FIFA Emergency Care Manual 2022

FIFA
EMERGENCY CARE
MANUAL
Fédération Internationale de Football Association
President: Gianni Infantino
Secretary General: Fatma Samoura
Address: FIFA
FIFA-Strasse 20
P.O. Box
8044 Zurich
Switzerland
Telephone: +41 (0)43 222 7777
Internet: FIFA.com
CONTENTS
1 INITIAL PITCHSIDE ASSESSMENT – THE FIFA APPROACH 5

Communication9
Roles within the team 11
FIFA extrication “set piece” 15
Top tips for successful pitchside outcomes 18
2 INITIAL ASSESSMENT – THE PRIMARY SURVEY 19

Flow chart for initial assessment pathway 21
The primary survey/primary assessment 22
Airway 23
Cervical spine 28
Breathing Circulation30
Disability 33
Extrication36
3 CARDIAC ARREST 39
Reversible causes of sudden cardiac arrest/traumatic cardiac arrest 51
Transfer of a player suffering from sudden cardiac arrest 53
Prevention of sudden cardiac arrest in football 55
Cardiovascular screening 57
4 CHOKING AND ANAPHYLAXIS 61

Choking and Anaphylaxis 62
Treatment65
5 MEDICAL EMERGENCIES 69
Chest pain 70
Asthma/exercise-induced bronchospasm 78
Seizures/epilepsy85
Hypoglycaemia89
6 TRAUMA EMERGENCIES 93
Spinal injury 97
Head and maxillofacial injuries 103
Chest trauma 118
Pneumothorax121
Abdominal injury 124
Pelvic injury 127
Limb injury 129
Wounds134
7 CONCUSSION 145
Definition and classification of concussion 146
Management of concussion 147
Baseline examination 147
Diagnosis and management in the first 72 hours after the head injury 148
Observation and recognition (phase 1) 148
1
CONTENTS
Emergency management and red flags for referral to hospital 151

Initial (on-pitch) examination of head injuries (phase 2) 153
Off-pitch examination (phase 3) 155
Quiet-area examination and treatment (phase 4) 156
Observation and serial re-examination until departure (phase 5) 156
Observation for 24 hours after head injury (phase 6) 157
Re-evaluation between 18 and 72 hours after head injury (phase 7) 158
Graduated Return-to-Football Programme (phase 8) 159
8 THE FEMALE ATHLETE 165

Lower abdominal pain 166
Vaginal bleeding 167
Sport-induced genital trauma 167
9 ENVIRONMENTAL EMERGENCIES 169

Altitude illness 170
Cold emergencies 177
Heat illness 185
10 THE FIFA EMERGENCY CARE BAG (FECB) 2022 195

Contents of the FECB 197
Other recommended pitchside emergency care equipment 198
Skill zone – practical skills and techniques 200
2
3
4 Initial pitchside assessment – the FIFA approach
INITIAL PITCHSIDE ASSESSMENT
– THE FIFA APPROACH
1
INITIAL PITCHSIDE ASSESSMENT –
TH E FIFA A PPROAC H
The assessment of a player who has collapsed or sustained an injury needs to be
structured and consistent.
Regardless of whether a player requires medical attention during training, a warm-

up session or a match, having a framework that can be applied in the same way each
time will help to ensure the best outcomes. This can, and should, be considered as the
medical version of a “set piece”.
The “chain of survival” as a concept in resuscitation outcomes also applies to us as we

need to understand that multiple elements combine to ensure we provide the best
care. We are only ever as strong as the weakest link in the chain.
We must have the appropriate equipment, knowledge and skills as well as an

understanding of our own and others’ roles within the medical team.
If any one of these aspects of the chain fails, it will result in poorer outcomes. It is only in
the last 15 years or so that the focus has been on ensuring that we provide the optimum
pitchside medical response. The emphasis was initially on knowledge and skills, but
the focus now also involves incorporating the human factors elements of what makes
a successful medical response and, importantly, what constitutes a poor response and
therefore leads to a poorer outcome.
It is understood that the availability of medical personnel will vary between clubs as
The clinical
well as within organisations, so having a predetermined plan in place to account for
these differences is paramount. If your players only have access to a physio during
team needs to
training, then you will need to think slightly differently about how you deal with an be proactive
emergency in this situation as opposed to a matchday scenario where the team may
have many more resources at its disposal. The actual clinical framework of how you deal rather than
with a presentation of collapse or injury will always be the same but, to achieve the
best outcome, some of the team may need to perform more than one role, depending reactive.
on when and where the emergency occurs. Planning and communicating in advance of
an event about who will assume these clinical responsibilities results in the best chance
of an optimum outcome.
6 1 Initial pitchside assessment – the FIFA approach

Planning is therefore a key element in ensuring that the chain is kept at its strongest.
Having access to the FIFA pre-match emergency action plan (PEAP) is a key part of
ensuring that proper attention to detail has been achieved prior to a clinical event
arising.
The clinical aspects of how we approach a critically ill or injured player remain
structured along the A C BCDE primary survey process, as described in chapter 2.
Our focus is always to prioritise and manage the issues in a way that tackles life-
threatening problems (or the potential for life-threatening problems) in a sequence
that maximises the chances of the best outcome and minimises the chance of missing
something that should have been prioritised and treated earlier.
It is human nature to be distracted by an “obvious” injury, such as a clearly angulated

lower limb, for example. The risk here is that we may forget to assess a more significant
injury, such as an associated chest/lung injury. Having a default structure for our
assessment is key to ensuring that, regardless of the pathology we face, we adopt a
clear approach to our assessment and actions.
MATCH DETAILS CONTACT INFORMATION
V
Team leader
Venue KO Time
EMERGENCY ACTION PLAN Mobile number
Nearest hospital
Phone # of nearest hospital (Ensure ambulance is called)
INITIAL PRIORITY OF THE TEAM = ALWAYS ASSESS FOR POTENTIAL SUDDEN CARDIAC ARREST
MAY FLIP ALL ASPECTS
DEPENDING ON SITE OF
RESPONSIBLE INJURY AND HAZARDS
Collapsed and unresponsive
TRAUMA = sudden cardiac arrest
NAME(S)
• Structured assessment of breathing and circulation PRIORITY IS TO ASSESS FOR SIGNS OF LIFE
• Assessment of disability and head injury If no signs of life:
• Take chest in log roll • Commence CONTINUOUS chest compression

andcall for AED application
• Apply airways adjunct if required
• Rotate from chest compressions after 2 minutes
•
AIRWAY MANAGEMENT
• Cervical spine immobilisation • Airway opening manoeuvres
• Jaw thrust • Insert Laryngeal Mask Airway (i-Gel or similar)
• Take head in log roll • Apply bag valve to Laryngeal Mask Airway and
squeeze every 10 compressions
EQUIPMENT – Bring FIFA bag and AED EQUIPMENT – Bring FIFA bag and
• Apply AED (if necessary) • Apply AED
• Assist with equipment • Assist with equipment
• Prepare to perform chest compressions
EQUIPMENT – Bring oxygen cylinder EQUIPMENT – Bring oxygen cylinder

• Apply oxygen to trauma mask at 15l • Apply oxygen to trauma mask at 15l
• Take the pelvis in log roll
EQUIPMENT – Bring on scoop and splints EQUIPMENT – Bring on scoop and splints
(Involve First Aiders prior to the match) (Involve First Aiders prior to the match)
• Take the legs in log roll
FIRST AIDERS
Figure 1: FIFA pre-match emergency action plan (PEAP)
7
Looking at the FIFA pre-match emergency action plan (PEAP), the
priorities and issues that need to be dealt with will not change; what
might differ are the number of people available to help you make
the best assessments and apply the best treatment.
A name should be written on the FIFA PEAP alongside each of

the tasks and it should be clear to each individual what their
responsibilities are. The medical team leader should ensure that they
have confirmation from each individual within the medical team
that they understand their role and responsibilities and that these
individuals have the clinical skills and knowledge to carry out this
role.
Familiarity within a team is important, but often it may be impossible

to know everyone who may be involved, especially when travelling
and playing in an unfamiliar environment. Each team’s medical
lead and the stadium doctor (where appropriate) must take the
time to go through the plan prior to a match and ensure a sound
understanding of the structure of the PEAP and how it aligns with
the resources available at the stadium as well as locally.
Practising scenarios or moulages prior to each match or during

training will help to emphasise the structure of the system being
applied. This encourages familiarity between the individuals working
within the team and should provide a degree of reassurance about
what each individual’s role entails.
The aim of the PEAP is to build on this understanding of roles and to

introduce other important details, such as where each person should
be positioned when on the pitch. Apart from physical obstructions
such as goalposts or advertising hoardings, there is no reason why
the individuals in the pitchside team cannot take up exactly the same
position on the pitch in relation to the injured player each time they
enter the field of play to:
• minimise any confusion over where each person should be;

• minimise the chances of people getting in each other’s way;
• make the extrication team more efficient; and
• inspire confidence in the team among those watching on
as well as among the players themselves.
This is fundamentally a scripted medical response that features lots

of moving pieces all working together in a predictable, synchronised
manner without each member interfering with the other members’
work. When practised regularly, this will result in the best response
and outcome.
If you think about this process as a scripted or staged response, the

analogy of a medical “set piece” becomes clearer and more fitting.

COMMUNICATION
Communication is an integral component of ensuring optimum
outcomes. This challenge may be greater in international football
than in domestic club football as the use of different languages may
affect communication and understanding.
During the COVID-19 pandemic, our ability to speak clearly, listen

and understand was physically impaired because of the extent of
personal protective equipment (PPE) that had to be worn to protect
ourselves, our colleagues and players.
It is useful to remember that whilst what you say may be heard, it

does not necessarily mean that it has been understood.
It is the team leader’s responsibility to ensure that their requests

are directed to the individual best placed to perform that task.
Furthermore, the team leader needs to ensure that the team member
has not only heard the request, but has also understood it. Once the
task has been completed, the team member should inform the team
leader so as to close the loop.
Closed-loop communication is helpful in ensuring that instructions

are not lost in translation.
Using peoples’ preferred names is an incredibly powerful leadership

tool, but forgetting them in the heat of an emergency situation is
The aim of
unfortunately common. It is very helpful to print out a copy of the
PEAP team structure as an aide-mémoire and to ensure that team
the PEAP is to
members’ names are used when you are giving them instructions. build on the
This is not only important in terms of accurately communicating understanding
instructions, but the impact of being able to tell a team member
that they have done a good job and using their name whilst you of roles and
do so is also incredibly powerful and is an approach that should be
employed wherever possible. Clearly, the importance of knowing
to introduce
the names of everyone in your team should not be understated. other
The impact of stress and how it affects us and our decision-making important
is widely documented. In many cases, it is not a lack of skill or
competence that leads to poor outcomes – it is down to shortcomings details.
in preparation and communication, compounded by our predictable
but natural response to the stress of managing an emergency, almost
certainly in a relatively unfamiliar environment.
One of the ways in which this stress can be reduced is by using

checklists to standardise processes and thus minimise the impact of
decision-making.
The FIFA PEAP is a good example of a checklist that everyone within

the team has access to and should be familiar with prior to an
emergency event. It is a script for everyone to work from. An PEAP
should only contain details relevant to the processes that the team
will follow.
9
Another checklist that should be used is the equipment checklist.
This should also be consulted at the same time as the team briefing
to go through the PEAP.
This is a vital step to ensure that:
• all of the equipment that is expected to be present is, in

fact, present and in date; and
• the team members allocated to look after or use the
equipment can check that they are familiar with the
particular make or brand of kit that will be used.
The chain will fail if the highly trained team finds, for example, that
the defibrillator battery is flat or that the oropharyngeal airway was
not replaced after it was last used. It is abundantly clear that the
easiest way to mitigate for this is to check the equipment against the
checklist, both immediately before and after a match.

ROLES WITHIN THE TEAM
Within many clubs and national teams, there are variations in terms of the number of
personnel in the medical team as well as their experience and skill sets.
There will also be variations win the pitchside emergency team in terms of who is
physically available at any given time, but this does not detract from the different
roles that will still need to be filled if an emergency arises.
It is sensible to look at these roles at this point to allow us to break down how our
assessments should be structured.
It should be remembered that first-aiders and paramedics are also a fantastic resource.
However, unless they are integrated into the team, and have a complete understanding
of their roles, they will not be able to contribute to the best of their ability.
In the event of a significant incident such as a cardiac arrest, there may be just as many
issues with having too many people as having too few.
It is vital that everyone is prepared in advance

MAY FLIP ALL ASPECTS
DEPENDING ON SITE OF
INJURY AND HAZARDS
Figure 2: Roles within the team
11
TEAM LEADER
Ideally, the team leader will operate in a “hands-off” role. This means that they will not
be involved in physically assessing and treating the player, but will instead coordinate
the process and ensure that tasks are clearly communicated and performed. This
hands-off role will give the team leader greater oversight of everything going on
around the injured player and prevent them from becoming fixated on any given task.
One example could be a situation in which there is a delay in applying a defibrillator

to a player in a cardiac arrest situation. If, for example, the defibrillator arrives slightly
after the team starts treating the player, the team will already be focused on chest
compressions and ventilations and may forget to use it as soon as it is available. Without
someone overseeing the situation, it would be easy for a significant amount of time to
pass before it became apparent that the defibrillator is available for the team to use.
Task fixation can be useful in terms of helping an individual to focus on performing

their individual task, but it is not necessarily good for the overall outcome in relation
to the player if other things end up being lost along the way.
The role of the team leader is to ensure that all tasks are completed and that overall
focus is retained. Referring to a checklist or to an PEAP is not a sign of weakness, but
rather a sign that the team leader understands the limitations of their ability to cope
under pressure.
Responsibilities Lead the team

Remain hands off or have a very specific but also
very limited role, i.e. applying the defibrillator and
ensuring safe defibrillation
Challenges Ensuring effective communication

Maintaining an effective overview
Remaining hands off
“TAKE THE HEAD” TEAM MEMBER

A key part of our assessment is to ensure that we cause no further harm.
The initial or “primary” injury may have already occurred, but unnecessary movements
thereafter may significantly exacerbate it.
The most important example of this relates to cervical spine injuries (or the potential
for a cervical spine injury). In order to take control of the cervical spine, one person
must take responsibility for restricting movement of the cervical spine. This team
member should not only approach the player in a manner that minimises the need
for the player to turn their head towards the team member, but they should also take
control of the spine by holding both sides of the player’s head. From this position, they
can speak to the player. This team member can undertake a number of interventions,
but they are limited in that they cannot take their hands off the player’s head unless
someone else takes control of the head for them or unless full immobilisation of
the cervical spine is achieved (see the section on cervical spine injuries for further
information relating to the management of suspected or confirmed neck injuries).

Responsibilities Control the cervical spine manually
Speak to the player
Perform a jaw-thrust at the same time
(but only if experienced in doing so)
Apply a face mask for bag-valve-mask
(BVM) ventilation
Control the log roll
Have good oversight as they are hands on but
limited in what they can do
Challenges Limited in what they can do because their hands

remain on the player’s head until the cervical spine is
either cleared or fully immobilised
“CHEST” TEAM MEMBER

This team member is located to the player’s right, level with their chest. Naturally, this
person will take on leadership duties if there is no one else available to undertake them.
They should therefore ideally be one of the most experienced members of the team.
Responsibilities Make an initial airway assessment

Apply airway adjuncts
Assess breathing
Apply oxygen
Squeeze bag during BVM ventilation
Assess circulation
Check pulse
Perform chest compressions during CPR
Assess disability/head injury
Take the chest in the log roll
Challenges Multi-tasking – therefore at increased risk of error,

especially if assuming the role of team leader in
addition to this role
“PELVIS” TEAM MEMBER

This person is also located to the player’s right, level with their pelvis. They do not
need to have a medical skill set, but they should be trained in how to respond and
carry out a log roll.
Responsibilities Take the pelvis in the log roll

Assist with spider straps
Can be tasked to bring on specific elements of the
required equipment
Challenges Lack of available medical personnel may mean that

non-medical persons take on this role. Training is
therefore paramount
13
“LEGS” TEAM MEMBER
This person is also located to the player’s right, level with their lower legs. As with the
previous role, this individual does not need to have a medical skill set, but they should
be trained in how to respond and carry out a log roll. Given that there is far less weight
involved in taking the legs in comparison to the other positions in a log roll, this task
could be assigned to one of the smaller team members if numbers are limited.
Responsibilities Take the legs in the log roll

Assist with spider straps
Can be tasked to bring on specific elements of the
required equipment
Challenges Lack of available medical personnel may mean that

non-medical persons take on this role. Training is
therefore paramount
“EQUIPMENT” TEAM MEMBER

Making sure that the bag is packed correctly and that all items are labelled are also key
to ensuring that you do not waste time searching through the bag for equipment that
you may need in a hurry. The FIFA Emergency Care Bag includes all of the equipment
stipulated in the regulations in an intuitive and well laid-out manner to make it very
easy for you to find everything you may need in an emergency, including a defibrillator.
Figure 3: FIFA Emergency Care Bag
As well as the FIFA Emergency Care Bag, you may need splints and extrication
equipment. All of this equipment can become relatively heavy and cumbersome,
making it very difficult or even impossible for one person to carry it all. Using team
members 4 (“Pelvis”) or 5 (“Legs”) ensures that everyone is aware of their shared
equipment responsibilities and is physically able to carry what they are asked to do.
The role of team member 6 (“Equipment”) is to ensure that the right equipment is given
to the right person at the right time, i.e. the person who is carrying out the assessment
and making the interventions as required. This is invariably team member 3 (“Chest”).

It is not necessary for the “Equipment” team member to be technically competent in
the use of the equipment, but they must have an understanding of the names and
functions of the equipment in the bag and know where in the bag each piece of
equipment is located.
During a match, when there is also access to a pitchside extrication team (usually
provided by the stadium), it is vital to involve them in the PEAP and ensure that all
parties understand their roles. These persons are highlighted in yellow in the FIFA
PEAP . Although they are physically separate from the rest of the medical team, they
can still be invited to join the team at any point to occupy any of the roles if there are
not enough medical personnel to complete the team.
Physical distance is maintained in an effort to minimise the number of people around

the player to avoid the issue of people getting in the way of each other and making
communications even more challenging.
Clearly, the situation (especially at a training site) may be very different in terms of the
number of personnel available. The challenges will therefore be different because,
regardless of the number of people available in your medical team – whether it be six
or one – all of the roles described above will still need to be undertaken at some point.
It is almost impossible to manage a critical incident with only one trained medical
person, but it becomes much easier with two and progressively simpler as the size of
your team increases. However, as soon as you have more people than roles for them to
fill, you risk them detracting from the provision of optimum clinical care.
One way to manage this is by going back to the PEAP and ensuring that it is clear at
the start of the activity (whether it is a training session or a match), checking which
medical personnel are available and outlining everyone’s roles and responsibilities,
prior to any incident occurring.
In chapter 2, we will go through the clinical process relating to the priorities for
assessment and management, but in terms of the FIFA framework for pitchside
assessment. After having described the roles and responsibilities of each team member
involved in the initial assessment in this section, we will now proceed to consider the
roles and responsibilities involved in safe extrication.
FIFA EXTRICATION “SET PIECE”

There are two parts to the extrication “set piece”:
1. Set-up of medical equipment at the player’s head

2. Set-up of extrication equipment
The purpose of the “set piece” is to simplify the emergency management of any
presenting condition as well as the extrication process so that all medical team
participants enter the field of play and take up a predetermined position.
This should result in the medical team undertaking a series of very coordinated actions
in a highly predictable way.
All positions and responsibilities must be allocated as part of the PEAP prior to the
match.
15
The key to the set piece is that the kit is brought on to the pitch and laid out as follows:
Medical equipment
The FIFA Emergency Care Bag and oxygen should be brought on and placed to one
side of the player’s head, and one team member should be tasked with handing out
the equipment as and when it is needed.
Extrication equipment
Basket stretcher with scoop stretcher inside, head huggers, tape and spider straps.
The basket should be placed in line with the player’s feet, two to three basket lengths
away.
The scoop should be removed from the basket and laid out between the basket
and the player, also in line with the player’s feet. It should be opened out and fully
extended, if this has not already been done.
The scoop should then be split, ready to slide up either side of the player.
It is vital that the team carrying the scoop does not get in the way of the medical team,
particularly if there has been a lower-limb injury.
Figure 4: FIFA extrication “set piece”

The extrication team (yellow) should stand or kneel beside either the scoop or the
basket (depending on how many members there are), facing the player, and await
further instructions from the team leader.
At the team leader’s request, they may be invited to take up positions for the log roll if
extra personnel are required. One person should remain free to pass the scoop up the
side of the player and slide the basket in place underneath once the player has been
strapped to the scoop and lifted.
Our medical “set piece” has so far involved the medical team members being briefed on
how things are expected to play out. Each person knows their role, their responsibility
and their place on the field of play. The leader in charge of the “set piece” knows that
it is their responsibility to enact the “play” and to ensure that all of the medical team
members take up their positions as practised.
Undertaking an assessment and performing life-saving interventions pitchside is very

stressful. Stress can be useful to allow us to perform to our best, but it can very quickly
overwhelm our ability to cope and it can negatively affect our ability to achieve
optimum clinical outcomes.
Planning, liaising, communication, the PEAP, checklists and training are all integral
components of ensuring the best outcome. There should be no excuse for not having
these processes and procedures in place. Practising our own medical “set piece” will
help us to achieve the best for our players and teams if and when an emergency
occurs.
Knowledge
Skills Equipment
Human Practice
Factors
Checklists
Figure 5: FIFA’s six key elements for successful pitchside assessment and extrication
17
TOP TIPS FOR SUCCESSFUL PITCHSIDE OUTCOMES
1. Focus on doing the simple things well as these can often make the
biggest difference, e.g. a jaw-thrust and an i-gel laryngeal mask airway
(LMA) are both treatments that can be used to manage an obstructed
airway. A jaw-thrust, however, may be all that is required to open an
airway, and choosing to use a more complicated technique, such as an
i-gel, may cause delays and additional issues.
Doing the simple things well may prevent you from having to do the
complicated things at all.
2. Cause no further harm – e.g. if a cervical collar you have measured
increases the player’s symptoms as you apply it, think about what is making
the situation worse.
Remember that every treatment or intervention has its own side effects or
complications.
3. Be proactive and not reactive in your preparations. Preparation avoids reparation.
4. Practise as a team, and then practise again and again.
5. Ensure that your preparations are structured – whatever your process, use
the same process each time as far as possible.
6. Pay attention to communication – this will make or break the situation.
7. The players are your patients – you must remember to treat them as such.
8. You must be defensible, but not defensive, in your actions – this means that
you can defend the decisions you have made and the reasons why you made
them. If your decisions are always based on the information at your disposal
when making your assessments, your conclusions will always be in the
player’s best interests.
REFERENCES
1. Semeraro F, Greif R, Bottiger BW et al. European Resuscitation Council
Guidelines 2021: Systems saving lives. Resuscitation, 2021, 161: 80-97.
2. Mountjoy M, Moran J, Ahmed H et al. Athlete health and safety at large

sporting events: the development of consensus-driven guidelines. British
Journal of Sports Medicine, 2021, 55(4): 191-197.
3. Pelto HF, Drezner JA. Design and Implementation of an Emergency Action

Plan for Sudden Cardiac Arrest in Sport. Journal of Cardiovascular Translational
Research, 2020, 13(3): 331-338.
4. Evans J, Lingard D, Peddle D & Slack M. Assessing non-technical skills in

prehospital ad hoc team resuscitation. Canadian Journal of Emergency Medicine,
2019, 21 (Supplement 1): S34.
5. van Maarseveen OEC, Ham WHW, van de Ven NLM, Saris TFF & Leenen LPH.
Effects of the application of a checklist during trauma resuscitations on ATLS
adherence, team performance, and patient-related outcomes: a systematic
review. European Journal of Trauma and Emergency Surgery, 2020, 46(1): 65-72.
6. Hodgson, L, Phillips, G et al. Interassociation consensus recommendations for

pitch-side emergency care and personal protective equipment for elite sport
during the COVID-19 pandemic. British Journal of Sports Medicine, 2021.

INITIAL ASSESSMENT –
THE PRIMARY SURVEY
2
INITIAL ASSESSMENT – THE PRIMARY SURVEY
Regardless of the number of medical personnel you have working with you, the
sequence of assessments and interventions described in this chapter should be applied
each time you enter the field of play.
The purpose of this structured sequence is twofold:
1. Ensure we do not miss life- or limb-threatening injuries.
2. “Set the scene” for ourselves, i.e. maximise our ability to manage the injuries
that are not life- or limb‑threatening by using a practised, structured method
of assessment that allows the brain to engage in processing the incident in
the most efficient manner.
The more automatic the assessment, the more comfortable it is to perform.
It is accepted that a physical examination of the cervical spine or chest may not always
be merited if the incident and the mechanism of the incident have been clearly seen
by the clinician managing the player and it is clear that the player has sustained an
isolated limb injury.
However, it is vital that the clinician considers the potential for an A, C , B or C issue as
they proceed onto the pitch to assess a seemingly isolated limb injury. If the clinician It is vital that
is not able to mentally tick off that they are completely satisfied that they are only
dealing with an isolated limb injury as they run on to the pitch to approach the player,
the clinician
a full primary survey should be initiated. considers the
Given the speed at which the game is played and without the benefit of a second pair potential for
of eyes feeding back to the pitchside clinician, the reality is that it is unlikely that the
mechanism will be absolutely, definitively and clearly seen from the touchline. an A, C , B or
Failing to undertake a full primary survey leaves the clinician at risk of missing a more C issue.
significant injury because of the distracting injury that they are dealing with. It is
worth remembering that such an injury is distracting for the player because of the
pain, but it is also distracting for the clinician who is drawn immediately to the most
obvious source of the pain – and this source may not always be the most significant
injury that the player has sustained.
Following a structured and consistent approach mitigates this distraction and ensures
focus. It can be confusing for a player with a dislocated ankle if the medics treating
them appear to be ignoring the obvious injury and start by assessing their cervical
spine, so player education is important to gain their trust and understanding.
20 2 Initial assessment – the primary survey

FLOW CHART FOR INITIAL ASSESSMENT PATHWAY
Injury
occurs
Clinician
enters pitch
• Mechanism clearly seen and injury is immediately felt • Mechanism is concerning or unclear
to be isolated and unconcerning for an A © or B injury OR
AND • Players response is concerning
• Player’s response is clearly seen and is unconcerning OR
AND • Referee or teammates response is concerning
• Referee and team-mate response is unconcerning
AND
• B
Clinician gives consideration to potential for A © and
as approaching player
• Immediately proceed to protect cervical spine

and assess player fully using A © B C primary survey
process
• Player confirms no other symptoms or issue

• No other concerns highlighted change in condition
• Clinical instinct is of isolated injury
Any concerns or
• Assess the injury change of condition
• Low threshold for going back to full primary survey
Figure 6: Initial assessment
The incidence of significant injury in football is low and it is therefore easy to have a
mindset that nothing serious is likely to happen. It is much riskier, however, for both the
player and the clinician, if the clinician adopts this mindset. It is therefore potentially
more significant and much riskier to follow the red pathway than the green pathway.
On the green pathway, you are mitigating the risk of missing a significant injury by
assuming that one is present until you go through the process of trying to exclude it
clinically.
If you follow the same structured assessment each time, not only do you mitigate
against missing another, more significant injury, but it also means that you will perform
the same assessment over and over again, thus preparing yourself to do it quickly and
consistently. This will take the pressure off you when you are handling a critical injury.
If you choose the green pathway, you will almost certainly overtriage, but your
assessments will be more secure. If you choose the red pathway and get it wrong, it
could be fatal for the player or career-ending for the clinician.
21
THE PRIMARY SURVEY/PRIMARY ASSESSMENT
The structure of the primary survey is well established and has been
the foundation for the assessment of critically ill or injured patients
for the last 40 years.
A sporting situation is different to any other assessment scenario

because of the variables that are present when an assessment is
performed.
Pressure comes from multiple sources: the players, the referee,

coaching staff, the fans and the media. Time is limited and available
resources may be variable.
Using a structure represents a way to effectively enact a checklist

in real time, allowing for a more thorough assessment with less
pressure on the treating clinician and the medical team.
The primary survey involves the immediate stabilisation of the

Cervical spine and a concurrent assessment of the Airway. This
is followed by an assessment of Breathing and Circulation before
moving onto an assessment of Disability, i.e. neurological status and
lastly planning for Extraction and Exposing other areas to ensure
that no hidden injury is missed.
This A C BCDE assessment is only altered (slightly) if there is active

bleeding, in which case a member of the team should apply simple
direct pressure to the bleeding point as a matter of priority.
If an issue is discovered during the assessment of any part of the

primary survey, it should be addressed prior to moving on to the
next stage, i.e. an airway obstruction, once identified, should be
addressed with a jaw-thrust manoeuvre, suction or an adjunct
before moving on to the assessment of breathing.
Whilst an injury or issue with A, B, C, D, E is assessed and the issues

are treated in turn, the purpose of immobilising the cervical spine is
not, in itself, to treat the injury, but to prevent the worsening of any
injury that might have already occurred. This is best done with manual
in-line stabilisation (MILS). Fitting a cervical collar at an early stage
in the assessment is unnecessary and may prevent other assessments
and interventions being carried out. Protecting the cervical spine by
using your hands to support the head and preventing movement at
the neck is far more beneficial, whilst the application of a cervical
collar should be considered more as part of the extrication process.
Before moving on to the primary survey assessment, it is important

to stress that protecting the medical team as well as the players they
care for is also paramount.
PPE is a requirement that we are all more familiar with on account

of COVID-19. However, it has always been incumbent upon medical
staff caring for players to ensure that they are wearing appropriate
PPE whenever they are interacting clinically with players. This is to

ensure the optimum clinical environment, particularly to protect
against blood-borne viruses such as hepatitis, for example. You
should always consider the PPE that is appropriate for the clinical
environment in which you are working and, at a minimum, this
should always involve using gloves where there is the potential for
clinical interaction. With respect to the evolving advice regarding
the care of a player and the transmission risk of the SARS-CoV-2
virus, FIFA urges all practitioners to follow the local health authority
and World Health Organization (WHO) guidelines and protocols
regarding PPE.
AIRWAY C B C D E
An immediate assessment of the airway is always the initial
consideration and the clinical priority when managing a potentially
critical injury.
Whilst this is the priority, it is also something that you may be able
to do very quickly as you approach the player. In your assessment, it
is key that you consider what information you can gain at each stage
of your involvement. Your best diagnostic tools are your eyes, ears
and hands.
As you approach, what can you see? What can you hear?
Hearing a player shouting or screaming is distressing, but it indicates

a patent airway and suggests that there is enough respiratory
movement to generate the noise.
There are two types of airway injuries – the good news is that the
management of both is exactly the same and involves a stepwise
progression of treatments that can be applied in a structured
manner.
1. Primary airway injury
This is an injury that directly affects the airway. It will

usually result from an injury to the face, head or neck. It
might be bleeding, broken teeth or direct trauma to the
larynx. Any associated swelling will compound the issue.
There is a physical obstruction to the airway.
2. Secondary airway injury
This is a loss of protective airway reflexes that is caused

by cerebral obtundation/decreased conscious level. Here,
there may be no injury to the airway itself, but the softer
structures of the airway lose their tone and fall backwards,
creating an obstruction to the airway itself.
Depending on the injury, it is obviously possible for there to be a

concurrent primary and secondary airway injury.
23
Symptoms and signs
• What can you see? What can you hear?

• Gurgling noises
• Snoring noises
• Choking
• Stridor
• Cyanosis
• Absence of respiratory effort
The presence of any of these features suggests an airway obstruction, and immediate
management should be instituted and supplemental oxygen applied as a priority.
The management of a player with an airway obstruction involves the same step-by-
step process, regardless of whether the injury is primary or secondary. Ultimately, this
comprises four steps and the use of suction as well as oxygen should also be considered
and applied early on:
1. Airway-opening manoeuvres
2. Airway adjuncts
• Basic
• Advanced
-------------------------------------------------------------------
3. Advanced airway skills – intubation
4. Surgical airway skills
It is not considered necessary for pitchside medics to be able to perform advanced or

surgical airway skills. In fact, unless these are techniques you perform on a daily basis,
it is highly possible that you may actually do more harm than good if you spend too
much time trying to do either of these, and this may ultimately end up worsening the
player’s hypoxia.
Instead, as outlined previously in this manual, the core concept of the FIFA approach is
to focus on doing the simple things well.
Accordingly, airway-opening manoeuvres and airway adjuncts are discussed in more

detail, whilst intubation and surgical airway skills are not.
1. Airway-opening manoeuvres (see “Skill zone – practical skills and

techniques” on page 200)
There are two airway-opening manoeuvres that should be considered.
In trauma, the jaw-thrust is preferred over the head-tilt/chin-lift approach because

it avoids movement of the cervical spine. It is also a painful stimulus to apply, so for
someone with a low Glasgow Coma Scale (GCS) score (explained on page 34) this
can be helpful in determining their response to pain should the player appear to be
unresponsive.

Both techniques involve moving the tongue forward and away from the posterior
pharynx, thus relieving obstruction to the airway at this point.
As part of our inherent, ongoing commitment to educating players, it is vital that we

emphasise to them that one of the most frequent causes of a primary airway injury are
other players’ fingers. There have been many reported examples of situations where
a player has put their hand/fingers into an unconscious player’s mouth in an attempt
to stop them “swallowing their tongue”. This is extremely dangerous and we must
educate players that it is not possible to swallow your tongue and that they will make
the situation worse and risk injury to themselves and their colleague.
Injured players who have survived these best-intentioned interventions have done so
not because of, but in spite of, such actions. It is our professional responsibility to
ensure that this does not continue.
2. Airway adjuncts (see “Skill zone – practical skills and techniques” on page
200)
In a situation in which an airway-opening technique is required, it is likely that an

airway adjunct may be beneficial. These have multiple benefits, such as relieving the
airway obstruction as well as releasing the person performing the jaw-thrust to carry
out other activities. As with all equipment, there are downsides and side effects to
using adjuncts. Sizing is estimated and items may therefore be under- or over-sized.
Guedel and i-gel adjuncts may stimulate the player to vomit, so care should be taken
to ensure that they do not gag on the airway as it is inserted.
25
BASIC
• Nasopharyngeal airway
A nasopharyngeal airway (NPA) is a soft plastic or rubberised tube and the

best-tolerated airway of the three adjuncts.
There is no one best method in terms of sizing, but a size seven or size eight
would generally be considered to fit a man and a size six or size seven a
woman. However, this is not always the case, so it is important to be careful
when using an NPA to ensure that you do not create further trauma to
the nose and worsen the primary airway issue due to bleeding. The NPA
should fit snugly into the nose and always be placed directly backwards
along the floor of the nose, rather than being aimed upwards, which takes
it towards the base of the skull. Because of this proximity to the base of
the skull, NPAs are relatively contraindicated for use where a base-of-skull
fracture is suspected.
• Oropharyngeal or Guedel airway
An oropharyngeal airway (OPA) is semi-circular with a plastic flange that is

inserted into the mouth. It helps by preventing the tongue from flopping
backwards and obstructing the airway.
Depending on the player’s conscious level, this may not be tolerated well
and care should be taken to avoid using an OPA if the player starts to gag.

ADVANCED
• i-gel laryngeal mask airway
An i-gel laryngeal mask airway (LMA) is a much more invasive airway in

comparison to an NPA or an OPA in terms of how it works. Placed just above
the vocal cords, it provides an airway that directs ventilation into the lungs.
It is, however, not a definitive airway because it does not provide a cuffed
seal to prevent aspiration from occurring. A definitive airway only occurs as
a result of intubation or a surgical airway.
When pitchside, this airway is much more likely to be tolerated by a player

who is in a cardiac arrest situation than any other clinical scenario, although
it can still be used if other adjuncts have failed and an airway obstruction
persists.
Suction and oxygen
Suction and oxygen with a flow rate of 15 litres/minute should both be available
pitchside, and both are important in the management of airway obstructions.
Oxygen should be applied as soon as it is available if there are concerns about a critical
illness or injury. Do not wait until the primary assessment has been completed before
applying oxygen.
27
A C CERVICAL SPINE B C D E
In any trauma, it is important to consider the potential for a cervical spine injury. This is
mandatory in any injury above the clavicles, but it is much easier to make it the default
approach in terms of how you perform your initial assessment of any injury, i.e. you
should assume that there is a spinal and/or cord injury until you can prove otherwise.
On the pitch, it may be possible to ascertain this very quickly with a player who is
cooperative and able to answer your questions and participate in your assessment.
Ultimately, though, if there is any doubt at all, spinal protection should be put in place
and maintained with the player being safely removed from the field of play.
Thankfully, the incidence of cervical spine injury in football is very low.
As discussed in chapter 6, if the mechanism is either concerning or unclear, immediate

protection of the cervical spine is required.
The spinal cord can be injured as a consequence of a primary or secondary injury:
1. Primary injury – this is the injury sustained as a result of the trauma at the
moment of impact. The main remit is to protect the spine and the cord from
the worsening of this initial injury due to unnecessary further movements at
the affected area.
2. Secondary injury – this is the injury that occurs at a cellular level and is
caused by issues such as hypoxia, low blood pressure and hypoglycaemia.
Applying oxygen early on is an easy way to help to protect any potential
secondary cord injury, whilst an assessment of the other elements, such as
blood pressure and glucose, will be carried out in turn as part of the initial
primary survey.
Arguably, the decision to clear the cervical spine is more difficult than the one relating
to whether to remove a player from the field of play. Our structure of assessment must
be robust, accurate and reproducible under pressure.
Clearing the cervical spine can wait until the primary survey has been completed
because the process of stabilising the spine using MILS ensures that no further harm
should come about as a result of the primary injury. If the spine cannot be cleared,
a cervical collar may be applied as part of the extrication process. Putting a cervical
collar on the patient early on in the primary survey achieves very little because, on its
own, a collar does not provide sufficient protection to stabilise the spine. In fact, there
is now evidence that even a properly fitted cervical collar may create more problems
than it actually resolves, given that an alert patient will naturally splint their neck and
prevent unnecessary and unwanted movement themselves. This is not necessarily the
case in an unconscious player though.
The decision as to whether or not to use a cervical collar may also come down to local
standards and practices, but if it is not used, care needs to be taken to ensure that
the spine is still properly protected using the alternatives that are available in the
particular region or area.

Clearing the cervical spine
In order to assess and clear the cervical spine, a number of assessments and
considerations should be made:
• No concerning mechanism – fall from height onto head, causing axial loading
• No midline tenderness
• GCS 15
• No distracting injury
• No neurology
• Active range of movement of 45° lateral rotation
No intoxication (whilst it would appear intuitive that this should not be an

issue in professional sport, it must still be borne in mind and consideration
given to the fact that intoxication refers not only to alcohol, but also
to other strong analgesic prescription drugs, such as codeine as well as
non-prescription drugs)
All of these assessments should reveal no abnormality.
It can be difficult to quantify what is or is not a distracting injury, given that a pitchside
medic is only called onto the pitch if there is concern over an injury (or collapse) and
therefore there will, by definition, be a distracting injury present.
It will be up to each clinician to decide the significance of the distraction in the context
of their overall clinical findings.
Active range of movement means that the player is able to move their neck in line
with the instructions to stop the rotation should they develop pain or neurological
symptoms. It is not the clinician who moves the neck.
If there is any concern about the potential for injury to the cervical spine, stabilisation
procedures should be carried out and the player should be safely extricated from the
field of play for further assessment.
29
A C Breathing Circulation D E
Carrying out an assessment of breathing and circulation on the pitch is always going
to be limited by a significant number of factors, such as time, noise and lack of privacy,
to name but a few.
The FIFA assessment for both breathing and circulation is described as the “hands-on
1, 2, 3” approach. This is simple to remember, but it maximises the information we can
expect to gain in a very short space of time.
The aim of breathing and circulation assessments is to gain as much information as

possible by using our eyes and ears as we approach the player, after which we aim to
put our hands onto the patient to make our assessments and obtain the all-important
clinical information.
The emphasis here is to use your eyes, your ears and especially your hands to allow
you to make rapid reproducible assessments, because many of the traditional tools
that we would usually depend on, such as a stethoscope or a blood-pressure monitor,
are simply impractical and unhelpful in the pitchside setting. In fact, the traditional
training to do an orderly and fully comprehensive examination of the respiratory
system is simply not conducive to the pitchside environment, so a shortened, focused
technique is described.
“Hands on (get your hands on the patient)

1 observation then 2 hands on 3 places”
Breathing
Use your eyes, your ears and then your hands to help with your breathing assessment.
As you approach the player, what can you hear and see?
Listen to the player, both in terms of what they are saying and the respiratory noises
that they might be making Gurgling and stridor imply upper-airway pathology.
Wheezing indicates a lower respiratory tract pathology.
Coughing is a protective reflex and is actually a reassuring sound.
Always consider the trend: are things improving or getting worse?
1 observation = respiratory rate.

2 hands on 3 places:
• The neck
• The chest wall anteriorly
• The chest wall posterolaterally
Assess for pain, surgical emphysema (a crackling feeling under the skin), swelling and
asymmetry of movement.
Is there evidence of a flail segment? This is characterised by the asynchronous

movement of one part of the chest wall, which is the result of multiple rib fractures
and signifies a potentially significant underlying lung injury.

