First Aid in Rugby No Videos en

Preface
Preface
Injuries are a part of any contact sport. Serious or life threatening injury in Rugby is, however, rare. The outcome of many injuries can
often be improved by very simple first aid skills from bystanders until emergency help arrives.
Planning for such events - the “What ifs?” - can make a situation less stressful for all involved and help co-ordinate safe and effective
care from the initial injury through to final treatment, which may be in the medical room at the venue or on transfer to hospital, for
example.
Experienced players or those who are “fitter” may be more resilient to not sustaining a game ending injury. Conditioning or injury
prevention initiatives such as the World Rugby Strength and Conditioning programme and the Rugby Ready resource may help protect
players from injury.
Strength and Conditioning Rugby Ready
Injuries will, however, still occur, and for the majority of the Rugby-playing world there is little qualified medical support available pitch
side. Thus, first aid responsibility may fall to bystanders until more experienced medical support arrives. Such bystanders may be
parents, club officials, coaches, referees or even other players.
FIRST AID IN RUGBY 1

Preface
Five steps to Player Welfare
World Rugby has developed a three-tiered medical education programme relevant to the immediate management of Rugby injuries
for all levels of the sport. The tiers are built around the five key messages relating to potentially serious injuries in Rugby.
Be a lifesaver; know your A-B-C

• A: Airway, B: Breathing, C: Circulation
• Saving a life always starts with A
• If you don’t have an A you won’t have a B or C
• Airway: open it, clear it, maintain it
If they are on the deck, think about the neck

• Don’t shake them, don’t roll them, don’t sit them up
• Think about the spine, keep it in line and take your time
• Stop the game and ask about pain
• An unconscious player has a neck injury until proven otherwise
Train to prevent injuries

• Don’t suddenly change your training
• Protect players returning from injury - they are at increased risk of injury
• Undertake high risk training (contact, sprints) at low risk times (when not fatigued)
• Injury prevention: it’s in the balance (exercises)
Tackle concussion
• Don’t lose your head, read the signs instead
• Concussion makes no sense - a confused player may be concussed
• If in doubt, sit it out
• Don't risk your brain to win a game

Preface
Kick infection into touch

• Don’t share your blood on clothes and towels; blood spreads infection; wash it or dispose of it
• A wound neglected is a wound infected
• The solution to pollution is dilution - wash the wound with large amounts of water
• Clean it, then cover it
World Rugby Medical Education
This online course is designed for club staff, coaches, referees and parents as a sports first aid course for Rugby Union, and is a pre-
requisite for anyone attending the World Rugby Level 1 First Aid in Rugby course.
Level 1 Level 2 Level 3

First Aid In Rugby Immediate Care In Sport Advanced Immediate Care
In Sport
Course descriptor: Training as a laymen Sports immediate care Advanced immediate care
responder in sports first aid training for pitch side medical training for pitch side medical
staff staff
Who is it for? Coaches, teachers, parents, Physiotherapists or athletic Physiotherapists or athletic

officials and interested others trainers, sports rehabilitation trainers, sports rehabilitation
who may be asked to respond and doctors who provide and doctors who provide
to an injured rugby player formal pitch side medical formal pitch side medical
cover cover within an immediate
care governance structure/
performance sport
Attendance or 50% online, 50% attendance 20% online, 80% attendance 20% online, 80% attendance
Accreditation? with knowledge and with knowledge and
competency-based competency-based
assessment assessment
Minimum duration: 8 hours 10 hours 20 hours
Prerequisites: • Over 14 years of age Registered medical Registered medical

• Completed Rugby Ready practitioner, physiotherapist, practitioner and post graduate
online programme sports trainer, sports physiotherapist, sports trainer,
• Completed First Aid In Rugby rehabilitation or therapist sports rehabilitation or
online programme practitioner therapist practitioner

Preface
Acknowledgements
The commitment to the task and efforts of the author and the consultancy team in contributing to the development of this
educational programme are gratefully acknowledged.
• Authors – Jonathan Hanson (SRU), James Robson (SRU)

• Editor – Mark Harrington (World Rugby)
• Consultancy Team – Andy Smith (RFU), Brian Carlin (IRFU, SRU), Omar Hassanein (IRUPA), Martin Raftery (World Rugby), David
Owens (HKRFU) and Warren McDonald (ARU)

General principles
Introduction
Primum non nocere is a medical adage that means “do no further harm”. Often when faced with an injury, the issue is what not to do
rather than what to do. Simple measures such as protecting the head and neck, ensuring an open airway or supporting an injured limb
are often all that is needed in the immediate stages of injury management.
Many things improve with a little bit of time and, commonly, taking control of a situation and preventing panic is all that is needed until
the player visibly improves or more experienced help arrives.
There are, of course, some conditions where the idea of simply supporting the player and waiting will be the wrong thing to do, e.g.
failing to recognise cardiac arrest. These are the types of situations that will be covered topics on the course. Whilst we will include
advice for the common bumps and bruises of Rugby, this course is designed to give you some skills for the rare occasion where you
may be dealing with someone who is potentially seriously injured or unwell in a Rugby setting.
The general principles of sports first aid are:
1. Do no further harm.
2. Take control.
3. Avoid unnecessary movement.
4. Simple skills save lives.
5. Ensure more experienced help is on the way.
6. Recognise when you need to do more.

General principles
Scene safety
The biggest catastrophe that can happen in a first aid scenario is where one casualty becomes two due to on-scene hazards and a lack
of rescuer awareness. Before assisting anyone else, it is of utmost importance that you consider how safe the scene is before entering.
For example, being aware of traffic hazards with casualties on or near roads, or electrical or water hazards.
If the match is still ongoing, there is a risk of injury to a rescuer. Players can also be a hazard by panicking or trying to help. Take control
of the situation, let everyone know you are in charge both vocally and by your actions and prevent panic. Well-meaning interference
from players such as rolling unconscious people over could seriously affect an injury.
Move other players away from the casualty as soon as possible

General principles
Rugby hazards
The referee may not have noticed the incident and may allow the game to continue. Even if he/she has noticed it, they may allow the
game to continue until there is a natural break in play.
This exposes the rescuer to the potential for coming into contact with one or more players who are continuing to play the game.
Therefore, if you are entering the field of play, you should consider the risks and benefits to both yourself and the casualty of what you
plan to do and if your assessment is such that the game should be stopped immediately, then you should be clear about how you will
communicate this to the officials.
Environmental hazards
Water
Water rescues are not integral to this course. However, the general principle of helping a conscious casualty who is in difficulty in the
water is to avoid entering the water at all costs. Objects such as life preservers, Rugby balls or other flotation devices may be available
that can be thrown to the casualty to help them stay afloat and swim ashore. It may be possible to reach them with long poles, tree
branches or ropes, etc.
Electricity
Casualties who have been electrocuted either indoors or through contact with an outdoor electricity supply or line should be checked
to ensure they are no longer in contact with the power source. If they are on the power source, e.g. cables, then this should be carefully
removed away from the casualty using a non-conducting object such as a wooden broom handle.

General principles
Emergency action planning
Whilst the role of the first aider is often reactive, there is no doubt that being prepared for illness and injury at a sports stadium will
make the situation calmer and more controlled for all involved.
Preparing for the “what ifs?” is a concept known as emergency action planning. This includes simple information such as checking for
presence of emergency kit like a defibrillator, being aware of the skills of anyone acting as a first aider or in an official medical role. Also,
knowing the contact phone numbers or signals for help can be of great value, especially at unfamiliar venues. Lines of communication
for activating the emergency services are also important.
Check for the presence of emergency kit like a first aid bag & defibrillator

General principles
Removal from the field of play
Never feel under pressure to move an injured player. If you think the
game should stop or move to another pitch whilst you await trained
medical assistance, then say so to the referee.

General principles
The injured Rugby player
The majority of Rugby injuries are to the limbs and are the usual bumps, bruises, strains and sprains. Rugby is a collision sport involving
tackling with the arms and shoulders. This inevitably comes with a small risk of players being knocked out (unconscious). On the field,
players may be unconscious because they have had a bang on the head, but in some situations such as in the changing room, it may
be due to another medical cause such as a diabetic player who has dangerously low blood sugar (hypoglycaemia) or even a cardiac
arrest.
If you have witnessed the injury, then the cause may be obvious. But it is important to keep an open mind about potentially serious
injuries and ensure you request help urgently.

General principles
Unconscious, head-injured players
Unconscious head injuries cannot tell you about any other symptoms they may have, such of a painful neck or loss of feeling for
example. So, it is important that we treat all injured Rugby players with head and potential serious neck injuries in mind when we first
attend to them. This is done through an approach called “manual in line stabilisation” (MILS) that simply shields and stabilises the head
and neck from accidental movement. It is particularly important that nobody moves the player unnecessarily or tries to turn them on
their side.
When someone is unconscious, the muscles become floppy and relaxed. The tongue – which is also a muscle - can fall back and block
the airway (swallowing the tongue). Thus, the absolute priority of all injured players is to assess the airway and ensure it is open so that
air can get in and out of the lungs with each breath.
The vast majority of unconscious Rugby players remain so for only a few seconds or up to a minute. It would be very unusual for a
player to remain unconscious for much longer than this, but of course that is not impossible.

General principles
Hidden injuries
In case an injured player's condition deteriorates, ensure that he/she is supervised at all times
Major chest or abdominal injuries in Rugby are extremely rare. However, if they do occur, they often can remain hidden and only
present late due to blood loss or “shock”.
Ensure all players who are removed from play with injuries have adequate supervision and are not left alone, just in case their condition
worsens. Have a low index of suspicion for asking for help or hospital for anyone you are not happy about.

General principles
Distracting injuries
A distracting injury is a visually dramatic injury that may distract you from the lifesaving aspects of looking after an injured player such
as a brain or neck injury, an obstructed airway or are whether they are breathing normally.
Typical distracting injuries in sport would be badly broken limbs that are deformed or wounds that are bleeding profusely. Do not be
distracted. Think about the whole casualty rather than just, for example, the badly broken leg.
Blood can distract from other more serious injuries sustained, such as injury to the brain

Standard approach to injury on the field of play
Aims of this chapter
1. To introduce a system of assessment for the injured Rugby player.
DR ABC
D – DANGER
Ensure that it is safe to approach and address any hazards that may be a risk such as from other players or environmental hazards, e.g.
lightning, etc.
R - RESPONSE
Check the level of responsiveness of the player by SPEAKING to him/her. If they don't reply, try to rouse the player by lightly TOUCHING
(squeezing) their arm. If they speaks back to you, you know the airway is open, the lungs are getting oxygen from the air and the heart
is pumping enough blood around the body. If an injured player is unresponsive, shout for help as loud as you can. If nobody comes to
assist and you have a mobile phone, call someone to help.
A - AIRWAY
B - BREATHING
C - CIRCULATION
Life depends upon oxygen being pumped around the body. Therefore, in order to stay alive, we need to be able to get oxygen into the
body through an OPEN AIRWAY. The oxygen needs to get deep into the lungs and bloodstream through effective BREATHING and then
pumped around the body by the CIRCULATION. If you don’t have A, you can’t have B and will never achieve C. Achieving an open
airway is the absolute priority in all casualties. Without it, the injured player will probably die.

Standard approach to injury on the field of play
Manual in-line stabilisation (MILS)
"Manual in-line stabilisation” (MILS) is the recommended approach for an injured Rugby player who may have a head or neck injury.
It simply describes the rescuer using his hands and forearms to cocoon the injured player’s head and neck and make an assessment of
DR ABC in greater detail.
The various stages and practical aspects of DR ABC and MILS are explained in later chapters relevant to various injuries.
Performing MILS

Head injuries in Rugby Union
1. Emphasise concussion as a significant injury.

