PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
PRE EVENT PREPARATION
 Establish and practice emergency protocols and
review sideline preparedness
 Safety check of potential hazards
 Emergency Protocols - Designated personnel
 Emergency vehicle access routes
 Location of emergency equipment
 Location of telephone
 Emergency telephone numbers (ambulance,
physician, dentist)
 Communication plan
 Hand signals - Cross arms: “send a physician out” -
Hand on top of head: “Send ambulance”
PRIMARY ASSESSMENT
 Primary survey - 30 seconds - 2 minutes
o Maximum on scene time: 10 Minutes
o Determine whether injuries are life threatening,
the severity of injury, and how the patient can be
moved
 Severe injuries - The longer the assessment takes,
the higher the mortality rate is likely to be.
 Charge person/Person in control - The examiner
designated
o Takes control by not allowing the patient to be
moved until some type of assessment is made,
the spine is supported as much as possible, and,
if required, assistance is obtained.
 Call person - The person the examiner calls to provide
immediate assistance, relay messages, and obtain
additional help, if necessary.
o Should know the location of the closest telephone
(a cell phone would be ideal) and what telephone
numbers to call in specific emergencies
o The call person must state the emergency
telephone information
 Emergency Telephone Information
→ Caller’s name
→ Number of telephone being used
→ Type of emergency (type of injury)
→ Degree of urgency
→ Exact location of facility
→ Emergency vehicle access route
→ Estimated time of arrival
→ Best entrance
 Other individuals - as many as six or seven may be
called as necessary to act as transporters or help
move the patient.
 Initial Assessment - Six situations can immediately
threaten the life of a patient
→ Airway obstruction
→ Respiratory failure
→ Cardiac arrest
→ Severe heat/cold injury
→ Head (craniocerebral) injury
→ Cervical spine injury
→ Severe bleeding
 The examiner must be most prepared for these
situations, because they are the most common
emergency life threatening situations
 Talking to the patient - If pt replies in a normal voice
and gives logical answers to questions:
We can assume the airway is patent and the brain is
receiving adequate perfusion
o Ask the mechanism of injury
o Ask the symptoms and their severity
o Reassure and explain what you are going to do
o Observe whether the pt moves, is still, or is
having a seizure.
o Movement: partially conscious, no apparent
neurological dysfunction, and has some
cardiopulmonary function
o If the patient is still: unconscious, has some
neurological dysfunction, or has other major
system failure
o Seizure: neurological, systemic, or psychological
dysfunction.
 If the pt is unconscious/unable to speak
o Ask the witness if the pt is unconscious or unable
to speak
 If unconscious (“collapsed athlete”), the examiner
must work with the assumption that a neck (cervical
spine) injury has occurred until proven otherwise
 Position of the patient
o (e.g., normal, deformity) and look for altered joint
alignment (e.g.,fracture, dislocation), swelling, or
discoloration
o SCI: pt should be left in the original position until
the nature and severity of the injury have been
determined, except in cases of respiratory or
cardiac distress.
POCKET CONCUSSION RECOGNITION TOOL
 Used if there is a suspected head injury and is mobile
 To determine if a concussion has occurred
Emergency Evaluation
Airway evaluation (A): 5–7 seconds
Breathing (ventilation) 5–8 seconds
check (B):
Circulation/heart rate 20–30 seconds
(C):
Blood loss: 20–30 seconds
Neurological injury: 10–20 seconds
TOTAL TIME: 60–95 seconds
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 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
ASSESSMENT FOR NERVOUS SYSTEM
INVOLVEMENT

 Rapid brain and spinal cord assessment can be

accomplished by asking the pt to do simple
movements, such as sticking out the tongue

LEVEL OF CONSCIOUSNESS

LEVEL OF CONSCIOUSNESS
 Determined by talking to the patient, not by
moving the patient.
o Sometimes referred to as “shake and shout”
stage: examiner tries to arouse the
unconscious individual by gentle shaking
NEW (2020 FROM MAGEE AND MANSKE)
(without allowing movement of the head and
neck) and by shouting into each ear.
o No response: examiner can initially assume
the pt is unconscious or not fully conscious
and proceed under that assumption.
o Further neurological assessment is left until
the examiner is sure that the pt has a patent
airway, is breathing normally, and has a
heartbeat.
o Regardless of state of consciousness, the pt
should not move or be moved until the
examination has been completed.
o Do not use ammonia inhalants be to arouse
the pt during initial assessment
o Only allowed if there is no SCI because the
fumes may cause a reflex head jerk

On-Field or Sideline Evaluation of Acute Concussion

ASSESSMENT FOR NERVOUS SYSTEM
When a player shows any features of a concussion (see
INVOLVEMENT (cont.)
Table 2.11):
ALERT: Fully conscious
A. The player should be evaluated by a physician or
other licensed health care provider on-site using - Is able to carry on an appropriate conversation with
standard emergency management principles and no delays and is aware of time, place, and identity
particular attention should be given to excluding a  Confused: drowsy
cervical spine injury.  Delirium
B. The appropriate disposition of the player must be  Obtundation: dulled sensations, especially pain and
determined by the treating health care provider in a touch
timely manner. If no health care provider is available,
 Stupor
the player should be safely removed from practice or
 Coma
play and urgent referral to a physician arranged.
C. Once the first aid issues are addressed, an SIDELINE CONCUSSION ASSESSMENT TOOL — 3rd
assessment of the concussive injury should be made edition (SCAT3) exam and a Neural Watch
using the SCAT5 (see Fig. 2.49) or other sideline
assessment tools. - Done to provide serial monitoring for the possibility of
D. The player should not be left alone following the injury an increasingly severe head injury
and serial monitoring for deterioration is essential BALANCE ERROR SCORING SYSTEM (BESS)
over the initial few hours following injury.
E. A player with diagnosed concussion should not be - Balance testing
allowed to return to play on the day of injury. - Three different stances (double, single and tandem)
twice on two different surfaces (the ground and the
foam)
- Six trials