Circulation
Use your eyes, your ears and then your hands to help with your circulation assessment.
What does the player look like as you approach?
What is their skin colour like? Are they paler than usual?
Is there an active bleeding point to which a member of the team can apply simple
direct pressure?
1 observation = pulse
Assess the pulse rate and volume and, again, always consider: what is the trend?
Are things improving or getting worse?
An exercise-induced physiological tachycardia is an expected initial finding in a player

who has been running around on the pitch, but this should also start to settle quickly. If there is no
Pain will also drive the sympathetic response and may result in a tachycardia, so it
is also very important to treat pain quickly. Progressively worsening tachycardia is a
evidence of
highly concerning finding. respiratory
2 hands on 3 places: effort, the
• Abdomen cardiac arrest
• Pelvis
• Long bones
protocol
should be
Assess the abdomen in four quadrants, feeling for sites of tenderness.
followed as
Assess the pelvis by feeling posteriorly and moving laterally, then anteriorly.
per chapter 3.
No downwards movement of pelvic instability should be made – this may worsen the
existing injury and result in further bleeding.
If the decision is made to perform an assessment of pelvic stability (and this is of very
questionable benefit on the pitch), this should be made from a posterior starting
position and involve effectively pulling the pelvis in an anteromedial/inwards direction,
thus “closing” any potential injury rather than opening it, as would be the case by
pushing downwards and out.
Assess the long bones by feeling the femurs and progressing down to the ankle.
A fractured femur can lose up to 1.5 litres of blood so long bone fractures are a very
relevant potential source of blood loss.
Simple circulation treatments include applying direct pressure to a wound, splinting

a fracture – which will help to reduce bleeding and also serve to alleviate pain – and
minimising movement where internal bleeding is a concern. It is for this reason that
scoop stretchers are preferred as extrication devices as the player only needs to be
moved by around 15° compared to a spinal board where they are log-rolled to 90°.
31
Remember: this is a quick but thorough assessment that is only valid for the pitch.
A more detailed assessment may be required once extrication has been carried out.
If an abnormality is found, a more focused assessment can be made. If time allows,
other assessments, such as capillary refill time, or items of equipment such as a pulse
oximeter, may also have a place in the initial pitchside assessment, although these will
be more useful in assessing the ongoing trends once the player is off the pitch.
Capillary refill time
With some caveats, the capillary refill time (CRT) test is a potentially useful test to
perform because it is easily and quickly reproducible and, like a pulse, it provides
a trend that can be observed, repeated and documented. A delay to the CRT may
suggest a state of hypoperfusion and an assessment of vital signs should be taken,
especially if there is a trend to suggest a delay to the CRT.
CRT testing is ideally performed centrally rather than peripherally. Centrally, this is
carried out by pressing on the player’s sternum with your thumb for a count of five
seconds. Once you take your thumb off the sternum, the skin underneath should
“pink up” within two seconds. A delay to this may suggest hypoperfusion, in which
case pulse and blood pressure should be immediately assessed.
Conversely, it should be remembered that a normal CRT does not exclude significant
injury, and bleeding and repeated clinical assessments should therefore always be
made where a clinical suspicion of injury remains. This is particularly true in the early
stages of trauma.
When carrying out this test peripherally on the fingertip, it is important to bear in
mind that a delay in the CRT may be due to a peripheral circulatory issue such as cold
skin, rather than an actual acute circulation issue. This explains why a central CRT is
preferred.
Blood pressure
Blood pressure (BP) is another potentially useful assessment to help monitor circulation
status and its trends. However, on the pitch, this is of almost no value.
Once in an appropriate environment, BP can complement the clinical assessment and

should always be available. Ensuring that there is an appropriately fitted BP cuff is vital
to allow accurate recordings to be made.
Radial pulse is also considered to be useful since it has a direct correlation with BP, but
caution should be applied in allocating a specific value to this, given that studies show
differing outcomes and no clear correlation of the presence of radial pulse with one
specific figure.
It is clear, however, that the clinical absence of a radial pulse is an extremely concerning
finding that may represent the potential for a cardiac arrest.

Blood glucose
Blood glucose (BG) is another very useful test to perform, although it is an investigation,
rather than part of an examination. A confused or collapsed player should have their
BG checked as soon as possible. Hypoglycaemia is a relatively common medical cause
of confusion, a decreased conscious level as well as seizure, so anyone with these
presentations should have their BG checked.
A C B C DISABILITY E
A disability assessment is effectively an assessment of the player’s neurological status.
It involves an assessment of:
1. conscious level;
2. pupil size; and
3. lateralising/localising signs, i.e. unilateral neurological signs or symptoms.
A disability assessment should be performed on the pitch to identify urgent neurological

issues as well as to establish a baseline from which a trend can be monitored.
Conscious level
The conscious level can be assessed using either the Alert, Voice, Pain, Unresponsive
(AVPU) or Glasgow Coma Scale (GCS) systems.
The AVPU scale is much simpler and is preferred in the acute setting, especially as
part of the initial assessment. The GCS can be performed if preferred, but because
it contains 13 potential scores (compared to four in the AVPU system), it is more
complicated and therefore prone to error, especially when under pressure.
Alert Voice Pain Unresponsive
This relates to the conscious level, scored as either:
A Alert
V Responds to voice
P Responds to pain stimulus
U Unresponsive to any stimulus
AVPU Roughly equivalent GCS

Alert 15
Voice 13
Pain 8
Unresponsive 3
Anything other than an appropriate and normal response in an “alert” player obviously
mandates removal from the field of play.
33
It is important to remember that being “alert” and responding normally does not, by
itself, exclude concussion in any way.
Glasgow Coma Scale
The GCS system is more complicated than the AVPU scale and is broken down into
three separate components:
Eyes: score out of 4 (the elements are the same as in AVPU)

Motor: score out of 6
Verbal: score out of 5
The lowest score in each category is 1 (not 0) and, therefore, adding these together
provides a combined score ranging from 3 to 15 (not 0 to 15).
A GCS score of anything less than 15 mandates immediate removal from the field
of play.
A GCS score of 15 does not exclude the potential presence of concussion.
Eyes Score Motor Score Verbal Score
Open 4 Obeys commands 6 Alert 5
Responds to voice 3 Localises to pain 5 Confused 4
Responds to pain 2 Withdraws to pain 4 Inappropriate 3
No verbal response 1 Flexes to pain 3 Incomprehensible 2
Extends to pain 2 No response 1
No response 1
Rules to remember regarding GCS:
1. Only one stimulus should be applied at a time, i.e. either a verbal response or
a response to pain – talking or shouting at the same time as applying a pain
stimulus confuses the interpretation of this response, so speak first and then
apply the pain stimulus only if there is no verbal response.
2. A pain stimulus should be applied above the level of the clavicles as this is
usually taken as a cut-off for a flexion response to pain. Performing a jaw-
thrust properly is a painful procedure and helps to assess motor response
and open the airway.
3. The motor score used is the best score elicited, i.e. no response to pain on
one side but withdrawing on the other would give a score of 5 and not 1.
Although the total score (out of 15) can be provided, it is more useful to break the
score down into the three individual components of the GCS.
These are then traditionally communicated in the format “Eyes (score out of 4), Motor
(score out of 6), Verbal (score out of 5)”.

An even better practice than inserting the actual numbers is to describe the actual
physical response to each component as this will negate any potential confusion about
what you have found clinically.
Example: the player appears unresponsive and does not respond when you ask them
a direct question. When you apply a pain stimulus, they localise to the stimulus and
appear to mumble something and then open their eyes.
• AVPU score is P
• GCS score is “Eyes 2, Motor 5, Verbal 2”
• This is better described as “No eye-opening, localises to pain stimulus and
makes incomprehensible sounds, giving a GCS of E2 M5 V2 – 9/15”
Clearly, while you are on the pitch, your ability to communicate this under pressure
will be significantly limited, so simplifying things and using the AVPU system would
definitely be preferable.
Scores of 15/15 or 3/15 are the only ones that would not need to be broken down, but
it is still good practice to break the score down wherever possible.
Pupil response
An assessment of direct and consensual pupillary response on the pitch is, in itself,
of relatively limited value in terms of yielding significant findings during the initial
assessment. However, it does provide a baseline response against which further
examinations can be compared.
A unilateral fixed and dilated pupil in the context of a head injury with a decreased
GCS score is the most concerning clinical finding and should immediately mandate
emergency transfer to a hospital with appropriate neurosurgical facilities.
Anisocoria is defined as pupils of unequal size, and up to 20% of the population may
have this as a normal examination finding. The difference between the pupil sizes of Consider
both eyes should be less than 1mm and the pupil should still react to light.
hypoglycaemia
Physiological anisocoria can only be diagnosed after other causes of pathological
pupil dilatation (mydriasis) or constriction (miosis) have been considered and excluded.
as a potential
In sport, direct trauma to the eye may cause traumatic mydriasis, which is the result
treatable cause
of trauma to the sphincter muscle of the iris, causing pain and blurring of vision. in anyone
Pharmacological mydriasis may occur after administration of topical medications or
even after nebulisation as treatment for asthma has been carried out using ipratropium, presenting
where the medication escapes from the top of the mask and affects one eye.
with a seizure.
As part of the neurological assessment, it is helpful to consider the pupil response
of eye movements when seeking to identify nystagmus or complaints of diplopia.
This may evoke more subtle symptoms such as dizziness or nausea, rather than actual
clinical signs.
35
Localising/lateralising signs
Assessing gross neurology is important but, obviously, an in-depth neurological

examination is simply not possible on the pitch.
The aim of this assessment is to quickly identify any unilateral neurological problem
stemming from either the brain or spinal column. It will require the player to be GCS
15 to be able to cooperate properly, although observation of clear unilateral signs in
someone with a GCS score below 15 is obviously exceptionally concerning and should
be acted upon.
Any unilateral findings may be attributable to a cervical spine injury, so spinal

immobilisation in the face of abnormal neurology will be required.
The player’s history is key – in particular, initially asking about subjective altered
sensations, tingling/numbness or weakness.
Player-initiated active movements while asking about symptoms is also important and,
as highlighted earlier, putting your hands directly onto the patient is also very useful,
starting with the upper limbs and working down to the lower limbs.
Standard gross neurological motor and sensory examination should be able to be

performed very quickly in the majority of players and, at that point, if appropriate,
an assessment of balance and gait can be undertaken when returning the player to a
standing position.
To reiterate: the assessment of “Disability” in the primary assessment is all about

identifying issues that mandate removing the player from the field of play. In terms of
head injury/concussion assessment, other aspects of the neurological examination will
need to be considered, but we will discuss these in chapter 7.
A C B C D EXTRICATION
Our approach to extrication from the field of play was covered in depth in chapter
1 as the flow of information and, therefore, communication needs to be completely
understood prior to a player being extricated by the medical team. Roles and
responsibilities must already be allocated and understood, and the team must practise
the routine regularly.
Thankfully, in the majority of instances in which players are extricated from the
pitch, it is because of a limb injury rather than actually requiring airway, breathing
or circulation interventions. So, whilst it is vital that at least one clinician has the
knowledge and skills to perform the primary survey and interventions on the pitch,
it is also essential that all of the team members have the appropriate knowledge and
skills to allow them to undertake the extrication process.

REFERENCES
1. 10TH Edition of the Advanced Trauma Life Support® (ATLS®) Student Course
Manual. Chicago (IL): American College of Surgeons; 2018
2. Iosson N. Images in clinical medicine: Nebulizer-associated anisocoria. The

New England Journal of Medicine, 2006, 354(9).
3. Mills B, Conrick K et al. Consensus Recommendations on the Prehospital Care

of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury.
Clinical Journal of Sport Medicine, 2020, 30(4): 296-304.
4. Zahir U & Ludwig SC. Sports-related cervical spine injuries: on-field

assessment and management. Seminars in Spine Surgery, 2010, 22: 173-180.
5. Ghiselli G, Schaadt G & McAllister DR. On-the-field evaluation of an athlete

with a head or neck injury. Clinical Journal of Sport Medicine. 2003, 22, 445-465.
6. Sanchez AR, Sugalski MT & LaPrade RF. Field-side and Prehospital

Management of the Spine-injured Athlete. Current Sports Medicine Reports,
2005, 4: 50-55.
7. Theodore N, Hadley MN, Aarabi B et al. Prehospital cervical spinal

immobilization after trauma. Neurosurgery, 2013, 72(suppl 2): 22-34.
8. Giza E & Micheli LJ. Soccer Injuries. In: Maffulli N, Caine DJ (eds):
Epidemiology of Pediatric Sports Injuries. Team Sports. Basel. Karger, 2005,
140-169.
9. Boran S, Lenehan B, Street J et al. A 10-year review of sports-related spinal

injuries. Irish Journal of Medical Science, 2011, 180: 859-863.
10. National Association of EMS Physicians and American College of Surgeons

Committee on Trauma. EMS Spinal Precautions and the Use of the Long
Backboard. Prehospital Emergency Care, 2013, 17: 392-393.
11. Swartz EE, Boden BP, Courson RW et al. National Athletic Trainers’
Association Position Statement: Acute Management of the Cervical Spine-
Injured Athlete. Journal of Athletic Training, 2009, 44 (3): 306-331.
12. Al-Kashmiri A & Delaney JS. Head and Neck injuries in football (soccer).
Trauma, 2006, 8: 189-95.
13. Whiteside JW. Management of Head and Neck Injuries by the Sideline
Physician. American Family Physician, 2006, 74(8): 1357-1362.
14. Nutbeam T, Fenwick R, May B et al. Assessing spinal movement during

four extrication methods: a bio mechanical study using healthy volunteers.
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine, 30, 7(22).
37
CARDIAC ARREST
3
CARDIAC ARREST
In the context of sport, cardiac arrest is thankfully a rare event.
In addition to the stress of managing a clinical situation, however, cardiac arrest

brings some other very considerable challenges that also need to be coped with and
managed, such as the presence of players and other members of the medical team as
well as the public watching at home or in the stadium.
Cardiac arrest in sport is a true time-critical emergency that occurs in a very public
setting, so being prepared and ensuring that your team is ready is of paramount
importance if a successful outcome is to be achieved.
The management of cardiac arrest must start with preparing well in advance of the
situation arising. Reacting to a player who has collapsed on the field of play without
first being proactive by preparing to manage the situation may not be enough to
achieve a good outcome.
Identifying the roles and responsibilities in advance, as described in chapter 1, is critical

– as is rehearsing how to respond should an incident of cardiac arrest occur.
Successful outcomes rely on three main things happening:
1. Recognition and identification of sudden cardiac arrest (SCA)
2. Early, good-quality chest compressions
3. Early and safe defibrillation
Personal protective equipment
It must be remembered that wearing the correct personal protective equipment (PPE)
is very important during a cardiac arrest situation. In this regard, it should be borne in
mind that this is an ever-evolving area and therefore it is vital to be familiar with the
most up-to-date guidance issued by the local health authorities in the area in which
you work.
Recognition of sudden cardiac arrest
Sudden cardiac arrest (SCA) should be diagnosed in any player who presents with the
following signs on the field of play:
1. Non-contact collapse
Any player who collapses on the field of play without having had any contact
with another player or the moving ball is to be regarded as suffering from
SCA, triggering an immediate response on the pitch and the activation of
the emergency medical plan. As the referee may be occupied with activities
involving the ball in play and therefore may not see the player collapse, it
is mandatory that once a non-contact collapse is recognised in a player, the
on-duty medical professionals, or equivalent persons, enter the field of play
immediately, with one previously designated person running to inform the
fourth official or alerting the on-pitch referee, as necessary. The medical
professionals or equivalent persons must not, under any circumstances, wait
40 3 Cardiac arrest
for the ball to go out of play. This immediate response on the field of play
for a non-contact collapse was first introduced, with full referee consent,
during the 2014 FIFA World Cup Brazil™.
2. The non-contact collapsed player will be totally unresponsive (unconscious)

to any verbal or pain stimuli.
3. Initial normal breathing deteriorating into gasping and/or slow, agonal

respiration will occur in the first minutes after SCA and must not be
interpreted as normal breathing. After 60-90 seconds, all breathing will usually
stop. Do not wait for this to happen before starting to apply cardiopulmonary
resuscitation (CPR) and an automated external defibrillator (AED).
4. Slow seizure-like activity presenting as involuntary arm and leg movements.
Therefore, any player who has a non-contact collapse with this slow seizure-
like activity must be regarded as suffering from SCA and this must NOT be
mistaken as a seizure.
41
• Safe approach wearing level 2 or 3 PPE; apply manual in line stabilisation as indicated
• Look for signs of life - normal breathing (but do not listen at the mouth for breath sounds, keep a distance)
• Collapsed and unresponsive to verbal stimuli - presume sudden cardiac arrest
• Feel for carotid pulse
• Head Tilt Chin Lift (HTCL) / Jaw thrust as required
Signs of life Signs of life

YES NO
Call for help Call for help

• Ambulance
• Responders minimum level 2 PPE
• Staff with minimum level 2 PPE
• Level 3 PPE if airway intervention potentially
• Level 3 PPE for airway management
required
• Request medical equipment incl; AED
• Ambulance if required
Player Player Level 2 Level 3

conscious unconscious PPE PPE
*
• Begin chest compressions
with towel or 02 mask • Begin 30:2^^
Level 2 Level 3 over face
PPE PPE • Apply AED as soon as it • Apply AED as soon as it
arrives arrives
• Airway ladder progression

MILS as indicated MILS as indicated and O2 after first shock if
• Do not begin airway shock advised.
• Airway- HTCL /Jaw thrust only • Airway- Airway ladder*** management until 2 or If no shock advised (non-
as required more persons present in shockable rhythm)
• Breathing- with 02 level 3 PPE continue CPR with airway
• Breathing- with 02 • 1 level 3 PPE on chest/AED management
• Circulation
• 1 level 3 PPE on airway
• Circulation • Transfer to definitive
• 3 persons minimum
• Dysfunction care/ambulance will
advised in Ievel 3 PPE for a
• Dysfunction require level 3 PPE
SCA scenario
• Extrication - all level 2 PPE stretcher bearers
• Extrication - all level 3 PPE
• If return of spontaneous
circulation R0SC move to • If ROSC move to blue side
blue side of algorithm of this algorithm
Hodgson L, et al. British Journal of Sports Medicine. 2020, 0:1–8. doi:10.1136/bjsports-2020-103226
42 3 Cardiac arrest
BASIC LIFE SUPPORT: 2021 GUIDELINES
There were no major changes to the 2021 Basic Life Support Guidelines compared to
the 2015 edition.
• Recognition of cardiac arrest is key.
• Ensure that an ambulance has been called for.
• Start chest compressions as soon as possible.
• Ensure that someone is sent to retrieve the nearest AED.
• Ensure that the AED is applied to the chest as soon as it is available and that the
instructions are followed.
Key aspects of adult basic life support
As already stated, the first priority is to identify that cardiac arrest has taken place.
If the collapsed player is unresponsive, the airway should be opened and an assessment
of whether the player is breathing undertaken.
If COVID-19 is suspected or the status is unknown, it is not appropriate to put your

own face down towards the patient’s face to look and feel for evidence of breathing.
Look for expansion of the chest instead whilst concurrently checking for evidence of
a carotid pulse.
Assessing breathing and circulation in this way represents a basic assessment for signs
of life, and absence of either indicates cardiac arrest.
The key priorities are now to ensure:
1. the safety of everyone around the player by checking that appropriate PPE is
being worn (or is in the process of being applied);
2. that advanced help has been called for in terms of paramedic support;
3. that chest compressions have commenced;
4. that the AED has been requested and that it is applied as soon as it arrives.
Basic life support is only “basic” in terms of the equipment needed to carry it out.
Chest compressions should be performed to a depth of approximately 5-6cm and at a

rate of 100-120bpm in an adult. Allow full recoil of the chest.
The location for compressions is in the middle of the chest over the sternum in the
midline.
After 30 compressions, proceed to perform two ventilations.
43
Key aspects of automated external defibrillators
One of the cornerstones for successful resuscitation is being able to cardiovert a

“shockable” arrythmia, if this is the cause of the cardiac arrest.
“Shockable” refers to ventricular fibrillation (VF) as well as pulseless ventricular

tachycardia (VT).
Limiting factors to cardioversion are the time it takes to get and apply the AED to the
player, and to recognise that cardiac arrest has actually happened.
An AED is a piece of equipment that must be available pitchside at all FIFA-organised

matches. It should also be immediately available pitchside at training sessions and not
left on the team bus or in the dressing room.
A delay in applying it is common when chest compressions are already taking place.
Waiting until the 30 compressions of that ongoing cycle have been completed is
commonly witnessed during simulation sessions. The AED must be applied as soon as
it is available. Designating one person to exclusively undertake this procedure makes
sense from a human factors perspective.
The vast majority of AEDs are preloaded with step-by-step instructions, and it makes
sense to practise simulating cardiac arrest situations with a dummy so that you are
familiar with the procedure. Many manufacturers provide dummies.
It is vital that the AED is updated with the most current guidelines, given that these
change around every five years. Liaising with the manufacturer should allow you to
do this relatively simply – usually, downloading an update from a computer straight to
the AED is all that is required.
Most AEDs will show the positions for pad placement. The anterolateral pad position
is the position of choice for initial pad placement. Ensure that the apical (lateral) pad
is positioned correctly (midaxillary line, level with the V6 ECG electrode position), i.e.
below the armpit.
Check the guidelines of your particular machine, but most adult pads can be used
on individuals over the age of eight. Between the ages of one and eight years old,
paediatric pads should be used, although adult pads can be considered if these are
the only ones available.
Safety is once again paramount, and the three key areas to consider are:
1. Ensure that the person discharging the AED has checked that everyone
is clear of the patient and that oxygen has been turned off. This is their
responsibility.
2. Try to minimise the player’s contact with water as much as possible – this is
not particularly an issue on the field of play, but if the player collapses in a
large puddle, for example, then it is safer to move them away from it prior
to using the AED.
3. A towel may be required to dry the player’s chest to ensure that the pads
adhere properly – many AEDs will come with a razor to assist with removing
chest hair if this also causes an issue when it comes to the pads sticking.
4. Minimise the risk of fire by removing any oxygen mask or nasal cannula and
place them at least 1m away from the patient’s chest.
44 3 Cardiac arrest
Key aspects of managing the airway in a cardiac arrest
One of the slightly counter-intuitive elements of managing a cardiac arrest relates to

the fact that management of the airway and breathing is not the priority in adults.
The airway is opened initially and an assessment is then made as to whether adequate
breathing is present or not. No attempt is made to support ventilation, and progression
is instead directed towards chest compressions and the application of the AED.
Once these measures are in place and Level 3 PPE has been applied, the airway can be
managed and supported ventilation can be started.
The adjunct of choice in a cardiac arrest is an i-gel LMA as this should provide an
easier way to achieve more successful ventilation and allow for continuous chest
compressions.
If an LMA is not available, use whatever adjunct you have, whether it is a Guedel or
an NPA.
The issue with using the more basic adjuncts over an LMA is that ventilation will need
to be a two-person technique: one person to hold the face mask in place and the
other to squeeze the bag and stop chest compressions to allow for ventilations.
With an LMA adjunct, the person holding the LMA can usually also perform the
ventilations by squeezing the bag.
The bottom line is that you should use the equipment with which you are most familiar
in order to achieve the best outcomes.
45
BASIC LIFE SUPPORT
Unresponsive with absent

or abnormal breathing
Call emergency services
Give 30 chest compressions
Give 2 rescue breaths
Continue CPR 30:2
As soon as AED arrives –

switch it on and follow
instructions
Basic life support (reproduced with the kind permission of the European Resuscitation Council —
www.cprguidelines.eu.assets/posters/bls-algorithms-portrait.pdf)
46 3 Cardiac arrest
Key aspects of supporting ventilation in a cardiac arrest
In a cardiac arrest situation, the player will require supported ventilation to ensure
that they have optimal oxygenation and ventilation. Attaching a bag with a reservoir
to the i-Gel and attaching this to oxygen at the highest flow rate of 15l/min is likely
to provide the best chance of achieving oxygenation and it is the preferred method
rather than using a BVM technique and Guedel, as this is a two-person technique and
less likely to achieve a successful seal.
Using an LMA should allow continuous chest compressions whilst ventilating at a

rate of approximately ten breaths per minute. If a gas leakage results in inadequate
ventilation using this method, pause compressions to allow ventilation using a
compression-ventilation ratio of 30:2.
The respiratory rate should thereafter be on every tenth compression.
Once you have squeezed the bag, allow it to refill again.
Ideally, a pulse oximeter should be available and applied to the player to allow for
monitoring of oxygen saturations. In a cardiac arrest situation, it is likely that the trace
of the waveform will be variable and therefore of little use during the actual arrest,
but if return of spontaneous circulation is achieved, saturations should be monitored
and oxygen rates can be titrated down from 15l/min to a rate that maintains the
saturation levels at 98-100%.
It should always be remembered that adequate oxygenation does not necessarily

correlate with adequate ventilation, so ensure that you have good symmetrical rise
and fall of the chest.
47
ADULT ADVANCED LIFE SUPPORT GUIDELINES 2021
There were no major changes to the 2021 Adult Advanced Life Support Guidelines.
High-quality chest compressions with minimal interruption and early safe defibrillation
are still priorities.
When adrenaline is used, it should be used in the following situations:
1. As soon as possible when the cardiac arrest rhythm is non-shockable; or
2. After three defibrillation attempts for a shockable cardiac arrest rhythm.
If a cardiac arrest in an adult is of a presumed primary cardiac aetiology, they should

be transported to a hospital with 24/7 coronary angiography capability wherever
possible.
Knowledge of advanced life support (ALS) is helpful, but not mandatory, when
managing a cardiac arrest. As mentioned previously, the most important determining
factors for a successful resuscitation are based on good-quality chest compressions
and early defibrillation. Everything else is secondary, and being distracted from
performing these basic techniques in order to implement ALS techniques instead may
adversely affect outcomes.
As can be seen from the algorithm in Figure 9 (page 50), the ALS process involves
determining whether the player has a shockable or a non-shockable presentation.
It is unlikely that the pitchside AED will actually demonstrate the presenting rhythm
visually (although many machines will capture the rhythm internally, and this can
subsequently be reviewed after the event when the machine memory can be checked).
The defibrillators that many paramedics use may demonstrate the rhythm on an
external display, and this can help with the ongoing management of the player.
In simple terms, the initial instructions from the AED can be used to categorise the
arrest as either shockable or non-shockable, regardless of the type of rhythm that is
actually present.
Shockable rhythms include ventricular fibrillation (VF) and pulseless ventricular (VT),
whilst non-shockable rhythms include asystole and pulseless electrical activity (PEA).
Shockable rhythms
If the AED indicates that a shock should be administered, this suggests a likely diagnosis
of VF or VT, and the shock should therefore be carried out as soon as is it is possible
to do this safely.
If oxygen is being administered to the patient, this should be turned off or disconnected
from the i-Gel. Turning off the flow of oxygen is preferable to disconnecting from
the i-Gel, as disconnecting it will increase the likelihood of aerosol dispersal from the
connector end of the i-Gel.
VF occurs as a result of the ventricles fibrillating rather than contracting meaningfully.

The primary cause of VF is hypoxia to the heart muscle. This results in hyperirritability
48 3 Cardiac arrest
in the cardiac muscle, meaning that no cardiac output is generated. An asynchronous
shock, as generated by the AED, is the best method to cardiovert the rhythm back
into sinus rhythm.
VT is a rhythm that also originates from the ventricles, resulting in a fast and abnormal
heart rate. It is a broad complex tachycardia (when seen on a AED with an external
display), and although there is electrical activity, it generates no meaningful cardiac
output. It is responsive to cardioversion via an AED, so this remains the initial treatment
of choice.
Treatment for VF/pulseless VT is via immediate chest compressions and defibrillation

as quickly as possible. Following defibrillation, chest compressions should immediately
resume without a pulse check and with ventilation support being provided once it is
safe to do so.
This should occur at a rate of 30 compressions: two ventilations (until an i-Gel is in

place, at which time you can consider asynchronous ventilation, i.e. ventilate on every
tenth chest compression as long as adequate symmetrical chest expansion has been
visualised on previous ventilations).
In the prehospital setting, it is vital to follow the instructions of the AED and ensure
that the AED is up-to-date with the most recent guidelines.
A rhythm assessment will take place after two minutes and you should continue with
compressions and ventilations until you are advised to stop by the AED or until the
player shows signs of life.
Adrenaline (epinephrine) at a dose of 1mg intravenously (IV) should be considered

after the third shock, i.e. it is not given immediately on the diagnosis of the cardiac
arrest where the presentation is “shockable”. It should be given every three to five
minutes thereafter, i.e. after every two cycles of two minutes of CPR.
Amiodarone at a dose of 300mg IV can also be considered after the third shock has
taken place, i.e. the cycle after the first dose of adrenaline has been given with a
subsequent dose of 150mg given after the fifth shock.
Figure 7: Ventricular fibrillation – Encyclopaedia of Heart Diseases 2006
49
Non-shockable rhythms
If the AED reads the rhythm as non-shockable, the likely diagnosis is either asystole
or PEA. Focus should again remain on performing the highest possible quality of
uninterrupted chest compressions with ventilatory support when it is safe to do so.
Adrenaline is recommended as soon as possible in this case, which is different from

the “shockable” side of the algorithm. Again, the dose is 1mg IV and this should be
repeated every three to five minutes. There is no good evidence for atropine and this
is no longer in the algorithm.
Figure 8: Asystole. Available at: https://commons.wikimedia.org/wiki/File:EKG_Asystole.jp
ADVANCED LIFE SUPPORT

Unresponsive with absent
or abnormal breathing
Call EMS/Resuscitation team
CPR 30:2
Attach desfibrillator/monitor
Assess rhythm
Shockable Non-shockable
(VF/PULSELESS VT) (PEA/ASYSTOLE)
1 shock
Immediately resume chest Return of spontaneous Immediately resume chest

compressions for 2 minutes circulation (ROSC) compressions for 2 minutes
Give high-quality chest compressions and Identify and treat reversible causes Consider
Hypoxia Coronary angiography/percutaneous coronary
Give oxygen
Hypovolaemia intervention
Use waveform capnography
Hypo-/hyperkalemia/metabolic Mechanical chest compressions to facilitate transfer/treatment
Continuous compressions if advanced airway Extracorporeal CPR
Hypo-/hyperthermia
Minimise interruptions to compressions Thrombosis – coronary or pulmonary
After ROSC
Intravenous or intraosseous access Tension pneumothorax
Use an ABCDE approach
Give adrenaline every 3-5 min Tamponade- cardiac
Aim for SpO2 of 94-98% and normal PaCO2
Toxins 12 Lead ECG
Give amiodarone after 3 shocks
Consider ultrasound imaging to identify Identify and treat cause
Identify and treat reversible causes
reversible causes Targeted temperature management
Figure 9: https://cprguidelines.eu/assets/posters/3.ALS-Algorithms-Advanced-Life-Support.pdf
50 3 Cardiac arrest
REVERSIBLE CAUSES OF SUDDEN CARDIAC ARREST/TRAUMATIC
CARDIAC ARREST
The main treatable cause of a pitchside cardiac arrest is a shockable cardiac arrythmia.
There are, however, a number of other potential reversible causes of cardiac arrest
and these should be considered in turn to ensure that another treatable cause is not
being missed.
“H” “T”
Hypoxia Tamponade
Hypovolaemia Tension pneumothorax
Hypokalaemia/hyperkalaemia Thromboembolic
Hypothermia/hyperthermia Toxins
The “4 Hs and 4 Ts”
The “4 Hs and 4 Ts” are a useful way to remember these possible reversible causes.
We are limited in terms of what we can treat on the pitch, but conditions such as:
• hypoxia
• hypovolaemia
• hypothermia
• tension pneumothorax
should be considered as potential causes depending on what occurred in the lea-up to

the cardiac arrest. These are all readily managed, but only if they are considered and
looked for as part of the ongoing assessment.
With hypoxia related to an airway obstruction, the majority of reversible causes

detailed above will progress to cardiac arrest over a period of time rather than
immediately and, therefore, the aim is to ensure that interventions are applied to
prevent this progression.
An assessment of the reversible causes should ONLY take place once chest compressions
have been started, once the AED has been applied and once the airway and ventilation
are being managed.
1. Hypoxia: managing the airway and breathing effectively should allow

hypoxia to be optimally treated.
2. Hypovolaemia, especially in the context of heat, may be a possible aetiology

of cardiac arrest, although this is also unlikely in an elite football context.
Internal bleeding as a consequence of significant trauma is a more likely
potential cause of hypovolaemia, but this will likely present as a player
deteriorating after an injury (usually to the chest, abdomen or pelvis). An
injury to these three areas in a patient who progresses to cardiac arrest will
likely be due to haemorrhage. However, in the case of a chest injury, the
cause may also be a tension pneumothorax (a very treatable prehospital
condition) or, exceptionally rarely in blunt trauma, cardiac tamponade (a
very difficult prehospital condition to treat).
51
It is important to consider the trend of vital signs after an injury – sometimes
hours after an injury in the case of a presentation such as a splenic injury –
and reassessments should be frequent after any injury that raises concern.
3. Hypothermia is exceptionally unlikely in the context of football, although

it should be considered in anyone found in an unexpected collapsed state
outside in the cold. Hyperthermia may result in profound hypovolaemia in
association with heat stroke, as described in chapter 9. Immediate cooling
and rehydration should be undertaken, with an emphasis on prevention
being key.
4. In the absence of significant chest trauma, a tension pneumothorax

is unlikely to occur spontaneously without the player presenting with
symptoms and signs of respiratory distress at an earlier point.
A tension pneumothorax occurs after a pneumothorax where the

pneumothorax expands to the point of compressing the mediastinal
structures, therefore impeding venous return to the heart. This happens due
to a one-way valve effect, which means that every breath taken expands the
volume of air in the pleural space.
Diagnosis should be based on clinical suspicion of increasing respiratory

distress, with unilateral chest signs indicating decreased air into one side of
the chest in association with signs of shock.
Signs such as tracheal deviation may not be present and cyanosis is always a
late sign.
Management of a tension pneumothorax involves decompression of the air

in the pleural space, and this is described in chapter 6.
The presence of these reversible causes highlights the need for frequent reassessments
and a monitoring of the trend of the vital signs to ensure that opportunities to treat
them are not missed.
52 3 Cardiac arrest
TRANSFER OF A PLAYER SUFFERING FROM SUDDEN CARDIAC ARREST Planning for
It cannot be emphasised strongly enough that planning for the transfer of a player the transfer
who has suffered cardiac arrest should be undertaken long before the situation arises.
of a player
This includes the planning of extrication from the field of play as well as the subsequent
transfer to the most appropriate medical facility. Extrication should ensure that delays who has
to CPR are always minimised – this is crucial. Other options, including the entry of
an ambulance onto the field of play, should be considered as part of the pre-match suffered
discussion. Such options may not be practical. Likewise, if it is easily facilitated, it is
always advised to bring an ambulance to a player in cardiac arrest rather than the
cardiac arrest
other way round. should be
A decision must also be made as to the most appropriate facility for the player to be undertaken
transferred to for definitive diagnosis and treatment. Again, this should be detailed
and confirmed prior to the match. long before
Although it is preferable for this to be to a centre that offers primary coronary the situation
angiography, it must also be confirmed in advance whether the centre is able to accept
prehospital triaged patients directly – it may not have the capacity for this. Ultimately,
arises.
it may be appropriate to consider bypassing nearer, non-specialist hospitals to ensure
that the player has access to immediate definitive care if there is a cardiac centre
with the ability to facilitate an emergency prehospital admission – this should also be
confirmed in advance of the match.
For extrication to occur safely and effectively, the player must be transferred onto
a long spinal/trauma board and immobilised so that the board, player and AED are
immobilised together as one unit. A scoop may also be used, but the long/spinal board
may potentially allow for better chest compressions due to its more rigid structure.
Use of mechanical chest-compression devices are also worthy of consideration as they
minimise the issues caused when there is interruption to CPR while the player is being
moved. Training to ensure familiarity with the device prior to its use is critical.
CPR must not be interrupted for more than a ten-second period and use of these
devices allows for transfers without interruption. If such a device is not available,
once the go-ahead has been given to move the player, the team carrying the player
should do so for no longer than ten seconds before stopping to place the strapped,
immobilised player on the ground and commencing chest compressions for at least
another two minutes. This “stop and start” transfer process is far less desirable than
an ambulance coming to the player.
Clearly, the cognitive load placed on the medical team looking after a player in this
situation is huge and, accordingly, we reiterate that it simply cannot be emphasised
strongly enough that planning for the transfer of a player who has suffered cardiac
arrest should be undertaken long before the situation arises.
Wherever possible, it is preferable for an ambulance to enter the field of play.
If a strapped, immobilised player is to be taken to a waiting ambulance, CPR must NOT

be interrupted for more than any single ten-second period. Therefore, once the go-
ahead has been given to begin moving the player physically and the team is carrying
the player, they must count for ten seconds and, once that brief period has elapsed,
they must halt the transfer, place the strapped, immobilised player onto the ground
and commence external chest compressions for at least another two minutes.
53
This “stop and start” transfer sequence is far less desirable than an ambulance coming
to the player, but it must continue until the player is inside the transferring ambulance.
Once CPR and defibrillation have commenced on the field of play, the resuscitation
process should be continued if medically indicated, en route to the nearest, most
appropriate emergency department or cardiac catheterisation laboratory by either
air or road ambulance, with staff who have been trained in performing CPR (manual
chest compressions/positive pressure ventilation/defibrillation/drug administration)
inside a moving ambulance.
54 3 Cardiac arrest
Key aspects of successful resuscitation
• Prepare: ensure that everyone in the medical team is aware of their role in
any player collapse
• Recognise the cardiac arrest – beware of any seizure
• Ensure that paramedic help is coming to enable the transfer
• Good-quality chest compressions while AED is applied
• Early, safe defibrillation
• Ventilations when safe to do so
PREVENTION OF SUDDEN CARDIAC ARREST IN FOOTBALL

SCA is the leading cause of sudden death in footballers on the field of play and is
typically the result of undiagnosed structural or electrical cardiovascular disease. The
infrequent, yet regular, occurrence of SCA during football can often be prevented
through cardiovascular screening.
The majority of SCA incidents in footballers occur during training or competition

because exercise is a trigger for lethal arrhythmia in players with an underlying cardiac
pathology.
Incidence of sudden cardiac death
The incidence of sudden cardiac death (SCD) associated with sport or exercise in the
general population has been reported as 0.46 per 100,000 person-years. The range
in the incidence of SCD in those below 35 years of age is more variable (1.0-6.4 cases
per 100,000 participant-years). A 2017 study looking at SCA during participation in
competitive sports involving 18.5 million person-years reported that the incidence of
SCA was 0.76 cases per 100,000 athlete years.
The FIFA Sudden Death Registry (https://www.uni-saarland.de/fakultaet-hw/fifa/en/

registry.html), ran in conjunction with Saarland University in Germany, shows that the
incidence of SCD in football varies from region to region. A study of deaths occurring
from 2014 to 2018 showed that 617 players had suffered cardiac arrest, with 142 (23%)
surviving. The most common cause of death in 35-year-olds and under was sudden
unexplained death, with coronary artery disease being the most common cause in
those over 35. There was a demonstrable increase in the survival rate when an AED
was used.
55
CAUSES OF SUDDEN CARDIAC ARREST
SCA in football is primarily due to structural and electrical cardiovascular abnormalities
that are usually undetected. The combined prevalence of all cardiovascular disorders
known to cause SCD in young athletes is estimated at three per 1,000 (0.3%).
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy (HCM) is one of the most common causes of SCA

and consists of an asymmetric left ventricular hypertrophy. A 12-lead resting
electrocardiogram (ECG) will reveal abnormal results in up to 95% of patients with
HCM, with T-wave inversion and ST depression usually in the inferolateral leads, or
prominent (wide) Q waves. Echocardiography can confirm the diagnosis.
Coronary artery anomalies
Coronary artery anomalies are the second leading cause of SCA, usually due to an
abnormal origin of the left coronary artery arising from the right sinus of Valsalva.
If suspected, transthoracic echocardiography can identify the coronary artery origins

in 80-97% of patients. Echocardiography can confirm the diagnosis.
Arrhythmogenic right ventricular cardiomyopathy
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is the leading cause of SCA

in the Veneto region of north-eastern Italy. ARVC is characterised by a progressive
fibro-fatty replacement of the ventricular myocardium, causing wall-thinning and
dilatation.
ECG abnormalities include anterior precordial T-wave inversion (V1-V3), QRS duration
>110ms, and right bundle branch block. Echocardiography can confirm the diagnosis.
Myocarditis
Acute inflammation of the myocardium may lead to lethal arrhythmias. Although

myocarditis may be asymptomatic, symptoms include a prodromal upper respiratory
tract viral illness and chest pain, followed by progressive exercise intolerance and
dyspnoea. An ECG may be abnormal and may help to confirm the diagnosis.
Ion channel disorders
Ion channel disorders such as long QT syndrome, short QT syndrome, Brugada

syndrome, Wolff-Parkinson-White syndrome (WPW) and catecholaminergic
polymorphic ventricular tachycardia (CPVT) are primary electrical diseases of the heart
predisposing to lethal ventricular arrhythmia.
56 3 Cardiac arrest
CARDIOVASCULAR SCREENING
FIFA pre-competition medical assessment
The goal of cardiovascular screening is to identify players with cardiac conditions at

risk of SCA. The FIFA pre-competition medical assessment (PCMA) involves a focused
investigation of:
• the player’s medical history;

