PRE-HOSPITAL CARE OF THE SPINE-INJURED ATHLETE

A COLLABORATIVE REQUEST FOR REVIEW OF CURRENT EMSA PROTOCOL REGARDING THE MANAGEMENT OF THE

EQUIPMENT-LADEN ATHLETE

INTRODUCTION

On behalf of the following: Central States Orthopedic Specialists Eastern Oklahoma Orthopedic Center Tulsa Bone and Joint The Spine and Orthopedic Center Oklahoma Athletic Trainers’ Association

Thank you.

Governing Purpose

To determine and implement a research-based, peer-reviewed, national standard of care regarding the best practice available for the management of the cervical spine injured equipment-laden athlete.

Governing Purpose

“The role of all intervening care givers, ranging from a passing good Samaritan to the receiving surgeon, will be to prevent and minimize secondary injury.”

Belanger and Levi, Spinal Cord Injury, Journal of American College of Surgeons, 2000.

Overview

Discussion of Current EMSA Protocol and Recommendations

Current Research Regarding Equipment Removal

Current Research Regarding Equipment Management in the Field

Documentation of the National Standard of Care

Educational Partnership in Sports Medicine

Discussion of Current EMSA Protocol and Recommendations

Current EMSA Policy

Synopsis per Dr. Goodloe: In an athlete with a suspected cervical spine injury, the

helmet and shoulder pads are to be removed prior to spine-board immobilization for transport due to:

1) Inadequate didactic training of emergency physicians in this procedure

2) Highly sufficient training of emergency medical technicians in this procedure

Current EMSA Policy

Standardized Tool for Face Mask Removal: Eliminates the usage of knives The design of some facemask clips

cannot be cut using pruning shears. (Riddell Revolution)

Provides for the assumptions that all tools, other than a regular screwdriver, are equal

Provides for the introduction of another facemask removal tool

Current EMSA Policy

“The SD”(cordless screw driver) “and QR” (quick release) “generally allowed for faster retraction of the face mask with less force and torque applied to the helmet than the cutting tools, TA and FM.” “Removal Tools are Faster and Produce Less Force and Torque on the Helmet Than

Cutting Tools During Face-Mask Retraction” Journal of Athletic Training, 2002

Current EMSA Policy

“The cordless screwdriver is more efficient than the FM Extractor and Trainer’s Angel.”

“Football Equipment Design Affects Face Mask Removal Efficiency” AJSM, 2005

Current EMSA Policy

“Combining the cordless screwdriver and cutting tool provided a fast and reliable means of on-field FM removal.”

The ”cordless screwdriver, is faster, easier to use, and creates less torque and motion at the head than many of the cutting tools commonly use to remove the face mask.”

The Combined Tool Approach for Face Mask Removal During On-Field Conditions.

Gale, S. et al…, Journal of Athletic Training, 2008.

Current EMSA Policy

“Before helmet removal, cervical spine stabilization should be transferred from the rescuer at the head to another rescuer, who assumes cervical spine control from the front.”

“National Athletic Trainers’ Association Position Statement: Acute Management of the Cervical Spine-Injured Athlete,

2009

Current EMSA Policy

“this maneuver serves to tighten the helmet at the occiput and the forehead.”

“Management of the Helmeted Athlete With Suspected Cervical Spine Injury, AJSM, 2004.

Current Research Regarding Equipment Removal

The Effect of Equipment Removal on the Unstable Cervical Spine

“Helmet and shoulder pad removal in the unstable cervical spine is a complex maneuver.

“In the unstable C1-C2 segment, helmet removal causes more angulation in flexion, more distraction, and more narrowing of the space available for the cord.”

Helmet and Shoulder Pad Removal From a Player with Suspected Cervical Spine Injury: A Cadaveric ModelDonaldson III, W et. Al, Spine, 1998.

The Effect of Equipment Removal on the Unstable Cervical Spine

“In the lower cervical spine (C5-C6), Helmet removal causes flexion of 9.32°, and during shoulder

pad removal the neck extends 8.95°, a total of approximately 18°.

Disc height changes from 1.24 mm of distraction to 1.06 mm of compression during helmet removal and shoulder pad removal for a total 2.3-mm change.

Translation…is greater at C5-C6 during shoulder pad removal.”

Helmet and Shoulder Pad Removal From a Player with Suspected Cervical Spine Injury: A Cadaveric ModelDonaldson III, W et. Al, Spine, 1998.

The Effect of Equipment Removal on the Unstable Cervical Spine

“Because of the motion observed in the unstable spine, helmet and shoulder pad removal should be performed in a carefully monitored setting. “

Helmet and Shoulder Pad Removal From a Player with Suspected Cervical Spine Injury: A Cadaveric ModelDonaldson III, W et. Al, Spine, 1998.

The Effect of Equipment Removal on the Unstable Cervical Spine

“Only after radiographs have been taken should the helmet and shoulder pads be removed in a controlled environment…initial workup of the helmeted athlete has shown CT films with helmet and shoulder pads in place were adequate for initial diagnosis and triage. “

Management of the Helmeted Athlete with Suspected Cervical Spine InjuryWaniger, K., et. Al, The American

Journal of Sports Medicine, 2004.

