Part Two:

The acute
manageme
nt of the  
sick and
injured
athlete

• Introduction 

• Sick and injured athletes 

• Care of the collapsed or seriously ill athlete 

• Commencing early CPR 

• The seriously injured athlete 
   
• Exercise testing and prescription 

○ Health screening prior to sport 

○ Pre­test evaluation 

○ Physical fitness testing 

○ Conditions limiting sports participation 

○ Guidelines for particular sports 
  Introduction  

Regardless of your particular expertise in medicine all doctors need to know how to
resuscitate and handle a life-threatening injury. Especially in sports medicine where the
athlete is ‘young’ and salvageable. The number of such situations that are life-threatening is
probably low. I have found that <5% of snow skiing injuries require immediate hospital
treatment. The risk of these injuries or illness amongst athletes depends the type and level
of sport (amateur versus professional), previous illness or injury and the level of fitness. The
profile of skiers with serious injury is male, under 14 years, experienced skier, colliding with
rocks, on steep slopes, at high speed, slushy snow, long skis, no head protection and
bindings did release.
You must have a SIMPLE approach to use in any case of potential life-threatening injury
(Table 1) or illness.

Sick and injured athletes

Resuscitating patients falls into two basic groups - non-trauma (dehydration, heat stress,
cardiac-start Basic Life Support and medical therapy) and trauma(injury, IV start, stop
bleeding, splint, transport).
Various treatment algorithms have been designed for each group (Australian Resuscitation
 Council, American Heart Association, Early Management of Severe Trauma, Advanced
Trauma Life Support). For athletes requiring resuscitation it is essential to determine from
the onset of first aid, if there has been any trauma present. If there is uncertainty about the
presence or absence of trauma, assume trauma is involved and treat accordingly (Table 2).
Table 1: On Field Approach to Injury
Injuries can be   Action 
Minor cuts/abrasions/sprains/cramps Return to game
Moderate sprains (swelling, pain,↓ Treat on site/later refer

ROM)
Severe severe pain, swelling,  Expert medical care

   
deformity (sprains, fractures, 

dislocations)
Life threatening stroke, head/neck injury, heart  Resuscitate

attack

Use:
A airway
B breathing
C circulation

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

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

Treat.

(Modified from Fig 1 Chapter 5 The Fallen Athlete in Sports Medicine Problems and
Practical Management GMM London p63)

Table 2 :Are they conscious?

  NO YES  
Call for Help STOP

(Dial Emergency) Stop, Talk, Observe, Prevent

Trauma Related?  

 
 NO YES
Assess-A B C Secure Airway with neck immobilization

Initiate CPR Assess breathing

Remove from further danger Assess circulation

Assist emergency medical services Control external bleeding

Ensure rapid transport to definitive care Remove from further danger

Assist emergency medical services

 
Ensure rapid transport to definitive care

  Care of the collapsed or seriously ill athlete  

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

• the early resuscitation and stabilization of the seriously ill patient

• the rapid delivery of the patient to definitive care.

This is best achieved when bystanders ‘call for help’ as the initial step in the caring for the
seriously ill patient. If 2 or more bystanders are present, one person should dial the
Emergency telephone number, whilst the other commences CPR.
Relate clear information regarding the location of the patient, and any other information
requested by the operator.

For the infant or child, in arrest, the most likely cause is an airway problem. Here it is best to
commence CPR, then call for help.
‘Call for help’ also implies gaining assistance at the scene, before the ambulance arrives.
Even for people experienced in resuscitation, CPR is always easier with 2 or more people
lending help. Don’t hesitate seeking help.

Commencing early CPR

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

Secure the airway

Firstly clear the airway, and then open the airway.

Clear the airway means removing any foreign bodies from the airway including dentures,
broken teeth, food, vomit or blood. This is done by the finger sweep, although care must be
taken not to dislodge ant loose teeth, especially in young children. If available a suction
device should be used. After clearing the airway, it may need to be opened by a combination
of extending the head, chin lift and jaw thrust (not neck extension as this may damage the
cervical spine).An oropharyngeal airway (Geudel’s airway)should be used.

