24 декабря 2016г.
Sports injuries and effective resuscitation issues is still an important and far-unresolved problems of modern medicine. Proper organization of the evacuation of the injured and effective emergency care in escape routes largely determine the success of treatment and subsequent rehabilitation of athletes. An important component of the complex events is the correct organisation of emergency care on the scene. Upcoming the FIFA World Cup 2018 in Russia objectively set important issues before the medical support organizers not only about organization, but also qualitative preparetion of anaesthetists-reanimatologov specialists, especially of cardiopulmonary resuscitation topic.
Introduction
With the vast number of participants worldwide engaged actively in playing amateur and professional football, it is not unreasonable to expect an equally large number of injuries each year. With football being the only sport where the unprotected head and neck is purposefully used to engage the moving ball, often at high speed and in competition between two players, it is to be expected that the total number of injuries from football each year will include head and/or neck injuries.
Each of these scenarios is to be managed as described below.
Treatment
General management of the head and/or neck injured football player.
A - Airway: ensure that the player's airway is open and protected from obstruction by the tongue and/or mandible or from aspiration of stomach contents, especially if the player is lying in a supine position (on their back) and, due to loss of consciousness, is not able to protect their own airway. In the unconscious player, the airway is opened and maintained by using any of the following, using as little motion on the injured neck as practically and safely as possible:
• Removal of any foreign material in the airway/mouth
• Opening the player's mouth
• Jaw thrust man oeuvre
• Insertion of oropharyngeal tube
• Insertion of nasopharyngeal tube
• Insertion of Laryngeal Mask Airway (LMA) Glasgow Coma Scale
Jaw Thrust Man oeuvre to open the airway.
• Insertion of an endotracheal tube if it is clinically indicated, the necessary expertise is available and the necessary advanced airway equipment is on hand. Insertion of the above airway devices has been shown to result in less movement of the cervical spine than the Jaw Thrust manoeuvre and are therefore to be preferred.
In the absence of endotracheal intubation, it is important to ensure that some form of adequate suction is available, should the player vomit, which is not uncom mon in head injury and its after effects. If this is not possible, one should immobilise the supine player to a long, rigid spinal-type board and turn the board into the lateral position or, if the player is not immobilised, turn the player slowly, gently and carefully into the lateral position. The lateral position prevents the tongue and/or mandible from obstructing the airway as well as preventing aspiration into the lungs during vomiting.
A - Alignment of the spine: All football players with a suspected or clinically symptomatic spinal injury must be adequately and appropriately immobilised so as to prevent the development of or deterioration to a neurological injury to the spinal cord. The basic principles of spinal column immobilisation comprise the following actions:
• Carefully, gently and slowly realign the head into the neutral position relative to the spine and maintain this position thereafter. If this slow, gentle realignment causes any neck or spinal pain, muscle spasm, abnormal neurological signs or symptoms, offers resistance or compromises the integrity of the airway, then immobilise the head in the original found position
Once the head has been adequately realigned and stabilised, carefully, gently and slowly align the entire spinal column into the neutral position, following the same principles as stated above.
If the player is lying on their back (supine), the player needs to be immobilised to a long, rigid, spinal-type board (RSB). This may be undertaken with a careful, gentle and coordinated log-roll manoeuvre to turn the player onto their side, placement of the RSB behind the player's back and then a careful, gentle coordinated log-roll to move the player onto the RSB in the supine position for immobilisation. Alternatively, the player may be carefully, gently and with coordination be lifted off the ground by a team straddling the player whilst an RSB is slipped under the player, who is then gently lowered onto the RSB.and transfer the player in this position to hospital on an available appropriate immobilisation device.
All players strapped to an immobilisation device should be strapped sufficiently such that the device can be urgently turned into the lateral position if the player vomits, without creating movement of the spine as a result.
If the player is lying on their side (lateral), an RSB can be positioned behind the player's back and the player then carefully, gently log-rolled onto the RSB into the supine position for immobilisation.
• If the player is lying face down (prone), a number of careful, gentle coordinated steps are required by the medical team to first realign the head into the neutral position, then log-roll the player onto his/her side, and finally log-roll the player onto an RSB into the supine position for immobilisation.