2
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
INDICATIONS THAT ATHLETE SHOULD BE - If breathing and heartbeat are not restored within 4-
REFERRED TO AN EMERGENCY FACILITY 6 mins, brain damage is probable.
- If there is no breathing and no heartbeat for 6 to 10
 Worsening headache minutes, biological death occurs, and brain
 Very drowsy or cannot be easily awakened damage is likely
 Cannot recognize people or places
 Develops significant nausea or vomiting
 Behaves unusually, more confused or irritable
 Develops seizures
 Weakness or numbness in the arms or legs
 Slurred speech or unsteadiness of gait

ESTABLISHING THE AIRWAY

ESTABLISHING THE AIRWAY

 Airway, Breathing, and Circulation (ABCs) of
Cardiopulmonary Resuscitation (CPR).
o May be immediately done while waiting for
assistance
o Check for abnormal or arrested breathing,
abnormal or arrested pulse, internal and
external bleeding, and shock
o FIRST PRIORITY: Maintain an adequate
airway, normal ventilation, and hemodynamic
stability
o Control bleeding by compression
o Assess the airway for patency by looking,
listening, and feeling for spontaneous ABNORMAL BREATHING PATTERNS
respirations - Cheyne-Stokes & ataxic respirations: often
associated with head injury

RESPIRATION  Hyperpnea: Abnormal increase in the depth and

 Movement of chest
 10 to 25 breaths per minute: Adults
 20 to 25 breaths per minute: Children.
 An athlete or someone who has been exerting before
injury may show a higher rate.
rate of the respiratory movements
 Apnea: Periods of non-breathing
→ Possible neurological lesion: Pons
 Ataxic breathing (Biot respiration): Irregular
breathing pattern, with deep and shallow breaths
occurring randomly
→ Possible neurological lesion: Medulla
 Hyperventilation: Prolonged, rapid hyperpnea,
resulting in decreased carbon dioxide blood levels
→ Possible neurological lesion: Midbrain, Pons
 Cheyne-Stokes respirations: Periods of
hyperpnea regularly alternating with periods of
apnea, characterized by regular acceleration and
deceleration in depth
→ Possible neurological lesion: Cerebrum,
cerebellum, midbrain, pons
 Cluster breathing: Breaths follow each other in
disorderly sequence with irregular pauses
between them
→ Possible neurological lesion: Pons, medulla

ASPHYXIA: Abnormal/arrested breathing

BREATHING
 look for the possible causes:
- If there is no breathing and no heartbeat: clinical → Compression of trachea
death occurs 0-4 mins → Tongue blocking airway

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 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
→ Foreign bodies
→ Tissue swelling
→ Fluid in air passages
→ Harmful gases or fumes
→ Suffocation
TONGUE
 Falling back of the tongue is the most common cause
of airway obstruction after a sport injury, especially in
the unconscious pt.
 Normally, the tone of the tongue muscles ensures
airway patency
 Unconscious pt: Especially in supine, loses muscle
tone and the tongue falls back, potentially leading to
an obstruction.
CHIN LIFT OR JAW THRUST MANEUVER
 If the tongue is the cause of obstruction, this is used
to restore the airway being careful to keep movement
of the cervical spine to a minimum.
 The chin lift maneuver is less likely to compromise the
cervical spine
 Either maneuver pulls the retropharyngeal
musculature forward, thus opening the airway
OBJECT OBSTRUCTION
 Oral screw and tongue forceps is used to remove an
object obstructing the airway
 The mouth should be held open with an oral screw or
something similar, a finger can be used to sweep the
mouth clear of debris (e.g., broken teeth, dentures,
mouthguard, chewing gum, tobacco).
 If the jaw is not held open and blocked from closing,
the examiner’s fingers are placed in the pt’s
mouth only with caution.
 Cause of blockage is other than the tongue (e.g.,
foreign body)
o If conscious, pt should be asked to cough.
 If this is unsuccessful, the Heimlich
maneuver should be performed until the
patient expels the object.
o If unconscious, pt should be placed supine and
ventilation attempted.
 If unsuccessful, six to ten subdiaphragmatic
abdominal thrusts are applied.
 This sequence of ventilation and thrusts is
repeated until a physician or EMS personnel
arrive to perform a laryngoscopy.
 Other causes of asphyxia may be treated by
epinephrine (anaphylaxis) or intubation
 If the concern is about maintaining a patent airway,
an oropharyngeal airway may be used.
 As a last resort, a wide-bore needle (18- gauge or
larger) may be inserted into the trachea to ensure an
airway
 If the patient is not breathing, artificial ventilation
(mouth-to-mouth resuscitation) must be initiated
immediately, by using the breathing portion of the
CPR techniques or by using a similar artificial
breathing method.
 If the pt has no patent airway, an airway must be
established
 If pt is moving in an attempt to get air into the lungs:
severe cervical injury is unlikely
 But, movement of the head in relation to the cervical
spine should be limited
Possibility of cervical injury: examiner should position
the pt so that airway clearance and resuscitation can
easily be accomplished.
- This is done to ensure that movement of the cervical
spine is kept to a minimum.
 If pt is comfortable in side-lying or prone and there is
no problem with cardiac function or breathing: moving
the pt to supine is not needed
 After the airway has been established, ensure that the
airway is maintained and that the pt continues
breathing.
 Non spontaneous respiration: assisted ventilation
(e.g., mouth-to- mouth, bagging) should be instituted.
 Ventilation can be compromised by a flail chest or
pneumothorax (tension or open)
 Endotracheal intubation is necessary if
nasopharyngeal bleeding, laryngeal trauma,
secretions, or aspirations prevent maintenance of an
adequate airway or end-ventilation
 Transtracheal ventilation: treatment of choice for pt
with breathing problems caused by brain, cervical
spine, or maxillofacial injuries.
 Endotracheal tube: cause straining and venous
hypertension leading to increased brain edema, and
extension of the head and neck to open upper airways
may aggravate cervical spine injuries.
 Hemorrhage in maxillofacial injuries prevents
effective use of a breathing mask and does not allow
adequate
AIRWAY OBSTRUCTION
Conscious Athlete Unconscious Athlete
1. If patient is breathing 1. Perform head tilt if no
or coughing, leave cervical spine injury
him/her alone but is suspected
continue to watch 2. If no response, try to
2. If no air is going in ventilate
and out of lungs,
administer four

