FOOTBALL

2008 SPINAL INTERVENTION GUIDELINES

Competent pre-hospital management of spine injured athletes is a concern for sports medicine providers.
Although EMS protocols vary regionally, there are basics that are common and guidelines that can be
developed to best meet the needs of the Canadian pre-hospital realities. These sports specific guidelines
are based on the following: (1) Pre-Hospital Trauma Life Support (PHTLS-2007) a standard in over 32
countries. (2) Pre-Hospital Care of Spine- Injured Athlete Inter-Association Task Force (NATA 2001).
Recent updates in CPR / AED (ILCOR 2005) and spinal care approaches with sports equipment have been
since made and these changes are reflected in the following directives. It is assumed that the best-trained,
practiced, and equipped personnel are on-site in the best of conditions and in a controlled setting.
These guidelines are meant to be used as a model for an ideal intervention in a non-ideal situation.
Mock-ups (simulations) should be done on a regular basis, and especially at the beginning of each season.
All sports medicine personnel must know their roles and have practiced their skills within the last 3 months
to be considered trained & rescue-ready responders.

DESCRIPTION
Most common spine injuries in sport are: sprains, strains, contusions, and fractures.
! Sprain: stretch or tear of ligament affecting stability of the spinal column allowing vertebrae to shift
and possibly pinch/injure a nerve, spinal cord, or neuro-vascular structures.
! Strain: stretching or tearing injuries of the muscles or tendon units that can affect stability.
! Contusion: a bruise to the bone, muscle or spinal tissue which in turn can constrict or pinch the
spinal cord, nerves or vascular supply.
! Fracture: broken vertebra can injure nerve, spinal cord, or neuro-vascular structures.

CAUSES
The way an injury occurred may give some idea if a spinal injury may be suspected.
Causes include: direct blow, compression, torsion or twisting.
! Significant head injury, especially with impact on the top of head / forehead.
! Violent collisions, spearing, compression with axial loading, etc.
! Athlete found unconscious with an unknown mechanism / reason.

SIGNS and SYMPTOMS

! Suspect mechanism of injury
! Head injuries with alteration in LOC or altered mental status
! Spinal pain or tenderness post trauma
! Anatomic deformity of the spine post trauma
! Possible altered motor and sensory functions
! Possible neurological deficit or complaint
! Priaprism (painful erection)
! Seizures post trauma
! Neurogenic shock, impaired speaking, vision, breathing as result of the injury, etc.

2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL

John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
GENERAL SPINAL INTERVENTION & CARE GUIDELINES
Primary Survey: (UABCd) ( where d = defib)
Spinal precautions: in-line immobilization
UABCd: identify, correct, maintain life support

Secondary Survey : (DEFG) (where D =disability)

Perform global secondary survey: head to toe with PMSC x 4
(PMSC x 4: Pulse, Motor, Sensory, Capillary refill x 4 extremities)
Identify potential life threatening injuries
Starting with HEAD allows early assessment of head related trauma.
Continuing body scan including PMSC x 4 assesses global spinal.
SAMPLE if conscious, bystander info / athlete card

Vitals: system status: Pulse / Ventilation Rate / BP / Glasgow Score (prn)

Focused Secondary in order of importance and care

D Disability) : Head: TBI major (bleed/contusion) vs. TBI minor (concussion)

Spinal: Neurogenic vs. Orthopedic dysfunction

Depending on patient status, focused spinal assessment is done

including dermatomes / myotomes, but not at expense of delaying the boarding.

EFG Epidermis (wounds dressed), Fractures (splinted), General care

Immobilization, Packaging, Transportation prep

Patient care
Monitoring

Note:
1. Usually difficult to apply rigid cervical collar with shoulder pads / helmet in place.
(check applicability in your specific sport setting). This is one of the rationales why pads
should be removed (in controlled setting) before transport.

