Football player Head/Neck Trauma

[Tigger]

We can use them as immobilizers if we can justify why. We are supposed to be getting at least one scoop/lsb combo board for each ambulance here pretty soon. That'll be nice.

One of those Hartwell things? They look pretty sweet. I would like one at work so we could easily move tib/fibs and other fractures onto the stretcher and then transport off the ice. That would count as "spinal immobilization" but one of the classic metal ones does not count for the AMR division that we work with apparently. Neither does the vacuum mattress we have. Protocols=lame.

 

[Handsome Robb]

One of those Hartwell things? They look pretty sweet. I would like one at work so we could easily move tib/fibs and other fractures onto the stretcher and then transport off the ice. That would count as "spinal immobilization" but one of the classic metal ones does not count for the AMR division that we work with apparently. Neither does the vacuum mattress we have. Protocols=lame.

Yep that's the one. They have a couple laying around and they seem pretty easy to use. The metal ones can be a pain in the *** to get apart sometimes.

 

[KellyBracket]

...
You can shoot x-ray through all of the football equipment. So if you suspect a neck injury, there is little reason to remove the equipment until it has been ruled out at the hospital.
...

I appreciate the perspective of the trainers, but a few things occur to me.

1 - All non-trivial trauma gets uncovered in the ED as the first step;
2 - Even necklaces and earrings/piercings screw up x-rays, let alone clips/rivets/etc; and lastly,
3 - For significant trauma, we're generally getting CTs these days, and the clips/rivets/etc on a helmet will cause a lot of scatter, making for a poor image.

This is just me, not speaking for any organization, but the pads, etc, need to come off, so it might as well be by someone who is familiar with the gear. If it's left to me, I'm just going to cut it off!

Interesting topic!

 

[hops19]

I appreciate the perspective of the athletic trainers, but a few things occur to me.

1 - All non-trivial trauma gets uncovered in the ED as the first step;
2 - Even necklaces and earrings/piercings screw up x-rays, let alone clips/rivets/etc; and lastly,
3 - For significant trauma, we're generally getting CTs these days, and the clips/rivets/etc on a helmet will cause a lot of scatter, making for a poor image.

This is just me, not speaking for any organization, but the pads, etc, need to come off, so it might as well be by someone who is familiar with the gear. If it's left to me, I'm just going to cut it off!

Interesting topic!

I'd cut it off as well. There's really no other way of taking it off without creating significant movement. Cut the jersey up the seams from waist up through the arms, cut the straps underneath the arms, and cut through the drawstrings at the front. Then we have to deflate and pop out the ear pads, cut the chinstrap, and all at once pull both the helmet and shoulder pads off of the athlete.

It's just not very suitable to do this on the field.

 

[mycrofft]

. I agree, but many EMS agencies do not recognize the scoop as an immobilizer (stupid), so we are stuck with the LBB.

When I was making that litter class last year, I ran across multiple instances where scoop litter manufacturers state categorically that it is NOT an immobilization device.

Gimme some tiedowns and sandbags and a head block and I'll show you a scoop as an immobilizer.

Would a SKED be a good "spatula" for lifting off an irregular or very hard surface (marble or ice) then onto a litter? If you can keep it from rolling up like a cigarette or a burrito that is.


I seem to remember a device a while ago designed to cut through a helmet, you could bivalve it. Powered shears or circular cutters would seem to be a good deal in that particular situation with pads and harnesses.

 

[Tigger]

I appreciate the perspective of the trainers, but a few things occur to me.

1 - All non-trivial trauma gets uncovered in the ED as the first step;
2 - Even necklaces and earrings/piercings screw up x-rays, let alone clips/rivets/etc; and lastly,
3 - For significant trauma, we're generally getting CTs these days, and the clips/rivets/etc on a helmet will cause a lot of scatter, making for a poor image.

This is just me, not speaking for any organization, but the pads, etc, need to come off, so it might as well be by someone who is familiar with the gear. If it's left to me, I'm just going to cut it off!

Interesting topic!

We want the pads off too, but it's not practical to do on the ice, so we send someone to help do it in the ED, where there are more hands and whatnot.