Assess and ensure breathing (rescue breathing or expired air resuscitation)

To assess the presence/ absence of breathing look for movement of the chest with
inhalation and exhalation, feel for chest movement and listen for the air movement.
If there is no evidence of breathing, rescue breathing should be commenced immediately.
This is commenced with 2 slow breaths, by the mouth-to mouth technique, ensuring that the
chest rises(Fig 4). If possible use a mouth to mask device-to reduce the risk of infection.
The rates and ratios of external cardiac compression and rescue breathing are: Ventilation-
15 breaths/min, Chest compressions 80 to 100 compressions/min and a ratio of 15
breaths/2 compressions (when one rescuer) and 5/1(when two).

Assess and maintain circulation (external cardiac compression)

To assess the circulation feel for the carotid pulse in the neck at the angle of the jaw. If the
pulse is present, but the patient is not breathing spontaneously, continue rescue breathing at
a rate of 15 breaths per minute, until either help arrives or spontaneous breathing
commences.

If there is no detectable carotid pulse, commence external cardiac compression (ECC)

immediately. The hands are placed on the lower third of the sternum, with the arms locked at
the elbows and the rescuer kneeling over the patient (Fig.5). Compressions are
approximately 5 cm deep in the adult, at a rate of between 80 to 100 compressions per
minute. Tiring work (if needed over a prolonged period), so don’t delay in getting help from
bystanders (change every few minutes).

To determine the adequacy of ECC, feel for the carotid pulse, and after every 2 minutes of
full CPR, check whether there is spontaneous breathing and circulation. Continue full CPR
until either help arrives, or there is return of spontaneous circulation.
 Stabilization and Transport
When pulse and breathing have returned place in the coma position until help arrives
(patient semi-prone, hands under head, upper knee bent forward in front of lower). Check
airway patency, breathing and circulation frequently and respond to any deterioration. Then
transport.

The seriously injured athlete

This is to that of the seriously ill athlete, with several points of note. The system taught in
Advanced Trauma Life Support and the Early Management of Severe Trauma courses, is
easy to remember (Table 3).
Remember the following:

Remove from danger, in order to prevent further injury. While doing so it is essential to
protect the patient’s neck, to prevent any trauma to the cervical spine and spinal cord (hold
the neck firmly without any movement as when removing a football helmet).

Airway management include care of the cervical spine. In the non-injured patient, one of the
first airway opening manoeuvres is to extend the neck. This should not done in the injured
patient, especially if unconscious, as it may damage the cervical spine. All airway clearing
manoeuvres must be accompanied by in-line cervical immobilization. The neck should be
immobilized with a rigid cervical collar.

In controlling the circulation, control blood loss. Use direct pressure. Do not use limb
tourniquets (may cause arterial or nerve damage). Immobilize long bone fractures,
especially of the femur (Donway splint)to reduce blood loss and control pain.

In the unconscious, injured athlete always consider severe head injury. These patient need
rapid stabilization and transfer to a hospital for life threatening intracranial bleeding (urgent
operation).

  Table 3:The approach to the severely injured athlete.  

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

Primary Survey Airway and cervical spine Immobilize head and neck

immobilization with in-line stabilization.

