IOC Manual of Emergency Sports Medicine

David McDonagh, MD, University of Science and Technology, Trondheim, Norway Medical Committees for the International Bobsleigh and Skeleton Federation and The International Boxing Association David Zideman, Director of Clinical Operations at East Anglian Air Ambulance, Consultant Anaesthetist at the Hammersmith Hospital, Imperial College Healthcare NHS Trust and Clinical Lead for Emergency Medical Services at the London 2012 Olympics and Paralympics.

List of contributors, xiii

Foreword, xvii

Preface, xix

About the Authors, xxi

1 Emergency Care at the Olympic Games 1
Richard Budgett

Introduction 1

Early Preparations 1

Final Preparations 2

Team and IF Doctors 4

Summary 4

2 Injury and Illness During the 2008 Summer and the 2010 Winter Olympic Games 6
Kathrin Steffen, Torbjørn Soligard and Lars Engebretsen

Vancouver Winter Games 2010 7

Beijing Summer Olympic Games 9

Bibliography 10

3 The Medical Team Response 12
David McDonagh and David Zideman

ABC on the Field of Play 14

Primary Survey 20

Primary Survey 22

Primary Survey 24

Transferring the Athlete from the FOP to the

Fieldside 27

Fieldside Assessment 27

Pupils - Pathological Findings 28

Blood Sugar 28

Blood Pressure 29

Athlete Medical Room Treatment 30

Transportation to Hospital 31

Discharge 31

Teamwork 31

Bibliography 32

4 Cardiopulmonary Resuscitation on the Field of Play 33
Ruth Löllgen, Herbert Löllgen, and David Zideman

Sudden Cardiac Arrest on the Field of Play 34

Recognition of Cardiac Arrest 34

Field of Play Airway 36

Foreign Body Airway Obstruction (FBAO or Choking) 37

Field of Play Breathing 38

Recovery Position 38

Field of Play Circulation 38

FoP: Combining Compressions and Ventilations 39

Expired Air Ventilation 39

Bag-Valve-Mask Ventilation (Two Rescuer Technique) 39

FoP Removal 40

Rhythm Analysis 40

Shockable Rhythms 41

Nonshockable Rhythms 42

Reversible Causes (The 4H's and 4T's) 42

Advanced Life Support 42

Advanced Airway 44

Simple Airway Adjuncts 44

Inserting an Oropharyngeal Airway (OPA) 44

Inserting a Nasopharyngeal Airway (NPA) 44

Advanced Airway Adjunct 45

Venous Access 45

Intraosseous Access 45

Drugs 45

Implantable Cardiac Defibrillators (ICDs) 46

Postresuscitation 46

Bibliography 46

5 Cardiac Emergencies on the Field of Play 47
Ruth Löllgen, Herbert Löllgen and David Zideman

Sudden Cardiac Death (SCD) 47

FoP Management Non-traumatic Sudden

Collapse 48

Clinical Findings/Management ACS (Fig 5.1) 50

Clinical Findings/Management AA or AD 52

FoP Management of Myocarditis 52

Clinical Findings/Management Hypertensive Crisis 53

Clinical Findings/Management Bradycardia 54

Clinical Findings/Management Tachycardia 57

Bibliography 57

6 Control of Hemorrhage and Infusion Management 58
Kenneth Wing Cheung Wu and Hiu Fai Ho

Introduction 58

FoP Management 59

External Bleeding Wounds 59

New Trends in Hemorrhage Control 60

Internal Bleeding 60

Infusion Management 61

Conclusion 62

Bibliography 62

7 Anaphylaxis 63
Andy Smith and Jerry Nolan

Introduction 63

Signs and Symptoms 64

Management of Anaphylaxis 64

Bibliography 67

8 Asthma and Respiratory Emergencies 68
Joseph Cummiskey

Observation - From Outside the FoP and While Approaching the Patient 68

FoP Management of a Suspected Chest Medical Event 68

Primary Survey 68

Fieldside Management of Chest Medical Conditions 69

Pulmonary Embolism 70

Bronchial Asthma and Exercise-Induced Bronchospasm (EIB) 70

The Effect of Environmental Conditions and Pollutants in Sport Activity 73

Bibliography 76

9 Seizures and Epileptic Emergencies 77
Geraint Fuller

Preparation 77

Fieldside Observation 77

Observations on Approaching the Athlete 78

Clinical Findings/Management Convulsing Athlete 79