When I was making that litter class last year, I ran across multiple instances where scoop litter manufacturers state categorically that it is NOT an immobilization device.

Gimme some tiedowns and sandbags and a head block and I'll show you a scoop as an immobilizer.

Would a SKED be a good "spatula" for lifting off an irregular or very hard surface (marble or ice) then onto a litter? If you can keep it from rolling up like a cigarette or a burrito that is.


I seem to remember a device a while ago designed to cut through a helmet, you could bivalve it. Powered shears or circular cutters would seem to be a good deal in that particular situation with pads and harnesses.

Ferno did a study that showed that there new plastic scoop did a better job immobilizing someone than an LSB. Granted Ferno wrote the study so it's tough to accept completely, but I think using one would not be an issue.

I have no idea how a SKED would work, but realistically the actual process of boarding someone on the ice is not much different than the typical scenario. Everyone's on their knees so falling is not likely. We only lift once to get the board on the cot (lowest position), and then wheel it off like that. Lifting it to "rolling height" happens off ice.

As for helmets, hockey helmets come off quite easily. Two screws get the top of the facemask, and three snips get the lower facemask and chinstrap. There is no air bladder system so we don't worry about that. For lacrosse helmets (also no bladders) we can't remove the facemask so we just use the typical motorcycle helmet removal technique. I have no idea why you would need to cut a helmet off.

 

[KellyBracket]

Ugh, just plowed through a bunch of the literature on football (& other helmet/pad sports) injuries. A "crash" course, if you will!

It still stands out to me that the injured football player is managed, to a certain degree, unlike most other patients.

For example, exposure of the patient is deferred to the ED, and two reasons are offered. As Tigger and hops19 point out, it's difficult to expose on the ice or public playing field. But this is not offered as a rationale for other injuries or mechanisms, even those that occur in public.

Much of the literature also supports the idea that it is too dangerous to potentially expose the spine to movement through helmet & pad removal. However, EMS routinely extricates patients from MVCs while maintaining spinal precautions.

This is a fascinating topic, representing the intersection between multiple professional organizations, as well as the evolving practice in identifying and managing the potential cervical spinal injury. Sounds like it's worth a short review, even though I just wrote about new cervical spine research!

As for the OP WWFDCorrie- the literature speaks, for the most part, about the need to align the helmet and shoulder pads, while little mention is made of the hip pads, for example. I'd be fine if EMS hadn't removed the lower equipment prior to backboarding.

 

[Tigger]

Ugh, just plowed through a bunch of the literature on football (& other helmet/pad sports) injuries. A "crash" course, if you will!

It still stands out to me that the injured football player is managed, to a certain degree, unlike most other patients.

For example, exposure of the patient is deferred to the ED, and two reasons are offered. As Tigger and hops19 point out, it's difficult to expose on the ice or public playing field. But this is not offered as a rationale for other injuries or mechanisms, even those that occur in public.

Much of the literature also supports the idea that it is too dangerous to potentially expose the spine to movement through helmet & pad removal. However, EMS routinely extricates patients from MVCs while maintaining spinal precautions.

This is a fascinating topic, representing the intersection between multiple professional organizations, as well as the evolving practice in identifying and managing the potential cervical spinal injury. Sounds like it's worth a short review, even though I just wrote about new cervical spine research!

As for the OP WWFDCorrie- the literature speaks, for the most part, about the need to align the helmet and shoulder pads, while little mention is made of the hip pads, for example. I'd be fine if EMS hadn't removed the lower equipment prior to backboarding.

The reason we do not remove the pads is that they assist with maintaining neutral alignment of the spine. If the helmet is staying on (and it is unless it has been knocked off), the shoulder pads keep the neck from flexing with a helmet left on. We could I suppose remove shoulder pads and helmet on the ice, but that just seems like a waste of time if no trauma is suspected elsewhere. The ice is also a cold place to be for the patient.

As for lower gear, we're just going to leave that on barring any suspected trauma. 9/10 times when someone gets lit up and has a suspected c-spine injury, there only complaints are going to come from the head and neck area.

