Presented by: Dr.

Anna
Zaheer, PT
UIPT, UOL
Presented by: Dr. Anna Zaheer, PT
UIPT, UOL
 Compression of lumbosacral nerve roots below conus medullaris
secondary to large central herniated disc/extrinsic
mass/infection/trauma
 motor (LMN signs)
-weakness/paraparesis in multiple root distribution
-reduced deep tendon reflexes (knee and ankle)
-sphincter disturbance (urinary retention and fecal
incontinence due to loss of anal sphincter tone)
 sensory
anesthesia (most common sensory deficit)
-pain in back radiating to legs, crossed straight leg test
-bilateral sensory loss or pain: involving multiple
dermatomes
 Surgical emergency - requires urgent investigation and decompression
(<48 hrs) to preserve bowel and bladder function
Injury Vessel
1st rib fracture Sub-clavian artery/vein
Shoulder dislocation Axillary artery
Humeral supracondylar fracture Brachial artery
Elbow Dislocation Brachial artery
Pelvic fracture internal iliac
Femoral supracondylar fracture Femoral artery

Knee dislocation Popliteal artery/vein

Proximal tibial Popliteal artery/vein
Injury Nerve

Shoulder dislocation Axillary

Humeral shaft fracture Radial

Humeral supracondylar fracture Radial or median

Elbow medial condyle Ulnar

Hip dislocation Sciatic

Knee dislocation Peroneal

 Most commonly fractured sites.
 The most common type of distal radial fracture is the Colles’ fracture,
which is most often associated with falling on an outstretched arm with
the wrist in extension The force associated with this mechanism of injury
tends to displace fractured fragments dorsally.
Smith’s fracture.
This is volar displacement of distal fragments following injury. The
mechanism of injury usually associated with a Smith’s fracture is
characterized by falling on an outstretched arm with the wrist in flexion.
 Radial and ulnar shaft fractures are most often the result of a significant
direct force.
 Radial shaft fractures are more prevalent at the middle and distal third
because of the decreased cross-sectional area of the musculature.
 Fractures of the elbow result from blunt trauma or falling on a
outstretched arm.
 Median nerve is commonly injured with fractures to the distal humerus.

 If the brachial artery sustains an injury that is not appropriately managed

Volkman’s ischemic contracture may result.
 Treatment for distal humeral fractures include application of a comfortable
compressive dressing and immobilization of the elbow with a rigid long-
arm splint.
 If the lateral condyle is affected, splint the forearm in supination with the
wrist in extension so as to alleviate tension on the wrist extensor
musculature.
 If the medial condyle is fractured, the wrist should be splinted in pronation
and flexion so as to ease tension on the wrist common flexor tendon
 Displaced olecranon fractures routinely rupture the triceps aponeurosis
and subject the ulnar nerve to compromise.
 If fractures is non displaced, the affected forearm may be immobilized in a
long-arm splint with the elbow joint flexed to 70 degrees and the wrist
joint in neutral.
 Complications include cubitus valgus or varus deformity, malunion,
arthritis, and ulnar nerve palsy.
 Violent mechanisms of injury to the radial head and neck may occasionally
result in an Essex-Lopresti fracture.
 This pathology manifests as rupture of the interosseous membrane and
warrants immediate activation of EMS for comprehensive care.
Proximal humeral fractures typically occur as the result of trauma, most likely
secondary to falling on an outstretched arm.
These fractures may also occur from a direct blow to the lateral aspect of the
bone hold the involved arm in an adducted position.

 GHJ fracture-dislocations cause the anatomical area to be more susceptible

to related rotator cuff lesions and brachial plexus and axillary
neurovascular pathology.
 Complications include malunion healing, myositis ossificans ,secondary
GHJ stiffness, and arthritis tenosynovitis of rotator cuff .
 Fractures to the humeral shaft are most often a consequence of either direct
or indirect forces.
 Direct force:
 To the humerus, such as a violent blow, frequently results in a transverse
fracture of the bone.
 Indirect force:
 Landing on an outstretched arm or the elbow, will likely result in a spiral
fracture
 Fractures to the middle and distal third of the Humerus carry the potential
for radial palsy, scapular fracture may be associated with life-
threatening thoracic injuries.
 Fractures to the clavicle usually result from a direct force to the bone or
are secondary to a traumatic force imparted onto the lateral aspect of the
shoulder complex
 Discomfort typically intensifies considerably with passive and active
excursion of the shoulder complex, especially GHJ horizontal adduction.
 Sternal fractures result from high-energy trauma and usually from a blunt
force directed to the anterior thorax. Extreme trunk hyperflexion injuries may
also generate fractures of the sternum, although such injuries are rare.
 Physical examination includes
 Pain.
 Tenderness.
 Occasional crepitus may be present with palpation of the fractured bone.
 difficulty breathing, which may indicate significant cardiopulmonary contusion.
 Palpitations may be noted secondary to dysrhythmia.
 Pelvis
 Pelvic fractures, although a rare, pelvic fractures are most often
the result of violent mechanisms of injury typically result from
a fall from a significant height.
 Symptoms specific to pelvic fractures include extreme pain and
tenderness, hematuria indicating internal hemorrhage.
 Destot sign
 Indicated by formation of a hematoma above the inguinal
region.
 Roux sign
 Indicates bilateral distance discrepancies between the greater
trochanter and anterior superior iliac spines, signifying an
acetabular fracture.
 Intra pelvic compartment syndrome, digestive and reproductive systems
dysfunctions, and internal infections subsequent to disruption of urinary and
bowel structures.
 Femur:
 An extremely significant force is required to disrupt its integrity. immobilize
the affected extremity with a rigid splint.
 An open fracture should be irrigated, ideally with sterile saline solution,
followed with the application of a sterile dressing to shield the wound.
 Successful realignment of femoral fractures often requires intravenous
opoid analgesic administration for pain control. Femoral fractures are
generally effectively stabilized with implementation of a traction splint by
EMS personnel.
 The most common mechanism of injury for tibial and fibular fractures is
direct trauma and indirect torsional forces.
 Direct force to the tibia often produces a transverse or comminuted
displaced open fracture with associated fibular fracture.
 Indirect torsional mechanisms of injury may result in spiral or oblique
fractures and are less likely to yield displaced fragments or coupled soft
tissue pathology.
 Although vascular tissues are not commonly injured in these
circumstances, periodic assessment of dorsal pedal and posterior tibial
pulses and capillary refill are necessary to recognize the onset of acute
compartment syndrome. This includes noting any symptoms of
exaggerated pain, pallor, paresthesia, or paralysis.
 Ankle fractures typically refer to pathology of the distal tibia and fibula and
the talus and calcaneus.
 The most common mechanism of injury is hyper inversion of the joint.
Although the ankle joint is less susceptible to hyper eversion mechanisms
of injury, pathology subsequent to this specific mode tends to produce
significant damage open fracture occurs.
 Principal management of ankle fractures is dependent on multiple factors,
with the preservation of anatomical integrity and correct physiological joint
function being critically important in preserving later gait and weight
bearing function.
1. Emergency Care in Athletic Training by: Keith M.Gorse, Robert O. Blanc,
Francis Feld, Matthew Radelet, 1st edition, 2010, F.A Davis Company.
Presented by: Dr. Anna Zaheer, PT
UIPT, UOL
 Sudden cardiac arrest (SCA) is the sudden and unexpected cessation of
the heart’s pumping activity.