• the player’s family medical history;
• a cardiac-specific physical examination; and
• a resting 12-lead ECG.
History and physical examination
Most players with unknown cardiac disease are asymptomatic. In fact, 60-80% of
players who suffer SCA have no previous symptoms.
• Warning symptoms, if present, may include syncope or chest pain with

exertion, unexplained seizure, and excessive shortness of breath or fatigue
with exercise.
• A family history of a genetic heart condition or premature death in relatives
under the age of 50 years requires careful cardiac evaluation.
• Physical examinations focus on the detection of murmurs and the physical
stigmata of Marfan syndrome.
ECG screening
An ECG is more sensitive than history and physical examination in identifying players
with an abnormal cardiac disorder. It is important to note that current ECG standards
of interpretation should be used to distinguish pathological ECG abnormalities from
physiological sport-related ECG alterations. Many ECG changes once referred to as
“abnormal” are now recognised as physiological sport-related adaptations in players
– so-called “athlete’s heart”.
1. An ECG should be performed on all players at the beginning of their playing

career and once every year thereafter.
2. Echocardiography should be undertaken by an experienced cardiologist

when abnormal results are found, and should be considered at least once
in a player’s early career to better detect structural disorders not routinely
identified by an ECG.
3. An exercise ECG test should be considered in athletes older than 35 years of

age to screen for ischaemic coronary artery disease.
57
REFERENCES
1. Hodgson L, Phillips G et al. Interassociation consensus recommendations for
pitch-side emergency care and personal protective equipment for elite sport
during the COVID-19 pandemic. British Journal of Sports Medicine. 2020.
2. International Liaison Committee on Resuscitation (ILOR). COVID-19 infection

risk to rescuers from patients in cardiac arrest. Available at: https://costr.ilcor.
org/document/covid-19-infection-risk-to-rescuers-from-patients-in-cardiac-
arrest
3. Olasveengen TM, Mancini ME, Perkins GD et al. Adult Basic Life Support:
International Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science With Treatment Recommendations. Resuscitation,
2020, 156: A35-A79.
4. Lott C et al. European Resuscitation Council Guidelines 2021: Cardiac arrest

in special circumstances, Ibid., 2021. Available at: https://doi.org/10.1016/j.
resuscitation.2021.02.01
5. Soar J et al. European Resuscitation Council Guidelines 2021: Adult

advanced life support, Ibid., 2021. Available at: https://doi.org/10.1016/j.
6. Harmon KG, Asif IM, Klossner D et al. Incidence of sudden cardiac death in
national collegiate athletic association athletes. Circulation, 2011, 123(15):
1594-1600.
7. Egger F, Scharhag J, Kästner A et al. FIFA Sudden Death Registry (FIFA-SDR):

a prospective, observational study of sudden death in worldwide football
from 2014 to 2018. British Journal of Sports Medicine, 2020.
8. Drezner JA, Rao AL, Heistand J et al. Effectiveness of emergency response

planning for sudden cardiac arrest in United States high schools with
automated external defibrillators. Circulation, 2009, 120(6): 518‑525.
9. Drezner JA, Toresdahl BG, Rao AL et al. Outcomes from sudden cardiac arrest
in US high schools: a 2-year prospective study from the National Registry for
AED Use in Sports. British Journal of Sports Medicine, 2013, 47(18): 1179-1183.
10. Harmon KG, Drezner JA, Wilson MG et al. Incidence of sudden cardiac death
in athletes: a state-of-the-art review. Heart, 2014, 100(16): 1227-1234.
11. Drezner JA, Chun JS, Harmon KG, et al. Survival Trends in the United States
Following Exercise-related Sudden Cardiac Arrest in the Youth: 2000-2006.
Heart Rhythm, 2008.
12. Maron BJ, Thompson PD, Ackerman MJ et al. Recommendations and

considerations related to preparticipation screening for cardiovascular
abnormalities in competitive athletes: 2007 update: a scientific statement
from the American Heart Association Council on Nutrition, Physical
Activity, and Metabolism: endorsed by the American College of Cardiology
Foundation. Circulation, 2007, 115 (12): 1643-1455.
13. Pelliccia A, Spataro A & Maron BJ. Prospective echocardiographic screening

for coronary artery anomalies in 1,360 elite competitive athletes. American
Journal of Cardiology, 1993, 72 (12): 978-979.
14. Drezner JA, Ackerman MJ, Cannon BC et al. Abnormal electrocardiographic

findings in athletes: recognising changes suggestive of primary electrical
disease. British Journal of Sports Medicine, 2013, 47 (3): 153-167.
58 3 Cardiac arrest
15. Surawicz B, Childers R, Deal BJ et al. AHA/ACCF/HRS recommendations
for the standardization and interpretation of the electrocardiogram: part
III: interventricular conduction disturbances:a scientific statement from
the American Heart Association Electrocardiography and Arrhythmias
Committee, Council on Clinical Cardiology; the American College of
Cardiology Foundation; and the Heart Rhythm Society: endorsed by the
International Society for Computerized Electrocardiology. Circulation, 2009,
119 (10): e235-240.
16. Dvořák, J, Grimm, K, Schmied, C et al. Development and implementation

of a standardized precompetition medical assessment of international elite
football players – 2006 FIFA World Cup Germany. Clinical Journal of Sport
Medicine, 2009, 19 (4): 316-321.
17. de Noronha SV, Sharma S, Papadakis,M et al. Aetiology of sudden cardiac

death in athletes in the United Kingdom: a pathological study. Heart, 2009,
95 (17): 1409-1414.
18. Corrado D, Pelliccia A, Heidbuchel H et al. Recommendations for

interpretation of 12-lead electrocardiogram in the athlete. European Heart
Journal, 2010, 31(2): 243-259.
19. Drezner JA, Ackerman MJ, Anderson J et al. Electrocardiographic

interpretation in athletes: the ‘Seattle criteria’. British Journal of Sports
Medicine, 2013, 47(3): 122-124.
20. Drezner JA, Fischbach P, Froelicher V et al. Normal electrocardiographic

findings: recognising physiological adaptations in athletes. Ibid., 2013, 47(3):
125-136.
21. Drezner JA, Ashley E, Baggish AL, et al. Abnormal electrocardiographic

findings in athletes: recognising changes suggestive of cardiomyopathy.
Ibid., 2013, 47 (3), 137-152.
22. Drezner JA. Detect, manage, inform: a paradigm shift in the care of athletes
with cardiac disorders? Ibid. 2013, 47(1): 4-5.
23. Andersen J, Courson RW, Kleiner DM & McLoda TA. National Athletic
Trainers’ Association Position Statement: Emergency Planning in Athletics.
Journal of Athletic Training, 2002, 37 (1): 99-104.
24. Drezner JA, Courson RW, Roberts WO et al. Inter-association task force
recommendations on emergency preparedness and management of sudden
cardiac arrest in high school and college athletic programs: a consensus
statement. Heart Rhythm, 2007, 4 (4): 549-565.
25. Landry CH, Allan KS, Connelly KA et al. Sudden cardiac arrest during
participation in competitive sports. New England Journal of Medicine, 2017, 377:
1943-1953.
26. Ackerman M, Atkins DL & Triedman JK. Sudden cardiac death in the young.
Circulation, 2016, 133: 1006-26.
27. Obermaier M, Zimmermann JB, Popp E et al. Automated mechanical

cardiopulmonary resuscitation devices versus manual chest compressions in
the treatment of cardiac arrest: protocol of a systematic review and meta-
analysis comparing machine to human. BMJ Open, 2021.
59
60 3 Cardiac arrest
CHOKING AND
ANAPHYLAXIS
4
CHOKING AND ANAPHYLAXIS
Choking and anaphylaxis have been grouped together because they are both
potential diagnoses for someone presenting with an airway obstruction associated
with circulatory collapse.
Management is based on correctly identifying the precipitating problem and then

treating it accordingly.
A history of what has happened should help to direct management, even though
this may need to come from a witness rather than the person themselves, who may
present to you in a number of different ways:
• coughing;
• stridorous;
• drooling;
• unable to speak;
• collapsed;
• cyanosed; and/or
• not breathing.
If a choking episode has been witnessed, it is relatively straightforward to proceed

through the choking algorithm.
Management of choking
This is predominately based on the absence or presence of an effective cough. If the

person can cough effectively, they should be encouraged to do so without any other
intervention being required. If, however, they cannot cough effectively, the next stage
depends on whether or not they are conscious.
If they are conscious, proceed to make five back blows followed by five abdominal
thrusts. Stop and reassess as soon as there is a change in the person’s condition. If there
is no change, continue alternating between five back blows and five abdominal thrusts.
If the person is not conscious or is apnoeic, the cardiac arrest algorithm should be
followed, chest compressions started and airway-opening manoeuvres and adjuncts
used where available.
Back blows are the initial intervention performed in a conscious patient with an
inadequate cough.
Stand behind the patient and, using the heel of your hand, strike the patient in a
firm movement between the shoulder blades. The patient is best positioned leaning
forwards. Repeat five times before proceeding onto abdominal thrusts.
Should the obstructing foreign body be expelled, stop and reassess.
Abdominal thrusts are performed in a conscious patient with an inadequate cough

and when back blows have been unsuccessful.
62 4 Choking and anaphylaxis

Stand behind the patient and ”hug” your arms around them. Clench one hand into
a fist and place the other hand over the fist. Position your hands on the patient’s
xiphisternum and pull upwards and backwards sharply. Again, repeat five times unless
something changes, in which case stop and reassess.
Adult choking
Choking?
Assess severity
SEVERE MILD
Airway obstruction Airway obstruction
(ineffective cough) (effective cough)
Encourage cough
Unconscious Conscious
Continue to check
for deterioration to
Start CPR 5 back blows ineffective cough or until
obstruction relieved
5 abdominal thrusts
https://www.resus.org.uk/sites/default/files/2021-04/Adult%20Choking%20Algorithm%202021.pdf
ANAPHYLAXIS
Anaphylaxis is an acute life-threatening allergic reaction, usually but not always
mediated by an immunological type IgE hypersensitivity mechanism that results from
the sudden systemic release of histamine, prostaglandin and leukotriene, usually from
mast cells and basophils.
An anaphylactoid reaction is similar in clinical presentation, but it does not occur as a

result of an immune response.
There is no need to make a distinction between the two types of reaction because the
management of both anaphylaxis and anaphylactoid reactions is the same.
While the incidence of anaphylaxis is increasing in the overall population, the risk of
death remains at 0.5-1 per million.
63
Trigger factors
• Foods: nuts, strawberries

• Drinks: alcohol
• Stings: wasp or bee
• Medications: penicillin, non-steroidal anti-inflammatory drugs (NSAIDs)
• Exercise
• Fever
• Idiopathic
A previous history of allergy or anaphylaxis may be documented, but this may not
always be the case, so team clinicians must be prepared to deal with this presentation,
regardless of whether it is noted in the player or staff medical records.
Diagnosis
Prompt recognition and immediate treatment is essential in anaphylaxis.
National Institute of Clinical Excellence (NICE) clinical guideline 134 states that:
“Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity
reaction. It is characterised by rapidly developing, life-threatening problems involving:
the airway (pharyngeal or laryngeal oedema) and/or breathing (bronchospasm with
tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases, there
are associated skin and mucosal changes.”
The three key elements are:
• rapidly developing illness;

• life-threatening compromise of A, B or C; and
• skin or mucosal symptoms.
It is important to remember that skin and mucosal changes, such as erythema or

urticaria, may therefore not always be present. In fact, they are absent in up to 20%
of cases of anaphylaxis.
Airway issues may include swollen lips, tongue or uvula or stridor.
Breathing issues may include dyspnoea, bronchospasm/wheezing or hypoxia.
Circulation issues may include hypotension or cardiac arrest.

TREATMENT
Once the diagnosis of anaphylaxis has been made, treatment should be instituted to
prevent further clinical deterioration. An ABC assessment should have been carried
out as part of the diagnostic process as this will allow a trend to be followed once
treatment has been instituted so that progress can be monitored.
Where circulatory collapse is present, intramuscular (IM) adrenaline is the first drug
of choice. If available, oxygen should be administered and, if it is tolerated, lying the
player on the ground and elevating their legs may help with hypotension.
However, if the airway is affected and compromised, it is likely that doing this may
worsen the situation. Instead, let the player find their own position of comfort and do
not force them to lie down if they are not comfortable to do so.
Remove or stop the trigger if possible.
Adrenaline/epinephrine
This is the drug of choice in the management of anaphylaxis.
In the prehospital setting, it should be given intramuscularly at a dose of 0.5mg in an

adult for all patients suffering from A, B or C problems. It should be administered into
the anterolateral thigh.
Use of an auto-injection EpiPen is preferred, although it should be remembered that

the dose of epinephrine is only 0.3mg and so repeated doses are more likely to be
required when using this method of administration in order to achieve an adequate
clinical effect.
Epinephrine also comes in a number of different volumes and doses, including pre-
filled 1:10000 syringes, which are primarily for use in the cardiac arrest situation. It is
important to be clear with what you use in any clinical situation.
Unless you have adequate clinical experience as well as adequate patient monitoring,
administering intravenous (IV) epinephrine is not recommended in the prehospital
setting.
If you do not have access to an EpiPen, the best solution is to carry a 1ml ampoule
of 1:1000, which also equals 1mg, so that this can be drawn up and 0.5ml given
intramuscularly.
The initial dose of intramuscular epinephrine can be repeated after five minutes if
there is no improvement.
If a player has a known severe allergy or a history of anaphylaxis, they should be told
to have two EpiPens with them at all times to ensure they have enough to repeat the
dose after the first injection should it be required. It is not uncommon to find that
they have left one in the car and one in their toilet bag rather than keeping the two
together. It is worth reminding them of this.
65
Intravenous fluids
Where there is clinical evidence of circulatory collapse, gaining IV access may be

prudent once intramuscular epinephrine has been administered. This will only become
more difficult if the player becomes more unwell and large volumes of fluids may need
to be administered to help cope with the profound hypotension resulting from the
anaphylaxis-induced increased capillary permeability.
If you are treating an adult, start with bolus 500-1000ml of crystalloid solution over
five to ten minutes. Large volumes may be necessary for the reasons stated above.
Oxygen
Oxygen should be applied wherever circulatory collapse is present or evidence of

hypoxia found. Titrate until saturations are 94-98%.
Antihistamine administration – chlorpheniramine
There is no evidence that the administration of antihistamines in severe anaphylaxis

has any beneficial effect in the initial prehospital management.
Its administration, once the patient has been transferred to the nearest, most
appropriate emergency department, can be considered after a full medical history
and examination has been undertaken, possibly for the relief of urticarial and itching
symptoms.
If you have access to an antihistamine and choose to administer it as part of the

algorithm, this must only be done once the primary assessment has been completed
and intramuscular epinephrine has been administered.
Glucocorticoid steroid administration – hydrocortisone
Again, there is no evidence that the administration of glucocorticoid medications

in severe anaphylaxis has any beneficial effect in the initial management or that it
prevents biphasic reactions.
Its administration, once the patient has been transferred to the nearest, most
appropriate emergency department, can be considered after a full medical history
and examination has been undertaken.
The main indication is for ongoing asthma-like symptoms or refractory shock.
As above, if you have access to a glucocorticoid steroid and choose to administer it as

part of the anaphylaxis algorithm, this must only be done once the primary assessment
has been completed and intramuscular epinephrine has been administered.

Beta-2 agonist administration – salbutamol
In the presence of anaphylactic-induced bronchospasm, in addition to epinephrine

administration, consider the use of beta-2 agonist inhalation, either by pMDI
(pressurised metered dose inhaler) and spacer or via oxygen-powered nebulisation (if
available). Repeat as often as necessary.
Anaphylaxis
Anaphylaxis?
A = Airway B = Breathing C = Circulation D = Disability E = Exposure
Diagnosis – look for:

•Sudden onset of Airway and/or Breathing and/or
Circulation problems1
•And usually skin changes (e.g. itchy rash)
Call for HELP

Call resuscitation team or ambulance
•Remove trigger if possible (e.g. stop any infusion)

•Lie patient flat (with or without legs elevated)
-A sitting position may make breathing easier
-If pregnant, lie on left side
Inject at
anterolateral aspect – Give intramuscular (IM) adrenaline2
middle third of the thigh
•Establish airway
•Give high flow oxygen
•Apply monitoring: pulse oximetry, ECG, blood pressure
If no response:
•Repeat IM adrenaline after 5 minutes
•IV fluid bolus
If no improvement in Breathing or Circulation problems1

despite TWO doses of IM adrenaline:
•Confirm resuscitation team or ambulance has been called
•Follow REFRACTORY ANAPHYLAXIS ALGORITHM
1. Life-threatening 2. Intramuscular (IM) adrenaline 3. IV fluid challenge

problems Use adrenaline at 1 mg/mL (1:1000) concentration Use crystalloid
Airway Adult and child >12 years: 500 micrograms IM (0.5 mL) Adults: 500–1000 mL
Hoarse voice, stridor Child 6–12 years: 300 micrograms IM (0.3 mL) Children: 10 mL/kg
Child 6 months to 6 years: 150 micrograms IM (0.15 mL)
Breathing Child <6 months: 100–150 micrograms IM (0.1–0.15 mL)
Work of breathing, wheeze,
The above doses are for IM injection only.
fatigue, cyanosis, SpO2 <94%
Intravenous adrenaline for anaphylaxis to be given
only by experienced specialists in an appropriate setting.
Circulation
Low blood pressure, signs of
shock, confusion, reduced
consciousness
https://www.resus.org.uk/library/additional-guidance/guidance-anaphylaxis/emergency-treatment
67
REFERENCES
1. National Institute for Health and Clinical Excellence. Anaphylaxis:
assessment to confirm an anaphylactic episode and the decision to refer
after emergency treatment for a suspected anaphylactic episode, 2021.
Available at: nice.org.uk/guidance/cg134/evidence/anaphylaxis-full-guideline-
pdf-184946941
2. Pflipsen MC & Vega Colon KM. Anaphylaxis: Recognition and Management.

American Family Physician, 2020, 102(6): 355-362.
3. Resuscitation Council UK. Adult choking, 2021. Available at: https://www.

resus.org.uk/sites/default/files/2021-04/Adult%20Choking%20Algorithm%20
2021.pdf
4. Lott C et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in

special circumstances, Resuscitation, 2021.
5. Turner PJ, Campbell DE, Motosue MS & Campbell RL. Global trends in
anaphylaxis epidemiology and clinical implications. The Journal of Allergy and
Clinical Immunology In Practice, 2020, 8: 1169.
6. Liyanage CK, Galappatthy P & Seneviratne SL. Corticosteroids in

management of anaphylaxis; a systematic review of evidence. European
Annals of Allergy and Clinical Immunology, 2017, 49: 196-20.
7. Resuscitation Council UK. Emergency treatment of anaphylactic reactions:

Guidelines for healthcare providers, 2021. Available at: https://www.resus.
org.uk/library/additional-guidance/guidance-anaphylaxis/emergency-
treatment

MEDICAL
EMERGENCIES
5
MEDICAL EMERGENCIES
1. Chest pain
• Cardiac chest pain (see also chapter 3)
• Ischaemic heart disease
• Pericarditis
• Non-traumatic non-cardiac chest pain
• Aortic dissection
• Pulmonary embolism
• Pneumothorax (see chapter 6)
• Inflammatory/infectious causes
• Gastrointestinal causes
2. Asthma/exercise-induced bronchospasm
3. Seizures/epilepsy
4. Hypoglycaemia
CHEST PAIN
Cardiac chest pain
There are many possible causes for a player presenting with chest pain, and although
the first thought with a football player suffering acute chest pain is usually towards
cardiac causes, there are a number of life‑threatening, non-cardiac conditions that
present with acute chest pain that also need to be considered.
Cardiac causes of collapse and SCA were described in chapter 3. Many of these will
present as collapse rather than chest pain. The differential diagnosis of chest pain is
vast and, in the majority of cases, the diagnosis will be based on the history presented
by the player or staff member.
Ischaemic heart disease
In patients under the age of 35, this is an unlikely but still a potential possible cause
of chest pain.
In players or members of coaching staff over the age of 35 presenting with chest pain,
an ischaemic cause should be considered.
Risk factors include smoking, a known previous history of ischaemic heart disease
(IHD), a positive family history of IHD, hypertension and hypercholesterolaemia.
Symptoms and signs of IHD
Classic history will be of exertional, crushing, central chest pain possibly radiating to
either arm or jaw, although any history of chest pain provoked by exercise is concerning.
70 5 Medical emergencies
Rest pain in a person known to have IHD is a highly concerning sign of critical ischaemia.
Atypical presentations are also common, so taking a full history from the player or
staff member is important.
The person may appear completely normal on examination. If they appear pale,
sweating or short of breath, again this is more concerning of critical ischaemia.
If you have access to an ECG, perform this while looking for changes of ischaemia or
myocardial infarction. A normal ECG does not exclude IHD as a diagnosis and, where
there is any concern, onward referral to hospital is prudent.
Treatment of IHD
The person should immediately stop what they are doing and sit or lie down –
whichever is most comfortable. If the diagnosis is possible critical IHD, administering
GTN spray and 300mg aspirin is prudent. Ensure that an ambulance has been called.
Measure oxygen saturations where possible and provide supplemental oxygen to

ensure saturations of 94% or above.
Pericarditis
Pericarditis is caused by inflammation of the pericardium: two thin layers that form a
sac around the heart. Viral infections such as influenza or coxsackie B are a common
cause of pericarditis, but post‑myocardial infarction, as a consequence of systemic
inflammatory disorders like rheumatoid arthritis or after trauma, can also occur.
Symptoms and signs of pericarditis
The history is usually of a sharp pain worsened by inspiration and lying down. The pain
tends to be improved by leaning forward. It is typically located behind the sternum or
to the left side of the chest, and it may also radiate to the shoulder or neck.
There may be other associated features such as a fever, cough, shortness of breath
or palpitations, so in the prehospital setting it may be difficult to be confident of the
diagnosis.
A pericardial rub may be present when auscultating the heart sounds, but this is not
always the case.
An ECG may show classic features of saddle-shaped ST elevation, and an echo of

the heart is usually required to assess for the potential for an associated pericardial
effusion.
A troponin will help to quantify an associated myocarditis.
Treatment of pericarditis
Pericarditis is usually a self-limiting disease and treatment is aimed at managing

symptoms and pain. Anti‑inflammatories may be useful and, if these do not help,
there may be a role for corticosteroids if symptoms recur.
71
Non-traumatic, non-cardiac chest pain
Primarily, non-cardiac causes of acute chest pain can be differentiated by the origin of
the pathology, namely from:
• the aorta, e.g. aortic dissection;

• the lungs, e.g. pulmonary embolism;
• the pleura, e.g. tension or simple pneumothorax (see chapter 6);
• the oesophagus/stomach/mediastinum, e.g. oesophageal rupture and
oesophagitis; and
• the musculo-skeletal system, e.g. costochondritis.
It should be noted that players with a potentially life-threatening cause of chest pain
may initially appear to be relatively well, showing neither vital-sign nor physical-
examination abnormalities. However, whatever the source of the chest pain may be,
medical professionals should always focus on the immediate detection of common
life-threatening causes of chest pain and treat them accordingly.
Some of these non-traumatic, non-cardiac life-threatening medical emergencies are

listed below and are included mainly for information and completeness.
Acute aortic dissection
The most critical cause of severe aortic-type chest pain is acute aortic dissection, usually
due to congenital abnormalities, hypertension or connective tissue disease.
An event that may precede a fatal tear/dissection of the vessel may be simple blunt
trauma to the chest.
Symptoms and signs of aortic dissection
• Chest pain: acute, intense tearing, with radiation to the back, anterior chest,
jaw or abdomen depending on the segment of the aorta that is affected
• Variation in blood pressure between upper limbs
• Due to subsequent obstruction of aortic branch arteries, signs may include:
• angina pectoris-type pain from myocardial ischaemia;
• acute upper and/or lower-limb ischaemia;
• acute abdominal pain; and
• acute neurologic deficits, e.g. decreased consciousness, syncope,
stroke or paraplegia.
• Clinical signs of life-threatening cardiac tamponade:
• cardiac shock with hypotension;
• tachycardia; or
• diminished heart sounds.
• Congestive heart failure due to acute aortic valve regurgitation
• Acute haemorrhagic shock
Treatment of aortic dissection
Diagnosis on the field of play may not be straightforward unless the diagnosis is
consciously considered.
The most important treatment strategy involves blood-pressure control in order to

reduce the sheer intensity of the stress and pulse flow. Therefore, do not administer
uncontrolled, large quantities of intravenous fluids or attempt to increase the systolic
blood pressure above 90mmHg.
• Administer supplemental oxygen if present

• Analgesia with intravenous morphine if possible
• If a 12-lead ECG is available, signs of acute myocardial infarction may be
present due to obstruction of the coronary arteries. Likewise, pulseless
electrical activity due to acute cardiac tamponade may be present and
require full cardiopulmonary resuscitation
• Transfer urgently to the nearest, most appropriate medical facility
73
Acute pulmonary embolism
Although pulmonary embolism (PE) is thought to be a rare life-threatening medical

emergency on the field of play, the exact incidence is unknown. However, it is always
a possibility because of the frequent travel, by road and air, that may increase the
risk of PE above the normal level. There is an increased incidence of thromboembolic
disease in patients who have been hospitalised as a consequence of COVID-19. The
administration of certain COVID-19 vaccines also appears to be associated with an
increased incidence of blood clots in the first 28 days following vaccination, so this is
also important to consider when taking a history.
Symptoms and signs of PE
• Dyspnoea and respiratory distress

• Tachycardia/tachypnoea
• Pleuritic-type chest pain
• Cough
• Haemoptysis
• Cardiogenic shock
• Sudden cardiac arrest
Treatment of pulmonary embolism
Treatment is based on:
• first, considering the diagnosis;

• applying oxygen if there is evidence of respiratory distress;
• administering analgesia if pain is a significant feature; and
• transferring urgently to hospital.
If an ECG is available, it is worth remembering that this may be normal even in the
presence of PE. Sinus tachycardia is the most common ECG sign, although the classic
12-lead ECG signs of PE include evidence of right heart strain:
• S1, QIII, T III pattern

• Right axis deviation
• Complete or incomplete right bundle branch block
The PERC score is a useful tool to use to determine whether further investigations are
required. PTE is a potentially catastrophic event, but it is also rare in elite athletes,
so the PERC score can be helpful in deciding who to transfer to hospital for further
investigation.
The pre-test clinical suspicion of a PTE should be low – in the studies performed to
validate a PERC score, a pre-test probability of <15% was used. If symptoms develop
on the field of play, time should be given to allow the heart rate to settle as long as
the player is otherwise well.
PERC SCORE – to be used where clinical suspicion is low and the clinician’s assessment
is that the likelihood of the diagnosis being a PTE is <15%
• Age > or = 50
• Heart rate >= 100
• Oxygen saturation on room air <95%
• Unilateral leg swelling
• Haemoptysis
• Recent surgery or trauma
• (Surgery or trauma ≤4 weeks ago requiring treatment with general anaesthesia)
• Prior PE or DVT
• Hormone use
• (Oral contraceptives, hormone replacement or estrogenic hormone use in
male or female patients)
(https://www.mdcalc.com/perc-rule-pulmonary-embolism)
All questions must be answered in the negative.
Any positive answers will require further investigation.
Inflammatory/infectious causes of non-cardiac chest pain
These include pleuritis, pneumonia, bronchitis and mediastinitis.
These inflammatory/infectious causes of chest pain are rare on the field of play because
signs and symptoms will usually present prior to the match or competition.
Symptoms and signs:
• Dyspnoea/respiratory distress
• Productive (bronchitis, pneumonia) or non-productive (pleuritis) cough
• Pleuritic-type chest pain
• Fever
• Oxygen desaturation
Treatment:
• Immediate removal from any further physical exercise

• Antipyretic drug therapy if required
• Treat the player symptomatically and transfer urgently to the nearest,
most appropriate medical facility
Acute gastrointestinal conditions
These can be a spectrum of conditions such as gastro-oesophageal reflux, oesophageal

spasm, peptic ulcer disease and oesophagitis.
75
Vomiting repeatedly can lead to Boerhaave’s Syndrome with oesophageal perforation
leading to mediastinitis, which is potentially life-threatening.
As the cardiac system and the oesophagus share some common neurological
innervations, acute pathology in either system can present with classical symptoms
of chest tightness, provocation by exercise and pain release by rest or nitrates. It may
therefore be difficult to distinguish clinically between cardiac chest pain and pain
originating from the oesophagus.
Typically, the symptoms of gastro-oesophageal reflux are of burning epigastric pain

worsened at night when lying flat and provoked by certain food types, alcohol and
prescribed medications such as NSAIDs.
Minimising exposure to the precipitant is key. Symptoms may be managed with a

proton-pump inhibitor such as omeprazole.
Boerhaave’s Syndrome
Symptoms and signs:
• Chest pain
• Pain or difficulty swallowing
• Pain at the perforation site (in the neck, chest or abdomen)
• Air bubbles under the skin
• Fever
• Tachypnoea/dyspnoea
• Cyanosis and shock may develop rapidly
Treatment:
• Cease any further physical exercise immediately

• Obtain intravenous access and administer analgesia and fluids if possible
• Treat the player symptomatically and transfer urgently to the nearest, most
appropriate medical facility
REFERENCES
1. Cui S, Chen S, Li X, Liu S & Wang F. Prevalence of venous thromboembolism
in patients with severe novel coronavirus pneumonia. Journal of Thrombosis
and Haemostasis, 2020, 18(6): 1421-1424.
2. Østergaard SD, Schmidt M, Horváth-Puhó E, Thomsen RW & Sørensen HT.

Thromboembolism and the Oxford-AstraZeneca COVID-19 vaccine: side-
effect or coincidence? The Lancet, 2021, 397(10283): 1441-1443.
3. Erbel R, Aboyans V, Boileau et al. 2014 ESC Guidelines on the diagnosis and
treatment of aortic diseases. European Heart Journal, 2014, Nov 1;35 (41): 2873-
926.
4. Sheikh AS, Ali K, Mazhar S. Acute aortic syndrome. Circulation, 2013, Sep
3;128(10): 1122-1127.
5. Konstantinides S, Torbicki A. Management of venous thrombo-embolism: an

update. Ibid., 2014, Nov 1;35(41): 2855-63.
6. Spangler M, Hawley H, Barnes N et al. A review of guidelines and

pharmacologic options for asthma treatment, with a focus on exercise-
induced bronchoconstriction. The Physician and Sportsmedicine, 2013, Sep;41(3):
50-57.
7. Alangari AA. Corticosteroids in the treatment of acute asthma. Annals of

Thoracic Medicine, 2014, Oct;9(4): 187-192.
8. Fenster PE. Evaluation of chest pain: a cardiology perspective for

gastroenterologists. Gastroenterology Clinics of North America, 2004 Mar, 33(1):
35-40.
9. Freimark D, Matetzky S, Leor J et al. Timing of aspirin administration as a

determinant of survival of patients with acute myocardial infarction treated
with thrombolysis. American Journal of Cardiology, 2002, 89: 381-385
10. Kline JA. Diagnosis and Exclusion of Pulmonary Embolism. Thrombosis

Research, 2018, 163: 207-220.
77
ASTHMA/EXERCISE-INDUCED BRONCHOSPASM
Asthma has recently become more prevalent in the general population, including the
athletic population. All clinicians who manage athletes with asthma must be prepared
to treat an acute exacerbation, be able to rapidly differentiate mild and moderate
from severe and life-threatening symptoms, and have pre-planned treatment routines
in place.
Due to the known critical complications of asthma/exercise-induced bronchospasm

(EIB) that may occur on the field of play in football players, appropriate emergency
medical care resources must be available inside a stadium to provide advanced life
support, along with emergency medication and the skills and scope of practice to
provide this. This minimum level of care may be provided either by the attending
ambulance emergency medical service and/or the venue medical officer and associated
medical staff located in the various stadium medical centres.
Asthma
Asthma is characterised by the triad of the following:
• Bronchoconstriction
• Increased mucous production
• Mucosal swelling due to inflammation
This triad will tend to produce symptoms of wheezing, shortness of breath and
coughing. It should be remembered that these symptoms are neither sensitive nor
specific to asthma.
Many athletes will be aware of their diagnosis and carry with them appropriate
medications, such as a salbutamol inhaler, but it is the team doctor’s responsibility
to ensure that they also carry with them appropriate treatments to manage an
exacerbation of asthma.
As part of a player’s medical assessment, a peak flow is a very helpful test to perform
– knowing the baseline norm for a player is preferable to comparing them to a
population-based value where possible. Physiologically, should a player present with
an exacerbation of asthma or EIB, comparing their peak-flow values is exceptionally
helpful in allowing categorisation of the severity of the exacerbation, thus helping to
direct treatment appropriately.
Differential diagnoses include the following:
• Anaphylaxis
• Pneumonia – including COVID-19
• Pneumothorax
• Pulmonary embolism
• Pulmonary oedema (this should be considered if sport is being played at
altitude)
Exercise-limiting pulmonary disorders include exercise-induced bronchospasm (EIB),
vocal cord dysfunction (VCD), exercise-induced laryngeal obstruction, exercise-
induced anaphylaxis and exercise-induced urticaria. EIB and VCD remain two of the
most common and disabling acute pulmonary disorders in athletes.
EIB and exercise-induced asthma are terms that are used to describe the onset of
lower-airway bronchospasm in susceptible athletes following exercise. Although EIB
may be found in a large percentage of athletes with asthma, up to 10% of healthy
athletes who participate in high-performance exercise may develop EIB.
The prevalence of EIB in sport is not uncommon, with rates between 10 and 50%.
Football is classified as an intermittent sprint sport, undertaken at relatively high
physiological intensity, normally on a grass pitch and in all weather conditions.
These conditions present risk factors for EIB, which include increased hyperpnoea,
increased exposure to cold environments, aeroallergens and irritants during training
and competition, either locally or when travelling nationally or internationally.
Additionally, EIB-related fatalities have been reported in medical literature.
One of the mechanisms of EIB causation is believed to be the increased minute

ventilation of cold, dry air. This may lead to cooling and dehydration of the airway
epithelial cells, with the resultant increased osmolarity causing an inflammatory
response, leading to symptomatic airway narrowing.
Typical signs and symptoms of EIB include:
• wheezing;
• coughing;
• chest tightness;
• shortness of breath;
• chest pain;
• excessive mucus;
• decreased performance;
• use of accessory breathing muscles; and/or
• inability to complete sentences, phrases or words due to shortness of breath.
Atypical signs and symptoms of EIB include:
• headache;
• abdominal pain;
• muscle cramps;
• dizziness; and/or
• fatigue.
Exercise/performance-related symptoms of EIB:
• Climate and/or season-related fluctuations in asthma or asthma-like

symptoms that may be related to environmental humidity, aeroallergen
content and air-borne irritants
• Poor performance, out of line with the athlete’s level of conditioning/
expectations
• Feeling “out of shape” or having “heavy legs”
79
While there are a considerable number of athletes who are later objectively assessed
as having EIB, there may be no obvious sign of wheezing or other symptoms or the
athlete may actually subconsciously depress or ignore their symptoms.
In EIB, provocation occurs after five to ten minutes of high-performance exercise,

whereas symptoms peak during the five to ten minutes after exercise has stopped and
disappear after 30 minutes.
VCD may be misdiagnosed as EIB because symptoms include noisy breathing, shortness
of breath, wheezing, coughing, and sensations of upper-airway obstruction. However,
symptoms are localised to the upper trachea with clear lungs on auscultation, unless
there is coexistent EIB. Throat tightness rather than chest tightness is present, including
voice changes. In VCD, symptoms occur abruptly during exercise and resolve after
exercise has stopped. Although the symptom complex is clearly different for EIB and
VCD, they are often not clearly differentiated in the acute setting on the field of play
and are therefore misdiagnosed and mistreated.
Treatment of bronchospasm
Treatment is primarily based on classifying the severity of the presentation and treating
accordingly.
The flow chart below is taken from the British Thoracic Guidelines/SIGN (Scottish
Intercollegiate Guidelines Network) Guideline 2019 and is generally applicable to the
management of asthma/EIB in the prehospital setting.
If in any doubt, perform a full ABCDE primary assessment considering the potential of
a differential diagnosis. Document your observations as you make them to allow for
classification of the severity and monitor trends as you administer treatment.
Anyone presenting with features of acute severe or life-threatening asthma should be

transferred to hospital with treatment ongoing.
Oxygen treatment should be commenced on anyone who is hypoxic or suspected

to be hypoxic. Once a pulse oximeter is available, administering oxygen to achieve
saturations of 94-98% is advised.
Where oxygen is used to drive a nebuliser, a flow rate of 6l/minute is necessary.
Management of acute asthma in adults in general practice
Many deaths from asthma are preventable. Delay can Assess and record:
be fatal. Factors leading to poor outcome include:
• Peak expiratory flow (PEF)
• Clinical staff failing to assess severity by objective • Symptoms and response to self treatment
measurement • Heart and respiratory rates
• Patients or relatives failing to appreciate severity • Oxygen saturation (by pulse oximetry)
• Under use of conicosteroids
Caution: Patients with severe or life-threotening attacks may not
Regard each emergency asthma consultation as for acute be distressed and moy not have all the abnormalities listed below.
severe asthma until shown otherwise. The presence of any should alert the doctor.
Moderate asthma Acute severe asthma Life-threatening asthma
INITIAL ASSESSMENT
PEF>50-75% best or predicted PEF 33-50% best or predicted PEF<33% best or predicted
FURTHER ASSESSMENT
• SpO2 ≥92% • SpO2 ≥92% • SpO2 <92%

• Speech normal • Can't complete sentences • Silent chest, cyanosis or poor
• Respiration <25 breaths/min • Respiration ≥25 breaths/min respiratory effort
• Pulse < 110 beats/min • Pulse ≥110 beats/min • Arrhythmia or hypotension
• Exhaustion, altered consciousness
MANAGEMENT
Treat at home or in surgery and
Consider admission Arrange invnediate ADMISSION
ASSESS RESPONSE TO TREATMENT
TREATMENT
• ß2 bronchodilator: • Oxygen to maintain SpO2 94-98% if • Oxygen to maintain SpO2 94-98%

- via spacer" available • ß2 bronchodilator with ipratropium:
lf no improvement: - via nebuliser (preferably oxygen-
• ß2 bronchodilator:
- via nebuliser (preferably oxygen- driven), salbutamol 5 mg and
- via nebuliser (preferably oxygen-
ipratropium 0.5mg
driven), salbutamol 5 mg driven), salbutamol 5 mg - or if nebuliser and ipratropium
• Give prednisolone 40-50 mg
- or if nebuliser not available, via not available, ß2 bronchodilator
• Continue or increase usual treatment
spacer* via spacer*
lf good response to first treatment • Prednisolone 40-50 mg or IV • Prednisolone 40-50 mg or IV
(symptoms improved, respiration and hydrocortisone 100 mg immediately
hydrocortisone 100 mg
pulse settling and PEF >50%) continue
or increase usual treatment and • lf no response in acute severe
continue prednisolone asthma: ADMIT
Admit to hospital if any: If admlttlng the patient to hospital: Follow up after treatment or
• Life-threatening features • Stay with patient until ambulance discharge from hospital:
• Features of acute severe asthma
arrives • Continue prednisolone until recovery
present after initial treatment
• Send written asssessment and (minimum 5 days)
• Previous near-fatal asthma
referral details to hospital • GP review within 2 working days
Lower threshold for admission if • ß2 bronchodilator via oxygen-driven • Monitor symptoms and PEF
aftemoon or evening attack. recent nebuliser In ambulance • Check inhaler technique
nocturnal symptoms or hospital • Written asthma action plan
admission, previous severe attacks,
• Modify treatment according to
patient unable to assess own condition,
or concem over social circumstances guidelines for chronic persistent
asthma
• Address potentially preventable
contributors to admission
* ß2 bronchodilator via spacer given one puff at a time, inhaled separately using tidal breathing;
according to response, give another puff every 60 seconds up to a maximum of 10 puffs
https://www.brit-thoracic.org.uk/document-library/guidleines/asthma/btssign-guideline-for-the-management-of-
asthma-2019/
81
Emergency exercise-induced bronchospasm medications
Beta-2 agonist administration – salbutamol
Beta-2 agonists are the first level of emergency medications administered for acute
bronchospasm and should be administered as early as possible.
In non-life-threatening bronchospasm, the use of simple pressurised metered multi-

dose inhalers (pMDI) with an appropriate volume spacer are as effective as oxygen-
driven nebulised beta-2 agonists. In the football stadium environment, where portable
pressurised oxygen or air is not always available, the use of pMDIs with a spacer is the
initial administration method of choice. If a commercial volume spacer is not available,
you can make a volume spacer using a ~500ml plastic soft drink bottle. Cut a hole
in the bottom of the plastic bottle, slightly larger than that of the spray head of the
pMDI. Eight puffs of the pMDI are dispensed into the spacer chamber, allowing the
player to inhale the medication at their own pace, placing their lips around the screw-
top end of the bottle and inhaling (see photos below).
Repeat doses of beta-2 agonists can be administered at 20-minute intervals for up

to four hours. If, however, there is little or no improvement or deterioration with the
use of pMDI + spacer, the player’s treatment should be converted to beta-2 agonist
administration via pressurised oxygen-driven nebulisation and/or transferred to the
nearest medical facility for further treatment.
Inhaled beta-2 agonists are as efficacious and preferable to intravenous beta-2

agonists in adult players in most instances.
The most frequent side effects of beta-2 agonist inhalation are tachycardia, muscle
tremors, headache and irritability.
It must be noted that regular use of short-acting beta-2 agonists or long-acting beta-
2 agonists may cause tolerance to the bronchodilator effects of the medication, thus
having a potential negative effect on acute rescue therapy.
Anticholinergic medications
Anticholinergic bronchodilators, e.g. ipratropium bromide, may be added to the beta-

2 agonist nebulisation or volume spacer in severe exacerbations or with poor response
to beta-2 agonist treatment. This combination is known to produce significantly
greater bronchodilation than a beta-2 agonist alone, leading to faster recovery. When
administered by pMDI + volume spacer, dispense eight puffs every 20 minutes into the
volume spacer in synchronisation with the beta-2 agonist administration. Commercial
combinations of beta-2 agonist + anticholinergic pMDIs (or nebulisation mixtures) are
available for use and are logistically easier for storage and administration by travelling
football teams.
Systemic corticosteroids
Corticosteroid administration is routinely indicated during acute bronchospasm

exacerbations as it reduces mortality, relapse exacerbations, further hospital admissions
and beta-2 agonist usage. It may be administered either orally or intravenously, with
neither route of administration being more efficacious than the other. Therefore,
there is no advantage to IV administration, unless IV access is already established for
additional reasons or there are potential problems with gastrointestinal transit or
absorption.
Use prednisolone 40-50mg orally as a single dose or Hydrocortisone 100mg as an

intravenous bolus. For convenience, consider use of 2x25mg oral tablets rather than
10x5mg tablets. Corticosteroids can be administered at any point in the treatment
regime of the acute exacerbation, whether prehospital or in the emergency
department.
Continue prednisolone 50mg oral administration daily for at least five days post
exacerbation or longer, if required for recovery.
Fluid administration
Athletes with EIB may require rehydration either orally or intravenously, whichever is
most appropriate, and potentially correction of electrolyte imbalance resulting from
beta-2 agonist and corticosteroid-induced hypokalaemia.
Other medications
In locations where intensive medical care levels of treatment can be delivered,

additional medications can be administered under senior or specialist supervision,
including intravenous beta-2 agonists (seldom used since there is no additional
benefit to inhalation), intravenous magnesium infusion (often used) or intravenous
aminophylline (seldom used due to serious side effects).
Care must always be taken to respect the anti-doping rules. Should a treatment be
given in an emergency setting, the clinician must ensure that all appropriate follow-
ups are conducted to satisfy the anti-doping regulations.
83
REFERENCES
1. https://www.brit-thoracic.org.uk/document-library/guidleines/asthma/
btssign-guideline-for-the-management-of-asthma-2019/
2. Lott C et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in

special circumstances, Resuscitation, 2021. Available at https://doi.org/10.1016/j.
3. Becker JM, Rogers J, Rossini G, et al. Asthma deaths during sports: Report of
a 7-year experience. The Journal of Allergy and Clinical Immunology, 2004, 13(2):
264-267.
4. Rundell KW & Weiss P. Exercise-Induced Bronchoconstriction and Vocal Cord

Dysfunction: Two Sides of the Same Coin. Current Sports Medicine Reports,
2013, 12(1): 41-46.
5. Ansley L, Kippelen P, Dickinson J et al. Misdiagnosis of exercise-induced

bronchoconstriction in professional soccer layers. Allergy, 2012, 67: 390-395.
6. Rundell KW & Jenkinson DM. Exercise-Induced Bronchospasm in the Elite

Athlete. Sports Medicine, 2002, 32(9): 583-600.
7. Martinez FD. Sudden Death from Respiratory Disease in Sports. Archivos de

Bronconeumolía, 2008, 44(7): 343-345.
8. Lang D. Asthma Deaths and the Athlete. Clinical Reviews in Allergy &
Immunology, 2005, 29: 125-29.
SEIZURES/EPILEPSY
Generalised tonic-clonic seizures remain one of the most common medical emergencies,
with an incidence of around 1% in the general population. It is vital that the team
clinician is equipped with the knowledge and tools to deal with this presentation.
From the perspective of a venue medical officer, seizures also often occur in large-
attendance spectator sports for many reasons such as:
• stress;
• visual and auditory stimuli;
• medication compliance issues;
• alcohol or drug ingestion; and
• acute hypoglycaemia.
It is therefore vital that the stadium is equipped with appropriate resources to enable
clinicians to manage these presentations.
If the seizure is short (less than five minutes of active, continuous convulsing), basic
medical care may be all that is required. Onwards management will then depend on
whether the person has a known history of suffering from seizures and what the
previous experiences and expectations are in relation to their usual pattern and the
underlying reason for their seizures.
However, if the seizure continues for longer than five minutes, clinical data indicates
that the seizure is unlikely to stop spontaneously without the use of emergency
medication. In fact, up to one third of patients suffering from status epilepticus do not
respond to benzodiazepine followed by a loading dose of a second-line treatment.
In this high-risk situation, the patient may deteriorate into status epilepticus. This is
known to have high morbidity and mortality complications if it is not stopped quickly.
Status epilepticus is a neurological emergency characterised by prolonged seizure

activity or multiple seizures without full recovery in between.
First-line, status-epilepticus-appropriate benzodiazepine medications and an easily

administered glucose source must be available as part of the medical services offered
within the football stadium environment.
Secondary causes of seizure
1. Cardiac arrest: as discussed previously, it is also vital that you consider a

cardiac arrest as a potential cause where a player collapses suddenly and
demonstrates short-lived seizure activity.
2. Hypoglycaemia: all patients having any type of seizure must be regarded as

being hypoglycaemic until a reading of their blood glucose level indicates
otherwise.
3. Post-trauma (specifically post-head injury): a short seizure may occur after a

player has sustained a head injury. Although this, in itself, may not require
further treatment, it is an indicator that hospital evaluation will be required
to assess the head injury.
85
Diagnosis
If they are not stopped quickly, tonic-clonic convulsing seizures become life-threatening
to patients. The response to these incidents should therefore be immediate and
structured, and appropriate interventions and treatments should be available.
If it is not practically possible to measure a patient’s blood glucose level while they
are having a seizure, glucose should be administered via an appropriate route in case
hypoglycaemia is present.
As comprehensive a medical history of the patient as possible should be obtained. If

possible, accompanying family members and/or friends should be asked for a seizure
history in relation to the player.
Treatment
The initial treatment of any convulsing patient focuses on injury prevention and
safety. Therefore, if the patient has not already been positioned in a safe horizontal
position, gently place the patient onto a horizontal surface, in such a way that no
harm will occur to them from any active movements of their head or body against any
solid structure. Place something soft under the patient’s head to provide a protective
cushion against the impact of any convulsing movements.
It is best to attempt to place the patient into the lateral (recovery) position to protect
the airway, but this may not always be possible.
• Loosen any restrictive garments, if necessary.