4
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
abdominal thrusts 3. If no success,  Weak or rapid pulse: Usually indicates shock, heat
(Heimlich maneuver); reposition head and exhaustion, hypoglycemia, fainting, or
some people also try to ventilate again hyperventilation.
administer four back 4. If unsuccessful,  Slowing pulse: Sometimes seen if there is a large
blows follow with four increase in ICP → severe lower brain stem
3. Repeat until patient abdominal thrusts
compression
can breathe (Heimlich maneuver);
independently or some people also  Rebounding and rapid pulse: Often the result of
patient becomes administer four back HTN, fright, heat stroke, or hyperglycemia.
unconscious blows
DEFIBRILLATOR
5. Perform a quick
sweep of the mouth  Increases chance of survival in cardiac arrest
6. If unsuccessful,  Although cardiac arrest is rare in athletes, sudden
repeat steps 1
death or commotio cordis resulting from low-impact
through 5 until there
is no longer blunt trauma is always a possibility in sports
obstruction, or SQUEEZING THE NAIL BED/HYPOTHENAR
qualified help arrives;
EMINENCE
a tracheotomy may
follow if obstruction  May also determine circulatory sufficiency
continues  Capillary refill is delayed if the pink color does not
ESTABLISHING CIRCULATION return to the nail bed or hypothenar eminence within
2 seconds after release of the pressure
 Circulation should be checked for 10 or 15s using the  Squeezing the hypothenar eminence is a better
carotid (preferred), brachial, radial, or femoral pulse. indicator if the patient is hypothermic.
 Sedentary adult: 60 to 90 bpm
SHOCK
 Children: 80 to 100 bpm.
 Highly trained athlete: as low as 40 bpm  May occur if pulse rate starts to weaken.
 With activity: HR ↑  Characterized by S/Sx that occur when the cardiac
 Depending on type and level of an individual’s output is insufficient to fill the arterial tree and the
activity, the HR for a fit person should decrease to blood is under insufficient pressure to provide organs
slightly above normal values within 5 minutes after and tissues with adequate blood flow.
exercise.  Maintained pink skin, in the face and extremities =
seldom hypovolemic after injury.
PULSE
 Ash-gray or white skin in the face or extremities =
 Note whether pulse is absent, rapid and rebounding, blood loss of at least 30%
or weak and diminishing.  S/Sx of Shock
 Most often checked at the carotid artery, because this → Pulse slowly becomes weak and rapid
is large and easy to locate. → Cold, clammy and pale skin
 No pulse detected = assume no heartbeat →CPR → Profuse sweating
initiated using either manual methods or an → Face is initially pale and later cyanotic around the
automated external defibrillator. mouth
 The examiner should estimate the rate, strength, and → Increased and shallow RR - Labored, rapid or
rhythm to obtain an indication of the cardiac output. irregular and gasping
 May also be used to determine BP → Dilated pupils
o If carotid pulse is palpable, systolic blood → Eyes usually dull and lusterless
pressure is 60 mm Hg or higher. → Increased thirst
o If femoral pulse is palpable, systolic blood → Nausea and Vomiting
pressure is 70 mm Hg or higher. → Restlessness and Anxiousness
o If radial pulse is palpable, systolic blood → Altered LOC
pressure is 80 mm Hg or higher → May become unconscious if shock develops fast
o Like HR, BP should drop to almost normal levels → To prevent or delay onset of shock, the examiner
within 5 minutes following termination of may cover the patient, elevate the pt’s legs, or try
exercise. to eliminate the cause of the problem.

5
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
CIRCULATORY COLLAPSE IN TRAUMA PATIENTS Septic Severe infection and
blood vessel damage
 Primarily caused by blood loss from vascular damage Anaphylactic Allergic reaction
or fracture, or hypovolemic shock Metabolic Loss of body fluid
 Shock in trauma may also be caused by tension
pneumothorax, CNS injury, or pericardial tamponade ASSESSMENT FOR BLEEDING, FLUID LOSS
(heart compression resulting from blood in the AND SHOCK
pericardium)
- Look for signs of external bleeding or hemorrhage
 When hypovolemic shock becomes evident, blood
loss may be as high as 20% to 25%.
 Incisions: are clean cuts/lacerations with jagged
 BP in Shock
edges.
o Normal BP: - 100 -120 mm Hg systolic pressure /
o Type of wounds where external bleedings or
- 60-80 mm Hg diastolic pressure
hemorrhage may be seen
o With shock, BP gradually decreases.
 Contusion: may produce internal bleeding
o It is best to assume that shock develops in any
 Puncture or abrasion: may show bleeding or oozing
injured adult whose systolic BP is 100 mm Hg or
on the surface.
less.
 Major traumatic injuries: such as fractures (e.g.,
 Normal Dark Skinned Patient
pelvis, femur), can cause a great deal of internal
o Usually has a red undertone and shows a healthy
bleeding.
pink color in the nail beds, lips, and mucous
membranes of the mouth and tongue.  Puncture wounds: most difficult to treat, has the
highest probability of infection.
 Dark Skinned Patient in Shock
o Gray cast to the skin around the nose and mouth,  Liver, spleen, or kidney injury → serious internal
especially if experiencing respiratory shock. bleeding
o Mucous membranes of the mouth and tongue, o Blood is not visible since it is contained within the
the lips, and the nail beds have a blue tinge. abdominal cavity.
o Pt may experience abdominal rigidity, pain, and
 Hypovolemic shock mucous membrane
difficulty breathing (pressure on diaphragm).
o Pale, graying, waxy pallor
 When inspecting a bleeding structure, the examiner
CPR should note the type of vessel affected.
o Artery spurts blood
 Done if no pulse is present  Vein provides an even flow
 Sports equipment should be removed, at least  Capillaries tend to ooze bright blood
anteriorly, to give the examiner clear access to the
anterior chest wall.
 Provides only approx. 25% of normal
 cardiac output, so it is imperative that it is performed
properly by knowledgeable persons
 Maintained until the pt recovers or EMS personnel
arrive.
 Must be done with care if a cervical spine injury is
suspected, because compression to the heart can
cause repeated flexion/extension of the cervical
spine.

