Sport Emergencies Preparedness :

Things to Consider before The Game Starts

Damayanti Tinduh
Sport Injury Rehabilitation division
Department of Physical Medicine and Rehabilitation
Faculty of Medicine Universitas Airlangga
Dr. Soetomo General Academic Hospital
Surabaya - Indonesia
 Subtopics
• Introduction
• Sport Injury Risk vs Risk Injury Sports
• 3 Important Ws: Warm up & down, Well
hydrated & Well nourished
• RICE – POLICE – MEAT  PEACE & LOVE
• Doctors Role in Sport Events
Fitness : Physical Activity & Exercise
…, planned, structured, repetitive,
purposeful (to improve and/or
maintain >1 components of
physical fitness

…, purposeful, that results in a

substantial increase in caloric
requirements over resting
Exercise
energy expenditure

Physical Activity
Bodily produced by skeletal muscle
Movement contraction
Physical Fitness
• … is the ability to carry out
daily tasks with vigor and
alertness, without undue
fatigue, and with ample
energy to enjoy leisure-time
pursuits and meet unforeseen
emergencies

• … is composed of various
elements that can be further
grouped into Health-related
and Skill-related components
 Adaptation Process of Physical Exercise
Level of homeostasis
disturbance Workability state
Amount
of
training Metabolic processes
load Critical level of activity
homeostasis Thereshold of Body
disturbance adaptability defense
Eccessive
Catabolic processes
activity

High
Anabolic processesOptimal
Exercise
zone
Medium

Mobilization of the body’s Body

Low energetic and plastic adaptation
Catabolic processes resources

Training Quiet High Activation Over- Stress

Activation Activation
Verkhoshansky N. General Adaptation Syndrome
and Its Applications in Sport Training, 2012
Consequences of Sport Activity
 Sport Injury Risk vs Risk Injury Sports

• Sport Injury Risk Factors

• Risky Sport
 Risk factors for sport injury Sport Injury mechanisms
(distant from outcome) (proximal to outcome)

Intrinsic risk factors:

prf
• Age ----- x E x C = I
• Gender tms
• Body composition (e.g body
weight, fat mass, BMD,
anthropometry)
• Health (e.g., history of previous
injury, joint instability)
• Physical fitness (e.g., muscle Predisposed Susceptible Injured
strength/power, maximal O2 athletes athletes athletes
uptake, joint ROM)
• Anatomy (e.g., alignment,
intercondylar notch width)
• Skill level (e.g., sport specific
technique, postural stability) Exposure to extrinsic risk factors: Inciting event:
• Human factors (e.g., team mates, opponents, • Playing
referee) situation
• Protective equipment (e.g., helmet, shin • Player/oppone
guards) nt “behavior”
• Sport equipment (e.g., skis) • Biomechanical
• Environment (e.g., weather, snow and ice characteristics
conditions, floor and turf type, maintenance)

A model of injury causation (Meeuwisse, 1994; Bahr & Krosshaug, 2005)

 Bobsledding/luge, *↑ Bodybuilding, *↑ Boxing, *

III. High (>50% MVC)

Field events (throwing), Downhill skiing, *↑ Canoeing/kayaking
Gymnastics, *↑ Skateboarding, *↑ Cycling, *↑
Classification Martial arts, * Snowboarding, *↑ Decathlon
Rowing
Sailing, Wrestling, *
of Sports by Sport climbing,
Water skiing, *↑
Speed skating, *↑
Triathlon, *↑
Physical Weight lifting, *↑
Windsurfing, *↑
Intensity Archery American football, * Basketball, *
Auto racing, *↑ Field events (jumping) Cross-country skiing (skating

(20-50% MVC)
II. Moderate
Diving, *↑ Figure skating, * technique)
Equestrian, *↑ Rodeoing, *↑ Ice hockey, *
 Motorcycling, *↑ Rugby, * Lacrosse, *
Running (sprint) Running (middle distance)
Increasing static component

Surfing, *↑ Swimming
Synchronized swimming, ↑ Team handball
Billiards Baseball/softball, * Badminton
Bowling Fencing Cross-country skiing (classic
I. Low (<20% MVC)

Cricket Table tennis technique)

Curling Volleyball Field hockey, *
Golf Orienteering
Riflery Race walking
Racquetball/ squash
Running (long distance)
Soccer, *
Tennis
A. Low (<40% maximal B. Moderate (40-70% C. High (>70% maximal O2)
O2) maximal O2)

* = danger of body
collision
↑= increased risk if
syncope occurs
MVC = Maximal Voluntary
Contraction
 3 Important Ws :
Warm up & down, Well hydrated & Well nourished