 

[Akulahawk]

Ugh, just plowed through a bunch of the literature on football (& other helmet/pad sports) injuries. A "crash" course, if you will!

It still stands out to me that the injured football player is managed, to a certain degree, unlike most other patients.

For example, exposure of the patient is deferred to the ED, and two reasons are offered. As Tigger and hops19 point out, it's difficult to expose on the ice or public playing field. But this is not offered as a rationale for other injuries or mechanisms, even those that occur in public.

Much of the literature also supports the idea that it is too dangerous to potentially expose the spine to movement through helmet & pad removal. However, EMS routinely extricates patients from MVCs while maintaining spinal precautions.

This is a fascinating topic, representing the intersection between multiple professional organizations, as well as the evolving practice in identifying and managing the potential cervical spinal injury. Sounds like it's worth a short review, even though I just wrote about new cervical spine research!

As for the OP WWFDCorrie- the literature speaks, for the most part, about the need to align the helmet and shoulder pads, while little mention is made of the hip pads, for example. I'd be fine if EMS hadn't removed the lower equipment prior to backboarding.

The pads and helmet stay on because those pieces of equipment do assist with cervical stabilization. Once you take the face mask off, there's actually very little metal in the way that prevents a shoot-through, lateral or AP views. Yes, I'm referring to "plain film" x-rays. The shoulder pads may be too wide to fit through the opening of the CT scanner, so you could do some screening shots first. The lower pads won't have much effect on the spine above the L-Spine.

As far as taking the equipment off, it's far better and easier to do it either in the training room OR in the ED where you have the benefit of lots of light, many hands, and the athlete on an elevated table. Athletes are treated a little differently than then general population because of all the equipment they wear. That equipment is also designed for stabilization, as well as protection from impacts received during play. The equipment is usually very well fitted and will provide better stabilization than a LSB alone. You normally don't find car crash victims, motorcycle crash victims, or fall victims wearing significant padding and a helmet. For motorcycle riders, I'm removing the helmet on scene because it's better to do it there, and can be done on scene with a minimal crew.

The other thing is that athletes that are injured enough to be put on a backboard and transported to the ED usually have been evaluated by an ATC and/or team-doc prior to transport. In other words, they're already known to be injured. Remember, ATC's are quite more able to evaluate athletic injury than any Paramedic I've met that hasn't been through a Sports Med Program.

 

[mycrofft]

The reason we do not remove the pads is that they assist with maintaining neutral alignment of the spine. If the helmet is staying on (and it is unless it has been knocked off), the shoulder pads keep the neck from flexing with a helmet left on. We could I suppose remove shoulder pads and helmet on the ice, but that just seems like a waste of time if no trauma is suspected elsewhere. The ice is also a cold place to be for the patient.

As for lower gear, we're just going to leave that on barring any suspected trauma. 9/10 times when someone gets lit up and has a suspected c-spine injury, there only complaints are going to come from the head and neck area.

As I thought. Stands to reason if they protect, then there is a lower freq of injury there.

 

[KellyBracket]

I understand the reasoning behind keeping the helmet and pads on as a unit - there are numerous radiographic studies, motion-capture studies, and expert opinions - but I do think it's valid to revisit the reasoning and logistics behind deferring exposure until the ED.

I also think some of the recommendations about imaging need to be updated, since they don't reflect current EM practice. EMS and trainers should know about this perspective, especially as the approach to suspected cervical-spine trauma evolves.

Here's one example: All patients come off the backboard when they hit the ED. In fact, ATLS states that patients with signs of paraplegia need to be removed from the board ASAP, due to the risk of skin breakdown, etc. Usually, a cervical collar provides sufficient spinal motion restriction after board removal, but the bulky pads and helmet would complicate this.

Another example:If it is believed that a patient very likely has a cervical spine fracture, there is basically no role for plain films these days. We're getting that CT, and probably moving on to MRI as well. We need immaculate images, and the gear is coming off to accomplish that.

Now, if a patient is very unlikely to have a fracture, we could use plain films. But since they are low risk, I am not too worried about getting their gear off to make sure we get a good series of films.

