SPORTS
TRAUMA "RED BAG" VITAL SIGN TRENDING
James
M. Kyle, MD, FACSM
Joe Leaman, MS, ATC
Ron Courson, ATC, PT, NREMT-I
Robb Rehberg, MS, ATC, NREMT
Jackie McGrady, Research Assistant
Introduction
When an athlete collapses during sports play, a skillful on-the-field
assessment is required to determine both the cause and the severity
of sports trauma.
Knowledge and thorough understanding of initial vital sign interpretation
in the downed athlete provides a foundation for determining the
severity of sports trauma. Accurate on-the-field vital sign determination
can be initiated simultaneously with airway and c-spine control.
Trends developing during serial vital sign measurement guide critical
decision making during the pre hospital component of emergency
care.
Initial Vital Signs
Athletes
with signs or symptoms of significant sports trauma should
have vital signs assessed promptly with attention to pulse
rate, systolic blood pressure, and body temperature.
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Pulse
checks at the wrist (radial pulse) provide valuable information
on the current state of the athletes' cardiovascular condition.
Athletes with initial vital signs demonstrating elevated heart
rates or low systolic blood pressures should have an electronic
oral or tympanic (ear) temperature recorded during the on-the-field
assessment. Initial temperatures above 100° F occur in
athletes with significant heat stress.
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RULE
of 100
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Pulse
> 100 |
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Temp
> 100 |
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Systolic
BP <100 |
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Initiate
Vital Sign Trending when any of the above apply
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When
any initial measurement in vital signs of pulse, systolic
blood pressure, or temperature is abnormal the "Rule
of 100" applies. The Rule of 100 is extremely helpful
in excluding serious cardiopulmonary conditions. Simply stated,
if the systolic blood pressure is greater than 100, and the
pulse and temperature are less than 100, significant sports
trauma is unlikely. On the other hand, if an elevated heart
rate or temperature is detected, or the systolic blood pressure
is low, serial measurements are required anticipating potential
9-1-1 activation for emergency department transport.
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Vital
Sign Trending
When initial vital signs suggest a significant sports trauma, measurements
at 10-minute intervals will differentiate between minor and serious
injury. A trending period of 30 minutes is adequate for decisions
regarding return to sports participation.
Heart rate trending can be very helpful in monitoring athlete recovery
and response to therapy. Conditioned athletes typically recover
from an initial accelerated heart rate at the conclusion of a sporting
event to a pulse rate under 100, 20 to 30 minutes post exercise.
Serial temperature measurements should be performed to confirm accuracy
of the initial reading. When heat stress is likely, early oral hydration
and external cooling should be instituted as body temperature is
trended. Nausea and inability to drink will allow early activation
of the EMS system.
The 30-minute interval of vital sign trending will result in normalization
of initial vital signs in the majority of injured athletes. At the
conclusion of the trending period, the Rule of 100 should be applied
a second time to determine player status. Persistent abnormalities
in vital signs of pulse, systolic blood pressure, and temperature
require emergency department evaluation and 9-1-1 activation.
Heat Stress
The most common abnormal vital sign in heat stress is an elevated
heart rate or sinus tachycardia. Initial heart rates greater than
140 should be suspected for severe heat illness or cardiac tachyarhythmia.
A normal systolic blood pressure should be maintained in all except
extreme cases of heat stress. A systolic blood pressure less than
100 signifies significant dehydration and should be verified immediately
with expedient activation of the system for emergency department
transport.
Persistent tachycardia is cause for alarm. Athletes that maintain
a heart rate greater than 100 at the conclusion of the vital sign
trending have dehydration or tachyarhythmia and should be transported
to the nearest emergency department for further evaluation. Likewise,
those athletes demonstrating no improvement in elevated temperatures,
or even worse, increase in the temperature over the 30-minute vital
sign trending, should be referred for emergency medical attention.
Vital sign trending for large track and field events in warm climates
requires protocols designed to assess multiple athletes in a short
interval. The protocol listed below was designed for Marathon coverage
at the 1996 Olympic Games utilizing multiple portable bedside ProPaq
monitors. During the women's Marathon 58 of 88 athletes completed
the course. 22 athletes sought medical attention post race and one
required IV hydration. In the men's Marathon 110 of 121 finished
the race and 50 sought post event medical care. Five male Marathoners
received IV fluid. No athletes required hospital transport.
