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Emergency Management of Head and Neck Injuries

PURPOSE: To set standard guidelines to follow in the event that an athlete suffers a suspected head and/or neck injury, and must be transported to the hospital for further evaluation and treatment. To coordinate a medical team approach involving the Staff Athletic Trainers (AT), athletic training students, team physicians, and local EMS agencies.

SECTION REFERENCE: Emergency Procedures

LEVEL OF PERSONNEL: Staff ATs, Athletic Training Students, Team Physicians, Coaches, Athletic Director, Assistant Athletic Director, Rockingham County Fire-Rescue personnel, Bridgewater Volunteer Rescue Squad personnel, and Bridgewater Volunteer Fire Department personnel

EQUIPMENT: Backboard, spider-straps, cervical collar, cervical immobilization device, towel rolls, tape, radio, cellular phone, and emergency care equipment/supplies

CONTRAINDICATIONS: Not applicable

INDICATIONS: In the event of a suspected head and/or neck injury in which transportation of the patient to the hospital emergency department is advisable.

PROCEDURES/GUIDELINES: 1. The Staff AT should be summoned to the injury site via the radio/cell phone if they are not already on site.
2. The athletic trainer should utilize the appropriate personal protection equipment to protect themselves and the athlete against the transmission of any bloodborne pathogens.
3. The athletic trainer should immediately establish manual stabilization of the head and neck. The head and neck should be stabilized in the position in which the patient was found. 
4. If the cervical spine and/or general spinal alignment is not in a neutral position, the athletic trainer should attempt to place the cervical spine in a neutral position unless the following events occur:
- The athletic trainer meets resistance while attempting to reposition.
- There are increased neurological symptoms or pain while attempting to reposition.
- The patient’s airway becomes obstructed while attempting to reposition.
5. If the patient is suspected of having an unstable vertebral fracture, skull fracture, spinal cord injury, and/or internal head injury, the EAP should be activated for the specific athletic venue and EMS should be immediately summoned (call 911). At this time an athletic trainer, athletic training student, or other bystander should acquire the closest automated external defibrillator (AED). The patient will need to be transported to the hospital emergency department as soon as possible.
6. The following information should be provided when the athletic trainer or bystander contacts EMS:
- Identify yourself.
- Give location, phone number, and the location of the injured athlete.
- Inform them of what injury is suspected and the condition of the athlete.
- Answer any questions as quickly and accurately as possible.
- Do not hang up until EMS arrives on the scene or the dispatcher hangs up. Make sure that the phone line remains open.
- Do not leave the phone unattended in case EMS would need to make follow-up contact.
7. Once EMS has been contacted, a Staff AT or athletic training student should contact the Bridgewater College Campus Police and Safety at 540-828-5609 and inform them of the emergency situation.
8. An athletic training student will be sent to obtain materials to be sent with the patient (medical history and insurance information) and return to the site in a timely and calm manner.
9. Another athletic training student will proceed to meet and direct the ambulance to the injury site. This athletic training student will insure that any door or gate is unlocked and the predetermined route of entry is used (see the Emergency Action Plan for the appropriate route of entry that local EMS will use to gain access to the specific athletic venue where the athlete is located).
10. All other athletic trainers and/or athletic staff not involved in the emergency plan are to continue their duties and be alert to assist as needed.
11. The primary assessment begins by determining the patient’s level of consciousness. A fully conscious patient is questioned regarding the presence of pain, particularly in the spinal region or a limb, altered sensation or strength of any body part, weakness, and visual and hearing function. If unconscious, the patient is presumed to have an unstable vertebral fracture, skull fracture, spinal cord injury, and/or internal head injury until it is proven otherwise. In the event there is an unconscious patient or a patient who exhibits any abnormal neurological function, the Glasgow Coma Scale should be used as a rapid, objective, and reproducible measure of cerebral function, until a more formal neurological examination is carried out. (Ammonia or smelling salts should always be avoided in the dazed or unconscious patient because a reaction of jerking away from this stimulus may cause additional injury).
12. The evaluation and maintenance of a functional airway should be rapidly performed with full consideration for the potential of a spinal injury. If the patient is unconscious or the patient is presumed to have an unstable vertebral fracture, skull fracture, spinal cord injury, and/or internal head injury, the athletic trainer should establish the airway using the jaw-thrust technique. Using the jaw-thrust technique, the athletic trainer places his or her fingers behind the angle of both sides of the patient's jaw and lifts up, bringing the mandible forward. The athletic trainer should use the look, listen, and feel method to assess breathing. Absence of breathing, ineffective breathing patterns, the use of accessory breathing muscles, or even apnea can be a sign of cervical spinal cord injury.