 The resultant lack of blood flow to the brain leads to unconsciousness in

about 20 to 30 seconds. If flow is not resumed, permanent brain damage
will begin to occur in 4 to 6 minutes, and the condition is generally fatal if
not treated in 10 minutes.
 When the heart is not pumping blood, there is no delivery of oxygen or
glucose to any of the body’s tissue—including the heart itself because the
heart tissue is perfuse by blood flowing from the aorta into the coronary
arteries. When sudden cardiac arrest results in death, it is termed sudden
cardiac death.
 The survival rate from SCA varies widely dependent on the specific setting
and the geographic location.

 Overall survival rate is about 5% to 7%.

 SCA presents with one of three cardiac rhythms:

 Ventricular fibrillation (VF).

 Pulseless electrical activity.

 Asystole.
 Ventricular fibrillation is the most common initial rhythm, occurring in
about 60% of cases when assessed by an on-site automated external
defibrillator (AED).

 This rhythm represents electrical chaos and usually not a mechanical

problem with the heart.

 It is the rhythm most amenable to treatment, which is a high energy shock

delivered to the heart called defibrillation.
 Pulse less electrical activity (PEA) is the term used for any other
electrocardiographic (ECG) rhythm, including normal sinus rhythm, when
there is no associated cardiac contraction.

 This may be amenable to treatment when a reversible condition is the

cause, such as hypovolemia or hyperkalemia, but the mortality from this
condition is higher than for VF.
 Asystole, or “flatline,” means the absence of any cardiac electrical activity
and therefore the absence of any mechanical cardiac function.

 Patients found in this rhythm have a grim prognosis, with most studies
reporting survival of only 0% to 2%.
 SCA should be differentiated from a “heart attack.” The medical term for a
heart attack is myocardial infarction. This condition results in the death of
some heart muscle resulting from total (or near total) occlusion of a
coronary artery.

 This is almost always a result of the acute formation of a blood clot at a site
of preexisting narrowing (atherosclerosis) in a coronary artery. A heart
attack predisposes to SCA but should be distinguished as a distinct process.
The risk of SCA is greatest in the first 2 hours after a myocardial infarction
and gradually diminishes over time.
 Because SCA is not a reportable disease and because there is no
standard criteria for listing the cause of death on death certificates,
the actual incidence of SCA is not precisely known.

 incidence in North America is likely 0.5 to 1/1000 persons, with the

lower rate reflective of more recent studies. Estimates ranging from
460,000/year to 200,000/year have been published.

 Despite this wide range, it is clear that SCA is the leading cause of
death in the United States, claiming more deaths than motor vehicle
crashes, fires, lung cancer and breast cancer combined!
 In the general population, SCA most often occurs in people age 50 to 75
years, which is consistent with the development of IHD and CHF. About 2/3
of people who experience SCA have CAD; SCA is often the first
manifestation of underlying heart disease.

 Exercise-related SCA has been defined as sudden cardiac arrest occurring

within 1 hour of participation in sport or exercise.

 Hypertrophic cardiomyopathy is most common, followed by congenital

coronary artery anomalies, aortic dissection or aneurysm from Marfan
syndrome, and valvular deformities.
 In about 2% of deaths, no structural abnormality can be found, and these
are considered primary arrhythmic deaths (often referred to as sudden
arrhythmic death syndrome [SADS] or autopsy-negative sudden
unexplained death [SUD]).

 These cases result from conditions that disrupt the electrical system on the
cellular level, including long QT, short QT, and Brugada syndromes and
familial catecholaminergic polymorphic ventricular tachycardia.
External factors may also directly cause or predispose to SCA. Most
prominent is the condition called commotio cordis, which is the provocation
of ventricular fibrillation or ventricular tachycardia by a blow to the anterior
chest over or near the heart , It happen in second half of T wave, known as
vulnerable period of repolarization.
 Hypertrophic cardiomyopathy
 Commotio cordis
 Coronary artery anomalies
 Left ventricular hypertrophy of indeterminate causation†
 Myocarditis
 Ruptured aortic aneurysm (Marfan syndrome)
 Arrhythmogenic right ventricular cardiomyopathy
 Tunneled (bridged) coronary artery‡
 Aortic valve stenosis
 Atherosclerotic coronary artery disease
 Dilated cardiomyopathy
 Myxomatous mitral valve degeneration
 Asthma (or other pulmonary condition)
 Heat stroke
 Drug abuse
 Other cardiovascular cause
 Long QT syndrome§
 Cardiac sarcoidosis
 Trauma causing structural cardiac injury
 Ruptured cerebral artery
 Proper cardiovascular screening.
 Physical examination.
 Assessment of congenital syndrome.
 Family history.
 Investigations.
Recognition of warning and signs
 Light headedness.
 Dizziness.
 Syncope or near-syncope.
 Chest pain or pressure.
 Palpitations (fluttering in chest).
 Nausea/vomiting (unrelated to other illness).
 Fatigue/weakness (disproportionate to baseline or to others).
 Shortness of breath.

Note:
These symptoms are particularly worrisome if they occur during
or immediately after exertion.
 SCA Awareness.
 Recognition of condition.
 Need for immediate action .
Response Planning:
 Every program should develop a written EAP.

 An effective plan is most critical for time-sensitive conditions, and none is

more time sensitive than SCA.
 Whether the SCA victim lives or dies is often determined by whether the
EAP was properly designed and implemented.
 The plan should be tested and verified in a variety of situations.
Equipments and supplies:

Equipment and supplies specific to management of SCA. These include the

following:
 Defibrillators.
 Ventilation aids.
 Telephone or other communication equipment to call 1122 and other
resources.
 Defibrillators are of two main types:

Manual
Automated
 This one must be used by medical personnel with specific training in
cardiac rhythm recognition an management and in operation of the
defibrillator. This type of defibrillator requires the user to interpret the ECG
rhythm and determine if an electric countershock should be delivered; if
so, the user must be able to set the energy level, activate the charging
process, and then push a button to deliver the shock.
The other type automated external defibrillator or AED.
These devices can be used by anyone, even without prior
training, although training is highly advised. These
portable, battery powered devices provide verbal and
visual prompts to the user once the device is turned on.
The most important user action is to place the two ECG
sensing defibrillation pads onto the proper locations on
the patient’s chest.
Some models require the user to push an “analyze” button
and/or a “shock” button to deliver the electric shock
(semiautomatic) and some perform analysis, charging, and shock
delivery without further user action (fully automatic).
 To analyze ECG waveform and determination of shock all AED’s
use computerized alogrithm.

 All models shock VF and rapid ventricular tachycardia (VT).

 At least one model has the capability to also perform

synchronized cardioversion of supraventricular tachycardia.
 The sensitivity is generally more than 90% (i.e., the device will
recommend shock at least 90% of the time when a shockable
rhythm is present).

 The specificity of these algorithms approaches 100% (i.e., it is

extremely rare that a shock is advised or delivered
inappropriately).
1. Emergency Care in Athletic Training by: Keith M.Gorse, Robert O. Blanc,
Francis Feld, Matthew Radelet, 1st edition, 2010, F.A Davis Company.
Presented by: Dr. Anna Zaheer, PT
UIPT, UOL
The right side of the heart receives deoxygenated
blood from the body which it then pump to the lungs
(through the pulmonary artery) where carbon dioxide
is exchanged for oxygen.

 Theleft side of the heart receives the oxygenated

blood from the lungs (through the pulmonary vein)
which it then pumps through the atrium to the
ventricle; from the ventricle the blood is pumped
through the aorta to the rest of the body.
 Uncomfortable pressure and squeezing, usually located in the center
of the chest

 Pain may spread to shoulders, arms, neck, and back (usually on the
left side)

 The pain is not always severe and may come and go (sharp,
stabbing twinges of pain usually are not signals of heart attack)

 Sweating, nausea, shortness of breath, feeling of weakness

◦ May occur in either sex, even young adults, and not necessarily
during physical or emotional stress.
 Help the victim into a comfortable position
◦ Sitting if he or she is short of breath
◦ Lying down if he or she is light headed

 Loosen clothing around neck and waist.