2. Recognise the signs of severe head injuries.
3. Appreciate the link between head and spinal injury.
4. Appreciate the management priorities in head injury are to open the airway and protect the neck.
Introduction
World Rugby has a separate module on concussion management which has far greater detail than will be covered here.
Concussion is a condition that is more commonly seen in Rugby, yet serious head injuries are extremely rare. However, in the early
stages, there is little difference between how a player is affected by concussion or a structural brain injury.
The World Rugby Player Welfare website concussion modules can be found at worldrugby.org/playerwelfare
Anatomy of head injuries
The brain is a jelly-like organ that is bathed in fluid (cerebro-spinal fluid or CSF) and enclosed in a layered membranous bag. This all
then sits in a rigid bony skull.
When there is a blow to the head, the brain wobbles a bit like a jelly and, if a concussion occurs, can be stunned (no structural injury to
the brain) or much less commonly, and far more seriously, the brain can be bruised or tear on the sides or within the brain causing
bleeding. The membranes outside the brain are known as the meninges and carry blood vessels on the surface of the brain between it
and the skull.
Anatomy of the head

Concussion
Tackle concussion
• Don't lose your head, read the signs instead

• Concussion makes no sense - a confused player may be concussed
• If in doubt, sit it out
• Don't risk your brain to win a game
Concussion should be regarded as a significant injury and taken seriously. It is a functional injury that affects the way the brain works
through processing and dealing with information. Although it is commonly caused by a blow to the head, it can come from a blow to
the body, where the force of the collision is transmitted up to the brain. It is not always associated with loss of consciousness.
Concussion has many different symptoms or signs and many these can be found in the World Rugby Concussion Guidelines. Common
symptoms include poor concentration, memory loss and balance difficulties. Tools such as the Pocket Concussion Recognition Tool™
are a useful adjunct that may help with the diagnosis of concussion.
If an athlete has a suspected concussion, he/she should be removed from the field of play and not allowed to return. A concussed
player will have difficulty processing the game happening around them and will let the team down as well as putting themself at risk of
greater injury. Anyone removed due to suspected concussion should be assessed by a doctor as soon as is practically possible. They
should not be allowed to drive a motor vehicle. Return to play should follow a graduated approach as per that described in the World
Rugby Concussion Guidelines.

Concussion
Pocket CONCUSSION RECOGNITION TOOL™ 3. Memory function

To help identify concussion in children, youth and adults Failure to answer any of these questions correctly may suggest a concussion.
“What venue are we at today?”

“Which half is it now?”
“Who scored last in this game?”
“What team did you play last week / game?”
“Did your team win the last game?”
Any athlete with a suspected concussion should be IMMEDIATELY REMOVED

RECOGNIZE & REMOVE FROM PLAY, and should not be returned to activity until they are assessed
Concussion should be suspected if one or more of the following visible clues, medically. Athletes with a suspected concussion should not be left alone and
signs, symptoms or errors in memory questions are present. should not drive a motor vehicle.
It is recommended that, in all cases of suspected concussion, the player is referred to

1. Visible clues of suspected concussion a medical professional for diagnosis and guidance as well as return to play decisions,
Any one or more of the following visual clues can indicate a possible concussion: even if the symptoms resolve.
Loss of consciousness or responsiveness

Lying motionless on ground / Slow to get up
Unsteady on feet / Balance problems or falling over / Incoordination RED FLAGS
Grabbing / Clutching of head If ANY of the following are reported then the player should be safely and
Dazed, blank or vacant look immediately removed from the field. If no qualified medical professional is
Confused / Not aware of plays or events available, consider transporting by ambulance for urgent medical assessment:
- Athlete complains of neck pain - Deteriorating conscious state

2. Signs and symptoms of suspected concussion - Increasing confusion or irritability - Severe or increasing headache
Presence of any one or more of the following signs & symptoms may suggest a concussion: - Repeated vomiting - Unusual behaviour change
- Seizure or convulsion - Double vision
- Weakness or tingling / burning in
- Loss of consciousness - Headache arms or legs
- Seizure or convulsion - Dizziness
- Balance problems - Confusion
- Nausea or vomiting - Feeling slowed down Remember:
- Drowsiness - “Pressure in head”
- More emotional - Blurred vision - In all cases, the basic principles of first aid (danger, response, airway, breathing,
- Irritability - Sensitivity to light circulation) should be followed.
- Sadness - Amnesia - Do not attempt to move the player (other than required for airway support)
- Fatigue or low energy - Feeling like “in a fog“ unless trained to so do.
- Nervous or anxious - Neck pain - Do not remove helmet (if present) unless trained to do so.
- “Don’t feel right” - Sensitivity to noise
- Difficulty remembering - Difficulty concentrating
from McCrory et. al, Consensus Statement on Concussion in Sport. Br J Sports Med 47 (5), 2013
© 2013 Concussion in Sport Group © 2013 Concussion in Sport Group
Pocket Concussion Recognition Tool™

What should you do if a player has a suspected concussion?
1. Remove from pitch.

2. Do not leave alone.
3. Do not allow to drive motor vehicle.
4. Same day medical review.
5. Graduated return to play protocol (refer to the World Rugby Concussion Guidelines).
A clash of heads is often the cause of concussion

Structural head injuries
Blows to the head that are sufficient to damage the brain, blood vessels or fracture the skull can be very difficult to tell apart from
concussion in the initial stages, but have much greater consequences over the subsequent hours, including disability and even death.
Injury to any of these structures results in bleeding and swelling. As the brain is very soft and sits in a rigid box, any bleeding or swelling
within the skull will press inwards squash the brain. This is one of the reasons why all head injuries should be taken seriously and players
removed from the field of play should not be left alone.
Any force that results in a sudden twisting or rotational injury can tear delicate brain tissue or blood vessels. The temple (temporal
bone) that is in front of and above the level of the ear is the thinnest part of the skull and has a large blood vessel underneath it. Hence,
a direct blow here can fracture the skull and damage the artery, resulting in bleeding from relatively minor force.
Presentation of serious head injury

1. The same as concussion
May or may not lose consciousness. Dazed, “in a fog”, amnesia, poor concentration, nausea or pale.
2. Prolonged loss of consciousness

Although most Rugby players who are knocked out will be conscious again within about 30-40 seconds.
3. Seizures
Seizures or fits are generalised shaking of the whole body when unconscious. They are a sign of brain injury.
4. “Talk and die”

After sustaining a minor head injury and perhaps briefly losing consciousness, the player may return to almost normal. Some minutes
later, they may suddenly collapse and lose consciousness again. This is due to the time lag for bleeding to accumulate after the initial
impact and eventually compress the brain.
5. Panda eyes and bruising behind the ears

Fractures of the skull can produce bruising around the back of the ears or blood tracking down from the around the brain may produce
two black eyes. However, these are late signs and are unlikely to be seen in the initial stages.

Head injury and neck injury
Unconscious players cannot tell you if they have a painful or tender neck. We know that significant head injuries occasionally have an
associated neck (cervical spine) fracture. Anyone who is unconscious from a head injury or complains of neck pain needs to be
considered to have a serious neck injury. Further unnecessary movement can turn a bony neck injury into a paralysing spinal cord
injury, so protection of the head and neck through manual in-line stabilisation (MILS) and discouraging the player to move it is a key
skill.
Time is our friend and after a short while of simply protecting the neck with MILS and making an assessment of DR ABC, the player may
regain consciousness and be able to tell you he does not have a neck problem, allowing you to release MILS. If there is any doubt,
however, MILS should be maintained. All players who are knocked out should be removed from play, not left alone or drive a motor
vehicle and be reviewed by a doctor as soon as possible.
If there are any concerning symptoms such as neck pain, weakness, difficulty breathing or altered sensation in the limbs, or the player
is obviously confused or unconscious, then you should maintain MILS and monitor ABC until more experienced help arrives.
Fits and seizures
A seizure is a period of unconsciousness accompanied by a period of violent contraction of all muscles in the body. They are often
associated with tongue biting and loss of bladder control and the sufferer may remain “sleepy” for up to an hour afterwards. During a
seizure, the casualty cannot breathe and may become cyanosed or blue. This can be distressing to see, but they will soon return to a
healthy colour once the seizure has passed. They can occur in people with epilepsy but occasionally following a sporting head injury.
Seizures and sporting head injuries can occur immediately at the time of head injury or later following the end of the match. Early
seizures following a blow to the head are usually short lived of less than a minute. Casualties who have a seizure may have anything
from a concussion to major head injury.
Late seizures (that occur after a period of the casualty being back to normal) are a worrying sign and suggest that the head injury is
getting worse. For example, the seizure may be due to blood vessels bleeding around the brain and directly irritating the surface of it –
causing the seizure.
Management of seizures
1. Take control.
2. Ensure an ambulance is on its way.
3. Move all dangerous objects away from the casualty.
4. Assess for DR ABC. Provide open airway for casualty until assistance arrives.

Combative head injuries
Some sporting head injuries can result in a confused and agitated casualty. This is in part due to disorientation when recovering from
being unconscious and sometimes a lack of oxygen if the player’s airway has been blocked due to the position they were in when
unconscious. The casualty can then be a risk to the rescuer and other team mates until the agitation settles, often over about 30
seconds to 1 minute.
If a head injured player becomes combative, simply release MILS and talk to them from a safe distance. Remain in control of other
people who may be around and may try to restrain the player, which will only make the situation worse. Do not try to maintain MILS in a
combative casualty as this will simply put more stress on the neck. Once the player calms down, MILS can be reapplied and a DR ABC
assessment performed.
Managing sporting head injuries
1. If on the field, approach with MILS (ideally from the front) and think, “Neck?”.
2. DR ABC assessment – having an open airway is the absolute priority.
3. Unconscious? – maintain MILS and continue to shout for help.
4. Combative? – let go and “talk the casualty down”.
5. Conscious? – make an assessment for symptoms of neck injury - “Do you have pain in your neck?”
6. Remove all concussions from field of play and seek medical assessment.
7. Never leave any head injury unsupervised and do not allow the casualty to drive.

Managing the airway in an injured athlete
1. Understand the basic anatomy of the airway

2. Recognise the importance of an open airway
3. Appreciate the difference between a complete or partially obstructed airway.
4. Understand the basic airway manouvres jaw thrust and head tilt chin lift.
5. Appreciate that an airway full of blood or vomit may need urgently moving on to his side.
Introduction
The airway refers to the passage from the mouth and nose, over the tongue, down the back of the throat (pharynx), through the voice
box (larynx) and into the windpipe and airways (trachea and bronchi). The airway is of prime importance as if this is blocked, then air
cannot pass in and out of the lungs to deliver oxygen to the body and take waste carbon dioxide away. So, if a blocked airway can be
fatal, ensuring it is open is the utmost priority in all casualties.
The airway is said to be “open” when breathing means air passes freely and quietly through the mouth and nose and down into the
lungs and back out again.
The airway can be:
1. Open
2. Partially obstructed
3. Completely obstructed
Airways can be become obstructed with soft tissues (tongue), foreign bodies (teeth), blood or vomit or due to injury to the airway, e.g.
larynx.
The human pharynx & larynx

Observing the airway
You can tell a lot about an airway by looking and listening. If the casualty is speaking normally to you, then they have a good (patent)
open airway and you can safely move on to B - Breathing. If they are not talking, however, listening to the noises coming from their
mouth can be useful.
Noise Interpretation
Normal quiet breathing Airway is “open”
Gurgling Partially obstructed by liquid, e.g. blood or vomit
Snoring Partially obstructed by soft tissues that block the airway
High pitched wheezing on Partially obstructed by inhaled foreign body, e.g. tooth, chewing gum or injury to airway/
breathing in (called ‘stridor’) larynx
No noise Completely obstructed airway or is not breathing. Move on to opening the airway
Airway noises and their meanings

Managing a completely or partially obstructed airway
Those with a completely or partially obstructed airway need the rescuer to attempt to open the airway for them. There are two well
described techniques for this.
1. Jaw thrust
The tongue is firmly attached to the jaw bone. So, if the airway is obstructed, lifting the jaw forwards will pull the tongue forwards and
away from the back of the throat - allowing the free passage of air in and out. This is known as the jaw thrust procedure. This is the
technique of choice for opening the airway in any head or neck injury as it causes very little movement of the neck.
Skill 1
Opening the airway with
the jaw thrust procedure
1. Kneel at the head end of the casualty

supporting the head with MILS (see later).
2. Place both thumbs on the casualty’s cheek bones.
3. Place the index and middle fingers behind the angle of the
jawbone.
4. Gently lift the jaw forward – ensuring minimal movement
of the head and neck.
5. Reassess the patient for airway sounds.
6. If you let go, the airway will close.
The jaw thrust procedure

for opening the airway

Managing a completely or partially obstructed airway

(continued)
2. Head tilt / chin lift
Another technique for opening the airway exists and is known as the head tilt / chin lift and relies on the position of the tongue relative
to the throat. Tilting the head backwards and lifting the chin forwards effectively moves the tongue forwards away from the back of
the throat and opens the airway. However, it involves significant movement of the neck and so is not recommended in a head or neck
injury in a Rugby setting.
Skill 2
Opening the airway. Head
tilt / chin lift (not if you
suspect a head or neck
injury)
1. Kneel at the side of the casualty’s head and neck.

