Chapter 2: Recognition, Evaluation, and Management

EDUCATIONAL OBJECTIVES

The learner should, at the completion of the chapter, be able to perform understand the following:

RECOGNITION AND EVALUATION OF INJURIES

Primary functions of an athletic trainer are to recognize when an injury has occurred, to determine its severity, and to apply proper evaluation procedures and treatment protocols.  The recognition of injuries is a process where the athletic trainer, either through direct observation or second hand accounts, determines the probable cause and mechanism of injury. There are two major considerations in emergency evaluations.  First, control of life threatening conditions and activation of emergency medical service, and second, management of non life threatening injuries.

Referral to a physician is critical when serious injury occurs. If any of the following situations exist, immediate referral is critical:

Student athletic trainers are not responsible for handling a seriously injured athlete. The student athletic trainers' responsibilities in emergency situations include:
  1. Becoming aware of the causes of serious injuries
  2. Making sure equipment and the playing area are safe
  3. Alerting the athletic trainer, coach and team physician of potential dangers
  4. Recognizing signs of serious injury
  5. Implementing a detailed plan to handle emergency transport
FIRST AID EMERGENCY CARE

Once an injury has occurred, properly evaluation must be administrated. The American Red Cross and American Heart Association have established protocols that will give the athletic trainer the necessary guidance to administer first aid emergency care. It is critical that certification in first aid and C.P.R. be maintained by athletic trainers and coaches. Additionally, a written statement (standing orders) should be drafted by the team physician that provides direction of how to handle specific injuries. This written document should include the proper protocol for handling life threatening and non-life threatening injuries along with protocol to follow in dealing with blood borne pathogens.

EMERGENCY TRANSPORTATION PROCEDURES

There are two points to consider in the area of transportation.  The first is the availability of emergency ambulance service and the second is the severity of the injury.  The athletic training staff or athletic coaches should never transport an athlete in a private vehicle.  With any athletic event or competition, the availability of emergency ambulance service should be present or on-call to handle and to transport potential serious injuries.  Emergency medical technicians (E.M.T.) are skilled, practiced professionals who routinely provide advanced medical care and transport injured patients. They have the proper equipment and training to prepare injured athletes for transportation and have vehicles equipped for safe and speedy transport.

EVALUATION OF LIFE THREATENING INJURIES

When serious injury is suspected, begin your evaluation with the primary survey. The primary survey assesses:

To conduct the primary survey, approach your athlete in a calm and reassuring manner. This enhances relaxation and maintenance of the respiratory and circulatory systems. With the primary survey, be prepared to clear and maintain the airway free of potential obstructions such as blood, vomitus, and foreign matter. Assist the patient in finding the most comfortable position for breathing. If necessary, be prepared to provide artificial ventilation or cardiopulmonary resuscitation (CPR) and to activate the emergency medical system.

Once your primary survey is completed and you determine the athlete's condition is non-life threatening, perform a secondary survey. The SECONDARY SURVEY consists of two elements.

    1. History
    2. Physical Examination
The History is that part of the evaluation in which the examiner questions the athlete to determine: The Physical Examination is your next step. Remember, physical examination findings may vary tremendously from athlete to athlete, yet still be within a normal range. Factors such as physical activity and exercise may account for this variance. Some signs and symptoms that may vary are respiratory rate; moistness, color and temperature of skin, and pulse rate. Essential to the physical examination is the evaluation of these VITAL SIGNS: abnormal nerve response, blood pressure, movement, pulse, respiration, skin color, state of consciousness, and temperature.

EVALUATION OF NON-LIFE THREATENING INJURIES

Once a life threatening injury has been ruled out, medical evaluation of the injury must be comprehensive. In the athletic training setting, two formats of evaluation are commonly utilized: H.O.P.S. and S.O.A.P.

Evaluation Format: H.O.P.S.

The first purpose of an evaluation is to determine if a serious injury has occurred. Initially, a fracture should always be suspected. Signs of a fracture include, but are not limited to, direct or indirect pain, deformity, or a grating sound at the injury site. Some fractures are not accompanied by swelling or pain. If a fracture is suspected, the extremity should be splinted and the athlete transported for medical evaluation. Young athletes are especially susceptible to fractures, due to their immature bone structure. Often, ligaments and muscles are stronger than the bones. The evaluation process to help determine the type of injury involves four steps: history, observation, palpation, and special tests.