Warm up &
Well hydrated Well nourished
down
• Body • Water • Macronutrients
temperature • Electrolytes (carbohydrates,
• Flexibility lipid, proteins)
• Micronutrients
(vitamins,
minerals)
 Warming Up & Down
Warm Up
• To prepare the body and mind for work
and/or more strenuous physical activity
• Increase kinesthetic awareness
• To minimize the chance of injury
• To indicate the possibility of injury (nagging
areas)
• Increase heart rate, blood flow, respiratory
rate and core and muscle temperature 
activate contractile mechanisms
• Mobilize the joints and increase synovial
fluid
• Neuromuscular facilitation stimulated
• Flexibility increased - 5% for every 1oC
increase in body temperature
Warm Down
• To prevent/reduce muscle soreness and
stiffness
• To aid in the removal of waste products,
primarily lactic acid
• Allow the heart rate to transition and
recover in a physiologically healthy way
(avoid blood pooling)
• Decrease chances of Delayed Onset
Muscle Soreness (DOMS)
Thomsasusell, 2012. Warm Up and Cool/Warm Down
 Warming Up
• Aerobic (continuous
rhythmic movement that
incorporates large muscle
groups) – light jogging
• Dynamic stretching/light
strength exercise/possibly
light static stretching, which
may be case specific and/or
sport specific
• Sport specific drills / Pre-
Game
• Keep warm
Thomsasusell, 2012. Warm Up and Cool/Warm Down
 Warm Down
• 2 phases
– Cardiovascular warm down – slow continual
movement after exercise for 3-5 minutes
– Stretching warm down – for minimizes stiffness
and muscle soreness
 Well Hydrated
• 60-70% of human
Composes 75-80% of body is consisted
brain

Makes up 83% of blood

of water
& carries nutrients & O2
to cells • Water is essential
Composes 90% of lungs,
moistens O2 for
breathing & helps carry
for life and
nutrients & O2 to cells
represents a
Helps convert food to
energy & regulates body
temperature
critical nutrient
Removes waste & for maintaining
protects & cushions vital
organs
the cell life
Cushions joints
• Importance in
Composes 22% of bones the elasticity of
connective tissue
Makes up 75% of
muscles
 DeHydration
Consequences of Water Loss
0.1% Cardiovascular strain
loss of Body Weight
from Dehydration Limit the body’s ability
2% Muscle cramp
loss of Body Weight
from Dehydration Brain shrinks
Body struggles with fatigue
5-7% Dry mouth
loss of Body Weight
from Dehydration Headaches
Dizziness
Slurred speech
Confusion
8% Little or no urine
loss of Body Weight
from Dehydration Fever
Swollen extremities
MEDICAL ATTENTION IS
NEEDED

www.GuardYourHealth.com
 DeHydration Strategies
• Focus on fluid intake all Before Exercise During Exercise After Exercise
days, every day, not just • Begin exercise Drink water or • Rehydrate
well-hydrated sport beverage • 1000-1500 cc
around workouts • Drink 500-600 every 15-20 min of fluid every
cc of water or during exercise kg lost within
• Always carry a water sports • 150-300 cc of first 2 hours
bottle beverage at water for after exercise
least 4 hours exercise < 60 • Chocolate
• Weigh self before and before min milk is a great
after exercise to know how • exercise • 150-300 cc of option to help
Drink 250-400 sport rehydrate and
much fluid to replace cc of water beverages for refuel after a
10-15 min exercise > 60 workout
• Track hydration by before min
checking urine color – the exercise

lighter the better hydrated

Adapted from
 Well Nourished
• Fuel for sport activity
• Fuel for the healing
process
• Battle anabolic
resistance
• Control inflammation
• Fruit & vegetables
• Macro-micro
nutrients
 Nutrition Strategies

Pre Workout fueling

0.5-2 hours prior to training : more carbs, low fiber, little protein, little/no fat

Fueling during training

Primary carbs and a little bit of protein

Post Workout fueling

0.5-1 hour after exercise  the window of opportunity  optimal recovery
period : 3:1 ratio of carbs:protein (carbs 1.2 g/kg/hour)
 RICE POLICE MEAT
• Rest • Protection • Movement
• Ice • Optimal Loading • Exercise
• Compression • Ice • Analgesics
• Elevation • Compression • Treatment
• Elevation