2. Place one hand across the forehead of the casualty.
3. Put two fingers of the other hand under the chin.
4. Lift the chin forwards whilst stabilising the forehead – so
tilting the head backwards.
5. Look in the mouth and assess the airway noises.
Putting fingers into the mouth to grab the slippery tongue will
Head tilt / chin lift manoeuvre to open airway (do not help open the airway and may make it worse. Do not do
not use if there is a head or neck injury) it!

Partially obstructed airways with blood or vomit
The only effective way to remove liquids from the back of the throat is to turn the casualty on to their side to allow it to drain away with
gravity. As injured players with an obstructed airway will almost certainly die unless you open it, airway takes absolute priority over any
potential neck injury.
Hence, you should not delay in rolling the player over onto their side if the airway is gurgling due to witnessed blood or vomit. If this
liquid travels further down into the lungs, it will cause further problems with breathing at a later stage.
Ideally, any attempt to roll the casualty should involve up to four people, but a lone rescuer can position the casualty on their side to
allow liquid to drain away or even use the HAINES (High Arm In Endangered Spine) manoeuvre. This is a modification of the traditional
roll and recovery position manoeuvre that produces less sideways bending of the neck. It can be found in more detail in the spinal
injuries chapter.
Once the airway has been opened, A of the DR ABC has been addressed and the rescuer can then make a more detailed assessment of
B - Breathing.
Skill 3
HAINES style emergency
roll manoeuvre
1. Place the player’s nearest hand on

their chest.
2. Raise the player’s opposite arm alongside their head.
3. Place your hand under the player’s head.
4. Place your second hand on the player’s nearest shoulder /
upper arm.
5. Supporting the head, roll the casualty away from you and
Emergency roll with HAINES manoeuvre for vomit tilt the head back.
that is obstructing airway
6. Allow liquid to drain away with gravity.
7. Return to original position.
8. Reassess airway.

Neck and spinal injuries in Rugby Union
1. Improve understanding of anatomy of the neck.

2. Understand injury mechanisms.
3. Understand immediate complications of a serious neck injury.
4. Understand how to best manage a potential neck injury.
Bones in the spine
Vertebrae, cartilage discs and the spinal cord canal
The spine is divided into separate regions – the lower back (known as the lumbar spine), the back of the chest (the thoracic spine) and
the neck (cervical spine).
Serious injury to the spine or spinal cord in Rugby is very rare. However, injury to the spinal cord in the neck can happen and result in
paralysis and disability or even worse.
The spine is made up of a column of bones (vertebrae) stacked on top of each other and separated by cartilage discs which act as
shock absorbers. The spinal cord runs in a meninges lined canal that sits behind the main vertebral bodies and is protected by bony
prominences to which the muscles of the back and neck attach. Multiple nerves come off the spinal cord between the vertebrae.

Spinal cord
The spinal cord continues from the base of the brain and travels down the length of the spine. It carries voluntary signals from the brain
to the muscles – telling them how and when to move. Nerves run from the skin to the brain carrying information about touch,
temperature and pain. The cord also carries nerve impulses from our automatic nervous system over which we have little control
(known as the autonomic system). The autonomic system is involved in things such as pulse rate, blood pressure control and digestion.
Nerves come off the spinal cord at all levels between the vertebrae and travel throughout the body delivering or collecting information.
Anatomy relevant to injuries
Serious injuries can occur to the vertebra (fractures or dislocations). Less serious but still significant injuries can occur to the discs,
which can bulge out (prolapse) and press on nerves leaving the spinal cord and running down the limbs, giving the classical shooting
type pain of “sciatica”. These nerves can also be bruised or stretched (stingers or burners) when the head is forced to one side in
contact – such as making a tackle.
Serious injuries to the cervical spine
1. Fractures through the vertebral bones.

2. Dislocations of one vertebrae over another through the levels of discs.
3. (Disc bulges or prolapses that may compress nerves or spinal cord).
All of the above may cause temporary or permanent injury to the spinal cord.
Fractures or dislocations to the main spinal column may or may not injure the cord. Injuries to the spinal cord can completely divide the
cord, partially divide the cord or simply press on the cord. It is impossible to tell these apart without special scans. Hence, the early
management of such injuries is extremely important to ensure that further damage is not done to the cord at that stage as a cord that
is simply compressed may present with the same symptoms as a complete division of the cord, yet may fully recover once the bony
spine is realigned in hospital.

Complications of spinal cord injury
1. Unable to feel anything below the injury.

2. Unable to move anything below the injury.
3. Difficulty breathing – due to chest muscle paralysis.
4. May feel faint or dizzy due to low blood pressure (autonomic nervous system problems).
Injured casualties with a cord injury will present with problems of all the major functions of the spinal cord. Namely, they will have pain
in the neck and may be unable to feel or move anything below the place (level) where the cord is injured. The chest muscles may be
paralysed, so that the casualty may find breathing difficult and be unable to take in enough oxygen. They may be panicking, and trying
to breathe as best they can, using any muscles that have not been paralysed. They may have a blue tinge to the lips (cyanosis) due to
lack of oxygen in the blood. This combination is known as “respiratory distress”. The lack of autonomic control may cause problems
with low blood pressure as the walls of the blood vessels become floppy. This may make the casualty feel dizzy or even lose
consciousness.

Cervical spine
The normal cervical spine is a curved structure that is similar to the design of the arch of a bridge. This curve allows it to support the
weight of the head. Injury mechanisms that predispose the cervical spine to injury often involve straightening out this curve to a shape
that is less able to cope with the sudden forces put upon it.
Sudden bending (forced flexion)
Mechanisms that suddenly force the neck forward can result in overload of the cervical spine and cause the ligaments between the
bones to tear and become unstable. The modern Rugby behaviour of ducking into tackles to protect the ball with the head bent
forward and the shoulders low would be one such potential mechanism. A collapsed scrum can also cause a sudden bending.
Squashing of the spine (axial compression)
Any force that straightens out the neck and compresses it from top to bottom (known as axial loading) such as a fall from height onto
the top of the head, can increase the risk of spinal injury. Examples include players who fall from a height, such as contesting a high ball
or who are forced head first towards the ground in a spear tackle or collapsed scrum.
Bending and twisting (flexion with rotation)
Any motion that involves bending the neck forwards or backwards with a twisting action can also cause bone, joint or disc injuries.
These are often a scrum related mechanism.
Rugby players who lose consciousness or sustain a potential spinal injury may fall or roll into any position. They may be face up, face
down or on their side. They may be able to move the head, or walk around and still have symptoms that are suggestive of a serious
neck injury.
Lumbar spine
In the lumbar spine, serious bone or cord injuries are much less common than in the neck, but disc injuries and sprains of the small
joints between vertebrae still occur. Lumbar spine injuries have been suggested as more common in training situations.
As with in the cervical spine, a motion that involves moving the head backwards or forwards with a twisting action may injure a disc,
causing it to bulge outwards (prolapse) and press on nerves running into the legs, producing shooting pains down the leg.

Recognising serious neck injury
Trying to tell a serious injury from a minor injury can be very difficult. Anyone who is knocked out cannot tell if they have neck pain or
weakness and so must be regarded as having a serious spinal injury until proven otherwise. They should be managed with manual in-
line stabilisation (MILS) to protect further movement of the head and neck.
If the casualty has neck pain, and reports they cannot feel or move their legs, then the injury is obvious. However, anyone with an injury
above the collarbone should make you think about whether this could potentially be a serious neck injury and if you are unsure, the
safest approach is to manage as if there has been a spinal injury.
Who should be treated as having a serious neck injury?
1. Anyone who is unconscious.

2. Anyone with an injury above the collarbone.
3. Anyone who has a pain in the neck.
4. Anyone who has loss of movement in the arms or legs and/or difficulty breathing.
5. Anyone you are unsure about!

Management of potentially serious neck injuries
1. Take control.
2. Approach with MILS.
3. DR ABC assessment.
4. Ensure help.
5. Don’t move unless absolutely necessary (e.g. obstructed airway or not breathing).
6. Keep warm and wait for help.
7. Reassess.
Although undoubtedly a very scary moment for anyone involved, the management priorities in serious neck injuries remain the same
as any other emergency and can be addressed through DR ABC and MILS. If they have an open airway and are breathing, then they
need not be moved. Protect the neck with MILS and ensure help is on its way. Having an open airway and breathing remains the
absolute priority as without it the casualty will die. Spinal injuries should not be moved. However, if you are unable to confidently
establish that the airway is open and they are breathing, then they must be moved to do so. The easiest way to do this is via an
emergency roll.

It is impossible to tell whether the spinal cord is permanently damaged or just temporarily squashed due to injuries to bones in the
neck. Hence, it is important to move the head and neck as little as possible to avoid making an injury worse. We do this through
avoiding all unnecessary movement and protecting the head and neck through MILS.
MILS is the mnemonic recognised approach for protecting the head and neck in spinal trauma. It is also known as the “trauma
handshake”. In addition to providing some feedback to the player to discourage them from trying to move their head, it also acts as a
red flag to others to be careful near the neck and provides a degree of protection from accidental contact from bystanders, etc.
Purpose of MILS
1. Discourage the spinally injured player from moving the head.

2. Protect the head and neck from accidental contact during a busy rescue.
3. “Red flag” to others that there is a problem with the neck.
Once MILS has been applied, it should not be removed.
However, if you are the only or most experienced rescuer present and a more pressing issue such as airway or major bleeding occurs, it
is acceptable to place a less skilled person maintaining MILS or even temporarily release it altogether.
Skill 4
Manual in-line stabilisation
(MILS)
1. Kneel or lie behind the head.

2. Place one hand on each side of the head.
3. Try not to completely cover the ears.
4. Continue with DR ABC assessment.
5. Instruct the player not to move their head.

Should I move the injured player?
The general answer to this question is no. Avoid moving the player until more skilled help arrives. There are, however, some
circumstances where you may need to move them and these are outlined here.
Weather
In a sporting setting, it is unlikely that environmental conditions will endanger an injured athlete. However, sudden extremes of
weather such as lightning, heavy rain or temperatures could put an injured athlete at risk. Blankets or umbrellas may help keep
someone warm and dry whilst waiting for assistance. Unless there is thought to be a serious risk to the casualty, they should NOT be
moved.
It is important to keep a casualty warm and dry in extreme weather conditions such as rain

Inadequate ABC assessment
Can you confidently confirm that the airway is open with normal quiet breathing and that the breathing has adequate respiratory
effort? If not, you must move the casualty into a better position to be sure.
If unconscious, the airway can be blocked by the soft tissues due to the position of the head and neck, e.g. with the head bent forward
or by bleeding from facial injuries. Unless the airway is opened, oxygen will not get into the lungs and the athlete may die. It may be
that the effect of gravity on a face down casualty means the floppy tongue falls forward and does not obstruct the airway so does not
need to be moved, or the face pressed against the floor may force the tongue back to cause on obstruction. Assess each case
individually before deciding if they need to be moved.
Airway assessment is covered in greater detail in a dedicated earlier chapter.
Paralysed breathing muscles from a spinal cord injury will lead to inefficient breathing, leading to lack of oxygen and ultimately
unconsciousness and cardiac arrest. If the ineffective breathing isn’t identified early and addressed, then the casualty may die.
If you are unhappy with the DR ABC assessment and think you need to improve the airway, it is acceptable to change the position of
the athlete in order to attempt to do so. This may be an emergency roll to allow you to perform an airway manoeuvre such as jaw
thrust, or position the casualty so that blood or vomit can freely drain away from the airway.
Take control and only move if absolutely necessary
There are frequent examples in the media of other players and officials hurriedly turning players over onto their sides. This is
unnecessary and may make a spinal injury worse. It is important to take control and prevent this happening until a DR ABC assessment
has been made. Players may panic and be an additional hazard. Take control and prevent others from interfering.

Knowing the options
Moving a casualty is not without risk. Any movement can turn an open airway into a partially or completely obstructed one. It can make
a spinal injury worse or cause problems with making internal bleeding or shock more serious. The “recovery position” is generally good
at maintaining an open airway but the position of the head is not ideal for potentially spinally injured casualties in whom being on their
back with MILS and a gentle jaw thrust is probably preferable. Having options through 2-3 different positions and manoeuvres that you
can do is useful in case a particular manoeuvre makes things worse.