2. A full vacuum mattress (VM) is not recommended for spinal immobilization of athletes wearing
protective equipment. The mattress tends to conform to the protective equipment which may be
loose fitting and not provide adequate immobilization. Some EMS systems (ie: Québec) use full body
vacuum mattress as protocol for all spinal trauma immobilizations. If your sport med team is not
comfortable with removing shoulder pads/ helmet on-field because of the setting, you may have to notify
arriving EMS crew that the athlete may be !claustrophobic" (contraindication for vacuum mattress use).
This approach would also prevent unnecessary transfers from a board to a VM once an athlete is
already immobilized and is ready for transport. VM have their uses, but are limited in sports setting.

2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL

John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
SPECIFIC SPINAL INTERVENTION & CARE GUIDELINES
Initially manually stabilize the head and neck in the position found.
Do not move the athlete unless absolutely necessary.

U AVPU / Glasgow Coma Score (actual GCS is calculated later)

Ask: What happened? , Open your eyes!, Where does it hurt? Move your fingers!
Invoke: Pain (triceps pinch or nail bed squeeze#$%&$'()*+(+$,-+./0($1+.2-/,$(-$(3-$&%1.($45+.(%-/.6

EMS / 9-1-1: If unconscious or if dictated by mechanism of injury (MOI)

Airway
Airway access / Mouthguard removal?
Open airway (reach under faceguard if possible to attempt trauma jaw thrust or trauma chin lift)

Breathing
Breathing check (max. 10 sec) -should be easy to verify post activity
Breathing present -$7-/(%/5+$(-$!8"
Breathing absent 9 if head/neck not aligned: place !in-line"
if semi-prone / side-lying: log roll to supine (onto board if close by?)
*Urgent Faceguard Removal: remove faceguard within 30 seconds to provide initial breaths
Emergency Removal Tools: Quick Release Tool (QRT), power / manual screwdriver, cutting tool
such as pruner shears should be available for use by skilled hands.
Airway access should be provided within 30 seconds of establishing breathlessness
Ventilate x 2 breaths ( 1 second each)

Circulation
Pulse check (max. 10 sec)
Pulse present- maintain ventilations as needed ( 1 breath every 5-6 sec.)
Pulse absent - shoulder pads: cut enough of jersey / pads to initially access chest for chest
chest compressions / ventilations 30:2 x 5 cycles and AED protocol
defibrillation
commence AED protocol if defibrillator available (witnessed vs. non-witnessed)

Disability Spinal immobilization (PHTLS):

Prepare for boarding while maintaining BLS (initiate AED, ACLS when available)
During CPR, assistant should make cuts necessary for equipment helmet / pad removal.
After a sequence of 2 minutes of CPR, helmet and shoulder pads are removed within 10-15 seconds.
If not ready, they are removed at the end of the next 2 minute CPR sequence (never after a shock).
Player should be boarded right after a 2 minute series of CPR, just before analysis.
Once on the board, AED analysis resumes.!"#!$%&'()!*+,-%.+/0!1-,.!%&'()!*2+!3.%45.!678!
immediately. While CPR in progress, strap player to board, place board onto stretcher,
evacuate. Dynamic CPR done while moving, stop only to analyze/shock as needed
Maintain patient care throughout: OA, O2, suction, blanket, immobilization, etc.

* Faceguard Removal: See Appendix

1. Riddell :2+7%&%7'(%-/$:)++($:+2($;<<=>$!?+@-*5(%-/$A'7+B5'1,$C5%7D$?+*+'.+$E'1,3'1+"6$$$$$$$$$$$
2. Riddell Technical Service Bulletin Feb 2003>!FG+1B+/7H$Removal of Revolution F'7+B5'1,."6

2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL

John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
FOOTBALL URGENT EQUIPMENT REMOVAL
1. During performance of UABCd on a fully equipped football player,
initially all equipment should be kept in place except for urgent access to:
Airway for obstructions / ventilations
Chest for compressions / defibrillation.

2. Airway / Ventilation access involves removal of 2 lateral snubbers and tilting up the faceguard.
Urgent Faceguard Removal: Three options for lateral snubber removal (see appendix):
#1) Quick release snubber with QRT (other pointy items also work: pen, golf tee, nail punch)
#2) Power Screwdriver- remove screws from 2 bottom lateral snubbers & tilt up faceguard.
#3) Pruner Shears- cut each snubber at its base with 2 parallel full thickness cuts.

