Football Equipment Removal Improves Chest Compression and Ventilation Efficacy

What to Cover When You're Covering: Preparing the Sideline Physician for the Season

The evolving role of the sideline physician in sports medicine frequently involves comprehensive responsibilities beyond direct medical care. We outline important aspects of sideline preparedness and management, including the development and rehearsal of Emergency Action Plans (EAPs), initial approaches to assessing injured athletes, equipment removal strategies, and return-to-play decision-making processes. Epidemiological insights into sports injuries, particularly catastrophic events, underscore the importance of venue-specific planning within EAPs. We also provide guidance and recommendations for nuanced medical procedures such as IV fluid administration, anesthetic joint injections, and Toradol use, addressing current controversies and evidence-based recommendations. Medicolegal and ethical considerations emphasize the necessity of navigating legal statutes and maintaining patient confidentiality while adhering to ethical principles. Overall, this concept review underscores the multifaceted nature of the sideline physician's role, emphasizing evidence-based practice, transparent communication, and collaboration with stakeholders for optimal athlete care across all levels of play.

Key Concepts

(1)Evolution of sideline physician role: the manuscript explores the expanded responsibilities of sideline physicians beyond direct medical care, encompassing aspects such as emergency action plan development and return-to-play decisions.(2)Importance of emergency preparedness: emphasizes the crucial role of rehearsed emergency action plans in effectively managing on-field emergencies and optimizing patient outcomes.(3)Nuanced medical procedures: discusses controversies and evidence-based recommendations surrounding procedures like IV fluid administration, anesthetic joint injections, and Toradol use.(4)Medicolegal and ethical considerations: addresses the necessity for navigating legal statutes, maintaining patient confidentiality, and adhering to ethical principles in sports medicine practice.(5)Collaborative care approach: underscores the significance of evidence-based practice, transparent communication, and collaboration with stakeholders for providing optimal athlete care across all levels of play.

An Evaluation of the Quality of CPR Chest Compressions Performed on Football-Equipped and Obese Simulation Manikins

OBJECTIVE

Protective athletic equipment may hamper the delivery of effective chest compressions. Unfortunately, an algorithm for managing cardiac arrest emergencies with equipment-laden athletes has yet to be established by national CPR certifying agencies. Further, athletes classified as being overweight or obese carry adipose in the thoracic region, which has been reported to inhibit the ability of rescuers to provide quality chest compressions. Thus, the purpose of this study was two-fold. The first purpose was to assess the ability of emergency responders to perform CPR chest compressions on an obese manikin. The second purpose was to analyze the effect of American football protective equipment on the performance of chest compressions by emergency responders.

METHODS

Fifty emergency responders completed four 2-minute bouts of compression-only CPR. The scenarios included performing chest compressions on both traditional and obese CPR manikins, and performing chest compressions over a set of shoulder pads/chest protector that is used in the sport of American football on both traditional and obese manikins.

RESULTS

The most notable outcomes in this study were related to chest compression depth, which fell well below the minimum recommended depth published by the American Heart Association in all conditions. Mean compression depth was significantly lower when performed on the obese manikin (avg over pads = 32.8, SD = 9.2 mm; avg no pads = 38.2, SD = 9.1 mm) compared to the traditional manikin (avg over pads = 40.0, SD = 10.9 mm; avg no pads = 40.8, SD = 14.8 mm), with statistical analyses revealing a significant effect due to both manikin size (p < 0.001) and the presence of equipment (p = 0.003), and a statistically significant interaction effect (p = 0.035). Chest recoil data revealed a statistically significant effect due to both manikin size (p = 0.017) and the presence of chest/shoulder safety pads (p = 0.003).

CONCLUSION

Within this sample of emergency responders, chest compressions were adversely affected both by the equipment and obesity. Additionally, the traditional manikin received comparable chest compressions regardless of the presence or absence of football protective equipment, albeit both conditions resulted in poor depth performance.

The Effect of Lacrosse Protective Equipment on Cardiopulmonary Resuscitation and Automated External Defibrillator Shock

CONTEXT

In the event of an acute cardiac event, on-field equipment removal is suggested, although it remains unknown how lacrosse equipment removal may alter time to first chest compression and time to first AED shock.

OBJECTIVE

To determine time to first chest compression and first AED shock in 2 chest exposure procedures with 2 different pad types.