 Call an ambulance. Call 911!

http://www.pbs.org/wgbh/nova/heart/troubled.html
 Coronary Heart Disease – the blood supply to a part of the heart is blocked; that part of
the heart not receiving oxygen begins to die.

 Respiratory Arrest – breathing stops

 Cardiac Arrest – the heart has stopped

 Stroke – the blood supply to a part of the brain is blocked; those brain cells not receiving
oxygen begin to die.
Clinical Death
– means the heart and breathing have stopped.

Heart attack
– A sudden severe instance of abnormal heart function.

Brain Death
– Occurs 4-6 minutes after clinical death when the cells of the brain begin to die.

Biological death
- all systems cease to function. Organ systems have shut down and are no longer working
Successful resuscitation of the victim of SCA requires the
proper interventions to be provided in a very short time.
The actions that must occur have been called the “Chain of
Survival.”

 Early recognition of SCA and call to 1122

 Early CPR
 Early Defibrillation
 Early Advanced Life Support

The first three steps can—and in most situations must—be

provided by bystanders, who may or may not be medical
professionals.
 The most important determinant of survival of SCA is time to intervention.

 Thus the key of survival is recognition of this condition.

 SCA is of high concern when collapse occurs without contact or fall under
unprotected manner.

 Collapse is determined by calling verbally if unresponsive then gentle shake

or physical stimulate the unconscious person.
 Caution should take during spinal or head injury.

 Unresponsive person should me immediately supplied by EMS, CPR and

AED asap.
 A presentation of cardiac arrest that may confuse rescuers and lead to delay in providing CPR and AED
use is seizure-like activity.

 This may occur immediately after the onset of the heart stoppage as a result of low blood flow to the
brain. The seizure usually lasts only a minute or two and may be followed by agonal respirations,
which are intermittent gasping breaths.

 These should not be confused with a normal breathing effort and do not indicate that the person has
a heartbeat or is breathing adequately. It is imperative to recognize that the patient is in cardiac
arrest and not simply in a postictal state.
 Due to mouth to mouth resuscitation it is not much needed
but in advanced planning cases.

 Prevention from blood and body fluids to facilitate better

ventilation.

 Various face shields and masks to cover victims mouth and

nose and to provide a port to the rescuer.

 Nasopharyngeal and or oropharyngeal advanced airway

adjuncts need special training with ventilation bags that can
also provide oxygen.
 AED should be brought to the victim and used asap.

 Personnel should be trained to use.

 If AED advises not to shock the personnel should be realize to

begin or resume chest compressions immediately.

 The AED can only recognize whether the patient has a shock
able rhythm, not whether the person has a pulse.
 The AED should be allowed to reassess for a shockable rhythm after every 2 minutes
of CPR or as per current guidelines.

 For children of age 1-8yrs, AEDs have specific defibrillation pads or other
modification to decrease the delivered energy.
 Until more advanced provision of care CPR and AED must be continued.

 It should be reported to the EMS personnel or care provider what actually happened
exactly before collapse or any medical conditions or medications.
 As part of the emergency action plan, all organized programs should have a reporting
system for medical emergencies.

 Document any known circumstances leading to the event, exactly what the examination
findings were, what care was rendered, and who assumed care of the victim.

 Times for key events should be documented as best as possible. AED is synchronized to a
known time source.

 Key events include time collapse recognized, time help arrived, time AED was used, time
of any specific interventions, and time when advanced help arrived.
 After incident the documentation is completed by every involved part and AED data is
retrieved.

 Team physician, the EMS medical director or another physician experienced in

emergency care, trainers, other responders and support personnel.

 All aspects of the EAP should be reviewed.

 Future incidents planning.

 Assessment of system factors, communication capabilities and accessibility of the

AED.
 Feedback should be provided to the responders which comprises commendation for actions well
done, constructive recommendations for areas of improvement, and information on the disposition of
the patient.

 The benefit of responders participating in a Critical Incident Stress Management (CISM) or similar
program should be considered, especially for incident involving a death or other significant stressors.
1. Emergency Care in Athletic Training by: Keith M.Gorse, Robert O. Blanc, Francis Feld, Matthew
Radelet, 1st edition, 2010, F.A Davis Company.
Presented by: Dr. Anna Zaheer, PT
UIPT, UOL
 Cerebral concussion can be defined as any transient
neurological dysfunction resulting from an applied force to the
head.
Coup injury:-
Usually produces maximum brain injury beneath the
point of cranial impact. This is known as a coup
injury.
When the head is stationary prior to impact, there is
neither brain lag nor disproportionate distribution of
CSF, accounting for the absence of contrecoup injury
and the presence of coup injury.
Contrecoup injury:-
A moving head hitting against an unyielding object
usually produces maximum brain injury opposite the
site of cranial impact (contrecoup injury) as the brain
rebounds within the cranium.
This brain lag actually thickens the layer of CSF under
the point of impact, which explains the lack of coup
injury in the moving head injury.
 If a skull fracture is present, the first two scenarios do not
pertain because the bone itself may absorb much of the
trauma energy or may directly injure the brain tissue.

 If the energy absorption is transient, a linear fracture may

result.

 If the absorption is permanent, a depressed fracture may

result.

 Focal lesions are most common at the anterior tips and the
inferior surfaces of the frontal and temporal lobes because
the associated cranial bones have irregular surfaces.
 Three types
of stresses can be generated by an applied force
when considering injury to the brain: compressive, tensile, and
shearing.

 Compression involvesa crushing force whereby the tissue

cannot absorb an additional force or load.

 Tension involves pulling or stretching of tissue, and shearing

involves a force that moves across the parallel organization of
the tissue.

 Uniform compressive stresses are fairly well tolerated by

neural tissue, but shearing stresses are very poorly tolerated.
Focal brain injuries are post-traumatic intracranial mass
lesions that may include subdural hematomas, epidural
hematomas, cerebral contusions, and intracerebral
hemorrhages and hematomas.

Detect signsof clinical deterioration or worsening

symptoms during serial assessments to classify the
injury and manage it appropriately.
Signs and symptoms of these focal vascular
emergencies can include loss of consciousness,
cranial-nerve deficits, mental-status deterioration,
and worsening symptoms.

Concern for a significant focal injury should also be

raised if the signs or symptoms arise after an initial
lucid period in which the person seemed normal.
Diffuse brain injuries can result in widespread or
global disruption of neurological function and are not
usually associated with macroscopically visible brain
lesions except in the most severe cases.

The brain is suspended within the skull in CSF and has

several dural attachments to bony ridges that make up
the inner contours of the skull.
Most diffuse injuries involve an acceleration–
deceleration motion, either within a linear plane or in
a rotational direction, or both.

Inthese cases, lesions are caused by the brain

essentially being shaken within the skull.
With a linear acceleration–deceleration mechanism
(side to side or front to back), the brain experiences a
sudden momentum change that can result in tissue
damage.

The key elements of injury mechanism are the velocity

of the head before impact, the time over which the
force is applied, and the magnitude of the force.
Rotational acceleration–deceleration injuries are
believed to be the primary injury mechanism for the
most severe diffuse brain injuries.

Structural diffuse brain injury (diffuse axonal injury,

or DAI) is the most severe type of diffuse injury
because axonal disruption occurs.

Causes disturbance of cognitive functions, such as

concentration and memory.