• Do not attempt to restrain the patient in any way, unless absolutely
necessary, so as not to increase the force of the patient’s contractions.
• Do not attempt to force any object into the patient’s mouth or between their
teeth, as this may result in severe bleeding and/or breakage of the teeth.
This may lead to blood or broken teeth being aspirated into the patient’s
respiratory tract, causing airway obstruction and related pathology with
critical consequences.
• All patients having any type of seizure must be regarded as being
hypoglycaemic until their blood glucose level reading indicates otherwise. If
it is not practically possible to measure the blood glucose of a patient having
a seizure, glucose should be administered via an appropriate route in case
hypoglycaemia is present.
If the seizure continues for longer than five minutes, and if hypoglycaemia has been
excluded or nominally treated, administration of a benzodiazepine is indicated as a
first-line anti-convulsant medication.
A number of benzodiazepines are available for use in terminating a seizure. It is

important that you use the one with which you are most familiar to minimise the risk
of an unexpected side effect occurring. Although first-line benzodiazepines include
midazolam, lorazepam, diazepam and clonazepam, the benzodiazepine “drug of
choice” in the football environment remains midazolam because of its rapid onset,
variable vial-strength availability, multiple routes of administration, lack of “cold
chain” storage and the ability to administer repetitive doses, if and when required.
All of these characteristics ensure safe, easy, effective and efficient use within the
football stadium environment or during travel.
Midazolam may be administered via the following routes, using the following
recommended doses:
Route of administration Child dose Adult dose
Intra-buccal: inside the cheek 0.3mg/kg (max. 10mg) 10mg
Intra-nasal: inside the nose 0.3mg/kg (max. 10mg) 10mg
Intramuscular 0.15mg/kg (max. 10mg) 10mg
IV 0.15mg/kg (max. 10mg) Titrated to 10mg
The risk of respiratory depression is a real issue, but must not be over-estimated, as the
seizure itself may also cause respiratory depression. The recommended doses shown
above are conservative for the average population, whereas the alternative is severe
complications from prolonged seizure activity.
It is, however, vital (and good clinical practice) to ensure that appropriate equipment to
provide airway adjuncts, supported ventilation and oxygen are immediately available
whenever benzodiazepines are administered.
For patients with IV access, IV lorazepam 0.1mg/kg (usually 4mg bolus) is the drug of
choice. IV diazepam emulsion (5-10mg) may also be used if lorazepam is not available.
If a single dose does not terminate the convulsions five minutes after administration,
you can consider repeating the dose.
Any patient who is administered anti-convulsant medication should be transferred,

in the lateral (recovery) position, to the nearest, most appropriate medical facility for
further evaluation and management.
When to transfer a patient to hospital
• Ongoing seizure activity (longer than five minutes)

• Seizure resulting in injury
• Seizure secondary to another process, such as cardiac arrest, hypoglycaemia
or head injury
• Respiratory depression post-seizure
• Multiple seizures
• First presentation of seizure
87
REFERENCES
1. Glauser T, Shinnar S, Gloss D et al. Evidence-based guideline: treatment of
convulsive status epilepticus in children and adults: report of the Guideline
Committee of the American Epilepsy Society. Epilepsy Currents, 2016, 16(1):
48-61.
2. Vossler DG, Bainbridge JL, Boggs JG et al. Treatment of Refractory Convulsive

Status Epilepticus: A Comprehensive Review by the American Epilepsy Society
Treatments Committee. Ibid., 2020, 20(5): 245-264.
3. Shearer P & Riviello J. Generalized Convulsive Status Epilepticus in Adults and

Children: Treatment Guidelines and Protocols. Emergency Medicine Clinics of
North America, 2011, 29: 51-64.
4. Meierkord H, Boon P, Engelsen B et al. EFNS guideline on the management

of status epilepticus in adults. European Journal of Neurology, 2010, 17: 348-355.
5. De Waele L, Boob P, Ceulemans B et al. First line management of prolonged

convulsive seizures in children and adults: good practice points. Acta
Neurologica Belgica, 2013, 113: 375-80.
6. Millikan D, Rice B & Silbergleit R. Emergency Treatment of Status Epilepticus:

Current Thinking. Emergency Medicine Clinics of North America, 2009, 27: 101-13.
HYPOGLYCAEMIA
Regular exercise is highly recommended for everyone due to its beneficial effects in
preventing and controlling disease. This recommendation is specifically prescribed for
anyone who is diagnosed with either type 1 or type 2 diabetes mellitus (DM). This is
due to the fact that blood sugar can be controlled with combinations of insulin, oral
medications, diet and exercise. This has helped many players with DM to be chosen to
represent their national teams.
It is therefore not unexpected for football medical professionals to be presented

with glucose-type emergencies in individuals who have either documented or
undocumented glucose-regulation disorders, such as DM. This is particularly relevant
since it is estimated that 54% of individuals with DM remain undiagnosed. The most
acute, life-threatening glucose-type medical emergency that might occur within the
football environment is hypoglycaemia, which can have devastating neurological
results if it is not diagnosed and adequately treated as soon as possible.
The brain relies on being constantly provided with glucose from the blood to maintain
its normal function and any decrease in glucose levels will detrimentally affect this
neurological function.
Although hypoglycaemia may occur in non-diabetic persons due to dehydration,

stress, intense exercise and heat-related disorders, it is more likely to occur in DM
sufferers, particularly if adequate precautions are not taken before, during and after
exercise. This is due to the effect that exercise has on increasing insulin sensitivity,
insulin-dependent glucose uptake and glucose usage on muscles, the effects of which
entail a greater risk of hypoglycaemia.
Despite significant advances in the treatment of DM, the reported incidence of severe
hypoglycaemia has not decreased over the last 20 years.
Diagnosis
A normal blood glucose concentration level is above 4mmol/l (70mg/dl) and any
level below this is considered to be hypoglycaemic. Common signs and symptoms of
hypoglycaemia may include any of the following:
Signs and symptoms of acute hypoglycaemia
Anxiety Blurred vision Confusion

Drowsiness Fatigue Headache
Hunger Incoordination Loss of consciousness
Nausea Odd behaviour Cardiac palpitations
Seizures Slow or slurred speech Tachycardia
Tremors Vertigo Weakness
89
Severe hypoglycaemia, defined as a level of hypoglycaemia that requires the assistance
of another person for treatment or that which is associated with loss of consciousness
or seizures, is a life-threatening condition that requires immediate diagnosis and
treatment.
However, almost all known neurological signs and symptoms may be a clinical
manifestation of acute hypoglycaemia and therefore this condition should always be
considered in any person who has a decreased level of neurological function, especially
those that are unconscious.
The signs and symptoms of acute hypoglycaemia may also overlap with those caused
by strenuous or prolonged exercise, dehydration and heat-related illnesses, thus
requiring the early consideration and measurement of blood glucose levels and/or the
administration of glucose substrates, if and when these signs and symptoms occur in
football.
Blood glucose measurement
It must be possible to measure a person’s blood glucose levels in a football stadium in

order to diagnose the presence of hypoglycaemia, monitor the effects of treatment
and assist with a decision on whether the person can later be discharged home or
should be transferred to hospital. Significant advances have been made in technology,
meaning that it is now possible to measure blood glucose levels in any environment. A
single drop of capillary blood is obtained by lancing the skin at the tip of a finger. This
drop of blood is placed on a disposable plastic strip embedded with a chemical and
inserted into the glucometer, with the result being obtained within just a few seconds.
This makes it an ideal, simple, safe method of measuring blood glucose levels before,
during and after exercise. Any level below 70mg/dL or 4mmol/L is to be regarded as
hypoglycaemic and requires supplemental glucose.
Whenever it is not possible to measure the blood glucose in a person displaying signs
and symptoms of hypoglycaemia, or any neurological signs or symptoms, supplemental
glucose should be administered as a precaution.
Management
Where the player is conscious:
If the player, coach or team medical professional recognises that the player is showing
signs and symptoms of hypoglycaemia, the player should immediately leave the field
of play and have their capillary blood glucose level measured. If hypoglycaemia is
diagnosed or if no glucometer is immediately available, at least 15-20g of fast-acting
glucose, in the form of a dextrose tablet, gel, powder or liquid, should be administered.
It must be noted that many isotonic beverages used to enhance exercise performance
do not contain adequate amounts of readily available glucose to rapidly correct
hypoglycaemia, particularly when compared with many fruit juices of the same
volume.
Where the player is unconscious:
Any player who is unconscious, whether this is due to hypoglycaemia or an unknown

cause, must have their airway opened and protected as a priority, by gently turning the
patient onto their side and opening their mouth. Only after this has been successfully
undertaken can supplemental glucose administration be undertaken. This also applies
if the patient is having a seizure.
Supplemental glucose can be administered to an unconscious player through a variety

of routes, depending on what is immediately available:
• Inject 1mg glucagon, if available, intramuscularly

• Administer 10% dextrose IV in 100-200ml aliquots. Other IV preparations,
such as 20% or 50%, of dextrose may be used where 10% is not available.
Although smaller volumes are needed compared to 10% dextrose, the
higher the percentage of dextrose, the higher the viscosity. This can be
difficult to administer and can irritate the veins.
Whichever route of administration and substrate is used, additional amounts should

be administered until the patient has returned to a state of alertness or their blood
glucose measurement is higher than 70mg/dL or 4mmol/L minimum.
Once the patient is fully awake, able to swallow oral glucose, provide a medical history
and has accompanying colleagues, family or friends to care for them, discharging them
home with medical instructions or to a family doctor may be all that is required. If not,
it may be safest to transfer them to hospital for further evaluation.
Acute hypoglycaemia is a life-threatening medical emergency that may happen to

anyone, including players, officials and spectators, regardless of whether they have
been diagnosed with DM, and this may occur on the field of play or anywhere inside
the football stadium environment. Successful management is dependent on prompt
recognition and management by initially measuring the blood glucose level and then
administering glucose in whichever form and route are appropriate.
91
REFERENCES
1. Zideman DA et al., European Resuscitation Council Guidelines 2021: First aid.
Resuscitation (2021)
2. Iqbal A & Heller SR. The role of structured education in the management of
hypoglycaemia. Diabetologia, 2018, 61(4):751-760.
3. Martin, D. Glucose Emergencies: Recognition and Treatment. Journal of

Athletic Training, 1994, 29:141-143.
4. Kirk, SE. Hypoglycaemia in Athletes with Diabetes. Clinical Journal of Sport

Medicine, 2009, 28: 455-468.
5. Farrel PA. Diabetes, Exercise and Competitive Sports. Available at: http://
www.gssiweb.org/Article/sse-90-diabetes-exercise-and- competitive-sports.
6. Meade A. The highs and lows of diabetes and exercise. Available at: http://
www.ausport.gov.au/sportscoachmag/nutrition2/the_highs_and_ lows_of_
diabetes_and_exercise.
7. Shugart C, Jackson J & Fields KB. Diabetes in Sports. Sports Health, 2010, 2(1):
29-38.
TRAUMA
EMERGENCIES
6
TRAUMA EMERGENCIES
• Spinal injury
• Head and maxillofacial injury
• Traumatic brain injury
• Soft-tissue facial injuries
• Epistaxis
• Bony facial injuries
• Maxilla
• Zygoma
• Nasal
• Mandibular
• Dental emergencies
• Tooth avulsion
• Dental fractures
• Crown fractures
• Root fractures
• Tooth luxation
• Alveolar fractures
• Orbital emergencies
• Chest trauma
• Rib fractures
• Flail segment
• Sternal fracture
• Pneumothorax and tension pneumothorax
• Abdominal trauma
• Pelvis trauma
• Limb trauma
• Posterior sterno-clavicular dislocation
• Shoulder dislocation
• Elbow dislocation
• Tibial fracture
• Foot and ankle dislocation
• Wounds
94 6 Trauma emergencies
The key to managing trauma is to follow the initial assessment approach described in
chapter 1. The assessment is structured to give priority to the most critical injuries first.
Failure to follow the structure leaves the clinician exposed to the risk of missing a
significant injury. This is commonly seen in the context of distracting injuries where
attention is directed towards a more obvious injury, such as a dislocated ankle, rather
than the more occult associated chest trauma.
Practically and pragmatically, however, if a clinician directly observes a trauma incident

from the touchline and they are clear that the incident has resulted in an isolated
injury, their assessment may focus on that injury.
However, they must have first considered the possibility of associated injuries and
balanced this against what they have seen.
If there is any doubt about the mechanism, a full A C BCDE assessment must be made.
Given the speed at which the game is played at professional level, the actual mechanism
of injury is usually unclear even when seen in real time. It is therefore sensible to
always work through the primary assessment first.
The flowchart for initial assessment details this decision-making process and places
emphasis on minimising risk and the potential for error by following the primary
assessment process as the default.
95
Injury
occurs
Clinician
enters pitch
• Mechanism clearly seen and injury is immediately felt • Mechanism is concerning or unclear
to be isolated and unconcerning for an A © or B injury OR
AND • Players response is concerning
• Player’s response is clearly seen and is unconcerning OR
AND • Referee or teammates response is concerning
• Referee and team-mate response is unconcerning
AND
• B
Clinician gives consideration to potential for A © and
as approaching player
• Immediately proceed to protect cervical spine

and assess player fully using A © B C primary survey
process
• Player confirms no other symptoms or issue

• No other concerns highlighted change in condition
• Clinical instinct is of isolated injury
Any concerns or
• Assess the injury change of condition
• Low threshold for going back to full primary survey
Figure 10: Initial assessment
SPINAL INJURY
Although it is rare for a player to suffer a spinal injury when playing football, any
injury to the spine or spinal cord can be catastrophic. If the injury affects the cord at
a cervical level, this is immediately life‑threatening. It is therefore vital to protect the
spine if there is any suggestion or concern that it might be injured.
Where a player is unconscious or has associated injuries, it is not appropriate to move

the cervical spine and so it should be protected and spinal motion should be restricted.
Protecting the spine is easily achieved by holding the player’s head and maintaining an
in-line position. This should be done at the same time as assessing and managing the
airway as described on page 20.
How the player sustains an injury may be an indicator of the type of associated spinal
injury they sustain. Falling from a height directly onto the top of their head will result
in axial loading of the spine and will increase the chances of a burst fracture of C1 in
comparison with a hyperextension injury, which is more likely to result in a fracture
of C1.
It is also worth bearing in mind that a fracture of the cervical spine may result in a
second spinal fracture in up to 10% of patients and it is therefore sensible to immobilise
the whole spine until a definitive assessment or investigation has been undertaken.
The thoracic spine is relatively immobile due to the thoracic cage, but the areas above
it at the cervico‑thoracic junction, as well as those below it at the thoraco-lumbar
junction, are more mobile. These junctions are therefore common sites of injury.
Cervical and high thoracic fractures are of significance because any associated
neurological involvement at this level may result in impairment of ventilation since
the diaphragm is affected.
Primary v. secondary injury
Although the initial (primary) injury will have already occurred before the player is
attended to, it is our responsibility to ensure that no worsening of this injury occurs.
This is the purpose of protecting the spine with MILS.
Secondary injury occurs at a cellular level and is usually the result of hypoxia or
hypotension. These are issues that can be avoided with the early application of oxygen
and sequential blood-pressure monitoring once off the pitch.
However, hypotension may occur as a consequence of neurogenic shock compounding

any hypovolaemia that may also concurrently exist. Neurogenic shock occurs as part
of a cord injury resulting in a loss of sympathetic innervation and, therefore, of
sympathetic drive. This manifests itself as bradycardia and hypotension: the BP not
responding to fluids.
97
Clearing the cervical spine
In order to assess and clear the cervical spine, a number of assessments and
considerations should be made:
• No concerning mechanism – fall from height onto head, causing axial loading
• No midline tenderness
• GCS 15
• No distracting injury
• No neurology
• Active range of movement of 45° lateral rotation
No intoxication (whilst it would appear intuitive that this should not be an

issue in professional sport, it must still be borne in mind and consideration
given to the fact that intoxication refers not only to alcohol, but also
to other strong analgesic prescription drugs, such as codeine as well as
non-prescription drugs)
All of these assessments should reveal no abnormality.
It can be difficult to quantify what is, or is not, a distracting injury given that the
pitchside medic is only called onto the pitch if there is concern over an injury (or
collapse) and therefore there will, by definition, be a distracting injury present.
It will be up to each clinician to decide the significance of the distraction in the context
of their overall clinical findings.
“Active range of movement” means that the player is moving their neck, having been
instructed to stop the rotation should they develop pain or neurological symptoms.
The clinician should not move the neck.
If there is any concern about the potential for injury to the cervical spine, stabilisation
procedures should take place and the player should be safely extricated from the field
of play for further assessment.
Protecting the cervical spine
The spine should only be considered to have been fully immobilised when either MILS
is being performed or the player is on an extrication device with a semi-rigid collar,
blocks and tape in place.
There is evidence to suggest that conscious players will be able to protect and splint Where the player
their neck themselves without a collar. In this situation, a cervical collar may create
more issues than it solves. As with any piece of equipment, there remains the potential is conscious,
for side effects and, even when appropriately sized and fitted, the semi-rigid collar may
be uncomfortable. It may also impede venous return, which could raise intracranial
the clinician
pressure. may decide that
For these reasons, some countries have chosen to remove the semi-rigid collar from spinal motion
their spinal protocols and the term “spinal motion restriction” becomes a more
appropriate term than “immobilisation”. restriction
Where the player is conscious, the clinician may decide that spinal motion restriction is more
is more appropriate than full immobilisation. In such cases, the collar is not used and,
instead, the head is restricted from moving using the headblocks and tape. appropriate
For the purposes of this manual and FIFA courses, full immobilisation is still advised (in
than full
particular, where the player is unconscious) and clinicians must know how to fit a collar immobilisation.
and fully immobilise the spine. It should also be re-emphasised that clinicians should
follow the processes as per their local guidelines and protocols. This is important as
these can change as evidence changes.
99
SKILL ZONE: how to size and fit a semi-rigid cervical collar
Technique
As always, it is vital to follow the manufacturer’s instructions as different collars may

have different sizing instructions.
One of the biggest challenges when fitting a cervical collar is to ensure that the
measured size translates into the best fit for the player. If your sizing measurement
falls between two sizing posts on the collar, you should always start with the smaller
size. If the size is too big, the collar will increase extension at the neck; if it is too small,
it may not provide enough support, but it is less likely to worsen the problem.
With the head in a neutral position, draw a line from the chin directly backwards until
it bisects the sternomastoid (see image 1 below). Measure (in fingerbreadths) from
this point down to the bulk of trapezius (see image 2). The number of fingerbreadths
is used to size the collar, using the different sizing options if you are using a multi-
adjustable collar (see images 3-5).
1. Draw a line from the chin to bisect the sternomastoid
2. Measure from this point down to the bulk of trapezius in fingerbreadths

3. Using the sizing marker, place your fingers on the collar and find the sizing point
closest to your fingers
4. Slide the collar underneath the player – do not slide too far
• To fit the collar, ensure that MILS is undertaken.

• Fold the Velcro underneath the collar and slide from one side under the
player’s neck.
• Push through, although not too far (see image 4) and pull out the Velcro
tab. Gently pull the collar round until the chin is resting comfortably in the
collar and the collar is in the midline.
• Fix the Velcro.
5. Final position
101
Important points to remember:
1. Recheck the player after you have fitted the collar: has their condition
changed in any way?
2. Having a collar on the player will not fully immobilise their neck. MILS must
be continued until blocks and tape (and an extrication device) have been
applied.
3. Because MILS needs to be continued until full immobilisation has occurred,

there is relatively little benefit to applying a collar early on in your
assessment. It should be regarded as part of the extrication process.

HEAD AND MAXILLOFACIAL INJURIES
As football is a contact sport, head and facial trauma are both common. Football is
the only sport where the unprotected head and neck are purposefully used to engage
the moving ball, often at high speed and in competition between two players. It is
therefore to be expected that the total number of injuries from football each year
includes head and neck injuries.
Epidemiologically, head injuries account for between 4% and 22% of the total injuries
in football, ranging from minor lacerations, abrasions and bruising to more serious
acute concussions and even rare skull fractures and internal cerebral bleeds.
It should be assumed that any trauma above the level of the clavicles may potentially
result in a cervical spine injury and immediate management should always involve
assessment of this, as described earlier. The assessment of the injured player’s head
should take place using the same primary A C BCDE assessment. This means that
the actual assessment of the head or facial injury – i.e. the Disability/neurological
assessment – should only take place once the Airway, Cervical Spine, Breathing and
Circulation assessments have been performed.
Both the head and face are highly vascular. This means that bleeding also commonly
occurs as a result of trauma to these areas. Depending on the nature of the wound,
this may need to be managed as part of the “Circulation” assessment. In the first
instance, direct localised pressure is all that is usually needed.
It is worth pointing out at this stage that significant bleeding (especially from epistaxis)
is considered as a potential aerosol-generating procedure and it is therefore vitally
important that the treating clinicians have access to, and are wearing, appropriate PPE
when managing these issues.
As with all wounds, it is important to consider potential underlying structural issues. In

addition, the face has cosmetic significance as well as functional properties. These are
extra factors to consider when managing these injuries. The pitchside environment is
not conducive to definitive wound management of these areas.
It is also vital that wound management does not distract from the assessment of the
head injury. Football is going through a transition period regarding the management
of head injuries, but, at the time of writing, the recommended assessment still only
lasts for a maximum of three minutes. Should those three minutes be used instead to
manage the associated wound, it must be remembered that no formal neurological
assessment will have been carried out.
If the neurological assessment is not carried out, it cannot be documented as having

been done. If it cannot be documented, it cannot be defended.
103
Traumatic brain injury
There are a number of different patterns of traumatic brain injury (TBI).

These include:
• cerebral contusion/intracerebral haemorrhage
• subarachnoid blood
• extra-axial bleeding
• subdural bleeding
• extra-dural bleeding
• concussion
They can be categorised as follows, based on the findings from a CT scan:
TBI diagnosed from CT scan TBI not diagnosed from CT scan
Cerebral contusion Concussion
Subarachnoid blood
Subdural blood
Extradural blood
Concussion is a TBI and should be viewed as such by the medical team, the coaching
team and the players – the only difference is that it is not diagnosed on the basis of
standard CT imaging.
The challenge for all sport (not just football) continues to be in accepting the
significance of concussion as a TBI and it is possibly the fact that it “cannot be seen”
on radiological studies that adds to this challenge.
Concussion is therefore a complicated subject and is considered separately in chapter 7.
Once the cervical spine has been cleared and an ABC assessment completed, the
assessment of a head injury can focus on looking for warning flags that would indicate
that there is the potential for a TBI.
Should any of these be present, removal from the field of play is mandated and
radiological imaging is recommended in most cases. Where imaging is deemed
unnecessary, the player must be observed to assess for any changes in the clinical
situation that would then require them to be referred to hospital for imaging.
It should be noted that there is no role for plain X-ray imaging of the skull with
suspected TBI.

Clinical features that are indicative of TBI
• LOC
• GCS <15 at any time
• Amnesia for events
• Evidence of skull fracture
• Cerebrospinal fluid (CSF) rhinorrhoea
• Blood or CSF leaking from the ear
• Battles sign (not an acute feature): bruising that tracks down over
the mastoid
• Racoon eyes: periorbital bruising that again may take time to develop
• Post-traumatic seizure
• Neurological symptoms or signs
• Repeated vomiting (two or more times)
• Severe and persistent headache
Should any of these features be present, removal from the field of play is mandated
and CT imaging should be considered.
Equally importantly, the absence of these features does not equate to the absence
of TBI and the position should be kept under review to ensure that no concerning
features develop.
Maxillofacial trauma
The face is a common site of injury in football. It is also a common source of potential
primary and secondary airway issues as well as cervical spine injury. The ABC primary
assessment process should always be followed when assessing a maxillofacial injury.
As described previously, facial trauma is complicated by the fact that there are cosmetic
as well as functional issues that need to be considered, irrespective of whether the
injury is to the bone or to the soft tissue.
The face can be considered in relation to the bones that form the different areas: each
area is designed to protect its own underlying structures of interest.
Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/

wjm/2014.010. ISSN 2002-4436.
105
Any examination should focus on:
1. listening to what the player says regarding the site of pain and potential loss
of function, e.g. double vision;
2. observing for swelling, bleeding or facial asymmetry;
3. palpating for sites of pain and potential fractures and assessing for loss of
function such as infraorbital paraesthesia or tethering of the inferior rectus
resulting in diplopia on upwards gaze.
If there is midface trauma, an assessment of the eyes is vital to look for and record the
presence or absence of a hyphaema (bleeding in the anterior chamber of the eye) and
pupil reactivity, to assess and record visual acuity.
If there is mandibular or dental trauma, an assessment of the inside of the mouth must
be performed to look for broken teeth and to assess for malocclusion, which would be
in keeping with a mandibular fracture.
Where a nasal fracture is suspected, an examination of the nasal septum should be

performed and the presence or absence of a septal haematoma should be recorded.
Injuries can generally be characterised as either “soft tissue” or “bony”. The

management of such injuries will depend on a number of factors, including the extent
of a wound, the clinician’s confidence in their ability to close a wound formally should
they have time to do so (e.g. at half-time) and the player’s own ability to continue to
function and play on despite significant pain, e.g. from a nasal fracture.
Maxillofacial soft-tissue injuries
1. Facial contusions/haematomas
A contusion (bruising) is a closed injury following a blunt trauma to soft tissue and
may involve injury to the underlying structures. The player may present with pain and
a bluish skin discolouration at the site of the injury as a result of localised bleeding
under the skin.
A haematoma is bleeding into a space or a potential space, such as the muscles and the
dermal layer (the bottom layer of the skin), and may occur alongside either minor or
major wounds. This injury presents as a bluish-black swelling or a lump at the injury site.
Treatment
1. Contusions and haematomas are generally classified as minor injuries that

resolve naturally over time.
2. Apply ice packs to the site of the injury. The player may be advised to
continue applying ice packs intermittently to reduce the swelling for the first
24 to 48 hours. Note: ice packs should not be placed directly onto the naked
skin for prolonged periods, as this can cause frostbite or cold burns on the
skin.
3. If the player is not removed from the field of play and substituted, but
wishes to return to play, ice and/or compression bandage treatment may
have to wait until the player is no longer involved in the match.

4. However, any player with a facial injury who may have clinically suspected
underlying fractures, due to pain, swelling, bruising or distortion, should be
referred for specialist assessment.
5. Consider simple pain management if clinically indicated.
Special areas for consideration
Pinna haematoma
Direct trauma to the ear can result in a haematoma to the pinna.
This is significant because, unless the haematoma is appropriately evacuated and

drained, it can result in a “cauliflower ear” abnormality. This can be done by the
team clinician if they are comfortable with the procedure and have the requisite
experience. Alternatively, it can be undertaken at a hospital by a specialist. One of the
challenges after draining this type of haematoma is preventing it from subsequently
reaccumulating.
Septal haematoma
This injury occurs after trauma to the nose and a resulting nasal fracture.
A septal haematoma is the development of a haematoma between the septal cartilage

and the overlying mucoperichondrium. Without drainage in the first 24 hours, there
will be irreversible septal injury with resulting necrosis. Anterior rhinoscopy shows a
cherry-red swelling arising from the nasal septum – this is usually bilateral.
Pulsatile haematoma
A pseudoaneurysm may develop after trauma. Haematomas to overly vascular

structures such as the temporal artery should be considered to be aneurysms until
proven otherwise. A referral for definitive assessment should be made.
2. Facial lacerations
Facial lacerations are open injuries that result from blunt trauma to the soft tissues
over the facial bones, usually from head-to-head or head-to-elbow contact between
players. Lacerations can be superficial or deep and may present as either a linear
(straight) or stellate (jagged/burst-type) laceration. Lacerations of the facial area
usually bleed profusely due to the rich blood supply to the face.
Treatment
1. Control any bleeding by first applying direct pressure with sterile gauze to
the injury site.
2. Once the bleeding has stopped, the player should receive a focused
assessment of the facial injury and be managed accordingly by either
returning to play, being substituted and/or referred for further radiological
and/or specialist evaluation.
3. Minor facial lacerations should be irrigated thoroughly with sterile

normal saline.
107
4. Where suturing is not clinically required, cover the wound with a dressing.
The player may return to play if no underlying injuries are suspected. Skin-
closure strips may be used to close simple linear lacerations, but these will
often fail to adhere to a player’s skin if they have been sweating.
5. Major facial lacerations, accompanied by obvious or suspected facial

fractures, should be stabilised and the player should be referred for further
radiological and/or specialist evaluation. Again, direct and localised pressure
may be all that is required to control bleeding temporarily.
6. Consider pain management if clinically indicated.
Special areas for consideration
Vermilion border: this area of the lip is important cosmetically because if it is not
aligned properly, the resulting wound will be noticeable. Typically, a 1mm difference
between the edges can be seen at conversational distance between two people, so it
is vital that the wound edges at the vermilion border are properly aligned at the time
of definitive closure.
Lip: full-thickness wounds of the lip that extend intra-orally will need to be assessed to
ensure that no fragments of tooth remain in the wound itself. The external lip wound
should be cleaned thoroughly and closed but the vast majority of internal lip wounds
can be left without closure.
Eyelid lacerations: blunt trauma to the orbital region may cause the skin over the eye
to tear, leading to an eyelid laceration. These injuries usually require cosmetic closure
under appropriate hospital conditions but, depending on the clinician’s experience,
this can be done in the treatment room as long as appropriate cosmetic outcomes are
achieved.
Use of tissue glue is not advised to manage these wounds.
Eyebrow: the eyebrow has the same cosmetic importance as the vermillion border in
terms of alignment at the time of closure. It is also important never to shave off the
eyebrow because it may not grow back again. Instead, thoroughly wet and clean the
area to allow you to visualise the wound edges and oppose them.
Tongue: reassuringly, the tongue rarely needs to be sutured and the vast majority
of wounds will heal with time. Maintaining adequate oral hygiene is the key to this.
Tongue wounds that extend to the tip or lateral borders of the tongue may need to be
closed, but this is not something that should be considered pitchside.
Epistaxis
Epistaxis (nasal bleeding) can result in profuse bleeding that should be considered as a
potentially aerosol-generating procedure and appropriate PPE should be worn by the
treating clinician, i.e. level 3 PPE where a COVID-19 infection is possible.
The majority of epistaxis cases are the result of trauma to the anterior nasal area
and therefore usually controlled with adequate compression of the bleeding vessels.

Posterior nasal bleeding cannot be controlled by direct pressure and usually requires
hospital management.
Treatment
1. Ask the player to clear their nose of any clot by blowing their nose into a
swab or small towel that can then be disposed of. They should do this while
facing away from everyone else, with the intention of ensuring all contents
are caught in the swab or towel.
2. Combined topical local anaesthetic and vasoconstrictor spray such as

lignocaine and phenylephrine sprayed onto the anterior nasal area may help
with pain and bleeding.
3. Phenylephrine is currently not on the WADA prohibited list, but always

check the medications you use.
4. Pinch the cartilaginous, anterior nose (nostrils) closed between the thumb
and index fingers; this usually applies pressure to the bleeding vessels,
causing the bleeding to stop.
5. Pinching the nose should stop most bleeding but this in itself may take up to
15 minutes.
6. Applying ice externally to the nose may also be useful to encourage

vasoconstriction.
7. Should the above measures fail to stop the bleeding, the use of a nasal
tampon may be required and topical lubricating gel should be used to
facilitate this.
The player may only return to the field of play once the bleeding has completely
stopped.
A check for blood contamination on the kit should be made and the player should
change kit items if necessary.
Maxillofacial bony injuries
Bony injuries to the face can broadly be divided into:
• Midface
• maxilla
• zygoma
• naso-ethmoidal
• Mandibular fractures
Maxilla fractures rarely present in isolation and usually coexist with fractures of the
alveolar ridge of the maxilla, anterolateral wall of the maxillary sinus and Le Fort
fractures. These midfacial fractures are associated with high-impact trauma such as
head-to-head and head-to-goalpost contact and may present with a combination of
different Le Fort fractures bilaterally.
There is no requirement to be familiar with the Le Fort classification system.
109
Physical examination may reveal midfacial mobility and may have accompanying
rhinorrhoea (cerebrospinal fluid from the nose), which is symptomatic of an associated
fracture to the anterior base of the skull.
Treatment of maxilla fractures
1. The airway in a patient with midfacial maxilla fractures may be at risk

and lead to primary airway obstruction from bleeding compounded by
decreased consciousness resulting in secondary airway injury. If the player is
unconscious, open the airway by using a jaw-thrust and use airway adjuncts
if necessary to help protect the airway.
2. Protection of the cervical spine should be undertaken at the same time as

airway management.
3. Suction is a key element of the management of this type of airway injury

and must be available pitchside.
4. Early use of oxygen is key to maximise oxygenation.
5. Support ventilation, if required, by using BVM ventilation.
6. Where possible, establish large-bore (16G cannula) access to allow

intravenous analgesia and crystalloid fluid administration should it be
required.
The sequelae of midfacial maxillae fractures should not be underestimated and may be
potentially life-threatening and extremely challenging to manage in the prehospital
setting.
Zygoma fractures: these are fairly common in contact sports like football. These injuries
clinically present with:
• diplopia;
• subconjunctival haemorrhage;
• global malposition;
• periorbital ecchymosis; and/or
• flattening of the cheekbones.
Treatment of zygoma fractures
1. There is no specific out-of-hospital management for zygomatic fractures.
2. Consider pain management by administering analgesia, if clinically indicated.
3. The player should be referred to hospital for further evaluation and medical
care. These injuries may require surgical reduction, with comminuted
zygomatic fractures requiring internal fixation.
Nasal fractures: these are the most common facial fractures in sport. The vast majority
of nasal fractures are accompanied with epistaxis. Nasal/septal fractures or dislocations
are also common and will present with:
• associated swelling and tenderness;

• deformity;
• periorbital ecchymosis (bluish discolouration around the eyes);
• nasal tenderness;
• crepitus; and/or
• restricted nasal airflow.
There may also be rhinorrhoea (cerebrospinal fluid from the nose), which is symptomatic
of a cribriform plate fracture.
Treatment
1. Anterior epistaxis is usually managed effectively pitchside as described

previously: ensure that appropriate PPE is worn and apply direct pressure to
the nostrils.
2. The decision about whether the player can return to the field of play will
depend on the clinical circumstances, the degree of pain, the presence of
bleeding and other associated injuries.
3. Players presenting with nasal fractures and rhinorrhoea should be assumed

to have suffered a cribriform plate fracture until proven otherwise and must
be referred to hospital immediately for further evaluation.
4. Consider pain management by administering analgesia, where indicated.
5. Follow-up with ENT specialists is usually planned to take place after five to
seven days to plan for any corrective surgery once the swelling has started
to settle.
Mandibular fractures: mandibular body fractures result from significant force and
associated cervical spine injury should always be considered. If alert, the player may
present with tenderness, swelling, malocclusion with abnormal range of motion, pain
on opening their mouth, intraoral lacerations and, occasionally, tooth avulsions.
Looking into the mouth is therefore vital.
The clinician should assess for normal function of the facial nerve which can be affected
by this injury. The player should be able to smile naturally if no neuropathology exists.
Equally, assess for paraesthesia of the chin to assess for involvement of the mental
nerve.
Treatment
1. The airway of a patient with a mandibular fracture may be at risk and this
may lead to primary airway obstruction from bleeding compounded by
cerebral obtundation, also resulting in secondary airway injury. Intraoral
lacerations can bleed significantly, avulsed teeth can be aspirated and
cause airway obstruction and, following bilateral fractures of the mandible,
posterior displacement of the tongue may obstruct the upper airway.
2. If the player is unconscious, open the airway by using a jaw-thrust and use
airway adjuncts, if necessary, to help protect the airway.
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3. Protection of the cervical spine should be undertaken at the same time as
airway management.
4. Suction is a key element of the management of these types of airway injuries

and must be available pitchside.
5. Early use of oxygen is key to maximise oxygenation.
6. Support ventilation, if required, by using BVM ventilation.
7. Where possible, establish large-bore (16G cannula) access to allow

intravenous analgesia and crystalloid fluid administration if required.
8. Mandibular fractures with dental involvement are technically compound

fractures and administration of antibiotics such as co-amoxiclav may be required.
Mandibular fractures can potentially be life-threatening and extremely challenging to

manage in the prehospital setting and may warrant emergency referral to the nearest,
most appropriate hospital.
DENTAL EMERGENCIES
Dental emergencies are common clinical presentations in sport, with football

accounting for an estimated 50% of sport-related orofacial trauma.
Injuries can be broken down as follows:
• Tooth avulsion
• Dental fractures
• Crown fractures
• Root fractures
• Tooth luxation
• Alveolar fractures
Tooth avulsion
Tooth avulsions are considered to be one of the most serious and prevalent dental
injuries associated with playing football. They account for up to 59.3% of all dental
injuries relating to the sport. This injury is associated with high-impact facial trauma
knocking the tooth out of the socket. The aim of the treatment should be to reimplant
the tooth within 30 minutes of the tooth avulsion, as recommended by the International
Association of Dental Traumatology. This gold standard has an optimal tooth survival
rate of 90%; thereafter, the long-term outcome is poor.
Treatment
1. Attempt to locate the avulsed tooth if possible. If it is just the crown that is
broken, the root may still be intact, leaving the tooth salvageable.
2. Once located, hold the tooth by the crown (white part) and avoid handling
the tooth at the root end as this will preserve the periodontal ligament fibers.
3. Do not scrub the tooth or allow it to dry. Instead, rinse the tooth with milk,
sterile normal saline or the patient’s saliva. Wrapping the tooth in cling film
is another option.

