BOOK EXCERPT
The Athletic Training Student Primer
Andrew P. Winterstein, PhD, ATC

CHAPTER Nine
Emergency Planning, Evaluation, and Initial Care

“First, do no harm. Don’t be afraid to take on a task or skill that you understand and know. Be hesitant to get in over your head until you have the specific knowledge and training. Remember, you are dealing with human lives.” Ronnie P. Barnes, MS, ATC Head Athletic Trainer National Football League—New York Giants

The ability of the athletic trainer to determine the severity of a specific injury or condition, outline a course of action (emergency or otherwise), and provide the appropriate care and follow-up are vital athletic training skills. Significant portions of the athletic training domains are dedicated to these skills. Athletic training students who understand how these skills fit into the professional domains of a certified athletic trainer (ATC) will be better prepared to make the most of their clinical rotations. The skills outlined in this chapter are presented as an overview; any student advancing in an athletic training education program will take individual courses (both didactic and clinical) in each area and have significant exposure to the content described in this chapter.

Upon completion of this chapter the student will be able to:

• Know the difference between a primary and secondary injury survey
• Describe the components of a physical exam
• Appreciate the importance and obligation of adequate emergency response plans
• Explain the key components to an emergency response plan
• Be aware of immediate care considerations following acute injury
• Be familiar with the relationship between physiologic response and use of therapeutic interventions
• Explain the common components of a rehabilitation and reconditioning program

Emergency Planning

An emergency plan is a comprehensive document that outlines how an emergency situation will be handled. Emergency plans can be thought of as blueprints.¹ Like blueprints that must be drawn before a building is built, the emergency plan must be in place before it is needed. Proper planning will allow the sports medicine team to respond to an emergency smoothly. The ability to properly respond when called upon may make the difference between life and death. In addition to planning, teamwork is the second essential component of a response plan. Everyone involved must know his or her role, work within his or her boundaries, and be prepared to act accordingly.

Emergency plans are not one size fits all. The plan must be specific to the sport activity in question and will need to be tailored to specific facilities. Compare the needs of the ATC at a track and field event to those at an equipment-intensive event like a football game. How you immobilize and transport an individual with a suspected cervical injury will require some equipment-specific planning. The most common equipment example is having a plan to remove a football helmet facemask if needed. The two main questions that an emergency plan should address are:

1. What are the roles and responsibilities of each member of the sports medicine team as he or she responds to an emergency?
2. What steps will be taken to activate the emergency medical services (EMS)?

Emergency documents should not be written for the sole benefit of the sports medicine team. The plan should be distributed to administrators, coaches, facilities staff, and any personnel that may be impacted by such an event. While plans must be flexible each should provide information on implementation, personnel, emergency equipment, communication, transportation, venue location, emergency care facilities, and documentation.¹ Table 9-1 outlines the NATA’s Position Stand on Emergency Planning in Athletics.

Types of Evaluation

Primary Survey

Athletic trainers must be prepared to assess emergent injury situations as well as the more common non-lifethreatening injuries. Any on-the-field injury assessment begins with a primary survey. The primary survey involves an assessment of the ABCs: airway, breathing, and circulation. The primary survey also requires that you establish the presence of severe bleeding.¹ At anytime during the primary survey an athletic trainer must be prepared to activate an emergency plan that includes summoning EMS, establishing an open airway, giving cardiopulmonary resuscitation (CPR), and providing first aid. Emergency care is a series of decisions, what you find as you assess the ABCs determines what steps must be taken. Figure 9-1 is a typical decision tree for assessing an emergency.

Athletic training students must be prepared to assist athletic training staff in the event of an emergency. Athletic training students in clinical rotations should hold a current CPR certification, be trained in CPR (including automatic external defibrillation), trained in basic care first aid, and should be trained in the use and maintenance of emergency care equipment and know the location of such equipment. Students may be asked to assist supervising staff in activating an emergency plan. Phoning EMS, assisting with CPR, spine boarding, and patient conveyance are all potential emergency situations an athletic training student should be prepared for. It is the responsibility of the athletic training education program to ensure that students are equipped to handle emergency situations prior to being placed in a clinical situation.

