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[Emergency Medicine]

On-Field Examination and Care: An Emergency Checklist

Michael J. Stuart, MD

Emergencies Series Editor: Warren B. Howe, MD


In Brief: The on-site physician at an athletic event must be able to recognize life-threatening conditions, provide initial care for all conditions, and direct transport if needed. Preparation is critical for avoiding catastrophe; it involves establishing communication and protocol beforehand, as well as developing a mental checklist for assessing injuries. After ensuring an adequate airway, breathing, and circulation, the examiner determines the patient's level of consciousness, mental status, and symptoms and assesses for neck injury. The physician may then need to prepare for emergency transport or for further evaluation on the sidelines.

Medical coverage of sporting events is an enjoyable and important contribution for many sports medicine professionals. These providers carry the responsibilities of emergency care, triage, and judgment concerning return to play. They know that their initial response to an injury on the playing field can make the difference between life and death. Education and preparation are critical for making informed decisions and giving proper treatment, and part of preparation involves establishing a mental checklist as outlined below.

[Checkbox]Planning Ahead

Serious, catastrophic, and life-threatening injuries are rarely encountered at athletic events, especially in young participants. Despite these favorable odds, the on-site physician must always anticipate the worst. A cardiac emergency is more likely to occur in a spectator, such as a parent or grandparent. Brain injury and spine trauma with spinal cord involvement do occur in sports.

The best approach is to plan for resuscitation and emergency transport before the event:

  • Introduce yourself to the ambulance crew (if available on site).
  • Establish a means of communication with a hospital and/or ambulance company, which can mean having a cellular phone or locating on-site phones for dialing 911. Phone numbers for nonemergencies should also be on hand.
  • Identify potential help in attendance (eg, athletic trainers, other physicians, emergency medical technicians, nurses, students, coaches).
  • Establish the availability and location of emergency equipment (eg, spine board, neck support, bolt cutters, first aid kit, crutches).
  • Determine the levels of care available at the local medical facility and where to refer injuries that require specialized evaluation and treatment.

[Checkbox]Initial Response

Start with basic cardiopulmonary resuscitation (CPR) by establishing responsiveness and initiating treatment as necessary. All medical personnel and preferably each member of the coaching staff should complete a basic CPR course available through the American Heart Association or the American Red Cross. Hands-on practice is excellent preparation.

Talk with the athlete without moving his or her head or neck and determine the level of consciousness. Proceed with the ABCs: airway (make sure the athlete has an adequate airway), breathing (ensure an air exchange: chest rise, breath sounds, and speech), and circulation (make sure the athlete has a pulse).

[Checkbox]Evaluation of the Unconscious Athlete

An unconscious athlete is, of course, unable to communicate symptoms, and the physical examination provides very limited information. Assume that the athlete has a serious neck injury until you ascertain otherwise. The athlete must remain in position: Place a hand or have an assistant place a hand on either side of the head to stabilize the neck until the evaluation is complete. Observe basic precautions:

  • Do not move the athlete.
  • Do not remove the helmet.
  • Do not use ammonia inhalants, which may cause the head to jerk from the noxious stimulus.
  • Do not give liquids or food.
  • Do not rush the evaluation.
  • Do not worry about delaying the game.

If the athlete is unresponsive, alert other medical personnel and coaches, and call for an ambulance.

The medical staff should then proceed with CPR steps as necessary. If the athlete is not breathing, start rescue breathing. For a football or ice hockey player, rescue breathing or CPR can be done with the helmet and shoulder pads in place once the face mask has been removed. A football face mask can often be removed by unscrewing the plastic mounting clips or cutting them with heavy-duty shears or bolt cutters. (Removal of face masks is further detailed in "Helmet Removal in Head and Neck Trauma," July, page 77.)

Use the log roll method to turn the patient supine onto a spine board (figure 1). Open the airway with a jaw-thrust maneuver, not neck hyperextension. If breathing is absent after 3 to 5 seconds, give respirations.

[Figure 1]

Similarly, CPR must be started if the athlete has no carotid pulse. Circulation is maintained through chest compressions.

If the patient has profuse bleeding, apply direct pressure with a sterile or clean dressing if possible. The major artery supplying the area can also be compressed.

In transporting the patient to the emergency department or trauma center, protective equipment should be left on because spinal alignment is closest to normal when the helmet and shoulder pads are in place. The head and neck should be stabilized at all times, and a spine board should be used. Remember: Transport can cause displacement of unstable cervical spine injuries and even lead to permanent spinal cord sequelae.

[Checkbox]Evaluation of the Conscious Athlete

The initial on-field evaluation of a conscious athlete determines the presence of a serious or life-threatening condition. Obtain a brief history and perform a screening physical examination. The athlete should not be allowed to sit up or walk until neck injury has been excluded.

