2014 jmsp symposium trauma in the er
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2014 JMSP Symposium Trauma in the ER. Dr. Jim Kyle, FACSM Team Physician, Concord University Sports Medicine Director Beckley ARH Hospital West Virginia EMS Regional Medical Director Marshall University School of Medicine Associate Clinical Professor. Sports Trauma in the ED. - PowerPoint PPT PresentationTRANSCRIPT
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2014 JMSP SymposiumTrauma in the ER
Dr. Jim Kyle, FACSMTeam Physician, Concord University
Sports Medicine Director Beckley ARH HospitalWest Virginia EMS Regional Medical Director
Marshall University School of MedicineAssociate Clinical Professor
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Sports Trauma in the ED Hand and Wrist Mallet finger
Coach’s finger
Skiers thumb
Scaphoid Fx
TFCC injury
Elbow and Shoulder Tennis elbow
Radial head Fx
Rotator cuff strain
Impingement syndrome
A-C separation
Low Back, Pelvis, Hip Spondylolysis
Apophyseal Avulsions
Femoral neck Stress Fx
SCFE
Knee Injuries Meniscal Tears Anterior Cruciate Ligament Medial Collateral Ligament Adolescent knee Ankle Injuries Lateral sprain Deltoid sprain High-Ankle sprain Jones Fx Head, Heart, Lung, Kidneys Concussion Syncope – HCM, SVT EIA, Rib Fx, Pulmonary Contusion Heat Stress, Rhabdo, ECAST
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International Symposia on Concussion in Sport
First ISC Vienna 2001 Second ISC Prague 2005
Simple vs Complex, SCAT2 sideline tool Third ISC Zurich 2008
Removed Simple vs Complex grading,
RTP based on progression Fourth ISC Zurich 2012 – SCAT3, Baseline NP,
BESS, enhanced MRI, mTBI vs Concussion
FIFA, IOC, IIHA
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2014 RTP GuidelinesED discharge instructions:• Physician follow-up in 72 hrs for
repeat exam • Graded Symptom Checklist at D/C• No date for return to contact• Neuro-Cognitive Testing • Sports medicine team should provide
protocol for gradual return to activity
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VT Sub Concussive Research
Helmets with accelerometer Sideline Box with recordings Many Hits with + 40g Physician Beeper set @ 50g Average 4 + 80g Hits Season # Hits position specific 5 concussions in 2013 season
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ED Discharge: Rhomberg Test Balance Error Scoring System
BESS
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BARH ED “Best Practice”Youth Concussion
Emergency Room: Head, C-spine evaluation- ?CT
BESS Testing, 72hr GSC at D/C Pediatrician: Review Graded Symptom Checklist
ImPACT testing School/ Coach: Equipment check, 5 day progession
Consult Physician RTP
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Collegiate Strength and Conditioning Coach
• BIGGER
• STRONGER
• FASTER
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Rhabdomyolysis
• Medical
• Trauma
• Sports - Exertional
• SCT – Fulminant Ischemic “Explosive” Rhabdo
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Rhabdomyolysis in Athletes
• January 2011
• University of Iowa
• Football players required to perform 100 squats with weight = 50% of prior max
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Rhabdomyolysis in Athletes
Cold day in Iowa City
13 cases of Rhabdo first day of conditioning drills after Holiday break
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Rhabdomyolysis
TRIAD of:
1. Muscle Weakness
2. Myalgia
3. Dark Urine
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Exertional Rhabdo
• Modest elevation of CPK
• Basic Training Military Recruits
• Common in August Football
• Marathon runners 10% > 3,000
• Recent increased awareness 2011
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CPK in Exertional Rhabdo
• 4-5x high normal consider diagnosis
• peak in 24-36, fall 30%/day
• Less than 20,000 unlikely ARF
• May peak at levels > 100,000
• ^ LDH, ^SGOT – 25%
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Rhabdo Complications
• ARF
• Hyperkalemia
• Hypocalcemia
• ^ LFT
• DIC
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ARF in Rhabdo
• CPK less than 20,000 – rare
• Early treatment
• Mortality approaches 20%
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Sodium Bicarbinate in Rhabdo
Use recommended in cases of:
1. Acidemia
2. Dehydration
3. Underlying Renal Disease
1 amp in 1 L NS @ 100cc/hr
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Exertional Rhabdo
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Rhabdomyolysis
• Medical
• Trauma
• Sports - Exertional
• SCT – Fulminant Ischemic “Explosive” Rhabdo
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Case Study ECAST
Dale Lloyd IISeptember 2006Rice5’9” 190lb defensive backStruggling during sprints Teammates attempted to asisst, coaches leave alone, unaware of SCT
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Workout Program
• 4:00 – weight lifting
• 4:30 - Outside sprints
• 16 sprints 100yards
• Rest 1 min first 4, 2 min next 4 1 min last 8.
