Lecture 19: Neck Injuries and On-field assessment

What are the three questions that you need to ask?

- Is the athlete at risk?

- life/limb

- Is the area stable

- Can they continue

• W/O significant risk – Safely

– Effectively

- How do I act athete of the field ?

– Walk

– Assist

– Non-weight bearing

- Immobilized/Boarded

What is primary survey?

• Determine the existence of potentially life-threatening situations

• U Responsiveness ( Alert, Verbal, Pain or Unresponsive)

• Airway

• Breathing

• Circulation

• Spinal Injury (suspected by mechanism or appearance)

- Supine - ensure ABC's and stabilize

- Prone - may need to reposition to ensure ABC's

What are the four steps with athlete with a suspected neck injury?

1. Stablize the c-spine

2. Assure athlete and tell them not to move

3. Get brief history and subjective report

4. Begin your palpation and assessment •Looking for pain, sensation, weakness or deformation •Dermatomes, myotomes •What is our differential diagnosis?

What are the eight questions to help you decide the course of action?

1. Can you tell me what happened (MOI)

2. Do you have pain in your head?

3. Do you have pain in your neck?

4. Do you have pain in your back?

5. Do you have tingling or numbness in any of your arms or legs? • Get specifics • Single arm or leg, both arms, both legs

6. Do you have pain anywhere else?

7. Can you wiggle your toes? • Check both sides

8. Can you wiggle your fingers? • Check both sides

What is the mechanism of a stinger/burner?

• Nerve traction or compression, particularly involving C5 and C6

1. Shoulder distracted down from head and neck

2. Blow to supraclavicular fossa

3. Forced neck extension and rotation to injured side

What is the signs/symptoms of a stinger/ burner?

• Rarely neck pain

• unilateral symptoms

• Can be transient

• Sensory changes C5-C6 distribution

• Motor changes C5 -C6 - Shoulder ABD/ER - Elbow flexion

• Heals quickly, often by the time they reach the sideline

Return to play following Stinger/Burner?

• quick resolution of all symptoms - (seconds to minutes)

• Full ROM

• Full strength

• Ability to complete sport specific skills - without symptoms

• Mentally ready

What is the MOI of a c-spine fracture?

Usually one of two mechanisms:

1. Axial load-vertical compression 1. Burst fracture

2. Compression- Flexion injury

1. Anterior portion compresses and posterior portion elongates

What is the on-field findings of a c-spine fracture?

• Neck pain

• Pain on central palpation (spinous process)

• Bilateral neural findings

- Myotomes

- Dermatomes

• Upper and lower extremity findings

Neck Injuries To board or not to board

• Recently, the emergency medicine community has started critically examining the rationale for routine immobilisation of trauma patients.

• Pain due to the application of the extrication collar and head blocks may lead to undesirable movement (in order to relieve the pressure) or to bias clinical examination of the cervical spine. It is necessary to revise the current practice of cervical spine immobilization.

• Practice is shifting from blanket immobilisation to a selective approach.

What is the palpation of the injured athlete?

• Need to palpate key structures of the upper back, neck, shoulder, clavicle and sternum.

• Failure to do so could mean aggravated injury, paralysis or death

• Know the Order and complete the same way every time!

What are the canadian c-spine rule?

1. Dangerous mechaism or parethesias extremities

2. Absence of midline c-spine tenderness

3. can they rotate 45 degree

What is another not on boarding?

• The following slides outline the present policy for Western University Athletics.

• These may change drastically over the next year.

• Many EMS professionals are no longer boarding. There is some discussion regarding hard collars. • For this course we will assume a short response time and stabilize an athlete with paralysis, until EMS arrives, unless there are other complications

What is the log roll - set up?

Prior to the roll- Make sure grip is firm and stable

- Make sure helmet is stable!

- Need to use cross-arm technique, so arms unwind as roll is performed

What is the log roll procedure?

Leader will instruct the assistants as to when to roll and when to stop rolling the athlete. Leader will use these commands: "prepare to roll " and "ROLL" It is important that the assistants follow the leader' s command and roll the athlete as one unit.

