Chapter 6

Developing the Emergency Plan

--Higher authorities to which the institution reports (e.g., an individual school as part of a school system; a fitness facility as a company owned entity) --Medical personnel (e.g., physicians; representatives from local EMS agencies; athletic trainers) --Legal personnel (e.g., school lawyer; company lawyer) The immediate on-site treatment for any given musculoskeletal injury may be the same regardless of the age or gender of the person, the population being served must be considered in developing an emergency plan (e.g., risk to 3rd grader vs elderly individual). Potential injuries - it is reasonable to anticipate and identify potential emergency conditions that could be associated with some situations. -- Example: head and neck injuries are more likely to occur in football than in tennis; an elderly population is more vulnerable to a cardiac episode than elementary school student. Personnel - plan should be developed with an understanding of the qualifications of the personnel that will be part of the emergency plan. Emergency response team - clear delineation of responsibilities. Availability of supplies/equipment - essential to ensure that the materials are appropriate to the level of expertise or qualifications of the personnel implementing the plan. Facility access - access to buildings/rooms ... process for emergency vehicles accessing property Communication - availability of a phone -- Who will call 911 -- Who will call parents -- Notifying appropriate institution personnel Documentation -- Essential -- Use of forms for efficiency and accuracy

Expectations for the Coach

-evaluate the situation -assess the severity of injury -recognize life-threatening conditions -provide immediate care -initiate procedures to ensure proper referral for on-going management

Role of Movement in the Healing process of Soft Tissue

Advantages of movement in the inflammatory phase: -encourages venous return -encourages fluid resorption -encourages phagocytosis -prevents contracture and loss of range of motion It is not within the standard of care of a coach to prescribe therapeutic exercises. However, a general understanding of the role of movement in the healing of soft tissue injury enables the coach to educate and advocate for injured individuals. In particular, it would be advantageous for the coach to understand the importance of movement during the inflammatory phase of healing. Bleeding can persist for up to 36 hours.

Bloodborne Pathogens

Bloodborne pathogens, such as Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Human Immunodeficiency virus (HIV) are microorganisms that are present in blood and other body fluids (e.g., semen; vaginal secretions) of infected individuals. The microorganisms can be transmitted when contaminated blood or bodily fluids enter the body of another person. Research suggests that the risk of transmission of bloodborne pathogens in an athletic or physical activity setting is relatively low. Regardless, such guidelines are necessary to minimize health risks and to protect both the coach and participant. In developing the guidelines, several areas should be addressed, including universal precautions, housekeeping and biohazard waste disposal, accidental exposure, preexposure prophylaxis with Hepatitis B vaccine, documentation, and wound management. Universal Precautions -- If possible, wash hands before treatment. -- If possible, cover any existing personal wounds. -- Apply gloves (e.g., latex) before initiating treatment; in some instances, it may be appropriate to give the patient a sterile gauze pad to apply to the wound while the gloves are being applied. -- If splattering or splashing of blood is anticipated, wear additional personal protective equipment (e.g., goggles; masks; gowns). -- If it becomes necessary to treat another individual, apply a new pair of gloves. -- Immediately following treatment, thoroughly wash hands and other skin surfaces with soap and warm water; in the absence of soap and water, disposable towel wipes or sanitizing lotions should be used. -- Dispose all contaminated material (e.g., gloves; gown; gauze pads) in an appropriate container marked for biohazardous waste. Treatment setting: -clean work surfaces immediately following treatment with a biohazard product or a bleach and water solution -Clean floor spills -dispose of biohazard materials appropriately -maintain record keeping and documentation

Determining of Findings

Determine if the situation can be handled on-site or if referral to a physician is warranted Acute care options available to the coach: -Standard acute care with no physician referral: provide the individual with a written instruction sheet identifying signs and symptoms that would necessitate immediate care by a physician

Implementing the Emergency Plan

Rehearse the plan Personnel other than just those involved in implementing the plan should evaluate the plan