In its most severe form, DAI can disrupt the brain
stem centers responsible for breathing, heart rate,
and wakefulness.
Traumatic Brain Injury (TBI).
TBI, can best be classified as a mild diffuse injury and
is often referred to as mild traumatic brain injury
(MTBI).
The injury involves an acceleration–deceleration
mechanism in which a blow to the head or the head
striking an object results in one or more of the
following conditions: headache, nausea, vomiting,
dizziness, balance problems, feeling “slowed down,”
fatigue, trouble sleeping, drowsiness, sensitivity to
light or noise, loss of consciousness, blurred vision,
difficulty remembering, or difficulty concentrating.
1- Depressed
Portion of the skull is indented toward the brain.
2- Linear
Minimal indentation of skull toward the brain
3- Nondepressed
Minimal indentation of skull toward the brain
4- Comminuted
Multiple fracture fragments
5-Basal/basilar
Involves base of skull
1. Concussion is caused by a direct blow to the head or
elsewhere on the body, resulting in a sudden mechanical
loading of the head that generates turbulent rotatory and
other movements of the cerebral hemispheres..

2. These collisions or impacts between the cortex and bony

walls of the skull typically cause an Immediate and short-
lived impairment of neurological function involving a variety
of symptoms. In some cases the symptomatology is longer
lasting and results in a condition known as postconcussion
syndrome.
3. Concussion may cause neuropathological changes or
temporary deformation of tissue; however, the acute clinical
symptoms largely reflect a functional disturbance rather than
a structural injury.

4. Concussion may cause a gradient of clinical syndromes that

may or may not involve loss of consciousness (LOC).
Resolution of the clinical and cognitive symptoms often
follows a sequential course but is dependent on a number of
factors including magnitude of the impact to the head and the
individual’s concussion history.

5- Concussion is most often associated with normal results on

Conventional neuroimaging studies, such as magnetic
resonance imaging (MRI) or computed tomography (CT) scan.
There are Several grading scales for classification
and managing cerebral concussions. None of the
scales have been universally accepted.

Most scales are based primarily on LOC and

amnesia.

Itis very important to consider other signs and

symptoms associated with concussion because
the majority of concussions will not involve LOC
or observable amnesia
 Concussion that can be checked off or graded for severity on
an hourly or daily basis following an injury.

 The graded symptom checklist (GSC) is best used in

conjunction with the Cantu Evidence-Based grading system for
concussion which very appropriately emphasizes signs and
symptoms other than LOC and amnesia in the grading of the
injury.

 Itis also important to grade the concussion after the person’s

symptoms have resolved because the duration of symptoms
are believed to be a good indicator of overall outcome.
Mild Concussion
 the most frequently occurring (approximately 85%), is the most
difficult head injury to recognize and diagnose.

The force of impact causes a transient aberration in the

electrophysiology of the brain substance, creating an alteration in
mental status.

 Although mild concussion involves no loss of consciousness, the

person may experience impaired cognitive function, especially in
remembering recent events (post-traumatic amnesia) and in
assimilating and interpreting new information.
 Dizziness and tinnitus (ringing in the ears) may also occur, but
there is rarely a gross loss of coordination that can be detected
with a Romberg test.

 Theclinician should never underestimate the presence of a

headache, which presents to some degree in nearly all
concussions.

 The intensity and duration of the headache can be an

indication of whether the injury is improving or worsening
over time.
 Moderate Concussion
The moderate concussion is often associated with
 transient mental confusion,
 tinnitus,
 moderate dizziness,
 unsteadiness.
 and prolonged posttraumatic amnesia (30 minutes).
 A momentary loss of consciousness often results, lasting
from several seconds up to 1 minute.
 Blurred vision, dizziness,
 balance disturbances, and nausea may also be present.
Severe Concussion
lasting significantly longer than those of mild and moderate
concussions.

blurred vision, nausea, and tinnitus are more likely to be

present. Most experts agree that a concussion resulting in
prolonged loss of consciousness should be classified as a
severe concussion.

classify
brief loss of consciousness (including momentary
blackout) as a severe concussion instead of the more widely
accepted moderate classification.

Thesevere concussion may also involve posttraumatic

amnesia lasting longer than 24 hours and some retrograde
amnesia (memory loss of events occurring prior to the injury).
 Compromised neuromuscular coordination
 Severe mental confusion
 Tinnitus
 Dizziness.
 LOC
 Amnesia
Grade 1 (Mild) No LOC PTA 30 mins, PCSS 24 hrs.

Grade 2 (Moderate) LOC 1 min or PTA 30 mins 24 hrs or

PCSS 24 hrs 7 days.
Grade 3 (Severe) LOC 1 min or PTA 24 hrs or PCSS 7
days

LOC, loss of consciousness; PTA, posttraumatic amnesia (anterograde/

retrograde); PCSS, postconcussion signs/symptoms other than amnesia.
1. Emergency Care in Athletic Training by: Keith M.Gorse, Robert O. Blanc,
Francis Feld, Matthew Radelet, 1st edition, 2010, F.A Davis Company.
Presented by: Dr. Anna Zaheer, PT
UIPT, UOL
The brain substance may suffer a cerebral contusion
(bruising) when an object hits the skull or visa versa.

The impact causes injured vessels to bleed internally,

and there is a concomitant LOC.

 A cerebral contusion may be associated with partial

paralysis or hemiplegia (paralysis of one side of the
body), one-sided pupil dilation, or altered.
vital signs and may last for a prolonged period.

Progressive swelling (edema) may further compromise brain tissue not

injured in the original trauma.

Even with severe contusions, however, eventual recovery without

intercranial surgery is typical.
 Bloodclots, or cerebral hematomas, are of two types, epidural and
subdural, depending on whether they are outside or inside the dura
mater.

 Eachof these can cause an increase in intracranial pressure and shifting

of the cerebral hemispheres away from the hematoma.

 Thedevelopment of the hematoma may lead to deteriorating

neurological signs and symptoms typically related to the intracranial
pressure.
Itis a heterogenous zone of brain damage that
consists of hemorrhage, cerebral infarction, necrosis,
and edema.

Sequela of head injury and is often considered the

most common traumatic lesion of the brain visualized
using imaging studies.

Typically,these are a result of an inward deformation

of the skull at the impact site.
Contusions can vary from small, localized areas of injury to large,
extensive areas of involvement.

Intracerebral hematomas are similar in pathophysiology and imaging

appearance to a cerebral contusion. The intracerebral hematoma, which
is a localized collection of blood within the brain tissue itself, is usually
caused by a torn artery from a depressed skull fracture, penetrating
wound, or large acceleration–deceleration force.
An epidural hematoma in a person most commonly results from a severe
blow to the head that typically produces a skull fracture in the temporo-
parietal region.

These injuries involving acceleration–deceleration of the head, with the

skull sustaining the major impact forces and absorbing the resultant
kinetic energy.

There isaccumulation of blood between the dura mater and the inner
surface of the skull as a result of an arterial bleed—most often from the
middle meningeal artery.
The hemorrhage results in the classic CT scan appearance of a biconvex or lenticular
shape of the hematoma.

These are typically fast-developing hematomas leading to a deteriorating

neurological status within 10 minutes to 2 hours.

The person may or may not lose consciousness during this time but will most likely
have at least an altered state of consciousness.

Theperson may subsequently appear asymptomatic and have a normal neurological

examination; this is known as a lucid interval.
The problem arises when the injury leads to a slow accumulation of blood
in the epidural space, causing the person to appear asymptomatic (lucid)
until the hematoma reaches a critically large size and begins to compress
the underlying brain.

 Immediate surgery maybe required to decompress the hematoma and to

control the hemorrhage.

The clinical manifestations of epidural hematoma depend on the type and

amount of energy transferred, the time course of the hematoma
formation, and the presence of concurrent brain injuries. Often the size of
the hematoma determines the clinical effects.
Complex mechanism.

