Shock, Soft Tissue Injuries, Sickle Cell, and Sudden Cardiac Death

Question 1

What are soft tissue injuries?

Answer 1

• Any injury to the skin, muscle or fat
• Open or closed
• The most common type of injury seen in sports
• Preparation and appropriate diagnosis are the most important aspects of care.

Question 2

O que são closed wounds?

Answer 2

• Hematoma or bruise
• Force to the body which disrupts blood vessels causing blood to leave the circulatory system
• Signs and symptoms include discoloration, swelling, pain, localized tenderness.

Question 3

What are the procedures of Care for Closed Wounds?

Answer 3

• Examine carefully
• Mechanism of injury
• Check circulation and sensation distal to the wound (se não hover circulação, sensação ou movimento, deve-se estabilizar a área, palicar gelo e referir o atleta para a emergência).
• History of injury to the area
• Rest, Ice, Compression (with caution), Elevation.

Question 4

Que tipos de feridas abertas são mais comuns?

Answer 4

• Abrasions (a fricção aplicada ultrapassa a elasticidade da pele);
• Lacerations (podem ocorrer com golpes afiados, geralmente nas proeminências ósseas. Decidir se precisa de ser suturada);
• Avulsions (fricção é aplicada na pele e uma porção é “arrancada”, expondo os tecidos mais internos);
• Punctures/ penetrations (com o conhecimento de anatomia podemos tentar perceber quais as estruturas que podem estar envolvidas)
• Crush.

Question 5

What is the care for open wounds?

Answer 5

• Standard precautions: gloves at a minimum
• Control bleeding – Sterile or clean gauze; Direct pressure; Elevation above the heart; Pressure points (artérias braquiais e triângulos femorais; Tourniquet (garrote).
• Clean wound with clean or sterile water
• If bleeding continues apply another dressing over the old one
• After bleeding stops, apply antibiotic ointment (pomada)
• Cover the wound with sterile dressing
• Sutures or staples if wound gaps open after bleeding stops
• Steristrips: small lacerations that gap.

Question 6

O que fazer em caso de amputação traumática?

Answer 6

• Control bleeding
• Watch for shock
• Some look for amputated part
• Wrap in gauze and place on ice
• Seal in plastic bag if possible
• Transport with athlete to hospital.

Question 7

Como prestar cuidado nas bolhas?

Answer 7

• Do not open unless the blister interferes with performance
• Then open
• Cover with medicated bandage if open
• Cover with Band-Aid or similar if closed
• Leave closed if possible and let fluid be reabsorbed by the body and body will cover the wound.

Question 8

A hockey player on your team collides with a player on the opposing team. The skate blade cuts through the jersey of your athlete and results in a laceration to the upper arm. Your athlete skates off the ice and comes to you for a bandage so he can return to play. How do you first respond to this athlete’s injury?

Answer 8

Put on gloves to apply direct pressure. You need to protect yourself first. Gloves are the minimum standard precaution to care for wounds. You can use gloves and sterile gauze to apply direct pressure.

Question 9

An opponent collides with your team’s defensive soccer player. The opponent’s cleat hits the inside of your athlete’s right shin, impacting the calf and the shin area. Your player limps off the field. Upon examination, the lower leg is swollen, very tender, and has some discoloration. What type of soft tissue injury would this be?

Answer 9

Hematoma or bruise. A hematoma or a bruise is a closed wound, typically caused by a force to the body, which disrupts blood vessels causing blood to leave the circulatory system. Common symptoms include discoloration, swelling, and pain, which are present in this situation.

Question 10

After you determine a hematoma or bruise, how would you first care for this athlete on the sideline?

Answer 10

Palpate the area and check movement, circulation and sensation.
The wound needs to be carefully evaluated by palpating the area. The athlete should show signs of circulation and sensation distal to the wound as well. There should be pulses in the hand in feet. If there is no movement, circulation, or sensation distal to the wound, then the area should be stabilized and the athlete should be referred to an emergency room.

Question 11

What is shock?

Answer 11

• Lack of adequate oxygenated blood flowing to the cells, tissues, and organs.
• Medical emergency which requires immediate medical attention.
• Death may occur if not properly managed.

Question 12

Quais os tipos de choque?

Answer 12

• Hypovolemic: result of blood loss
• Cardiogenic: failure of cardiovascular organs – heart;
• Anaphylactic: allergic reaction
• Septic: severe infection
• Neurogenic: damage to nerves that affect the heart and blood vessels.

Question 13

What are the causes of shock?

Answer 13

• Sudden severe loss of blood
• Disruption of heart activity, heart attack
• Anaphylaxis: eating certain food or exposed to allergy trigger
• Septic: untreated infection that spreads throughout the body.

Question 14

How do we know when someone is going into shock? What signs and symptoms they present?

Answer 14

• Pale, clammy skin
• Rapid, thready pulse
• Rapid breathing
• Low blood pressure
• Dizziness
• Fainting (desmaio), confusion, anxiety
• Cyanosis
• Chest pain (as mulheres também podem ter dor interescapular).
• Nausea or vomiting
• Enlarged pupils
• Weakness or fatigue

Question 15

What to do in case of shock?

Answer 15

• Supine position with legs elevated
• Maintain body temperature
• Apply direct pressure to minimize blood loss
• ABC, possibly CPR
• AED
• Call 911 ASAP.
• Se possível, administrar a máscara de oxigénio (15 litros/minuto).
• Em caso de choque anafilático, aplicar EpiPen.