Clear air-way

Open air-way, remember not

to extend neck
  Assess and ensure adequate Commence rescue breathing
 breathing/ventilation
  Control bleeding and control Apply pressure to external

circulation bleeding

Commence external chest

compressions, if NO pulse
  Assess disability (neuro loss) If unconscious, assume major

head injury and transport to

hospital ASAP

If unable to move arms or

legs, assume spinal injury

(DO NOT MOVE until further

help arrives)
  Control environment Remove from danger

Prevent excessive heat loss if

injured

Gather information about

series of causative events

Resuscitation Fix any immediate life-  
threatening problems from

primary survey
   
 
Secondary Survey Done in hospital Examine all systems

Head to toe, front to back Good history

Examination looking for Allergies

injuries. Medications

Includes x-rays and blood Last tetanus

tests. Last ate

Events of injury
Stabilization and transport Re-assess ABC, before moving Transport to hospital-ASAP

Splint any limb injuries

  Exercise testing and prescription  

The purpose of an exercise prescription is to enhance physical fitness, reduce risk factors
and ensure safety during exercise. In regard to intensity of exercise consider level of fitness,
current medications, risk or cardiovascular or orthopaedic injury, individuals preference and
objectives. Can use target HR range as guide(Target HR range=[(HR max- HR rest) x 0.5
 and 0.85] +HR rest).
METS are a useful concept of judging the energy costs of various sports (Table 4)for fit
athletes.

Table 4:METS for various Sports

Data from Table 7-3 p164 ACSMs Guidelines for Exercise Testing and Prescription 5th Ed.
W Larry Kenney Williams and Wilkins PA 1995
   

Note: METs x 3.5 x body weight(kg)/200=kcal/min

Exercise duration:20-60 mins continuous aerobic activity(ACSM recommendation)

Exercise frequency: Where functional capacity<3METs then multiple short daily sessions; 3
to 5 METs use 1-2 sessions/day;>5METs use 3to 5 sessions/week.

Progression of exercise: Initial(weeks 1 to5)at 60-70%VO2max for 12-20 mins duration;

Improvement(weeks 6-27) at 70-80%VO2max for 20-30 mins duration and
Maintenance(after 28 weeks)at 70-85%VO2max for 30-45 mins.
Muscular flexibility guidelines:
Frequency: 3 sessions/week
Intensity: To mild discomfort
Duration: 10-30 secs each stretch
Repetitions: 3 to 5 each stretch
Type: Static

Muscular Fitness(resistance training).Gain strength with weights near max ,gain endurance
with greater number of repetitions. Dynamic exercise are better for adults. For fit adult
perform 8 to 10 exercises for major muscle groups, set of 8 to 12 repetitions and 2 days per
week.

Supervised where athlete has >2 CAD risk factors or functional capacity <8METs.

The benefits of regular physical activity are now well established:

-Improved cardiorespiratory function (*max oxygen uptake,*myocardial oxygen cost for a
given task,*HR and BP for a task,*exercise threshold for accumulation of lactate,*threshold
for onset of disease e.g. angina)
-Reduction in CAD Risk Factors(*HBP both syst and diast.,*serum HDL cholesterol,*serum
triglycerides,*body fat,*insulin needs with better glucose tolerance)
-Decreased Mortality and Morbidity(Primary Prevention as lower fitness is associated with
*CAD, Secondary Prevention showing *longevity and post-MI have *cardiovascular
mortality)
-Other (*anxiety,*well-being,*performance at work/recreation/sport)

In general, it’s a matter of ‘getting more people more activity more of the time’. Exercise will
also lessen the impact of many chronic diseases(all-cause mortality, CAD, HBP, Obesity,
Stroke, Cancer Colon, Non –Insulin Diabetes, Osteoporosis).

Health screening prior to sport

This important for safe participation in sport. It:

• -identifies individuals at risk

• -defines a need for supervision of sport

• -clarifies special needs

It must be cost and time effective (the PAR-Q from the ACSM is in appendix A). Risk
stratification is possible (into Apparently Healthy-healthy with no more than one coronary risk
factor; Increased Risk-possible cardiopulmonary disease or metabolic disease and/or two or
more; Known Disease-known cardiac, pulmonary or metabolic problems).

Cardiac patients should be further stratified into low, moderate or high risk groups (use
either the American College of Physicians or the American College of Cardiovascular and
Pulmonary Rehabilitation systems, Table 5).