The force of a blow to the skull thrusts the brain against the point of impact.

The Subdural vessels stretch and tear.

Venous in origin;

 Hematoma form after a longer period of time compared to an epidural

hematoma.

This pathology has been divided into acute subdural hematoma, which presents
in 48 to 72 hours after injury, and chronic subdural hematoma, which occurs in a
later time frame with more variable clinical manifestations.
As bleeding produces low pressure with slow clot formation, symptoms may
not become evident until hours or days (acute) or even weeks later (chronic),
when the clot may absorb fluid and expand.

The clinical presentation of a person with acute subdural hematoma can vary
and includes those who are awake and alert with no focal neurological
deficits,
typically individuals with any sizeable acute subdural hematoma have a
significant neurological deficit. This may consist of alteration of
consciousness, often to a state of coma or major focal neurological deficit.
Treatment for any person who has suffered LOC or altered mental status
should include prolonged (several days) observation and monitoring
because slow bleeding will cause subsequent deterioration of mental
status.

In such a case, surgical intervention may be necessary to evacuate

(drain) the hematoma and decompress the brain.
 These injuries are not usually associated with a lucid interval and are
often rapidly progressive; however, there can be a delayed traumatic
intracerebral hematoma.

 Intracerebral hematomas are the most common cause of lethal brain

injuries, along with subdural hematoma.
A special condition involves that of second impact syndrome (SIS). SIS occurs
when a person who has sustained an initial head trauma, most often a
concussion, sustains a second injury before symptoms associated with the first
have totally resolved.

Often, the first injury was unreported or unrecognized.

SIS usuallyoccurs within 1 week of the initial injury and involves rapid brain
swelling and herniation as a result of the brain losing autoregulation of its blood
supply.
 Brain stem failure develops in 2 to 5 minutes, causing rapidly dilating pupils, loss of
eye movement, respiratory failure, and eventually coma.

Unfortunately, the mortality rate of SIS is 50%, and the morbidity rate is 100%.
 Recognition of a concussion due a LOC.

 Unfortunately, 90% to 95% of all cerebral concussions involve no LOC, only a

transient loss of alertness or the presence of mental confusion.

Three primary objectives

1. Recognizing the injury and its severity through primary and secondary survey.
2. Determining if the person requires additional attention and/or assessment.
3. Deciding when it is safe for the person to return to activity.
A primary survey involving basic life support should be performed
first. This is easily performed and usually takes only 10 to 15
seconds as respiration and cardiac status are assessed to rule out a
life-threatening condition Once life-threatening conditions have
been ruled out, the secondary survey can begin.

The secondary survey specific to head injuries begins with the

clinician performing a thorough history. The history is thought to
be the most important step of the evaluation because it can
narrow down the assessment very quickly. The clinician should
attempt to gain as much information as possible about any mental
confusion, loss of consciousness, and amnesia.
Confusion can be determined quickly by noting facial expression (dazed,
stunned, “glassyeyed”) and any inappropriate behavior such as running
the wrong play or returning to the wrong huddle. Some physicians
monitor level of consciousness through the use of a neural watch chart
If the person is unconscious or is regaining consciousness but
is still disoriented and confused, the injury should be managed
similar to that of a cervical spine injury because the clinician
may not be able to rule out an associated cervical spine injury.

Therefore, the unconscious person should be transported

from the field on a spine board with the head and neck
immobilized.
Vital signs should be monitored at regular interval(1–2 minutes), as the
clinician talks to the person in an attempt to help bring about full
consciousness.

 If the person is in a state of lethargy or stupor or appears to be

unconscious, do not attempt to arouse the individual by shaking.
Shaking the person is contraindicated when a cervical spine injury is
suspected.
Ifloss of consciousness is brief, lasting less than 1 minute, and
the remainder of the examination is normal, the person may be
observed on the sideline and referred to a physician at a later
time.

 Prolonged unconsciousness, lasting 1 minute or longer, require

immobilization and transfer to an emergency facility so the
person can undergo a thorough neurological examination.
Perform amnesia testing by first asking the person simple questions
directed toward recent memory and progressing to more involved
questions.

 Asking the person for the first thing he or she remembered after the
injury will test for length of post-traumatic amnesia, also known as
anterograde amnesia.
Retrograde amnesia is generally associated with a more
serious head injury. Questions of orientation (name, date, time,
and place) may be asked

The person should also be asked if he or she is experiencing any

tinnitus, blurred vision, or nausea.
The clinician should use a concussion symptom checklist similar to that
found in to facilitate the follow-up assessment of signs and symptoms.

Portions of the observation and palpation plan should take place during
the initial on-site evaluation.
See for Deformities and abnormalities in facial expressions
(indicating possible compromise of cranial nerve VII),

speech patterns,

respirations
and movement of the extremities; all of this can
be performed while asking the person questions.
Gentle palpation of the skull and cervical spine should be performed to
rule out an associated fracture.

The person who is conscious or who was momentarily unconscious

should be transported to the sidelines or locker room for further
evaluation after the initial on-site evaluation.

 If the person is unconscious, moving and positioning should be done

carefully, assuming possible associated cervical injury
After maintainingairway can perform detail physical examination with
observation and palpation.

A quick cranial nerve assessment should first be conducted.

Visual acuity (cranial nerve II: optic) can be checked by asking the person
to read or identify selected objects (at near range and far range).
1. Emergency Care in Athletic Training by: Keith M.Gorse, Robert O. Blanc, Francis Feld, Matthew
Radelet, 1st edition, 2010, F.A Davis Company.
 Normal movement of cervical spine are flexion, extension,
rotation, and lateral flexion
 Extremes of these motions or to axial forces of either loading
or distraction are at high risk of experiencing permanent
neurological deficit, paralysis, or death.
 Injury may caused by direct or may occur indirectly as a result
of swelling compressing the spinal cord and disrupting its
blood supply.
 The posterior vertebral structures are compressed and the
anterior soft tissues will be stretched. Disruption of the disc,
along with compression of the interspinous ligaments or
fracture of the posterior vertebrae, is possible.
 Instability of the cervical spine may be present if there is
injury to the ligaments or fracture of the vertebrae.
 Cause fractures to the anterior body of the vertebrae,
stretching or rupture of the posterior longitudinal and
inter-spinous ligaments, compression of the spinal cord,
and disruption of the disc.
 Instability.
 Rotational injuries are much less common.
 Lateral flexion: Injuries from this mechanism would
cause compression fractures of the vertebrae on one
side and stretching or tearing of the ligaments and
muscle tissue on the opposite side may lead to
instability of the spine. The amount of force to cause
injury with lateral flexion is generally less than that
needed with extension or flexion injuries.
 A force is applied through the length of the spine, as
is the case when an person is struck on the top of the
head with the body fixed causing compression
fractures of the vertebrae, herniation of the disc, and
compression of the spinal cord.

 Distraction of the cervical spine is the opposite of

loading. This mechanism is most commonly seen in
hangings and causes stretching of the soft tissues
including the spinal cord.
 Damage to the soft tissues may adversely affect
the stability of the vertebral column, dislocation
or subluxation of one or more vertebrae to occur,
thus causing damage to the spinal cord.

 Fractures to any of the bony structures may also

cause instability, sharp bone fragments could
lacerate or completely transect the spinal cord,
resulting in permanent neurological deficit or even
death.
 Injuries to the spinal cord may be primary or
secondary.
 Primary injuries are those that occur as a direct
result of a traumatic event for which the effects are
immediate (e.g. a compression, stretching, or
transection of the spinal cord). Some primary injuries,
such as a neuro-praxia, are temporary in nature.
Others, such as a partial or total transection, are
permanent.
 Which effect the initial injury and is not immediately
apparent. Typically, occur after swelling and ischemia
have developed as a result of the trauma. The spinal
cord can be contused, in which (bruising of the tissue of
the spinal cord.)