(H) History: This involves asking questions of the athlete to help determine the mechanism of injury. Answers to these questions will help the certified athletic trainer in assessing the injury and the physician in a diagnosis.

  1. Mechanism of injury (How did it happen?)
  2. Location of pain (Where does it hurt?)
  3. Sensations experienced (Did you hear a pop or snap?)
  4. Previous injury (Have you injured this anatomical structure before?)
(O) Observation: The athletic trainer should compare the uninvolved to the involved anatomical structure and look for bleeding, deformity, swelling, discoloration, scars, and other signs of trauma.

(P) Palpation: Palpation is the physical inspection of an injury. First, palpate the anatomical structures/joints above and below the injured site. Then, palpate the affected area. The entire area around the injury may be sore, but the athletic trainer should try to pinpoint the site of severe pain. From knowledge of the human anatomy and injury mechanism, the type and extent of injury can be evaluated. Involve the athlete in the evaluation as much as possible. Using bilateral comparison, these items should be palpated/performed:

  1. Neurological stability (motor and sensory)
  2. Circulation function (pulse and capillary refill)
  3. Anatomical structures (palpate)
  4. Fracture Test (palpation, compression, and distraction)
(S) Special Tests: With all special tests, the athletic trainer is looking for joint instability, disability, and pain. It is possible to further damage an injury through manipulation. Years of training are necessary before a NATABOC certified athletic trainer would be considered competent to performing special test. These tests are well beyond the expertise of a student athletic trainer. To determine if damage has been done to the anatomical structures, the athletic trainer uses special stress and functional tests to assess disability. These include the following:
  1. Joint stability (stress applied to determine ligament stability)
  2. Muscle/Tendon (stress applied to determine muscle/tendon stability)
  3. Accessory anatomical structures (test to determine status of accessory anatomical structures, such as synovial capsule, bursa, menisci, etc.)
  4. Inflammatory conditions (test to determine if neurological disorders exist and type of inflammation present which can be a significant clue to the type of injury, i.e. intra-articular effusion, extra-articular edema, synovial, etc.)
  5. Range of motion (activities using active, assistive, passive and resistive movement)
  6. Pain or weakness in the affected area (test to determine if there is pain or disability)
Evaluation Format: S.O.A.P.
Assessing an injury using the Subjective, Objective, Assessment, and Plan (S.O.A.P.) format is another standardized procedure that provides comprehensive review of probable cause and mechanism of injury.  This injury evaluation process is reviewed next.

(S) Subjective assessment (history) requires the athletic trainer to ask detailed questions of pre-existing or existing injuries.

(O) Objective assessment involves visual, physical and functional inspections.  Items to assess are: swelling, deformity, ecchymosis, symmetry, gait/walk, scars, facial expression, circulation, neurological tests (sensation, reflex, motor), bone, soft tissue, range of motion (active, passive, resistive), and sports specific movements.

(A) Assessment reviews the probable cause and mechanism of the injury, impressions of injury site (structures involved), severity of injury, and treatment goals.

(P) Plan should outline appropriate action that should be taken to care for the injury. Initial actions could include: immediate action and referral, modalities utilized, preventive techniques, rehabilitation considerations, and criteria for return to active lifestyle.

BASIC TREATMENT PROTOCOL: P.R.I.C.E.S.

Regardless of the mechanism of injury, the student athletic trainer's response to an acute injury should include the basic treatment protocol of protection, rest, ice, compression, elevation, and support (P.R.I.C.E.S.), followed by referral to a physician. Listed below is a brief description of P.R.I.C.E.S. protocol.

P - Protection: Once an injury has occurred, protect that injury from further damage by removing the athlete from participation.

R - Rest: After the evaluation is completed, rest the injury. The length of rest is dependent on the severity of the injury; therefore rest could easily be longer than 24 hours.

I - Ice: Apply cold to the injured area.  This will aid in controlling bleeding and the associated swelling. This can be performed in one of two ways that are equally effective:

C - Compression: Utilizing a compression wrap to control swelling, begin the elastic wrap distally (farthest from the heart) to the injury and spiral the wrap toward the heart. Remove the wrap every 4 hours. Note: Compression wraps applied too tight could interfere with circulation or nerve function.  Signs and symptoms include extremities turning blue or pink, numbness and tingling of extremities, and increased pain.

E - Elevation: Keep the injured body part elevated higher than the heart.  This will allow gravity to keep excessive blood and associated swelling out of the injured area.