Referral or Discharge? 80

Differential Diagnoses of Seizures 80

Bibliography 81

10 Head Injuries 82
David McDonagh and Mike Loosemore

Sideline Observation 83

FoP Management of a Convulsing Athlete 83

Primary Survey - Convulsing Patient 84

FoP Management of a Nonconvulsing Athlete with a Head Injury 85

Primary Survey on the FoP 85

FoP Management of Head Injury with a Low GCS 85

Management of Head Injury with a GCS 12-14

on the FoP 85

Fieldside Evaluation 86

Secondary Survey at the Fieldside 86

Management of Patients with Head Injuries 86

Pupil Examination 87

Glasgow Coma Scale 88

Binocular Hematomas - Raccoon Eyes 90

Battles Sign 90

A Focused Medical History 90

Transfer to the Hospital 91

When Should the ED Request a Cranial CT? 91

Scalp Lacerations and Bleeding 92

Smelling Salts 92

Bibliography 92

11 Concussion - Onfield and Sideline Evaluation 93
Paul McCrory and Michael Turner

Introduction 93

Epidemiology 93

Definition of Concussion 93

Symptoms and Signs of Acute Concussion 94

Fieldside Recognition of Concussion 94

Concussion Injury Severity and Recovery 94

Concussion Management 100

Concussion in Child and Adolescent Athletes 103

Prevention of Concussion 103

Other Specific Issues 104

Conclusion 105

Bibliography 105

12 Throat Injuries 106

Jonathan Hanson, Padraig B. Sheeran, Brian Carlin and David Zideman

Penetrating Trauma 107

Clinical Findings/Management Penetrating Neck Wound 108

Blunt Trauma 108

Clinical Findings/Management Blunt Neck Trauma 108

Clinical Findings/Management Laryngeal Contusion 109

Clinical Findings/Management Laryngeal Fracture 110

Needle Cricothyrotomy 110

Surgical Cricothyrotomy 111

VASCULAR INJURY - Clinical Findings Acute Vascular Neck Injury 112

Clinical Findings Delayed Presentation Vascular Neck Injury 112

Management Aerodigestive Track Injury 113

Bibliography 113

13 Facial Injuries 114
David McDonagh and Mike Loosemore

FoP Management Serious Facial Injuries 114

Facial Injury - Clinical Findings/Management Serious Facial Injury 115

Fieldside Management Serious Facial Injury 115

Clinical Findings/Management Serious Facial Injury 116

Clinical Findings/Management LeFort Fracture 117

Clinical Findings/Management Mandibular Fracture 118

Clinical Findings/Management Orbital Fracture 118

Clinical Findings/Management Zygomatic Fracture 119

Clinical Findings with a Nasal Fracture 121

Clinical Findings/Management NOE Fracture 122

Clinical Findings/Management Septal Hematoma 122

Clinical Findings/Management Epistaxis 123

Bibliography 124

14 Eye Injuries and Other Ocular Emergencies 125
Sibel Kocabeyoglu, U?ur Erdener and David McDonagh

Fieldside Observation and Observations on Approaching the Athlete 126

Fieldside Management Eye Injury 126

Eye - Blunt Trauma 127

Clinical Findings/Management Hyphema 128

Clinical Findings/Management Lens Subluxation 128

Posterior Chamber Hemorrhage 129

Clinical Findings/Management Retinal Detachment 130

Clinical Findings/Management Blowout Fracture 130

Clinical Findings/Management Orbital Fracture 131

Clinical Findings/Management Rupture of the Globe 131

Clinical Findings/Management Retrobulbar Hemorrhage 132

Clinical Findings/Management Periocular Ecchymosis 132

Clinical Findings/Management Subconjunctival Hemorrhage 133

Eye - Penetrating Injuries 134

Treatment 134

Non-traumatic Ocular Emergencies 135

Bibliography 136

15 Dental Injuries 137
Paul Piccinini and Anthony Clough

Types of Injuries 137

Management of Dental and Orofacial Injuries 138

Fractured Teeth 138

Dental Luxation 138

Intrusions 139

Avulsions 139

Trauma to the Alveolus 139

TMJ Trauma 140

Soft Tissue Trauma 140

Injury Prevention 141

16 Thoracic Injuries 142
David McDonagh and David Zideman