 The damage is usually minimal and mostly from the

effects of swelling or bleeding.
PRIMARY SECONDARY

occur after swelling and ischemia

Immediate effect on function as a have
result of:
developed as a result of trauma

Delayed effect on function, usually

■ Compression as a result
■ Stretching of progressive or ongoing ischemia.
■ Laceration ■ Spinal cord contusion
■ Concussion of the spinal cord ■ Spinal cord compression
■ Spinal cord hemorrhage
 May be complete or incomplete
 A complete transection is one in which the spinal cord is
totally cut and the ability to send and receive nerve impulses is
therefore entirely lost.
 If the transection is incomplete, some fibers of the spinal cord
remain intact, which may allow for some function.
 Nerve roots exiting the spinal cord below the level of the
transection will no longer provide for function in the areas
they innervate.
 For example, injury below the T1 level will result in
incontinence and paraplegia and injuries in the
cervical region will result in quadriplegia,
incontinence, and possible respiratory paralysis.
  Three types:

ANTERIOR CENTRAL BROWN-

CORD CORD SEQUARD’S
SYNDROME SYNDROME SYNDROME
 Anterior cord syndrome is caused by a disruption of the blood
supply to the spinal cord as a result of compromise of the
arterial supply.
 This is usually secondary to bone fragments or a compressive
force preventing the supply of blood to the spinal cord.
 The prognosis in these cases is poor.
 Patient’s suffering anterior cord syndrome will present with a
loss of pain sensation and motor function, loss of light touch
sensation, and loss of temperature control distal to the level of
the injury.
 Most commonly seen as the result of a hyperextension injury.
It is often associated with a pre-existing condition of arthritis
or a narrowing of the vertebral canal.

 The results are motor weakness of the upper extremities

rather than the lower extremities and, possibly, loss of bladder
control.

 Of the three syndromes associated with incomplete

transections of the spinal cord, central cord syndrome has the
best potential for recovery.
 Caused by a penetrating injury that severe one side of the spinal cord.
 With loss of sensory and motor function on the affected side and loss of
pain and temperature perception on the opposite side. Unless the
penetration is direct, some recovery may be expected.
 Caused by trauma to the spinal cord. Spinal shock is a
temporary condition triggered as the body’s response to
injury.

 Identified when the body becomes flaccid and without

sensation, unable to move and appear to be paralyzed below
the level of the injury. It may be accompanied by loss of
bladder and bowel control.
 It is common for hypotension to be present as a
result of vasodilation.

 Spinal shock is a transient condition unless the spinal

cord has been seriously damaged.
 Occurs when the brain loses its ability to maintain control over
the rest of the body as a result of damage to the spinal cord

 Assessment
 Determine mechanism of injury if possible
 Determine level of consciousness
 Manually stabilize head and neck of injured athlete
 Determine level of consciousness; if unconscious, activate
emergency medical service.
 Check ABCs.
 This may require rolling a prone person.
 Activate EMS, manage airway, and begin CPR if necessary.
 Perform secondary assessment.
 Continue to monitor vital signs for changes.
1. Emergency Care in Athletic Training by: Keith M.Gorse, Robert O. Blanc,
Francis Feld, Matthew Radelet, 1st edition, 2010, F.A Davis Company.
On-Field Secondary Assessment
1. Palpation of neck: pain, obvious deformity
bleeding, spasm
2. Motor testing of upper extremities
3. Sensory testing of upper extremities
4. Motor testing of lower extremities
5. Sensory testing of lower extremities
6. Reassessment of vital signs
7. Continued reassurance of injured athlete
 The presence of shallow, diaphragmatic or absent
respirations,
 hypotension,
 or bradycardia is a strong indication of injury
 to the spinal cord.
 Individuals with spinal cord
 injuries lose their ability to maintain normal body
temperature; changes may be noted during evaluation,
especially below the level of the injury.
 Sensation loss
 Deterioration of any vital signs is
 indicative of an emergent situation.
 The major goal of managing a suspected
injury to the spinal cord is to maintain a
neutral, in-line position.
 Beyond CPR, this is the single most
important action that can be performed
in these situations.
 The major goal of managing a suspected injury to the
spinal cord is to maintain a neutral, in-line position.
 The decision as to how and when to move the athlete
must be made based on the condition of the victim, the
availability of adequate assistance, and proper
equipment.
 Many methods are acceptable to move the.
 Person onto a long spine board, the most common being
the log roll and straddle slide.
 The key factor throughout any procedure is to move the
athlete as a unit, maintaining the head and neck in
neutral alignment.
 1. All commands will come from the rescuer controlling
the head of the person.
 2. The person is positioned with arm straight, straight
legs.
 3. Rescuers and spine board are positioned.
 4. The person is grasped by rescuers.
 5. On command, the athlete is carefully rolled toward
rescuers until the command to stop is given; the person is
held against rescuers’ thighs.
 6. The spine board is positioned.
 7. On command, the person is carefully rolled back to
supine position.
 1. All commands will come from the rescuer controlling the
head of the person.
 2. The person athlete is positioned with straight legs, arms
at sides.
 3. Rescuers and spine board are positioned.
 4. The person is grasped by rescuers.
 5. On command, the person is carefully lifted straight up
until the command to stop is given.
 6. The spine board is positioned.
 7. On command, the person is carefully lowered
back down to the spine board.
 1.All commands come from the rescuer controlling
the head of the person.

 2. The person’s arms and legs are straightened .

 3. Three (or four) rescuers are positioned on the

side of the direction of the roll with the spine
board lying against their upper legs; one rescuer
is positioned on the opposite side of the person to
help control the roll and to help prevent the person
from sliding as the board is lowered.
 4. On command, the person is carefully rolled from prone to
side-lying and then down onto the spine board; the position of
the head in relation to the trunk is maintained throughout the
roll.
 5. The spine board is carefully lowered to the ground.
 6. The head can then be slowly returned to a
neutral position
 7. A rigid cervical collar should then be applied. Or,
in cases where the person is wearing a helmet, the
face mask should be removed.
 Immobilization
 The Lift and Transfer
 Managing Protective Equipment
 Face Mask Removal
 Removing the Helmet and Shoulder Pads
 Neurogenic Shock Management
 Athletic training professionals currently universally
support the theory that the helmet and shoulder pads
should remain in place until definitive care can be
achieved.

 Some controversy has existed with EMS professionals

who have been taught to remove helmets prior to spine
boarding a person.
 The most common reasons given for helmet removal include
inability to obtain proper immobilization with the helmet in
place, inability to visualize injuries to the skull, inability to
control the airway, and hyper-flexion of the neck with the
helmet in place.

 These reasons certainly may apply to motorcycle and auto

racing helmets but not to the football helmet.
 The football helmets used today are designed to fit
properly and therefore do not allow the head to move
inside the shell.

 The mechanism of injury in a football player is generally

axial loading or an extreme motion in one direction, such
as hyperextension.

 Traumatic injuries to the skull and soft tissues of the head

and face are simply not seen as is frequently the case in
motorcycle accidents, which involve exponentially higher
forces than those experienced sports such as football.
 Removal of the face mask will allow the rescuer to
effectively maintain control of the airway

 Removing the Helmet and Shoulder Pads

 If the athletic trainer cannot remove the face mask

to access the airway in a relatively short amount of
time, or if it appears that the helmet or shoulder
pads fit loosely and therefore will not hold the
person motionless once secured to the spine board,
it is recommended that the helmet and shoulder
pads be removed
 In the spinal cord injury, the secondary injury caused
by inflammation, steroids have been used to limit the
inflammatory process and therefore reduce the
damage that could occur due to swelling.

