 1, reduction for displaced fractures
Discoid Meniscus
Meniscus shaped like a disc instead of semilunar. Usually occurs in lateral compartment. Usually complaints of snapping in preschooler and then complaints of pain in elementary school. May have TTP at joint line or positive McMurray’s. MRI confirms. Will have bow tie appearance on sagittal MRI. Will rehab for largely asymptomatic presentations (such as snapping only). Can do resection if painful, degenerated, or unstable.
Saltar-Harris of Distal Fibula
Typically type 1, often misdiagnosed. Occur with plantarflexion/inversion. Hallmark is pain on palpation of distal fibular physis (1-2 fingers proximal to distal fibula). Cast of boot for 3+ weeks.
Cardiovascular Changes With Aging
- Decreased VO2 Max
- Heart can’t beat as fast during exercise, resting relatively unchanged (target HR 60-80% of max or RPE 12-16 -> just able to speak)
- Higher systolic BP, possibly lower diastolic (need to refer at >200 resting BP)
Pulmonary Changes With Aging
- Less oxygen available to body and transport of the oxygen is less efficient
- Breathing is more work for adult
- Respiratory events more likely
- Use pulse ox (95-100 normal, less than 95 more concerning, need to refer less than 90)
Musculoskeletal Changes With Aging
- Cartilage: atrophied and less hydrated
- Joints: more stiffness due to more collagen and more cross linkage
- Connective tissue: less pliable, more difficulty regaining length after injury
- Skeletal mm: sarcopenia, smaller/shrinking type 2 fibers (replaced by type 1 and fat)
- Bone: decreased bone mineral density
- Posture: more kyphosis
More injury prone, slower healing, less power, increased fracture rate, falls more likely.
Neurological Changes With Aging
- Decrease in sensory receptors (more with diabetes and PVD)
- Decrease in mechanoreceptors (loss or proprioception)
Integumentary changes with aging
- Delayed inflammation
- Delayed healing time
- Decreased sweat production (watch for heat stroke)
Symptoms seen with vertebral compression fracture
Sudden onset of pain that may wrap around anteriorly (can be confused with cardiac or pulmonary symptoms)
Heat Related Injuries in Senior Athlete and Signs/Sx’s of Dehydration
More susceptible to dehydration, heat stroke, and sunburn. Signs/sx’s: most consistent of dehydration may be low systolic BP, but could also have confusion, dizziness, HA, dry mouth ,lack of sweating, rapid pulse, decreased urination, and constipation.
Hypoglycemia in senior athlete
<70 mg/dL. Can be more likely to happen with senior athlete, may need glucose (gel or sugary snack). Severe cases may look like they are drunk (confusion, slurred speech, abnormal behavior, seziures, LOC).
Differences in MI presentation for men vs women
Women may not present with chest pain but only SOB, muscle weakness, and unusual fatigue.
When does puberty begin/end for the sexes? When does adolescence end.
Girls: starts at 10-11 and ends at 16 (adolescence ends around 18)
Boys: starts at about 12.5 and ends around 18 (adolescence ends around 21)
Tanner’s Stages of Development
1: Prepubescent. No pubic hair.
Boys: no genital enlargement.
Girls: small projection of breasts.
2: Minimal pubic hair.
Boys: mild genital enlargement.
Girls: 1st growth spurt and breast budding with areolar growth
3: Hair over pubis
Boys: Genitals continue to grow. 1st growth spurt.
Girls: rapid growth rate. Hair in axillae.
4: Boys: rapid growth rate. Axillary hair growth and voice deepens.
Girls: growth slows, menarche begins
5: Max height achieved.
Boys: Facial hair develops.
Girls: Adult breast shape and pubic hair looks like adult.
Estrogen and testosterone in males/females
Estrogen rises equally in males and females during puberty. Girls have a minor rise in testosterone and boys have a significant rise. Women had a fall in estrogen from 20’s to 50’s which is when menopause typically starts. Testosterone remains consistent for men and declines starting in the seventh decade of life.
Conditions where exercise induced asthma is more likely
Endurance athletes, winter athletes (cold, dry air), swimming athletes (presence of chemical gases used to treat water)
Goal measures for DM, hyperlipidemia.
DM: Resting blood sugar less than 108
LDL: < 160 mg/dL
Autonomic Dysreflexia
Experienced by athletes with SCI above T6 level. An internal noxious stimulus (bladder distention) or external noxious stimulus (WC strap or insect sting) can create involuntary response of ANS. Results in rapid vasoconstriction and variability of HR as well as elevated BP and S/S’s such as HA, diaphoresis above SCI, piloerection, blurred vision, nausea. This is a medical emergency. Can result in stroke, intracranial hemhorrage, and death. Manage by signaling ERS, sit upright, loosen thigh clothes, remove stimulus, and assist with prescribed medication. Some athletes will self-induce this for performance benefits though (sitting on tack or other noxious stimulus), called boosting and this is banned.
Food and water with seizure
Be careful issuing this because it can be an obstruction if they have another seizure.