13. The patient’s pulse rate and quality should be simultaneously assessed by palpating the pulse at the carotid artery.
14. If the patient is not breathing, the athletic trainer should begin providing ventilations using an appropriate airway adjunct (nasal, oral, or King airway), resuscitation mask, and/or bag-valve mask, with supplemental oxygen.
15. If the patient does not have a pulse, the athletic trainer should begin cardiocerebral resuscitation (CCR) and the AED should be attached to the athlete as soon as possible and used as indicated by the AED unit.
16. Any extensive bleeding should also be identified and controlled using the appropriate technique given the circumstances
17. If the suspected spinal-injured athlete is equipment laden, the following steps should occur:
- If possible, the facemask must be removed from the helmet as soon as possible. Using the appropriate tool (consisting of but not limited to; electric screwdriver, Quick release installation tool, FM Extractor, Trainer’s Angel, etc.), remove all facemask loop-straps. Once all facemask loop-straps have been cut or removed, carefully remove the facemask from the helmet.
- If an air cell–padding system is present, deflate the air inflation system by releasing the air at the external ports with an inflation needle.
- The jersey and all shoulder pad straps will be cut.
- Two to four rescuers will support the patient’s chest and upper extremities between the shoulder pads and scapula, bilaterally.
- The helmet chin straps will be cut.
- Cervical spine stabilization will be transferred to a secondary rescuer, who will hold c-spine stabilization in an anterior cephalad position (front, in-line stabilization) by placing their hands posteriorly under the occiput and anteriorly under the chin.
- Once c-spine stabilization is secure, an 8-person lift will be performed.
- If due to patient’s size the Staff AT does not feel that an 8-person lift can be performed safely, then the superior portion of the patient’s body will be slightly flexed at the waist.
- The individual positioned at the patient’s head will remove the helmet and shoulder pads with as minimal movement of the patient as possible.
- The patient will then be lowered back down to a neutrally supine position.  The individual positioned at the patient’s head will then re-establish c-spine stabilization. 
- A cervical collar will be applied as soon as it is feasible.
18. Conduct a secondary survey (including vital signs) for any other injuries that may have been sustained.
19. A neurological screening examination is performed to assess motor, sensory, reflexes, and cranial nerve function.
20. When EMS personnel arrive, both they and the athletic training staff should work as a team in the immobilization process and preparing the patient for transportation. All arriving medical personnel should be briefed on the situation efficiently and effectively.
21. Using the appropriate technique, the patient should be transferred onto a backboard. To transfer a supine patient from the ground onto the backboard, use the 8- person lift technique along with a rigid backboard or scoop stretcher. To transfer a prone patient, logroll the athlete directly onto the backboard using at least 4 persons. When log rolling an athlete, the head and trunk must be moved as one unit. Cervical immobilization should always be maintained during this process.
22. Immobilize the patient’s head and neck using the cervical immobilization device (CID) on the spineboard or towel rolls. The head should additionally be secured to the board with adhesive tape or straps.
23. Secure the patient to the spineboard using the correct technique. The securing of a patient to a spineboard should always include straps to secure the pelvis, shoulders, legs, and, lastly, the head. The straps must be applied snugly. Any gaps in the backboard strapping should be filled in with towels or rigid foam.
24. If the patient is vomiting or bleeding from the oral cavity after being secured on the spineboard, the patient and backboard must be turned on its side as a unit to prevent aspiration of blood or vomit into the airway. A suction unit should be used to assist in clearing the airway as soon as it is available.
25. Once the patient is completely stabilized, the person at the head relinquishes control, and the patient is transported to the Sentara RMH emergency department via EMS, unless EMS deems and notifies another area facility more appropriate for providing medical services.
26. A staff AT or athletic training student should travel with the pateint to the hospital if possible. The individual traveling to the hospital with the pateint should have a cell phone with them so they can easily communicate with the athletic training staff and team physician as needed.
27. Once the patient is secure and stabilized, the Director, Clinical Athletic Training (DCAT) will be notified of the emergency situation (if not already aware). The DCAT and/or DCAT’s representative should notify the patient’s emergency contact person and/or parents/guardians.
28. The DCAT will be responsible for notifying the Athletic Director, Executive Assistant to the President, and/or the President of Bridgewater College.
29. The DCAT will be responsible for assisting the Athletic Director with any media contact if it is necessary.
30. The Staff AT should complete all documentation of the injured athlete and all actions taken.