Fieldside Observation and Observations on Approaching the Athlete 142

FoP Management Chest Injury 143

Clinical Findings/Management Chest Injury 143

Fieldside Management Chest Injury 144

Clinical Findings Traumatic Pneumothorax 145

Clinical Findings Major Traumatic Pneumothorax 146

Clinical Findings Tension Pneumothorax 146

Pneumothorax Treatment 147

Tension Pneumothorax - Immediate Treatment 147

Needle Thoracostomy of Tension Pneumothorax 148

Clinical Findings/Management Hemothorax 149

Clinical Findings/Management Flail Chest 150

Clinical Findings/Management Pulmonary Contusion 151

Clinical Findings/Management Sternal Fracture 152

Needle Pericardiocentesis 153

Primary Management of Penetrating Thoracic Injuries 155

Bibliography 156

17 Abdominal Injuries 157
David McDonagh and Dara Lundon

FoP Management of an Abdominal Injury 158

Clinical Findings/Management Abdominal Injury 158

Clinical Findings/Management Penetrating Abdominal Wound 160

Clinical Findings/Management Blunt Abdominal Injury 161

Clinical Findings Splenic Injury 162

Clinical Findings Liver Injury 163

Clinical Findings Kidney Injury 164

Clinical Findings/Management Scrotal Trauma 165

Clinical Findings/Management Testicle Torsion 166

Bibliography 167

18 Pelvic Injuries 168
Andy Smith and João Grangeiro Neto

FoP Management Pelvic Injuries 169

Clinical Findings/Management Pelvic Injury 169

Fieldside Management Pelvic Injury 171

Clinical Findings Pelvic Injury at the Fieldside 171

Summary 175

Bibliography 175

19 Spinal Injuries 176
Éanna Falvey and Craig Roberts

Preparation for Onfield Management 177

FoP Management Potential Spinal Injury 177

Primary Survey Potential Spinal Injury 177

FoP Management of a Patient with Findings Indicative of a Spinal Cord Injury 178

Transfer of the Patient onto the Spinal Board/Lifting Device 179

Transfer from the FoP to the Fieldside 179

Fieldside Management Potential Spinal Injury 179

Clinical Findings with a Potential Spinal Injury 180

Return to Play After a Fieldside Evaluation of a Neck Injury 180

Clinical Findings with a Potential Cervical Spinal Fracture 181

Clinical Findings/Management Facet Joint

Injuries 182

Clinical Findings/Management Stinger Injury 183

Clinical Findings/Management Acute Prolapsed Disc 184

Clinical Findings Spondylolysis and Spondylolisthesis 185

Bibliography 185

20 Extremity Injuries 186
Michael R Carmont and David McDonagh

Fieldside Observation and Observations on Approaching the Athlete 186

FoP Management - Limb Injury 187

Clinical Findings Limb Injury 187

Onfield Management Limb Injury 188

Realignment of Fracture/Dislocations 188

Transfer from the FoP 189

Fieldside Management Limb Injury 189

Splint Selection and Application (See Chapter 30) 190

Analgesia 193

Ski Boot Removal 194

Paralympic Sport 195

Documentation 195

Bibliography 195

21 Aquatic Athlete Injuries and Emergencies 196
Margo Mountjoy and Saul Marks

Introduction 196

Swimming 196

Synchronized Swimming 198

Diving and High Diving 199

Water Polo 201

Open Water Swimming 202

Conclusion 204

Bibliography 204

22 Emergency Care of the Adolescent Athlete 205
Lisa M. Vopat and Lyle J. Micheli

Introduction 205

Primary Survey and Stabilization (See Chapter 3) 206

Differences in Injury Pattern 208

Emergency Planning and Fieldside Preparedness 211

Conclusion 211

Bibliography 211

23 Emergency Medical Care in Paralympic Sports 212
Peter Van de Vliet and Mike Wilkinson

The Paralympic Athlete 212

Injury and Illness in Paralympic Athletes 214

Impairment-Specific Considerations of Medical Care 216

Specific Paralympic Medical Concerns 218

Autonomic Dysreflexia 218

Conclusion 219

Bibliography 219

24 Cold Injuries 220
Ken Zafren, Gordon Giesbrecht and David McDonagh

