12/26/2012 Agenda da Eastern Athletic Trainers’ Association The Set-up Grant nt Lectur ure e Background and Context Clinical Recommendations Football Equipment Designs - Effects on Acute Airway and The Study Cardiovascular Care in Medical Emergencies Methods and Results Erik E Swartz, PhD, ATC, FNATA Technique Considerations Co-Investigators: The Implications Jason P Mihalik, PhD, ATC, CAT UNC-Chapel Hill Clinical Interpretation Laura C Decoster, ATC Thoughts for Discussion NH Musculoskeletal Institute The e Set-up up Why do we we strive ve to to minimize e mot otion? on? Carlson on GD et. al. ( JBJS 2003) Horizontal sections taken from spinal Magnetic resonance images of the spinal cords of cords subjected to 30 (A) or 180 (B) dogs with T13 injury after 30 minutes (A) or minutes of spinal cord compression. The 180 minutes (B) of spinal cord compression. arrows indicate areas of preserved white matter 1
12/26/2012 Deviatio ions ns fro rom neutral l alignment nt can decrease the Carlson on GD et. al. ( JBJS 2003) diameter of the spinal l canal and the space available le for the spinal l cord rd “Longer duration of compression is associated with increased pathological changes and decreases in neurologic recovery” “Damage to the spinal cord depends strongly on the duration of displacement and timing of treatment” Pati tient ent Outcom omes es Deviati ation on from Neutral al Ching RP et. al. ( Spine . 1997) investigated the effect of Kang JD et. al. ( JBJS 1994) reviewed medical records of 288 post-injury position of the cervical spine on spinal patients (age ~ 36 yrs) w closed cervical spine canal occlusion Burst fractures created in cadaver cervical spines fractures or dislocations between 1966-1992. Each specimen moved into: 83 no neurologic def, 30 nerve root, Flexion / Extension 92 incomplete, 83 complete R/L Lateral Flexion Determined SAC at injured levels: 4 intermediate positions (45º) 10.5mm* for complete injury L/R Rotation 16.7mm for no neurologic injury Traction Compression Identified an association between the space available for the cord at Compared with the neutral position; the level of injury and the severity of neurologic deficit. compression, extension, and extension combined with lateral flexion all increased canal occlusion. Why do we we strive ve to to minimize e mot otion? on? If the head/neck is OUT of neutral alignment… in a suspected cervical “ We minimize motion in an effort to avoid positioning away from neutral spine injury, it is ok to move the alignment!” head/neck … back to neutral. 2
12/26/2012 Kevi vin Eve verett tt Septemb mber 9, 2007 “Do no Further Harm….” Does not necessarily mean.. ……….“Do Nothing” Repos ositioni oning ng the Cervi vical al Spine Three general contraindications exist to moving the cervical spine to neutral: 1. the movement causes or increases pain, neurologic symptoms, or muscle spasm compromising the airway, 2. resistance to movement is encountered, or 3. the patient expresses apprehension. ANNUAL AL SURVEY EY OF CATASTROP OPHIC C FO FOOTBAL BALL L INJUR URIES ES 1977 – 2011 Clinic inical al Recommen ommenda dation tion “There has been a reduction of permanent cervical cord injuries when compared to data from the early 1970's. For the past ten years, 2002- 2011, there has been an average of Always ensure the cervical spine is in, and 9.4 cervical cord injuries with incomplete neurological remains, in neutral alignment recovery, and 8.2 cerebral injuries with incomplete recovery in football. The prior ten years averaged 7.7 cervical cord injuries with incomplete recovery and 5.0 cerebral injuries with incomplete recovery .” National Center for Catastrophic Sport Injury Research 3
12/26/2012 What t is a Major r Part of the The e Rise of Catas astrophi ophic Injur ury? Problem?. m?... .. 1969-1972 It is discouraging to say the least that countermeasures (protective equipment) designed to lower the burden of injuries in sport and recreational activities do not warrant the same scientific scrutiny as in almost any other field of health research Head impacts sustained in helmets-only (22.47 1.81 g) and full-contact practices ..the possibility exists that the countermeasure.. may have other negative (22.65 1.80 g) were significantly higher than those sustained in games or unintended consequences..including shifting the distribution of injury, a change in scrimmages (21.12 1.73 g). behavior of participants resulting from a false sense of security, to reduced participation..due to public discontent “there seem to be no light days for football players ” Mihalik, Jason P.; Bell, David R.; Marshall, Stephen W.; Guskiewicz, Kevin M. Measurement of Head Impacts in Collegiate Football Players: An Investigation of Positional and Event-Type Differences.Neurosurgery. 