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Resuscitation

IMPORTANT NOTICE:
On March 30, 2008, the American Heart Association broke away from the ILCOR position
and stated that
COMPRESSION-ONLY CPR WORKS AS WELL AS , AND SOMETIMES BETTER THAN,
TRADITIONAL CPR.
The method of delivering chest compressions remains the same, as does the rate
(100 per minute), but the rescuer delivers only the compression element which,
the University of Arizona claims, keeps the bloodflow moving without the
interruption caused by MTM respiration. It has been claimed that the use of
compression only delivery increases the chances of lay person delivering CPR
(REF Wikipedia, accessed 26/9/08. http://en.wikipedia.org/wiki/CPR)
 

· Introduction
· Sick and injured athletes
· The collapsed athlete
· Early CPR
· The seriously injured
Introduction
 

The number that are life-threatening is probably low.
The risk of these injuries or illnesses amongst athletes depends upon factors, such as the
type and level of sport (amateur versus professional), and the athlete’s previous illness or
injury and level of fitness. Use a simple approach for cases of potential life-threatening
injury (Fig. 1) or illness as confusion or doubt can be lethal..
Sick and Injured Athletes
Resuscitating patients falls into two basis groups:
non-trauma related or
trauma related (Fig. 2).
Various treatment algorithms have been designed for each group (Australian Resuscitation
Council, American Heart Association, Early Management of Severe Trauma, Advanced
Trauma Life Support).
For athletes requiring resuscitation it is essential to determine from
the onset of first aid, if there has been any trauma present.
If there is uncertainty about the presence or absence of trauma,
assume trauma is involved and treat accordingly (Fig. 3).
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Figure 1
 

Field Approach to Injury
 

Injuries can be:                                                                                            Action

 

1.      Minor               ­  cuts/abrasions/sprains/cramps                              Return to game

 

2.      Moderate          ­ sprains (swelling, pain, ▼ ROM)                         Treat on site/later

                                                                                                                       refer

 

3.   Severe              ­ severe pain, swelling, deformity                            Expert medical care

                                 (severe sprains, fractures,

                                 dislocations)

 

4.  Life                   ­ stroke, head/neck injury, heart attack                     Resuscitate

     threatening

 

 

Use:

 

A  airway

B  breathing

C  circulation

 

History:

 

Brief talk to athlete or witness/details of accident/extent pain/assess severity.

 

Examine:

 
Check for:  swelling/deformity/tenderness/ROM and classify (as above).

Treat.

 

 

 
Figure 2
 

Basic differences between non­trauma related and trauma related illness in athletes
     

Non­trauma Related    Trauma Relates
     

Examples Dehydration   Contact sports

  Exertional heat illness ­         spear tackle (rugby)

  (heat stroke) ­         boxing

  Cardiac disease Motor sports

  (eg angina, heart attack, or  Water sports

  arrhythmia) ­         near­drowning

  Exercise induced acute asthma ­         diving into shallow water

  Epilepsy Falls

  Diabetic hypoglycaemia ­         rock climbing

     

     

Airway Management Standard Basic Life Support Must protect the neck and prevent 

  (see below) head movement

     

     

Circulation Management Standard Basic Life Support Require early intravenous therapy

(see below) Obvious external bleeding must be 
stopped

­         pressure

­         bandage

­         Do not use tourniquets

 
Care of the Collapsed or Seriously Ill Athlete
 

The basic principles of the resuscitation of collapsed or seriously ill patients are outlined
(Fig. 4).
The steps in this Chain of Survival are:
1.Early Access to emergency medical services. This “call for help” allows the rapid delivery
of care in the field by ambulance services to commence early stabilisation and delivery of
the patient to a hospital for definitive care.
2. Early commencing of bystander CPR (cardiopulmonary resuscitation), when
required. This will buy time for the arrival of ambulance personnel, particularly in the setting
of cardiac arrest, where early defibrillation is the most important factor determining
survival.
3. Early Defibrillation is the most important factor in determining survival in cardiac arrest
due to either ventricular fibrillation or pulseless ventricular tachycardia.
4. Early Advanced Care implies the rapid delivery of the seriously ill patient to hospital. In
the non-trauma related illness this allows the early administration of advanced medical care.
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Early Access to Emergency Medical Services
 