The Effect of Equipment Removal on the Unstable Cervical Spine

“Abnormal intervertebral motion, even as little as 1mm, may cause significant neurologic damage. This is especially true in the subaxial spine. In this region, the cord demonstrates an exceptional intolerance of even small amounts… and can lead to further neurologic injury in the athlete in whom the spinal cord and osseoligamentous structures are already compromised.”

I. Palumbo M, et al, The American Journal of Sports Medicine, 1996.II. Emergency Care and Transportation of the Sick and Injured, American

Academy of Orthopedic Surgeons, 1987.III. McLain Rf, Aretakis A, Moseley TA, The Spine Journal, 1994.IV. Owen, Jh, Naito M, Bridwell KH, The Spine Journal, 1990.V. Towbin A, Archives of Pathology, 1964.

Current Research Regarding Equipment Management in the Field

“a properly fitted football helmet holds the head in a position of neutral spinal alignment, provided the athlete is wearing shoulder pads.”

Feld F., Blanc R., Journal of Emergency Medical Services, 1987.

“reported similar cervical alignment when comparing full equipment (helmet and shoulder pads) with no equipment”

Cantu RC, Clinical Sports Medicine Journal, 1999.

The Effect of Athletic Equipment on Cervical Spine Alignment

The Effect of Athletic Equipment on Cervical Spine Immobilization

“The tight-fitting football helmet allowed less than 5 degrees of head movement inside the helmet with BTLS immobilization.”

Waniger, MD, et al, Clinical Journal of

Sports Medicine, 2001.“When immobilizing the neck, physicians should avoid

movement and maintain proper alignment of the cervical vertebrae. This usually can be done with the helmet and other protective gear (e.g. shoulder pads) in place, and such equipment should not be removed.”

Whiteside, American Family Physician, 2006”This article exemplifies the AAFP 2006 Annual Clinical Focus on caring for children and adolescents.”

The Effect of Athletic Equipment on Proper Management of Cardiorespiratory

Emergencies

“Any facemask should be rapidly removed to provide adequate airway access..assisted ventilation...is usually performed using a bag-valve device and face mask.”

Sideline and Ringside Evaluation for Brain and Spinal InjuriesVincent J. Miele, MD, John A. Norwig, ATC,

Julian E. Bailes, MD, Neurosurgery Focus, 2006.

“The helmet and shoulder pads should remain in place unless removal is required to gain access to the airway.”

The Effect of Athletic Equipment on Proper Management of Cardiorespiratory

Emergencies

Sideline and Ringside Evaluation for Brain and Spinal InjuriesVincent J. Miele, MD, John A. Norwig, ATC,

Julian E. Bailes, MD, Neurosurgery Focus, 2006.

“A solid understanding of the treatment principles discussed in this article will improve the preparedness of a physician to deal with these situations and provide the athlete with the best chance of recovery.”

“the front of the shoulder pads can be opened to allow for chest compressions and/or defibrillation.”

Documentation of the National Standard of Care

Documentation of the National Standard of Care

Prehospital Care of the Spine-Injured Athlete: A Document from

the Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete

Documentation of the National Standard of Care

Participating Authors/Organizations of Interest: National Association of EMT’s

Connie McAdam, MICT, AAS

National Athletic Trainers’ Association Douglas Kleiner, PhD, ATC, EMT, FACSM (Chair)

Professional Football Athletic Trainers’ Society T. Pepper Burress, ATC, PT

American Association of Neurological Surgeons

Julian Bailes, MD

Documentation of the National Standard of Care

“a properly fitted football helmet holds the head in a position of neutral alignment, provided the athlete is wearing shoulder pads. Therefore, the Inter-Association Task Force recommends that neither the football helmet nor the shoulder pads be removed before transportation.”

Documentation of the National Standard of Care

Subsequent Publications/Endorsements: American College of Emergency Physicians

Documentation of the National Standard of Care

Subsequent Publications/Endorsements: North American Spine Society Emergency Medicine Clinics of North America Journal Emergency Medical Services Journal of the American College of Surgeons American Academy of Pediatrics Journal of Primary Care NFL Professional Football Athletic Trainers’ Society NCAA USA Football Texts:

Emergency Care and Transportation of the Sick and Injured Neurological Sports Medicine: A Guide for Physicians and

Athletic Trainers. Access Emergency Medicine

Educational Partnership in Sports Medicine

Educational Partnership in Sports Medicine

Proposal:1. EMSA MCB Designates a Training Officer for each

major hospital in Tulsa and OKC

2. OATA will coordinate and partner ATC’s and Orthopedic Physicians with each Training Officer

3. Annual Fall In-services reviewing a mutually agreed upon standardized protocol for effective equipment removal techniques will be conducted on-site at each hospital location with the most current and up-to-date styles of football equipment.

In Conclusion

“Due to the effectiveness of maintaining cervical alignment while leaving the helmet and shoulder pads on, every effort should be made to provide appropriate treatment without removing this equipment.”Hardy, R. et al., Journal of Emergency Medical Services, 2009.