The HAINES manoeuvre
HAINES stands for “high arm in endangered spine”. It assists the lone rescuer in protecting the neck whilst moving the casualty. It
effectively uses the arm as a splint for the head and neck whilst the casualty is being rolled, preventing them from sagging under their
own weight.
It can be used in one of the following situations:
1. An emergency log roll, e.g. the casualty needs to be moved to assess or sort out the airway
2. The recovery position
As the casualty may be face down, face up or in an irregular position, the direction you roll the casualty may vary. For example:
• If face down, it is probably easier to pull them up towards you.

• If they are face up and vomiting, it is better to roll them away from you (so you aren’t covered in vomit).
• If they are face up and you putting them in the recovery position, you may wish to roll them towards you.

HAINES emergency roll
Skill 5 Skill 6
HAINES emergency roll HAINES emergency roll
(face down) (face up and airway
compromise - vomit)
1. Release MILS.
2. Kneel alongside the casualty at the level of the upper 1. Release MILS.
back. 2. Kneel alongside the casualty at the level of the upper
3. Raise the nearest arm so it lies alongside the head. back.
4. Place your hand to support the head. 3. Raise the opposite arm so it lies alongside the head.
5. Place your other hand on the opposite or uppermost 4. Tuck the casualty’s other arm close to the chest.
hip or shoulder. 5. Place your hand to support the head.
6. Support the head as you pull the hip towards you, 6. Place your other hand on the hip or shoulder on your
turning the casualty over onto their side and then their side.
back. 7. Support the head as you roll the casualty away from
7. Repeat DR ABC, consider MILS and airway opening you onto their side. Support their body with your knees
manoeuvre, e.g. MILS. and open the airway.
8. Shout for help as appropriate. 8. Repeat DR ABC, consider MILS and airway opening
manoeuvre, e.g. MILS.
9. Shout for help as appropriate.
HAINES emergency roll

(rolled away from rescuer for airway compromise)

HAINES recovery position (face up)
Skill 7
HAINES recovery position
(face up)
1. Release MILS.
2. Kneel alongside the casualty at the level of the upper back.
3. Raise the nearest arm so it lies alongside the head.
4. Bend the opposite knee up to act as a lever.
5. Place your hand to support the head.
Step 1: Kneel by the casualty. Raise the arm on
6. Place your other hand on the opposite bent knee. your side to the side of the head.
7. Support the head as you pull the knee towards you, turning
the casualty over onto their side.
8. Use the bent knee and the uppermost arm to brace the
casualty on their side.
9. Repeat DR ABC, consider MILS and airway opening
manoeuvre, e.g. MILS.
10. Shout for help as appropriate.
Step 2: Support the head and roll onto side by

pulling the opposite knee towards you.
Step 3: Support the weight of the casualty with the bent knee
and place the hand under the cheek. Ensure the head is tilted
back and the casualty is breathing normally.

Controlled log roll
If you have more rescuers available, a more controlled roll is appropriate for someone who obviously has some respiratory effort but in
whom you are not happy that the airway is patent or that the breathing is normal. Hence, you are moving to perform a more detailed
DR ABC assessment with some urgency. This roll requires at least three rescuers, ideally four, especially if the casualty is very tall or
heavy. It requires clear direction from the lead rescuer.
Skill 8
Controlled log roll
1. Lead rescuer at head with MILS (if

face down, cross hands).
2. Largest rescuer at level of upper back.
3. Middle rescuer at buttocks.
4. Smallest rescuer at thighs.
5. “3 hands over, 3 hands under” technique.
6. Clear commands from lead rescuer - “Prepare to roll, and
roll”.
Controlled log roll 7. On the command, roll towards rescuer onto casualty’s
back.
8. Repeat DR ABC assessment and maintain MILS. Consider
jaw thrust if casualty appears unconscious.

Wandering athletes with neck pain or pins and needles in the

arms
It is occasionally possible for a player to sustain a serious neck injury during a match and then get up and walk around. They may be
able to approach the touchline or present afterwards to complain of neck pain or electric shocks in the arms or legs.
It is impossible to tell major or minor injuries apart in this setting. Treat the casualty as if they have a serious injury with spinal cord
compression. Move them very cautiously and as little as possible. Carefully sit them down and support their head and neck through
MILS. Perform a DR ABC assessment and ensure more experienced medical assistance is called.

Breathing assessment and chest injuries
1. Appreciate that Rugby players are breathless due to activity as well as serious injury.
2. Understand signs of normal or abnormal breathing.
3. Understand chest wall and lung injuries.
4. Understand abnormal breathing can be related to cardiac arrest or internal bleeding.

Athletic work of breathing
Sports people breathe rapidly. For the majority of match or training scenarios, they are either working hard or recovering from working
hard. Injured or unwell players may also be breathing rapidly. At rest, most people will breathe around 15 breaths per minute and each
breath will be roughly of the same depth and duration.
Normal quiet breathing involves the diaphragm, a thin muscular sheet that goes across the body separating the chest from the
abdomen. The diaphragm goes up and down as we breathe, helping draw air into the lungs. The muscles between the ribs (intercostal
muscles) also help make the chest larger to suck air in and out as we breathe.
As people breathe faster, the rate increases and more chest wall muscles are involved. This effort is called the work of breathing. As well
as breathing quickly, you may notice their tummy muscles (abdominals) rib muscles and even neck muscles working to assist
breathing. As long as the work of breathing is decreasing with time, then this is reassuring. If, however, the rate and work of breathing is
persistently high or increasing, this is a worrying sign and help is urgently needed.
Rib cage Rib cage

expands as rib becomes
Air inhaled muscles Air exhaled smaller as rib
contract muscles relax
Lung Lung
Diaphragm Diaphragm
INHALATION EXHALATION
Diaphragm contracts (moves
Diaphragm relaxes (moves up)
down)

Cyanosis
The red pigment in blood is known as haemoglobin and is responsible for binding to oxygen and carrying it around the body.
Haemoglobin with oxygen attached is bright red in colour and gives us the red colouring of our lips, gums and tongue. Haemoglobin
without oxygen turns blue. If breathing is inefficient and sufficient oxygen cannot get through the lungs to bind to haemoglobin, then
the lips and tongue may appear blue. This blue discolouration is called cyanosis.
Cyanosis can occur in the fingers due to cold weather and is known as peripheral cyanosis. This is not a sign of inefficient breathing
unless the lips and tongue are also discoloured (central cyanosis), but instead may simply reflect the cold weather. Central cyanosis is
always significant and should be looked for during an assessment of breathing. If you see central cyanosis, the casualty is not able to
get enough oxygen into the body and you need help urgently. Lack of oxygen is known as hypoxia and hypoxic people can die.
Potential causes of rapid breathing
1. Normal – post exertion.

2. Pain or panic / anxiety.
3. Chest wall or lung injuries.
4. Other injuries – shock or blood loss.
5. Medical problem, e.g. asthma.
Athletes may be breathing fast for many reasons, many of which do not suggest serious injury. This can make life difficult for the
rescuer trying to assess breathing. However, players who are simply breathing fast after exercise or due to temporary pain will quickly
settle back to normal over a couple of minutes. Panicking athletes will remain breathing fast, but some reassurance that help is on its
way help them to try to stay calm.

Chest wall or lung injuries
With chest wall or lung injuries, the player may be distressed and describe the pain as being in one particular site. Chest wall injuries are
most commonly minor but very painful. However, anyone who you think may have sustained one should be reviewed by medical staff.
The problem is not the chest wall injury itself, but the important lungs and heart that lie underneath the ribs and to make sure they are
not injured.
Signs of chest wall or lung injury
1. May be distressed due to pain or being unable to breathe properly.

2. May localise pain to a particular site.
3. May or may not be tender over the ribs and have swelling or you may feel the ribs move.
4. Symptoms will persist and not really improve with time.
5. In lung injury, you may notice that one side of the chest is not moving as well as the other.
Rib cartilage injuries
We have twelve pairs of ribs that are made of roughly 2/3 bone, 1/3 cartilage, with the cartilage portion sitting at the front and
merging together with others. It is this area where players may sustain a “popped rib cartilage”. This is a minor but very painful injury
with tenderness over the front lower ribs and pain on breathing over the injured joint. It involves the cartilage joints where the ribs
merge to form the lower part of the front of the chest wall.
Rib or breastbone fractures
Similarly, ribs can be bruised or occasionally fractured. These produce pain on breathing not unlike the popped rib cartilage, but the
casualty may indicate pain further back around the ribs into the bony portion. There may or may not be painful movement in the ribs
on gentle pressure and it can be impossible to tell on field whether ribs are just bruised or fractured (and similarly impossible in
hospital). It is safest to judge decisions on whether the player can breathe normally and whether they think they are too sore to take
contact again on that area.
A fractured rib can cause bleeding around the underlying lung (haemothorax) or even puncture it due to a sharp bony edge causing it
to collapse down (pneumothorax). Hence, suspected fractured ribs need to be treated with respect, the player removed from the field
and not left alone until reviewed by medical staff.
The lower ribs also protect other organs of the body- the liver on the right, the spleen on the left and, to a small degree, the kidneys at
the back. Consequently, injuries to the ribs can also mean injuries to any of these organs also.
Breastbone injuries (sternum) are different in that the heart sits directly underneath the injured area. Those who sustain a painful
injury to the sternum and who describe a painful click need assessing in hospital.

Lung injuries
The lungs are a pair of spongy organs that help the body take on oxygen and breathe out carbon dioxide. They inflate and deflate like
balloons and can be pierced by sharp pieces of bone from broken ribs or just the impact of a heavy tackle. When burst, this causes a
“collapsed lung” or pneumothorax.
Pneumothorax
Casualties with a collapsed lung may complain of sharp chest pain that is worse on taking a
breath in. Most young, healthy adults will cope well with a collapsed lung, but they may
show the blue colour of cyanosis if they cannot get enough oxygen into the blood with
only one working lung. There may be signs of chest wall injury, such as pain and
tenderness of a fractured rib that pierced the lung, or chest wall examination may be
normal if the pneumorthorax was “spontaneous”.
Haemothorax
Bleeding around the lung can also prevent it from working normally. The blood usually
comes from a chest wall injury although may come from the lung itself if the bony edges
of a rib fracture cut lung tissue. Bleeding into the chest can cause them to breath faster
and work harder. The injured side of the chest may not move as well as the uninjured side.
They may appear pale due to blood loss out of the circulation. They may show signs of
confusion or agitation due to “shock” and lack of oxygenated blood getting to the brain.
All lung injuries should be treated as emergencies and transported safely to hospital via
ambulance:
1. Sit them up (easier to breath sitting up).

2. Contact the emergency services.
3. Reassure and support them.

Fast breathing due to other causes – blood loss
This will be covered in more detail in the chapter about shock.
Our circulation carries essential nutrients such as oxygen and glucose to the cells of the body and takes away waste products like
carbon dioxide. If we lose a significant amount of blood either internally or externally, the ability of the circulation to meet the oxygen
needs of the body may be challenged. As a result, one of the changes that occurs is the brain makes us breathe more frequently to
help take on more oxygen and breathe away more carbon dioxide. Casualties with insufficient blood in the circulation may appear pale
and confused as well as be breathing faster than you would expect for the setting.
Remember that it usually takes a little time for people to lose enough blood to show signs of shock. Early breathing problems are more
likely to indicate pain or injury.
Medical problems and asthma will be covered in a separate chapter.
Slow breathing
This is much less common and is an extremely worrying sign. Injured or unwell players who begin to breathe very slowly or not in a
regular pattern may be about to stop breathing altogether and may already be in cardiac arrest.
Recognition of cardiac arrest is a key skill and fundamental part of the course and will be covered in detail in another section. However,
at this stage, it is important to realise that current guidelines suggest that casualties who are not breathing normally, such as slow
irregular (known as agonal) breathing should be regarded as in cardiac arrest and cardiopulmonary resuscitation begun as the
absolute priority. How to help someone who is not breathing is covered in the cardiac arrest chapter.

Assessment of breathing
When assessing the breathing, make sure the airway is open. Allow 10 seconds to decide if the casualty is breathing normally or not.
• Open the airway.

• Look for the chest rising.
• Listen for air being breathed on your face.
• Feel air on your cheek.
Open the airway and LOOK, LISTEN and FEEL for breathing for a maximum of ten seconds
When assessing a casualty for breathing, there are a number of questions to consider:
1. Is the casualty breathing via LOOK, LISTEN, FEEL?