Secondary Survey

While the athletic trainer should always be prepared in the event of an emergency, most on-the-field evaluations and decisions are not emergent. In this situation the ATC must then perform a secondary survey. The secondary survey is a survey for trauma once it is established that the patient is stable. Throughout the secondary survey the practitioner must always continue to assess the ABCs while checking the patient from head to toe for additional signs of injury or trauma. The secondary survey should help the athletic trainer determine the safest method for removing the athlete from the field of play. Once on the sidelines or in the athletic training facility, a more comprehensive evaluation can be preformed.

A Complete History and Physical Exam

A Step-by-Step Process

A comprehensive evaluation consists of taking a history and carrying out a physical examination. This type of evaluation is performed when an athlete or patient comes to you with an existing problem or is done on the sidelines after an acute non-emergent injury. These evaluations will most often follow the SOAP note format. SOAP is a format for evaluation and documentation that stands for subjective, objective, assessment, and plan.² Subjective information is information gathered from the patient (history), while objective information involves visual information, results of tests performed by the athletic trainer and graded in a consistent manner. Assessments are the results of the evaluation. They are an impression of how the injury occurred and the severity of the injury. The plan outlines what management, treatment, or referral actions will be taken to care for the injury.

Athletic training students should only do an evaluation if they have been properly instructed in evaluation techniques and are under the guidance of a supervising athletic trainer. While the SOAP note format for evaluation and documentation guides the evaluation process, the steps in an evaluation are often remembered by the acronym HOPS. This stands for history, observation, palpation, and special tests. The steps below are an overview of the components of an injury evaluation.

History

As the word implies, the history is what has already happened. The athletic trainer must gather information from the patient. This subjective information is critical to establishing a starting point for the athletic trainer to begin his or her “search” for the underlying injury that has brought the patient to him or her. During a history, ask questions to determine:

• Mechanism of injury
• History of previous injury
• Onset of symptoms
• Location of injury
• What type of pain is present
• Does the patient have any abnormal sensations
• Anything that makes the injury worse or better
• What treatment has been done
• Taking any medications or supplements

Of all the questions asked of the patient, the mechanism of injury and previous history often are the most informative to the athletic trainer. The athletic trainer must be equally adept at evaluating illnesses as well as injuries. Refer to More Than Just Injuries on the following page for more information on evaluating illnesses.

Observation

The athletic trainer must observe the area of the injury as well as the overall actions of the patient. During the observation phase of an evaluation the athletic trainer must observe for:

• Swelling (edema)
• Discoloration (ecchymosis)
• Deformity
• Signs of infection and inflammation
• The patient’s facial expressions (pain)
• Presence of a painful gait (limp)
• Smooth and coordinated movement
• Bilateral comparison (compare one side to the other)

With practice and experience the athletic training student will learn to gather observational information while asking questions during the history phase.

Palpation

To palpate means to gather information with one’s hands. The athletic trainer needs to palpate the proper structures to gather information. This brings to light a general assumption of the evaluation process, that one must have a strong knowledge of the anatomical structures to gather appropriate information. During a physical examination, palpate for:

• Pain (response to touch)
• Crepitus (a “crunchy” sensation associated with tendonitis, bursitis, and bone abnormalities)
• Swelling (edema)
• Deformity
• Muscle tone
• Changes in temperature

Palpation may be uncomfortable for the patient, therefore the athletic trainer must proceed with caution and palpate areas that he or she suspects will be painful last.

Special Tests

Range of Motion Testing

Functional testing refers to the assessment of active range of motion (AROM), passive range of motion (PROM), and resisted range of motion (RROM). AROM is motion that is initiated and carried out by the patient. The athletic trainer performs PROM with the patient completely relaxed. No active muscle activity is present during PROM. When evaluating active range, the patient must be provided with simple instructions that he or she understands. Asking the athlete to abduct or perform forward flexion may not mean anything to him or her. Therefore, you need to use simple commands like “raise your arms over your head.” During active motion any pain with movement, limitation in movement, or asynchronous movement should be noted. Evaluation of AROM and PROM should be done bilaterally to compare extremities. A goniometer may be used to get a measurement (in degrees of motion) of the available range.

PROM requires the evaluator to “feel” tissues at the end of the available range. The athletic trainer must note any pain with passive movement, limitation in movement, or change in “end-feel.” End-feel is the type of tissue resistance that the practitioner feels as the joint is passively moved. For example, if you extend the elbow the end-feel is hard, compared to flexing your knee which has a soft feel as the tissues of the gastrocnemius contact the thigh. Knowing the expected end-feel allows the athletic trainer to make a comparison to his or her physical exam findings.