TYPES OF SHOCK AND THEIR CAUSES

TYPE CAUSE
BLEEDING CHARACTERISTICS AND THEIR SOURCE
Hemorrhagic Blood loss
(hypovolemic) Source Bleeding
Respiratory Inadequate blood supply Characteristics
Neurogenic Loss of vascular control Artery Bright red, spurting or
by nervous system pulsating flow
Psychogenic Common fainting Vein Dark red, steady flow
Cardiogenic Insufficient pumping of Capillary Slow, even flow
blood by the heart Lungs Bright red, frothy
Stomach “Coffee grounds” vomitus

6
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
Upper bowel Tarry black stools
Kidneys Smoky, red urine
Bladder Red urine, difficulty
urinating
Abdomen Blood not visible;
abdominal rigidity, pain,
difficulty breathing
 Pressure points: Important since arterial bleeding is
of greatest concern. Tells where to apply proper
treatment.
o Choose the pressure point closest to the area of
bleeding and apply pressure to the artery to slow
or stop the bleeding
 Tourniquets: used with extreme caution and in
selected instances and then only with enough
pressure to stop bleeding.
o Accidental amputation of a limb,
o Very severe bleeding from a major artery
o Need to apply CPR with no assistance available
o Time of tourniquet application is noted
carefully to prevent unnecessary tissue damage.
 Hemodynamic stability: best maintained by
applying direct pressure to an open wound,
keeping the pt in a recumbent position, and
minimizing the number of times the patient is moved
 If S/Sx of shock are present but visible bleeding is
minimal, suspect hidden bleeding within the
abdomen, chest, or extremities.
o Suspected bleeding in the abdomen: palpate
the abdominal wall for shape and distention.
o Suspected bleeding in the chest or
extremities: look for deformities (e.g., fractures).
Percuss the chest area, noting any loss of hollow
sounds, to help locate presence of fluid or blood.
o Hyporesonance: solid organ or the presence of
fluid or blood
o Hyperresonance: air or gas filled spaces
 After the ABCs systems have been assessed and
controlled, proceed to the remainder of the primary
assessment.
CSF & BLEEDING
 Check the ears & nose for CSF presence
 Blood or CSF leakage from ear: may indicate a skull
fracture.
 Incline the head toward the affected side to facilitate
drainage, unless a cervical injury is suspected.
 Gauze pad may be placed over the pt’s ear or nose
where bleeding is occurs to collect the fluid on the
gauze
 Look for an orange halo forming on the pad
o Halo: is a good indication of a skull fracture
PUPIL CHECK
 Checks pupils for shape and for response to light by
using a penlight or by covering the eye with one hand
and then taking it away.
 Pupils normally react to the intensity of light or focal
distance.
 Dilation: Dark environment or long focal distance
 Constriction: Light environment or short focal
distance.
 Pupils are normally equal or almost equally dilated
(diameter range, 2 to 6 mm; mean of 3.5 mm)
o CNS injury may cause the pupils to dilate
unevenly.
o However, some people normally have unequal
pupil sizes.
 Trauma near the eyes to a conscious alert person:
Dilated, fixed pupil may most likely result of trauma to
the short ciliary nerves of that eye
 Drugs may affect pupillary size
o Opiate drugs cause pinpoint pupils
ASSESSMENT FOR SPINAL CORD INJURY
 Regular cervical assessment is given if the athlete
walks off the field before notifying the medical staff of
a potential neck injury
 If the athlete appears to have or communicates a
neck injury on the field or is unconscious, then a neck
or head injury should be assumed, and cervical
assessment is modified.
 So that movement may be minimized during
examination
 The athlete is immobilized and transported to a
medical facility after examination
Upper SCI (Cervical Spine Injury) is suspected, initially
if pt has/is:
 Neck pain or Stiffness
 Asymmetric or abnormal head pos
 Cervical mm spasm
 Respiratory difficulty, especially if the chest is not
moving (absence of abdominal or diaphragmatic
breathing)
 Priapism (erection of the penis)
 Unconscious after a fall or other contact activity.
 Numbness, tingling, or burning, especially below the
clavicles
 Mm weakness; twitching; or paralysis of the arms or
legs, especially bilaterally (flaccid paralysis).
 Loss or bowel or bladder control
o Quick assessment of brain and SC to note wether
pt can follow instruction and can do the activity:
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 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
 Ask pt to stick out the tongue, wiggle the toes,
move the feet or may arms, or squeeze
examiner’s fingers
Unconscious Patient
 Level of unconsciousness must be reassessed if
possible and treat the pt as though a spinal injury has
occurred.
 Watch for spontaneous limb movement, especially
after the application of a painful stimulus, movement
indicates that the patient is less likely to have suffered
a severe cervical injury.
 Also watch for tonic posturing that indicates a severe
head injury.
 Fencing response may occur at time of impact with
one limb extending and the other flexing regardless of
position or gravity
 Decerebrate rigidity: all four extremities being in
extension.
 Decorticate rigidity: LE in extension andUE in
flexion
ASSESSMENT FOR HEAD INJURY (NEURAL
WATCH)
 Used to note any changes in the pt over time.
 Initially performed every 5-15 mins, since it also
facilitates monitoring of the pt’s v.s.
 After pt is stabilized, Neural Watch recordings may be
made every 15-30 mins.
 Reassessment by the same examiner allows the
detection of subtle changes.
 Examination should include an evaluation of the pt’s
facial expression; a determination of the pt’s
orientation to time, place, and person; and the
presence of both post traumatic amnesia and
retrograde amnesia.
 Emergency S/Sx of Head injury
→ Increased headache
→ Nausea and vomiting
→ Inequality of pupils
→ Disorientation
→ Altered level of consciousness
→ Increased blood pressure
→ Decreased pulse rate
→ Decreased reaction to pain
→ Decreased or altered values on Neural Watch