Player turned from the prone position onto the side.
Player turned onto the side from the prone position, ready for placement of a rigid spinal board.
• Once the player has been adequately and appropriately aligned in the supine position, anatomically neutral onto an immobilisation device, manual cervical spinal stablisation should be converted into external immobilisation using external devices, e.g. foam-based head blocks
B - Breathing: It is important to ensure that the player with a head and/or neck injury, with neurological signs or symptoms, does not become hypoxic because of its detrimental effects. The player's oxygen saturation, measured by a non-invasive pulse oximeter placed onto a player's finger, should not drop below 90%. If hypoxia occurs, supplemental oxygenation should be administered accordingly.
B - Blood pressure: It is important to ensure that the player with a head and/or neck injury, with neurological signs or symptoms, does not become hypotensive because of the detrimental effects of preventing adequate blood perfusion to the injured neural tissues. Hypotension in the head or neck of the injured player may result from acute spinal shock, heat-related illness and/ or internal bleeding. Every effort must be made to keep the systolic blood pressure above 90mmHg, either by positioning the patient appropriately and/or intravenous infusion.
C - Consciousness: On approaching the player, ascertain whether the player is;
• Conscious - fully alert player with no clinical signs or symptoms
• Conscious - fully alert player with neurological signs and/or symptoms
• Unconscious player who is breathing adequately
• Unconscious player with abnormal or no breathing Each of the above is treated as follows:
• The conscious, fully alert, asymptomatic player may return to play
• The conscious, symptomatic (neurological signs/ symptoms) player is removed from the field-of-play with spinal/neck immobilisation as required and transferred to the nearest, most appropriate trauma centre. The symptomatic spinally injured patient is no longer administered high-dose methylprednisolone intravenously as there is little evidence of its efficacy and it therefore remains a controversial treatment
• The unconscious player who is breathing adequately is stabilised, immobilised and transferred by ambulance to the nearest, most appropriate trauma centre.
• The unconscious player with abnormal or no breathing is fully resuscitated, stabilised, immobilised and transferred by ambulance to the nearest, most appro priate trauma centre. NB: Any player who is unconscious and not breathing may require immediate external chest compressions and application of an AED due to the occurrence of sudden cardiac arrest. Do not feel for a central pulse for longer than 10 seconds in order to decide that CPR is necessary.
C - Cervical spine injury exclusion: It is possible for a team physician to exclude a cervical spine injury clinicaly in a player, and thus not have to expose the player to a mandatory RSB immobilisation and radiological examination to exclude a fracture. This is in line with the current recommendations of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. Players post-injury who fulfil all of the following criteria do not require immobilisation on an RSB:
• Are fully awake - GCS 15 out ofl5
• Do not have spine tenderness or anatomic abnormality
• Do not have neurological signs or symptoms
• Do not have serious injuries whose pain could detract from a spinal injury
• Have not had any alcohol or chemical substances
D - Dextrose: Any player who presents any neurologial signs or symptoms must have their blood glucose level measured as part of the initial examination, even if trauma is the likely cause of the neurology, because of the possibility that hypoglycaemia may have been partly responsible for the injury. Furthermore, if hypoglycaemia is missed, it can result in further neurological dete rioration and prevent effective treatment.
D - Dehydration: Whatever the likely cause of any injury on the field of play, players that have been involved in intense exercise may have varying degrees of dehydration, the effects of which may compound the gravity of the injury. Therefore dehydration must always be factored into the measurement of an injured player's vital signs, be considered clinically present and, if neces-sary, treated, unless or until it can be proved otherwise.
E - Environment: Heat fatigue or heat stroke must be excluded in a player who presents with a likely head and/ or neck injury with neurological symptoms. Heat stroke, because of the neurological signs and symptoms that indicate its presence, may well be the initial cause of the apparent injury due to the player's inability to function adequately physiologically, physically or psychologically. Its delayed diagnosis and consequent emergency treatment, due to the trauma event that takes precedence, may have critical medical consequences. It is therefore mandatory to exclude in a player with any neurological symptoms, similar to hypoglycaemia and its mandatory exclusion, even in trauma.
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