Table 5:Risk Stratification for Cardiac Patients. ,

Low Risk

○ Uncomplicated MI ,CABG , angioplasty, atherectomy

○ Functional capacity > or= 8METS 3weeks after event

○ No (resting or exercise-induced)ischaemia/left ventricular

dysfunction(EF>50%)/ complex arrhythmias

○ Asymtomatic at rest with exercise tolerance OK for most requirements

Moderate Risk

Functional capacity <METS 3 weeks after event

• Shock or CHF during recent MI (<6 months)or EF< 31 to 49%.

• Failure to comply with exercise advice

• Exercise- induced ST-segment depression <1-2mm or reversible ischaemic defects

High Risk

• Severely depressed LV function(EF<30%)

• Resting complex ventricular arrhythmias (low grade IV or V) or with exercise

• PVCs with exercise

 • Exertional hypotension(*sys by>15 mmHg with exercise or failure to rise with
exercise)

• Recent MI (<6 months)complicated by serious ventricular arrhythmias/CHF/shock.

• Exercise-induced ST-segment depression >2mm

• Survivor of cardiac arrest

Pre-test evaluation

Performed prior to exercise testing:

○ History(standard and include exercise and work history)

○ Physical Exam(standard)

○ Blood Tests(cholesterol, fasting glucose, blood chemistry)

○ Other (ECG, CXR, PFTs, other tests as indicated).

No exercise test when recent ECG change, recent MI, unstable angina, ventricular or atrial
arrhythmia, third degree hear block without pacemaker, acute CHF, severe aortic stenosis,
dissecting aneurysm, myocarditis, pericarditis, thromphlebitis, thrombi, PE, acute infections,
emotional stress

Relative contraindications are BP at rest>200/115,valvular heart disease, electrolyte

problems, fixed pacemaker infrequent ventricular ectopic, ventricular aneurysm, uncontrolled
metabolic disease, chronic infectious disease, advanced/complicated pregnancy,
musculoskeletal disease aggravated by exercise

Physical fitness testing

Wear comfortable clothing, be rested/hydrated and fed beforehand. No coffee, food, alcohol
for 3 hours prior.

Measure body composition (hydrostatic weighing, skinfold measures, height, weight, girth).

Measure VO2 max (open circuit spirometry) using maximum-effort (for the fit) and
submaximum for most using a cycle ergometre (use the ACSM Health/Fitness Instructor(sm)
examination).

Other methods are the Submaximal treadmill tests (Bruce and Balke protocol), 3min Step
tests (YMCA protocol) and Field Tests (Cooper 12-minute test and the 1,5 mile test for time).

Stop test when angina, drop in sysBP>20mm or does not rise with exercise, BP
rises>260/115,poor perfusion, change heart rhythm, wants to stop, severe fatigue, failure of
equipment.

Muscular fitness

Measure muscular strength (in Newtons) can be measured in static mode (cable
tensiometres, handgrip dynamometres) or in dynamic mode(1-RM the heaviest load that can
be lifted once, warm up permitted, use bench press or military press or for lower limb-leg
 press). Isokinetic testing uses equipment which allows control of the speed of joint
rotation(measure torque).

Muscular endurance

The measure of a muscle group to perform repeated contractions over a set time to cause
fatigue. Use the 60 sec sit-up test or the maximum number of push-ups performed without
rest. Can also use resistance training and isokinetic equipment(such as the YMCA bench
press test with 30 repetitions/min and 80lb-barbell for men and 35lb for women).

Flexibility (ability to move a joint through ROM).

Measure with goniometre, Leighton flexometre, the shoulder elevation test, ankle flexibility
test, trunk flexion (sit-and-reach)test and trunk extension test. Use ACSM Fitness Book for
list of good stretches.

Prescription for cardiac and pulmonary patients

This is beyond the realm of this text, refer to the ACSM’s Guidlelines for Exercise Testing
and Prescription(Williams and Wilkins PA 1995). Ed W Larry Kenney.