RROM is also known as manual muscle testing (MMT). This portion of the physical examination assesses the strength and muscle function for a specific movement. MMT skills require students to have a working knowledge of the muscles and muscle actions. Manual muscle tests are graded by comparing the strength of a given muscle group to the opposite extremity. Muscle strength is commonly graded on a scale of zero to five. A grade of 5/5 strength would equal 100%; a grade of 0/5 would indicate that there is no muscle activity.

Ligament and Special Tests

The athletic trainer utilizes ligamentous tests to apply stress to a joint and determine if specific structures have been injured. The ability to position the patient, place one’s hands, apply the test, and interpret the results are clinical skills required of all athletic trainers. These tests allow the ATC to identify sprain injuries. The amount of laxity, pain, and the quality of the “end-point” of a ligament test are all indicators of injury. Special tests are designed to help identify specific injuries or conditions based on a particular maneuver by the patient or action by the examiner. For instance, an injury to the acromioclavicular joint of the shoulder may cause the distal clavicle to ride upward and create a deformity. The athletic trainer can perform a special test called a “spring” test by pushing the distal clavicle down to its normal position and observing if it springs back upward when released. This is a special test to determine the severity of an acromioclavicular sprain. There are several special tests that must be learned to adequately examine a wide range of injuries and conditions. Special tests are often named after the physician who identified the test (eg, Noble, Ober, Kennedy-Hawkins) or named after the position the patient assumes to perform the test (eg, single leg stance, impingement).

Neurovascular Testing

Several acute and chronic injuries can affect nervous or vascular structures in the body. Nerve injuries may cause changes in sensation, muscle weakness, or loss of function. Athletic trainers evaluate neurological function by assessing dermatomes, myotomes, and deep tendon reflexes. Dermatomes are sensory areas of the skin that are supplied from a specific nerve root. Finding a change in sensation in a specific area may be an indication of a nerve injury at that level of the spinal nerve root. Myotomes are muscle actions that are related to particular spinal nerve roots. For example, if there is pressure on the fifth cervical nerve root (C5), a patient may demonstrate weakness in his or her deltoid or biceps brachii when it is evaluated. Deep tendon reflexes can be evaluated in many locations. The patellar tendon, Achilles tendon, biceps brachii tendon, and triceps brachii tendon are common locations for reflex testing. When the patient is properly positioned and the tendon tapped with a reflex hammer the results can be noted. Some patients display excessive response and are hyper-reflexive, while others may show decreased reflexes. Changes in reflexes can be associated with injury at a specific nerve root level. Athletic trainers must be skilled in assessing the neurological status of an injury for the purpose of initial care and appropriate referral.

It is common practice to check for circulation distal to the site of a traumatic injury (fracture or dislocation). This is done by checking a pulse at a location distal to the injury. Vascular structures may be affected by both acute and chronic injury; taking the pulse and confirming normal circulation should be a part of any physical examination.

Immediate Care and Management of Athletic Injuries

The prospective athletic training student should have a basic understanding of first aid and the principles of immediate care of athletic injuries. The initial care for an athletic injury will involve the following components: protection and support of the injured body part, the use of ice to control pain, compression and elevation to reduce swelling, and rest of the injured body part pending further evaluation. The use of the acronym PRICE is commonly used to remember the appropriate steps (Table 9-2).

Once an injury as been determined to be non-emergent (primary survey), the initial care will likely consist of using the PRICE concept prior to referral to a physician. Initial care also requires the athletic trainer to also determine the need for splinting, immobilization, and proper conveyance of the injured athlete.

As part of a comprehensive athletic training education program, athletic training students will take courses in the use of therapeutic modalities. A modality is a method of therapy, or an apparatus used for therapy, that is designed to elicit a desired physiologic response. Students will learn the common physiologic responses, clinical conditions that specific modalities can be applied, as well as the actual clinical skills needed to apply them. The physiology is the key. The athletic trainer must know the underlying physiology associated with injury (see Chapter 8) and the desired physiologic responses of the modality. The application of ice, compression, and elevation is performed with knowledge of the desired physiologic responses. Table 9-3 compares the physiologic effects of ice and heat. The decision when to apply heat to an injury is often a conundrum for the average person. However, the athletic trainer is aware of the physiology of injury and the physiologic effects of hot and cold.