4. Do not attempt to reimplant the avulsed tooth where there is a coexisting
maxillae or mandibular fracture.
5. Once the tooth has been cleaned, the clinician should attempt to replant
it by firmly pressing it into the socket if the player is not to return to the
field of play. If the player elects to return to the field of play, rather than be
substituted, and to have the avulsed tooth manually reimplanted, the dental
consequences of this decision should be explained to them, and the tooth
should be preserved in an appropriate container in cold milk or iced salt water
if available. Once the match has ended, reimplantation may be attempted.
6. During insertion, a palpable click should be felt. This is indicative of correct

reimplantation of the avulsed tooth. Ask the player to bite down on gauze
or a handkerchief to keep the tooth secured in place.
7. If reimplantation is not possible or fails, the avulsed tooth must be preserved

by keeping it either in the player’s cheek or under their tongue as saliva is
the best transportation medium. Alternatively, preserving the avulsed tooth
in cold milk is preferable to doing so in water. However, do not allow the
tooth to dry.
8. If the avulsed tooth is not located, consideration should be given as to

whether it may have been aspirated. Treatment should aim to control
bleeding and a physical examination should take place to rule out any
coexisting fractures.
9. After the match, the player should be referred for dental consultation and
appropriate management.
Dental fractures
In addition to tooth avulsions, additional types of dental trauma include tooth luxation
and dental fractures of the crown and the root, and open alveolar fractures.
Crown fractures
This is a simple fracture of the enamel of the crown. Clinically, the player will present
with pain with or without sensitivity to cold water or air. The exposed dentine may
have an ivory-yellow appearance while a pink blush or a drop of blood in the centre of
the tooth will represent pulpal exposure.
Treatment
1. Attempt to locate the tooth fragment if possible and handle only the
enamel (white) end of the tooth.
2. If located, do not scrub the fragment or allow it to dry. Instead, rinse the
fragment with milk, sterile normal saline or the patient’s saliva. Wrapping
the tooth in cling film is another option.
4. The player may return to play.
5. After the match, the player may be referred for dental consultation.
113
Root fractures
A tooth may sustain a root fracture following high-impact dental trauma. The tooth
may be intact or mobile; pain may or may not be present, depending on the severity
of the fracture.
Treatment
1. Assess the number of injured teeth involved while simultaneously

attempting to control any bleeding with a gauze dressing.
2. Use the adjacent tooth as a splint to secure the mobile tooth using a custom-
made mouth guard or sugar‑free gum, if available, to stabilise the fractured
tooth.
3. Return to the field of play should not normally be considered.
5. After the match, the player must be referred immediately for dental
consultation.
Tooth luxation
Tooth luxation is described as the displacement or rotation of the tooth within the socket
following significant dental trauma. These injuries are painful, indicating underlying
root, neurovascular and periodontal ligament structural involvement or injury.
Treatment
1. Assess the stability and the number of injured teeth involved while
simultaneously attempting to control any bleeding with a gauze dressing.
2. Attempt to reposition the tooth back into its original position.
3. Should this procedure fail or cause excessive pain, the player should be
removed from the field of play and referred for dental consultation as
soon as practically possible. If the player wishes to return to the field of
play after failure to successfully reposition the tooth or does not wish to
have the tooth manipulated, it is up to the player and clinician to reach a
decision, understanding the complications that may result as this is not a life-
threatening injury.
5. On the other hand, should this procedure be successful, an immediate return

to play can be considered, provided the player uses some form of mouth
guard, even custom-made, which is used for dental stability and protection.
The clinician must also rule out any possibility of coexisting alveolar
fractures before making this decision. Should the latter occur, the player
should be referred for urgent dental/maxillofacial consultation and related
management.

Alveolar fractures
Alveolar fractures usually coexist with other dental injuries previously discussed in this
section and rarely present on their own. These injuries are diagnosed through careful
palpation of the gum line and sockets, can be identified by increased tenderness and
are usually accompanied by bleeding.
Treatment
1. Control any bleeding using a gauze dressing and apply gentle pressure
around the identified tooth/teeth.
2. If a fracture is suspected, do not attempt to reposition an avulsed tooth and

do not remove any displaced alveolar fragments.
4. The player should be referred for immediate dental/maxillofacial

consultation and management.
OCULAR EMERGENCIES
The complex anatomical structures of the face may make it quite difficult to diagnose
facial injuries, especially ocular emergencies. Besides diagnosis, management of acute
ocular injuries can be extremely challenging pitchside. For this to occur adequately,
the healthcare provider needs to be skilled in recognising a range of acute ocular
injuries, evaluating these accurately and then managing them appropriately, aware of
the medical limitations in the prehospital setting. A recent study revealed that sport-
related eye injuries are one of the chief contributors to non-congenital blindness.
Accordingly, emergency care efforts aim to prevent vision loss.
Minor ocular trauma
Periorbital contusion (“black eye”) is usually the consequence of blunt trauma to the
ocular region, leading to periorbital ecchymosis (bluish discolouration around the eyes)
and severe swelling of the eyelid. If this presents bilaterally in severe head trauma, it is
indicative of possible underlying basilar skull fractures.
Treatment
There is no specific treatment for an acute periorbital contusion, but the aim of
any treatment is to prevent any sudden increase in intraocular pressure and the
unintended exacerbation of any underlying or missed global injury/herniation. The
clinician should therefore examine the eye and the surrounding soft tissue before
oedema develops and note any abnormal finding that may require routine or urgent
specialist ophthalmological consultation and management. It is vitally important that
this includes an assessment of visual acuity.
115
Corneal abrasion: a glancing blow to the eye from another player’s finger or an object
can easily damage the corneal epithelium, leading to a corneal abrasion. In addition
to direct trauma, a corneal foreign body (grit or dust) may adhere to the corneal
epithelium or the inner surface of the upper eyelid and lead to a corneal abrasion.
During blinking, the foreign body may rub across the cornea, causing an abrasion
associated with acute pain. The diagnosis of an abrasion may require fluorescent drops
and a blue light source.
Treatment
The symptoms caused by the presence of any foreign body may be relieved by removing
it using sterile normal saline (or equivalent liquid) and irrigating the cornea using a
20ml syringe, preferably under local anaesthesia. If the presence of a foreign body is
suspected, it is important to evert and look under the upper eyelid as the foreign body
may be adhering to the under surface of the upper eyelid, resulting in ongoing trauma
to the surface of the eye every time the eye is closed.
Corneal abrasions without any obvious foreign body may be treated by applying a
local antibiotic ointment and then subsequently re-evaluating the abrasion. Visual
acuity should always be documented.
Returning to the field of play during a match will depend on the clinical condition of
the eye.
Severe ocular trauma
Orbital blow-out fractures: facial injuries affecting the medial facial region are
commonly associated with orbital blow-out fractures. These fractures result from
high-velocity, blunt trauma to the eye. Energy is transmitted to the orbit, increasing
intra-orbital pressure, which pushes against the relatively weak inferior orbital wall,
causing a blow-out fracture.
Occasionally, these injuries are accompanied by maxillary sinus herniation of the

orbital contents.
Diplopia on upwards gaze results from tethering of the inferior rectus muscle and is
a maxillofacial emergency in children as the muscle is more prone to ischaemia and
necrosis in this population.
Without prompt surgical intervention in children, this may result in permanent disability.
Clinically, the patient may present with differences in pupil size, diplopia (double
vision), impaired upward gaze, periorbital ecchymosis (bluish discolouration around
the eyes) and an irregular orbital rim edge on palpation. Lack of sensation in the cheek
of the affected side is suggestive of injury/neuropraxia of the infra‑orbital nerve.
Treatment
1. Treatment aims to assess and preserve the integrity and function of the
associated injured eye. In children, emergent referral to maxilla-facial services
is mandated if tethering is found.

2. Assess visual acuity and document. Look for hyphaema and also for
traumatic mydriasis resulting in a fixed dilated pupil on the affected side as a
consequence of injury to the sphincter pupillae muscle.
3. These injuries will require the player to be removed from the field of play
and to be referred urgently to the nearest, most appropriate hospital.
4. Ensure that the player is advised not to blow their nose.
Acute global rupture: on rare occasions, extreme blunt or penetrating trauma to the
orbit may lead to acute global rupture, leading to a severe reduction or complete loss
of vision. This is associated with poor outcomes.
Treatment
1. When possible, always treat the player in the seated position, keeping the
head upright, and maintain this position even during transportation to
hospital.
2. Avoid any manoeuvres that will lead to an increase in intraocular pressure by

keeping the player calm, reassured and informed at all times.
3. Simple vision checks should be undertaken to assess the integrity of the

injured eye. Physical findings and accurate visual acuity should be well
documented.
4. Avoid any pressure to the eyeball (globe) during examination or when

applying a protective eye shield over the injured eye. If a protective eye
shield is not available, tape the bottom end of a polystyrene or plastic cup
over the injured eye. Do not apply eye pads in acute global rupture, only
protective eye shields.
5. Avoid Valsalva manoeuvres by aggressively treating any nausea and

vomiting with an appropriate antiemetic, if clinically indicated. Ondansetron
is the drug of choice in this instance and should be administered, if available.
6. Please note that all ocular emergencies should be treated as life-threatening

emergencies and should be urgently referred to the nearest, most
appropriate hospital for specialist ophthalmological consultation and
management.
Retrobulbar haematoma: this unusual injury presents after significant facial trauma.
Bleeding behind the eye causes a progressive increase in intra-orbital pressure,
reducing retinal and optic nerve blood flow. It is effectively an ocular compartment
syndrome. This causes pain that is disproportionate to what would be expected, and
loss of vision and proptosis of the affected eye may occur. A relative afferent pupillary
defect may also be present.
Treatment
1. Treatment is time-critical and decompression of the haematoma is required.

This is undertaken by performing a lateral canthotomy, usually in the
emergency department.
2. Sit the player in an upright position for transfer to hospital.
3. Provide analgesia and anti-emetics if required.
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CHEST TRAUMA
The management of chest-wall injuries is based on three principles:
1. Maximising oxygenation
2. Maximising ventilation
3. Identifying and treating specific reversible causes
Oxygenation can be achieved with the ready availability and application of oxygen as
soon as possible once a problem has been identified.
Pain can restrict ventilation, so the early administration of appropriate analgesia can
help to maximise ventilation until definitive treatment is achieved. If ventilation is not
adequate in the player with a reduced conscious level, it may need to be supplemented
with BVM ventilation.

Assessment of a chest injury should never detract from the assessment and Assessment
management of an airway issue, which should always take priority.
of a chest
The assessment of chest injury is as described in chapter 2. Focus should be placed on
using the “hands on 1, 2, 3” approach: injury should
1. observation: respiratory rate is a simple, yet key, observation to assess, never detract
record and repeat.
from the
2. placing hands on the player, assessing in 3 places: the neck, the anterior
chest and the posterolateral chest. assessment
This assessment is a simple and reproducible method of assessing for the presence of: and
• crepitus/surgical emphysema;
management
• tenderness; of an airway
• asymmetry of expansion of the chest during respiration; and
• positioning of the trachea. issue, which
should always
A saturation probe is a useful tool to assess oxygen saturation as well as pulse rate. The take priority.
strength and reliability of the signal is best confirmed using a probe that also shows
the plethysmography trace, and these are preferred where possible.
At this point, it is also important to highlight that the majority of chest-injury

complications take time to evolve and signs and symptoms may be absent initially and
may only be detected on repeat examination.
If the initial clinical examination indicates chest-wall pathology, a full, more formal
respiratory examination should take place away from the pitch.
At this point, full exposure of the chest and abdomen should be achieved and the more
traditional “Look, Listen and Feel” method of assessment (including auscultation)
should be undertaken.
Stethoscope assessment should not take place pitchside.
Ultrasound is an exceptionally useful prehospital tool, but it should only ever

be used when the clinician performing the ultrasound has received appropriate
formalised training. It has excellent sensitivity and specificity for assessing the lung
for pneumothorax and haemothorax as well as assessment for free fluid within the
abdomen after trauma and for pericardial fluid as well.
Rib fractures
Although a rib fracture is an extremely painful injury, it usually has an uncomplicated

course. Full healing is expected to take between four and six weeks.
Clinical examination may reveal bruising and palpable crepitus or a click when the rib
is pressed. Due to pain, the player may protectively splint the chest wall which may,
therefore, appear not to move as much as the opposite side when expansion is being
assessed. Appropriate analgesia and auscultation are therefore both important as the
aim of the assessment is primarily to identify whether an underlying pneumothorax
is present.
119
Indication for referral to hospital is primarily to exclude an associated underlying lung
(or abdominal) injury and it may be clinically impossible to exclude a pneumothorax
without imaging. An X-ray should not be used to confirm the presence or absence of
a fractured rib.
Fractures of the first to fourth ribs are uncommon and are usually the result of significant
forces. Fractures in these areas in association with clavicle or scapula fractures are
linked to a high incidence of brachial plexus and vascular injury and should therefore
be treated with caution.
Fractures to the fifth to ninth ribs are the most common and usually heal well unless
they are displaced internally or create a flail segment.
Fractures of the tenth to twelfth ribs overlie the liver and spleen and are a potential red
flag for associated injury. They should be treated with caution and, where suspected,
CT imaging of the chest and abdomen may be indicated.
Treatment is based on providing adequate analgesia as well as identifying early

complications such as pneumothorax or haemothorax or later complications such as
secondary lower respiratory tract infections.
Strapping the chest wall may help to provide support and pain relief to allow the player
to return to play as soon as possible. However, it should be understood that strapping
is an intermittent and temporising treatment that stops the chest from moving
normally. Expansion is important to minimise the risk of superimposed infection.
Flail segment
A flail segment describes an injury to the chest wall resulting in multiple fractures
to ribs in more than one place. This is usually a fracture to three ribs in two or more
places.
This results in paradoxical movement of the affected segment, and the lung underlying
it does not expand properly resulting in hypoventilation with resulting hypoxia and
respiratory distress.
It will only be seen if it is looked for and, therefore, all patients with suspected
significant chest injury should have their chest and abdomen exposed for examination
to assess for this paradoxical movement. Signs of paradoxical chest wall movement
are usually quite apparent and, when found, these require oxygen, analgesia and
immediate transfer to hospital.
Sternal fracture
The sternum is not usually injured in a football context and is much more commonly
seen as a consequence of high-speed road traffic accidents.
The force required to fracture the sternum is significant, and the main cause of concern
is not the bone itself but rather the heart which it overlies and protects.

Where a sternal fracture is suspected due to tenderness, bruising or swelling overlying
the sternum, referral for imaging should be undertaken. An ECG and ultrasound are
both useful tests to perform and, if normal, hospital admission may not be required.
Treatment is primarily aimed at providing appropriate analgesia.
PNEUMOTHORAX
A pneumothorax usually occurs as a consequence of a rib fracture, although it should
be remembered that it can also occur spontaneously.
A pneumothorax occurs from leakage of air from the lungs into the space between
the visceral and parietal pleura.
Clinical signs may be subtle, although if there is progression to a clinical tension

pneumothorax, the clinical picture is dramatic.
A pneumothorax should be suspected if there is the presence of:
• increased respiratory rate;

• decreased expansion on the affected side;
• decreased air entry on the affected side;
• hyperresonance on percussion.
121
If there are any associated features to suggest shock or circulatory collapse, the
diagnosis becomes a tension pneumothorax rather than a “simple” pneumothorax.
Management of a possible pneumothorax involves the administration of oxygen,

analgesia (where possible) and transfer to hospital. It should be noted that Entonox as
an inhaled medication may significantly worsen the clinical effects of a pneumothorax
on the basis that it diffuses into the pleural cavity and increases the size of the
pneumothorax. For this reason, Entonox should not be administered where a rib
fracture or pneumothorax is suspected.
Tension pneumothorax
A tension pneumothorax occurs when the pneumothorax involves a one-way valve

that traps air in the pleural space on inspiration, but does not allow for this air to be
released on expiration. This increasing volume of air starts to compress the lung and,
subsequently, the mediastinal structures, thus preventing venous return to the heart,
eventually resulting in cardiac arrest. Distended neck veins and tracheal deviation
away from the side of the injury may be present but are unreliable signs.
A diagnosis of a tension pneumothorax should be considered if there are any features

suggestive of a possible pneumothorax in the presence of shock or circulatory collapse.
A player who is clinically well and not distressed does not have a tension pneumothorax,
and decompression of the pleural space does not need to take place in this situation.
The diagnosis of a tension pneumothorax is understandably associated with a lot of

concern and worry from clinicians who have never seen someone present with this
diagnosis.
The intervention of needle decompression is indeed life-saving, but it does not need
to be undertaken pitchside unless clinical signs of shock, circulatory collapse or peri-
arrest state are present.
Emergency treatment of a tension pneumothorax
The aims of treatment of a tension pneumothorax are to immediately decrease the

raised intra-pleural pressure, thereby allowing the displaced heart to return to its
original position, with the resultant unkinking (opening) of the superior and inferior
vena cavae, and therefore restoration of venous return and cardiac output.
This is achieved by making a hole in the chest wall into the pleural cavity and thus
releasing the air trapped under pressure. Where the clinician has the appropriate skill
set, a formal thoracostomy is the treatment of choice. However, this is considered to
be beyond the scope of this manual.
As a temporising procedure, a needle decompression can be performed. Ideally, this is

undertaken using specific cannula for this purpose. If these are not available, this can
also be undertaken by inserting a large bore (16G / 14G) intravenous catheter needle
into the affected pleural cavity. However, it needs to be borne in mind that studies
have repeatedly shown that a needle length of 7cm is required to reach the pleural
space in the second intercostal space in up to 90% of the population and a standard
IV cannula may well be too short.

The process is as follows:
• Ensure the player has oxygen at the maximum rate, ideally 15l/min, via a
non-rebreather mask.
• Clean the skin.
• Remove the cap from the top of the cannula so that the air can escape once
the pleural space has been entered.
• Insert the cannula:
• in the fourth or fifth intercostal space;
• immediately above the rib perpendicular to the skin; and
• in the anterior/mid axillary line.
• As the pleural space is entered, air may be heard escaping from the end of
the cannula.
• Remove the needle, leaving the silicon catheter in situ.
• Secure the catheter in place to prevent dislodgement.
• Transfer the player urgently to hospital for definitive treatment (usually
tube thoracostomy).
Cannula are known to kink and displace fairly easily, and therefore the patient must
be constantly monitored until safe arrival in the emergency department where
radiological investigations can be undertaken to determine the exact diagnosis and
treated accordingly.
Should the player deteriorate again en route to hospital, a second cannula should be
inserted into the pleural cavity.
Tip: you can use the actual roll of tape to stop the cannula from bending, i.e. place the
roll of tape directly over the cannula to prevent it from kinking. You can then stick the
roll of tape onto the chest, keeping the cannula perpendicular to the skin.
NB: it is therefore important to ensure that the clinical symptoms and signs are indeed
present and that a diagnosis of tension pneumothorax is clinically evident or highly
suspected. Do not insert any needles into the chest without initial chest auscultation,
palpation and percussion.
Decompression at the fourth intercostal space, anterior

axillary line. Source:
http://www.epmonthly.com/departments/clinical-skills/needle- decompression-for-tension-pneumothorax/
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ABDOMINAL INJURY
Direct trauma to the abdomen is not uncommon in football and is almost always blunt
in nature. It may result from a kick, a knee or directly from the impact of a football
moving at high velocity.
In some cases, it may result from sudden deceleration, such as falling from height or
running into a goalpost.
Abdominal injuries do not present as obviously as many other orthopaedic injuries

because of the internal and concealed locations of the intra-abdominal organs. Strong
consideration and knowledge of the mechanism of injury may contribute to the earlier
diagnosis of acute, serious abdominal injuries.
Signs and symptoms of significant injury may also be absent on initial assessment as
these can take time to evolve. A pitchside assessment is therefore usually insufficient
to rule out intra‑abdominal pathology. Serial examinations or direct transportation to
hospital (where there is clinical concern) may be required instead.
The assessment of an abdominal injury should never detract from the assessment and
management of the airway and the chest, both of which should always take priority.
The ninth to eleventh ribs, in particular, are designed to protect the upper abdomen
from injury and there is a direct correlation between injuries to the lower chest wall
and injuries to the solid organs of the upper abdomen.
Movement of the abdomen and its contents is affected by respiration. This makes the
solid upper organs more exposed and vulnerable during deep inspiration.
On the pitch, the assessment of abdominal injury is part of the Circulation assessment
described in chapter 2 focus should be made on using the “hands on 1, 2, 3” approach:
1. observation: pulse rate is a simple, yet key, observation to assess, record and
repeat.
2. placing hands on the player, assessing in 3 places:
• Abdomen
• Pelvis
• Long bones
Once a player has been removed from the field of play, a more comprehensive
examination can take place. The abdomen should be exposed and inspected for bruising
and swelling. The four quadrants should be palpated in turn, with consideration being
given to the structures within these quadrants and the potential underlying injuries.
Traditional signs of significant intra-abdominal pathology, such as guarding, or the

absence of bowel sounds, may take time to develop and so greater importance should
be placed on the actual mechanism of injury, trends observed in the player and serial
examinations of the abdomen.
A player complaining of shoulder tip pain, in particular, should give rise to concerns of
potential internal bleeding.

Evidence of ongoing tachycardia is highly suspicious for intra-abdominal injury, whilst
a drop in blood pressure at any point also mandates referral to hospital.
The treatment options pitchside or in the dressing room are limited to recognising
the potential injury, maximising oxygenation and ventilation, and administering
appropriate analgesia.
If there is a drop in blood pressure, it is sensible to gain IV access with a large bore
cannula (14G or 16G) and crystalloid can be given to maintain blood pressure of
90mmHg.
Increasing the blood pressure above 90mmHg may disrupt any clot formation that
may have occurred, thus resulting in further bleeding. For this reason, IV crystalloid
fluid administration should only be used cautiously in a player who has normal blood
pressure.
Spleen
The spleen is located in the left upper quadrant and is protected by the ninth to
eleventh left ribs.
The bigger the spleen gets, the less it is protected and increased spleen size is
unfortunately a common finding in someone with infectious mononucleosis. This
increase in size makes it more vulnerable to injury, and confirmation that the spleen
is not enlarged should therefore be sought before a player who has had infectious
mononucleosis returns to play.
After trauma, the spleen may bleed slowly over a period of time and a delay to
diagnosis can therefore occur. A postural drop in blood pressure after standing in
association with abdominal trauma strongly indicates occult bleeding and further
evaluation and imaging should be sought.
Where occult bleeding is suspected, apply oxygen, provide analgesia and IV fluids
where required and transfer to the nearest, most appropriate hospital.
Ultrasound can be a useful test to look for evidence of free fluid, but, ultimately, a
CT scan is the investigation of choice. Depending on the imaging findings and the
patient’s clinical status, splenic injury may be managed conservatively. Where the
situation is more serious, splenectomy is required.
Liver
The liver is located in the right upper quadrant and is also afforded some protection
from the ribs. Like the spleen, it is prone to becoming bigger in certain medical
conditions such as viral hepatitis.
The liver is also a highly vascular structure and, although liver lacerations are uncommon
in football, they can be catastrophic in terms of the volume of bleeding.
Where liver lacerations are suspected, apply oxygen, provide analgesia and IV fluids
where required and transfer to the nearest, most appropriate hospital.
125
Diaphragm
The diaphragm is a structure of interest because it may rupture after direct abdominal
trauma. However, this may also take place over time, rather than immediately.
Once the diaphragm ruptures, there may be herniation of abdominal contents into
the chest cavity – usually the left-hand side – resulting in signs of respiratory distress
and potentially mimicking signs of a tension pneumothorax, with absent air entry
and hyperresonance to percussion. Apply oxygen, provide analgesia and transfer the
patient to hospital.
If there is doubt about the diagnosis, it must be remembered that a tension

pneumothorax is a much more common diagnosis. Accordingly, performing needle
decompression on a player who is in a peri‑arrest or is clinically shocked may be
life‑saving.
Renal
The kidneys are located retroperitoneally and are afforded some protection by the
lower ribs.
Injuries to the kidneys can be sustained after direct trauma to the back from a kick, fall
or collision. Renal contusion is the most common kidney injury and many such injuries
can be managed conservatively.
After trauma, frank haematuria or microscopic haematuria in association with

abnormal clinical signs always require further investigation to exclude significant
pathology.
Apply oxygen, provide analgesia and transfer the patient to hospital.
Bowel
The large and small bowels tend to be affected by blunt trauma as they shear at the
sites of fixation. This usually occurs as a consequence of sudden deceleration, which is
possible, but uncommon, in football.
The thoracolumbar spine should be assessed because of the high association of lumbar
fractures, in particular with sudden deceleration forces.
Again, symptoms and signs of pain, tenderness and guarding may take time to develop,
so it is sensible to have a low threshold for suspicion based on the patient’s history and
the mechanism of their injury.

PELVIC INJURY
The pelvis is a ring structure located at the lower end of the lumbar spine. It acts as a
fulcrum between the torso and the legs. The pelvic bones include the:
• sacrum;
• coccyx (tailbone); and
• hip bones – the ilium, ischium and pubis – that are separate during childhood,
but then fuse to form the acetabulum to house the femoral head.
The pelvis is fundamentally a very strong ring-like structure, meaning that significant
forces are required to break it – more commonly in two places, rather than just one.
Unstable injuries as a result of trauma are therefore uncommon in football, although
the pelvis is a common site for non-traumatic acute and chronic injury.
Bone stress injuries affect the symphysis pubis, pubic rami, femoral neck and sacrum,
with stress fractures occurring more commonly in women than men.
As a cavity, the pelvis is a vast potential space for bleeding and contains significant
vascular structures, meaning that trauma to this area can result in catastrophic bleeding.
The pelvis can fracture in a number of different patterns. This can be predicted
depending on the initial injury mechanism.
In football, the most likely injury mechanism is for the player to fall from height onto
their side, thus compressing the iliac crest.
127
The main scope of our assessment and the management of pelvic injuries is therefore to
ensure we do not worsen any bleeding that may already be occurring. The mainstay of
management is therefore to recognise the potential for injury and to minimise movement
and turning of the player with a suspected pelvic injury as this may worsen bleeding.
Bleeding into the pelvis (abdomen or chest) is one of the main reasons to move away
from extrication using a long board because there are far fewer movements involved
in placing a scoop stretcher underneath a player.
Assessment
On the pitch, the assessment of a pelvic injury is part of the Circulation assessment
described in chapter 2. It is vital to ensure that consideration has been given to
assessing and managing the Airway (cervical spine) and Breathing first. An assessment
of Circulation should then be made using the “hands on 1, 2, 3” approach described
in chapter 2:
repeat.
• Abdomen
• Pelvis
• Long bones
The assessment of whether there is a pelvic injury should focus mainly on the injury
mechanism, and then on clinical findings. The pelvis should not be compressed to
assess for stability as this may worsen bleeding.
Look for asymmetry and assess for tenderness, swelling and bony crepitus.
The pelvis should be palpated, starting posteriorly at the sacro-iliac joints and moving
laterally over the ilium and round towards the anterior. Groin tenderness may suggest
pubic injury.
If there is no evidence of tenderness to palpation and there is no suggestion of other

lower-limb injury on assessment, the player may then actively move their hips (if they
are comfortable to do so), stopping if there is pain.
If the player has full active and passive range of movement of the hips and no
tenderness or pain, a significant pelvic fracture is less likely.
Treatment
Where there is still concern about a pelvic injury, it is sensible to apply a pelvic splint/
pelvic binder, especially if there is any evidence of haemodynamic compromise.
However, this is a rarity on the football pitch.
If a pelvic binder is not available, it may be helpful to tie a sheet or a player’s jersey
around the pelvis.

As with any intervention, a reassessment should be made once the binder has been
applied. If the intervention is associated with a deterioration in the player’s clinical
condition, consideration should be given to the possibility that the intervention itself
has worsened matters.
This is possible depending on the type of pelvic fracture sustained.
Given the lower likelihood of high-force trauma in football, the benefit of a binder or
splint is primarily to help with pain rather than bleeding.
Hip dislocation
Hip dislocation in football is rare and usually results from landing on an uneven
playing surface or falling onto a flexed knee. It may or may not be associated with an
acetabular fracture.
It usually results in a classic clinical presentation where the player will hold their hip
flexed, adducted and internally rotated because the hip dislocates posteriorly in the
vast majority of cases.
Once other potential ABC assessments have been made, pain that is significant and
distressing should be managed with the strongest analgesia available.
No attempt should be made to reduce a dislocated hip in the prehospital setting, and
transfer to hospital should be organised and facilitated, moving the hip as little as possible.
It is important to assess sciatic nerve function.
The aim is to reduce the dislocation as quickly as possible in theatre to minimise the
risk of avascular necrosis, which is known to increase significantly after six hours.
LIMB INJURY
Bone and joint injuries account for around 10% of all football injuries. Fractures in the
lower extremities are more common than in the upper extremities.
The vast majority of limb injuries are not life-threatening, but are a cause of significant
morbidity and may occasionally be potentially limb-threatening and, therefore, career-
ending.
Limb injuries are, by definition, distracting injuries for both the player and the medical
staff so it is vital that the primary assessment initially focusing on ABC is still performed
and the deformed wrist, shoulder or ankle does not distract from this.
Fractures tend to occur as a consequence of either: forces that are stronger than the
normal bone can cope with; or, where otherwise normal forces are applied against
weaker-than-normal bone, i.e. stress fractures.
This is worth bearing in mind where a player appears to have suffered an innocuous
mechanism of injury but this still results in a fracture.
Assessment of a limb injury takes place as part of the assessment of Circulation.
129
As detailed earlier, the Circulation assessment should consist of the “hands
on 1, 2, 3” approach described in chapter 2:
repeat.
• Abdomen
• Pelvis
• Long bones
In general terms, an examination of the injured limb should involve an assessment

of the joints above and below the injured area to look for associated injuries and
dislocations.
The “look, feel and move” examination is still the preferred method to assess for injury.
Look for swelling, deformity and bruising. Is there a wound?
Feel for tenderness, bony crepitus and check pulses where possible.
Move: check the patient’s active range of movement, followed by their passive range
of movement.
Assessment for the presence of a wound is a vitally important aspect of fracture

management. A compound injury where there is a break in the skin overlying or near
a fracture (or potential) fracture is highly significant and increases the possibility of
contamination of the fracture and subsequent infection.
Associated wounds must be cleaned thoroughly and covered with saline-soaked swabs
and dressed or splinted. The patient should be referred to hospital and it is advisable
to administer antibiotics early.
Splinting a fracture is helpful, not only in terms of protecting the injured area from
further harm, but also for pain, and access to simple splints should always be available
pitchside.
Selected upper-limb injuries
The vast majority of upper-limb injuries are neither life- nor limb-threatening. The aim
of the assessment is to try to decide whether the injury means that the player should
be immediately withdrawn from the field of play for further assessment, treatment
or imaging.
In many cases of shoulder, elbow and wrist injury, this can be facilitated by folding the
player’s jersey upwards to form a makeshift sling.
A number of injuries are worthy of note as their treatment may be more involved.

Posterior sternoclavicular joint dislocation
The sternoclavicular will usually dislocate anteriorly after trauma.
A posterior dislocation can arise due to either direct anteroposterior force to the
medial aspect of the clavicle, or to a more indirect mechanism where a blow to the
posterolateral aspect of the shoulder displaces it anteriorly.
In cases of posterior dislocation, the medial end of the clavicle causes one of the few
truly life‑threatening limb injuries. Some studies suggest that 30% of patients in these
circumstances will develop life-threatening complications.
Encroaching posteriorly, the medial end of the clavicle impacts directly upon the
mediastinal structures, with the brachiocephalic vein in particular affected by this.
Respiratory compromise, brachial plexus and mediastinal haematoma may all occur
so a formal structured primary assessment should be undertaken and documented.
It can be exceptionally difficult to make a diagnosis clinically or using plain X-ray. A

CT scan is therefore commonly required. Closed reduction is usually unsuccessful and
operative fixation is required in the majority of cases.
At pitchside, ensure that the ABC assessment has been followed, provide analgesia
and a sling (if tolerated) and immediately refer the patient to hospital.
Shoulder dislocation
Shoulder dislocations are common injuries and can often be recurrent.
The vast majority of shoulder dislocations in sport are anterior and have a classic
clinical appearance, with loss of the normal curvature of the humeral head, which can
help to distinguish them from other injuries, such as fractures of the humeral head.
The assessment and documentation of neurovascular status should always be

undertaken with particular emphasis on the axillary nerve, which supplies sensation
to the shoulder “badge” area.
Ideally, reduction should be undertaken as soon as possible to minimise the onset of

muscle spasm, which can make reduction much more difficult.
Shoulder dislocation is managed by reducing the dislocation and this can usually be
achieved using simple traction. Where this takes place will depend on a number of
factors, but this mainly comes down to:
• the confidence of the individual clinician in making the diagnosis and in their own
ability to undertake the reduction; and
• the patient’s compliance with treatment.
Entonox or Penthrox are both ideal agents for analgesia that can be self-administered
by the player.
131
It is beyond the scope of this manual to describe the numerous methods that can
be used to undertake shoulder reduction. However, it is also important to say that
simple traction has proven to be highly successful and is associated with the least risk
of complication.
Traction in an axial direction avoids manipulating the joint in any way. There are two
ways to do this:
1. It is best performed with the player lying supine on the ground, using their own
body weight as counter-traction. The player’s arm is supported and lifted up
towards the sky (see image 1 below).
2. The player needs to have confidence in the clinician’s ability to undertake this
procedure and they should be encouraged to relax and focus on their breathing
whilst traction is undertaken slowly and gently.
Traction can also be performed by the player themselves, lying face down in a prone
position on a massage bed or trolley, with their arm hanging over the side towards the
floor. This method uses gravity to help to pull the arm down and this traction can be
augmented by the player holding a weight or water bottle in their hand (see image 2
on the next page).
1.

Traction
can also be
performed
by the player
themselves.
2.
Elbow dislocation
Elbow dislocations are the second-most common major joint dislocation after the
shoulder.
The majority of elbow dislocations are posterolateral in nature and occur as a

combination of an axial load with supination/external rotation of the forearm.
Pain, swelling and deformity are usually obvious upon examination.
There is a loss of the normal triangle created between the olecranon posteriorly and
the two epicondyles.
It is vital that a neurovascular examination is undertaken and documented to check

for the presence of pulses.
Although the reduction technique can be undertaken relatively easily, it is almost

always performed in hospital due to the requirement for sedation in addition to
analgesia.
A traditional broad arm sling may not be tolerated due to the position of the arm,
although a collar and cuff may provide some comfort.
133
Selected lower-limb injuries
Tibia fracture
The tibia requires significant force to break it and this usually only occurs when the
foot is planted on the ground, either in association with direct trauma to the shin from
another player or with rotational forces being applied though the lower leg with the
foot planted.
A tibia fracture is first managed by assessing for associated injuries (as per our
structured primary assessment) and providing analgesia and then splinting the lower
leg, ideally ensuring that the knee and ankle are also splinted.
It is vital to assess for neurovascular injury and any evidence of a wound that would
make this a compound injury.
Fracture-dislocated ankle
This injury has a high association with neurovascular compromise and, therefore,
where there is a risk that the blood supply has been affected and critical ischaemia is
occurring, reduction will need to be undertaken pitchside.
This is a classically distracting injury and a primary assessment should still be undertaken
prior to focusing on the limb injury itself.
Analgesia should always be provided to the player and it is vital to assess the circulatory
status of the ankle as soon as possible.
Again, traction, rather than manipulation, is the key to correcting the injury and it
should be possible to align the foot and ankle with the use of traction alone.
WOUNDS
Protect yourself and protect the player: remember the importance of (non-COVID-19-
related) appropriate PPE.
Wounds are common in all contact sports, including football.
Part of the challenge with pitchside wound management is that this can be stressful
because of the difficulty in treating these appropriately, balanced against returning
the player to the field of play as quickly as possible.
However you choose to manage a wound, the first priority should always be to act
in the player’s best interests. With head injuries in particular, wounds can be very
distracting from other potential associated injuries and it is vital to always ensure that
a full primary assessment has been carried out, with the wound being managed as
part of the Circulation assessment.
As detailed in chapter 2, if a player has a clearly visible bleeding wound, direct pressure
should be applied to this at the same time as the Airway and Cervical Spine are assessed
and managed.

Laws of the Game: rules concerning bleeding wounds
• Any player bleeding from a wound must leave the field of play.
• They may not return until the referee is satisfied that the bleeding has
stopped.
• A player is not permitted to wear clothing with blood on it.
Key aspects of managing wounds
• Clean the wound

• Applying direct pressure stops most bleeding. However, direct pressure
means putting pressure on the bleeding point (and not pressure in the
vicinity of the bleeding) so clean the wound again to ensure you can see the
bleeding point properly.
• Inspect the wound considering the following questions:
• Will the treatment I administer pitchside allow the player to safely

play on?
• Is the treatment temporary or definitive?
• Have I missed anything else associated with the injury, i.e.
• Is the injury a wound of concern? (see below)
• Is the wound contaminated?
• Are there associated injuries?
• Is the wound clean enough? Probably not, so clean it again
• Work within your competence. Do not close wounds using techniques or

materials with which you are unfamiliar. Tissue glue is very useful in the right
circumstances, but tissue glue in a player’s eye may also be career-ending.
• Once you have closed the wound, ensure that it is subsequently kept clean
and dry. Dressings that become wet are much more likely to result in wound
dehiscence, skin maceration, delayed healing and infection.
• Consider taking a picture of any wound on the player’s phone so it can be
shown to other clinicians in the hospital instead of uncovering the wound
multiple times.
As highlighted above, the importance of cleaning a wound properly cannot be

overstated.
The majority of wounds will heal well as long as they are given the correct environment
in which to heal. This starts with cleaning.
Crucially, it is not the type of cleaning solution that is important – it is the volume.
Pressure is also helpful (although, as highlighted above, appropriate PPE should always
be worn where there is a risk of splashing or blood spray) in wound cleaning, so ensure
you have the correct materials to allow you to clean the wound properly. 500ml of
bottled water should be readily available and is a very good starting point for cleaning
a wound.
135
Wound irrigation should always be considered and this is performed by creating a
high-pressure water jet: take a white (large bore) needle and break the needle off,
leaving the hub attached to the syringe to create a small hole, through which cleaning
solution can be injected.
Alternatively, an IV cannula (with the needle removed) can be attached to a syringe to

achieve the same effect.
Types of wound
In football, the majority of wounds resulting from trauma are abrasions and lacerations.
Abrasions
An abrasion is a superficial open injury following trauma to the epidermal and dermal
layers of the skin. This occurs when the skin is rubbed against a rough surface, shearing
off the epidermal layer (the top layer of the skin) exposing the dermis (the bottom
layer of the skin).
Treatment
1. The aims of the treatment of abrasions are to prevent infection, promote

healing and prevent traumatic “tattooing” from the embedded debris and
foreign bodies in the dermis.
2. Irrigate the wound with sterile, normal saline/water.
3. Clean the wound and attempt to remove any visible debris and foreign
bodies where possible.
4. Seal the wound with a dry dressing if possible.
5. The player may return to play if no other underlying injuries are suspected.
Contusions/haematomas
A contusion (bruising) is a closed injury following a blunt trauma to soft tissue and
may involve injury to the underlying structures. The player may present with pain and/
or a bluish skin discolouration at the site of the injury as a result of localised bleeding
under the skin.
A haematoma is bleeding into a space or a potential space, such as the muscles and the
dermal layer (the bottom layer of the skin) and may occur alongside either minor or
major wounds. This injury presents as a bluish-black swelling or lump at the injury site.
Treatment
1. Generally, contusions and haematomas are classified as minor injuries that

resolve naturally over time.
2. Apply ice packs to the injury site. The player can be advised to continue
applying ice packs intermittently to reduce the swelling for the first 24 to 48
hours. Note: ice packs should not be placed directly onto the naked skin for
prolonged periods, as this can cause cold burns on the skin or frostbite.