chart or GCS
 Verbal and physical stimuli may determine reaction to
pain and the LOC
 If (-) cervical injury, verbal stimuli may include calling
the pt’s name and shaking and shouting at the pt.
 Physical stimuli include:
→ Squeezing the Achilles tendon,
→ Squeezing the trapezius muscle,
→ Squeezing the soft tissue b/w the pt’s thumb and
index finger
→ Squeezing an object (pen or pencil) between the
patient’s fingers
→ Squeezing a fingertip
→ Applying a knuckle to the sternum. (Be cautious,
may cause bruising.)
 LOC can best be determined with the use of the
Glasgow Coma Scale (GCS)
o The sooner the pt is tested with the scale the
better
o Initial assessment can be used as a baseline for
improvement or deterioration in the patient.
o The GCS is often used in conjunction with the
Neural Watch.
 Deterioration of consciousness may result from many
conditions, such as increased ICP caused by an
expanding intracranial lesion, hypoxia (which can
aggravate cerebral edema and increase the ICP),
epilepsy, meningitis, or fat embolism.
 Always look for signs of expanding intracranial
lesions, especially if the pt is conscious.
o These are emergency conditions that must be
attended to immediately because of their
potentially
 If pt experiences LOC or appears to have disturbed
senses, is seeing stars or colors, is dizzy, or has
auditory hallucinations or a severe headache, the pt
should not be left alone or allowed to return to activity.
 Nausea, vomiting, lethargy, increasing BP, disturbed
sensation of smell, or a diminished pulse should lead
to the same conclusion.
 Amnesia, hyperirritability, an open wound, unequal
pupils, or CSF/Blood leakage from the ears or nose
also indicates an emergency condition.
 Numbness on one side of the body or a large
contusion in the head area should also lead the
examiner to handle the pt with care.
 Frontal Lobe Affectation: May experience lapses of
memory, personality changes, or impairment of
judgment.
 Temporal Lobe Affectation: May experience
feelings of unreality, déjà vu, or hallucinations
involving odors, sounds, or visual disturbances, such
as macropsia (seeing objects as larger than they
really are) or micropsia.
 Head injury depends not only on the magnitude and
direction of impact and the structural features and
physical reactions of the skull but also on the state
of the head/brain at the moment of impact.
8
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
ASSESSMENT FOR HEAT INJURY
 If there is a suspected heat-type injury with no
cervical injury, heat exhaustion and heat stroke
need be considered as lifethreatening.
o Heat fatigue or exhaustion: Person is exposed
to high environmental temperature or humidity
and perspires excessively without salt or fluid
replacement.
o Heat stroke: A non-acclimatized person is
suddenly exposed to high environmental
temperature or humidity. The thermal regulatory
mechanism fails, perspiration stops, and body
temperature increases.
 Above 42°C oral body temperature, brain damage
occurs, and death follows if emergency measures are
not instituted.
 The diagnostic keys are high body temperature and
absence of sweating.
 Initial signs of heat injury: muscle cramps,
excessive fatigue or weakness, loss of coordination,
decreased reaction time, headache, decreased
comprehension, dizziness, and nausea and vomiting
 Body temp varies according to the site at which the
measurement is taken.
o Oral: 37° C (98.6° F).
o Armpit or axilla: 36.4° C to 36.7° C (97.5° F to
98.1° F)
o Rectum: 37.3° C to 37.6° C (99.1° F to 99.7° F).
 Palpating the skin can get some idea of the
external temperature of the body and
possible pathology.
 Hot and dry skin: caused by heat stroke, high fever,
or hyperglycemia.
 Cold and clammy skin: caused by hypoglycemia,
shock, fainting, or hyperventilation.
 Cool and moist skin: caused by heat exhaustion
 Cool and dry skin: caused by exposure to cold.
SKIN COLOR
 White Pallor/Whitish skin: circulatory disturbance or
decreased circulation and is most often associated
with trauma and shock.
 Cyanosis (blue pallor): respiratory distress, as does
a gray tint.
 Redness/Red Pallor: increase in blood flow as a
result of fever, heat stroke, exercise or inflammation
ASSESSMENT FOR MOVEMENT
 Consider how the pt will be moved and immobilized
(e.g., self-ambulation, stretcher, spinal board)
depending on the severity of injury, and whether the
pt can move him or herself or can move only with
assistance
 If the pt has not moved, ask pt to move the limbs to
reassess for a cervical spine injury and look for major
trauma (e.g., fracture, dislocation, third-degree strain,
third-degree sprain).
 At the same time, palpate areas of potential injury, not
any pain, abnormal bone or joint alignment, swelling,
hypersensitive or hyposensitive areas, or palpable
defect (third-degree strain).
 If movement is relatively normal, quickly check the
myotomes of the UE or LE for any possible motor
involvement or motor impairment.
 Changes in limb power: may be caused by a
contractile tissue injury, a neurological injury, or an
expanding intracranial lesion, which will be displayed
as progressive weakness in the contralateral arm or
leg.
 Decreased limb power: caused by reflex inhibition
as a result of previously unrecognized limb injury.
o In these cases, contractions are weak and
painful.
o These types of injuries are in the low priority
group since they represent a threat to the limb
rather than to the life of the pt.
POSITIONING THE PATIENT
 Normally, a pt is left in the position in which he or she
is found until primary assessment is completed.
 If there is breathing difficulty or no pulse, pt must be
positioned to do CPR.
 If a conscious pt is prone and in respiratory difficulty,
the examiner, with assistance, should log-roll the pt
onto a spinal board so that an attempt to restore the
airway is made.
 During any movement of the pt, traction of about 4.5
kg (10 lbs) may be applied to the cervical spine to
maintain stability.
 Before any movement is attempted, the pt and those