2. Is the breathing “normal”?
3. Is the breathing regular or not?
4. Is the breathing fast (>25 bpm) or slow (<10bpm)?
5. Are both sides of the chest moving equally?
6. Is the casualty pink or blue?
An unconscious casualty with slow irregular breathing should be treated as if a cardiac arrest and cardiopulmonary resuscitation begun
immediately.

Circulation and shock
1. Become familiar with the anatomy of circulation.

2. Appreciate what shock is and be aware of its different causes.
3. Appreciate possible sites of internal bleeding and blood loss.
4. Remember that blood can carry serious infections like HIV or hepatitis – use gloves when handling wounds or bleeding.
Introduction
“Circulation” refers to the heart pumping oxygen blood around the body to help fuel the body’s organs and muscles with oxygen, as
well as taking away carbon dioxide and other waste products to the lungs or kidneys to breathe out or dispose of in the urine.
The heart beating pumps blood through the muscular walled arteries under pressure – “blood pressure”. Arteries have a thick muscular
wall to support this pressure and take blood away from the heart. Veins, however, have thin walls to collect blood under low pressure on
its way back to the heart. The body’s organs depend on blood pressure to function normally. Hence, if the pressure in the system drops
due to not enough blood being in the circulation through bleeding, or the heart not beating correctly, then the organs can fail to
function normally. Evidence of the body’s organs not working correctly is known as “shock”.
Shock
Clinical shock is a medical condition that is much more serious than the general emotional shock which someone may sustain when
they witness or are involved in a minor road traffic collision.
To function normally, the organs need sufficient blood pressure (perfusion pressure) to maintain blood flowing through them to deliver
oxygen and other nutrients. If that pressure fails, then the organs cannot work properly. In a contact sport setting, this can be due to:
1. Not enough blood or fluid in the circulation (most commonly due to bleeding – haemorrhagic shock).
2. A spinal cord injury interrupting the nerve supply that normally constricts the arteries to support the blood pressure. Hence, they
dilate and blood pressure falls (neurogenic shock).
Blood loss and haemorrhagic shock is far more common than neurogenic shock. The fundamental difference between these two
types is that in haemorrhagic shock there is not enough blood in the circulation, but in neurogenic shock there is the correct amount of
blood but in the wrong place. Consequently, there may be confusion from the brain not functioning correctly or the casualty may feel
faint due to low blood pressure.
REMEMBER THAT CONCUSSION IS A MORE COMMON CAUSE OF CONFUSION THAN SHOCK.

Haemorrhagic shock
The average person has five litres of blood in the circulation and loss of more than about 30% of this can make people very unwell.
Internal bleeding is like turning on a tap and it is often some time before the tank is sufficiently empty to cause problems or signs of
blood loss. It is unlikely to be present if you respond to an injured player immediately after injury. But haemorrhagic shock may be
present at the end of the match or half time, in someone who came off injured. The younger and fitter you are, the more able your
system is to cope with blood loss before you become unwell, so they may look “well” for some time before rapidly and suddenly
becoming very unwell and looking obviously “shocked”.
With not enough blood in the system, the skin may appear pale as the body tried to divert it to the other organs and is classically
described as “clammy” (although this may be of limited benefit in a recently exercising sweaty athlete.) If the brain fails to get enough
blood, the player may feel faint or lose consciousness, or simply appear confused. The lungs may be working harder to try and get
more oxygen to the tissues. Clues as to where the blood loss has occurred may be evident such as persistent abdominal pain, or chest
pain and evidence of rib fractures, etc.
The take home message for the first responder is to consider shock as a marker of serious injury and recognise the need for immediate
transfer to hospital.
Signs of haemorrhagic shock
1. Pale and clammy (not enough blood in circulation).

2. Signs of organs under stress (brain – confusion; lungs - breathing fast).
3. Clues as to where the blood may be (pain in abdomen, chest movement asymmetrical).
Neurogenic shock
Rather than not enough blood in the system, neurogenic shock is due to blood in the wrong place in the circulation as the autonomic
nerve supply to the muscular tone of the arteries that carry the blood to the organs is lost. It occurs with a spinal cord injury so that the
nerve supply to the blood vessels below the injury is interrupted. With a loss of the high pressure system, the blood pools in the low
pressure areas in the veins and small capillaries.
Hence, for neurogenic shock, the skin appears pink and warm, but with evidence of organ dysfunction, etc and only in the context of a
suspected spinal cord injury (motor weakness, neck pain, respiratory problems or simply unconsciousness).

Assessment of circulation
The first aid assessment of the circulation in an injured Rugby player should be based on the general condition rather than specific
parameters. These may include the mechanism of injury (if you saw it), the time since the injury, the colour of the player and how well
organs such as the brain, skin and lungs are functioning. For example, are they conscious or confused? Are they breathing rapidly, with
no obvious chest injury? Are they pale, cool and clammy? All of which may suggest blood has been lost from the circulation and is not
able to sufficiently perfuse the organs of the body.
1. Assessment of skin (pink and warm, or pale and cool?).

2. Assessment of function (brain, skin, lungs).
3. Any obvious external bleeding?
4. What are they complaining of? Where is the pain?
Pulse checks
Although pulse checks used to be an important part of a first aider's assessment of an ill patient, they are currently not recommended.
This is because they can be difficult to find and assess unless it is something you are doing on a regular basis.
On the floor and four more
“On the floor and four more” is a handy way of understanding where the blood loss may be coming from. Bleeding could be coming
from the following areas:
1. The chest.
2. The abdomen.
3. The pelvis.
4. In a limb from a broken bone.
5. On the floor – bleeding from a visible wound.
The most important aspect of considering bleeding is recognising it and getting help. There is very little you can do on your own.
People with internal bleeding often need an operation so ensuring safe transport to hospital for further assessment is the most
important step. Laying the player flat with legs raised will help divert blood to the heart and the brain while waiting for help/transport
to arrive.

Bleeding in the chest
Bleeding can occur from a broken rib or lung injury. The space where the lung sits (the chest cavity) is very large and can hold up to 5
litres (the total blood volume) so there is little you can do to stop it if you suspect it, other than get help and get them to hospital.
Possible signs include:
1. They may have sharp pain on one side with each breath, a bit like a chest wall injury.
2. They may be breathing rapidly.
3. The injured side of the chest may not be moving as much.
4. They may show poor perfusion of other organs like the skin and brain.
5. They may be PALE, COOL, CONFUSED or DROWSY.
Bleeding in the abdomen
There are many organs in the body that can be injured and bleed. The classical organs are in the upper abdomen and mostly protected
by the lower ribs. These are the liver on the right and the spleen on the left.
Liver Spleen
Stomach
Large Small
intestine intestine
Anatomy of the abdomen

The liver
The liver is the “factory” of the body in that it processes many chemicals within the body and helps process what we eat into many
different hormones, enzymes and energy stores. It is a large organ that sits behind the lower right ribs and underneath the diaphragm.
As we breathe hard during sport, the diaphragm descends to help suck air into the lungs above it and the liver can peek out under the
lower border of the right ribs. A liver injury is rare but can occur and it can tear or split in a contact sport setting.
The spleen
The spleen is a much smaller organ that sits under the left lower ribs. It acts a bit like an oil filter on a car in that it filters out old or
unwanted blood cells from the circulation and also as a store for infection-fighting white blood cells should they be needed in a hurry. It
can become significantly enlarged in some infections – most notably glandular fever – when it protrudes well below the ribs and even
crosses the abdomen where it is very fragile and can easily rupture.
Glandular fever is a viral illness of young adults, such as those who typically play contact sports such as Rugby. But anyone who has had
glandular fever should not play Rugby until a doctor has confirmed the spleen has returned to normal, such is the risk of injury and
bleeding to an enlarged spleen.
The kidneys
The kidneys are paired organs that sit on either side of the body, one behind and slightly below both the liver and the spleen. They deal
with removing the waste products from the blood and making urine for us to pass.
Signs of a possible abdominal injury
May appear “winded” that fails to improve.

May localise the pain to the right side of the abdomen (liver) or the left (spleen).
Blood is irritant to the lining of the stomach and pain may spread to be felt elsewhere.
May show signs of shock as time progresses and appear pale or show possible confusion.
May pass bright red blood when passing water (suggests a kidney injury).

Bleeding from pelvic injuries
Pelvic injuries in Rugby are extremely rare and are more recognised in motor vehicle accidents. It is unlikely you will come across one
due to the level of protection caused by the strong bony pelvis. They can be a significant cause of blood loss, however, due to the large
number of veins in the pelvis as they group together from the legs and sharp pieces of bone from a pelvic fracture.
It is important not to cause unnecessary movement of the pelvis if you suspect it is injured in any way. This could cause further
bleeding and increase pain. Remember that an open airway and MILS are the most important things to consider.
Bleeding from limb injuries
In a young adult in a Rugby setting, it is unlikely we will see blood loss from a limb injury that is sufficient to cause haemorrhagic shock.
However, fractures of the thigh bone (femur) have occasionally been seen in Rugby and this can cause about 1-1.5 litres of bleeding
into the thigh.
Open fractures (where sharp pieces of bone stick out through the skin) can be a cause of external bleeding but this is rarely significant.
Refer to the limb injury chapter for further explanation.

Bleeding and wound management
Whenever there is a risk of blood exposure, the rescuer must

protect themselves and other players. Blood can carry serious
infections with long-term health implications such as the Human
Immunodeficiency Virus (HIV), Hepatitis B or Hepatitis C. These
infections can result in liver failure, liver cancer or even death up to
20 years after exposure.
Visible blood must be treated with respect. The rescuer must wear
gloves and use clean single-use sterile dressings which are
disposed of in line with local infection control policy. Do not use
towels or other items which may be used by other players when
contaminated with blood.
Players with visible blood should have it removed at the first

opportunity, including changing of contaminated clothing. Those
with visible active bleeding should be removed and not return until
the bleeding is stopped and visible blood removed, depending on
the rules for the level of the game at which you are playing.
Visible bleeding is simply treated by pressure and elevation.

Pressing on the bleeding area with a sterile dressing and, if
possible, holding it above the level of the heart (so less blood
reaches it) will stop most bleeding wounds over 30 seconds to 1 First aiders should wear gloves and use clean
minute. Those that don’t should be maintained with pressure, single-use sterile dressings when removing blood
elevation through an absorbent sterile dressing and more
experienced medical assistance sought.
In the context of cardiac arrest and cardio-pulmonary resuscitation (CPR), there has never been a documented case of HIV
transmission during CPR, but if there is blood around the mouth, then wear gloves, use a pocket mask or face shield or even consider
compression-only CPR.

Cardiac arrest and choking
1. Understand what a cardiac arrest is.

2. Appreciate the “chain of survival” and your key role in it.
3. Appreciate importance of recognising and starting cardiopulmonary resuscitation.
4. Understand automated external defibrillators (AEDs).
5. Understand the 2010 resuscitation guidelines, the importance of early defibrillation and minimising interruptions to chest
compressions.
The guidelines for this topic vary according to whether your territory falls under the American Heart Association (AHA) or
the European Resuscitation Council (ERC).

Introduction
Cardiac arrest occurs when the heart stops beating. Without a heartbeat, there is no blood pressure in the circulation and so no blood is
getting to the brain and other vital organs. Unless the circulation is supported using basic life support (BLS) and cardiopulmonary
resuscitation (CPR or “cardiac massage”) with attempts to restart the heart (with a defibrillator), the brain will die or become severely
damaged within 5-10 minutes.
BLS is the process of supporting the airway and assisting breathing and circulation without the use of equipment other than a
protective face shield. Automated external defibrillators are now widely available in public places and are simple to use devices
designed for people with no prior experience to deliver an electric shock to the heart in an attempt to restart it.
Cardiac arrest is a rare event in athletes. But the death of a young adult playing sport is very emotive and is high profile in the media.
Recent figures suggest an incidence of up to 1 in 43,000. It is far more likely that a member of the crowd or team management will
have a cardiac arrest than a player.
Nevertheless, any unwitnessed or off the ball collapse should be regarded as a potential cardiac arrest. You will do little harm by
wrongly starting CPR as the player will soon wake up or move to let you know he doesn’t like what you are doing and automated
defibrillators are extremely accurate in knowing whether an electric shock is needed. If there is significant delay in commencing
resuscitation, then brain damage or death can occur within a few minutes.
Whilst cardiac arrests are a rare occurrence in sports people, they do happen

Cardiac screening programmes
Some countries have players who have taken part in screening programmes to try and identify those who have a heart condition that
may predispose them to having a cardiac arrest.
From a pitch side perspective, the screening programme is of little relevance as these have only been shown to reduce the incidence of
sudden cardiac death and not prevent it.
Globally, cardiac screening programmes remain controversial. Those who are present pitch side still need to be aware that an on field
or crowd cardiac arrest may happen and to be prepared for it in case it does.