DESIGN

Crossover study Setting: Simulation laboratory Participants: Thirty-six athletic trainers (21 females, 15 males; age=30.58±7.81) Main Outcome Measures: Participants worked in pairs to provide 2 rescuer CPR intervention on a simulation manikin (QCPR manikin, Laerdal Medical, Wappingers Falls, NY) outfitted with lacrosse pads and helmet. Participants completed a total of 8 trials per pair (2 chest exposure procedures X 2 pad types X 2 participant roles). The dependent variables were time to first compression (s) and time to first AED shock (s). The independent variables were chest exposure procedure with 2 levels (procedure 1: removal of helmet while initiating CPR over the pads followed by pad retraction and AED application; procedure 2: removal of helmet and removal of pads followed by CPR and AED application) and pad type (Warrior Burn Hitman shoulder pads; Warrior Nemesis chest protector).

RESULTS

We found a statistically significant interaction between chest exposure procedure and pad type for time to first compression (F1,35=4.66, P=0.04, ω2p=0.10) with significantly faster times during procedure 1 for both the Nemesis pads (16.1±3.4 s) and the Hitman pads (16.1±4.5 s) compared to procedure 2 (Nemesis pads: 49.6±12.9 s, P<0.0001; Hitman pads: 53.8±14.5 s, P<0.0001).

CONCLUSIONS

Completing the initial cycle of chest compressions over either shoulder pads or a chest protector hastens time to first chest compression without diminishing CPR quality which may improve patient outcomes. Time to first AED shock was not different between equipment procedure or pad type.

Best Practices and Current Care Concepts in Prehospital Care of the Spine-Injured Athlete in American Tackle Football March 2-3, 2019; Atlanta, GA

Sport-related spine injury can be devastating and have long-lasting effects on athletes and their families. Providing evidence-based care for patients with spine injury is essential for optimizing postinjury outcomes. When caring for an injured athlete in American tackle football, clinicians must make decisions that involve unique challenges related to protective equipment (eg, helmet and shoulder pads). The Spine Injury in Sport Group (SISG) met in Atlanta, Georgia, March 2-3, 2019, and involved 25 health care professionals with expertise in emergency medicine, sports medicine, neurologic surgery, orthopaedic surgery, neurology, physiatry, athletic training, and research to review the current literature and discuss evidence-based medicine, best practices, and care options available for the prehospital treatment of athletes with suspected cervical spine injuries.1,2 That meeting and the subsequent Mills et al publication delineate the quality and quantity of published evidence regarding many aspects of prehospital care for the athlete with a suspected cervical spine injury. This paper offers a practical treatment guide based on the experience of those who attended the Atlanta meeting as well as the evidence presented in the Mills et al article. Ongoing research will help to further advance clinical treatment recommendations.

Delivering Chest Compressions and Ventilations With and Without Men's Lacrosse Equipment

CONTEXT

  Current management recommendations for equipment-laden athletes in sudden cardiac arrest regarding whether to remove protective sports equipment before delivering cardiopulmonary resuscitation are unclear.

OBJECTIVE

  To determine the effect of men's lacrosse equipment on chest compression and ventilation quality on patient simulators.

DESIGN

  Cross-sectional study.

SETTING

  Controlled laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Twenty-six licensed athletic trainers (18 women, 8 men; age = 25 ± 7 years; experience = 2.1 ± 1.6 years).

INTERVENTION(S)

  In a single 2-hour session, participants were block randomized to 3 equipment conditions for compressions and 6 conditions for ventilations on human patient simulators.

MAIN OUTCOME MEASURE(S)

  Data for chest compressions (mean compression depth, compression rate, percentage of correctly released compressions, and percentage of optimal compressions) and ventilations (ventilation rate, mean ventilation volume, and percentage of ventilations delivering optimal volume) were analyzed within participants across equipment conditions.

RESULTS

  Keeping the shoulder pads in place reduced mean compression depth (all P values < .001, effect size = 0.835) and lowered the percentages of both correctly released compressions ( P = .02, effect size = 0.579) and optimal-depth compressions (all P values < .003, effect size = 0.900). For both the bag-valve and pocket masks, keeping the chinstrap in place reduced mean ventilation volume (all P values < .001, effect size = 1.323) and lowered the percentage of optimal-volume ventilations (all P values < .006, effect size = 1.038). Regardless of equipment, using a bag-valve versus a pocket mask increased the ventilation rate (all P values < .003, effect size = 0.575), the percentage of optimal ventilations (all P values < .002, effect size = 0.671), and the mean volume ( P = .002, effect size = 0.598) across all equipment conditions.