3. If the player is not removed from the field of play and substituted and wishes
to return to play, ice and/or compression bandage treatment may have to wait
until the player is no longer involved in the match.
4. However, any player with a facial injury who may have clinically suspected
underlying fractures, due to pain, swelling, bruising or distortion, should be
referred for specialist assessment.
5. Consider simple pain management if clinically indicated.
Lacerations
Lacerations are open injuries that result from blunt trauma to the soft tissues over
the bones, usually from head-to-head or head-to-elbow contact between players.
Lacerations can be superficial or deep, and present as either a linear (straight) or
stellate (jagged/burst-type) laceration. Lacerations of the facial area usually bleed
profusely due to the rich blood supply to the face.
Treatment
1. Control any bleeding by first applying direct pressure with sterile gauze to the
injury site.
2. Once the bleeding has stopped, the player should receive a focused
assessment of the injury and be managed accordingly by either the player
returning to play, being substituted and/or referred for further radiological
and/or specialist evaluation.
3. Minor lacerations should be irrigated thoroughly with sterile normal saline.
4. Where suturing is not clinically required, cover the wound with a dressing. The
player may return to play if no underlying injuries are suspected. Skin-closure
strips may be used to close simple linear lacerations, but these will often not
adhere to the skin if a player has been sweating.
5. Major facial lacerations, accompanied by obvious or suspected facial fractures,

should be stabilised and the player referred for further radiological and/or
specialist evaluation. Again, direct and localised pressure may be all that is
required to control bleeding temporarily.
6. Consider pain management if clinically indicated.
Special lacerations for consideration
Wound management has two prime outcomes: function and cosmesis. Cosmetic
outcomes are an important consideration when dealing with wounds affecting the
face. Time needs to be spent to ensure that the long‑term outcomes are as optimal
as possible. This involves ensuring that the wound is as clean as possible and that
wound edges are opposed and aligned. This is particularly important if the wound has
a tangential component and alignment can therefore be difficult.
Thin thread filament should be used on the face and sutures should be removed after
around five days to minimise scarring from the suture marks themselves.
137
Eyelid: eyelid wounds are particularly tricky to manage due to the thin nature of the
affected tissue. In this situation, it is very easy to make the situation worse with poorly
placed or overlapping sutures. If in doubt, a referral for hospital assessment should be
made.
It should be remembered that a suture can always be removed, so if you are unhappy
with how a wound looks, remove the suture and start again.
Vermilion border: this area of the lip is important cosmetically because if it is not
aligned properly, the resulting wound will be noticeable. Typically, a 1mm difference
between the edges can be seen at conversational distance between two people, so it
is vital that the wound edges at the vermilion border are properly aligned at the time
of definitive closure.
Lip: full-thickness wounds of the lip that extend intra-orally will need to be assessed
to ensure that no tooth fragments remain in the wound itself. The external lip wound
should be cleaned thoroughly and closed but the vast majority of internal lip wounds
can be left without closure.
Eyebrow: the eyebrow has the same cosmetic importance as the vermillion border in
terms of alignment at the time of closure. It is also important never to shave off the
eyebrow because it may not grow back again. Instead, thoroughly wet and clean the
area to allow you to visualise the wound edges and oppose them.
Tongue: reassuringly, the tongue rarely needs to be sutured and the vast majority
of wounds will heal with time. Maintaining adequate oral hygiene is the key to this.
Tongue wounds that extend to the tip or lateral borders of the tongue may need to be
closed, but this is not something that should be considered pitchside.
Fight bite: these wounds stem from a punch injury, resulting in a wound from the
opposite person’s tooth, usually over the fifth metacarpal. They are highly prone to
infection due to the bacteria present in the mouth. If the force also results in a bony
injury, the result is a compound fracture that will need to be formally washed out.
These wounds should be cleaned repeatedly and then dressed, leaving the wound
open and not closing or suturing it. Prophylactic antibiotics will be required in almost
all cases.
Compound injuries including puncture wounds: compound injuries should always

be considered in any wound close to, or overlying, a joint where a fracture is also
suspected. This may be clearly apparent in the case of a bony fragment sticking out
through the skin, or it may be more subtle and appear to be only a small abrasion to
the skin which, on closer examination, is actually a wound connecting skin to fracture.
All cases require cleaning and irrigation, but recent evidence shows that this is best
undertaken in an operative environment rather than pitchside. All gross wound
contaminants should be carefully removed pitchside and the wound should be covered
with saline-soaked gauze. Ideally, take a picture of this on the player’s phone so it can
be shown to other clinicians in the hospital instead of uncovering the wound multiple
times.

What to consider when managing wounds
From a medico-legal perspective, it is always important to document the nature of any

wound and how it was treated. This protects both you, as the clinician, and the player.
Document:
• How the wound happened.

• Where the wound is located. This is important because the same-sized
wound in two different places may need to be closed in a different way,
e.g. a supraorbital wound will bleed into the player’s eye unless it is closed,
whereas the same wound on the occiput is not as functionally or cosmetically
important and might be quicker to manage.
• The length of the wound.
• The depth of the wound (this may be difficult to be sure about, but it is
important to classify wounds as being superficial or full thickness).
• Where full thickness is defined as a wound that extends through the
epidermis and dermis (all layers of the skin) into the subcutaneous tissues
or deeper.
• Are any underlying structures involved?
• In the scalp, the involvement of the galea is important as this should
also be closed.
• Wounds that extend through fascial planes may also need to be closed
in layers.
• Is the wound grossly contaminated?
• Is there normal function?
Lastly, recording the player’s tetanus and blood-borne virus statuses is also important
so that you can advise them accordingly. This is not important pitchside, but it is
important to know and record for ongoing management.
The mechanism of how a wound is sustained is important in terms of the underlying

associated injuries that might be sustained in addition to the type or level of
contamination that may have occurred. A wound sustained from a clash of heads may
result in tearing of the skin overlying the point of contact and a laceration may be
evident. If, however, the wound has been caused by the opposite player’s tooth as
the two players jumped for the ball, the resulting wound might initially look similar
to the first, but the level of contamination will be significantly higher in the second
injury due to the bacteria present in the mouth. Both wounds will need to be cleaned
repeatedly, but the second will almost certainly require antibiotics, whereas the first
injury almost certainly will not.
Options for wound management (not thought to be directly related to a fracture)
If you only do one thing to a wound, clean it.
If you only do two things to a wound, clean it twice.
When deciding how to manage a wound, a number of issues will need to be balanced.
You must formulate a plan and decide whether the management is going to be
definitive or temporary with a view to definitive management later on (e.g. at half-
time, full-time or in hospital). You should use materials with which you are comfortable
(taking into account any special considerations, as described on the next page).
139
The amount of time that has elapsed since the injury occurred is important since
wounds should ideally be closed within the first six hours to minimise the potential for
infection, which increases as time goes on. “Primary closure” means the closure of a
wound in this initial time period.
Outside of 6-12 hours (depending on the site of the wound, e.g. for the scalp or the
face, this period might be a little longer because of the good blood supply to the area)
a decision will need to be made as to whether to close the wound or to leave it for a
couple of days and close it at that point instead (delayed primary closure).
The alternative is to leave the wound to granulate. This may be the best option, but it
might also result in larger scar formation and a worse cosmetic outcome.
There are several ways to close a wound and, sometimes, a combination of two
methods can work quite well, e.g. sutures plus steri-strips.
Steri-strips
These are readily available and relatively cheap adhesive strips that can be used to
close wounds that are superficial and not full thickness.
They are particularly good for superficial wounds to the forehead and face, but are
not useful in areas where there is hair, such as the scalp or even eyebrow wounds.
In a sporting context, steri-strips are of little use pitchside as they are unlikely to be
adherent due to sweating on the skin. They also need a bloodless field to work best.
They may be useful in the medical room once the player has left the field of play.
Tissue glue
Tissue glue is another readily available wound-closure method that is useful for
wounds that are superficial and not full thickness. It is vital to check the method of
storage for the brand of glue you use – many need to be refrigerated and solidify if
they are stored at room temperature. Checking what you have with you – particularly
when travelling – is key.
Tissue glue sets very quickly, so it should be thought of as a “one-shot” treatment.

Again, a bloodless field works best, with the glue forming a seal over the top of the
wound.
Tissue glue should not be used around the eye.
Staples
Staples can be very useful in certain players and with certain wounds. They can also be
used in superficial wounds as they only close the superficial layers of the skin and result
in a cavity below the wound in deeper wounds.

Staples can be easily removed if they do not achieve the best result (as long as you have When
access to a staple remover or forceps). It will be up to the player to decide if they need
local anaesthetic before the staples are inserted. One benefit of local anaesthetic is deciding how
that it allows thorough cleaning to take place.
to manage
Staples can be useful in scalp wounds, but they should not be used on the face itself,
especially if the wound is on the forehead and the player is returning to the field of
a wound, a
play. number of
issues will
Sutures
need to be
Sutures allow full-thickness wounds to be closed, and deeper wounds to be closed in
layers, using absorbable suture materials. Whether they are used very much depends
balanced.
on the operator and a player should not be sutured unless this is a skill that has been
practised and acquired.
It takes time to set up to suture a player so this is not something that should be
undertaken pitchside. The player should be removed to the medical room for
assessment and suturing. Setting up a suture kit prior to the match will save time, as
will preparing local anaesthetic for administration, but this incurs costs whenever it is
not used.
One consideration when using sutures is to try to give the coaching staff as much
information as possible about how long you think it might take you to suture a player
should it be needed, so they can decide whether or not to make a substitution.
If you decide to use sutures, it is important that you identify the best size for the wound
you are treating and how long they should stay in place and arrange for removal at an
appropriate time. The longer the sutures stay in place, the more the suture marks will
be visible. If they are removed too early, the wound will dehisce.
REFERENCES
1. Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T & Lin CW. Accuracy of the
Canadian C-spine rule and NEXUS to screen for clinically important cervical
spine injury in patients following blunt trauma: a systematic review. Canadian
Medical Association Journal, 2012, Nov 6;184(16): E867-876.
2. 10TH Edition of the Advanced Trauma Life Support® (ATLS®) Student Course

Manual. Chicago (IL): American College of Surgeons; 2018
3. Hwang K. Field Management of Facial Injuries in Sports. Journal of Craniofacial

Surgery, 2020, Mar/Apr 31(2): e179-e182.
4. McCrory P, Meeuwisse W, Dvořák J et al. Consensus statement on concussion

in sport – the 5TH international conference on concussion in sport held in
Berlin, October 2016. British Journal of Sports Medicine, 2017, 51: 838-847.
5. Kramer E, Dvorak J editors. Facial Injuries. F-MARC Football Emergency

Medicine Manual. 2ND ed. Zurich: Fédération Internationale de Football
Association; 2015. p. 12-19.
6. Zideman DA et al. European Resuscitation Council Guidelines 2021:

First aid, Resuscitation, 2021. Available at: https://doi.org/10.1016/j.
141
7. Marston AP, O’Brien EK & Hamilton GS. 3RD Nasal Injuries in Sports. Clinical
Journal of Sport Medicine, 2017, Apr 36(2): 337-353.
8. Correa MB, Schuch HS, Collares K, Torriani DD, Hallal PC & Demarco FF.
Survey on the occurrence of dental trauma and preventive strategies among
Brazilian professional soccer players. Journal of Applied Oral Science, 2010, Dec
18(6): 572-576.
9. Fouad AF, Abbott PV, Tsilingaridis G et al. International Association of Dental

Traumatology guidelines for the management of traumatic dental injuries:
2. Avulsion of permanent teeth, Dental Traumatology, 2020, 36: 331-342.
Available at: https://doi.org/10.1111/edt.12573
10. MacEwen C & McLatchie G. Eye Injuries in Sport. Scottish Medical Journal, 2010,
55 (2): 22-24.
11. Repanshek ZD, Ufberg JW, Vilke GM et al. Alternative treatments of

Pneumothorax. Journal of Emergency Medicine, 2013, 44 (2): 457-466.
12. Hecker M, Hegenscheid K, Volzke H et al. Needle decompression of tension

pneumothorax: population-based epidemiologic approach to adequate
needle length in healthy volunteers in Northeast Germany. The Journal of
Trauma and Acute Care Surgery, 2016, 80: 119-124.
13. Lott C et al. European Resuscitation Council Guidelines 2021: Cardiac

arrest in special circumstances, Resuscitation, 2021. Available at: https://doi.
org/10.1016/j.resuscitation.2021.02.011
14. Clemency BM, Tanski CT, Rosenberg M et al. Sufficient catheter length
for pneumothorax needle decompression: a meta-analysis. Prehospital and
Disaster Medicine, 2015, 30: 249-253.
15. Ryan JM. Abdominal injuries and sport. British Journal of Sports Medicine, 1999,
33: 155-160.
16. Chouhan JD, Winer AG, Johnson C, Weiss JP & Hyacinthe LM. Contemporary
evaluation and management of renal trauma. The Canadian Journal of Urology,
2016, Apr;23(2): 8191-7.
17. Stricker PR, Hardin BH & Puffer JC. An unusual presentation of liver
laceration in a 13-yr-old football player. Medicine & Science in Sports
Exercise, 1993, 25: 667-672.
18. El-Matbouly M, Jabbour G, El-Menyar A, Peralta R, Abdelrahman H,

Zarour A, Al-Hassani A & Al-Thani H. Blunt splenic trauma: Assessment,
management and outcomes. The Surgeon, 2016, Feb;14(1): 52-58.
19. Houshian S. Traumatic duodenal rupture in a soccer player. British Journal of

Sports Medicine, 2000, 34: 218-219.
20. Luther A, Mann C, Hart C et al. Duodenal rupture secondary to blunt trauma
from a football. The Journal of Strength and Conditioning Research, 2013.
21. Dutson SC. Transverse colon rupture in a young footballer. British Journal of
Sports Medicine, 2006.
22. Bakalakos M, Benetos IS, Rozis M, Vlamis J & Pneumaticos S. Posterior hip
dislocation in a non-professional football player: a case report and review of
the literature. European Journal of Orthopaedic Surgery and Traumatology,
2019, Jan;29(1), 231-234.

23. Sytema R, Dekker R, Dijkstra PU et al. Upper extremity sports injury: risk
factors in comparison to lower extremity injury in more than 25 000 cases.
24. Robertson GA, Wood AM, Bakker-Dyos J., et al. The epidemiology,
morbidity, and outcome of soccer-related fractures in a standard population.
Am J Sports Med. 2012;40(8): 1851-1857
25. Robertson GA & Wood AM. Return to Sport After Tibial Shaft Fractures: A
Systematic Review. Sports Health, 2016, Jul;8(4): 324-330.
26. Roepke C, Kleiner M, Jhun P, Bright A & Herbert M. Chest Pain Bounce-Back:
Posterior Sternoclavicular Dislocation. Annals of Emergency Medicine, 2015,
66(5): 559-561. Available at https://www.annemergmed.com/article/S0196-
0644(15)01303-7/fulltext
27. Sayegh FE, Kenanidis EI, Papavasiliou KA et al. Reduction of acute anterior
dislocations: a prospective randomized study comparing a new technique
with the Hippocratic and Kocher methods. The Journal of Bone and Joint
Surgery, American volume, 2009, 91(12): 2775-2782.
28. Quinn JV et al. Traumatic lacerations: what are the risks for infection and
has the ‘golden period’ of laceration care disappeared? Emergency Medicine
Journal, 2014, 31(2): 96-100.
29. Sabatino F & Moskovitz JB. Facial wound management. Emergency Medicine
Clinics of North America, 2013, 31: 529-538.
143
CONCUSSION
7
CONCUSSION
Head injuries can result in substantially different outcomes, ranging from no detectable
effect to transient functional impairments or life-threatening structural lesions. In
high-level international football tournaments, one head injury occurs every third
match on average. This makes it essential for team doctors to be able to immediately
diagnose a head injury and to determine its severity, whether on or off the pitch. Both
elements can be challenging because clinical signs of a brain injury do not necessarily
present immediately, but instead can develop over several minutes, hours or even days
after the incident. FIFA therefore provides a standardised approach to support team
doctors to make decisions about whether a player should be allowed to continue to
play or should be removed from play after a head injury. If there is any suspicion of a
concussive injury at any stage, you should remove the player from the match or training
session and assess and treat them appropriately, as described in the following protocol.
DEFINITION AND CLASSIFICATION OF CONCUSSION

“Concussion” is defined as a traumatic brain injury (TBI) induced by biomechanical
forces.
Several common features may be used to clinically define the nature of a concussive
head injury. These include the following:
• A sports-related concussion may be caused either by a direct blow to the

head, face or neck or by a blow to another part of the body with an impulsive
force that is transmitted to the head.
• A sports-related concussion typically results in the rapid onset of the short-
lived impairment of neurological function, which resolves spontaneously.
However, in some cases, signs and symptoms evolve over a number of
minutes to hours.
• A sports-related concussion may result in neuropathological changes, but
the acute clinical signs and symptoms largely reflect a functional disturbance
rather than a structural injury and no abnormalities are therefore identified
in standard structural neuroimaging studies.
• A sports-related concussion results in a range of clinical signs and symptoms
that may or may not involve a loss of consciousness. The resolution of the
clinical and cognitive features typically follows a sequential course. However,
in some cases, symptoms may be prolonged.
To diagnose concussion, the clinical signs and symptoms should not be explainable
by drug, alcohol or medication use, other injuries (such as cervical injuries, peripheral
vestibular dysfunction, etc.) or other comorbidities (e.g. psychological factors or
coexisting medical conditions).
The evaluation after a head injury always includes an examination of associated

structures, i.e. the neck and labyrinth, since symptoms alone cannot distinguish
physiologic concussion from cervical/vestibular injury.
146 7 Concussion
MANAGEMENT OF CONCUSSION
Several steps can be taken before any concussion even occurs that will improve the
management of concussed players. These include baseline examinations and the
implementation of a structured plan for post-concussion management.
BASELINE EXAMINATION
A baseline examination is a concussion assessment performed at a time when a player
has not recently had a concussion incident (e.g. pre-season). The baseline examination
provides information that is valuable when diagnosing and managing head injuries.
Results from the baseline examination can be helpful as they make it possible to compare
signs and symptoms following a potential concussion incident and to assess the level of
impairment in comparison to what is normal for the individual player concerned. They
can also be instrumental when deciding if and when a player can return to football, but
are not useful when deciding whether to remove a player from play.
FIFA recommends using the newest version of the Sport Concussion Assessment Tool
(currently SCAT5) for baseline examinations. The SCAT is the most widely used pitchside
assessment tool internationally and provides a battery of tests to assess several aspects
of brain function that are typically impaired in concussion. It measures consciousness,
orientation, neurocognitive function, self-reported symptoms and postural stability. It
further includes a section for acute concussion evaluation, taking note of observable
signs of concussion, including red flags, the Glasgow Coma Scale and cervical spine
function, and a neurological screening examination. The SCAT should take a minimum
of ten minutes to complete. It has a sensitivity of 0.83-0.96 and a specificity of 0.81-0.91.
147
DIAGNOSIS AND MANAGEMENT IN THE FIRST 72 HOURS AFTER THE
HEAD INJURY
An eight-phase, systematic approach is recommended in the first 72 hours after a
head injury is sustained in high-level football, starting with the initial examination and
continuing with diagnosis and management:
Phase 1: Observation and recognition
Phase 2: Initial (on-pitch) examination
Phases 3-4: Off-pitch/quiet-area examination
Phases 5-7: Post-match examinations and observation
Phase 8: Graduated Return-to-Football Programme
Notably, this procedure is the sole responsibility of the team doctor.
The purpose of the on-pitch assessment is to identify clinical signs, symptoms or

mechanisms that require the player to be removed from play for a more detailed
examination. If there are signs or symptoms of brain damage, or if a concussive injury
is suspected despite the absence of signs or symptoms, the doctor/therapist should
remove the player from the pitch for a more detailed examination and the player should
be replaced by a concussion substitute if available/required. Due to the potentially
severe neurological consequences of a head injury, any suspicion of abnormal findings
should result in the initiation of an appropriate examination and the removal of the
player from the match or training session (if any orange flags are identified as per
table 4 on page 154). Remember that orange flags can always turn into red flags that
require emergency management. Players may be allowed to continue to play or train
only where they have no suspected signs or symptoms of concussion or any other
significant injury (i.e. only if no orange flags are identified).
The post-match examinations serve to establish a diagnosis so as to accurately initiate

therapeutic strategies and enable a safe return to football. The doctor should be aware
that an emergency situation can arise at any time in the hours and days immediately after
the head injury was sustained. Repeated comprehensive examinations are therefore
required. Ideally, the team doctor should know each individual player, including their
characteristics, medical history and baseline examination results (if such tests have been
performed), and should be able to communicate with all players appropriately.
OBSERVATION AND RECOGNITION (PHASE 1)

Team doctors should observe the match (or training session), focusing on potential head
injuries such as (suspected) loss of consciousness, convulsion or abnormal posturing,
slowness or imbalance. The injury mechanism and player behaviour are best observed
directly, being supported, if possible, by immediate video review. There are specific
signs following a head injury that should increase the suspicion of concussion (see
Table 1 on the next page). If there is access to video review, relevant recommendations
can assist with the approach (Table 2).
148 7 Concussion
Table 1: Observable signs of concussion (adapted from Davis GA, Makdissi M,
Bloomfield P et al, 2019)
Lying without purposeful movement on the playing surface

for >2 seconds*. The player does not appear to move or react
purposefully, respond or reply appropriately to the game situation
(including team-mates, opponents, match officials or medical
staff). Concern may be shown by other players or match officials.
Lying motionless
* >2 seconds is the threshold for removing and assessing the
player. Significantly longer periods of lying motionless may
necessitate immediate and permanent removal from play,
depending on the circumstances.
The player appears unsteady on their feet (including losing balance,

Motor staggering/stumbling, struggling to get up or falling) or in the
incoordination upper limbs (including fumbling). This may occur when the player
is getting up from the playing surface or is walking or running.
Involuntary clonic movements that comprise periods of

Impact seizure
asymmetric and irregular rhythmic jerking of axial or limb muscles.
Involuntary, sustained contraction of one or more limbs (typically

upper limbs), so that the limb is held stiff despite the influence of
gravity or the position of the player. Other muscles, such as the
cervical, axial and lower-limb muscles, may also be involved. Tonic
Tonic posturing posturing may be observed while the player is on the playing
surface or in the process of falling, where the player may also
demonstrate no protective action*.
*This was previously known as “no protective action – stiff”.
The player falls to the playing surface in an unprotected manner (i.e.

without stretching out their hands or arms to lessen or minimise
No the fall) after direct or indirect contact to the head. The player
protective demonstrates loss of motor tone (which may be observed in the
action limbs and/or neck*) before landing on the playing surface.
– floppy *When the player’s arms are being held by a tackling opponent,
this may only be observed in the neck, which was previously known
as “cervical hypotonia”.
The player exhibits no facial expression or apparent emotion in

response to the environment*.
Blank/vacant
look *This may include a lack of focus/attention of vision. A blank/
vacant look is best appreciated in reference to the player’s normal
or expected facial expression.
149
Table 2: Six key video review steps for the team clinician (adapted from Patricios JS,
Ardern CL, Hislop MD et al, 2018)
1 Look for the suspected head impact event
Does the player fall to the ground? If the

Look for the immediate player falls, is there loss of head and neck
2 response of the injured control? Does the player protect themselves
player (0-2 seconds) when falling? If the player remains upright,
are they steady on their feet?
If the player falls, do they move

spontaneously? Is there evidence of
purposeful voluntary movement (e.g.
placing the ball or completing a tackle)? Is
there evidence of a concussive convulsion
or tonic posturing? How does the player
Look for the subsequent
3 respond to the attending medical staff (this
response (2-5 seconds)
phase may last for substantially longer than
five seconds, particularly if in-line cervical
immobilisation is required)? If the player
remains standing, the distinction between
the subsequent and late responses may be
unclear.
Is the player unsteady when attempting to

Watch for the player’s late get to their feet and return to play? Does
response when returning to the player need help from others to stand
4
their feet (if the player has up? Are the player’s movements fluid and
fallen) coordinated? Does the player fall to the
ground?
Are their actions appropriate? Do they

Watch the player’s behaviour
5 move immediately to the correct position
on returning to sport
on the pitch?
6 Observe the responses of other players and match officials
150 7 Concussion
EMERGENCY MANAGEMENT AND RED FLAGS FOR REFERRAL TO
HOSPITAL
Prior to the initial examination, it is important to consider the differential diagnoses
of a deteriorating or collapsed player. Potentially life-threatening emergency concerns
after an acute head injury include signs or symptoms of cardiopulmonary arrest or
severe structural injuries to the brain, skull, face, cervical spine or spinal cord, which
have been denoted as red flags. The emergency assessment and management
after any acute head injury should be performed according to clear principles and
standardised practice, as per the FIFA Emergency Medicine Manual.
Any head injury should be regarded as having a concomitant cervical spine injury until
this has been excluded by clinical examination, or by imaging if indicated (see Table
3 on the next page). Any suspicion of a cervical fracture or intraspinal lesion (e.g. as
prompted by a GCS score of <15 on initial assessment, neck pain or tenderness, focal
neurological deficit, paraesthesia or weakness in the extremities, or any other clinical
suspicion of cervical spine injury) should result in immobilisation and stabilisation of
the cervical spine, appropriate removal from the pitch and emergency transportation
to a hospital.
Any suspicion of a skull fracture should result in the player being removed from play
immediately. In addition to local ocular tenderness to palpation, other significant
signs and symptoms of an orbital floor fracture are periorbital haematoma, double
vision (diplopia) and abnormalities in eye movements. Any deterioration of signs
and symptoms can indicate intracranial bleeding and/or swelling, which can only be
diagnosed by tomographic imaging (e.g. computerised tomography) of the brain.
Therefore, it is also important to continuously observe players even if they are initially
symptom-free.
151
Table 3: Emergency management principles
Concern (C),
Domain Actions Consequence
Examination (E)
- Start cardiopulmonary resuscitation Remove the player

(CPR) chain: emphasis on chest from the pitch
and continue
Cardiopulmonary
compression and rapid defibrillation

- Place the AED on the player, but emergency
C: Cardiopulmonary
shock them only if the AED device management if
arrest
self-charges and verbally recommends indicated
E: Unresponsiveness, not
breathing normally pressing the shock button
Consider
- Place the player onto a spinal
immediate
stabilisation device (e.g. spinal
emergency
board) and strap appropriately
transport to
hospital
C: Intracranial lesion
E: Glasgow Coma Scale - Neutralise and stabilise the cervical
score <13/15, loss of spineappropriately
consciousness, severe - Maintain and protect the airway as safely
headache, repetitive as possible
Brain
vomiting, seizure/ - Ventilate the unconscious patient if

convulsion, abnormal necessary
posturing, new - Place the player onto a spinal stabilisation
difference in pupil size, device (e.g. spinal board) and strap
nystagmus, fall due to appropriately
imbalance
C: Fracture
E: Severe headache, - Neutralise and stabilise the cervical spine
Skull and face
blood or clear appropriately

fluid exiting from - Control any external bleeding
the ear(s) or nose, - Place the player onto a spinal stabilisation
deformity, periocular device (e.g. spinal board) and strap
or retroauricular appropriately
haematoma
C: Fracture or intraspinal
Cervical spine
- Neutralise and stabilise the cervical spine

lesion
and neck
appropriately
E: Deformity, severe
- Place the player onto a spinal stabilisation
pain, swelling over the
device (e.g. spinal board) and strap
neck, paresis, impaired
appropriately
sensation
152 7 Concussion
INITIAL (ON-PITCH) EXAMINATION OF HEAD INJURIES (PHASE 2)
The outcome of the initial (on-pitch) examination is the basis for the team doctor’s
decision on emergency management, referral to hospital, removal from play and/or
off-pitch assessment in a quiet area. The doctor’s decision should be communicated to
the referee and the coach.
The recommended aspects of the initial inspection and examination are based on
the latest version of the Sport Concussion Assessment Tool (currently SCAT5) and the
National Institute of Health and Care Excellence (NICE) criteria (see Table 4 on the next
page). During this initial examination, it is essential to focus on red and orange flags.
The inspection concentrates on visible signs (e.g. loss of consciousness, vomiting,

mechanism of injury), while the examination assesses core signs and symptoms of
neurological impairment of different brain areas (cortical, subcortical, cerebellar, brain
stem) and of a cervical spine or intraspinal injury. Any period of loss of consciousness
or GCS <15 indicates a brain injury. At any stage during this initial examination, the
medical personnel attending to the injured player can use information/assistance from
other available resources, such as video-replay technology or eyewitness accounts. The
procedures for all of these, as well as the relevant lines of communication, should be
agreed pre-match/training and documented in the FIFA PEAP.
In non-emergency situations, the injured player should be removed to the off-pitch

location for
further assessment in either of the following scenarios:
The outcome in one or more aspects of the initial assessment is considered or suspected
to be abnormal and additional time for examination is required.
All tests yield normal results, but the team doctor suspects that the player is suffering
from functional neurological impairment.
If there is no evidence of red or orange flags, if the team doctor’s on-pitch assessment
is not concerning and if the inspection and examination are both normal, the team
doctor should continue to observe the player throughout the match and re-evaluate
them serially to watch for the delayed onset of signs or symptoms (phase 5). All players
who have suffered a head injury should be observed for the first 24 hours after the
injury was sustained (phase 6).
153
Table 4: Initial (on-pitch) examination of a head injury
1 Acute signs
Short-term loss of consciousness No Yes
Deformity or swelling of the head or neck or holding of the
Inspection
No Yes
head due to pain/for stabilisation
Blood or clear fluid exiting from the ear(s) or nose No Yes
Blank look No Yes
Slowness in getting up No Yes
Vomiting No Yes
Uncharacteristic behaviour No Yes
2 GCS: 15 points
Eye opening: spontaneous (4 points) Yes No
Verbal: oriented (name, place, date) (5 points) Yes No
Motor: obeys commands (6 points) Yes No
3 Selected new acute symptoms
Headache or pressure in the head No Yes
Neck pain No Yes
Nausea No Yes
Vertigo, dizziness, drowsiness, unsteadiness No Yes
Blurred or double vision, sensitivity to light No Yes
Tinnitus, hypacusis, hyperacusis No Yes
Impaired sensation in the upper or lower extremities No Yes
4 Orientation and memory (Maddocks questions)
What venue are we at today? Correct Incorrect
Which half of the match is it now? Correct Incorrect
Examination
Who (which team) scored last in this match? Correct Incorrect

Which team did your team play last week/match? Correct Incorrect
Did your team win the last match? Correct Incorrect
5 Delayed, slow or inappropriate responses No Yes
New difference in pupil size, crossed eyes,
6 No Yes
spontaneous nystagmus
Range of motion of the cervical spine
7
(only if no acute neck pain)
Normal and Impaired
Active rotation to the left and right from a neutral position
painless or painful
Normal and Impaired or
Active flexion and extension from a neutral position
painless painful
8 Strength of the upper and lower extremities Normal Impaired
9 Touch sensation of the upper and lower extremities Normal Impaired
10 Balance, control and coordination of posture and the limbs
Stand on both legs with heel and toe together
Stable/no sway Failed
(eyes closed, 10 seconds; if failed, maximum of 1 repetition)
Finger-to-nose task (right and left) (eyes closed, 2
All trials correct Failed
repetitions, both sides)
If no signs or symptoms 4 player allowed to return to play or training; further observation until
leaving the sports facilities
Orange flags can turn into red flags

If any orange flag or if the doctor is in doubt 4 removal from football and further examination
If any red flag 4 emergency management
154 7 Concussion
OFF-PITCH EXAMINATION (PHASE 3)
The off-pitch examination should focus on red and orange flags (see Table 5 below). This should
include tests of ocular motor function as many of the pathways in the brain potentially affected
by head injuries are involved in ocular motor control. Obvious minor injuries, such as lacerations
or bruises, might be treated.
Table 5: Selected signs and symptoms indicating red and orange flags after a head
injury
Domain Red flags Orange flags

GCS 13/15 or 14/15, blank look,
Signs: confusion, disorientation, delayed, slow
or inappropriate response, difficulty
Alertness/ concentrating or remembering
GCS <13/15
attention
Symptoms: Feeling slowed down, “don’t feel
right”,drowsiness, fatigue, “low energy”
Seizure/convulsion or postictal signs, Impaired control of trunk or limb

Neuromotor Signs:
abnormal posturing movements
Signs: Nausea or vomiting (once), holding of the

Headache Severe headache, repetitive vomiting head
Symptoms: Pressure, headache
Signs: Imbalance
Dizziness/
Fall due to imbalance
balance
Symptoms: Vertigo, dizziness, fogginess, unsteadiness
Vision/ Crossed eyes, nystagmus, other acute

Blurred vision, “eyes cannot follow”,
ocular motor disordered eye movements, new Symptoms:
sensitivity to light
function difference in pupil size
Emotion/ Emotional instability, irritability or

Signs:
behaviour aggressionwith little or no provocation
Hearing Acute hearing loss Symptoms: Hyperacusis, hypacusis, tinnitus
Pain, tenderness, swelling, Signs: Impaired hearing, tinnitus, sensitivity to

Cervical spine/ deformity, paresis, impaired noise
spinal cord sensation in the upper or lower
extremities Symptoms: Neck pain
Blood or clear fluid exiting from the

Skull/face ear(s) or nose, deformity, periocular Signs: Contusion, laceration
or retroauricular haematoma
Personal
Anticoagulation, clotting disorder Previous brain injury
history
Note: some signs and symptoms can be attributed to different domains. Orange flags can turn into red flags.
RED FLAGS: Potential life-threatening problems or hints of intra- or extracerebral lesion
4 if any: emergency management and consider immediate transportation to hospital

ORANGE FLAGS: Neurological or orthopaedical impairment
4 if any (or the doctor is in doubt): removal from football and further examination,
with a specialist to be consulted if required
155
QUIET-AREA EXAMINATION AND TREATMENT (PHASE 4)
If any orange flags are suspected or identified during the initial on‑ or off-pitch
examination, the player should be examined in the medical room using the latest
version of the Sport Concussion Assessment Tool (SCAT5) and should undergo a
detailed neurological examination.
The neurological examination should include an examination of cranial nerves,

vestibular, balance and coordinative functions (spontaneous nystagmus, head impulse
test, vertical eye deviation, dynamic visual acuity, balance (Romberg) and positioning
manoeuvres), the cervical spine (range of motion, stability, proprioception, strength
and muscle tone), the motor function of the upper/lower extremities, and standardised
neurocognitive tests. Based on the outcome of the neurological examination, the
team doctor may decide on further examinations, as recommended by NICE for head
injuries and by the European Federation of Neurological Societies guidelines for mild
traumatic brain injuries, as well as other approved guidelines.
Players who continue playing or who return to the match in which they incurred the
head injury, and who have no further signs or symptoms after phase 2 (or 3) may
participate as usual in the next training session and match.
Players who are removed from a match or training session and have signs or symptoms
of a TBI or another significant head injury at any time should complete the Graduated
Return-to-Football Programme (phase 8) once their symptoms have resolved.
OBSERVATION AND SERIAL RE-EXAMINATION UNTIL DEPARTURE

(PHASE 5)
The team doctor should observe the player until the end of the match for worsening
or additional signs or symptoms, regardless of whether the player has returned to
or been removed from match play. Medications that may mask or worsen symptoms
should be avoided unless a more severe head injury has been ruled out. Any worsening
or newly developed signs or symptoms should result in emergency management in the
case of red flags or further examinations in the case of orange flags.
Prior to leaving the sports facilities, all injured players should be re-examined for new
or worsening signs and symptoms using the latest version of the SCAT. Any worsening
symptoms regarding any form of brain, skull or cervical spine injury should be checked
before travelling without any access to emergency care (e.g. flights) and any concerns
should be allayed using appropriate diagnostic imaging.
An initial CT scan is recommended on the date on which the injury is sustained if any
of the following are present:
• GCS <13 (or <15 after two hours)

• Suspected skull fracture
• More than one episode of vomiting
• Post-injury seizure
• Loss of consciousness
• Persistent anterograde amnesia
• Focal neurological deficit
156 7 Concussion
OBSERVATION FOR 24 HOURS AFTER HEAD INJURY (PHASE 6)
In general, all players who have suffered a head injury should be observed for 24
hours, either by the team doctor or by a responsible adult instructed to immediately
contact the team doctor or the emergency department of the closest hospital in the
event of new or worsening symptoms (red or orange flags). Until re-evaluation (phase
7), physical and cognitive rest is recommended, which includes avoiding the use of
electronic devices.
If a player was allowed to return to play on the day of the injury and is free of
symptoms, and if the neurological examination does not show anything abnormal,
the team doctor may decide that the observation is not necessary. In any case, the
injured player should be informed and instructed to report any new or worsening
symptoms, and the team doctor should contact the player the following morning with
respect to symptom development and further steps. Brain injury advice cards should
be issued if appropriate – an example is shown below.
CONCUSSION INJURY ADVICE
(To be given to the person monitoring the concussed athlete)
This patient has received an injury to the head. A careful medical examination has been carried out and no
sign of any serious complications has been found. The recovery time is variable across individuals and the
patient will need monitoring for a further period by a responsible adult.
The treating doctor will provide guidance as to this time frame.
If you notice, or the patient notices, any change in the patient’s behaviour, vomiting, a worsening
headache, double vision or excessive drowsiness, please telephone the patient’s doctor or the nearest
hospital emergency department immediately.
Other important points for the patient to bear in mind:
Initial rest: limit physical activity to routine daily activities (avoid exercise, training and sport) and limit
activities such as school, work and screen time to a level that does not worsen symptoms.
1. Avoid alcohol
2. Avoid prescription or non-prescription medications without medical supervision. Specifically:
a. Avoid sleeping tablets
b. Do not use aspirin, anti-inflammatory medications or stronger pain medications such as narcotics
3. Do not drive until cleared to do so by a healthcare professional
4. Any return to play/sport requires clearance from a healthcare professional
Clinic phone number: Patient’s name:
Date/time of injury:
Date/time of medical review: Healthcare provider:
157
RE-EVALUATION BETWEEN 18 AND 72 HOURS AFTER HEAD INJURY
(PHASE 7)
Players who have been removed from football, or who continued to play and developed
specific signs or symptoms at any time after the head injury, should be re-evaluated
within 72 hours by a doctor who is experienced in head injury assessment.
The time frame of up to 72 hours has been chosen because symptoms can develop with
latency and a brief initial period of cognitive and physical rest after a brain injury is
currently recommended. The team doctor should assess the injured player daily during
this period if the number or intensity of the signs and symptoms do not improve or if
they worsen.
The cervical spine, the motor function of the upper/lower extremities, balance, vestibular
and ocular motor functions, vision, coordination, emotions and neuropsychological
tests, a detailed medical history (e.g. previous head injuries, pre-existing headache
or sleep problems) – and, if indicated, neurocognitive tests – should be examined in
addition to the cranial nerves. These examinations provide valuable guidance that can
be considered in conjunction with the baseline tests to assist with different head injury
diagnoses.
The aim of the examinations in phase 7 is to decide on the next step:
In the event of no, minimal or improving symptoms and a normal outcome in all
examinations in phase 7, the player can be medically cleared to start the Graduated
Return-to-Football Programme (phase 8).
In the event of persistent orange flags, the player should be referred to a medical
specialist for further examination and treatment.
158 7 Concussion
GRADUATED RETURN-TO-FOOTBALL PROGRAMME (PHASE 8)
The Graduated Return-to-Football Programme (see Table 6 on the next page) is based
on the protocol drawn up by the Concussion in Sport Group and is intended to ensure
a controlled, stepwise return to sports activities for high-level adult football players
after concussion/traumatic brain injuries. For players with structural damage (such as
intracranial haemorrhage or a skull fracture), the return-to-football procedure should
be determined on an individual basis by the doctor in charge.
The player should be re-examined by the doctor in charge before starting symptom-
limited activity (stage 1), ideally within 18-72 hours of the head injury (phase 7), and
before returning to “routine/contact training” (stage 5). The medical re-evaluations
should focus on the following:
1. Abnormal diagnostic findings on the day of the injury
2. Persistent or additional signs or symptoms or changes in their character,

intensity or frequency symptom development under an increasing physical
and cognitive training load
Current guidelines and position statements are consistent in that a player with a
(suspected) concussion should not return to sport on the same day. An initial phase of
cognitive and physical rest (24 to 48 hours) is recommended before a graduated return
to training and match play. After this initial rest period, low-level exercise that does not
heighten the pre-exercise intensity of symptoms or lead to new symptoms has been
identified as beneficial. Allowing a player to participate in low-level exertion without
an exacerbation of symptoms or the risk of contact or a fall may also minimise the
player’s likelihood of emotional dysregulation as a psychological response to the injury.
The period until the player can return to match play varies and might be influenced
by the player’s age or injury history. A multidisciplinary approach is recommended,
especially with respect to the return to routine/contact training.
The Graduated Return-to-Football Programme comprises six stages with a

progressive increase in physical demands (“aerobic” to “anaerobic”, “no resistance”
to “resistance”), football-specific exercises (“simple” to “complex”), and the risk of
contact (“individualised” to “team training”, “non-contact” to “full contact”) and
head impact (“no heading” to “heading”). Each stage should include at least one
training session and last a minimum of 24 hours. In the event of worsening or recurring
symptoms during or after a training session at any stage, the player should rest until
these symptoms have resolved (for a minimum of 24 hours) and then continue the
programme at the previous symptom‑free stage. The player should only be medically
cleared to return to match play when each stage has been completed without
symptoms. A more conservative approach must be followed with younger players and
players with certain risk factors, such as a history of repetitive concussive injuries.
The Accelerated Return-to-Football Programme should only be initiated if: (a) any
acute post-injury symptoms and signs were classified as not specific to concussion;
(b) these unspecific symptoms and signs lasted for under 24 hours; and (c) the results
of the re-evaluation were normal (or similar to the pre-injury baseline, if baseline
tests were performed). A player is not eligible for an accelerated return to football
in the event of persistent orange flags or one or more red flags at any time after
the head injury. The accelerated approach focuses on stages 2 and 5 and requires
close cooperation between the player, the coach, the team doctor (who should be
experienced in concussion management) and the FIFA Medical staff.
159
Medical clearance for a return to football should always be given by the treating doctor
and be based only on medical considerations, regardless of a player’s desire to play,
the dissimulation of symptoms and/or pressure from others including the coaching
staff, parents or the media.
Table 6: Graduated Return-to-Football Programme for high-level players
STAGE FOCUS ACTIVITY

Symptom-limited Daily activities without exaggeration of symptom threshold (worsening of pre-activity symptoms
1
activity or additional symptoms), e.g. 10 minutes of slow walking
Light aerobic a. Cardiovascular exercise on stationary bike; 25-40 minutes including warm-up and cool-
down; controlled activities, low-to-moderate intensity
2 exercises
(unspecific) b. Mobility/stretching, stabilisation and balance (double- and single-stance) exercises
a. Cardiovascular training on the pitch
• Warm-up for 10 minutes at moderate intensity with variable running tasks

• Interval runs at higher intensities with sufficient breaks
• Cool-down for 5-10 minutes at low intensity
b. Technical training with the ball (1:1)
• Basics: balance and passing; short/long passing; easy shooting at targets

Football-specific
3 c. Body training (no resistance/add elastic resistance)
exercises
• Mobility and stretching exercises
• Trunk strength/stabilisation exercises (no resistance; no explosive movements)
• Basic lower-/upper-extremity strength exercises (elastic resistance)
• Balance exercises (double- and single-stance) on unstable surfaces
• No heavy-resistance training, no contact activities
For goalkeepers: controlled diving movements (not explosive) on a foam surface in the gym
(without catching the ball)
a. Cardiovascular training on the pitch

• Warm-up for 10 minutes at moderate intensity with straight running, changes of
direction, lateral shuffles, forward-backward running, zigzag running
• Interval runs at high intensity up to 90% HR max
• Cool-down for 5-10 minutes at low intensity
b. Technical training (with a small group of players)

• Small-sized game
• Short/long passing
• Shooting at goal/targets
• Plant and cut, dribbling with the ball
• Basics: easy heading with only a soft ball (increase in complexity: while balancing), controlled
setting and limited quantity
Non-contact
c. Body training (including elastic resistance)
4.1 football
• Mobility and stretching exercises
training drills
• Trunk strength/stabilisation exercises (including free weights)
• Basic lower-/upper-extremity strength exercises (elastic resistance, free weights)
• Balance exercises (double- and single-stance) on unstable surfaces
d. Strength training
• Keep resistance below about 80% 1RM, no Olympic weightlifting or exercises with the
head below the level of the hips
• Progressively increase external resistance for multi-joint exercises
No contact activities
For goalkeepers: diving drills on a foam surface, some without catching the ball and others with
catches (shots from short/medium range; 1:1 with the goalkeeping coach)
160 7 Concussion
Controlled contact activities: simulate controlled contact situations (e.g. headers, checks, tackles)
• Stepwise increase in intensity
• Move from playing with 1 partner (e.g. rehabilitation coach) to training in small groups
of players
Football training • Increase from a small playing area (1/3, 1/4) to the whole pitch
4.2 drills with • Heading with a regular ball in controlled settings (e.g. after throwing the ball; heading
controlled contact without opposition); gradual increase in the number of headers
For goalkeepers: controlled diving drills on grass, some without catching the ball and others with
catches (shots from short/medium/long range; 1:1 with the goalkeeping coach)
Following medical clearance, which should ideally be issued by a multidisciplinary team, participation
in normal team training
Full-contact
a. Cardiovascular training: continue to progress
5 practice (team
training) b. Body and strength training: resume usual routine training (unrestricted)
c. Assess and ensure psychological readiness
Return to
6 competitive Normal match play
football
Note: only move to the next stage when activities are tolerated without any worsening of pre-activity
symptoms or the emergence of additional symptoms. Abbreviations: HR max = maximum heart rate; 1RM
= one repetition maximum.
SUMMARY
Head injuries can result in different outcomes and signs and symptoms can develop
or change rapidly within the minutes, hours and days after a head injury is sustained.
Concussion can manifest itself 72 hours after the initial injury. Therefore, a systematic
procedure for the examination and management of football players after head injuries
should be implemented to support team doctors in their decision as to whether a
player should be allowed to continue to play or should be removed. Awareness of
the potential severity of head injuries should be raised across sports and medical
professionals.
161
REFERENCES
1. Feddermann-Demont N, Chiampas G, Cowie CM et al. Recommendations
for initial examination, differential diagnosis, and management of
concussion and other head injuries in high-level football. Scandinavian
Journal of Medicine & Science in Sports, 2020, 30(3): 1846-1858.
2. Michaleff ZA, Maher CG, Verhagen AP et al. Accuracy of the Canadian

C‑spine rule and NEXUS to screen for clinically important cervical spine
injury in patients following blunt trauma: a systematic review. Canadian
Medical Association Journal, 2012, 184(16): E867-876.
3. McCrory P, Meeuwisse W, Dvorak J et al. Consensus statement on

concussion in sport - the 5TH international conference on concussion in
sport held in Berlin, October 2016. British Journal of Sports Medicine, 2017,
51: 838-847.
4. Chiang Colvin A, Mullen J, Lovell MR et al. The role of concussion history

and gender in recovery from soccer-related concussion. American Journal of
Sports Medicine, 2009, 37(9): 1699-1704.
5. Prien A, Grafe A, Rössler R et al. Epidemiology of Head Injuries Focusing on

Concussions in Team Contact Sports: A Systematic Review. Sports Medicine,
2018, 48(4): 953-969.
6. Zuckerman SL, Kerr ZY, Yengo-Kahn A et al. Epidemiology of Sports-Related

Concussion in NCAA Athletes from 2009-2010 to 2013-2014: Incidence,
Recurrence, and Mechanisms. American Journal of Sports Medicine, 2015, 43(11):
2654-2662.
7. Junge A & Dvorak J. Injury surveillance in the World Football Tournaments

1998-2012. British Journal of Sports Medicine, 2013, 47(12): 782-788.
8. Maher ME, Hutchison M, Cusimano M et al. Concussions and heading in

soccer: a review of the evidence of incidence, mechanisms, biomarkers
and neurocognitive outcomes. Brain Injury, 2014, 28(3): 271-285.
9. McDonald T, Burghart MA & Nazir N. Underreporting of Concussions

and Concussion- Like Symptoms in Female High School Athletes. Journal of
Trauma Nursing, 2016, 23(5): 241-246.
10. Kroshus E, Garnett B, Hawrilenko M et al. Concussion under-reporting

and pressure from coaches, teammates, fans, and parents. Social Science &
Medicine, 2015, 134: 66-75.
11. Kerr ZY, Register-Mihalik JK, Kay MC, et al. Concussion Nondisclosure
During Professional Career Among a Cohort of Former National Football
League Athletes. American Journal of Sports Medicine, 2018, 46(1): 22-29.
12. Schepart Z & Putukian M. Sideline assessment of concussion.