Emergency medical services are able to achieve two major goals: the early resuscitation
and stabilisation of the seriously ill patient, and the rapid delivery of the patient to definitive
care. This is bet achieved when bystanders “call for help: as the initial step in the caring for
the seriously ill patient. If two or more bystanders are present, one person should dial the
Emergency telephone number, while other commence CPR. When doing this it is important
to relate clear information regarding the location of the patient, and any other information
requested by the operator.
For the infant or child, in arrest, the most likely cause is an airway problem. In this
setting it is best to commence CPR, then call for help.
“Call for help” also implies gaining assistance at the scene, before the ambulance arrives.
Even for people experienced in resuscitation, CPR is always easier with 2 or more people
lending help. Do not hesitate seeking help.
Commencing Early CPR ( SEE ABOVE)
 

The window of opportunity for survival from cardiac arrest is small. As such the aim of
bystander CPR is to increase the time before death occurs, allowing emergency medical
services the opportunity to deliver earl defibrillation, and other advanced care techniques.
After assessing the person’s responsiveness, the steps in bystander CPR or basic life support
for the collapsed patient are as follows (Fig. 5):
 

1. Secure the airway
 

To do this requires 2 actions, firstly clearing the airway, and then opening the airway.
Clearing the airway removes any foreign bodies from the airway including dentures, broken
teeth, food, vomit or blood. It is achieved by the finger sweep, although care must be taken
not to dislodge any loose teeth, especially in young children. When available a suction
device should be used. After clearing the airway, it may need to be opened by a combination
of extending the head, chin lift and jaw thrust (Fig. 6). Various devices such as
oropharyngeal airways or Guedel’s airway (Fig. 7) should be used if available.
2. Assess and ensure breathing (rescue breathing or expired air resuscitation).
To assess the presence or absence of breathing one must look for movement of the chest
with inhalation and exhalation, feel for chest movement and listen for the movement of air.
This can be easily achieved by using the technique shown in Fig. 8.
If there is no evidence of breathing, rescue breathing should be commenced immediately.
This is commenced with 2 slow breaths, by the mouth-to-mouth technique, ensuring that
the chest rises (Fig. 9). If a mouth to mask device is available (Fig. 10), this may be used,
reducing any risk of infection.
The rates and ratios of external cardiac compression and rescue breathing are shown in Fig.
10.
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Figure 11
 

Ratios of breath to chest compressions for cardiopulmonary resuscitation
 

        

Ventilation Chest Compressions Ratio

 
       

One Rescuer   15 breaths/min     80 to 100/min               15 to 2
       

Two Rescuers   15 breaths/min     80 to 100/min                 5 to 1
 

3. Assess and maintain circulation (external cardiac compression)
To assess the circulation the rescuer feels for the carotid pulse, in the neck at the angle of
the jaw. If the pulse is present, but the patient is not breathing spontaneously, continue
rescue breathing at a rate of 15 breaths per minute, until either help arrives or spontaneous
breathing commenced.
If there is o detectable carotid pulse< commence external cardiac compression (ECC)
immediately. The hands are placed on the lower third of the sternum, with the arms locked
at the elbows and the rescuer kneeling over the patient (Fig. 12). Compressions are
approximately 5 cm deep in the adult, at a rate of between 80 to 100 compressions per
minute. This is tiring work, if continued for a prolonged period, so do not hesitate in getting
help from other bystanders, changing every few minutes.
To determine the adequacy of ECC, the carotid pulse should be felt for, and after every 2
minutes of full CPR, a check should be made for the return of spontaneous breathing and
circulation. Full CPR should be continued until either help arrives, or there is return of a
spontaneous circulation.
4. Stabilisation and Transport
 

When the patient begins to maintain their own airway and breathing, and has return of a
spontaneous circulation, they should be placed in the coma position until help arrives (Fig.
13). Airway patency, adequacy of breathing and circulation, should be frequently
reassessed, and any deterioration should be acted upon immediately. Once available, the
patient should be transported to hospital, as soon as possible.
The Seriously Injured Athlete
 