The chain of survival
To survive an out of hospital cardiac arrest needs teamwork at every stage. Good communication to request assistance followed by
effective, high quality basic life support at the scene and early use of a defibrillator are equally as important as safe transport to
hospital and specialist care. Each step is as important as the others. The essential stages of care are known as the “chain of survival”.
The chain of survival varies according to whether your territory falls under the American Heart Association (AHA) or the
European Resuscitation Council (ERC). Therefore, please ensure you take note of the diagram applicable to your territory.
The American Heart Association chain of survival
The European Resuscitation Council chain of survival

Recognising cardiac arrest
The guidelines for this topic vary according to whether your territory falls under the American Heart Association (AHA) or
the European Resuscitation Council (ERC).

This section is based on the American Heart Association guidelines
Recognising cardiac arrest can be difficult. The mechanism of an unwitnessed collapse or a collapse
that occurred away from contact – players do not “faint” on the Rugby pitch - should always be
assessed with cardiac arrest in mind. All such casualties should be initially approached via the DR
ABC and MILS system. When assessing responsiveness, tap their shoulder and shout, “Are you OK?”.
Note if the player is not breathing or not breathing normally (gasping) and decide if the player
needs to be moved.
To decide if a cardiac arrest has occurred in an unresponsive player, the key assessment is whether the player is breathing “NORMALLY”.
This needs to be interpreted in context as the player may have been sprinting the length of the pitch just before the collapse and so
you would expect them to be breathing rapidly and with symmetrical chest movement.
Safe approach: Make sure the area is clear
Assess: Tap and shout, “Are you OK?"
Call for help
Airway and breathing: Check for signs of ‘normal’ breathing; dusky colour and agonal breathing (gasping) is NOT normal
Send someone to phone for Emergency Services and bring an AED
Start CPR

This section is based on the European Resuscitation Council Guidelines
Recognising cardiac arrest can be difficult. The mechanism of an unwitnessed collapse or a collapse
that occurred away from contact – players do not “faint” on the Rugby pitch - should always be
assessed with cardiac arrest in mind. All such casualties should be initially approached via the DR
ABC and MILS system. When assessing responsiveness ask, “Can you hear me?” and touch the
casualty gently. Assess the airway and breathing as described and decide if the player needs to be
moved.
To decide if a cardiac arrest has occurred in an unresponsive player, the key assessment is whether the player is breathing “NORMALLY”.
This needs to be interpreted in context as the player may have been sprinting the length of the pitch just before the collapse and so
you would expect them to be breathing rapidly and with symmetrical chest movement. Once the airway has been opened with a
gentle jaw thrust or head tilt chin lift (see Chapter 1), breathing should be assessed for up to TEN SECONDS via placing your cheek
close to the casualty's mouth and using the LOOK, LISTEN, FEEL assessment.
The LOOK, LISTEN, FEEL assessment
Place your cheek near the casualty's mouth and…
LOOK for the chest wall moving.

LISTEN for air going in and out.
FEEL the air on your cheek as they breathe.
Allow TEN SECONDS to decide if they are breathing normally or not. If not, start CPR and ensure help is on its way.
If you are not sure, start CPR.

If you decide the casualty is not breathing NORMALLY, then you should start chest compressions.
People in cardiac arrest can still gasp a little, but the breathing is weak, irregular and ineffective – a bit like a fish out of water.
If you are NOT SURE if they are breathing NORMALLY, then you should start chest compressions.
You should call for help with any unresponsive casualty, but if you decide that the casualty is in cardiac arrest, then it is worth asking if
there is an AED available and if anyone else is trained in CPR. Doing high quality CPR for any length of time is exhausting, so having a
second person to take turns means the quality is likely to remain higher.
Checklist
• Shout for help.

• Ask someone to bring an AED.
• Check to see if other bystanders are trained in CPR who can help you.
No pulse checks
Note that checking pulses is now seen as very difficult and even unreliable unless you do it regularly – particularly in what will be a very
stressful situation. As a result, pulse checks are no longer recommended.
Be confident about your decision making for cardiac arrest and do not be afraid to do CPR and use an AED. The overall survival for out
of hospital cardiac arrests without basic life support and defibrillators is only about 6%. However, if CPR is performed and a defibrillator
used on the scene within a few minutes, the survival can be as high as 60%. So, definite decision making is key and you are far better
off to “overcall” a situation as cardiac arrest, only to be proved wrong (you can do little harm), than to delay and find the casualty is
dead before anyone is brave enough to do anything.

About CPR
CPR is effectively squashing the heart between the spine and the breast bone so that blood is forced out of it. There is a lot of recent
evidence that suggests that effective CPR with minimal interruptions is crucial in terms of improving survival.
Performing chest compressions at the correct rate and depth is extremely tiring. The more tired you become, the poorer the quality of
the compressions will be. Team work is vital and using other bystanders who are trained in CPR to take turns or even “coaching”
someone who is not is preferable to a lone tired rescuer.
European Resuscitation Council (ERC) guidelines and

American Heart Association (AHA) guidelines
Resuscitation guidelines are based on evidence based research and general consensus from the International Liaison Committee on
Resuscitation (ILCOR). Whilst all of the guidelines are based on evidence and consensus from the expert group there are a few minor
variations between European Resuscitation Council (ERC) guidelines and American Heart Association (AHA) guidelines. The same main
message persists no matter which guideline you follow, the emphasis is on good quality CPR and early defibrillation.
Good quality CPR is delivered by giving:
• Compressions at a rate of 100 per minute.

• Depth of at least two inches
• Minimal hands off time/ minimise interruptions in chest compressions
• Allow complete chest recoil
Research has shown that lay responders can find it difficult to recognise cardiac arrest and agonal breathing is a major distracter in
recognising cardiac arrest. Many victims of cardiac arrest do not receive CPR because of lack of recognition of cardiac arrest and the
fear of doing wrong among bystanders. With this in mind, the AHA in their 2010 guidelines decided to remove the head tilt chin lift
technique in the initial airway opening sequence. The lay rescuer should approach the victim checking firstly that the area is safe for
their approach. Gently tap the victim’s shoulders and check for response. If there is no response, call for the emergency services and
call for an AED. Then scan the chest for normal breathing. If the victim is not breathing normally, place the heel of one hand on top of
the other in the centre of the chest and commence compressions immediately. The sequence here differs slightly from the ERC
sequence. The responder continues CPR at a rate of 30 compressions to two breaths. When the AED arrives, attach the AED. 30
compressions and 2 breaths are the same in both ERC and AHA guidelines. The AHA for simplicity state that the compression rate
should be at least 100 compressions but they do not state an upper limit.
No matter which guidelines you choose to follow, remember you can do no harm by performing CPR on an unresponsive victim. If you
have no AED available, continue compressions and breaths until you hand over to the emergency services. Remember, the more
continuous compressions the better the victims chance of survival.
If you are in a position where you do not wish to give breaths to the victim, “hands only CPR” is still a very good option for the victim.
Commencing CPR early doubles the victim’s chances of survival.

Chest compressions
Once you decide that a cardiac arrest has occurred, commence CPR with chest compressions. The purpose of chest compression is to
help keep some blood pumping to keep the heart and other organs alive until a defibrillator arrives to try and restart the heart.
Skill 9
Performing chest
compressions
1. Kneel by the side of the victim.

2. Place the heel of one hand in the centre of the chest /
lower half of breastbone.
3. Place the heel of your second hand on top of the first.
4. Interlock the fingers. Make sure you press only on the
breastbone, not the ribs or upper stomach.
5. From a vertical position above the chest and with straight
arms, press down 5-6cm.
6. After each compression, relax the pressure, but maintain
contact with the skin. Repeat for 30 compressions at a rate
of 100 to 120 beats per minute (roughly 2 per second).
7. Compression and release should take equal amounts of
time.
PUSH HARD, PUSH FAST, DON'T STOP
Place hands in centre of chest for

cardiac compressions

Rescue breaths
Current guidelines are that, after 30 compressions, we should deliver two rescue breaths to the casualty. However, some people may
be unwilling to perform mouth-to-mouth resuscitation as it can be unpleasant or there may be added risks to the rescuer such as blood
or vomit around the mouth.
Passing infection during mouth to mouth resuscitation is extremely rare, but a face shield or a pocket mask can be used to deliver
breaths without skin-to-skin contact. If none is available and you are unwilling to perform mouth-to-mouth or mouth-to-nose, then
compression only CPR is acceptable.
Skill 10
Performing rescue breaths
1. After 30 compressions, open the

airway with head tilt / chin lift.
2. Pinch the soft part of the casualty’s nose – using the index
finger and thumb on the casualty’s forehead.
3. Maintain chin lift but open the mouth.
4. Take a normal breath in and place your lips around the
casualty’s to make a seal.
Mouth-to-mouth ventilation 5. Blow steadily into the mouth for about 1 second until the
chest rises.
6. Maintain head tilt / chin lift, move your mouth away and
watch as the chest falls.
7. Repeat for a second rescue breath. The two breaths should
be completed in less than 5 seconds.
8. Without delay, place your hands back on the chest and
deliver 30 more compressions. Then repeat the
ventilations again.

Mouth-to-nose ventilation
Mouth-to-nose ventilation is an effective alternative to mouth-to-mouth. It may be considered if the casualty's mouth is seriously
injured or cannot open, or in rescue situations in water.
Mouth-to-nose ventilation

Pocket masks
Pocket masks are widely available and, as the name suggests, are a simple device that help the rescuer provide ventilations without
skin-to-skin contact. They usually come in a hard case and collapsed down. They need assembling prior to use.
Skill 11
Using a pocket mask
1. Open the device and unfold the

central portion.
2. Attach the filter to the narrow port of the mask.
3. Place it over the mouth and nose with the narrow part
covering the nose.
4. With your thumbs holding the mask over the cheekbones,
reach all of your fingers under the line of the jaw.
Rescue breaths via a pocket mask 5. Pull the jaw forward – towards the mask to help open the
airway.
6. Deliver rescue breaths as described previously.
CPR pocket mask

When to stop CPR
You should continue performing cycles of CPR at 30 compressions to two rescue breaths. If performing compression-only CPR, you
should continue compressions with no interruptions other than to change a tired rescuer. If you are using an AED, the device will ask
you to stop to allow it to reassess after 2 minutes.
Only stop CPR if:
1. The casualty shows signs of life, e.g. moving, moaning, coughing or opening the eyes AND starts to breathe normally.
2. Someone more qualified arrives and takes over.
3. You are exhausted and cannot carry on.

Automated external defibrillators (AED)
High quality CPR will help keep the heart and other organs alive, but often, further treatment is needed to restart the heart and help it
beat normally again. This is done with a controlled electric shock that stuns the electrical activity of the heart (defibrillation) and allows it
to start beating normally again. (Defibrillation is not needed in every type of cardiac arrest).
The guidelines for this topic vary according to whether your territory falls under the American Heart Association (AHA) or the
European Resuscitation Council (ERC).

Resuscitation flowchart for AED use

(courtesy of American Heart Association)
The AED is a complex computer that is capable of studying the heart and deciding if defibrillation is needed or not. There are many
different makes, but is usually a small box attached to two sticky pads or electrodes that are placed on the chest.
They are designed for use by people who have never used one before and will talk to you as you are using it, telling you where to put
the pads, how to do CPR and keep time for you.
Most modern models will recognise the need to defibrillate and advise you as such. They will then charge up and recommend that
nobody touches the patient whilst it asks you to press a button that ultimately delivers the shock.

This section is based on the Resuscitation Council UK Guidelines
Resuscitation flowchart for AED use

(courtesy of Resuscitation Council UK)
The AED is a complex computer that is capable of studying the heart and deciding if defibrillation is needed or not. There are many
different makes, but is usually a small box attached to two sticky pads or electrodes that are placed on the chest.
They are designed for use by people who have never used one before and will talk to you as you are using it, telling you where to put
the pads, how to do CPR and keep time for you.
Most modern models will recognise the need to defibrillate and advise you as such. They will then charge up and recommend that
nobody touches the patient whilst it asks you to press a button that ultimately delivers the shock.

