Fig. 3.1
Manual in-line cervical spine stabilization with jaw-thrust maneuver. Image provided by Anthony Luke, M.D.
Protective equipment such as helmet and shoulder pads can make safe airway management more challenging; however, an athlete wearing such protective equipment should have their gear left in place, if it is possible to do so while still performing resuscitation, in order to minimize risk of further injury from undue cervical spine motion [12]. If the facemask, however, interferes with access to the airway, it should be removed. The tool and technique used to remove the facemask should be fast and easy to use and most importantly create the least head and neck motion. A combined-tool approach is recommended to avoid chance of failure. For football helmets, a screwdriver or cordless screwdriver can be used in the first attempt, followed by the use of a backup cutting tool to cut away any remaining loop straps if necessary. More recently developed helmets have quick-release mechanisms triggered by depressing a button. Regardless of the type of helmet, the goal is the same; remove the facemask in the most efficient manner without causing further harm [9].
The helmet and shoulder pads should not be removed unless the airway is unable to be accessed by other means. This should follow an “all or none” principal whereby the helmets and shoulder pads are either both removed or both left in place. Removal of the helmet alone results in hyperextension of the athletes’ cervical spine, while removal of only the shoulder pads alone leads to neck flexion and inability to maintain neutral cervical spine stabilization.
Similar to adults, pediatric athletes ages 8 and older should ideally have their equipment left in place [13]. While athletes 8 years and older may have residual skeletal disproportion until maturity is reached, no modification of alignment is necessary. No statistically significant difference in cervical spine angulation has been found for this age group when comparing the fully equipped athletes to those without equipment. Therefore, adult guidelines following the “all or none” equipment principle apply to the older child or adolescent athlete [13]. If equipment is properly fitted, leaving the helmet and shoulder pads strapped in place will minimize motion and angulation of the cervical spine, thus decreasing the risk of further injury [14]. For younger athletes (age 8 years old and younger), the emphasis on performing the necessary modifications to maintain neutral alignment is the same, although no formal guidelines on equipment have been established.
In certain situations, it may be necessary to remove an athlete’s protective equipment. An athlete’s equipment should be removed if: the helmet and chin strap do not hold the head securely to allow for complete immobilization; the airway and ventilation cannot be controlled despite removal of the facemask; the facemask is unable to be successfully removed; the helmet prevents proper neutral alignment for cervical spine immobilization; or the equipment is interfering with needed access to the chest, neck, or head [9, 15]. Helmet and shoulder pad design is variable, and therefore, the sideline medical team should familiarize themselves with their team’s particular model. In general, to remove the helmet, the chinstrap is removed from the helmet followed by cheek pad removal. Helmet air bladders should be drained with a needle or blade to loosen fit of the helmet. Cervical spine stabilization should be transferred from the person at the athlete’s head to another person that can apply stabilization from the front. The person at the head grabs the helmet from the sides pulling the sides outward and then rotates the helmet up while sliding it off the head [9]. The athlete’s jersey is slit along the midline and sleeves allowing the strings or buckles on the front of the pads to be cut. While maintaining cervical spine control from the front, the rescuer from the head carefully removes the shoulder pads by sliding them out from under the athlete [9].
Breathing
Assessment of breathing includes evaluation of respiratory rate, effort, adequacy of air excursion, and the presence or absence of cyanosis to ensure adequate oxygenation and ventilation [16]. Airway patency does not ensure adequate ventilation. Hypoxia is the most common cause of cardiac arrest in a child and is of significant concern especially in a head injured athlete [10]. Younger athletes (ages 4–5) have faster respiratory rates at 22–34 breaths per minute, while adolescents have rates similar to adults (12–18 breaths per minute) [16]. Children also have small tidal volumes so chest wall rise may be subtle, but should be readily seen when the chest clothing is uncovered [10, 16]. Breath sounds should be assessed for symmetry. Transient respiratory arrest and hypoxia are common with severe brain injury [8]. Bag-valve-mask ventilation should be initiated if breathing is inadequate and equipment is available. Bag-valve-mask ventilation is much easier in children than adults due to smaller size and more compliant physiology, but regardless of age it is always essential to ensure a proper seal around the mouth. Care should be taken to avoid overventilation. In cases of traumatic brain injury, hyperventilation can be detrimental by worsening cerebral ischemia [10].
C irculation
Rapid assessment of hemodynamic status can be achieved by evaluating skin color, pulse, and level of consciousness. Pink skin and normal capillary refill, especially in the face and extremities, are suggestive of adequate perfusion. However, skin assessment can be affected by ambient temperature and is not always reliable. Pulse should be assessed for quality, rate, and regularity [8, 10]. In addition to several other etiologies (e.g., traumatic brain injury or metabolic dysregulation), reduced central and cerebral perfusion may be a cause of an altered level of consciousness.
Vital signs are less sensitive for identification of shock in children than in adults [10]. Children have increased physiologic reserve that allows for maintenance of perfusion even in the presence of shock [8, 10]. The presentation of a child in early shock can be subtle; thus, a high index of suspicion is warranted. Tachycardia is the earliest finding of circulatory compromise in children and therefore mandates closer attention and evaluation [10]. Slowing of the heart rate below normal is also a concerning sign, which may indicate neurogenic shock in an athlete with cervical spinal cord injury [8].
Disability and Neurologic Status
A focused neurologic evaluation quickly establishes the athlete’s level of consciousness, pupillary response, and focal neurologic deficit. The goal during the primary survey is to assess the general level of injury until there is more time for an in-depth evaluation. The most rapid assessment can be performed using the Alert-Voice-Painful-Unresponsive (AVPU) mnemonic. Those athletes that are not fully alert and only respond to voice, pain, or not at all should be presumed to have a head injury [10, 16]. These athletes have an unreliable neurologic exam and therefore should have full spinal precautions. Subsequent steps should include checking the size and reactivity of the pupils followed by gross assessment for movement and sensation in each extremity. Unequal or poorly reactive pupils can indicate brain injury. Abnormal posturing (involuntary flexion or extension of the arms and legs) also signifies severe brain injury and poorer outcomes. Any evidence of loss of sensation, paralysis, or weakness of the extremities suggests spinal cord injury [8, 10].
The Glasgow Coma Scale is a simple, objective, and reproducible clinical measure of level of consciousness and neurologic status. This 15-point system estimates the severity of brain injury by evaluating eye opening, verbal response, and best motor response (Table 3.1) to different stimuli. A GCS score less than 8 is concerning for severe brain injury or coma; a score of 9–12 is moderate, while a score of 13–15 is the classification for possible minor injury. The AVPU mnemonic is preferred during the primary assessment; therefore, determination of the athlete’s GCS can be deferred until there is time for more in-depth evaluation [10].
Table 3.1
Glasgow Coma Scale
Assessment | Scale | |
|---|---|---|
Eye opening (E) | Spontaneous | 4 |
To speech | 3 | |
To pain | 2 | |
None | 1 | |
Verbal response (V) | Oriented | 5 |
Confused | 4 | |
Inappropriate words | 3 | |
Incomprehensible sounds | 2 | |
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