Conditions limiting sports participation

Firstly classify sports contact versus non-contact(Table 6):

Table 6:Contact versus Non-contact

Adapted from Committee on Sports Medicine 1988 Pediatrics 81 737

  Guidelines for particular sports (Table 7)  

Table 7
Collision Limited Strenuous Somewhat Non-

strenous Strenous
Atlantoaxial instability N N Y (for Y Y

swimming-no

butterfly,

breast stroke

or diving

starts)
Acute illness *individual * * * *

assessment required
Cardiovascular-carditis N N N N N
-HBP mild Y Y Y Y
Mod or severe * *
Congenital Heart Dis Mild form can perform all, where Moderate or severe

see cardiologist

first.
Eyes

-one eye: use approved

eye guards and consult

opthalmologist first.

-detached retina:

consult opthalmologist
Inguinal hernia Y Y Y Y Y
One kidney N Y Y Y Y
Enlarged Liver N N Y Y Y
Orthopaedic problems-

individual assessment
Neurological Problems Individual Individual Y Y Y

-previous serious assessment assessment

head/spine injury,

repeated concussions

or craniotomy.

See chap 5
-well controlled Y Y Y Y Y
-poorly controlled N N Y(no Y Y(no archery

swimming or or shooting)

weight lifting)
Ovary-one Y Y Y Y
Respiratory * * * * Y

-pulmonary

insufficiency*maybe OK

if oxygenation remains

satisfactory during a

graded stress test

-asthma Y Y Y Y Y
Sickle cell trait Y Y Y Y Y
 Skin boils, herpes, * * Y Y Y

impetigo, scabies* no

gymnastic with mats,

martial arts, wrestling or

contact sports until no

longer contagious
Spleen enlarged N N N Y Y
Testicle one or Y(with Y(with cup) Y Y Y

undescended protective cup)

Y=yes, N=no

From Comm on Sports Medicine Paediatrics 81 738 1988

Legends

Fig 4 Rescue(mouth-to-mouth) breathing. Watch the chest move as you maintain the airway. (Reproduced,

with permission, from Chapter 5 ,The Fallen Athlete By Stuart Stapleton, (1997) in Sports Medicine Problems

and Practical Problems Eds E Sherry D Bokor GMM London Fig 9,p66)

Fig 5 Technique of CPR. Hands over lower one third of sternum, elbows locked, rescuer kneeling over patient.

(Reproduced, with permission, from Chapter 5 ,The Fallen Athlete By Stuart Stapleton, (1997) in Sports

Medicine Problems and Practical Problems Eds E Sherry D Bokor GMM London Fig 12,p68)
 

RW Squires 1985 Moderate altitude exposure and the cardiac patient J Cardiopulmon Rehab 5 421-426

E Sherry 1984 Skiing injuries in Australia Med J Aust 140 530-531

E Sherry 1986 Factors determining the severity of skiing trauma MPH thesis University of Sydney

RA Hahn SM Teutsch RS Paffenbarger JS Marks 1990 Excess deaths from nine chronic diseases in the

US,1986 JAMA 264 2654-2659

Chaps 1 to 3 1995 in ACSMs Guidelines for ExerciseTesting and Prescription 5th Ed Ed W Larry Kenney

Williams and Wilkins Phila p1-48

CAD risk factors are Age(M>45,F>55);Family History(MI or sudden death before 55 of male or65 for female

relative);Cigarette smoker;HBP(.>140/90);*chol(>200 mg/dl);Diabetes mellitus(IDDM >30 years or NIDDM>35

years);Sedentary

Health and Policy Comm,Am Coll Physicians,Cardiac Rehab Service 1988 Ann Int Med 15 671-673

Am Assoc of Cardiovascular and Pulm Rehab 1994 Guidelines for Cardiac Rehab Programs 2nd Ed Human

Kinetics Books IL

Actual tests described in:LA Golding CR Myers WE SimpsonEds 1989 Y’s Way to Physical Fitness 3rd Ed

Human Kinetics Pub IL