Therefore the decision must be made based on the status of the injury and the desired outcome. Apply heat too soon and the increase in blood flow could lead to greater amounts of swelling. However, once the swelling has subsided heat may be beneficial to improving the ROM and bringing nutrients to the injured site. A variety of thermal, electrical, and mechanical modalities can be used in the care of athletic injuries. Students pursuing a degree in athletic training will be required to take coursework and demonstrate proficiency in the use such modalities.

Rehabilitation of Athletic Injuries

The same evaluation skills required to provide initial assessment of athletic injuries are also used during the treatment and rehabilitation process. The athletic trainer must determine the status of injuries to determine appropriate treatment, rehabilitation, and reconditioning.³ Rehabilitation of athletic injuries requires clinicians to possess skills that allow them to control pain, restore ROM to injured joints, re-establish muscle strength and endurance, and regain neuromuscular control and proper balance. In addition, the ATC must have the ability to apply these skills in a progressive and functional fashion to assist the patient in returning to his or her desired level of activity as soon as is safely possible.⁴ Much like the use of therapeutic modalities, rehabilitation requires a keen awareness of the physiology of healing and the effect injury has on the function of joints and related structures. An extensive discussion of rehabilitation and therapeutic exercise is beyond the scope of this text. A general overview of the components of a rehabilitation program is provided in Appendix D.

Summary

The athletic trainer must possess the skills to evaluate both emergent and non-emergent injuries to determine an appropriate course of action. Primary and secondary surveys are evaluation schemes that allow the athletic trainer to properly assess the injured individual, render initial care, and make the necessary referral. The primary survey includes the ABCs of airway, breathing, and circulation. The initiation of an emergency response plan is the appropriate action when the athletic trainer identifies an emergency. Institutions and organizations must have well-documented and frequently rehearsed emergency action plans.

The secondary survey is a survey for trauma once the athletic trainer establishes that the patient is stable and aids in determining if (and how) the patient will be transported from the field of play. A complete history and physical exam is a step-by-step process that requires an understanding of the underlying anatomy and proper function of the musculoskeletal structures. Athletic trainers must be able to evaluate both injures and illnesses and make appropriate adjustments to the history process.

Athletic trainers must be skilled in the initial care of acute injuries and should adhere to the PRICE protocol until a full medical evaluation has been completed. Longterm care and rehabilitation of athletic injuries requires a comprehensive program that takes into consideration ROM, strength, neuromuscular function, functional progressions, and criteria for return to activity. Athletic training students in an accredited education program will receive instruction and clinical experience in each of these areas.

References

1. Kleiner DM, Anderson J, Bailes J, et al. Pre-hospital Care of the Spine-Injured Athlete: A Document from the Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete. Dallas, Tex: National Athletic Trainers’ Association; 2001:1-31.
2. Ginge K. Writing SOAP Notes. Philadelphia, Pa: FA Davis; 1990.
3. National Athletic Trainers’ Association Board of Certification. Role Delineation Study. 4th ed. Omaha, Neb: Author; 1999.
4. Arnheim DA, Prentice WE. Principles of Athletic Training. 10th ed. New York, NY: McGraw-Hill Higher Education; 2000.

Bibliography

• Arnheim DA, Prentice WE. Essentials of Athletic Training. 5th ed. New York, NY: McGraw-Hill Higher Education; 2002.
• Denegar C. Therapeutic modalities for athletic injuries. In: Perrin D, ed. Athletic Training Education Series. Champaign, Ill: Human Kinetics; 2000.
• Starkey C. Therapeutic Modalities. 2nd ed. Philadelphia, Pa: FA Davis; 1999.
• Shultz SJ, Houglum PA, Perrin DH. Assessment of athletic injuries. In: Perrin D, ed. Athletic Training Education Series. Champaign, Ill: Human Kinetics; 2000.
• Anderson JC, Courson RW, Kleiner DM, McLoda TA. National Athletic Trainers’ Association position statement: emergency planning in athletics. Journal of Athletic Training. 2002;37:99-105.

Web Resources

• National Collegiate Athletic Association
  http://www2.ncaa.org/media_and_events/ncaa_publications/health_and_safety/index.html
  Links to National Collegiate Athletic Association Sports Sciences page provides copies of position papers, NCAA-sponsored research, and links to the sports medicine handbook. The Sports Sciences section is under the guidance of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports. Includes a link to emergency planning information.
• National Athletic Trainers’ Association
  www.nata.org
  Copies of positions statements regarding emergency planning and pre-hospitalization care of spine-injured athletes can be found on the NATA Web site.