 The most commonly used steroids for this purpose are

methylprednisolone and dexamethasone.

 These medications are most effective if administered

within the first eight hours of trauma.
 To treat this, a fluid challenge is followed by the
introduction of a vasopressor such as dopamine. The
fluid challenge is accomplished by infusing 250 mL of
IV fluid through a large-bore IV catheter.

 If the response to this infusion is that of increased

blood pressure, slower heart rate, and better
perfusion, then a second infusion should be
considered. If there is not a positive response to the
first bolus of fluid, then the administration of a
vasopressor (dopamine) should be considered. If the
bradycardia persists, then the use of atropine may be
indicated to increase the heart rate.
 On-Field Assessment of an
 Athlete with a Potential Cervical

 Spine Injury

 1. Determine mechanism of injury if possible.

 2. While moving to athlete, determine level of

 consciousness of athlete if possible (is the

 athlete moving?).

 3. Manually stabilize head and neck of

 injured athlete.

 4. Determine level of consciousness; if

 unconscious, activate EMS.
 5. Check ABCs. This may require rolling a prone athlete.
 6. Activate EMS, manage airway, and begin rescue breathing
or CPR if necessary.
 7. Perform secondary assessment.

 8. Continue to monitor vital signs for

changes.
1. Emergency Care in Athletic Training by: Keith M.Gorse, Robert O. Blanc,
Francis Feld, Matthew Radelet, 1st edition, 2010, F.A Davis Company.
Presented by: Dr. Anna
Zaheer, PT
UIPT, UOL
Presented by: Dr. Anna Zaheer, PT
UIPT, UOL
 Open Fractures
 Acute Compartment Syndrome
 Neurovascular injuries
 Dislocations
 Septic Joints
 Cauda Equina Syndrome
 An open (or compound) fracture occurs when the skin overlying a
fracture is broken, allowing communication between the fracture and
the external environment
 Type I:
Small wound (<1cm), usually clean, no soft tissue damage and no skin
crushing (i.e. a low energy fracture)
 Type II:
Moderate wound (>1cm), minimal soft tissue damage or loss, may
have comminution of fracture (i.e. a low-moderate energy fracture)
 Type III:
Severe skin wound, extensive soft tissue damage (i.e. high energy
fracture)
Three grades: A – adequate soft tissue coverage, B – fracture cover
not possible without local/distant flaps, C – arterial injury that needs
to be repaired.
 ABCDE – check neurovascular status (pulses, cap. refill, sensation,
motor) , fluid resuscitation, blood
 Antibiotics, tetanus prophylaxis – 48-72 hrs
 Surgical debridement – removal of de-vitalised tissue, irrigation
 Stabilization of fracture – internal/external, if closure delayed then
external prefered
 Early definitive wound cover – split skin grafts, local/distant flaps
(involve plastics)
 Displacement of bones at a joint from their normal position
 Do xrays before and after reduction to look for any associated
fractures
 Wound infection – 2% in Type I , >10% in Type III
 Osteomyelitis – staph aureus, pseudomona sp.
 Gas gangrene
 Tetanus
 Non-union/malunion
 An injury or condition that causes prolonged elevation of
interstitial tissue pressures
 Increased pressure within enclosed fascial compartment leads to
impaired tissue perfusion
 Prolonged ischemia causes cell damage which leads to oedema
 Oedema further increase compartment pressure leading to a
vicious cycle
 Extensive muscle and nerve death >4 hours
 Nerve may regenerate but infarcted muscle is replaced by fibrous
tissue (Volkmann’s ischaemic contracture)
 Crush injury
 Circumferential burns
 Snake bites
 Fractures – 75%
 Tourniquets, constrictive
dressings/plasters
 Haematoma – pt with
coagulopathy at increased risk
5Ps of ischaemia  Severe pain, “bursting” sensation
Pain (out of proportion to  Painwith passive stretch
injury)  Tense compartment
Paresthesias  Tight, shiny skin
Paralysis
Pulselessness
Pallor
 Early recognition
◦ Muscle
◦ Irreversible injury 4-6 hrs
 Remove cast, bandages and
dressings
 Arrange urgent fasciotomy
 Volkman ischaemic contractures
 Permanent nerve damage
 Limb ischaemia and amputation
 Fractures of the human skeletal system result when a bone is
cracked or broken as a result of a single large force applied all
at once (macrotrauma) or many small forces that accrue over a
long period (microtrauma).
 General clinical symptoms of fractures involve the disruption
to correct osseous anatomical integrity, significant focal pain,
enema, and ecchymosis.
 Alignment
Refers to the association of long-bone fragment axes to one another
and is measured in degrees of angulation from the distal fragment in
relation to the proximal fragment.

Apposition:-
Is referred to as the contact of skeletal fracture fragments and may
be expressed as a partial, bayonet, or distraction.
 Bayonet apposition presents as displaced fragments overlapping
one another,
 Distraction occurs as fragments are displaced along a
longitudinal axis.
 Fractures to the skeletally immature are of special concern
because injury to the epiphysis or growth plate may result in
abnormal future bone development. The epiphysis is located near
the end of long bones and influences mature skeletal length and
morphology.
 Activate EMS when appropriate.
 Remove clothing and protective equipment from site of injury.
 Carefully visually inspect area bilaterally.
 Carefully inspect skin in the area for breaks.
 Carefully palpate area for pain and crepitus.
 Evaluate neurovascular function distal to injury.
 Evaluate joint integrity proximal and distal to injury.
 Monitor for shock.
 Bilateral sensation testing of skin distal to fracture site (“Does this feel the
same on both sides?”)
 Testing of motor function distal to fracture site (flexion and extension of
wrist)
 Bilateral comparison of pulse distal to fracture site
 Capillary refill test.
 Once fracture has been properly evaluated, it should be
splinted prior to transport from the field.
 Proper immobilization of the injury tends to diminish irritation
and pain and consequently limits oedema or effusion
furthermore, immobilization of skeletal fractures reduces the
danger of magnified fragment displacement.
 Lacerations, abrasions, and avulsions should be suitably
cleansed and dressed with sterile supplies prior to application
of a splint. It is also vital that an extremity be assessed for the
sudden onset of acute compartment syndrome and
neurovascular compromise before and after splinting
 Five basic classes of splints are used in orthopaedic sports
medicine and emergency medical care.
 Rigid splints
 Constructed of stiff and sturdy materials are most
appropriately used for protecting and immobilizing misaligned
skeletal fractures or gross joint instability.
 Soft splints
 Use air pressure or bulky padding for immobilization and
protection purposes of skeletal fractures and pathological joint
instability. Varied forms of soft devices include pillow and air
splints.
Pillow splint
Is a comfortable piece of equipment commonly used with foot
and ankle complex injuries that applies mild and steady pressure
on the affected anatomy. A pillow splint is wrapped around the
foot and ankle complex and then secured with either tape or
triangular bandages.
 These particular devices rely on air pressure, which shapes
and reinforces the splint to compress and immobilize an
injured area. Air splints provide the advantage of
supplemental compression that may be beneficial in limiting
excessive haemorrhages.
 These specific air splints typically cover the foot, which makes evaluating
distal pulses and sensory perception problematic. Air splints are not to be
used with humeral or femoral fractures because of their inability to
adequately limit proximal joint excursion.
 A formable splint
Consisting of a semi-rigid shell and soft inner lining. The semi rigid shell of
formable splints is typical constructed of a pliable metal that permits manual
contouring. The formable splint’s soft inner lining is usually composed of
foam and serves to support the injured area.