Soft Tissue Wound Management

The first step in managing an open wound is to control the bleeding. In order to initiate the healing process, the blood must clot. Clotting will not take place when blood is flowing. Using gauze pads to apply the pressure to the wound will promote the clotting process. While applying direct pressure, elevating the wound to a position above the heart will slow the flow of blood and make it easier to control the bleeding. If bleeding cannot be controlled using direct pressure and elevation, indirect pressure should be applied. Specifically, pressure should be applied to sites where the blood vessel is relatively superficial and at a spot between the wound and the heart. Common sites for indirect pressure include: -- The upper arm for the brachial artery -- The groin region for the femoral artery -- The posterior knee for the popliteal artery Cleaning the wound: -- Mild soap and water should be used to clean the wound and the area around it (i.e., at least twice the size of the wound). The area should be cleaned and rinsed thoroughly, ensuring removal of any debris or soap. -- Saline water can also be used to cleanse the wound. Saline is often preferred over water as it is less irritating than water. Dressing the wound: -- Simple gauze pad or an occlusive type pad -- An antiseptic ointment can be used to reduce bacterial growth -- Laceration, incision, or avulsion - butterfly strips can be used to join the edges of the wound If the wound is deep enough that that subcutaneous fat is visible or wide enough that it cannot be easily closed, it may require stitches. Location of the wound can be a factor in determining the need for stitches. If the wound site is an area that readily stretches or moves, a medical professional should evaluate the condition. If necessary, stitches should be applied within 6 hours to avoid contamination of the wound. If a physician's evaluation suggests contamination, a wound cannot be stitched, as doing so would compromise the healing procedure Close wound - goal: reduce inflammation, pain, and secondary hypoxia -treatment: price principles- protect, rest, ice, compression, and elevation Application of cold -physiological effects: vasoconstriction at the cellular level, analgesic -decreased: tissue metabolism (decreases the need for oxygen) which reduces secondary hypoxia, capillary permeability, pain, muscle spasm Physiological perspective: it is not appropriate to use ice massage or whirlpool in the immediate management of an injury. The massaging effect produced by these techniques is not a desirable effect until bleeding has subsided. Plastic bags: -- Filled with crushed ice or small cubes can be safely applied to the skin without danger of frostbite -- Can be molded to the body's contours, held in place by a cold compression wrap, and elevated above the heart to minimize swelling and pooling of fluids in the interstitial tissue spaces. Instant (chemical) cold packs: -- Convenient to carry in a first aid kit -- Disposable after a single use -- Can conform to a body part -- Disadvantages: short duration of the cold application, the expense in using the pack only once, and the potential for the pack tearing or leaking. The chemical substance that produces the cold has an alkaline pH, which can cause burns if the liquid substance comes in contact with the skin. As such, the packs should never be squeezed or used about the face, and if possible, should be placed inside another plastic bag. Length of application time can range from 15-30 minutes. The time for a larger muscle mass, such as the quadriceps, would be 30 minutes and for a smaller site, such as a finger, 15 minutes should be sufficient. Cold applications should be repeated every 1-2 hours while the patient is awake and continue for at least 72 hours post injury. -- Example of compression that compounds trauma: acute compartment syndrome of the lower leg -- Distal-to-proximal direction: to avoid forcing extracellular fluid into the distal aspect of an extremity. -- Tension: As a general rule, the patient should feel the firmness of the wrap, but should not experience a throbbing sensation. Another way to ensure that a wrap is not overly tight is to assess the distal pulse of the involved limb. If a wrap is too tight, it should be removed and re-applied, not simply removed. -- Using an elastic wrap to secure the cold agent to the body part produces a significant reduction in subcutaneous tissue temperatures as compared with simply placing the cold agent on the skin. One layer of the wrap should be applied to the injured site prior to placing an ice bag over the area. The remainder of the wrap should be used to secure the ice bag in place. When the treatment time for the cold pack is complete, a dry compression wrap should be applied. -- The compression wrap should be worn throughout the day and night. -Length of application time: constant -Option: cold wet compression wear to secure cold pack -Do not use compression if additional pressure compounds trauma Evaluation of injured site: -physiological effects: reduces bleeding in the area, encourages venous return, prevents pooling of blood in the extremities -techniques 6-10 inches about the heart If the injury is to a lower extremity and the individual is unable to walk pain free without a limp, the individual should be placed on crutches and an appropriate protective device applied to limit unnecessary movement of the injured joint. If the injury is to an upper extremity and the individual is unable to move the limb without pain, the individual should be fitted with an appropriate splint or brace. While the protected rest is an important component of injury management, it is equally as important to appreciate the effects of both immobilization and remobilization on injured tissues. In certain instances, immobilization can prolong the repair and regeneration of damaged tissues, while early controlled mobilization can optimize the healing process. Example: -- Muscle: immobilization can lead to a loss of muscle strength within 24 hours. This is manifested with decreases in muscle fiber size, total muscle weight, mitochondria (energy source of the cell) size and number, muscle tension produced, and resting levels of glycogen and ATP (adenosine triphosphate), which reduces muscle endurance. In comparison, muscle regeneration begins within 3 to 5 days after mobilization. -- Ligaments adapt to normal stress by remodeling in response to the mechanical demands placed on them. Stress leads to a stiffer, stronger ligament, whereas immobilization leads to a weaker, more compliant structure. This causes a decrease in the tensile strength, thus reducing the ability of ligaments to In general, soft tissues respond to the physical demands placed on them, causing the formation of collagen to remodel or realign along the lines of stress, thus promoting healthy joint biomechanics (Wolff's law). Continuous passive motion (CPM) can prevent joint adhesions and stiffness, and decrease joint hemarthrosis (blood in the joint) and pain. Early motion, and loading and unloading of joints, through partial weight-bearing exercise maintain joint lubrication to nourish articular cartilage, menisci, and ligaments. This leads to an optimal environment for proper collagen fibril formation.

Bone Injury Management

The immediate management should include splinting the extremity in the position in which it is found and immobilizing the joint above and below the fracture site. There should be no attempt to realign the bone or move the individual until the suspected fracture is stable. Immobilization is necessary to prevent any further damage to the bone and surrounding tissues (e.g., blood vessels; nerves; muscle) and it should aid in reducing pain Medical emergency: -- Best to avoid moving or transporting the individual, because movement could aggravate the condition. The individual should remain in the position found and the paramedics should handle transport. Suspected fracture associated with a major trauma or injury- treat as a medical emergency Waiting for EMS: -Control any bleeding (e.g., application of gentle pressure) -Immobilize the injured area in the position in which it was found -Apply cold to the area -If shock is suspected, provide treatment for shock

Emergency/Accident Plan

The plan should provide direction to those individuals that will have responsibilities in managing the condition. The plan should not be limited to emergency conditions, but rather it should include injuries of varying severity (e.g., mild; moderate; severe; life-threatening). Comprehensive, yet flexible enough to adapt to any emergency situation at any activity venue. While some items should automatically be included in an emergency/accident plan, no single plan can satisfy the needs of every institution, organization, or facility. ....every program should design a plan specific to their facility, population served, personnel, and any other factors that could influence injury management.