I can't speak for every EM doc, but I tend to be "middle-of-the-road" when it comes to risk and completeness; not OCD, but no cowboy!

There still remain a number of questions. For example, we are (presumably) all talking about football players with well-fitted equipment. The evidence is more muddy for other "helmet & pads" sports, and especially when the helmet is not well-fitted.

 

[mycrofft]

As far as taking the equipment off, it's far better and easier to do it either in the training room OR in the ED where you have the benefit of lots of light, many hands, and the athlete on an elevated table. Athletes are treated a little differently than then general population because of all the equipment they wear. That equipment is also designed for stabilization, as well as protection from impacts received during play. The equipment is usually very well fitted and will provide better stabilization than a LSB alone. You normally don't find car crash victims, motorcycle crash victims, or fall victims wearing significant padding and a helmet. For motorcycle riders, I'm removing the helmet on scene because it's better to do it there, and can be done on scene with a minimal crew.

The other thing is that athletes that are injured enough to be put on a backboard and transported to the ED usually have been evaluated by an ATC and/or team-doc prior to transport. In other words, they're already known to be injured. Remember, ATC's are quite more able to evaluate athletic injury than any Paramedic I've met that hasn't been through a Sports Med Program.

Brother Akulahawk tuned me up for a sports gig, and it was very eye-opening. I recommend such for anyone dealing in ortho period.

What is time element for most football injuries? How often is the patient stressed due to being placed and held supine in their gear?

 

[Tigger]

Here's one example: All patients come off the backboard when they hit the ED. In fact, ATLS states that patients with signs of paraplegia need to be removed from the board ASAP, due to the risk of skin breakdown, etc. Usually, a cervical collar provides sufficient spinal motion restriction after board removal, but the bulky pads and helmet would complicate this.

Exactly, due to the pad's design, we are not typically able to use a c-collar. We have found that a large vacuum splint applied to the head, neck, and upper torso of the athlete is the best way to immobilize a helmeted head with no c-collar. This does a better job than blocks in our opinion. Once at the ED the helmet and shoulders can be removed and then a c-collar applied I supposed?

Another example:If it is believed that a patient very likely has a cervical spine fracture, there is basically no role for plain films these days. We're getting that CT, and probably moving on to MRI as well. We need immaculate images, and the gear is coming off to accomplish that.

Now, if a patient is very unlikely to have a fracture, we could use plain films. But since they are low risk, I am not too worried about getting their gear off to make sure we get a good series of films.

I can't speak for every EM doc, but I tend to be "middle-of-the-road" when it comes to risk and completeness; not OCD, but no cowboy!

There still remain a number of questions. For example, we are (presumably) all talking about football players with well-fitted equipment. The evidence is more muddy for other "helmet & pads" sports, and especially when the helmet is not well-fitted.

If the helmet does not fit well to the point that makes stabilization difficult, we will go ahead and remove it and pad under the athletes head with towels so as to raise the occiput inline with the level that the shoulder pads have brought the torso up to.

 

[mycrofft]

How often are "spinal drills" carried out and properly critiqued?

Age and conditioning count in this picture also. I was seeing lower thoracic and lumbar injuries in 8 yr olds (Jr Peewee) coming off scrimmage line.

 

[hops19]

The National Athletic Trainers' Association has a position statement about the "acute management of the cervical spine-injured athlete" available on their website. It would not allow me to post the direct link because I am so new...

This position statement is from 2009 so it is a couple of years old, but is likely the most current thing the NATA has out..

Good discussion all!

 

[Tigger]

How often are "spinal drills" carried out and properly critiqued?

Two or three time per season per sport. We are lucky in that we have the same two paramedics at nearly every hockey and lacrosse game. This setup has done our organization wonders and I would recommend it to every sports medicine department.

The National Athletic Trainers' Association has a position statement about the "acute management of the cervical spine-injured athlete" available on their website. It would not allow me to post the direct link because I am so new...

This position statement is from 2009 so it is a couple of years old, but is likely the most current thing the NATA has out..

Good discussion all!

That NATA paper is the one that referenced scoop stretchers that I was talking about earlier. Seemed to come out of left field, so to speak.