What SCI levels have dysfunction of sympathetic nervous system? Why is this a problem with athletics?
T8 or higher. These athletes have trouble with regulation of core body temperature. Have a hard time with sweating and alterations in dialating peripheral vasculature.
How do beta-2 agonists help with performance
There are some oral versions you can take, not just inhaled. Can improve anaerobic performance. May increase strength and power output.
How do beta-blockers help performance
Decreased heart rate, tremor, reduced anxiety.
How does insulin affect performance. Side effects?
Slow down muscle degradation, improve muscle endurance. Rapid HR, hunger, coma, death, insulin shock.
What does blood doping do? Methods to accomplish it? Testing for It?
Increases hemoglobin in blood to carry more oxygen to tissues. Done with blood transfusions, injections of EPO, or injections of synthetic oxygen carriers. Can’t detect if they use their own transfusion but can take blood at different times during season to measure hemoglobin. Can detect EPO or synthetic carries through urine test.
Wrestling Time for Bleeding and Injuries?
Blood time starts when the provider begins attending to the athlete and max time is 5 minutes. If athlete can’t return in 5 min he loses (unless due to unsportsmanlike conduct). Once bleeding is controlled, injury time begins. Wrestling injury time is 90 seconds. No injury time for concussion but if there are signs/symptoms the athlete should be removed from play. If injury from illegal maneuver, unnessecary roughness, unsportsmanlike then allowed 2 minutes and this is not counted against injury time. If not able to continue then they lose. Max 2 team attendants on the mat for athlete. Clean up is not counted in the 5 minutes.
How to handle the bleeding on wrestler?
Able to return when bleeding controlled. If nasal plug in it has to be secure and not in danger of further harm or infectious. Clean the athlete with microbial wipe and uniform. Clean other athlete with microbial wipe and clean the mat.
Can a wrestler with headache return to play?
No. Any contestant who exhibits S/S’s consistent with concussion should be immediately removed from play. They should not return to play that day.
Care for bleeding athlete?
- Remove from play
- Stop bleeding
- Clean with antimicrobial wipe
- Wash with soap and water ASAP
- Cover to return to play
- Must be secure and not in further harm
What to do if blood on another athlete?
- Clean with antimicrobial wipe
- Clean with soap/water ASAP
- Change uniform unless blood is dried
- If exposure, confidential medial evaluation
How to clean mat at wrestling meet?
- Absorb the contaminants with absorbent towels and place in biohazard bag
- Disinfect area with diluted solution of tuberculocidal or freshly prepared bleach solution 1:10 (bleach to water).
How are contaminated linens cleaned?
Laundered at temperature of 71 C / 160 farenheit at 25 minute cycle.
Tinea Corporis (other name as well). Treatment to play with this.
Fungal infection on the body with well-defined, scaly plaque with raised borders. Also called ringworm. Athletes have to have used a topical fungicide for at least 72 hours and be adequately covered with a gas permeable membrane.
Treatment and return for Herpes Simplex
Active lesions must be treated with oral antiviral medical, such as valacyclovir. Must be free of systematic symptoms (fever, malaise), no new blisters for 72 hours. All lesions must have firm adherent crust. Complete minimum of 120 hours of systemic antiviral therapy. Can’t just cover active lesions to participate.
Tinea Pedis and Restrictions/treatment
Not restricted from practice or competition. Topical anti fungal cream, oral anti fungal therapy if severe.
MRSA and participation.
Can look like a spider bite and can quickly spread to become multiple lesions, highly contagious. No new lesions for >48 hours, oral antibiotics >72 hours, no moist or draining lesions, active lesions can’t just be covered, report outbreaks to local health authorities.
Tinea Capitis
Fungal condition of head. Must be treated for 14 days with oral anti fungal medication
Impetigo and return to play.
Bacterial infection characterized by honey colored crust. No new lesions for >48 hours. Completion of >72 hours antibiotic therapy. No drainage or exudate from wound. Can’t just cover active infection.
Molluscum Contagiousum and treatment
Flesh colored dots. Destruction with sharp curette and cover with gas permeable dressing/membrane.
Name for head lice and treatment for return.
Pediculosis capitis. Medicated shampoo. Restrict activity for 24 hours after treatment. Must show no new evidence of infestation.
Guidelines for furuncle/carbuncle
- Must complete 72 hour course of antibiotic therapy
- No drainage or exudate from wounds
- No new lesion for 48 hours
- Active lesions can’t be covered to allow participation
Guidelines for cellulitis.
All lesions scabbed, active lesions may not be covered.
Guidelines for folliculitis
- Whole bunch of bumps around areas of hair growth
- May be in areas that are shaved or taped often
- Less contagious but is form of staph
- All lesions scabbed and may be covered when inactive
Guidelines for scabies
Complete treatment or 24 hours post treatment. No evidence of infestation.
Duty to Act vs Required to Act
No legal duty to assist unless responsible for the accident of legal guardian. Required to act in contractual agreements, formal obligations, continuation of care, “on duty”, and established relationships.