The Collapsed Cold Athlete 221

Primary Survey in a Cold Athlete 221

Prehospital Treatment for a Cold But

Nonhypothermic Patient or for a Mildly Hypothermic Patient 222

Prehospital Treatment of a Patient With Moderate or Severe Hypothermia 222

CPR and Severely Hypothermic Patients 223

Frostbite 223

Clinical Findings/Management Frostbite 224

Nonfreezing Cold Injuries (NFCI) 226

Bibliography 227

25 Severe Dehydration and Exertional Heat Illness 228
Eunice M. Singletary

Introduction 228

Fieldside Observation and Observations on Approaching the Athlete 228

Primary Survey Severe Dehydration or Heat Illness 229

Blood Pressure and Pulse 230

FoP Management Dehydration, Exercise-Associated Hyponatremia and Heat-Related Illness 230

Specific Conditions 231

Bibliography 235

26 Hypo- and Hyperglycemia 236
Kathryn E. Ackerman and David McDonagh

Hypoglycemia 236

Clinical Findings Severe Hypoglycemia 237

Clinical Findings Mild Hypoglycemia 237

Hyperglycemia 238

Clinical Findings Hyperglycemia 238

Bibliography 240

27 Wound Care 241
David McDonagh and Sally Whitmore

FoP or Fieldside Management 241

Wound Location 242

Reassessment of Wounds and Dressing Changes 243

Tetanus Vaccines 245

Burns, Abrasions, and Blisters 245

Bibliography 247

28 The Role of the Paramedic on the Field of Play 248
Mike Nolan and David Whitmore

Planning and Logistics 248

Clinical Practice 249

Additional Information 251

29 The Role of the Physiotherapist on the Field of Play 253
Mark Brown, Michael Kenihan and Marie-Elaine Grant

Introduction 253

An Emergency Situation When Traveling with a Team of Athletes Either Nationally or Internationally 254

An Emergency Situation Either Nationally or Internationally Where the Physiotherapist is Covering the Event Alone and There is No Doctor or Paramedic Available 256

Onfield Assessment and Management 257

Bibliography 260

30 Emergency Medications and Equipment at the Fieldside 261
Mark Faulkner, Fionna P. Moore and David Zideman

The Bag 262

Immobilization and Carrying 263

Stretcher or Trolley Bed 263

The Spinal Board 263

The Scoop Stretcher 263

The Basket Stretcher 263

Carry Sheet 264

Semi-Rigid Cervical Collars 264

Head Blocks 264

Body Straps 264

Vacuum Mattresses 264

Limb Splints (See Chapter 20) 264

Pelvic Splints (See Chapter 18) 265

Resuscitation (See Chapter 4) 265

Dressings and Hemorrhage Control 266

Drug Administration and Intravenous Access 267

Medications 267

Intravenous Fluids 271

Bibliography 272

31 Emergency Medications and the WADA Prohibited List 272
Alan Vernec and Eduardo de Rose

Therapeutic Use Exemption 275

Strict Liability 276

Supplements 276

Possession of Prohibited Medication and Physician Responsibility 277

Summary 277

32 Retrieval and Repatriation of Injured and Ill Athletes 279
Mark Brown and Glenn Brown

Introduction 279

Preplanning 279

Team Medical Staff Skills 280

Equipment Requirements 280

Medical Transport Options 281

Specialist Medical Evacuation and Repatriation Services 281

Insurance/Repatriation Processes 282

Other Procedural Considerations 282

Bibliography 283

Appendix 1 International Olympic Committee Executive Board 284

PREAMBLE 284

Olympic Charter, July 2007 284

Chapter I: Relationships Between Athletes and Health Care Providers 285

Chapter II: Protection and Promotion of the Athlete's Health during Training and Competition 288

Chapter III: Adoption, Compliance and Monitoring 289

Chapter IV: Scope, Entry into Force and Amendments 290

Appendix 2 Sport-Specific Injury Profile and Equipment Guide 292

Winter Olympics Federations 292

Summer Olympics Federations 295

Appendix 3 Healthcare Professional Skillbase 304

Field of Play (FoP) 304

Appendix 4 Treatment Algorithms at a Glance 306

Index 315