Question 16

You are the sports physical therapist assigned to a local high school cross-country meet. You receive a call that one of your runners has been struck by an automobile and is lying at the side of the road. Upon arrival you notice that the runner has a larger laceration in her thigh and is not responsive to verbal stimuli. Her skin is pale, moist and clammy.
• How do you respond?
• What is your primary concern for this athlete?
• What is the most likely cause of the athlete’s shock?

Answer 16

• Stabilize cervical spine as she is unresponsive then check ABC. Being on the roadway, there is someone there who can call 911. This person can also stabilize C-spine while CPR is initiated. The bleeding is a concern but does not take precedent over life-threatening ABC evaluation and CPR if needed.
• Shock. The player can die from shock.
• Sudden severe loss of blood, primary cause of shock.

Question 17

What is sickle cell (falciforme) trait in athletes?

Answer 17

Sickle cell trait is an inherited blood disorder. Unlike sickle cell disease, a serious illness in which patients have two genes that cause the production of abnormal hemoglobin (the substance in red blood cells that helps carry oxygen), individuals with sickle cell trait carry only one defective gene and typically live normal lives.

Question 18

O que pode induzir sickle cell trait?

Answer 18

• Intense exertion causes normal Red Blood Cell from round to quarter moon shape (sickle)
• Exertional sickling: top four in deaths (9 in 7 years)
• Log jam vessels leading to exertional rhabdomyolysis
• Increased with heat, dehydration, altitude, asthma.

Question 19

Quais os sinais e sintomas de sickle cell?

Answer 19

• Mistake for cardiac or heat collapse
• Occurs within the first 30 minutes of workout
• Core temp is normal
• Sickling has pain different from muscle cramping
• Heat cramp pain is more intense
• Slumping to the ground with muscle weakness
• No localized spasm
• Catch early and treat properly: recover faster
• Return to normal with rest: cells transmit oxygen to muscle.

Question 20

Qual o tratamento, se alguém colapsar devido a sickel cell?

Answer 20

• Collapse is true medical emergency, 911
• Administer oxygen 15 l/min
• Cool if necessary
• AED/ IV
• May develop explosive rhabdomyolysis, inform MD and EMS;
• Have appropriate equipment available.

Question 21

During the first week of football training at the local college, several freshmen move from low intensity workouts to intensive training regimens. Due to the unusually warm weather and the transition to a high altitude environment, you are concerned that if an athlete has a history of sickle cell disease, they may be at risk for exertional rhabdomyolysis. What symptoms or situations are exertional rhabdomyolysis manifested by?

Answer 21

Bilateral LE cramping that progressed proximally. This is the typical presentation of exertional rhabdomyolysis and it may be mistaken for cardiac or heat collapse.

Question 22

Forces that foster sickling include severe hypoxemia, metabolic acidosis, hyperthermia in muscles, and red cell dehydration. Acute sickling is known to increase with heat, dehydration, altitude, and asthma. When would you consider request screening for a player with suspected sickle cell anemia?

Answer 22

Abnormal bilateral cramping that does not resolve in a normal fashion. This may be a sign of sickle cell anemia and should be investigated before it results in serious side effects. Athletes will return to normal with rest if this is caught early and treated properly.

Question 23

A healthy 19-year-old football player participated in the third day of his preseason practice. He participated in a cold-water immersion treatment after practice, as recommended by his coach for all players. He then presented with leg cramping and no sign of heat illness. He had no family or personal history of sickle cell or heat conditions. After the sickling continued to progress to his lower back, he was transported to the emergency department and diagnosed with exertional rhabdomyolysis. When would you allow the return to play for a player with diagnosis of sickle cell anemia?

Answer 23

• Proper hydrations status. Dehydration is a predisposing factor for exertional sickling. Hydration, thus, is key to preventing exertional rhabdomyolysis.
• Physician clearance.
• Educational programs for coaching staff completed. All coaching staff should be trained to recognize if the athlete complains of symptoms associated with sickling. Precautions, such as allowing long periods of rest and stopping activity if symptoms occur, are key to preventing increased sickling episodes.
• Avoid extended exposure to hot, humid weather. Heat and adjustments in climate may result in increased risk of sickling. Keep athletes hydrated and allow time for acclimatization.

Question 24

Qual a incidência da sudden cardiac death (SCD)?

Answer 24

• Four (4) cases per one million athletes of all ages
• SCD occurs 10-25 times per year in the US in all athletes under the age of 30
• Significant cause of sports-related deaths in athletes of all ages
• Ventricular fibrillation is most common type of
arrhythmia preceding death.

Question 25

Quais os efeitos fisiológicos do exercício dinâmico?

Answer 25

• Increase cardiac output by raising heart rate and stroke volume
• Higher systolic blood pressure
• Decreases peripheral vascular resistance
• Mean blood pressure (BP) remains relatively unchanged.

Question 26

E qual o efeito dos exercícios estáticos, como levantamento de pesos?

Answer 26

• Raises peripheral vascular resistance
• Increases diastolic and mean BP
• Moderately raises heart rate, stroke volume, and cardiac output
• Increased myocardial oxygen consumption causes increased wall tension and contractility (both static and dynamic)