It should take less than 10 seconds per snubber with training and appropriate tools.
Snubber removal should allow base of faceguard to be tilted up from helmet.
Careful with tilting up faceguard as often this can cause unwanted movement.
Cut chin strap if not already removed, pry off /deflate cheek pads if in the way.
Access should be made in " 30 seconds in order to allow admin of first 2 breaths.

3. If both snubbers are not removed or cut within 30 seconds, should proceed to
Urgent Helmet Removal with faceguard attached (remove at least cheek pads).
This option is more difficult and causes more movement, especially with heavy linemen
$$$$$3)-.+$)+',.$!&%**$()+$)+*G+(". Also problematic are removing helmets with long faceguards
still in place. In any case, helmet removal itself should never take more than total of 30 seconds.
Urgent helmet removal alone is never a good initial option because shoulder pad removal
should theoretically follow immediately to maintain in-line stability. In the case where AR / CPR
was necessary initially (ie: primary reason for emergency access), the spine would have been
I+((+1$21-(+7(+,$5/(%*$!7-/(1-**+,"$ equipment removal could be performed.

4. Chest access:
Jersey / Shirts9 Initially pull up and cut just enough for emergency access to the chest
If difficult or too tight: CUT (scissors) : cut down the side, across shoulders and down front sleeves
Shoulder Pad- CUT laces / material with scissors, CUT plastic plate if present with shears.

5. Ideally CPR is never delayed for more than 10-15 seconds, which is the realistic time
required to perform a manoeuvre ie: spinal roll , suction, transporting down stairs etc.
Urgent faceguard removal should never go beyond 30 seconds ((3%7+$()%.$!1+'*%(H$(%G+").
Urgent Helmet Removal should never go beyond a total 60 seconds which is the time
required for failed faceguard removal (30 sec) + urgent helmet removal (30 sec)

6. Once urgent access has been provided for airway / ventilation / chest access, on-going
Airway / AR / CPR is maintained as needed. Preparations for the rest of the equipment
removal should be made to ensure proper boarding/immobilization as per PHTLS.
Ideally helmet/pads could be prepped during first 2 minutes of AR / CPR and removal
done right after a 2 minute sequence of AR / CPR (never right after a shock).
When indicated, the helmet/pads are removed no later than 4-6 minutes after injury.
This is ample time to have necessary equipment & trained personnel in place.

2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL

John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
FOOTBALL SPINAL INTERVENTION GUIDELINES
CONSCIOUS / BREATHING (STABLE)
Spinal precautions in effect, primary, secondary survey and vitals have been taken.
OPTION #1 Immediate Equipment Removal
If skilled and professional responders are on-field, weather and other factors permitting,
this could be considered a controlled setting, equipment removal could then be performed on-field

CONTROLLED FACEGUARD REMOVAL: Quick release, unscrew, or cut the four snubbers, remove.
Remove cheek pads with bandage scissors/release air bladder, unsnap/cut chinstrap.
PADS: Jersey: cut down the side, across shoulders and down front sleeves.
Pads: cut anterior chest pad laces / fasteners, release all straps.
REMOVAL: Lead therapist (charge person) supports head with occiput / submandibular hold, or with
heavier players, the occiput would need to be cradled with two hands (cradle hold).
Important to ensure that jersey or straps are not caught under 1+.2-/,+1.0 arms/hands
Assistant therapist expediently removes helmet with slight spread, cranial / gentle
forward flexion movement of helmet without causing movement to head / neck.
Therapist then reaches across anterior/superior aspect of pads and separates and
pulls pads longitudinally out from under athlete. Helpful to have an extra assistant with
scissors to cut snags during shoulder pad removal. Proceed with boarding guidelines.