S - Support: Various techniques can be used to support an injury.  If necessary, place the injured extremity in a first aid splint.  Examples of other types of support could include the use of crutches for a lower extremity injury or use of a sling for an upper extremity injury.

 FIRST AID SPLINTING EQUIPMENT

A number of different types of equipment are available for the athletic trainer to use in splinting an injured anatomical structure. Splints are intended to protect the injury from further damage.  The following is a list of medical splints utilized in emergency situations.

Fixation Splints: These are the most common adaptable splints utilized.  Board, wire ladder, pillow, and blankets are examples of fixation splints.

Vacuum Splints:These splints are appropriate for dislocations or misaligned fractures and adaptable to any limb angulation.
Pneumatic (air) Splints: Best suited for nondisplaced fractures, air splints are easy to apply.

Traction Splints: Used for long bone fractures (femur and humerus), they prevent fractured bone ends from touching.  Advanced medical training is needed to become proficient in application of traction splints.

When using emergency splinting equipment, these 10 key points should be followed:

1. Inspection of the extremity for open wounds, deformity, swelling, and ecchymosis.
2. Check Pulse, Motor, Sensation (PMS) and capillary refill of the injured site distal to the injury.
3. Cover all wounds with a dry sterile dressing before applying a splint and notify the receiving medical facility of all open wounds.
4. Do not move the athlete before splinting extremity injuries unless there is an immediate hazard to the athlete or you.
5. Select proper splint in which length and size should cover above and below the injury site.
6. Place splint beside the injured extremity and then smooth out the contents of the splint.  The larger end of splint should be placed proximal to the injury.
7. When applying the splint, use your hands to minimize movement.  Also, support the injury above and below when applying the splint on the extremity.  For stabilization purposes, apply a gentle traction to the limb.
8. Secure splint with straps by applying firm compression.
9. Again, check Pulse, Motor, Sensation (PMS), and capillary refill at a point distal to the site of injury.
10. Apply cold to the injured area and document time.  It should be noted that the injury can be X-rayed through some commonly utilized splinting equipment.

SUMMARY

The accurate documentation of injury and illness is essential in the process of providing quality health care to the athletic population.  Two styles of evaluation formats have been presented in this chapter - HOPS and SOAP.  There are a number of other formats, but these two provide the most common record documentation format. When treating injuries, the basic treatment protocol of protection, rest, ice, compression, elevation, and supports (PRICES) is a good rule to follow.  In all injury management protocols, make sure that you know the proper techniques and work within your knowledge base.
 

REFERENCES

American Academy of Orthopaedic Surgeons (1991).  Athletic Training and Sports Medicine.  Park Ridge, IL: AAOS.

American Red Cross (1996) Responding to Emergencies (2nd ed.).  St. Louis: Mosby Lifeline.

Booher, J. & Thibodeau, G. (1994).  Athletic Injury Assessment.  St. Louis: Times Mirror/Mosby College.

Gonza, E. & Harrington, I. (1990).  Biomechanics of Musculoskeletal Injury.  Baltimore:  Williams & Wilkins.

Katch F. & Freedson, P. (1986).  Clinic in Sports Medicine (vol. 5).  Philadelphia:  W.B. Saunders.

Kettenbach, G. (1990) Writing S.O.A.P. Notes.  Philadelphia: F.A. Davis.

Parcel, G. (1990)  Basic Emergency Care of the Sick and Injured. (4th ed.) St. Louis: Mosby.

Thibodeau G. & Patton, K.  (1996) Anatomy and Physiology (3rd ed.) St. Louis: Mosby.

 
 

 
 

Chapter 2 - Review Questions

Completion:

1. When palpating and performing assessment tests, always compare ______ by examining the uninvolved extremity first.
2. Physical inspection begins at the _____ step.
3. List the recommended treatment time for an ice bag: ______.
4. Compression should be accomplished by using an ______ wrap.
5. A student athletic trainer in a ______ ______ should never perform transportation of an injured athlete.

Short Answer:

1. What is the first step in the injury process?

2. Why are special tests performed?

3. How should a fracture be properly immobilized?

4. In injury evaluation, what do these terms mean?
    H O P  S

    S O A  P

5. What are the two major considerations in emergency evaluation?

6. What do the letters P.R.I.C.E.S. represent?

7. What are the four different types of splints?
 
 


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