When you check an athlete for breathing, look, listen, and feel for no longer than

Int J Sports Phys Ther. 2011 Sep; 6(3): 267–270.

Abstract

During the initial assessment of the injured athlete, the Sports Physical Therapist (PT) must first be concerned with life-threatening emergencies such as absence of breathing and pulse. The sports PT must also be aware of the possibility of “sudden cardiac death” that could occur in others, including coaches, officials, and fans. If the PT assumes the role of “most medical” person at the contest or event, the responsibility for life saving action falls squarely on their shoulders. Therefore, skills and ongoing certification in cardio- pulmonary resuscitation techniques and the use of an automated external defibrillator are a basic necessity. These skills are required as part of the specialty practice of sports PT (BLS Healthcare Provider course or CPR for the Professional Rescuer in addition to completion of the First Responder Course OR credentials as an EMT or ATC), and are mandatory for being qualified to sit for the exam to become a sports certified specialist (SCS) by the American Board of Physical Therapy Specialties (ABPTS).3

Keywords: automated external defibrillator, cardiopulmonary resuscitation and emergency response

INTRODUCTION

During the initial assessment of the injured athlete, the Sports Physical Therapist (PT) must first be concerned with life-threatening emergencies such as absence of breathing and pulse. If the athlete is conscious and talking, the athlete has a pulse and is breathing. However, should the athlete be found unconscious on the field or court, the initial concern of the sports PT should be the immediate threats to the life of the athlete. There are numerous reports of athletes suffering “sudden cardiac death” while participating in both competition and practice situations.1,2 The sports PT must also be aware of the possibility of “sudden cardiac death” that could occur in others, including coaches, officials, and fans. If the PT assumes the role of “most medical” person at the contest or event, the responsibility for life saving action falls squarely on their shoulders. Therefore, skills and ongoing certification in cardio-pulmonary resuscitation techniques and the use of an automated external defibrillator are a basic necessity. These skills are required as part of the specialty practice of sports PT (BLS Healthcare Provider course or CPR for the Professional Rescuer in addition to completion of the First Responder Course OR credentials as an EMT or ATC), and are mandatory for being qualified to sit for the exam to become a sports certified specialist (SCS) by the American Board of Physical Therapy Specialties (ABPTS).3

SIGNS AND SYMPTOMS OF CARDIAC EMERGENCY

The most noticeable symptom of a heart attack is complaint of persistent chest pain or pressure in the chest. These symptoms are often ignored as related to indigestion, muscle spasms, chest cold, or other chest related maladies. However, in athletes who experience cardiac events during participation, these symptoms are typically absent and the first symptom is loss of consciousness for no apparent reason during a game or a practice session. Sudden cardiac emergencies, although uncommon, must be recognized as critical, and the prepared provider must have a plan for management of these situations. The PT must take immediate action in the evaluation of the athlete by determining if a pulse and/or respiration is present. If no respiration is present, the pulse will soon fail.

CARDIOPULMONARY ASSESSMENT AND RESUSCITATION

All PT's should be competent in performance of cardiopulmonary resuscitation (CPR) and should maintain CPR certification. The direction “Look, Listen, and Feel” for air moving in and out of the lungs of the athlete is the standard for determining respiratory effort. Should no respiratory effort be noted, the airway of the athlete must be opened by extension of the cervical spine and tilting the head in a posterior direction. If there is any concern about an injury to the cervical spine, the chin lift-jaw thrust maneuver should be used. If no movement of air is detected, rescue breathing must be initiated using mouth to mouth technique, or through the use of a barrier such as a resuscitation mask in order to provide the flow of oxygen into the lungs of the victim. Two rescue breaths are the standard, making certain the chest rises with each breath. The PT should then check the carotid pulse to determine if a pulse is present.

Should no pulse be detected, immediate initiation of cardio-pulmonary resuscitation (CPR) is initiated after calling 911 or sending someone to make the call to 911. The correct hand position on the chest is found by locating the xiphoid process or the tip of the sternum, place your middle finger on the notch and place your index finger next to your middle finger. Next, place the heel of your hand next to your middle finger. Once your hand is in position, place your other hand on top of the first hand and interlock you fingers using the top hand to keep the fingers of the lower hand off the chest. Position yourself directly over the chest of the victim with your elbows locked and the weight of your trunk over your elbows. (Figure 1) Begin 30 compressions at the rate of 100 compressions per minute. For an adult, compress the sternum at least 2 inches. For a child, the compressions should be to a depth of about 2 inches, and for an infant the depth of compression should be about 1 1/2 inches. Continue at the rate of 30 compressions to 2 breaths for approximately 2 minutes, then recheck breathing an pulse. All sports PT should have specialized training in one person, two person and three person CPR as well as airway insertion, use of a bag-valve-mask resuscitator, and oxygen administration. In athletic settings, this is continued until the arrival of a medical response team.

