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Name of the game when covering high school sports: Be prepared
At athletic games, orthopedic surgeons must be equipped to treat athletes for common cardiac conditions, asthma and anaphylaxis.
WASHINGTON — A recent presentation provided orthopedic surgeons with the essentials for handling medical emergencies when covering high school sporting events and offered some tips for preventing injuries. It was part of an instructional course lecture on caring for the adolescent athlete held at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting.
Lecturer Connie Lebrun, MD, FACSM, told course attendees to forget about going to these sporting events in a spectator capacity. “You’re there to cover the game … so basically you have to be prepared for just about anything. And, in your initial assessment of the athlete who is on the ground, the fallen athlete, you need to check the ABCDEs,” she said.
Lebrun outlined how to conduct a primary survey under such circumstances and provide initial management. She is the director of Primary Care Sport Medicine at the Fowler Kennedy Sport Medicine Clinic at the University of Western Ontario in London.
Athletic emergency steps
In the ABCDEs, A stands for checking the individual’s airway and cervical spine, and B stands for breathing assessment, supplementing that with artificial ventilation or oxygen if needed.
C, in the quick-check guidelines, stands for circulation: “You may have to use CPR or an automatic external defibrillator (AED),” she said. D — for disability — involves treating the athlete using defibrillation, if it is heart-related. It might also include administering drugs or ensuring he or she is not having a reaction to ones taken prior to play. E represents exposure and protection from the environment, looking for environmental causes, she said.
A secondary survey includes checking complete vital signs and performing a head-to-toe evaluation and continuous reassessment of steps A through C from the primary survey. Lebrun’s handout included information on emergency injury assessment contained in a book on orthopedic sports medicine by De Lee and Drez. Among its contents were handling head and neck injuries and conducting differential assessments of injured athletes.
Exercise-induced asthma, a common problem, presents as shortness of breath during or after exercise, sometimes with persistent cough and chest pain. Dizziness with exertion is another sign as is the observation that the athlete is poorly conditioned, Lebrun noted. Avoiding dry cold air, irritants and allergens helps as does rewarming the individual’s airway after it becomes cool or dried.
Avoiding playing games in smoggy environments or where there is a lot of air pollution helps, she said.
Separating true asthmatics from those with seasonal—onset asthma is the challenge. True asthmatics exhibit “falls in peak flow with exercise and low-grade inflammatory changes in the lungs. These athletes will have more severe attacks, but they’re also more familiar with these symptoms,” Lebrun said, whereas seasonal asthmatics present with signs of allergic rhinitis, skin itching and watery eyes.
“Most of the time you’ll be involved in clinical screening,” Lebrun explained, but crashing asthmatics with respiratory rates over 30 and audible wheezing need to be treated urgently. She recommended using an inhaler epinephrine 0.3 mL of 1:1000 solution in emergencies. “There’s good evidence that using a 1.6 meter dose inhaler with a spacer gets the beta agonists inhaled to the athlete quickly. You need to establish oxygen and an airway, and then transport them to the emergency room, because every year there are people who die of asthma.”
Covering orthopedists may also encounter anaphylaxis, which is easy to diagnose because it presents with bronchospasm, laryngospasm with or without vascular collapse, and is typically related to a specific cause, like peanuts the athlete ate or a bee or wasp sting. But, it can also be exercise-induced.
Typical signs include initial bumps or itchy lumps, tightness in the throat or change in voice, and swelling of the mucous membranes. “Again, this is an emergency and should be treated as such. … You need to get intravenous (IV) access, if you can, and fluids,” Lebrun said. Epinephrine used subcutaneously or intramuscularly (IM) helps, as does Benedryl in 25 mg or 50 mg doses via IM or IV. But, the patient still needs to be transported to the hospital because once the initial epinephrine dose wears off, rebound anaphylaxis is likely, she said.
Most on-the-field cardiac problems are congenital, like hypertrophic cardiomyopathy or Marfan’s syndrome. The ones that are not include commotio cordis, cardiac arrest following a nonpenetrating blow to the chest, and myocarditis, which usually results from a virus.
Lebrun said wearing chest protectors and using softer baseballs might prevent commotio cordis. Myocarditis can only be accurately diagnosed through a biopsy. She recommended becoming familiar with the American Heart Association guidelines for such conditions and conducting a thorough exam of the adolescent, including blood pressure checks and heart murmur evaluations before the sporting season begins.
For more information:
- Lebrun C. Care of the high school athlete — basics and beyond — medical emergencies — prevention and treatment. ICL#211. Presented at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting. Feb. 23-27, 2005. Washington.