The importance of defibrillation
Treatment with effective CPR and defibrillation can improve survival for out of hospital cardiac arrest from 8% to 60%. The defibrillator
(AED) is the key step in this improvement.
Each minute’s delay in failing to use the AED results in a 10% decrease in the chance that it will be successful. So, wait 5
minutes, and that’s only a 50% chance of success.
Recommendations state that defibrillation should occur within 3 minutes of cardiac arrest. So, ideally, AEDs need to be close the
playing area and easily accessible when needed. As soon as you decide the casualty has had a cardiac arrest, you should be asking for
help and a defibrillator if there is one.
Application of an AED
1. Open and apply the AED as soon as it arrives.

2. Minimising interruptions to CPR is a priority – continue high quality chest compressions.
3. Remove/cut clothing over the front of the chest.
4. Dry the chest if wet.
5. Apply the sticky pads as shown on the labels.
6. Only stop compressions when the machine tells you to.
7. If shock is advised, it will tell you when it is charged and ask you to press a button to shock.
8. As soon as the shock is delivered, commence CPR again immediately.
9. The device will automatically assess the casualty for a further shock after two minutes.
Note that some models are fully automatic and will deliver the shock itself without the need to press a button.

Integrating an AED into ongoing CPR
Minimising interruptions to resuscitation is a key step in CPR. When the AED arrives, continue chest compressions until the machine
tells you to stop. When removing clothing, drying the chest or applying the pads, work around the rescuer doing chest compressions so
that their work is minimally interrupted.
Application of AED pads

Safe defibrillation
There is a small risk of accidentally providing an electric shock to a bystander if they are touching the body of the casualty as the AED
releases its energy. Generally, however, the electricity will travel between the two pads and not elsewhere.
Before pressing the button on the AED to deliver the shock, it is important to give a clear “Stand clear!” command and look all around
to make sure nobody is touching the casualty. When you are happy that the area is clear, give a further command of “Shocking” and
press the button.
Concerns over rain, puddles or metal surfaces are generally unfounded, although it is good practice to dry the chest or move the player
out of large puddles if able.
Showing signs of life?
If your resuscitation has been successful, the casualty will start to show signs of life and breathe normally again. This may be coughing,
moving or moaning. At this point, the casualty should be put into the recovery position.

The recovery position
The recovery position is previously described as the HAINES position. It places a semi-conscious or unconscious casualty in a position
that keeps their airway open and allows any blood or vomit to drain out of their mouth. Once you have positioned the casualty in the
recovery position, it is important to keep them warm with blankets or clothing and frequently reassess them for and open airway and
normal breathing.
The recovery position

Resuscitation in younger children

The guidelines for children in cardiac arrest are the same as those for an adult. There is no absolute
age where a distinction should be drawn between and adult and a child. If a child is very small, only
one hand can be used for chest compressions rather than two hands. Generally, adults have a
cardiac arrest from heart related problems such as a heart attack. Cardiac arrests in children,
however, are more commonly due to a breathing issue such as drowning or choking. Hence, rescue
breaths play a higher profile role in basic life support in children.
Paediatric basic life support guidelines
Standard adult AED pads can usually be used on children aged 8 and over with the same energy levels for emergency use.
Guidelines for cardiac arrest in children
• Follow the same guidelines as for adults.

• If you are on your own, perform 2 minutes of CPR before going for help.
• Compress the chest by at least 1/3 of its depth. Use one or two hands to achieve adequate depth of compression.

Those who are trained in adult basic life support but have no training with children can use the
adult skills on child casualties in cardiac arrest. There is no absolute age where a distinction should
be drawn between and adult and a child.
Those with both adult and child training are suggested to make a decision on which guidelines to
follow based on the size of the child. Generally, adults have a cardiac arrest from heart-related problems such as a heart attack. Cardiac
arrests in children, however, are more commonly due to a breathing issue such as drowning or choking. Hence, ventilations play a
higher profile role in basic life support in children.
Paediatric basic life support guidelines (courtesy of Resuscitation Council UK)

Standard adult AED pads can usually be used on children aged 8 and over with the same energy levels for emergency use.
Guidelines for cardiac arrest in children
• Give five initial rescue breaths before starting assessing signs of life and chest compressions.
• If you are on your own, perform 1 minute of CPR before going for help.
• Compress the chest by at least 1/3 of its depth. Use one or two hands to achieve adequate depth of compression.
• Ratio of compression to ventilation is 15:2 as ventilation is of higher importance in children.
When choking occurs
Choking occurs when a small object inside the mouth, often food or chewing gum, goes down the wrong way and ends up at the
entrance to the voice box or larynx. This can cause a complete blockage of the airway, where air can neither get in or out, or it may
cause a partial obstruction where some air can still get through but the irritation caused by the obstruction is very distressing for the
individual.
Severe airway obstructions are a real emergency as, unless the object moves to allow air through the larynx, the casualty will soon lose
consciousness and suffer a cardiac arrest. If no air is moving in, the casualty will look distressed, they may be pointing to their throat
and will be quiet as they are unable to effectively cough or speak. They can, however, still communicate, so ask them “Are you
choking?” They will nod their head back to you.
Mild airway obstructions do allow some movement of air and so the casualty will be distressed but may be able to tell you what the
problem is and may have a reasonable cough.
Partial obstructions simply need you to encourage the casualty to cough up the object. Complete obstructions, on the other hand, may
need some help.

General signs of choking
• Casualty may have been eating.

• Casualty may clutch their neck.
Signs of severe airway obstruction
Response to question - “Are you choking?”:
• Casualty unable to speak.

• Casualty may respond by nodding.
Other signs:
• Casualty may be unable to breathe.

• May sound wheezy.
• Silent, ineffective coughing.
• May be unconscious.
Signs of mild airway obstruction
Response to question - “Are you choking?”:
• Casualty speaks and answers “Yes!”
Other signs:
• Casualty able to speak, cough and breathe

Management of complete airway obstruction

Abdominal thrusts
Stand behind the casualty and reach your arms around them, gripping your hands in the pit of the stomach. Pull the hands forcefully
upwards and backwards under the ribs. Repeat this five times if the obstruction is not relieved. Signs that the obstruction has been
relieved include less distress in the casualty or a more effective cough.
If the casualty deteriorates and stops breathing, place them on the floor and commence CPR. Be aware that often chest compressions
will dislodge the obstruction which may sit at the back of the throat. The same technique of abdominal thrusts is used on children.

Back slaps
Stand behind the casualty and bend them slightly forward. With the heel of your hand, hit them firmly upwards between the shoulder
blades, as if you are pushing the obstruction upwards and out of the mouth. Repeat this five times and check each time to see if the
obstruction has been relieved.

Abdominal thrusts
If back slaps have been unsuccessful in removing the

obstruction, stand behind the casualty and reach your
arms around them, gripping your hands in the pit of the
stomach. Pull the hands forcefully upwards and
backwards under the ribs. Repeat this five times if the
obstruction is not relieved. Then revert to backslaps. Signs
that the obstruction has been relieved include less
distress in the casualty or a more effective cough.
If the casualty deteriorates and stops breathing, place

them on the floor and commence CPR. Be aware that
often chest compressions will dislodge the obstruction
which may sit at the back of the throat.
If this occurs in small children, it is acceptable to place them over the knee when delivering back slaps.
Adult choking treatment (courtesy of Resuscitation Council UK)

Limb injuries
1. To learn about the anatomy of the muscles, bones and joints.

2. To appreciate the types of limb injuries that occur.
3. To understand the PRICE principles of soft tissue management.
4. To appreciate that despite looking dramatic, DR ABC is most important.
5. To improve knowledge about slings and splinting.
Introduction
Injuries to the muscles and joints such as sprains and strains are common in all contact sports, including Rugby. Occasionally, broken
bones (fractures) or joint dislocations can occur as in any other contact sport. Any of the above can prevent the athlete from playing on
and can often be very difficult to tell apart.
The bones are bound together in the joints with strong ligaments which can be torn or suffer a stretch known as a “sprain”. The medical
term for a broken bone is a fracture. If the ligaments tear and the two ends of bone making a joint slip away from one another, this is
known as a “dislocation”.
The muscles work across the joints and attach to them via strong tendons. Muscles or tendons can suffer a tear or “strain”. Athletes
with such injuries will complain of pain and be reluctant or unable to move the limb which may be accompanied by deformity and
rapid swelling.
Limb injury symptoms
Athletes with a limb injury complain of the following:
Localised pain - May be distressed but can clearly identify what hurts.
Reluctance to move - Movement of an injured limb will increase pain, or they may be unable.
Swelling - Bleeding in and around injured tissue causes swelling. This restricts movement and causes further pain.
Deformity - Usually only with a fracture or a dislocation. Dramatic to look at but don’t forget DR ABC.
When dealing with someone with a deformed or dramatic looking limb injury, it is important not to be distracted from the DR ABC
assessment. Limb injuries can be dramatic, but it remains most important to make sure the player has an open airway and is breathing
normally.

Limb injuries
Soft tissue injuries
Muscle injuries such as around the thigh (quadriceps) or hamstring

are common and may present as swelling and pain on movement
after a tackle or other incident. Swelling causes more pain and is a
vicious circle. Hence, first aid treatment is based on protecting the
injured area, limiting movement and helping to reduce swelling.
For treating most soft tissue injuries, we follow the PRICE

mnemonic.
Hamstring injuries are common in Rugby

Limb injuries
PRICE Action
Protect Protect the injured limb from further injury. Removal from the field, a compression bandage or perhaps a simple
splint if appropriate will protect the injured area and support it in terms of pain relief.
Rest Using a sling or support bandage will help the athlete use the injured limb as little as possible, giving pain relief
and preventing worsening swelling
Ice Ice provides direct pain relief and helps minimise swelling. Ideally a bag of half ice/half water. On for 20
minutes and then reapplied after 2 hours.
Compression Compressing the injured muscle with a bandage can support the injured area, preventing unnecessary
movement and relieving pain. It also opposes swelling.
Elevation If possible, raising the limb with a sling or on a stool aids blood flow away from the injury and helps minimise
swelling.
First aid treatment of limb injuries depends on the degree of symptoms present. It can be very difficult to tell a muscle injury from a
serious ligament injury and so often the initial treatment is the same - that of DR ABC consideration and PRICE, until more skilled
assistance comes to help.
Muscle injuries
Tackles to the legs can result in bruising or bleeding to the thigh (quadriceps). These can range from a minor “dead leg”, where the
player feels he can continue after some minor on field treatment, right up to being unable to continue.
Like any muscle injury, the first aid management would include DR ABC, a plastic bag of half ice/half water applied for 20 minutes
every two hours and a light strapping or compression applied.
If the athlete can still walk, it is acceptable to seek a medical or physiotherapy review over the next few days if they fail to improve. If
they cannot walk, however, then review by a doctor on the same day as the injury would be important. Similar treatment is acceptable
for calf or hamstring strains or general soft tissue bruising.

Limb injuries
Ligament injuries
Ligament injuries happen if a joint is twisted or forced into a position

it is not normally comfortable in. Ligaments bind the bones together
in joints and can become stretched or torn. If the ligaments tear
altogether and the bones in the joint fall out of line, then a
dislocation occurs.
Ligament injuries commonly occur in the ankle (a sprained ankle) or

the knee (a twisted knee) or at the end of the collar bone in the
shoulder (AC joint) but the ligaments of most joints can be injured,
sprained or torn.
First aid is very similar to muscle injury in that it follows the DR ABC
and PRICE regimen. Severely painful joints following a ligament
injury may benefit from “splinting” or supporting the joint to protect
it from further painful movements, e.g. a sling for the shoulder. A
plastic bag of ice with water should be applied and compressed to
the sore area for roughly 20 minutes with a light bandage or cling
film and light compression applied after removal.
Ligament injuries or joint “sprains” can be difficult to tell from

fractures, so early medical or physiotherapist review is needed. As in Support the joint to protect it from
muscle injuries, if the player is having real difficulty walking or using further painful movements
the injured limb, then medical assessment is needed on the same
day as the match.