Proper hand placement for CPR, note proper elbow position as well.

THE AUTOMATED EXTERNAL DEFIBRILLATOR

AEDs are portable electronic devices that have the capability of analyzing heart rhythm and delivering a shock to the heart when indicated. (Figure 2) The AED can greatly increase the likelihood of survival if administered soon enough, in fact reducing the time to defibrillation after an event improves survival in out of hospital cardiac arrest situations.5 Most experts recommend a three (3) minute “drop to shock” application to increase the likelihood of survival.4,5 There are a number of AED manufacturers today, however, most AED's have common features such as visual displays, auditory prompts, and lighted buttons with instructions as to when to deliver a shock if indicated. The AED will determine if there is a “shockable rhythm” in the heart that will respond to defibrillation. These units give specific demands related to the use of the AED as well as reminders to call 911, open the airway, check for pulse, beginning CPR, etc. Most AED's come with specified pads to be used with the unit. (Figure 3) AED manufacturers have simplified the units to make safe and efficient operation very simple. Special training is required for the use of the AED to assure safe and effective application of the shock. AED training is obtainable at CPR/AED courses or as a part of the Emergency Responder preparation course.

Automated External Defibrillator (Zoll AEDPLUS, Dixie Medical Inc., Franklin, TN).

AED pads out of the box (Zoll AEDPLUS pads, Dixie Medical Inc., Franklin, TN), note scissors and razor for use prior to application.

All PT's should also be trained in the use of an Automated External Defibrillator (AED). In the clinic area, an AED should be available to all clinicians and staff members, who should also be educated in the proper use of the AED. Recall the three (3) minute “drop to shock” rule in the event of a cardiac emergency. This applies not only on the athletic field or court, but also in outpatient clinical settings. Should a patient in the clinic show signs of cardiac distress, a call to 911 is indicated and immediate application of the AED should be carried out, even if the victim is conscious and alert. Do not wait until the victim loses consciousness as a result of a cardiac emergency in order to apply the AED. Remember, the AED functions as a diagnostic tool; if a normal sinus rhythm is present, the AED will not allow a shock to be delivered. Should a shockable rhythm be noted by the AED, the AED can be promptly utilized to attempt to restore normal sinus rhythm.

The competent use of an AED is an essential part of the practice of sports PT. (Figures 4, ​5) The presence of the AED is indicated on the sidelines or at courtside of athletic events. According to the consensus task force authors, “in any collapsed and unresponsive athlete, SCA [sudden cardiac arrest] should be suspected and an AED applied as soon as possible for rhythm analysis and defibrillation if indicated”.5, p. 56 The likelihood of the use of the AED on athletes is minimal compared to the potential use of the AED on game officials, coaches, and those individuals in attendance at the athletic event. Many times, the sports PT is the “most medical” person present and would be looked upon as the individual to respond to a cardiac emergency. The presence of the AED makes response more effective and efficient. In fact, the authors of the consensus statement published in 2007 stated that prompt recognition of emergent situations , access to an AED for early defibrillation, coordination of onsite responders and AED training programs, and presence of a trained rescuer all increase the possibility of successful management of a sudden cardiac incident.5

Improper application of AED pads (upside down).

Proper application of AED pads.

CONCLUSIONS

The practice of sports PT requires quick decision-making in emergent conditions. This includes competency in providing CPR and in the use of an AED when indicated. Whether in a clinic or sideline/court setting, the sports PT must have a plan for managing any sudden cardiac event or other emergent condition that may occur, in athletes and/or patients, as well as spectators and others present at contests. Table one provides a summary of the progression of a typical emergency response. (Table 1).

Table 1.

Basic AED Protocol.

REFERENCES

1. Lorridhaya PStephen Huang SK. Sudden cardiac death in athletes. Cardiology. 2003;100:186–195 [PubMed] [Google Scholar]

2. Hedrich OEstes M. Sudden cardiac death in athletes. Curr Cardiology Rep. 2006;8:316–322 [PubMed] [Google Scholar]

3. American Red Cross Emergency Medical Response. Staywell Health and Safety Solutions, Yardley, PA; 2011 [Google Scholar]

5. von Alem JDVrenken RHdeVos RTijssen JGKoster RW. Use of AED by first responders in out of hospital cardiac arrest; A prospective controlled trial. BMJ. 2003;327:1312–1317 [PMC free article] [PubMed] [Google Scholar]

6. Dresner JACourson RWRoberts WOMosesso VNLink MSMaron BJ. Inter-association task force recomendtion in emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: A consensus statement. Heart Rhythm. 2007;4:549–565 [PubMed] [Google Scholar]

Articles from International Journal of Sports Physical Therapy are provided here courtesy of North American Sports Medicine Institute