Immune system Immune system

response ↓ response ↑
Blood flow to injured Blood flow to injured
area ↓ area ↑
Collagen formation Collagen formation
hindered encouraged
Speed of recovery Speed of recovery
delayed (lengthened) hastened (shortened)
ROM of joint ↓ ROM of joint ↑
Complete healing ↓ Complete healing ↑
 Doctors Role in Sport Events
• Pre Event
• Event Coverage
• Post Event
• Emergencies on the field
Pre Event Mass Screening for PPE :
Atlit PUSLATDA JATIM 2013-2016
Siswa Baru SMANOR 2015/2016
Siswa Baru SMANOR 2016/2017
Atlit PUSLATDA JATIM 2017-2020
 Contraindication for Sports
Participation
• Active myocarditis or pericarditis
• Acute enlargement of spleen or liver
• Eating disorder in which athlete is not compliant with therapy and
follow-up, or when there is evidence of diminished performance or
potential injury because of the eating disorder
• History of recent concussion and symptoms of postconcussion
syndrome (no contact or collision sports)
• Hypertrophic cardiomyopathy
• Long QT syndrome
• Poorly controlled convulsive disorder (no archery, riflery, swimming,
weight lifting or powerlifting, strength training or sport involving
heights)
• Recurrent episodes of burning upper-extremity pain or weakness, or
episodes of transient quadriplegia until stability of cervical spine can be
assured (no contact or collision sports)
• Severe hypertension until controlled by therapy (static resistance
activities, such as weight lifting, are particularly contraindicated)
• Sickle cell disease (no high-exertion, contact, or collision sports)
• Suspected coronary artery disease until fully evaluated (patients with
impaired resting left ventricular systolic function less than 50%,
exercise-induced ventricular dysrhythmias, or exercise-induced
ischemia on exercise stress testing are at greatest risk of sudden death)
Adapted with permission from Kurowski K, Chandran S. The preparticipation
athletic evaluation. Am Fam Physician. 2000; 61(9):2688
American Heart Association Recommendation
on Screening for Cardiovascular Abnormalities
in Competitive Athletes
• Personal History
– Elevated blood pressure
– Excessive dyspnea or fatigue associated with exercise
– Exertional chest pain or discomfort
– Prior recognition of a heart murmur
– Unexplained syncope or near-syncope
• Family History
– Disability from heart disease in a close relative younger than 50
years
– Premature death (sudden and unexpected, or otherwise) before
50 years of age due to heart disease
– Specific knowledge of certain cardiac conditions in family
members: hypertrophic or dilated cardiomyopathy, long QT
syndrome, Marfan syndrome, or arrhytmias
• Physical Examination
– Brachial artery blood pressure (sitting position)
– Femoral pulses to exclude aortic coarctation
– Heart murmur (auscultation in the supine and standing
positions or with Valsava maneuver to identify murmur of
dynamic left ventricular outflow tract obstruction)
– Physical stigmata od Marfan syndrome
Adapted with permission from Maron BJ, Thompson PD, Ackerman MJ, et al.
Recommendation 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. Circulation. 2007;115(12):1646
How to do if Does Not Participate in Participate in Regular Exercise
Athlete…. Regular Exercise previously previously
No CV, Metabolic or Renal Medical Clearance not necessary Medical Clearance not necessary
Disease Light to Moderate Intensity Exercise Continue Moderate or Vigorous
AND May gradually progress to Vigorous Intensity Exercise
No signs or symptoms Intensity Exercise following ACSM May gradually progress following ACSM
suggestive of CV, Metabolic Guidelines Guidelines
or Renal Disease
Known CV, Metabolic or Medical Clearance recommended Medical Clearance for Moderate
Renal Disease Intensity Exercise not necessary
AND Medical Clearance (within the last 12
Asymptomatic months if no change in signs/symptoms)
recommended before engaging in
Vigorous Intensity Exercise
Following Medical Clearance, Light to Continue with Moderate Intensity
Moderate Intensity Exercise Exercise
May gradually progress as Tolerated Following Medical Clearance, may
following ACSM Guidelines gradually progress as Tolerated
following ACSM Guidelines
Any Signs or Symptoms Medical Clearance recommended Discontinue Exercise and seek Medical
suggestive of CV, Metabolic Clearance
or Renal Disease Following Medical Clearance, Light to May return to Exercise following
(Regardless of disease Moderate Intensity Exercise Medical Clearance
status) May gradually progress as Tolerated Gradually progress as Tolerated
following ACSM Guidelines following ACSM Guidelines
 Event Coverage
• Checking the medical equipment properly
• Coordination within and between team(s) –
the role of team member
• Understanding about the particular sport
game in nature and its modes of injury
 Post Event
• Review injuries and illnesses that occurred
during the event
• Doing the follow up participants who required
emergency management
• Reporting
 Emergencies on the field
• Cardiopulmonary arrest
• Exercise-induced collapse
• Asthma
• Anaphylaxis
• Heat stroke
• Acute hemorrhage
• Head and neck injuries
• Facial injuries
• Eye injuries
• Oral injuries
• Chest injuries
• Abdomen injuries
• Musculoskeletal injuries
 Take Home Messages
• Injury is one of consequences of doing sport activity  could
be prevent partially
• Safe sport activities could be promoted with screening with
Preparticipation Physical Examination to find out the risk of
sport injury, doing the 3 important Ws (Warm Up & Down,
Well hydration & Well nourished)
• Injury management : PEACE & LOVE
• Doctors Role : Comprehensive management
• ACSM’s Guidelines for Exercise Testing and
Prescription 10th edition.
• Mirabelli MH, Devine MJ, Singh J and
Mendoza M (2015). The Preparticipation
Sports Evaluation. Am Fam Physician. 2015 ;
92 (5) : 371-376.