CONCLUSIONS

  For a men's lacrosse athlete who requires cardiopulmonary resuscitation, the shoulder pads should be lifted or removed to deliver chest compressions. The facemask and chinstrap, or the entire helmet, should be removed to deliver ventilations, preferably with a bag-valve mask.

Airway Management in Athletes Wearing Lacrosse Equipment

CONTEXT

  Patient ventilation volume and rate have been found to be compromised due to the inability to seal a pocket mask over the chinstrap of football helmets. The effects of supraglottic airway devices such as the King LT and of lacrosse helmets on these measures have not been studied.

OBJECTIVE

  To assess the effects of different airway management devices and helmet conditions on producing quality ventilations while performing cardiopulmonary resuscitation on simulation manikins.

DESIGN

  Crossover study.

SETTING

  Simulation laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Thirty-six athletic trainers (12 men, 24 women) completed this study.

INTERVENTION(S)

  Airway-management device (pocket mask, oral pharyngeal airway, King LT airway [KA]) and helmet condition (no helmet, Cascade helmet, Schutt helmet, Warrior helmet) served as the independent variables. Participant pairs performed 2 minutes of 2-rescuer cardiopulmonary resuscitation under 12 trial conditions.

MAIN OUTCOME MEASURE(S)

  Ventilation volume (mL), ventilation rate (ventilations/min), rating of perceived difficulty (RPD), and percentage of quality ventilations were the dependent variables.

RESULTS

  A significant interaction was found between type of airway-management device and helmet condition on ventilation volume and rate ( F_12,408 = 2.902, P < .0001). In addition, a significant interaction was noted between airway-management device and helmet condition on RPD scores ( F_6,204 = 3.366, P = .003). The no-helmet condition produced a higher percentage of quality ventilations compared with the helmet conditions ( P ≤ .003). Also, the percentage of quality ventilations differed, and the KA outperformed each of the other devices ( P ≤ .029).

CONCLUSIONS

  The helmet chinstrap inhibited quality ventilation (rate and volume) in airway procedures that required the mask to be sealed on the face. However, the KA allowed quality ventilation in patients wearing a helmet with the chinstrap fastened. If a KA is not available, the helmet may need to be removed to provide quality ventilations.

The Ability to Provide Quality Chest Compressions Over Lacrosse Shoulder Pads

CONTEXT

  Performance of quality cardiopulmonary resuscitation is essential for improving patient outcomes. Performing compressions over football equipment inhibits compression depth and rate, but lacrosse equipment has not yet been studied.

OBJECTIVE

  To assess the effect of lacrosse shoulder pads on the ability to provide quality chest compressions on simulation manikins.

DESIGN

  Crossover study.

SETTING

  Simulation laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Thirty-six athletic trainers (12 men: age = 33.3 ± 9.7 years; 24 women: age = 33.4 ± 9.8 years).

MAIN OUTCOME MEASURE(S)

  No shoulder pads (NSP), Warrior Burn Hitman shoulder pads (WSP), and STX Cell II shoulder pads (SSP) were investigated. Outcomes were chest-compression depth (millimeters), rate (compressions per minute), rating of perceived exertion (0-10), hand-placement accuracy (%), and chest recoil (%).

RESULTS

  We observed a difference in mean compression depth among shoulder-pad conditions ( F_2,213 = 3.73, P = .03, ω² = 0.03), with a shallower depth during the WSP (54.1 ± 5.8 mm) than the NSP (56.8 ± 5.7 mm; P = .02) trials. However, no differences were found in mean compression rate ( F_2,213 = 0.87, P = .42, ω² = 0.001, 1-β = .20). We noted a difference in rating of perceived exertion scores ( F_2,213 = 16.41, P < .001, ω² = 0.12). Compressions were more difficult during the SSP condition (4.1 ± 1.3) than during the NSP (2.9 ± 1.2; P < .001) and WSP (3.3 ± 1.1; P = .002) conditions. A difference was present in hand-placement accuracy among the 3 shoulder-pad conditions (χ²₂ = 11.14, P = .004). Hand-placement accuracy was better in the NSP than the SSP condition ( P = .002) and the SSP than the WSP condition ( P = .001).

CONCLUSIONS

  Lacrosse shoulder pads did not inhibit the ability to administer chest compressions with adequate rate and depth. With appropriate training to improve hand placement, the pads may be left in place while cardiopulmonary resuscitation is initiated during sudden cardiac arrest.