The approach to the seriously injured athlete is similar to that of the seriously ill athlete,
with a couple of points of note. The system taught in Advanced Trauma Life Support and the
Early Management of Severe Trauma courses, is an easy to remember system for dealing
with such cases (see Fig. 14).
Remember:
1. Remove from danger, in order to prevent further injury. While doing so it is essential
to protect the patient’s neck, to prevent any trauma to the cervical spine and spinal cord.
Fig. 14 shows how this may be achieved.
2. Airway management includes care of the cervical spine. In the non-injured
patient, one of the first airway opening manoeuvres is to extend the neck. This should not
be done in the injured patient, especially if unconscious, as it may damage the cervical
spine. All airway manoeuvres must be accompanied by in-line cervical immobilization).
When available, the neck should be immobilized with a rigid cervical collar (see Fig. 16).
3. In controlling the circulation, control blood loss. This can be achieved over the site
of any external bleeding by pressure (Fig. 17). Limb tourniquets should not be used, as
they may cause arterial or nerve damage. Any long bone fractures, especially fractures of
the femur, should be splinted to reduce blood loss and help control pain (Fig. 18).
4. In the unconscious, injured athlete always consider severe head
injury. These patients need rapid stabilisation and transfer to a hospital to allow a further
assessment for potentially life threatening intracranial bleeding, which will require urgent
operation (Fig. 19).
 

Figure 14
                    The approach to the severely injured athlete.  At the scene, it is important to prevent 
further injury by removing the patient from any danger. It is essential to care for the patient’s neck whilst 
doing so.

 
     

Primary Survey Airway and Immobilise head and neck with in­line 

  cervical spine immobilisation stabilisation

    Clear airway

    Open airway – remember not to extend 
the neck
   

  Assess and ensure adequate Commence rescue breathing

  breathing (ventilation)  

     
Control bleeding and Apply pressure to external bleeding
 
maintain circulation commence external
 
chest compression, if no pulse
 

 
     

  Assess disability If unconscious, assume major head injury 

  (neurologic function) and transport to hospital ASAP

    If unable to move arms or legs, assume 
spinal cord injury, and prevent further 
   
injury by not moving until help arrives
   
 
   
     

  Control environment, and be Remove from anger

  able to clearly explain the events  Prevent excessive cooling if injured

  causing injury Be clear about the mechanism of injury 

    (events), as this is important in looking for 
  injuries later
Resuscitation Any immediately  

Phase life threatening problem  

  found in the primary survey is   

  addressed  

     
     

Secondary Survey Usually done in hospital System by system

  head to toe, examination

  front to back examination Thorough history:

  looking for injuries Allergies

  Usually includes x­rays and blood  Medications, last tetanus

  tests Previous illness/surgery

    Last ate

    Event – what happened

     
Stabilisation and  Re­assess ABC, Transport to hospital as soon as possible

Transport  before moving

  Splint any limb injuries

 
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Legends for Chapter 5 – The Fallen Athlete
Figure 1 - On Field Approach to Injury
Figure 2 - Some basic differences between non-trauma related and trauma related illness
in athletes.
Figure 3 - Initial assessment of the sick or injured athlete.
Figure 4 - The Chain of Survival (adapted from the American Heart Association Guidelines
for Cardiopulmonary Resuscitation and Emergency Cardiac Care)
Figure 5 - Basic Life Support
Figure 6 - Opening the airway. Note how each of the manoeuvres results in moving the
tongue from the back of the pharynx. Remember in the injured patient not to use head
extension, as this may damage the cervical spine.
Figure 7 - An oropharyngeal (Geudel’s) airway. When inserting the airway take care not to
dislodge teeth as the airway is rotated into position. This is especially important in young
children with primary dentition.
Figure 8 - Assessing the adequacy of breathing. By adopting this position it is easy to look
for the chest moving, feel for the chest moving, and listen for the movement of air, while
keeping the airway open.
Figure 9 - Rescue (Mouth to Mouth) breathing. Note how the rescuer is able to assess the
adequacy of rescue breathing by watching the chest move, while maintaining an open
airway.
Figure 10 - Mouth to mask ventilation. Such devices are portable and reduce the risks to
the rescuer due to vomiting and infectious diseases. They should only be used by people
adequately trained in their use.
Figure 11 - Ratios and rates for CPR.
Figure 12 - Technique of CPR> Hands over lower 1/3 of sternum, elbows locked, rescuer
kneeling over patient.
Figure 13 - The Recovery (coma) position. Placing the patient in this position allows the
patient op keep their airway open, and reduces the risk of aspiration of vomitus.
Figure 14 - The approach to the severely injured athlete.