Handbook of Clinical Neurology, 2018, 158: 75-80.
13. Harmon KG, Clugston JR, Dec K et al. American Medical Society for Sports
Medicine position statement on concussion in sport. British Journal of Sports
Medicine, 2019, 53(4): 213-225.
14. Levin HS & Diaz-Arrastia RR. Diagnosis, prognosis, and clinical

management of mild traumatic brain injury. The Lancet Neurology, 2015,
14(5): 506-517.
162 7 Concussion
15. Leddy JJ, Baker JG, Merchant A et al. Brain or strain? Symptoms alone do
not distinguish physiologic concussion from cervical/vestibular injury.
16. Arshad Q, Roberts RE, Ahmad H et al. Patients with chronic

dizziness following traumatic head injury typically have multiple
diagnoses involving combined peripheral and central vestibular
dysfunction. Clinical Neurology and Neurosurgery, 2017, 155: 17-19.
17. Elzière M, Devèze A, Bartoli C et al. Post-traumatic balance disorder.

European Annals of Otorhinolaryngology, Head and Neck Diseases, 2017,
134(3): 171-175.
18. Vos PE, Alekseenko Y, Battistin L et al. Mild traumatic brain injury.
European Journal of Neurology, 2012, 19(2): 191-198.
19. National Institute for Health and Care Excellence. Head injury: assessment
and early management. 2014. Available at: https://www.nice.org.uk/
guidance/cg176
20. Makdissi M, Davis G & McCrory P. Updated guidelines for the

management of sports-related concussion in general practice. Australian
Family Physician, 2014, 43(3): 94-99.
21. American Academy of Neurology Quality Standards Subcommittee,

Minneapolis, MN US. Summary of Evidence-based Guideline Update:
Evaluation and Management of Concussion in Sports. 2013. Available at:
www.aan.com/Guidelines/home/GuidelineDetail/582
22. National Football League. Head, Neck and Spine Committee’s Concussion
Diagnosis and Management Protocol. 2017. Available at: https://www.
nfl.com/playerhealthandsafety/ resources/fact-sheets/nfl-head-neck-and-
spine-committee-s-concussion-diagnosis-
23. World Rugby. Concussion Management.

Available at: https://playerwelfare.worldrugby.org/concussion
24. Davis GA, Makdissi M, Bloomfield P et al. International consensus

definitions of video signs of concussion in professional sports. British
Journal of Sports Medicine, 2019, 53(20): 1264-1267.
25. National Institute for Health and Care Excellence. Pre-hospital management
for patients with head injury. 2014. https://pathways.nice.org.uk/pathways/
head- injury#path=view%3A/pathways/head-injury/pre-hospital-
management-for-patients- with-head-injury.xml&content=view-
node%3Anodes-first-priority-treat-the- greatest-threat-to-life-
and-avoid-further-harm
26. SCAT5. British Journal of Sports Medicine, 2017. Available at: https://bjsm.bmj.
com/content/bjsports/early/2017/04/26/ bjsports-2017-097506SCAT5.full.pdf
27. Petersen JA, Straumann D & Weber KP. Clinical diagnosis of bilateral
vestibular loss: three simple bedside tests. Therapeutic Advances in
Neurological Disorders, 2013, 6(1): 41-45.
28. Mucha A, Collins MW, Elbin RJ et al. A Brief Vestibular/Ocular Motor

Screening (VOMS) Assessment to Evaluate Concussions: Preliminary
Findings. American Journal of Sports Medicine, 2014, 42(10): 2479-2486.
163
29. Echemendia RJ, Meeuwisse W, McCrory P et al. The Sport Concussion
Assessment Tool 5TH Edition (SCAT5): Background and rationale. British Journal
of Sports Medicine, 2017, 51(11): 848-850.
30. Feddermann-Demont N, Echemendia RJ, Schneider KJ et al. What domains

of clinical function should be assessed after sport-related concussion? A
systematic review. Ibid., 2017, 51(11): 903-918.
31. Patricios JS, Ardern CL, Hislop MD et al. Implementation of the 2017 Berlin
Concussion in Sport Group Consensus Statement in contact and collision
sports: a joint position statement from 11 national and international
sports organisations. Ibid., 2018, 52: 635-641.
164 7 Concussion
THE FEMALE
ATHLETE
8
THE FEMALE ATHLETE
INTRODUCTION
With over 40 million female football players globally, acute gynaecological medical
emergencies will occur regularly during play or training sessions. Many of these
emergencies will present with either pain and/or bleeding and may require referral to
the nearest, most appropriate hospital for further evaluation and management.
One of the challenges for male doctors when managing potential gynaecological
presentations is the ability to appropriately and adequately examine female players
with a chaperone in a safe and secure environment. This may simply be impossible
to achieve, especially within the team dressing‑room environment. In most cases,
the history itself is key and examination can be limited to abdominal assessment and
observation trends provided the history is not concerning for more serious pathology.
LOWER ABDOMINAL PAIN

There are multiple causes of acute lower abdominal pain in the female footballer and
the clinician should always be familiar with the management of the more common
conditions that may present to them. It should be remembered that not all pain will
be gynaecological in nature and surgical presentations such as acute appendicitis may
also need to also be considered.
Past medical history may be useful and the use of pain scores is very helpful in trying
to determine the significance of the presentation compared with the player’s previous
history and experiences as well as the trend of this particular presentation and its
response to treatment.
Common gynaecological presentations include:
• Dysmenorrhoea
• Ectopic pregnancy
• Torsion of an ovarian cyst
• Rupture of an ovarian cyst
• Acute pelvic inflammatory disease
• Ovarian haemorrhage
• Torsion of uterine leiomyoma
Although all of the above medical conditions are due to different pathological
processes, they all present primarily with acute lower abdominal pain associated
with nausea, vomiting, vasovagal-induced fainting, and possible signs of peritoneal
irritation. In some cases, they may also present as hypovolaemic hypotensive shock.
Postural symptoms in association with abdominal pain indicate significant pathology

and will always merit referral to hospital.
Shoulder tip pain strongly indicates peritoneal irritation from internal bleeding and
should always be taken seriously.
166 8 The female athlete

VAGINAL BLEEDING
Genital bleeding may be functional (due to menstruation) or pathological, as may
occur with a ruptured ectopic pregnancy or the various types of abortion (miscarriage).
Functional bleeding may present with or without associated lower abdominal pain.
It is always important to clarify the origin of the bleeding and ensure it is vaginal and
not urethral or rectal in origin.
It should also be remembered that a ruptured ectopic pregnancy may not present
with bleeding and the absence of bleeding does not exclude an ectopic pregnancy.
Treatment
1. Ensure that the player’s airway is open, maintained and protected as described
in chapter 2.
2. Ensure that the player is breathing adequately and, if necessary and available,
administer supplemental oxygen via a face mask, keeping the blood oxygen
saturation level above 90%.
3. Obtain the pulse and blood pressure. If the player is hypotensive, consider
elevating their legs, obtain intravenous access and administer a bolus of
250ml-500ml normal saline, or equivalent crystalloid, in order to elevate the
blood pressure to at least 90mmHg.
4. Administer appropriate analgesia only via a diluted, slowly titrated,

intravenous infusion.
5. If the player cannot be adequately and speedily managed within the football
stadium medical centre environment, refer the player to the nearest, most
appropriate hospital for further evaluation and management.
Any player with symptomatic vaginal bleeding, particularly if in hypovolaemic

hypotensive shock, should be urgently referred to the nearest, most appropriate
hospital for further evaluation and management.
SPORT-INDUCED GENITAL TRAUMA

Although sport-induced (accidental) genital trauma can be caused by various straddling
activities, in football it may be caused by sudden abduction of the legs that result in
a “splits-type” genital injury, especially in pre-pubertal girls, or by being kicked or
kneed in the groin.
Signs and symptoms include pain and bleeding in the genital area. Bleeding may be
mild to severe depending on the site, extent and nature of the injury and the amount
of traumatised tissue. A large haematoma may occur in the injured tissue, particularly
around the vagina, because the external genitalia have a rich blood supply located in
loose connective tissue.
167
Treatment
The treatment of sport-related genital trauma may either be managed within the
football stadium environment if it is a minor injury or the player may need to be
urgently referred to the nearest, most appropriate hospital for further gynaecological
evaluation and management if the injury and/or bleeding is severe.
Treatment of this type of injury may include:
• Ice pack application

• Vaginal gauze tamponade insertion
• Suturing of lacerations in the hospital environment
• Direct, digital gauze tamponade of the bleeding site using the player to
apply the pressure wherever possible
If the bleeding is severe, resuscitation (as described above) for vaginal bleeding should
take place and the player should be referred to hospital immediately.
REFERENCES
1. Marion LL & Meeks GR. Ectopic pregnancy: History, incidence, epidemiology,
and risk factors. Clinical Obstetrics and Gynecology, 2012, Jun;55(2):376-386.
2. Findlay RJ, Macrae EHR, Whyte IY, Easton C & Forrest Née Whyte LJ. How the
menstrual cycle and menstruation affect sporting performance: experiences
and perceptions of elite female rugby players. British Journal of Sports Medicine,
2020, Sep;54(18):1108-1113.
168 8 The female athlete

ENVIRONMENTAL
EMERGENCIES
9
ENVIRONMENTAL EMERGENCIES
ALTITUDE ILLNESS
Introduction
Football is the most popular sport played globally. It is therefore played in most
geographic locations not covered by water, ice or snow, including at different altitudes
and under varying climatic conditions which include heat, cold, humidity and wind
. As a result, to respect the basic principles of fair play for both home and visiting
teams wherever football competitions are played internationally, the FIFA Medical
Committee held a meeting of 12 international scientists and clinical experts in altitude
medicine to develop a consensus statement on playing football at different altitudes.
Although this consensus statement is meant primarily to guarantee fair play and
secondarily to prevent any altitude-related illness or associated injury, altitude-related
morbidity and/or mortality are still risk factors for visiting teams playing football at
altitude. This chapter is concerned exclusively with the medical illnesses that may
arise in those visiting high altitudes to compete in football due to a combination of
the location’s altitude, the rate of ascent to that altitude, factors of acclimatisation,
exercise at altitude, comorbid diseases, medications, weather factors and individual
variability, all of which can trigger an acute medical event singularly or in combination.
Definition
For the purpose of this chapter, the following altitude definitions will apply. All clinical
signs and symptoms related to different levels are based on average group effects
and may not serve as predictions for particular individuals due to individual variability.
0 to 500m near sea level
501m to 2,000m low altitude
2,001m to 3,000m moderate altitude
3,001m to 5,500m high altitude
Above 5,500m extreme altitude
170 9 Environmental emergencies

Preparation for altitude
Research on preparation prior to ascent to altitude for competitive football focuses on

performance issues, to respect the principle of fair play and to ensure that competing
teams can perform. Although these preparations are not being undertaken to prevent
clinical illness at altitude, they will, in and of themselves, help to prevent acute illness
caused by altitude.
However, even where a team (including team officials, coaches and other non-playing
staff) actively takes all of these preventive preparatory steps, high-altitude headache,
acute mountain sickness (AMS) and, rarely, high-altitude cerebral oedema (HACE) or
high-altitude pulmonary oedema (HAPE) may nevertheless occur.
Medical plans must therefore be in place to prevent altitude illness or injury, to

diagnose any occurrence in its early phase, to treat any such illness or injury accordingly
and, if necessary, to ensure that it is possible to descend rapidly if the clinical condition
warrants such measures.
No football team should ever ascend to altitude without having put these preparatory
measures in place.
In healthy players who live and routinely play near sea level or at low altitude and who
ascend to moderate or high altitude to play, there is an individual risk of AMS. The
accepted threshold altitude level for AMS is 2,000m and above.
171
At moderate altitude levels, the risk of AMS in healthy players who usually live and
play near sea level is low and, if it does occur, the illness is usually mild. However,
in team members who have comorbid disease, are obese or are taking prescription
medication, AMS may be more severe and HACE or HAPE, although unlikely, remain
possible.
At high altitude, specifically at or above 4,000m, the risk of AMS in healthy players
who usually live and play near sea level is considerable; AMS is more severe and, if not
diagnosed early and treated appropriately, can progress to life-threatening HACE and
HAPE.
Generally, both HACE and HAPE can be managed and effectively treated once
diagnosed, as long as the necessary measures for treatment are in place. This involves
planning.
A staged ascent (from near sea level or low-altitude level ascending to high altitude
where the competition will be played) should therefore be undertaken by the team to
prevent the onset of AMS in team members.
In those non-playing individuals of the team known to be susceptible to AMS,

prophylactic acetazolamide 125mg twice daily orally or dexamethasone 2mg six-
hourly or 4mg 12-hourly orally can be taken. However, players may not take these
medications since they are on the WADA list of prohibited substances.
When staging an ascent to altitude, allow for one day of acclimatisation for every
300m to 500m above 2,000m.
As mentioned earlier, the development of AMS in any team member depends mainly on
individual factors, together with general external factors which include the degree of
acclimatisation, the rate of ascent to altitude and the intensity of exercise undertaken.
High-altitude headache
High-altitude headache (HAH) is the first unpleasant symptom to occur as a result of

ascending to altitude. It may be the only presenting symptom, but if it occurs together
with any one of the other symptoms described below, it has progressed to acute
mountain sickness. HAH occurs within a few hours of ascent to altitude, is worse after
a night’s sleep, is more common in men, is of moderate intensity and responds well to
mild analgesics such as paracetamol. The literature suggests that HAH can be prevented
and, if necessary, effectively managed with mild NSAIDs and acetaminophen, with
ibuprofen and aspirin appearing to be the most effective medications.
Acute mountain sickness
The basic cause of acute mountain sickness (AMS) is hypoxaemia. The diagnosis of AMS
depends on the factors related to the ascent, the symptoms, the results of medical
examinations and the exclusion of other disease entities, which, in football and in this
environment, may include concussion, hypothermia, hypoglycaemia or an underlying
infection. A throbbing headache that is usually bitemporal and worse at night or after
sleeping, very much like a “hangover”, together with any one of the other symptoms
mentioned on the next page, confirms the diagnosis of AMS.

A player with AMS exhibits no neurological findings. This is in contrast to HACE, which
usually comes on between 24 and 72 hours after a gain in altitude and is characterised
by ataxia and/or a change in mental status.
HACE usually occurs in a person with AMS or HAPE and is a medical emergency.
Symptoms of AMS
Headache plus one of the following:
• Gastrointestinal symptoms: anorexia/nausea/vomiting

• Fatigue/weakness
• Dizziness/lightheadedness
The authors of the 2018 Lake Louise Revised Criteria removed sleep disturbance, which
had featured in previous criteria.
Treatment of AMS
The earlier that AMS is diagnosed and treated, the easier it is to treat and the more
successful the outcome. Symptomatic headache treatment involves the administration
of mild analgesics, namely:
• Aspirin 500mg
• Acetaminophen 500mg to 1,000mg
• Ibuprofen 400mg to 800mg
Ondansetron 4mg via orally disintegrating tablets every four hours will resolve nausea
and vomiting.
Anyone experiencing AMS should avoid alcohol and medication that has a respiratory
depressant effect in order to prevent any exacerbation of the existing hypoxaemia.
High-altitude cerebral oedema
The same process that causes HAH and AMS can progress to cause high-altitude
cerebral oedema (HACE), which is a life-threatening condition that requires early
recognition and immediate medical management. Mild AMS may progress to HACE
unconsciousness within 12 hours, but will typically progress over three days.
Symptoms and signs of HACE
• Headache
• Nausea and vomiting
• Ataxic gait
• Severe lassitude
• Confusion
• Drowsiness
• Decreased level of consciousness: stupor, coma
• Retinal haemorrhages
173
HACE is mainly a clinical diagnosis and time must never be wasted on unnecessary
investigations such as lumbar puncture or radiological investigations, namely
computerised tomographic (CT) scanning or magnetic resonance imaging (MRI) unless
other diagnoses are expected and need to be excluded.
Treatment of HACE
If instituted immediately, the treatment of this life-threatening condition is usually

successful and leads to complete resolution of the condition. For this to occur, it
is mandatory that all of the necessary treatment modalities are pre-arranged,
immediately available and fully functional, if and when necessary.
As with all life-threatening medical emergencies, resuscitation and stabilisation begin

with ensuring that the Airway, Breathing and Circulation are assessed and treated
where needed.
Airway: the airway should be assessed and managed as described in chapter 2,

especially if there is evidence of loss of consciousness.
Breathing: supplemental oxygenation may be all that is required to ensure adequate

blood saturation levels, unless severe HAPE is also present. If this is present, positive
pressure ventilation in order to provide adequate oxygenation may be required.
Circulation: as many of these patients may be hypovolaemic from altitude-induced

diuresis, which can be further compromised by the use of loop diuretics in the treatment
of HACE, it is important to monitor and, when necessary, replace intravascular volume
so that adequate peripheral and cerebral perfusion pressures are maintained.
D.R.O.P.: the D.R.O.P. method of treating HACE consists of:
Descend to an altitude at which the effects of hypoxaemia can be reversed.
This descent from the location at which symptoms first occurred may either be
undertaken by road ambulance or air transfer. Whichever transportation method is
used, it is imperative for full ALS medical care to be in place and arranged in advance
of the team’s arrival. If it is not possible to descend with the patient immediately, other
forms of management may assist temporarily until the descent can be undertaken
safely.
Rest. The patient with HACE should be withdrawn from all forms of exercise or
activities in order to conserve energy and oxygen utilisation. In addition, adequate
hydration and caloric nutrition should be ensured. This may include determining blood
glucose levels and administering hypoglycaemia treatment if required.
Oxygenation is the mainstay of treatment for HACE and is the first form of management
applied when symptoms occur. It may be administered via nasal cannulae or a face
mask at 2-4 litres/minute or at whatever level of oxygen administration is required
to raise the blood oxygen saturation above 90%, measured by means of peripheral
oximetry.

Pharmacological measures include the administration of dexamethasone 4mg-8mg
intravenously, intramuscularly or orally initially, followed up with a 4mg dose every six
hours. Additionally, loop diuretics such as furosemide 40mg-80mg or bumetanide 1mg-
2mg, via whichever appropriate route of administration is available, may successfully
reduce brain oedema. However, adequate intravascular volume must be maintained
in order to ensure adequate peripheral and cerebral perfusion pressures.
High-altitude pulmonary oedema
As the most common cause of mortality from altitude-related acute illness, high-
altitude pulmonary oedema (HAPE) can be fully and easily treated if it is diagnosed
early and appropriately and effectively treated. HAPE is a form of non-cardiogenic
hypoxaemic-induced pulmonary oedema, usually developing after a rapid ascent to
altitude without prior acclimatisation.
Symptoms and signs of HAPE
• Symptoms of AMS
• Persistent dry cough
• Decreased exercise performance
• Increased recovery times
• Fatigue
• Dyspnoea on exertion
• Cyanosis around lips and in nail beds
• Tachycardia and tachypnoea
• Pink frothy sputum
• Signs of HACE may predominate
• Unilateral or bilateral crepitations
• Abnormal pulse oximetry and chest radiography
Treatment of HAPE
Patients with HAPE are usually fully conscious, unless they have concomitant HACE,
and can therefore often be adequately treated with supplemental oxygenation and
descent from altitude.
The ABC of managing a HAPE patient is the same as described above for the treatment
of a HACE patient. The D.R.O.P. method for managing HAPE is also similar, with a
pharmacological adaptation as follows.
Pharmacological measures in HAPE are of limited value, with oxygen and descent
from altitude being the mainstays of treatment. Medications are only really indicated
when oxygenation or descent from height is not possible. This should never occur
when a football team is travelling to altitude. Oxygen should always be available in
the locations where the team is staying, training and competing.
However, emergency medications include:
• Furosemide 80mg every 12 hours

• Morphine 15mg titrated via intravenous infusion
• Nifedipine 30mg via slow release every 12 hours
175
REFERENCES
1. Roach RC, Hackett PH, Oelz O et al. The 2018 Lake Louise Acute Mountain
Sickness Score. High Altitude Medicine & Biology, 2018, 19(1):4-6.2. Gore
CJ, McSharry PE, Hewitt AJ et al. Preparation for football competition at
moderate to high altitude. Scandinavian Journal of Medicine and Science in
Sports, 2008, 18 (Suppl I): 85-95.
2. Bärtsch P & Saltin B. General introduction to altitude adaption and mountain

sickness. Ibid., 2008, 18 (Suppl I): 1-10.
3. Levine BD, Stray-Gundersen J & Mehta RD. Effect of altitude on football
performance. Ibid., 2008; 18 (Suppl I): 76-84.
3. DeFranco MJ, Baker CL, DaSilva JJ et al. Environmental Issues for Team
Physicians. American Journal of Sports Medicine, 2008, 36(11): 2226-2237.
5. Bergeson MF, Bahr R, Bärtsch P et al. International Olympic Committee
consensus statement on thermoregulatory and altitude challenges for high-
level athletes. British Journal of Sports Medicine, 2012, 46: 770-79.
4. Chalkias A, Georgiou M, Böttiger B et al. Recommendations for resuscitation

after ascent to high altitude and in aircrafts. International Journal of Cardiology,
2013, 167: 1703-1711.
5. Hackett PH & Roach RC High-Altitude Medicine and Physiology. In: Auerbach

PC, editor: Wilderness Medicine, Elsevier. Philadelphia, 2012. Chapter 1.
6. Bärtsch P, Saltin B & Dvořák J. Consensus statement of playing football at

different altitude. Scandinavian Journal of Medicine and Science in Sports, 2008,
18 (Suppl I): 96-99.

COLD EMERGENCIES
Cold weather is generally no barrier to outdoor football, as long as the environmental
risks are evaluated, the necessary precautions taken and cold-related injuries constantly
anticipated, identified and managed in time.
Prevention
The factors that are responsible for producing cold injuries in football are primarily
low environmental temperatures, wind, low solar radiation and rain. Each of these
factors can dramatically increase heat loss from the human body, more so if they are
combined. If other personal factors are taken into consideration, namely body habitus,
clothing, health status, comorbid diseases, age, sex, and exercise intensity, cold injury
in a particular player or players may be a high risk. In general, it is far better to prevent
cold injury than to have to treat it.
General principles to avoid cold injury: the S.H.E.L.T.E.R. mnemonic
• Shelter team members from the cold, wind or wet weather as much as
practically possible within the logistics of the surrounding environment.
Plan ahead rather than having to be reactive.
• Hydrate players well when playing in cold weather. Intrinsic metabolic heat
production (thermogenesis) and increased exercise activity all require water,
as well as the need to counter the cold-induced diuresis that occurs from
peripheral vasoconstriction and central redistribution of the blood volume.
• Eliminate alcohol, nicotine and caffeine, if possible, as these may have
detrimental effects on cold‑induced vasoconstriction which forms part of the
body’s protective mechanism to counter heat loss. Alcohol may decrease the
blood glucose level and thereby decrease the shivering thermogenic response.
• Layered clothing will adequately insulate the player by principally promoting
sweat transfer from the skin to the outer layers. The middle inner layers
trap heat and the outer layers are composed of water- and wind-resistant
material. Exchange wet clothing, including socks, gloves and head coverings
for warm, dry alternatives when it is logistically and/or clinically necessary.
• Thermogenesis should be promoted in order to balance body heat production
against heat loss. This is promoted by frequent and intense exercises of the
major muscle groups, adequate intake of carbohydrates, adequate hydration
and elimination of various substances and supplements. On the field of play,
this applies particularly to goalkeepers, who are not as active as the rest of
the team, and to those sitting on the bench at the touchline.
• Examine Exposed player and other members of the team, namely those who
are on the field of play or located on the team bench, for any symptoms and/
or signs of cold injury, e.g. hypothermia, frostbite, chilblains, cold-induced
urticaria, cold-induced bronchospasm, etc.
• Recognise those individuals who are, or may be, at risk of cold injury,
namely those with premorbid diseases, e.g. asthma, exercise-induced
bronchospasm, cold-induced urticaria and previous cold injury incidents,
and ensure that they have been managed adequately and appropriately to
prevent and, if necessary, treat the relevant potential cold injury.
177
Cold-induced injuries that are frequently mentioned in published literature are
described in more detail below. However, there are no validated statistics on the actual
global frequency of any particular cold injury in football. This section is therefore a
review of which cold injuries could happen and how to recognise and treat them.
Hypothermia
Hypothermia is defined as a decrease in core body temperature by more than 2°C from
its present normal level (although, pragmatically, it is currently defined as a core body
temperature of 35°C or lower).
It is conventionally divided into three stages of severity:
• Mild (32°C to 35°C)

• Moderate (28°C to 32°C)
• Severe (below 28°C)
Primary hypothermia occurs as a result of exposure to the cold (whereas secondary

hypothermia occurs as a consequence of an illness and is more commonly seen in
the elderly).
Mild hypothermia (32°C to 35°C) is not always easy to identify, but is characterised
by intense shivering, initially of the muscles of the trunk and then the periphery. This
sign is the most consistent and easy to observe on the field of play or from the bench.
Other signs, particularly those present when the core body temperature is 32°C to 33°C,
include irritability, apathy, ataxia, dysarthria and confusion. These signs are similar
to, and may be confused with, acute concussion. Because peripheral vasoconstriction
shunts blood away from the periphery to the body core, the skin appears pale and
cool and the increased volume in the core causes a cold-induced diuresis, both of
which should be looked for when attempting to diagnose hypothermia.
Moderate hypothermia (32°C to 28°C) is more easily diagnosed because of the obvious
neurological abnormalities evident in the patient. Signs include very cold skin upon
palpation, slurred speech, gross motor incoordination, loss of consciousness, muscle
rigidity and dilated pupils.
Bradycardia hypotension develops and there is a high risk of cardiac arrhythmia.

Shivering ceases at this level of severity and is one of the distinguishing features
between mild and moderate hypothermia.
No member of any football team on the field of play or touchline should ever reach
this level of hypothermia.
Severe hypothermia (below 28°C) is rare in football, if ever. These patients appear
clinically dead with no reflexes, a lack of corneal reflexes, and profound bradycardia
or asystole and can only be effectively diagnosed and managed in a fully equipped
emergency department.

Treatment
The treatment of hypothermia depends on its severity. The principles of hypothermia

treatment include the following:
The international standard for temperature determination in all environmental

medical emergencies, both heat and cold, is a rectal temperature reading. Although
this is the medical standard, its applicability in football, even in an enclosed players’
medical centre, may not always be practically or logistically practical.
The European Resus Council Guidance 2021 states that if a player is spontaneously
breathing and a low reading tympanic thermometer is available, this may suffice. It
is important to note that many thermometers may not be designed or calibrated to
read temperatures below 34°C, which makes their use in hypothermia management
of no value.
If either the oral or axillary temperature is above 35°C, the person is unlikely to be
suffering from hypothermia because these devices “under read” the core temperature.
Remove the player from the wet, windy, cold environment and take them to a warm,
sheltered, indoor area, preferably the players’ medical centre. This allows the player to
be fully assessed and, if necessary, treated.
Remove all wet clothing and equipment and replace it with dry, preferably warmed,
clothing.
In any player who is conscious and shivering, mild hypothermia is present and can be
managed by wrapping the player in blankets, giving them non-alcoholic hot food and
drinks containing around 7% carbohydrates, which helps to maintain the shivering
response, and undertaking other thermogenic activities and/or being exposed to
warm radiant or convective heat, e.g. increase the heat from an air conditioner or sit
near, but not next to, a radiant heater.
Players with signs of prehospital cardiac instability (i.e. systolic BP <90 mmHg,
ventricular arrhythmia, core temperature <30°C) should be rewarmed using minimally
invasive techniques. Where possible, they should be directly transferred to a hospital
with stand-by extracorporeal life support (ECLS). ECLS should only be established if
patients arrest or deteriorate (e.g. decreasing blood pressure, increasing acidosis).
Any player who is not fully conscious, is not shivering and has a core temperature
below 32°C is to be regarded as having life-threatening hypothermia. These patients
require full advanced life support and intensive medical care management in hospital
as they are unable to produce adequate heat internally to overcome the hypothermia.
Therefore, internal active warming is required and can only be undertaken safely
and effectively in hospital. Additionally, transportation of these patients has to be
undertaken with extreme care because any movement can precipitate ventricular
fibrillation, meaning that such transportation should be undertaken by experienced,
knowledgeable emergency medical service personnel, if available. Similarly, all invasive
procedures, including intravenous access, airway management and transfer must all
be done with increased care, efficiency and vigilance. A fully functional and prepared
AED must always be present before these medical procedures are undertaken.
179
Hypothermic cardiac arrest
A number of differences apply in the hypothermic patient suffering cardiac arrest.

Given that a severely hypothermic patient may appear dead, a full minute should be
allowed to check for signs of life.
Hypothermia diminishes the oxygen demand of the body (6-7% per 1°C of cooling)
and thereby protects the most oxygen-dependent organs of the body, brain and heart
against hypoxic damage.
This translates into a higher survival rate compared to other types of cardiac arrest and
also has better neurological outcomes.
Chest compressions and ventilations should be performed as per the usual life-support
guidance.
It is recommended to withhold adrenaline and delay defibrillation until the patient

has been warmed to a core temperature of 30°C. Once 30°C has been reached, the
intervals between drug doses should be doubled when compared to normothermia
(i.e. adrenaline every six to ten minutes) with a return to normal protocols once a core
temperature of 35°C has been reached.
Use of a mechanical chest-compression device is recommended.
Transfer to a facility that can perform ECLS should therefore be considered at an early
stage.
Frostbite
Frostbite is a clinical condition caused by the freezing of the tissue of exposed parts
of the body, particularly the ears, nose, uncovered wrists and also the hands and feet,
when the environmental temperature is below 0°C.
Due to protective peripheral vasoconstriction, warm blood is diverted away from the
extremities and peripheral areas of the body, leaving these specific areas devoid of
adequate blood flow. As the temperature of the tissue falls, destructive changes occur
to the cells of the tissues, from superficial to deep, depending on the severity of the
temperature drop. In mild frostbite, also known as frostnip, only the superficial skin
is frozen with little, if any, permanent damage. If the temperature decrease is more
substantial, deeper layers are affected and this may progress to damage to the muscle,
tendons and bone.
Prevention
The prevention of frostbite involves insulation of the areas of the body that are
normally exposed to a cold environment, namely the ears, nose, hands and wrists. This
is particularly important to those players who have had any previous cold-related injury
and who are more susceptible to repeated injury with further morbidity or who are at
risk of such injuries due to comorbid disease or syndromes, e.g. Raynaud’s disease.

Diagnosis
As the skin temperature decreases to below 10°C, symptoms begin. Superficial frostbite
may begin with skin numbness, transient tingling, burning or pain, localised swelling
and colour progression from an initial red-looking skin, to waxy white to areas of white
or blue-grey patches. When the fingers are involved, there may be loss of dexterity
and fine coordinated movement. Deeper damage involving adjacent structures may
present with a hard, waxy skin that may be white, grey, black or purple, have vesicles
or haemorrhagic blisters, which may be painful or burning. As deeper tissues undergo
necrosis, muscle, nerve and joint damage will occur. In football, particularly if played
icold environments without adequate insulation, superficial frostbite is possible, but
deeper frostbite should not occur unless there is insufficient preplanning, the denial
of signs or symptoms or related logistical inadequacies.
Frostbite occurring in exposed areas from decreased skin temperatures occurs

in association with a general decreased core temperature, which could lead to
hypothermia. Therefore, whenever frostbite is considered, the core temperature must
be measured to ascertain if concomitant hypothermia is present or not.
Treatment
The aim of treating frostbite is to warm the affected area so as to reverse the
pathophysiological process. If a decision to warm the affected area is undertaken,
this should only be attempted if it can be assured that refreezing will not reoccur.
Refreezing of a frostbitten area after initial warming may cause greater morbidity
than if the frostbitten area is allowed to remain in its frozen state until adequate
warming can be assured.
Warming can be undertaken by removing the patient from the cold, wet, windy
environment and allowing the patient to warm up at room temperature. Alternatively,
hands or feet may be warmed slowly in a bath at water temperatures of 40°C. The
temperature of any water bath must be monitored so that it is neither too hot (above
40°C) nor too cold (below 35°C), thus avoiding further necrosis.
Thawing should be undertaken slowly: 15 to 30 minutes is acceptable. Resolution is

complete when the skin colour, sensation and pliability have returned to normal or
near normal.
Thawing of a frostbitten area with return of circulation may elicit burning or moderate
to severe pain. Analgesia may be required as part of the treatment process and must
not be ignored.
Ibuprofen and other non-steroidal anti-inflammatory medications may be considered

for analgesia and to limit the inflammatory response to the tissue injury.
Avoid the application of any friction massage to the area, or the application of any
creams or ointments and leave all vesicles and blisters intact. Clear blisters may be
debrided if necessary, but haemorrhagic blisters should be left intact as they are a sign
of deep tissue injury and should only be debrided in hospital if they restrict movement.
Do not apply any steam or radiant dry heat to the affected area.
181
If rewarming is not undertaken for various logistical and practical reasons, protect the
frostbitten area from any external damage, but do not wrap the area with any form
of padding as this will cause it to thaw.
Any debrided area should be managed with appropriate infection-control methods.
Chilblains
A chilblain is a superficial cold injury that occurs mainly in the digits after an exposure
of approximately one hour to the cold (below 16°C) and wet conditions, as may occur
by wearing wet socks and boots in the rain. As with frostbite, other exposed areas
of the body can also be affected by chilblains. It develops as a cold injury-induced
inflammatory response from local hypoxaemia and microcirculatory vessel wall
inflammation.
Prevention
Replacing wet clothing (particularly socks) with dry clothing whenever possible will
prevent this type of injury.
Diagnosis
This superficial, non-freezing injury appears as red or cyanotic, swollen, itchy, painful
papules, nodules, vesicles, bullae or ulcerations on the affected exposed skin.
Treatment
Remove the player from the wet, cold environment. Replayer any wet clothing with
equivalent dry clothing.
The area may be gently washed with warm water to reverse the process, carefully
dried and either left exposed to the warm environment or carefully padded for
comfort. Elevation may prevent swelling. As with frostbite, avoid the application of
any friction massage or any creams or ointments to the area and leave all vesicles
and blisters intact. If necessary, these can be debrided under optimal conditions in
hospital. Do not apply any steam or radiant dry heat to the affected area. Do not put
any weight on the affected area until it is healed. If weight-bearing is necessary, pad
the area accordingly.
Cold-induced urticaria/anaphylaxis
Cold-induced urticaria is a reaction induced by exposure to a cold environment. It

may begin at any age and affects both sexes, but it is most prevalent in young adults
between 18 and 25 years of age.
Mast cell degranulation and the activation of inflammatory mediators can result in
the development of urticarial wheals, angioedema or, in rare cases, acute anaphylaxis.
Some players may also experience respiratory, cardiovascular or gastrointestinal
symptoms which may signal anaphylaxis. Urticarial wheals usually occur during warm-
up exercises after exposure to the cold.

Prevention
Avoidance of the cold is the only known prevention for this condition.
Treatment
Urticarial wheals/hives may be treated with oral antihistamines, which, if severe,

may require oral corticosteroids as an emergency measure. If signs of angioedema or
anaphylaxis develop, intramuscular epinephrine/adrenaline, e.g. an EpiPen, may be
required. See the section on anaphylaxis for more details.
Cold-related exercise-induced bronchoconstriction
Exposure to cold is known as a trigger for bronchospasm and exercise undertaken in a

cold environment is likewise a known trigger for exercise-induced bronchoconstriction
(EIB). See the section on asthma for more details.
183
REFERENCES
1. Lott C et al. European Resuscitation Council Guidelines 2021: Cardiac arrest
in special circumstances, Resuscitation, 2021. Available at: https://doi.
2. Strapazzon G, Procter E, Putzer G et al. Influence of low ambient

temperature on epitympanic temperature measurement: a prospective
randomized clinical study. Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine, 2015, 23: 90.
3. Cappaert TA, Stone JA, Castellani, JW et al. National Athletic Trainers’

Association Position Statement: Environmental Cold Injuries. Journal of
Athletic Training, 2008, 43(6): 640-658.
4. Saczkowski RS, Brown DJA, Abu-Laban RB et al. Prediction and risk

stratification of survival in accidental hypothermia requiring extracorporeal
life support: an individual patient data meta-analysis. Resuscitation, 2018,
127: 51-57.
5. MacMahon JA & Howe A. Cold Weather Issues in Sideline and Event

Management. Current Sports Medicine Reports, 2013, 11(3): 135-141.
6. Castenalli JW, Young AJ, Ducharme MB et al. Prevention of Cold Injuries

during Exercise. Medicine & Science in Sports & Exercise, 2006, 38(11): 2012-
2029.
7. Sallis R & Chassy CM Recognising and treating common cold-induced injury

in outdoor sports. Ibid., 1999, 31(10): 1367-1373.
8. Shephard RJ Biology and medicine of soccer: An update. Journal of Sports

Science, 1999, 17(10): 757-786.
9. Noonan B, Bancroft RW, Dines, JS et al. Heat-and Cold-induced Injuries in

Athletes: Evaluation and Management. Journal of the American Academy of
Orthopaedic Surgeons, 2012, 20: 744-754.