who are going to assist the examiner should know
what the examiner plans to do and what their jobs are.
This requires frequent practicing of emergency
procedures.
o Only rolling, not lifting—should occur.
o With pt in supine, proper CPR techniques may be
applied, or the pt may be transported.
o Pt may be covered with a blanket to provide
warmth.
9
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
Spinal injury suspected in a conscious pt is in prone
but has no difficulty breathing
 pt is log-rolled halfway toward the assistants while
another assistant slides the spinal board as close as
possible to the pt’s side.
 pt is then rolled directly onto the spinal board in prone.
Spinal injury is suspected in a pt in supine position
and breathing normally
 pt is rolled toward the assistants while another
assistant slides the spinal board under the pt as far
as possible.
 pt is then rolled back onto the spinal board in supine.
Spinal injury is suspected in a pt in side lying
 pt is log-rolled directly onto the spinal board and into
supine.
→ In each of these cases, the examiner controls the
head, applies traction, and instructs the
assistants.
→ The pt’s head is then stabilized and immobilized
with sandbags, a head immobilizer, or triangular
bandages, and the pt is strapped to the spinal
board with restraining belts.
→ If a collar is used to stabilize the spine, it must do
so during movement as well as when the patient
is stationary
 it must not hinder access to the carotid pulse,
airway, or performance of CPR;
 it must be easy to assemble and apply;
 it must be adaptable to patients of all ages
and sizes
 it must allow radiological examination without
removal
→ Any major injury (e.g, head injury a spinal injury,
or fracture) requires appropriate handling, slow
and deliberate. management, and proper
transportation to provide a satisfactory outcome
RECOVERY POSITION
 Is used if pt is nauseated, vomiting, or has fluid
draining from the mouth, and provided breathing and
circulation are normal and as long as there is no
suspicion of a spinal injury.
 This position enables continuous monitoring (ABCs)
and allows easy observation of any change in
condition +while waiting for emergency personnel.
 pt’s head should be positioned to keep airway open
and to allow drainage from the throat and mouth.
 If blood flow to the heart and brain has diminished,
circulation can be improved by elevating the lower
limbs, provided that position change can be
accomplished without causing further pain or
breathing problems or aggravating an injury.
 If pt has breathing difficulties or a chest injury or has
experienced a heart attack or stroke, it may be
desirable to lower BP in the injured parts by elevating
the upper part of the body slightly, if position change
can be accomplished without causing further pain or
breathing problems
 If pt is unconscious and cardiac & circulatory
functions are not compromised, pt should be left in
the original position until consciousness is regained.
 if pt is unconscious and lying supine, always watch for
possibility of the pt “swallowing” the tongue and
obstructing the airway.
 An unconscious pt loses the cough reflex, and if
vomiting or bleeding occurs, vomitus, mucus, or blood
may enter and obstruct the airway. Therefore, the
examiner may elect to put the pt in the recovery
position.
 If pt is unconscious and in respiratory or cardiac
distress, quickly assess the pt and attempt to restore
respiratory and cardiac function. This pt is then
treated the same as the conscious pt.
 If pt’s spine is twisted or flexed and the pt is
reasonably comfortable, the pt should be stabilized in
that position until a spinal injury is ruled out.
 If there has been a loss of breathing or cardiac
function, the examiner must carefully correct the
deformity, place pt supine lying, and perform the
appropriate measures to deal with the problem.
If a cervical spine injury has occurred to a 7yr old or
younger child
 The head is normally larger in proportion to the rest of
the body.
 If the child is positioned on a spinal board without
modification, the neck will be forced into some flexion.
 The spinal board should have a cutout for the head,
or a pad for the chest or rest of the body should be
added to elevate it in relation to the head
o If pt is in the water and unconscious
 He or She must be reached ASAP
 Do not jump into the water, because this
creates waves that may rock the pt’s head
10
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
and could cause severe consequences if a
neck injury has occurred.
 Approach the pt head-on and place an
extended arm down the middle of the pt’s
back with the pt’s head in the examiner’s
axilla.
 The examiner then grasps pt’s biceps with
the forearm around the pt’s forehead, slowly
lifts the arm, and turns the pt face up.
 The examiner’s forearm locks the pt’s head in
the examiner’s axilla during the turn.
 Once pt is supine, both of the examiner’s
arms support the pt’s head and spine in the
water.
 An assistant then slides the spinal board
under the pt in the water and blocks the pt’s
head with towels.
 The pt is next strapped to the spinal board
with restraining straps and is lifted out of the
water
 If no spinal board is available and a cervical
injury is suspected, pt should be supported in
the water until emergency personnel arrive.
Athletes who wear helmets.
 Generally if the pt is unconscious, the helmet should
not be removed unless absolutely certain that there
has not been a neck injury.
 If pt wears both a helmet and a shoulder pads, both
should be left on the pt, because they help to maintain
the cervical sagittal alignment close to normal.
 Ideally, the helmet and shoulder pads should be
removed in a controlled setting, such as the
emergency department
 Helmets should be removed only if
o Facemask or visor interferes with adequate
ventilation
o Facemask interferes with the clinician’s ability to
restore an adequate airway
o Helmet is so loose that it does not provide
adequate immobilization of the head when
secured to the spinal board