 Vacuum splints (used in as a temporary splint)

Are constructed of fabric or vinyl material containing micro-Styrofoam bead
that are fixed and secured to the injured area by straps. A pump is used to
draw air from the material to compress the Styrofoam beads together,
thereby stiffening the splint. This allows the splint to conform to the affected
anatomy, thereby increasing its versatility and adaptability for immobilizing
an injured extremity.
1. Emergency Care in Athletic Training by: Keith M.Gorse, Robert O. Blanc,
Francis Feld, Matthew Radelet, 1st edition, 2010, F.A Davis Company.
CARDIOPULMONARY
RESUSCITATION ANS
CHOKING

Presented by: Dr. Anna Zaheer, PT

UIPT, UOL
Cardio-Pulmonary
Resuscitation
 1. Airway – head tilt, chin lift
2. Breathing – look, listen, feel
3. Circulation – give chest compressions
A. Check the Victim for unresponsiveness.
Gently shake them and ask “Are you all right,
are you okay?”
B. If the victim doesn’t respond SEND SOMEONE
TO GET HELP. Call 911 and return to the victim .
C. Use the head tilt, chin lift method to
open airway. Look, listen and feel for
breathing.
D. If the victim is not breathing normally,
pinch the nose and cover their mouth
with yours. Give 2 full breaths until you
see the chest rise. Each breath should
last about 1 second.
E. With each breath the chest should
lower and rise so you know that air is
getting in.
F. After giving two breaths, immediately
begin chest compressions.
G. Use the nipple line (“armpit over”) to
determine the proper place to do chest
compressions.
H. Push down on the chest 1 1/2 to 2 inches,
30 times right between the nipples where
the heart lies. (ratio 30:2)
J. Pump at the rate of 100 compressions / 1
minute
K. If you see chest movement, put the victim
in the side position in case they vomit.
Chest compressions should be performed on the lower
½ of the sternum
For each compression it is important to push down
far enough and to be sure the chest is completely
released after each compression. This will allow
the heart to fill with blood after each compression.
What is the
Recovery Position?
•First Aid procedure to use if
the person is unconscious,
breathing and have a pulse.
•It is a safe position to put
them in while you are waiting
for the EMS to arrive
•Allows them to breathe easily
and prevents them from
choking on their tongue or
any vomit.
A. Check for unresponsiveness
B. If you are alone with the child give 4-5 cycles of 30
compressions before calling 911.
C. Open the airway
D. Check for breathing: look, listen, feel
E. Not breathing: give 2 breaths
F. Perform chest compressions on the nipple line in
the center of the chest.
G. If the child is small, use one hand for
compressions. If the child is larger, use 2 hands.
H. Press the sternum down 1” to 1 ½”.
I. Give 30 compressions to 2 breaths (ratio of 30:2).
J. Pump at the rate of 100 compressions per 1 minute
K. You should perform 5 cycles of 30 compressions in
2 minutes.
A. Check for
unresponsiveness:
tickle, touch, pinch
the infant gently.
B. If there is no
response, perform 5
cycles of 30
compressions before
calling 911.
C. A = Open The Airway.
D. Tilt the head back gently, only far enough so that the
infant’s mouth is facing the ceiling. Do not tilt the head
too far back! This may injure the neck, and collapse the
airway.
E. B = breathing: Look, listen, and feel for air.
F. If the infant is NOT breathing give 2 small
gentle “puffs” of air.
G. Cover both the baby's mouth AND nose with
your mouth.
H. You should see the baby's chest rise with
each breath.
 I. The proper placement for chest
compressions is just below the nipple line.
J. Position your 3rd and 4th fingers in the
center of the chest ½ inch below the
nipples.
K. Press down ½” to 1”.
L. Perform 30 chest compressions at a ratio
of 30:2 (30 compressions for every 2
breaths)
M. At least 100 compressions should be
given within 1 minute.
If the infant recovers, put them in the recovery position by
gently supporting the neck and picking them up.
The victim responds.
The rescuer collapses.
A doctor pronounces the victim dead.
Someone with equal or more training takes
over.
With a child/infant – stop after 1 minute to call
911 if you alone, and no one will be coming.
 Partially obstructed airway with good air exchange: victim
can make some sounds; may be able to speak and cough
 Partially obstructed airway with poor exchange: victim
cannot speak, may be wheezing or coughing weakly
 Fully obstructed airway: victim cannot make any sounds
 The most common cause of an airway obstruction in a
conscious person is food or a foreign object.
 The most common cause of an airway obstruction in an
unconscious person is the tongue.
A. Ask the victim: : “Are you choking?”
B. If the victim nods yes, ask them “Would you like my help?”
 If they say “NO”, do not help them. If they say yes, you may
help them.
C. Position yourself by placing one of your legs between the legs
of your victim. Give 5 abdominal thrusts and continue as
needed.
◦ For a pregnant or obese person, perform chest thrusts.
D. Repeat thrusts until the object is expelled and the obstruction
is relieved OR the victim becomes
unresponsive/unconscious.
CONSCIOUS ADULT CHOKING
A. Call 911.
B. Open the airway.
C. Perform a finger sweep to remove possible foreign object in
mouth.
D. Open the airway and try to get air in. Give 2 breaths. If air does
not go in, reposition the head and give 2 more breaths. If air still
does not go in, the airway is obstructed.
F. With the victim lying on the floor, give 5 abdominal thrusts while
straddling your victim.
G. Repeat the steps until victim is no longer choking or continue the
steps of CPR as needed.
 ADULT UNCONSCIOUS CHOKING

You would straddle the victim while

performing any needed CPR and abdominal chest thrusts.

Do not push down on the Xiphoid process!

A. Check for breathing difficulty, ineffective
cough, weak cry.
B. Confirm signs of severe or complete airway
obstruction.
C. Give 5 back blows with your open hand and
5 chest thrusts, using your 3rd and 4th fingers.
D. Repeat back blows and chest thrusts until
object is expelled OR the victim becomes
unresponsive.
 BACK SLAPS

FINGER SWEEP

CHEST THRUSTS
A. Call 911
B. Open the airway and if you see the object, remove it
C. Try to give 2 breaths. If the chest does not rise, re-
open the airway and try to give 2 more breaths.
D. If the air still does not go in they are choking. Give 5
back blows, 5 chest thrusts and 2 breaths. Re-open
airway and give 2 more breaths.
E. Repeat above steps until breathing is effective.
Perform CPR if needed.
F. If the rescuer is alone and the airway obstruction is
not relieved after 1 minute, call 911.
Treat a conscious or unconscious child (1-8 years old) with
an airway obstruction like a conscious or unconscious
adult with an airway obstruction.

Example of a conscious choking child

 When performing CPR, the victim must be placed on a firm, flat
surface, in the “head-tilt, chin-lift” position
 The universal sign for choking is two hands placed at the throat
 If you give a victim 2 full breaths and they don’t seem to go in,
you should re-tilt the head (head tilt, chin lift) and try again. If
the air still does not go in your victim may be choking..
 In a two person rescue situation, rescuers should rotate
between compressions and breathing every 2 minutes to
avoid fatigue.
 Ideally, the rescuers should switch positions within 5
seconds so the victim is not left unattended for too long.
Lawthat protects rescuers from prosecution or civil
law suits, unless their actions constitute willful
misconduct and negligence.
The Rescuer MUST comply with proper emergency first aid and CPR guidelines; acting
in good faith by being prudent and responsible in their rescue efforts.
 1. Retrieved from http://www.wikihow.com/Do-CPR-on-an-Adult access
on 10-12-2013
2. Emergency Care in Athletic Training by: Keith M.Gorse, Robert O. Blanc,
Francis Feld, Matthew Radelet, 1st edition, 2010, F.A Davis Company.