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Timeline Athlete Collapse
4:55: Completes sprints
C/O bilateral lower extremity pain and SOB
Alert , over next 10 minutes became lethargic 5:05: Unable to walk , EMS called
Cart to Training Room, O2 via BVM 5:12 : University EMS arrived
IV and 100% Oxygen, Fire Department EMS called 5:28: FD EMS arrival: Patient unresponsive
GCS=3, O2Sat =67% room air
Nasotracheal intubation, EKG with peaked Twave V2,V3 5:52: ED arrival: BP =150/50 Pulse = 126
Temp = 97 O2Sat = 100%
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Sudden Death SCT All died under similar distinctive circumstances: non-
instantaneous collapse with rapid deterioration (dyspnea, fatigue, weakness and muscle cramping) over 10-45 minutes
Each event occurred during vigorous or exhaustive maximal physical exertion, usually during training (22)
17 of 23 (74%) Summer or early Autumn 20 deaths in southern or border states with Temp > 80* Florida (n = 5) , Texas (n = 4)
Maron, BJ, Eichner, ER, et.al. Sickle Cell Trait Associated With Sudden Death in Competitive Athletes. Am J Card: 2012, 110(8)
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ECAST - On the Field Management
Conditioning FocusRemove athlete if leg, back pain SOBVital Sign with O2 therapyEMS alertIV Fluids, Normal Saline Bolus
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ED Management: Exercise Collapse Associated with SCT (ECAST)
• Awareness that ECAST in Diff Dx• ABG monitoring for metabolic acidosis• Aggressive Fluid and Electrolyte Management• Anticipated Explosive Rhabdo• Early Dialysis ^K, to avoid lethal cardiac
arrhythmias ( within minutes to hours of syndrome onset )
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Sports Trauma in the ED Hand and Wrist Mallet finger
Coach’s finger
Skiers thumb
Scaphoid Fx
TFCC injury
Elbow and Shoulder Tennis elbow
Radial head Fx
Rotator cuff strain
Impingement syndrome
A-C separation
Low Back, Pelvis, Hip Spondylolysis
Apophyseal Avulsions
Femoral neck Stress Fx
SCFE
Knee Injuries Meniscal Tears Anterior Cruciate Ligament Medial Collateral Ligament Adolescent knee Ankle Injuries Lateral sprain Deltoid sprain High-Ankle sprain Jones Fx Head, Heart, Lung, Kidneys Concussion Syncope – HCM, SVT EIA, Rib Fx, Pulmonary Contusion Heat Stress, Rhabdo, ECAST
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Athletes at Risk for SCA
• Chief complaint of syncope
• Chest Pain with or post activity
• History of palpitations
• Family History of Sudden death
• Abnormal EKG
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Symptoms: HCM
• Dysnea in 90% of symptomatic athlete
• Syncope during exercise - from inadequate cardiac output or cardiac arrhythmia
• Chest Pain during exercise
• Palpitations, Dizziness, Presyncope
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Athlete SCA : Have We Changed the Playing Field ?
Emergency Department • Athlete Collapse – Assume Cardiac
Etiology (Sentinel Seizure)• EKG Attention: Delta and Epsilon Waves,
LQT• Syncope, Near Syncope, Chest Pain Work
Up: Consider advanced imaging, Cardiac CT, MRI* vs ECHO
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The Faces of SCA
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Medical “Time-Out”Prior to Games and Practice• NATA petition to NCAA
• EAP Venue specific
• On the Field – EMS communication and readiness Head and Neck
• Athlete Collapse – EHS , SCA and SCT
• Spectator Coverage
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Sideline ER DoctorBlunt Torso Trauma When to Worry
CHEST TRAUMA
Rib FracturePneumothoraxPulmonary contusion
ABDOMINAL TRAUMA
Spleen InjuryRenal ContusionAppendicitis
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Chest and Abdomen
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Rib Fractures
• Ribs 4-9 – Most common ribs injured
• Ribs 1-2 and Sternum– Great vessel injury
– Cardiac contusion
• Ribs 9-12– Injury to spleen, liver or kidney
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Rib Fractures
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Thoracic Emergencies
• Pneumothorax
• Tension Pneumothorax
• Flail Chest
• Diaphragmatic Rupture
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Wrap or tape Chest
• No longer recommended
• Leads to pulmonary complications
• Decreased ability to take maximal breath during exertion
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Return to play
• 3-6 weeks• Pain permits• Protective padding 6-8
weeks• Stress fracture
– 6-8 weeks stopping the inciting repetitive motion
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What was happening at the hospital
Patient #2: Jacob
•16 years old
•California
•Pulmonary Contusion
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Rib Fractures
• Ribs 4-9 – Most common ribs injured
• Ribs 1-2 and Sternum– Great vessel injury
– Cardiac contusion
• Ribs 9-12– Injury to spleen, liver or kidney
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Abdominal Blunt Trauma
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Abdominal Blunt Trauma
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Abdominal Blunt Trauma
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Sideline Abdominal Exam
• LUQ pain
• Radiating to L Shoulder
• Guarding
• Rebound tenderness
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Abdominal Blunt Trauma
Dip the Urine – test for Hematuria
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Abdominal Blunt Trauma
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Abdominal Blunt Trauma
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Abdominal Blunt Trauma
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Abdominal Blunt Trauma
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Sideline AlertMAJOR KNEE
• Mechanism- Downward
Forward
Inward
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The Unstable Knee
• High Index Suspicion
• Popiteal Artery
• Sideline ABI < 1
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