o If life- threatening hemorrhage under the helmet
cannot be controlled
o If in children, the helmet is too large and causes
flexion of the neck when used as part of the
immobilization
o If it is necessary to defibrillate the pt.
 In the last case, the shoulder pads must be removed,
so the helmet should be removed to maintain spinal
position
If pt is in respiratory distress,
 Facemasks can usually be easily removed with an X-
Acto knife or a similar device to release the restraining
straps while holding the mask in place.
If the decision is made to remove the headgear, the
neck and head must be held as rigid as possible.
 At least two people are needed: one to stabilize the
head and neck and one to remove the facemask.
 One person, usually the assistant, first applies in-line
traction is to the helmet to ensure initial stability.
 A second person, usually the examiner, then stands
at the side of the pt and employs in-line traction by
applying a traction force through the pt’s chin and
occiput.
 The assistant stops applying traction and, if the
helmet is a football helmet, first removes the cheek
pads by sliding a flat object (e.g., scissors handle)
between the cheek pad and helmet, twisting the
object to cause the pads to unsnap.
o After the pads are removed, the assistant applies
bilateral expansion to the helmet so that the ears
are cleared as the helmet is removed.
o After the helmet has been removed, the assistant
reapplies in-line traction from the head, and the
examiner then releases the traction and
continues the primary examination
o If desired, a cervical collar, such as the Stifneck
collar, this should be done with caution because
cervical collars do not completely eliminate
movement in the cervical spine.
o If the helmet is removed and the pt is wearing
shoulder pads, the person holding the head must
ensure that the head does not fall back into
extension, and a modification must be made to
the spinal board.
o Shoulder pads should be removed only if it is
impossible to do this or if defibrillation is
necessary.
 If pt is conscious and there appears to be no cervical
injury or other severe injury, the pt may be moved to
another area for a more appropriate and complete
secondary assessment.
 If the injury is in the UE and the injured part is
immobilized, the pt may first be moved from a supine
to a sitting or kneeling position, then from sitting or
kneeling to supported standing, to unsupported
standing, and finally the person may walk off the field.
 During these changes in position, the examiner or
assistants are positioned to provide support and
assistance if the patient feels dizzy or unsteady.
 If the injury is in the LE, the athlete may be helped off
the field by teammates, stretcher, or cart.
11
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
 Spinal injuries require greater care and the use of a R: Normal Labored or Absent
spinal board and cervical collar with support. respirations shallow
 Again, assistance may be required, and everyone, A: Abdomen Abdomen Abdomen
including the pt and assistants, should be aware of abdomen & thorax & thorax &
the movement sequence before it is attempted. no tender tender rigid or flail
chest
Movement Sequence to Remove Conscious,
M: motor Normal Response No
Mobile Athlete from Field of Play
Supine lying only pain response
↓ S: speech Normal confused No
Sitting (supported) intelligible
↓ words
Kneeling (supported, 4 point → 2 point)
↓
Standing (supported) SECONDARY ASSESSMENT
↓
Standing (unsupported)  Secondary assessment is done if the pt is conscious,
↓ is able to respond by talking coherently, shows
Walk off field (assistance ready) minimal or no distress in terms of breathing, and
displays normal circulation.
INJURY SEVERITY  Keep in mind that the pt may still have suffered a
catastrophic injury that, although not life-threatening
 Galveston Orientation and Amnesia Test, which tests
at the present time, could lead to significant problems.
for posttraumatic amnesia;
 The secondary survey is predicated on the pt’s being
 Abbreviated Injury Scale, the Injury Severity Score,
clinically stable.
Trauma Score, Triage Index, Circulation, Respiration,
 When secondary assessment begins, any possible
Abdomen, Motor, and Speech (CRAMS) Scale;
life-threatening situations should be eliminated and
 The Trauma Score illustrates the ease of scoring and
then injury assessment can be complete
the survival probabilities that can be expected in
 In the case of a sudden injury, remember that the pt
trauma patients. This tool provides a dynamic score
has had no time to prepare psychologically or
that monitors changes in the patient’s condition and
practically for the injury. The injury may represent a
is useful in making triage decisions.
sudden and frightening change in the pt’s physical
 The CRAMS scale illustrates a similar scoring
state.
pattern.
 Other concerns experienced by the pt may be related
THE REVISED TRAUMA SCORE to the pt’s job, financial situation, family, or prognosis,
and these concerns, suddenly magnified, may affect
Glasgow Systolic Respiratory RTS Value the pt’s behavior, especially in later secondary or
Coma Blood Rate (RR) “sideline” assessments
Scale Pressure  The secondary assessment is a head-to toe rapid
(GCS) (SBP) physical examination and can be performed after the
13-15 >89 10-29 4 examiner has ascertained that there is no threat to the
9-12 76-89 >29 3 pt’s life.
6-8 50-75 6-9 2  The secondary survey involves a complete body
4-5 1-49 1-5 1 survey to detect other injuries that may cause serious
3 0 0 0 complications or lead to a pt’s not being allowed to
return to activity.
 It is important to maintain communication throughout
Major Trauma (CRAMS scale < score 8) the examination.
 During this time, the examiner is testing for possible
2 1 0
spinal injuries, fractures, dislocations, or soft-tissue
C: Normal Delay No
injuries. Care must be taken that injuries are not
circulation capillary capillary capillary
refill & refill or missed
refill or
SBP SBP > 85 SBP < 85
> 100 <
100