OPTION #2 Delayed Full Equipment Removal

If for any reason the on-field situation is deemed a non-controlled setting, delay full removal:

CONTROLLED FACEGUARD REMOVAL: Quick release, unscrew or cut the four snubbers, remove.
Immobilize athlete on spine board with equipment on & safely remove from field (usually no collar).
On sideline if controlled setting, proceed to remove helmet/pads if still no ambulance.
If ambulance arrives, proceed to take off equipment together on sideline or in ambulance.
Eventually the helmet (and thus pads) will need to be removed by trained personnel.
The trained therapist should assume the lead role and safely remove equipment with EMS assistance.
Athlete is immobilized as per PHTLS spinal immobilization guidelines.
The goal is to safely remove equipment and have complete access before a change in status
necessitates the use of an emergency technique (poorer outcome).

UNCONSCIOUS / BREATHING (UNSTABLE)

Spinal precautions in effect, primary, secondary survey and vitals have been taken.
CONTROLLED FACEGUARD REMOVAL: Quick release, unscrew, or cut the four snubbers, remove.
Remove cheek pads with bandage scissors / release air bladder, unsnap/cut chin strap.
PADS: Jersey: cut down the side, across shoulders and down front sleeves.
Pads: cut anterior chest pad laces / fasteners, release all straps.
REMOVAL: Lead therapist supports head with occiput / submandibular hold (or cradle hold)
making sure that jersey or straps are not caught under 1+.2-/,+1.0 arms/hands
Assistant therapist expediently removes helmet with slight spread, cranial / gentle
forward flexion movement of helmet without causing movement to head / neck.
Therapist then reaches across anterior/superior aspect of pads and separates and
pulls pads longitudinally out from under athlete. Assistant with scissors for snags.
BOARDING: Proceed with boarding guidelines, maintain airway, monitor athlete throughout

2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL

John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
FOOTBALL INTERVENTION GUIDELINES
UNCONSCIOUS / NON-BREATHING (UNSTABLE)
Spinal precautions in effect, focus primary survey, secondary survey / vitals verified by assistant .
Two lateral snubbers removed, faceguard tilted up, 2 breaths (1 second each), pulse check (max 10sec)
Pulse present, continue AR: 1 breath every 5-6 seconds (adult), monitor pulse.

URGENT FACEGUARD REMOVAL: Only two lateral snubbers need to be removed in this situation.
Remove check pads with bandage scissors/ release air bladder, unsnap/cut chin strap.
PADS: Jersey: cut down the side, across shoulders and down front sleeves
Pads: cut anterior chest pad laces / fasteners, release all straps.
REMOVAL: Assistant therapist supports head with occiput / submandibular hold (or cradle hold)
making sure that jersey or straps are not caught under 1+.2-/,+1.0 arms/hands.
Must also ensure to not interfere with first responder ventilations until ready.
On a coordinated count, ventilations are stopped for no more than 10-15 seconds.
Lead therapist expediently removes helmet with slight spread, cranial / gentle
forward flexion movement of helmet without causing movement to head / neck.
Therapist then reaches across anterior/superior aspect of pads and separates
and pulls pads longitudinally out from under athlete. Ventilations are resumed
immediately after equipment removal (# 10-15 seconds).

UNCONSCIOUS / NON-BREATHING / PULSELESS (UNSTABLE)

Spinal precautions in effect, focus primary survey>$JK80.$L$JFM
Secondary survey verified by assistant, or at very latest prior to boarding.
Two lateral snubs removed, faceguard tilted up, 2 breaths (1 second each), pulse check (max 10 sec)
Pulse absent. commence compressions / AED protocol

Chest access: pads/jersey partially cut enough to access mid-mammalian level for compressions.
First Responder continues with CPR 30:2 until defibrillator available or ACLS / EMS arrives.
Assistant therapist and other personnel join pre-determined ERP without disrupting CPR/AED.