Limb injuries
Dislocations
A dislocation occurs when the ligaments supporting a joint are stretched and rupture, allowing the bones in the joint to fall out of line.
Dislocations usually result in deformed limbs that are dramatic to look at. They cause considerable pain, due to the soft tissues around
the dislocated joint being unpleasantly stretched and can cause problems with blood circulation or nerve supply to the limb. Hence,
they should be regarded as an emergency. Nevertheless, a pitfall of providing first aid to deformed and dislocated joints is their
appearance can distract the rescuer from the principals of DR ABC and other more serious problems such as a serious neck injury or an
obstructed airway can be missed. Consequently, they are sometimes called “distracting” injuries. Do not be distracted!
In Rugby, the more common joints that may dislocate are in the upper limb, with the shoulder joint and the fingers the most common.
Ankles can also dislocate if there is a fracture. The same principals of DR ABC and PRICE apply, although the urgency of the situation
and distress the player is in mean that protecting and supporting the injured limb becomes more of a priority as they need immediate
transfer to the local emergency department.
First time shoulder dislocations are particularly painful and often have an obvious deformity. A player's arms should be supported in
whichever position they find most comfortable. This may be simply cradled in the upturned lower border of their Rugby shirt or in a
broad arm sling, or simply with themselves holding the arm. Ice can be applied if tolerated, but swift transfer to hospital is needed.
Dislocated fingers will be obviously deformed at the level of the joints and again extremely painful. Players will probably simply hold the
wrist to support their own hand whilst being transferred to hospital.
Ankle dislocations are usually combined with a fracture and known as fracture-dislocations. They should simply be supported until an
emergency ambulance arrives.
Never attempt to put a dislocated joint back in. To do so requires experience and training and usually an X-ray first to make sure it is
what the doctor thinks it is.

Limb injuries
Fractures
Fracture is the medical term for a broken bone. There is no difference between a crack, a fracture or a break. Fractures are extremely
painful with swelling, may be deformed and the player will be reluctant or find it too painful to move the limb.
Occasionally, both you and they may notice a very painful grinding sensation from the broken ends rubbing together. Any bone in the
body can break, but common sites in contact sports are the collarbone, the wrist, the hand or the ankle. A broken bone can produce
two sharp ends that can damage blood vessels or other soft tissues, or even poke through the skin, causing what is known as an “open”
fracture (historically called a compound fracture).
Again, the DR ABC and PRICE principles are the mainstay of treatment, as it will often be difficulty to tell a ligament sprain from a
fracture unless there is obvious deformity and a large amount of swelling.
The pain from fractured limbs can often be helped by correctly supporting or “splinting” or the injured limb. Generally, however, if the
player is too uncomfortable to move, particularly with lower limb fractures, despite supporting the injured limb, they should remain
where they are and wait until more experienced help arrives.
Splinting
When a bone fractures, the two ends can move

about, rubbing against each other and the soft
tissues, causing considerable pain and ongoing
tissue damage. If there is deformity that is
stretching the soft tissues, this is also significantly
painful.
Therefore, providing support to the whole limb to

minimise the amount of movement at the fracture
site provides pain relief and prevents further
damage. Support can be provided simply with the
rescuer’s hands against the ground, or by
improvising such as using a folded newspaper
inside a sling, or with dedicated splints such as
mouldable metal splints or foam “box splints”. The A player with a suspected fracture to the leg is removed
from the field of play
principle of splinting is that the “splint” should
support the joint above and below the fracture.

Limb injuries
Open fractures
Open fractures are a problem as they allow germs to get into the bones and prevent healing. If you are faced with a wound with a piece
of sharp bone sticking out, simply place a sterile first aid dressing over it and support the limb as normal. If there is significant active
bleeding from the wound, then simply press on it to stem the flow, again with a sterile dressing. This will turn an open fracture into a
closed fracture.
The player’s shirt
Painful injuries to the upper limb where the player is reluctant to

move can simply be supported by folding the Rugby shirt back up
on itself and tucking the injured arm into it.
This supports the wrist, the forearm, the elbow and the shoulder.

Limb injuries
Broad arm sling
This is a simple sling to support the upper limb using a triangular bandage.
1. Put a knot in the short corner of the bandage.
2. With the knot at the elbow, put the leading edge of the bandage under the forearm.
3. Lift the two unknotted corners of the bandage up either side of the neck and tie together.
4. Keep the elbow bent at 90 degrees and tie the ends behind the neck.
The broad arm sling is good for supporting the shoulder, elbow, forearm or wrist. Should
additional support or splinting of the forearm be needed, a folded newspaper or malleable metal
splint can be placed within it.

Limb injuries
High arm sling
This is another simple sling using a triangular bandage that provides elevation. Hence, it is a good
choice for hand or wrist injuries.
1. Put a knot in the short corner of the bandage.
2. Place the injured hand across the chest toward the opposite shoulder.
3. Place the knot over the elbow.
4. Place the leading edge of the bandage on top of the forearm and drape the corner over the
opposite shoulder.
5. Take the lower edge of the bandage and lead it underneath the forearm and around the back
to tie to the other corner behind the neck.

Limb injuries
Malleable or SAM splints
Highly versatile padded aluminium splints are available that can be moulded to support an injured limb. They are particularly useful for
wrists, hands, forearms and ankle. They can be doubled over for added support and wrapped around an injured wrist or ankle with a
“sugar-tongs” approach and they can be bent into any shape to accommodate deformity. They should be gently bandaged in place to
provide support, protection and pain relief.
Malleable splint applied to ankle fracture
Malleable splint on forearm fracture

Limb injuries
Polyurethane box splints
Orange “box” splints are common and simple to apply. They are made of soft polyurethane foam and are applied via Velcro straps.
They simply “fold up” around injured bone.
Polyurethane box splint applied to ankle fracture

Limb injuries
Manual splints
Sometimes the only available splints are the ground, the opposite leg and the rescuer’s hands. Remember to support the limb above
and below the fracture to protect it from accidental contact with others.
Manually stabilising limb above and below fracture

Medical problems
1. To improve awareness of common medical problems in sport.

2. To highlight role of first aider in medical emergencies.
Introduction
Medical problems can be common in sport. Some of the athletes will have problems such as asthma, diabetes or epilepsy. Perhaps
some of the management may have high blood pressure or angina.
Diabetes
Diabetes is an incurable condition where the body is unable to take up sugar from the blood and into the muscles due to lack of the
hormone known as Insulin (Type I diabetes). The blood sugar rises will damage the blood vessels, eyes and the kidneys over many
years. Diabetes is treated with insulin injections to try to keep the high blood sugars within normal limits.
Diabetics can be unwell and fall into a coma if the sugar gets too high or too low (a “hypo”). Coma due to hypos can cause brain
damage or death. Prior to becoming unconscious, diabetics with hypos become agitated, confused, irrational or disorientated.
If you find someone who is unconscious, after completing the DR ABC approach, look for medic alert bracelets which may reveal if the
casualty is diabetic. Low sugars are more dangerous than high sugars and so if you do find an unconscious or confused disorientated
diabetic casualty, you should try to give them sugar. If they are conscious, this can be via a sugary drink. If they are unconscious, this
could be via honey or a carbohydrate gel which can be rubbed into the inside of the cheek.
An emergency ambulance is essential.
Older people, particularly the overweight, may develop resistance to their own insulin and so are given tablets to help it move sugar out
of the blood (Type II diabetes). It is extremely rare for Type II diabetes to have an emergency related to their diabetes and they do not
get the hypoglycaemic attacks unless they are being treated with insulin injections.

Medical problems
Asthma
Asthma is a condition where the airways become narrowed, making it difficult to breathe. Air passing through the narrowed airways
causes wheezing. There are many triggers to asthma, including pollen, cold, animal hair, exercise or a viral infection.
People with asthma use inhalers to help open up the airways again. Most asthmatics have mild asthma, but occasionally it can be
serious or life threatening. An unwell asthmatic will be short of breath and struggling to speak in sentences. If they are really unwell,
they may appear blue around the lips (cyanosed) due to lack of oxygen.
Unwell asthmatics need urgent medical attention. Get emergency help quickly. They will find breathing easier if they are sat upright. If
the casualty has an inhaler, help them to use it whilst you wait for the emergency services. As they have difficulty breathing, making a
hole in the base of a polystyrene cup or plastic bottle and putting the mouthpiece of the inhaler in it to form a face mask can improve
the amount of medication they receive. Place the cup over the nose and mouth and activate the inhaler 6-8 times consecutively. Ask
them to breathe in and out as deep as they can for 30 seconds.
If the casualty stops breathing altogether whilst waiting for trained assistance, then start CPR.
Making a hole in a plastic bottle or polystyrene cup can help an asthmatic person
who is gasping for breath to breathe more easily

Medical problems
Epilepsy
Epilepsy is a condition that involves fits or seizures. A seizure is random electrical activity in the brain that causes the muscles in the
body to contract and the casualty to lose consciousness. The player shakes violently usually for 20-30 seconds up to a few minutes.
Occasionally, a fit can go on for much longer.
There is little than can be done other than get emergency help and move any hazards out of the way so that the patient doesn’t injury
themselves during the seizure. Once the seizure is over, the casualty can be very sleepy for a couple of hours. Place them in the
recovery position and keep them warm with a blanket until help arrives.
If the player is not known to have epilepsy and has been taking part in contact sport, the seizure may be related to a head injury.
Emergency action planning
Performing risk assessments and planning for emergency events, such as illness or injury, can make an incident less stressful for those
involved and may improve the quality of care provided.
Considering procedures at Rugby clubs relevant to first aid training, supervision of sessions, lines of communication, activation of
emergency services and availability of emergency equipment such as an AED is a good example of such planning.

Further information
Further information
If you'd like to enquire about attending a face-to-face Level 1 course, please contact your Regional Training
Co-ordinator.
Rugby Europe (Europe)
Douglas Langley - douglas.langley@worldrugby.org
NACRA (North America & the Caribbean)
Mike Luke - rtcnacra@worldrugby.org
CONSUR (South America)
Alejandro Degano - rtcconsur@worldrugby.org
ARFU (Asia)
Gene Tong - rtcarfu@worldrugby.org
Rugby Africa - English Speaking
Denver Wannies - rtccaren@worldrugby.org
Rugby Africa - French Speaking
Adama Bakhoum - rtccarfr@worldrugby.org
FORU (Oceania)
Talemo Waqa - rtcforu@worldrugby.org

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Preface

Strength and Conditioning Rugby Ready

FIRST AID IN RUGBY 1

Five steps to Player Welfare

Be a lifesaver; know your A-B-C

If they are on the deck, think about the neck

Train to prevent injuries

FIRST AID IN RUGBY 2

Kick infection into touch

World Rugby Medical Education

Level 1 Level 2 Level 3

Who is it for? Coaches, teachers, parents, Physiotherapists or athletic Physiotherapists or athletic

Minimum duration: 8 hours 10 hours 20 hours

Prerequisites: • Over 14 years of age Registered medical Registered medical

FIRST AID IN RUGBY 3

• Authors – Jonathan Hanson (SRU), James Robson (SRU)

FIRST AID IN RUGBY 4

The general principles of sports first aid are:

FIRST AID IN RUGBY 5

Move other players away from the casualty as soon as possible

FIRST AID IN RUGBY 6

FIRST AID IN RUGBY 7

Emergency action planning

FIRST AID IN RUGBY 8

Removal from the field of play

FIRST AID IN RUGBY 9

The injured Rugby player

FIRST AID IN RUGBY 10

Unconscious, head-injured players

FIRST AID IN RUGBY 11

FIRST AID IN RUGBY 12

FIRST AID IN RUGBY 13

Aims of this chapter

1. To introduce a system of assessment for the injured Rugby player.

FIRST AID IN RUGBY 14

Manual in-line stabilisation (MILS)

FIRST AID IN RUGBY 15

Aims of this chapter

1. Emphasise concussion as a significant injury.

Anatomy of head injuries

Anatomy of the head

FIRST AID IN RUGBY 16

• Don't lose your head, read the signs instead

FIRST AID IN RUGBY 17

Pocket CONCUSSION RECOGNITION TOOL™ 3. Memory function

“What venue are we at today?”

Any athlete with a suspected concussion should be IMMEDIATELY REMOVED

It is recommended that, in all cases of suspected concussion, the player is referred to

Loss of consciousness or responsiveness

- Athlete complains of neck pain - Deteriorating conscious state

© 2013 Concussion in Sport Group © 2013 Concussion in Sport Group

Pocket Concussion Recognition Tool™

FIRST AID IN RUGBY 18

What should you do if a player has a suspected concussion?

1. Remove from pitch.

A clash of heads is often the cause of concussion

FIRST AID IN RUGBY 19

Structural head injuries

Presentation of serious head injury

2. Prolonged loss of consciousness

4. “Talk and die”

5. Panda eyes and bruising behind the ears

FIRST AID IN RUGBY 20