What are the clinical recommendation for C-Spine Immobilization?

- Be Neutral if Possible

- When a cervical spine injury is suspected, the spine should be immobilized in the neural position. The neutral position can reduce spinal cord compromise and may facilitate airway management and application of immobilization devices.

Three general contraindications (unsafe) exist to moving the cervical spine to neutral?

(1) the movement causes or increases pain, neurologic symptoms or muscle spasm compromising the airway;

(2) resistance to movement is encountered; (3) the patient expresses apprehension.

What are removal tools?

cordless screwdriver is more efficient (less movement, faster and easier) then FM extractor and trainer's angel

- plus a backup method; cutting tool

What is hockey, and should there be a pad/ helmet removal?

stable ice hockey helmets not be removed from injured players, with rare exceptions, because doing so results in unnecessary motion of the cervical spine.

What is football, and should there be a pad/ helmet removal?

Recommendation that removal of helmet and pads be "all or none"

P only- increased cervical extension by roughly 100 Recommendation: Players with suspected c-spine be transported with helmet and shoulder pads left in place.

What is lacrosse, and should there be a pad/ helmet removal?

players with suspected cspine be transported with helmet and shoulder pads left in place!?!

What is the helmet removal protocol

- (ONLY if applicable i.e. Straps crossing facemask or if full helmet removal is indicated)

- unscrews/cuts lateral clip on both sides.

- grip to the patient to maintain cervical alignment and stability.

- maintains the vice grip or alligator

What are the equipment for helmet removal guidelines?

1. If after a reasonable period of time the face mask cannot be removed to gain airway access

2. If the design of the helmet and chin strap is such that event trolled or ventilation provided

3. If the helmet and chin straps do not hold the head securely such that immobilization of transport in an appropiate position

4If the helmet prevents immobilization for transport in an approproiate position

What are the equipment for shoulder pad removal guidelines?

1. Multiple injuires requiring full access to the shoulder area

2. Ill-fitting shoulder pads resulting in the inability to maintain spinal immoblization

3. Cardiopulmonary resusitation requiring access to the thorax that is inhibited by the shoulder pads

4. Always if the helmet is removed

What is the recommendation for transport to spine board?

Use vertical lift when able

What is Transport to Spine Board?

Securing the Athlete

•Once on the spine board, the leader must continue to stabilize the head and neck

• The assistants can now secure the athlete to the board

Important note for Transport to Spine Board?

Begin with the thoarx, the head, the lower body

What is the primary on-field assessment?

Responsiveness A-airway B-breathing C- circulation

Life or Limb

What is the secondary on-field assessment?

- History

- Vital Signs

- MSK Evaluation

- Treatment Considerations

- Transportation

What is the history for c-spine (non-emergent or extremity)?

• Evaluation of injury sustained by athlete - Unique - you often see the MOI - pay attention to the game/event! • What happened? • Where does it hurt? • Did you hear or feel any pops/grinding • Have you injured this or the other side before

What is the On-field (non-emergent or extremity) Examination?

1. clear above and below

2. Palpate

3. Special tests for stability of bones and joints - a few not all

Can they continue pay or no?

• Can they play Continue/walk off

• How do we get them off the field?

- Stable/unstable

- Able to Stand

- Weight bearing status

• Full

• Partial

• Non-weight bearing

What is the treatment and transportation of a c-spine fracture?

•severity of the injury dictates medical management • Take your time and complete your side-line assessment Return to play • Looking at strength and function - Athlete can participate in the sport safely? - Athlete can play effectively? - Athlete can perform relatively pain-free? • Observation on sideline with possible return to play • Removal from play and referral for follow-up • Send to Hospital

What do coaches want to know?

During the Game • Can they Play? yes or no • Are they 100%? If not, what are they xx?

• Will they be available this game? minutes, period? After game

• How are they? What laymans terms

• How long are they out for? • When will we know about next game?

What is the follow-up a c-spine fracture?

• Be sure to follow-up with all injured athletes post game

• Arrange for a clinical assessment if necessary