URGENT FACEGUARD REMOVAL: Only two lateral snubbers need to be removed in this situation.
Remove check pads with bandage scissors / release air bladder, unsnap/cut chin strap.
PADS: Jersey: fully cut down the side, across shoulders and down front sleeve
Pads: cut any other obstacles or straps anterior / inferior shoulder.
REMOVAL: Assistant therapist supports head with occiput / submandibular hold (or cradle hold)
making sure that jersey or straps are not caught under their arms/hands.
Must also ensure to not interfere with first responder CPR/AED until ready.
On a coordinated count, CPR/AED is stopped for no more than 10-15 seconds.
Lead therapist expediently removes helmet with slight spread, cranial / gentle
forward flexion movement of helmet without causing movement to head / neck.
Therapist then reaches across anterior/superior aspect of pads and separates
and pulls pads longitudinally out from under athlete. Head is placed neutral, resume
AED/CPR protocol. Equipment removal is best performed right after a 2 minute cycle
of 30:2 compressions, but never right after a shock where immediate chest compressions
are indicated. The same applies when lifting (better than rolling) an athlete onto the board.

2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL

John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
SUMMARY
FACEGUARD REMOVAL
The faceguard (facemask) should always be removed for a suspected spinal, no exceptions.
Research has shown there is less movement of the head/neck during helmet removal when the facemask is
first removed. This is especially true with obese players (ie: linemen) because their helmets tend to fit so
tight (skin folds and fat fit all parts of the helmet). Long facemasks also present a challenge with pads still in
place and helmet rotation needed to clear face is limited. Urgent (<30 secs) or Controlled (<60 seconds)

UNCONSCIOUS SPINAL
At the professional therapist level, equipment (helmet & pads) are always removed for an unconscious
athlete before an urgent situation arises. This should be done on the field if personnel / equipment permit, or
when the ambulance arrives (on field / back of ambulance). The athlete should not have pads/helmet on for
transport as chest access, full airway access is compromised. This is difficult to manage by one paramedic
in the back of a moving vehicle if something goes wrong. The only rational for leaving equipment on for an
unconscious athlete is the absence of trained responders or need for urgent removal from a non-controlled
setting.

CONSCIOUS SPINAL
In the case of a conscious athlete with suspected spinal injury (includes potential spinal shock / neurogenic
shock), initially a controlled faceguard removal is carefully performed on-field as there is no urgency (yet).
Full equipment removal for a conscious spinal has been a controversy over the past years.
Most literature* had suggested removal only in controlled settings due to potential movement during
equipment removal in less than ideal conditions. Much of this research had been done with cadavers
managed without skilled PHTLS spinal precaution techniques.

On-field responders in professional football are highly-trained and skilled rescuers. They are practiced in
procedures to safely remove facemask/helmet/shoulder pads on-field in the event of an emergency. Such
emergencies include a suspect spinal injury in a conscious player who must be safely transported off the
field and transferred by ambulance to a hospital emergency room. Such procedures are to be performed in
a "controlled situation" where the rescuers are able to apply (as a minimum) reasonable skill and knowledge
within a safe environment (eg: weather permitting). If environment is not controlled, as a minimum the
facemask must be removed (4 snubbers) and athlete immobilized/packaged and safely removed from the
field. Depending on the situation the helmet/shoulder pads are then removed either; once off the field and
on sidelines, in the ambulance, or at the ER. Athlete safety is compromised at each stage where there
is a delay in equipment removal. Each therapist must evaluate their situation and provide best care
possible taking into consideration available personnel, equipment, urgency, & potential for athlete instability.

Circulation Vol 112, Issue 24 PHTLS ! 6th edition, 2007 Emergency Care Manual,-Oct 2008
Supplement Dec 13, 2005 page 268 9 box 9-4 Canadian Red Cross, page 229

Comments welcomed and may be directed to: John Boulay CAT(C), EMT, D.O. john@sportsfirstresponder.com

2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL

John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
APPENDIX 1.

2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL

John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
APPENDIX 2.

2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL

John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
 2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL
John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008
 2008 SPINAL INTERVENTION GUIDELINES - FOOTBALL
John Boulay B.Sc., EMT, CAT(C) www.sportsfirstresponder.com Updated: Nov 2008