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ATLANTA
'96 OLYMPIC STADIUM HEAT ILLNESS PROTOCOL
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| 1. |
Place athlete on Medical Bed |
| 2. |
ProPaq
monitor vital signs (include temperature; tympanic preferred
over oral) |
| 3. |
If
pulse >140, BP <100, or 02 sat <90: place on cardiac
monitor and 02 face mask at 10 L/minute |
| 4. |
Ice/ice
towels: place on groin, axillae, and neck; do not place on
extremities; replace with new as needed |
| 5. |
Oral
fluids as tolerated |
| 6. |
Consider
IV - normal saline - after 15 minutes of cooling, oral fluids
not tolerated (#16, 18 angiocath) |
| 7. |
Repeat
vitals every 5 minutes and record |
| 8. |
Rectal probe temp if tympanic or oral temp >102 at 10 minutes |
Transport
Criteria: seizures, altered mental status after
treatment, continued temperature elevation
Discharge Criteria: vital
sign normalization, not orthostatic, tolerating oral fluids
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Kyle,
J.; Terry, G.; Courson, R
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Unconscious
Athlete
Cardiac etiologies for athlete collapse typically result in an accelerated
heart rate. The heart rate may be sinus tachycardia, supraventricular
tachycardia, or ventricular tachycardia. The most serious of this,
ventricular tachycardia, may result in cardiac arrest with ventricular
fibrillation.
In the normal response to strenuous exercise, a sinus tachycardia
occurs. This heart rate may approach the level of 180 to 200 beats
per minute. After stopping exercise, the heart rate quickly returns
to a baseline rate below 100 in the conditioned athlete. Supraventricular
tachycardia (SVT) is typically in the range of 140 to 160 beats
per minute and may be hard to be differentiated between sinus tachycardia
on rhythm strip analysis. Ventricular tachycardia will result in
heart rates in the 160 to 180 range. Ventricular tachycardia is
a very dangerous rhythm and must be recognized and treated promptly.
Like supraventricular tachycardia, it does not improve with vital
sign trending.
Ventricular fibrillation is a lethal heart rhythm occurring in cases
of sudden cardiac arrest. On-the-field vital signs will demonstrate
absence of a pulse. Collapse is sudden and may be proceeded by blunt
chest trauma in young athletes. Some athletes experience a brief
seizure (sentinel seizure) at the onset of ventricular fibrillation.
Resuscitation efforts in sudden cardiac arrest must focus on rapid
cardiac defibrillation with a sideline automated external defibrillator
(AED.)
Asthma Attack
10% of elite athletes have been found to have exercise induced asthma.
On the junior high and high school level, up to 20% of athletes
may demonstrate bronchospasm with sports play. Newer medication
and increased acceptance of inhaler use by athletes, has resulted
in increased sports play for those patients with asthma syndromes.
When an acute asthma attack occurs, it can be frightening to both
the athlete and the athletic training staff. In order to accurately
assess the severity of athlete asthma attack, respiratory vital
sign needs to be added to the initial triad utilizing the "Rule
of 100's." Predictors of asthma severity on sideline evaluation
include peak expiratory flow rate (PEFR) measurements and pulse
oximetry for oxygen saturation (02 sat).
If the athlete is unable to perform an initial peak flow measurement
secondary to anxiety or extreme shortness of breath, an Albuterol
MDI, meter dose inhaler, treatment should be given immediately.
The athlete should be requested to perform a second peak flow attempt
as soon as possible.
If peak flow measurements remain below 300 at the 30-minute mark,
EMS activation should be considered and a second MDI treatment administered
prior to EMS arrival.
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ATLANTA
'96
OLYMPIC STADIUM ASTHMA PROTOCOL
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| 1. |
Place
athlete on bed 1 or 2 |
| 2. |
Give
O2 via face mask at 10 L/min. |
| 3. |
ProPaq
vital signs (including axillary temp) |
| 4. |
Peak
flow meter measurement |
| 5. |
Offer
Albuterol Inhaler - 2 puffs |
| 6. |
If
no improvement in 10 min., repeat |
| 7. |
ProPaq
vital signs and Proventil Nebulizer treatment |
| 8. |
Repeat
peak flow meter at 15 min. and inform physician/ATC |
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Kyle,
J.; Terry, G.; Courson, R.
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Conclusion
When medical emergencies occur, the sports medicine team frequently
works with emergency medical personnel for initial treatment and
accurate diagnosis. Utilization of local EMS needs to be encouraged.
Good communication including on the field cellular phone availability
will enhance quality of event medical coverage.
When sports trauma occurs, a triad of vital signs should be performed
as soon as possible. This includes a systolic blood pressure recording
together with pulse and temperature. The "Rule of 100's"
should be applied in interpreting these initial vital signs.
During vital sign trending, systolic blood pressure, pulse, and
temperature are recorded at 10-minute intervals. The athlete is
offered water or electrolyte solution by mouth and encouraged to
consume 500 to 1000 cc's for the first 15 minutes. In special cases
involving asthma, peak expiratory flow rate measurements are included
as an important component of initial vital signs as well as trending.
At the end of the 30-minute vital sign trending, vital signs are
reassessed and the "Rule of 100's" is repeated.
Those athletes with persistent vital signs demonstrating tachycardia,
hypotension, or persistent temperature elevation, 9-1-1 is activated
with EMS transport to the nearest emergency department. In cases
of severe tachycardia with heart rates greater than 140, supplemental
oxygen should be administered and dispatch should be aware of the
need for advanced cardiac life support staffing equipment.
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