61(6):1229-1235, December 2007. Histor tory: Rules and Helmet met Design 2005- 1800’s 1939 1960 1976 2010 No Rules No Rules No Rules Rule Rule Change Changes No Helmets Head Advanced ‘Covers’ Helmet No No Spearing, Major Design Intentional Injuries Minor etc Spearing Injuries Major Minor Injuries Injuries Major Major Injuries Injuries 4
12/26/2012 TABLE 3. Frequency (number) of head impacts sustained by impact location in 2005 and 2006 football seasons Location of head impact Frequency of recorded Mean (sd) linear impacts impacts acceleration (g) of recorded head Top 10,728 (18.81%) 29.22 (1.95) Front 20,450 (35.86%) 20.84 (1.68) Back 17,617 (30.89%) 21.71 (1.79) Left 4303 (7.55%) 19.74 (1.67) Right 3926 (6.88%) 18.85 (1.64) Total 57,024 22.25 (1.79) *Adapted with permission Clinic inical al Recommen ommenda dation tion “Athletic training encompasses the prevention, diagnosis, and intervention of emergency, acute, and chronic medical conditions involving impairment, functional limitations, and disabilities.” What are YOU doing to prevent head/neck injury? KEY Y POINTS! The e Study dy Contact, Collision, and “Big Hits” are a part of the game Head impacts are cumulative and can result in detrimental, catastrophic outcomes We must continue our efforts to prevent catastrophic head and neck injuries and to strive for excellence in treating them… 5
12/26/2012 The primary acute treatment goals in equipment laden athletes are to ensure that the cervical spine is immobilized in neutral Face e Mask Removal val is Safer than and vital life functions are accessible. Removal of helmet and shoulder pads in any equipment intensive sport should be val …. Right Right ? deferred 21-24 until the athlete has been transported to an Helmet Removal emergency medical facility, except under 3 circumstances 25, 26 : 1) the helmet is not properly fitted to prevent movement of the head independent of the helmet, 2) the equipment prevents neutral alignment of the cervical spine, or 3) the equipment prevents airway or chest access. 21, 22 Evidence Category: C Full face-mask removal using established tools and techniques 27- 29 is executed once the decision has been made to immobilize and transport. Evidence Category: C Recent changes in football helmet, facemask, and No research h comparing mparing mot otion n shoulder pad designs have implemented quick- creat ated ed by facema emask k and helme met release systems aimed at reducing removal time. removal al have ve been reported ed Full QR Helmet met Options ons Full QR Helmet met Options ons 6
12/26/2012 Objec ecti tive To determine the safest emergency intervention to allow for successful airway and chest access in recently modified styles of helmets and shoulder pads. Hypothes theses es Study dy Design 1. There will be significantly less head movement Quasi-experimental design comparing airway and time to task completion during facemask access and chest access techniques removal compared to helmet removal A controlled laboratory setting 2. There will be significantly less head movement and time to task completion during shoulder pad removal using a quick release shoulder pad design compared to a traditional shoulder pad design Participan ants ts Participan ants ts Participants reported in pairs Forty athletic trainers (ATs) free of physical All participants were informed of the study’s purpose pathology preventing them from completing the required tasks were recruited through email A general overview of the study was provided Required to sign an informed consent form approved distribution from the population of certified by the university’s IRB. athletic trainers (ATs) in the New England region Participants completed a general health history Males Females Age Mass Height Experience questionnaire to determine their inclusion eligibility. Incentive included a $30 gift-card and up to 2 CEUs. 21 19 33.7±11.2yrs 80.7±17.1kg 173.1±9.2cm 10.6±10.4 yrs Participants were then randomly assigned to serve as Rescuer 1 or 2 7
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