11. DeFranco MJ, Baker CL, DaSilva JJ et al. Environmental Issues for Team
12. Benelli E, Longo G, Barbi E & Berti I. Anaphylaxis in atypical cold urticaria: case
report and review of literature. Italian Journal of Pediatrics, 2018, 44(1): 135.

HEAT ILLNESS
Hyperthermia occurs when the body’s ability to thermoregulate fails and the core
temperature then rises above normothermia (>37.5°C).
It occurs either primarily (related to environmental conditions) or secondarily (related

to endogenous heat production).
If the prevailing temperature, humidity, duration of exposure, intensity of exercise

or other relevant risk factors are present alone or in combination, acute heat illness
syndromes may develop, which, if not recognised and managed early enough, can
result in the death of the athlete. Heat illness, including heat exhaustion and heat
stroke, is preventable. If and when it does occur, adequate and appropriate treatment
should guarantee good outcomes.
Risk factors for heat illness
• High environmental heat/humidity

• Fever from illness/immunisation
• Lack of heat acclimatisation
• Decreased fitness
• Intensity and duration of exercise
• Time of day when exercise takes place
• Vapour-barrier exercise clothing
• Sleep deprivation
• Lack of fluid availability/decreased fluid intake
• Dehydration and/or fatigue
• Playing surface heat reflection and radiation
• Medication
Training and competition should be modified and adapted according to the presence
of the above risk factors by decreasing or eliminating risk factors, decreasing the
duration and intensity of the exercise activity, or instituting additional measures such
as intermittent forced “rest and water” breaks.
It is therefore advisable that team doctors prepare players involved in training or

competitions in hot, humid climates in advance for the problems of heat illness, its
expected symptoms, diagnosis and treatment.
The three traditional clinical syndromes that are classed as heat illnesses are the
following:
• Heat syncope
• Heat exhaustion
• Heat stroke
185
Heat syncope
Heat syncope is the mildest form of heat illness and typically presents in persons who
are unacclimatised to an environment that is warmer than they are used to. It is not a
condition usually seen in players and, instead, it tends to occur in individuals who are
standing for long periods of time, usually while wearing clothing that is unnecessarily
inappropriate for the warm environment in which they are standing. The presentation
is in keeping with orthostatic dizziness.
The treatment is to remove the person from the environment precipitating the
problem and to place them in a cool environment with passive cooling techniques and
isotonic or hypertonic oral fluids.
Heat exhaustion
Heat exhaustion is the inability to effectively exercise in the heat. It is the most common
heat illness diagnosed in exercising populations. If taken, a rectal temperature reading
will be <40°C (104°F). Evidence seems to suggest that heat exhaustion results from
a combination of central initiation that causes decreased peripheral tone, resultant
hypotension and collapse as a protective mechanism against rising core temperatures
and dehydration.The signs and symptoms of exertional heat exhaustion are neither
specific nor sensitive and include:
• Rectal core temperature, if measured, <40°C/104°F

• History of exposure to heat, intense exercise, prolonged exercise duration
• Collapse with hypotension <100mmHg, tachycardia, tachypnoea
• Dehydration
• Sweaty, pale, ashen skin
• Headache, dizziness, weakness
• Nausea, vomiting, diarrhoea
• Deceased muscle coordination
If there are any central nervous system signs or symptoms, the diagnosis of
hypoglycaemia and exertional heat stroke (EHS) must be excluded before any other
diagnoses are considered due to the life‑threatening nature of these two medical
conditions. This will involve taking a blood glucose measurement and a rectal core
temperature measurement. If, for whatever reason, neither measurement can be
undertaken in a player who has central nervous system signs or symptoms, both
conditions must be diagnosed empirically and immediate treatment initiated with
glucose administration and effective cooling therapy.
Treatment of heat exhaustion
• Remove the player from the field of play to a shaded, cool area or to the
player medical centre, team dressing room or an equivalent private location
if clinically necessary.
• Remove any restrictive or excess clothing, as appropriate.
• Place the player in a supine position, with their lower limbs elevated.
Generally, this is all that is required and, together with a period of rest, it
will return the player to the pre-morbid state.

• Evaluate the player’s clinical vital signs and perform a focused medical
examination.
• Assess the player using the primary assessment for Airway, Breathing
and Circulation, blood glucose measurement, neurological signs and/or
symptoms. Monitor these parameters regularly, as deterioration may require
urgent consideration of EHS management and/or immediate transfer to the
nearest, most appropriate medical facility.
• If the player does not complain of nausea or signs of vomiting, administer
oral fluids carefully. If this is not possible or if the player does not recover
with simple positional leg elevation and rest, it may be necessary to establish
intravenous access and administer 0.9% normal saline to replace lost fluid,
particularly if the player is dehydrated.
Heat stroke
This is characterised by a triad of:
1. a rectally measured core body temperature of above 40°C (104°F); in

association with
2. central nervous system signs and symptoms; and
3. recent passive environmental exposure (classic or passive heat stroke) or

excessive exercise (EHS or exertional hyperthermia).
It is a life-threatening medical emergency.
The player may present as agitated or aggressive or with a seizure.
Mortality is 10% and this approaches 33% in the presence of hypotension.
It occurs when the heat that is generated or accumulated within the body exceeds the
body’s ability to effectively dissipate the heat. The elevated body temperature causes
damage to bodily tissues and stimulates an inflammatory response, which rapidly
leads to multi-organ dysfunction and death.
EHS presents in individuals who are exercising in hot and/or humid conditions, often
with associated risk factors, and generate large amounts of metabolic heat, whereas
classical heatstroke occurs without effort, usually in very hot environments amongst
the elderly, ill and/or those exposed to associated risk factors.
Whatever the nature of the heatstroke, recognition and management must be

undertaken early if the patient is to survive.
A rectal temperature probe is required to accurately record core temperature.

No other temperature‑measuring devices, including ear (aural canal or tympanic
membrane), oral, skin or axillary thermometers should be used to determine player
core temperature, as these are notoriously inaccurate and are lowered artificially by
air flow and skin secretions.
187
It is medically mandatory for any player suspected of suffering from EHS to be
removed from the field of play to the players’ medical centre, team dressing room
or equivalent private location in order to have their rectal temperature measured. It
is fully understood and appreciated that a player may not wish to undergo a rectal
thermometer measurement. In this situation, it is important to give a full explanation
to the player regarding the life-threatening nature of EHS and the need to diagnose it
definitively using a rectal temperature measurement.
It is equally important to recognise that aggression, irritability and uncooperative

behaviour may be part of the symptom complex of EHS.
Where a player is suspected to have a heat illness, but a rectal temperature cannot be
undertaken for whatever reason, EHS should be the default diagnosis and should be
treated as such immediately until proven otherwise. This is because of the seriousness
of EHS and the need for time-critical treatment. Other clinical features may include:
• Sweaty, cool skin

• Central nervous system: confusion, disorientation, irrational and unusual
behaviour, aggression, inappropriate comments, headache, inability to
walk, seizures, loss of consciousness or any neurological symptom or sign
that is out of the ordinary for the player
• Circulatory: collapse, hypotension <100 mmHg, tachycardia
• Respiratory: hyperventilation
• Gastrointestinal: vomiting, diarrhoea
• Musculoskeletal: lack of muscle coordination, fatigue, loss of balance
In any circumstances where central nervous system signs or symptoms are present,
whatever their nature or severity, the player’s blood glucose level must be measured
in order to exclude hypoglycaemia, which often coexists with EHS and which itself may
be life-threatening.
Treatment of exertional heat stroke
EHS is a time-critical, life-threatening medical emergency requiring immediate

effective cooling on site. Ensure that facilities are present to allow this prior to transfer
to hospital.
Body-cooling measures should be commenced immediately upon any person

diagnosed with EHS. The morbidity and mortality rate of EHS is directly related to
the time of onset of body cooling, with a greater delay in proportion to increased
complications, organ failure and death.
• Remove the player from the field of play and transfer them to the designated
area prepared for cooling.
• Remove the player’s clothing, as appropriate. This is not a priority if cold
water immersion is being undertaken.
• Evaluate the player’s clinical vital signs and perform a focused medical
examination.
• Assess the player using the primary assessment for Airway, Breathing and
Circulation, blood glucose measurement and level of consciousness.
• Provide immediate on-site cooling in order to decrease the core body
temperature to <40°C/104°F, with an initial target of <39°C and ideally 38°C.

1. Conduction techniques
Cold-water immersion from the neck down is preferred, where possible. At a water
temperature of 1-17°C, a cooling rate of roughly 1°C for every three to five minutes
is possible. Stirring the water will shorten the time needed for the core temperature
to drop. Cold-water immersion for around 10-15 minutes should bring the core
temperature down by approximately 3°C.
Apply ice packs to vascular areas of the body, e.g. neck, axilla and groin, with/without
rapidly rotating ice-water-soaked towels to the head, chest, abdomen and extremities.
2. Evaporation techniques
Wet the body surface with large amounts of water and fan continuously to cause
evaporation. Once the player’s clothing has been removed, the body surface may
either remain naked or covered with wet towels/sheets during the application of
water to the body. Tap water may be used to keep the body surface continuously wet,
although it has been recommended that lukewarm water be used if possible as it has
the advantage of aiding evaporation from the skin and maintaining peripheral blood
flow, both of which aid heat distribution and evaporation.
FLUID ADMINISTRATION IN EXERTIONAL HEAT STROKE

If the player has a normal mental status, they can take medication orally with additional
electrolytes if tolerated.
If the player has an altered mental status, consider obtaining IV access and administering
0.9% normal saline if the player is dehydrated and/or hypovolaemic, so as to preserve
adequate renal blood flow.
Where point-of-care testing is available, measuring sodium may be beneficial as may

administering hypertonic saline 3% as described in the European Resuscitation Council
Guidelines summarised below.
Where early recognition of EHS is combined with immediate on-site cooling with/
without other resuscitative measures, as indicated, there is an almost 100% chance
of recovery on site to the premorbid state, and this may even preclude the need for
the player to require medical facility transfer and evaluation. However, if emergency
transfer is required due to the presence of life-threatening complications, e.g. cardiac
tachyarrhythmia, refractory status epilepticus or intractable shock, adequate and
appropriate cooling must be continued en route to the medical facility, with other
resuscitative procedures. This may necessitate opening as many windows and doors as
possible in the air/road ambulance used to facilitate air current movement during the
in-transit cooling procedure, which must be continued in transit and not delayed until
medical facility arrival.
Prevention of heat-related illness – FIFA cooling breaks
Mandatory cooling breaks have been established by FIFA under certain environmental
conditions of heat and humidity in order to prevent the development of heat-related
illness in players and/or referees on the field of play.
189
In any location or environmental condition known to be hot and/or humid, a Wet Bulb
Globe Temperature (WBGT) is measured 90 minutes before the start of the match
and repeated 60 minutes before the start of the match. Should either of the WBGT
readings be at 32°C/89.6°F or above, cooling breaks must be used or the match may be
either postponed or cancelled, depending on the level of the WBGT and the decision
of the match management team. In order to measure the WBGT, a fully calibrated,
validated digital temperature device should be used.
It is important to coordinate the WBGT measurement with the watering of the pitch
by the ground staff as this may artificially decrease the measured WBGT, with possible
adverse effects. All WBGT measurements should be recorded on paper and, if possible,
photographically.
In the event that the WBGT reading is near, at or above 32°C, there should be
communication between the general coordinator/match commissioner, referees, the
FIFA chief medical officer/venue medical officer and other persons managing the
match so as to reach an operational consensus about what precautions need to be
taken to prevent any heat-related illness from occurring. At major FIFA tournaments,
it may also be necessary to inform other related departments, e.g. media, marketing,
logistics, etc.
Once cooling breaks have been established, the following logistical and practical
points should be considered:
• Ensure that the practical logistics of cooling breaks are agreed with the
referee(s).
• Ensure that the practical logistics of cooling breaks are discussed with the
team doctors or other medical professionals and show them the various
items to be used, e.g. cooler box, towels, etc. Some teams may wish to
use their own cooling items. These are allowed and should be encouraged
where possible.
• Likewise, discuss the planned heat stroke protocol, should the need arise.
Advise the team doctors or other relevant team medical professional to
inform the players of the need for cooling breaks, the purpose and the
relevant logistics so that all players congregate at the side of the pitch, and
obtain their cold, wet towels and cold bottled water to drink. Players must
be informed that cooling breaks are not for additional practice or to discuss
match tactics, but are instead for body cooling to prevent heat-related illness.
• Obtain all of the necessary equipment and prepare well ahead of time,
namely:
• Adequate quantities of ice, at least ten standard packets
• Two cooler boxes on wheels
• Two separate sets of ice-water-soaked towels for each player and
match official
• 11 x 2 = 22 for the players and four for the referees
• The first set is used during the first cooling break after 30 minutes
of play and the second set is used during the second cooling break
after 75 minutes of play.
• Two sets of cold bottled water for each player and match official

• 11 x 2 = 22 for the players and four for the officials
• The first set is used during the first cooling break after 30 minutes
of play and the second set is used during the second cooling break
after 75 minutes of play. It is sensible to provide extra cold bottled
water and towels.
• In tournaments where extra time and/or penalty shoot-outs are
possible, discuss the provision of ice-water-soaked towels and/or cold
bottled water with the referees and teams, in case it is requested
and/or expected, as this requires further logistical planning in
advance.
• This is usually unnecessary due to the natural rest period that occurs
after full-time and the rehydration that players may undertake
spontaneously.
• Ensure that all heat stroke diagnostic and treatment logistics are
available, should the need arise, and that all relevant medical staff
on duty have been adequately briefed. These items include:
• Appropriate rectal temperature-measuring devices
• A glucometer (measuring device) and intravenous dextrose
• Intravenous anti-convulsant medications
• A tub for player immersion with sufficient quantities of ice
and water
• Sufficient towels for ice-water soaking and body application
and rotation
• Tepid (tap) water spray device and fan, if relevant
191
HYPERTHERMIA
YES
Universal ALS
Require CPR? algorithm
TIME IS KEY: COOL AND RUN APPROACH
• Cool first, transfer to hospital after
NO
• Immediate cooling
Bathtub, ½ to ¾ filled • Rapidly cool to <39°C until symptoms resolve
water & ice, 1-17°C,
stirred or circulated
Use a YES
temperature Core temperature
probe >40.5ºC
Continue monitoring for at least
Stop cooling at core 15 min after cooling
NO Rapid cooling (cold
temperature <39°C • Rehydrate as required
water immerssion) • Check for improved mental status
Core temperature • Avoid accidental hypothermia
≤40.5ºC, & confused/ (<35°C)
desoriented YES
NO
If abnormal mental state initiate IV

YES 100ml bolus of 3% saline at 10 min Hyponatraemia
Blood sodium intervals, 2nd and 3rd bolus only
<130 mEq/L algorithm
if required. If normal mental state
administer oral sodium
NO
If abnormal mental state administer

Severely YES IV normal saline or Ringer’s lactated.
dehydrated? If normal mental state provide oral
rehydration and sodium
NO
NO YES Appropriate algorithm

Release with exercise
Other symptoms e.g. Hypoglycaemia
restrictions
Lott C et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances, Resuscitation,
2021. Available at: https://doi.org/10.1016/j.resuscitation.2021.02.011
REFERENCES
1. Douma MJ, Aves T, Allan KS et al. First aid cooling techniques for heat
stroke and exertional hyperthermia: a systematic review and meta-analysis.
Resuscitation, 2020, 148: 173-90.
2. Epstein Y & Yanovich R. Heatstroke. The New England Journal of Medicine, 2019,
380: 2449-2459.
3. Lipman GS, Gaudio FG, Eifling KP et al. Wilderness Medical Society Clinical
Practice Guidelines for the prevention and treatment of heat illness: 2019
update. Wilderness & Environmental Medicine, 2019, 30: S33-46.
4. Lott C et al., European Resuscitation Council Guidelines 2021: Cardiac

arrest in special circumstances, Resuscitation, 2021, Available at: https://doi.
5. Casa DJ, DeMartini JK, Bergeron MF et al. National Athletic Trainers’

Association Position Statement: Exertional Heat Illnesses [published
correction appears in J Athl Train. 2017 Apr;52(4):401]. J Athl Train.
2015;50(9):986-1000. doi:10.4085/1062-6050-50.9.07

6. Mazerolle SM, Scruggs IC, Casa DJ et al. Current Knowledge, Attitudes, and
Practices of Certified Athletic Trainers regarding Recognition and Treatment
of Exertional Heat Stroke. Journal of Athletic Training, 2010, 45(2): 170-180.
7. Glazer JL Management of Heatstroke and Heat Exhaustion. American Family

Physician, 2005, 71(11): 2133-2140.
8. Armstrong LE, De Luca JP & Hubbard RW Time course of recovery and

heat acclimation ability of prior exertional heatstroke patients. Medicine &
Science in Sports & Exercise, 1990, 22(1): 36-48.
9. Hada E, Rav-Acha M, Heled Y et al. Heat Stroke: A Review of Cooling

Methods. Sports Medicine, 2004, 34(8): 501-511.
10. Wallace RF, Kriebel D, Punnett L et al. The Effects of Continuous Hot
Weather Training on Risk of Exertional Illness. Medicine & Science in Sports &
Exercise, 2005, 37(1): 84-90.
11. Heled Y, Rav-Acha M, Shani Y et al. The “Golden Hour” for Heatstroke
Treatment. Military Medicine, 169(3): 184-186.
12. Casa DJ, Armstrong LE, Ganio MS et al. Exertional Heat Stroke in Competitive
Athletes. Current Sports Medicine Reports, 2005, 4: 309-317
13. Costrini A. Emergency treatment of exertional heatstroke and comparison of

whole body cooling techniques. Medicine & Science in Sports & Exercise, 22(1):
15-18.
14. Smith JE. Cooling methods used in the treatment of exertional heat illness.
British Journal of Sports Medicine, 2005, 39: 503-507.
15. Na. US Soccer Federation: Youth Soccer Heat & Hydration Guidelines.
Available at: http://www.ashburnsoccer.net/docs/USSF_Youth_Soccer_ Heat_
Stress_Guidelines.pdf. Cited on 9TH February 2014.

17. DeFranco MJ, Baker CL, DaSilva, JJ et al. Environmental Issues for Team
18. Armstrong E, Casa DJ, Millard-Stafford M et al. American College of Sports

Medicine position
19. Exertional Heat Illness during Training and Competition. Medicine & Science in
Sports & Exercise, 2007, 39(3): 556-572.
193
10
THE FIFA
EMERGENCY CARE
BAG (FECB) 2022
THE FIFA EMERGENCY CARE BAG (FECB) 2022
In 2012, FIFA recognised the need to standardise the level of care that can and should
be provided to players participating at FIFA-recognised tournaments such as the FIFA
World Cup™.
When deciding upon the contents of the FIFA Emergency Care Bag (FECB), consideration
was given to the global nature of football, while at the same time recognising the
need for an optimum level of football emergency care for all, a level that all member
associations should strive for during training and competition, irrespective of the
location.
It should be appreciated, however, that this only ensures a minimum standard. Each
member association can add to the required equipment lists should it choose to do
so, as long as this does not detract from the treating clinicians’ ability to provide the
expected levels of care as detailed in this manual and the accompanying FIFA courses.
The more kit we have, the more risk there is that it might detract, or distract us, from
using a simpler and effective alternative.
Therefore, although individual or team medical staff may use their own discretion
to add any items to the FECB due to local circumstances, it is recommended that the
basic inventory of the FECB not be altered and always be available when used by
on-duty medical staff, in accordance with FIFA’s recommendations. This will ensure
basic consistency of contents across matches and enable professional healthcare to be
delivered by different teams which are able to work in unison, on the same pitch, on
single or multiple players, using a number of FECBs, all with the same basic contents.
At the forefront of good clinical care, it must be remembered that it is the simple
things that make the biggest differences – complexity can be the enemy of success in
an emergency situation.
The 2022 version of the FECB has therefore been designed using the human factors
principles of ergonomics to achieve a bag that, in itself, has been built around all of
the kit listed in the minimum FIFA standards.
The purpose of doing this is to ensure that, even if someone has not used the bag
before, it is clear to them where each piece of equipment is stored and located so they
can access this easily and without delay. When using equipment that has not been
196 10 The FIFA Emergency Care Bag (FECB) 2022

designed in this way, it is not uncommon to see candidates in moulages simply empty
the entire contents of their own pitchside medical bags onto the ground to try to
locate the one piece of equipment they need.
The FECB is intended to be used in training and competition by all FIFA member
associations internationally. It is the recommended emergency medical bag for
football team doctors, field-of-play medical teams and other medical professionals on
duty during football events.
CONTENTS OF THE FECB

The contents of the bag have been laid out to account for the likely emergency
situations that may present on the pitch. Priority is given to immediate life-saving
equipment, rather than that used simply for wound-based care. The contents are
suitable for an expected age of greater than 14 years old and weight of over 50kg.
The equipment has been grouped together so that airway adjuncts fold into one
another, keeping them together in the smallest possible space. All other elements of
Airway, Breathing and Circulation are clearly laid out and labelled. The AED is easily
accessed from its own compartment. Diagnostic and wounds equipment are also
present and all compartments are labelled and sealed with waterproof zips to ensure
that contents stay dry at all times unless being accessed.
Oxygen is a critical element of our immediate care processes, but crucially it is also
something that we are unable to fly with and the bag therefore allows for a CD cylinder
to be clipped on to the outside of the bag where required. No space is therefore
wasted inside the bag and weight is minimised.
There is space in each bag for IV fluids, although these are not included as standard
as they are considered to be medication and should be added depending on the
clinician’s preferences.
The two sides of the bag have removable trays to allow clinicians to easily clean, change
and restock kit as well making the bags exceptionally functional.
197
Standardised contents of the FECB
Airway Suction Breathing Ambu BVM Circulation IV cannula 14G

NPA size 6 Trauma O2 mask IV cannula 16G
NPA size 7 Nebulisert mask Syringe 10ml
NPA size 8 Pocket mask Syringe 5ml
OPA size 2 Spacer device Needle 23G
OPA size 3 Needle 21G
OPA size 4 Vecafix
i-Gel size 4 Tourniquet
i-Gel size 5 Small swab 5x5cm
Optilube Sterets
Magills Forceps Small scissors
IV fluid giving set
Philips HS1 Defibrillator
Cervical Spine Hard collar
Diagnostics Stethoscope Wounds Suture set PPE Aprons

BP machine 2/0 suture Gloves Medium
Glucometer 4/0 suture Gloves Large
Saturation probe Steristrips 6mm Alcohol gel
Peak Flow Steristrips 3mm Protective spectacles
Pen torch Leukoplast Sharps bin
Digital Finepore
thermometer
Gauze swab 10cm
Tough cut shears
Eye wash
OTHER RECOMMENDED PITCHSIDE EMERGENCY CARE EQUIPMENT

• Oxygen should be provided at stadiums and there should be an expectation
that this will be provided wherever elite players are training or playing
• A scoop stretcher is preferred over a spinal/long board but it is appreciated
that costs may make this prohibitive and spinal/long boards can be used:
these should be updated with scoop stretchers where possible
• Spider straps or clip-on straps to allow the player to be immobilised safely
• Head huggers/restraints
• Basket-type stretchers are highly recommended to ensure safer extrication
processes. Carrying a scoop or spinal board is tricky once a player is lying
on it and this becomes much easier to do safely if the scoop/board is placed
inside the basket
• Mix of splints, either vacuum or individual

The contents of the FECB and the recommended pitchside care equipment have been
selected to manage the following life-threatening football medical emergencies:
• Anaphylaxis
• Chest pain
• Concussion
• Dehydration
• Exercise-induced bronchospasm
• Fractures
• Grand mal seizures
• Head injury
• Heat stroke/head exhaustion
• Hypoglycaemia
• Spinal column injury
• Sudden cardiac arrest
In order to treat these conditions, the following list is a sample checklist of the types of
emergency medication that should be present pitchside. Non-emergency medications,
such as antibiotics, are not needed at the pitch, but should be available in the medical
room.
CHECKLIST
Emergency Medication
🖉 Adrenaline 1: 10000 10ml prefilled syringe x1
🖉 Emerade / Epi-Pen
🖉 Atropine 3mg prefilled syringe
🖉 Amiodarone 300mg prefilled syringe x1
🖉 GTN spray x1
🖉 Aspirin tabs 300mg or 75mg (total 900mg)
🖉 Diazepam IV 10mg in 2mls x1
🖉 Diazepam rectal 5mg rectal tube x1
🖉 Hydrocortisone 100mg IV x1
🖉 Salbutamol nebules 5mg x 2
🖉 Salbutamol inhaler x1
🖉 Chlorpheniramine 10mg amp x 2
🖉 Dextrose gel x 3
🖉 Glucagon prefilled syringe x1
🖉 Prochlorperazine 12.5mg IM x1
🖉 Ondansetron IV or melts
🖉 Lignocaine amps 1% x 5ml x 4
🖉 Water or saline flush 10ml x 4
199
SKILL ZONE – PRACTICAL SKILLS AND TECHNIQUES
1. Airway opening: how to perform a jaw-thrust
2. Airway opening: how to perform a head-tilt and chin-lift
3. Airway adjunct: how to size and insert a nasopharyngeal airway
4. Airway adjunct: how to size and insert an oropharyngeal airway (Guedel
airway)
5. Airway adjunct: how to use an i-gel LMA
6. How to size and fit a cervical collar
7. How to apply a pelvic binder
8. How to perform a log roll
Airway opening – jaw-thrust
Indications
• Evidence of airway obstruction from either primary or secondary injury

• Decreased GCS assessment of response to painful stimulus (relative indication)
Contraindications
• Nothing specific, but use with caution if there is a suspected mandibular

fracture and performing the technique appears to worsen the situation.
• If the technique is being performed by the same person immobilising the
cervical spine and this results in any movement of the neck, stop and ensure
that the spine can be protected by a second person whilst the jaw-thrust is
performed.
Technique
By lifting the mandible forward, the soft-tissue structures are also moved forward and
away from the posterior pharyngeal wall.
A jaw-thrust is usually performed by a person positioned by the player’s head.

The middle and ring fingers are placed under the angle of the mandible and pulled
in an upwards movement, as shown by the yellow arrows in the picture. Only the jaw
itself should be moved; the head and midface do not move and the neck should not
move.
Airway opening – head-tilt and chin-lift
Indications
• Evidence of airway obstruction

• Apnoea (prior to ventilation)
Contraindications
• Airway obstruction with suspected trauma
Technique
Place the palm of one hand on the player’s forehead and use your other hand to
gently lift the chin up so that the player’s neck is extended into a “sniffing” position.
The easiest way to do this is to place the index and middle fingers underneath the chin
in the midline, and then extend the head slightly. The thumb can also be placed on the
chin just under the lower lip and this can help to open the mouth if it is closed.
This movement again pulls the soft tissues of the oropharynx forward and lifts them
away from the posterior pharyngeal wall, allowing air to flow through the pharynx
into the lungs.
201
Airway adjuncts: nasopharyngeal airway (NPA)
Indications
• Evidence of airway obstruction

• Apnoea prior to ventilation (an i-Gel LMA is preferred to the NPA in apnoea)
Contraindications
• Airway obstruction with suspected trauma to the base of the skull

(this is a relative, not an absolute, contraindication – if this is the only adjunct
that helps to secure the airway then it can still be used in players with head
injuries)
• Epistaxis: trauma from the NPA is common and caution should be exercised
to make sure the airway obstruction is not worsened by the intervention of
placing the NPA
Technique (always follow manufacturer’s instructions)
Size the NPA by finding the one that is slightly smaller than the opening to the nostril.
There are different types of NPA, but if a safety pin or similar is required to be placed
to stop it passing too far in, ensure that it has been attached. Lubricate the NPA and
place it directly backwards along the floor of the nose and not upwards. A gentle
twisting motion may be required to help it pass through.
If there is significant obstruction, withdraw the NPA and try again using the other
nostril. Usually, one side will pass more easily than the other, but never force the
adjunct into the nose.
Various sizes

Place along floor of nose
Airway adjuncts: oropharyngeal airway (OPA) or “Guedel”
Indications
• Evidence of airway obstruction (not caused by foreign body)

• Apnoea prior to ventilation (an i-Gel LMA is preferred to the OPA in apnoea)
Contraindications
• Foreign body causing choking

• Coughing suggests the presence of a gag reflex
• It may not be possible to position the OPA if the patient has their teeth
clenched – commonly an issue in a player having a seizure
The OPA is a plastic moulded airway that sits over the tongue with the flange against
the lips. It comes in numerous sizes, from paediatric through to a range of sizes for
adults. There are different-coloured plastic flanges for each size which allows for easy
recognition.
The correct size for the patient is found by first measuring the OPA from the midline
of the incisors to the angle of the mandible. The most commonly used sizes are size 3
(orange) for an adult man and size 2 (green) for an adult woman, although measuring
is always recommended. In particularly tall players, a size 4 (red) or even size 5 (purple)
may be required.
The OPA is traditionally inserted “upside down” and rotated 180 degrees, although
it can be placed under direct view, also using a tongue depressor. Once in place, it
should sit with the flange resting at the lips. The flange should not be pushed out of
the mouth; this would suggest the size is too big.
203
Multiple sizes are available
Size from incisors to angle of mandible
Airway adjuncts: i-Gel LMA (supraglottic airway)
Indications
• Evidence of airway obstruction not improved by NPA or OPA

• Apnoea (prior to ventilation)
• The i-Gel LMA is the preferred airway adjunct (rather than an OPA or NPA)
in apnoea or cardiac arrest situations
NOTE: intubation is the gold standard definitive airway and is superior to the LMA in
protecting the airway. However, it is beyond the remit of the FIFA course to teach this
skill, so the focus will be on the adjuncts described.

Contraindications
• Coughing suggests that a gag reflex is present and, in these circumstances,

setting an LMA will not be tolerated by the patient.
The i-Gel LMA is a second generation one-piece pre-moulded airway adjunct with
a soft gel-like non-inflatable cuff. It is positioned by placing the patient into the
“sniffing” position. Lubricate the LMA and push it directly backwards over the tongue,
following the hard palate initially and then the posterior contours of the oropharynx
on into the laryngopharynx where it should rest above the vocal cords. Push until
resistance is felt.
The LMA comes in seven sizes in total, with each size determined by body weight. The
green size is appropriate for 50-90kg and the orange size is for anyone over 90kg.
Size related to estimated or known weight
205
The i-gel® supraglottic airway - adult s
Preparations for use

Open the i-gel Remove
1. package, and on 2. and tran
a flat surface take palm of t
out the protective hand tha
cradle containing the prote
the device. supporti
between
and inde
4.
Grasp the i-gel with the opposite (free) hand along the integral
bite block and lubricate the back, sides and front of the cuff
with a thin layer of lubricant.
Insertion technique
Remove the i-gel from the
6. protective cradle. Grasp the 7.
lubricated i-gel firmly along the
integral bite block. Position the
device so that the i-gel cuff
outlet is facing towards the b
chin of the patient. The patient
should be in the ‘sniffing the
morning air’ position with head
extended and neck flexed. The a
chin should be gently pressed
down before proceeding. Glide the device downwards and backwards
Introduce the leading soft tip continuous but gentle push until a definitive
into the mouth of the patient in
The tip of the airway should be located into th
a direction towards the
opening (a) and the cuff should be located ag
hard palate.
(b). The incisors should be resting on the inte
This poster does NOT constitute a comprehensive guide to the preparation, insertion and use of the i-gel. The user should first familiarise themselves with the Instr
supplied with the product before attempting to use the i-gel. Additionally, a User Guide is available by contacting Intersurgical or by visiting our website www.i-gel.
The i-gel must always be separated from the protective cradle prior to insertion. The cradle is not an introducer and must never be inserted into the pat
K-Y Jelly ® is a registered trademark of Johnson and Johnson Inc.
https://www.intersurgical.com/info/igel

sizes
e the i-gel Place a small bolus

nsfer it to the 3. of a water-based
the same lubricant, such as K-Y
at is holding Jelly®, onto the middle
ective cradle, of the smooth surface
ing the device of the protective
n the thumb cradle in preparation
Patient Size Size Weight
ex finger. for lubrication.
Small adult 3 30-60kg
Medium adult 4 50-90kg
Large adult 5 90+kg
5.
Inspect the device carefully,

confirm there are no foreign
bodies or a BOLUS of Important notes to
lubricant obstructing the distal
opening. Place the i-gel back
the recommended
into the protective cradle in insertion technique
preparation for insertion.
Sometimes a feel of ‘give-way’ is
felt before the end point resistance
is met. This is due to the passage
of the bowl of the i-gel through
the faucial pillars. It is important to
continue to insert the device until a
8. definitive resistance is felt.
c
Once definitive resistance is met and
the teeth are located on the integral
bite block, do not repeatedly push
the i-gel down or apply excessive
force during insertion.
It is not necessary to insert fingers

or thumbs into the patient’s mouth
s along the hard palate with a The i-gel should be taped during the process of inserting
resistance is felt. down from ‘maxilla to maxilla’. the device.
he upper oesophageal
gainst the laryngeal framework
egral bite block (c).
Visit the i-gel website www.i-gel.com
ructions for Use Intersurgical Ltd, Crane House, Molly Millars Lane, lnteract with us
.com Wokingham, Berkshire, RG41 2RZ, UK
tient’s mouth. T: +44 (0)118 9656 300 F: +44 (0)118 9656 356
info@intersurgical.com www.intersurgical.com www.intersurgical.com
I-GELADULTPOSTER issue 2 10.16
207
How to size and fit a semi-rigid cervical collar
Indications
• Suspected or confirmed cervical spine injury
Contraindications
• Airway obstruction: the application of a cervical collar brings the potential

for worsening or causing an airway obstruction. In this situation, continue
MILS instead until the airway obstruction has been dealt with.
• There is growing concern that even a well-fitted cervical collar may not
confer added protection to the cervical spine and may instead cause other
significant issues such as raised intracranial pressure, for example. Being
aware of the guidance locally is important as cervical collars are being
removed from trauma management in some countries.
Technique
As always, it is vital to follow the manufacturer’s instructions as different collars may

have different sizing instructions.
One of the biggest challenges when fitting a cervical collar is to ensure that the
measured size translates into the best fit for the player. If your sizing measurement
falls between two sizing posts on the collar, you should always start with the smaller
size. If the size is too big, the collar will increase extension at the neck; if it is too small,
it may not provide enough support, but it is less likely to worsen the problem.
With the head in a neutral position, draw a line from the chin directly backwards until
it bisects the sternomastoid (see image 1 below). Measure (in fingerbreadths) from
this point down to the bulk of trapezius (see image 2). The number of fingerbreadths
is used to size the collar, using the different sizing options if you are using a multi-
adjustable collar (see images 3-4)
1. Draw a line from the chin to bisect the sternomastoid

2. Measure from this point down to the bulk of trapezius in fingerbreadths
3. Using the sizing marker, place your fingers on the collar and find the sizing point
closest to your fingers
4. Slide the collar underneath the player – do not slide too far
209
Important points to remember:
• Recheck the player after you have fitted the collar: has their condition
changed in any way?
• Having a collar on the player will not fully immobilise their neck. MILS must be
continued until blocks and tape (and an extrication device) have been applied.
• Because MILS needs to be continued until full immobilisation has occurred,
there is relatively little benefit to applying a collar early on in your assessment.
It should be regarded as part of the extrication process.
How to apply a pelvic splint
Indications
• Suspected or confirmed pelvic injury
Contraindications
• No contraindications. However, there are certain types of pelvic injury that

may be worsened by the application of a binder so, as with any intervention,
recheck the patient after application and ensure that the situation has not
worsened.
Technique
A number of pelvic binders are commercially available. As with any piece of equipment,
ensure familiarity with the device before you are required to use it in an emergency.
The binder is applied underneath the knees (see image 1 below) and gently worked up
to the level of the greater trochanter using a “see-saw” motion. This will require two
people to be involved. It may be necessary to apply gentle pressure to the iliac crest to
stop the player being moved as you move the binder.
The binder should be secured (see image 2 below) according to the manufacturer’s
instructions and the player should be reassessed.

Golden rule: NOT TOO HIGH
How to perform a log roll
Indications
• Suspected or confirmed spine injury for assessment of cervical/thoracic/

lumbar spine
• Decreased GCS with possibly head or neck injury
• To facilitate extrication of the above
• Maintain spinal precautions in someone who is vomiting
Contraindications
No contraindications. However, a formal log roll to 90 degrees may not be required if

a scoop is used.
Supine technique
If the player is in a supine position, firstly gain control of the cervical spine with MILS.
Four people are needed to perform the log roll and a fifth person is needed if an
extrication device is going to be used.
• Head/“Take the head” – MILS

• Chest: one hand on player’s opposite shoulder and one hand on their hip
• Pelvis: one hand on the player’s waist and the other under their knee
• Legs: one hand under the player’s lower leg and the other under their ankle

211
The person who is taking the head controls the move. They must explain the signal
that announces the start of the move and they must ensure everyone in the team is
aware of how far the player is being turned, e.g. 90 degrees in a full log roll versus 15-
20 degrees in a tilt for a scoop.
1.
2.
3.

4.
5.
6.
213
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FIFA

1 INITIAL PITCHSIDE ASSESSMENT – THE FIFA APPROACH 5

2 INITIAL ASSESSMENT – THE PRIMARY SURVEY 19

4 CHOKING AND ANAPHYLAXIS 61

Emergency management and red flags for referral to hospital 151

8 THE FEMALE ATHLETE 165

9 ENVIRONMENTAL EMERGENCIES 169

10 THE FIFA EMERGENCY CARE BAG (FECB) 2022 195

Regardless of whether a player requires medical attention during training, a warm-

The “chain of survival” as a concept in resuscitation outcomes also applies to us as we

We must have the appropriate equipment, knowledge and skills as well as an

6 1 Initial pitchside assessment – the FIFA approach

It is human nature to be distracted by an “obvious” injury, such as a clearly angulated

MATCH DETAILS CONTACT INFORMATION

• Take chest in log roll • Commence CONTINUOUS chest compression

EQUIPMENT – Bring oxygen cylinder EQUIPMENT – Bring oxygen cylinder

Figure 1: FIFA pre-match emergency action plan (PEAP)

A name should be written on the FIFA PEAP alongside each of

Familiarity within a team is important, but often it may be impossible

Practising scenarios or moulages prior to each match or during

The aim of the PEAP is to build on this understanding of roles and to

• minimise any confusion over where each person should be;

This is fundamentally a scripted medical response that features lots

If you think about this process as a scripted or staged response, the

8 1 Initial pitchside assessment – the FIFA approach

During the COVID-19 pandemic, our ability to speak clearly, listen

It is useful to remember that whilst what you say may be heard, it

It is the team leader’s responsibility to ensure that their requests

Closed-loop communication is helpful in ensuring that instructions

Using peoples’ preferred names is an incredibly powerful leadership

One of the ways in which this stress can be reduced is by using

The FIFA PEAP is a good example of a checklist that everyone within

This is a vital step to ensure that:

• all of the equipment that is expected to be present is, in

10 1 Initial pitchside assessment – the FIFA approach

It is vital that everyone is prepared in advance

Figure 2: Roles within the team

One example could be a situation in which there is a delay in applying a defibrillator

Task fixation can be useful in terms of helping an individual to focus on performing

Responsibilities Lead the team

Challenges Ensuring effective communication

“TAKE THE HEAD” TEAM MEMBER

12 1 Initial pitchside assessment – the FIFA approach

Challenges Limited in what they can do because their hands

“CHEST” TEAM MEMBER

Responsibilities Make an initial airway assessment

Challenges Multi-tasking – therefore at increased risk of error,

“PELVIS” TEAM MEMBER

Responsibilities Take the pelvis in the log roll

Challenges Lack of available medical personnel may mean that

Responsibilities Take the legs in the log roll

Challenges Lack of available medical personnel may mean that

“EQUIPMENT” TEAM MEMBER

Figure 3: FIFA Emergency Care Bag

14 1 Initial pitchside assessment – the FIFA approach

Physical distance is maintained in an effort to minimise the number of people around

FIFA EXTRICATION “SET PIECE”

1. Set-up of medical equipment at the player’s head

Figure 4: FIFA extrication “set piece”

16 1 Initial pitchside assessment – the FIFA approach

Undertaking an assessment and performing life-saving interventions pitchside is very

3. Be proactive and not reactive in your preparations. Preparation avoids reparation.

4. Practise as a team, and then practise again and again.

6. Pay attention to communication – this will make or break the situation.

1 INITIAL PITCHSIDE ASSESSMENT – THE FIFA APPROACH 5

2 INITIAL ASSESSMENT – THE PRIMARY SURVEY 19

4 CHOKING AND ANAPHYLAXIS 61

Emergency management and red flags for referral to hospital 151

8 THE FEMALE ATHLETE 165

9 ENVIRONMENTAL EMERGENCIES 169

10 THE FIFA EMERGENCY CARE BAG (FECB) 2022 195