12
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
Musculoskeletal Injuries Commonly Missed during
Emergency Assessment
 Closed tendon injuries of the hand
 Carpal bone injuries
 Occult elbow fractures
 Femoral neck fractures
 Posterior shoulder dislocations
 Epiphyseal plate injuries
 Pubic ramus fractures
 Patellar tendon rupture
 Lisfranc (tarsometatarsal) fractures
 Compartment syndromes
 In secondary assessment, consider whether the pt
should be allowed to return to activity.
 The decision whether further evaluation is required
on-site or whether the pt should be taken to some
other venue. In addition, keep in mind that home
monitoring may be necessary and therefore should
determine whether a responsible person is at home
to watch for changing S/Sx in the pt.
 Neural watch or the GCS and watching for signs of
an expanding intracranial lesion or other
complications must continue.
 Advanced cerebral edema may further reduce the
perfusion of an already damaged hemisphere of the
brain, and compression of the descending motor
tracts may decrease limb power.
 Pt’s LOC can reveal a deficit previously
overshadowed by other evidence of severe brain
injury.
 The pt’s abilities to assimilate information and act with
split-second timing are more likely to be impaired after
a concussion than are strength and endurance.
 If a head injury is suspected, it is important to
determine the pt’s reasoning and processing ability.
 The examiner also checks coordination or motor
neurological function
 When testing for proper neurological function palpate
the neck and back for any pain or tenderness
 Balance and motor coordination: tested by
determining whether the pt can maintain balance
through unsupported standing.
 Motor neurological function: checking the pt’s grip
strength or the various myotomes.
 Eye coordination and peripheral vision: asking the
pt to follow the examiner’s fingers up and down, side
to side, diagonally, and in circles, noting any
wandering eye movements.
o Test visual disturbance: pt is asked to read or
observe something from a short distance (e.g.,
eye chart, how many fingers the examiner is
holding up).
o Test for vision at distance: pt can be asked to
read the score clock, as an example.
 After brain function is tested “clearing,” or scanning,
assessments performed for the cervical or lumbar
spine is done.
 At this stage, the assessment follows the same basic
protocol as in the detailed assessment of specific
joints.
 This is followed by a detailed examination of the
specifically injured structures, (active, passive, and
resisted isometric movements, special tests, reflexes
etc.)
 Simple non-leading questions should be asked, and
information should be clarified.
 After the pt has been questioned, others who
witnessed the accident or injury may also be
questioned to complete the history.
o Also helps detect abnormal behavior that may not
be noticed initially.
 Carefully watch for developing S/Sx of an expanding
intracranial lesion by noting changes in facial
expression, the pupils, and the level of consciousness
and by performing the Neural Watch and GCS
several times.
 The basic observation is the same as that performed
during joint assessment and includes observation of
bony and soft tissue contours, scars, deformities, the
ability to move, and body alignment.
 Scanning examination: quick scanning of the entire
body through observation, by asking the pt to make
particular movements (depending on where the
suspected injury has occurred), and by testing
myotomes, dermatomes, and reflexes.
o May be done with pt wearing clothes but it is
better without.
o Warn the pt if clothes need to be removed
especially if in a public place, and every effort
should be made to maintain the patient’s dignity.
o Detailed assessment of the appropriate parts of
the body after scanning examination may be
done.
Signs Indicating Need for Immediate Transport to
Hospital
 May happen any time during the primary or
secondary evaluation:
→ Abnormal pupil or extraocular movement
→ Increasing facial or extremity weakness or
flaccid paralysis
→ Amnesia, confusion, or lethargy
→ Sensory or cranial nerve abnormality
→ Decreasing value in GCS
→ Positive Babinski sign
→ Deep tendon reflex asymmetry
→ Posttraumatic seizures
13
 PT SPORTS MOD 1:
EMERGENCY PROCEDURES AND ASSESSMENT
 Proper care for the pt must always be uppermost in
the mind of the examiner
 After the assessment has been completed and the pt
has been stabilized, has returned to competition, or
has been referred for further medical care by
ambulance, the examiner should be sure to document
what happened and the subsequent care that was
given, noting any potential difficulties. These notes, if
taken at the sideline, should be transferred to the
patient’s medical record as soon as possible

Priorities in the Management of Injuries: Beware of

Injury to the Cervical Spine!

Highest Priority
1. Respiratory and cardiovascular impairment: Facial,
neck, and chest injuries
2. Hemorrhage: External, severe
High Priority
3. Retroperitoneal injuries: Shock, hemorrhage
4. Intraperitoneal injuries: Shock, hemorrhage
5. Craniocerebral spinal cord injuries: Open or
closed, observation
6. Severe burns: Extensive soft-tissue wounds
Low Priority
7. Lower genitourinary tract: Hemorrhage,
extravasation
8. Peripheral vascular, nerve, locomotor injuries:
Open or closed
9. Facial and neck injuries: Except priorities 1 and 2
10. Cold exposure
Special
11. Fractures, dislocations: Splinting
12. Tetanus prophylaxis

Emergency On-Field Procedures

 Stabilize head and spine (Do not move patient.)
 Talk to patient and determine level of
consciousness
 Move patient only if in respiratory or cardiac
distress
 Check or establish airway
 Check heartbeat/rate/pulse
 Check for bleeding, shock, cerebrospinal fluid
 Check pupils
 Check for spinal cord injury (Neural Watch)
 Position the patient
 Check for head injury
 Assess for heat injury
 Assess movement

14