Mental status. Assess orientation to person, place, time, and situation (ask the athlete to describe the circumstance of the injury). Check for retrograde amnesia (loss of memory of events immediately before the injury).

Symptoms. Ask about pain, headache, dizziness, nausea, blurred or double vision, and numbness, tingling, or electric-shock sensations in the extremities.

Mechanism of injury. Serious neck injuries (cervical spine fractures and dislocations) are most commonly caused by an axial load to the head with the spine in a flexed position (impact to the top of the head with the chin down).

Rule out neck injury. The athlete should not sit up or walk unless he or she has:

  • no neck pain or tenderness;
  • no pain, feeling of numbness, or tingling sensations in the arms or legs;
  • normal sensation to touch on the chest, arms, hands, legs, and feet; and
  • normal motor function on both sides (can make a fist, bend the elbow, lift the arm, curl the toes, move the ankle up and down, bend the knee, and lift the leg).

Regional physical exam. Briefly examine the area of the athlete's complaint. Check for deformity, swelling, bleeding, tenderness, and active range of motion.

Postural symptoms. Have the athlete sit up, and reassess for dizziness, nausea, pain, or other symptoms. When an athlete sits up, he or she should always do so under his or her own power, rather than be pulled up by helpful bystanders. It is often at this point that the athlete decides not to get up, and the injury is shown to be more serious than previously suspected.

Move to sidelines. If there is no evidence of head, neck, or spine trauma, unstable fractures, or uncontrolled bleeding, the athlete can be helped carefully off the field. If these serious injuries remain a possibility, the athlete should be transported off the field on a spine board.

Helping the athlete to the sidelines may require splinting of an injured extremity and/or assistance with walking to avoid weight bearing. Obtain a more detailed history and physical examination on the sidelines or in the locker room or training room.

[Checkbox]Injury Severity

The initial assessment of injury severity will guide further evaluation and treatment (table 1). Mild injuries are treated on site according to first-aid principles. Moderate injuries may preclude immediate return to play. Referral to a specialist is indicated for dental or eye trauma or if there is any question about the type or severity of an injury. Severe injuries require prompt transport to a medical facility for further assessment and care.

Table 1. Classification of Injury Severity

Degree of Injury

Type of Injury Mild Moderate Severe Life-Threatening

Skin or penetratingAbrasion; superficial lacerationDeep laceration without neurovascular or articular involvementDeep laceration with neurovascular or articular involvementMajor artery laceration
MusculoskeletalSprain, strain, or contusion without swelling or loss of motionSprain, strain, or contusion with some swelling,pain, and limitation of motionSprain, strain, or contusion with marked swelling, pain, and limitation of motion; fracture or dislocation
Brain or spinal cordHead trauma with transient confusion (complete resolution in <15 min)Concussion with symptoms >15 min but without loss of consciousnessConcussion with retrograde amnesia or loss of consciousness Head injury with prolonged loss ofconsciousness; cervical spine injury with spinal cord involvement
Miscellaneous Blister Dental injury Cardiac arrest; respiratory failure or airway obstruction

Life-threatening injuries demand relevant resuscitation efforts and emergency transportation to the most appropriate trauma care facility available. These conditions include respiratory arrest or irregular breathing, severe chest or abdominal pain, excessive bleeding from a major artery, suspected spinal injury, head injury with prolonged loss of consciousness, fractures or dislocations with no pulse, and any signs of shock or internal hemorrhage.

[Checkbox]An Orderly, Logical Assessment

The first responder at the scene of an athletic injury needs to be able to recognize a life-threatening condition, provide emergency care, and facilitate transportation to a medical facility when indicated. An orderly, logical primary assessment on the field can help identify serious conditions promptly and guide further evaluation and treatment.

Suggested Readings

Allman FL, Crow RW: On-field evaluation of sports injuries, in Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 141-149

Fox K: Emergency procedures, in Anderson MK, Hall SJ (eds): Sports Injury Management. Baltimore, Williams & Wilkins, 1995, pp 57-101

Hunter-Griffin LY: Emergency assessment of the injured athlete, in Athletic Training and Sports Medicine. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1991, pp 156-166

Magee DJ: Emergency sports assessment, in Magee DJ: Orthopedic Physical Assessment, ed 3. Philadelphia, WB Saunders, 1997, pp 727-757

Dr Stuart is an associate professor of orthopedic surgery and the co-director of the Mayo Clinic Sports Medicine Center in Rochester, Minnesota. Dr Howe is the team physician at Western Washington University in Bellingham and an editorial board member of The Physician and Sportsmedicine. Address correspondence to Michael J. Stuart, MD, Mayo Clinic, 200 1st St SW, Rochester, MN 55905; e-mail to [email protected].



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