The examiner must quickly determine whether the patient is conscious. At no time during the initial assessment should ammonia inhalants be used to arouse the patient. Inhalants should be used only after the examiner is absolutely sure there is no spinal injury, because the fumes may cause a reflex head jerk, complicating the possible neck injury.8 At this early stage, the examiner simply determines whether the patient is alert (fully conscious), confused (drowsy), in delirium, in obtundation (dulled sensations, especially pain and touch), in a stupor, or in a coma. A patient is classified as alert if he or she is able to carry on an appropriate conversation with no delays and is aware of time, place, and identity. See Chapter 2 for an explanation of the levels of consciousness.

The examiner determines the level of consciousness or arousal by talking to the patient, not by moving the patient. This stage is sometimes referred to as the “shake and shout” stage, in which the examiner tries to arouse the unconscious individual by gentle shaking (without allowing movement of the head and neck) and by shouting into each ear. If the patient does not respond to this verbal stimulus, the examiner can, at least initially, assume that the patient is unconscious or not fully conscious and proceed under that assumption. Further neurological assessment is left until the examiner is sure that the patient has a patent airway, is breathing normally, and has a heartbeat. If the patient is conscious, the examiner should reassure the patient that help has arrived. The patient should be informed of what the examiner is doing and proposes to do in terms of examining and moving the patient. Regardless of the patient’s state of consciousness, he or she should not move or be moved until the examination has been completed.

On the sideline, the examiner can perform a Sideline Concussion Assessment Tool—3rd edition (SCAT3) exam (see Chapter 2) and begin a Neural Watch to provide serial monitoring (see later discussion) for the possibility of an increasingly severe head injury (i.e., progressive deterioration of signs and symptoms). In addition, balance testing may be performed using the Balance Error Scoring System (BESS).¹⁴ This is a quantifiable low technology test that uses only a stopwatch and a piece of medium density foam. The athlete is asked to do three different stances (double, single and tandem) twice on two different surfaces (the ground and the foam) (see Figure 2-37) for a total of six trials. The athlete begins in the required stance with the hands on the iliac crests and, while standing quiet and motionless, is asked to close both eyes for 20 seconds. During the single leg stance, the athlete stands on the non-dominant foot and is asked to hold the opposite non–weight-bearing limb in 20^o to 30^o of hip flexion and 40^o to 50^o of knee flexion. For tandem stance, the non-dominant foot is placed behind the dominant foot. If the athlete is losing his or her balance, he or she can make any necessary adjustments and returns to the test position as quickly as possible. The athlete is scored by adding one error point for each committed error (see Table 2-22). If the athlete cannot maintain the desired stance for at least 5 seconds of the 20 second test period, the athlete has failed the test. The maximum error score for normal athletes is 10.

While waiting for assistance, the examiner can immediately begin to check for abnormal or arrested breathing, abnormal or arrested pulse, internal and external bleeding, and shock. This initial assessment is called the airway, breathing, and circulation (ABCs) of cardiopulmonary resuscitation (CPR). New guidelines also include the use of automated defibrillators if required.15 The first priority is to maintain an adequate airway, normal ventilation, and hemodynamic stability (see Table 18-1).^16,17 Also, obvious bleeding should be controlled by compression.

While the cervical spine is protected and immobilized, the examiner quickly assesses the airway for patency by looking, listening, and feeling for spontaneous respirations.^5,8 Respirations can be determined by watching for movement of the chest, feeling the breath on the examiner’s cheek, or hearing the air move in and out (Figure 18-4). The normal resting ranges of respirations are 10 to 25 breaths per minute for adults and 20 to 25 breaths per minute for children. An athlete or someone who has been exerting before injury may show a higher rate. If a patient is not breathing and has no heartbeat, clinical death occurs between 0 and 4 minutes (Figure 18-5). If breathing and heartbeat are not restored within 4 to 6 minutes, brain damage is probable. If there is no breathing and no heartbeat for 6 to 10 minutes, biological death occurs, and brain damage is likely.¹⁸

If the patient is breathing without difficulty, the rate and rhythm of the respirations and their characteristics should be noted. Cheyne-Stokes and ataxic respirations are often associated with head injuries.¹⁹ Table 18-2 indicates some of the abnormal breathing patterns that may occur in a patient in an emergency situation.

If the conscious patient exhibits abnormal or arrested breathing (asphyxia), the examiner should look for possible causes.²⁰ Causes include compression of the trachea; tongue falling back, blocking the airway; foreign bodies (e.g., mouthguard, gum, chewing tobacco); swelling of the tissues (e.g., anaphylactic shock after a bee sting); fluid in the air passages; presence of harmful gases or fumes; pulmonary and chest wall trauma; and suffocation.^20,21

Falling back of the tongue is the most common cause of airway obstruction after a sport injury, especially in the unconscious patient. Normally, the tone of the tongue muscles ensures airway patency. However, the unconscious person, especially one in the supine position, loses muscle tone and the tongue falls back, potentially leading to an obstruction. If the tongue is the cause of obstruction, the examiner can simply pull the chin forward in a chin lift or jaw thrust maneuver to restore the airway, being careful to keep movement of the cervical spine to a minimum. The chin lift maneuver is less likely to compromise the cervical spine.^22,23 Either maneuver pulls the retropharyngeal musculature forward, thus opening the airway.²⁰

If the examiner can see an object obstructing the airway, an oral screw and tongue forceps can be used to remove the object. The mouth should be held open with the oral screw or something similar, and the examiner can use a finger to sweep the mouth clear of debris (e.g., broken teeth, dentures, mouthguard, chewing gum, tobacco). If the jaw is not held open and blocked from closing, the examiner should put fingers in the patient’s mouth only with caution. If the cause of the blockage is something other than the tongue (e.g., foreign body), the patient, if conscious, should be asked to cough. If this does not expel the object, the Heimlich maneuver should be performed until the patient expels the object. If the patient loses consciousness, he or she should be placed supine and ventilation attempted. If it is unsuccessful, six to ten subdiaphragmatic abdominal thrusts are applied. This sequence of ventilation and subdiaphragmatic abdominal thrusts is repeated until a physician or EMS personnel arrive to perform a laryngoscopy.²⁴ Other causes of asphyxia may be treated by epinephrine (anaphylaxis) or intubation.²⁴ If the examiner is concerned about maintaining a patent airway, an oropharyngeal airway may be used. As a last resort, a wide-bore needle (18-gauge or larger) may be inserted into the trachea to ensure an airway.²⁰

If the patient is not breathing, artificial ventilation (mouth-to-mouth resuscitation) must be initiated immediately, by using the breathing portion of the CPR techniques or by using a similar artificial breathing method.

If the patient is conscious but obviously in respiratory or cardiac distress, the examiner must deal with the presenting situation immediately (Table 18-3). If the patient does not have a patent airway, an airway must be established, as has been described. If the patient is moving in an attempt to get air into the lungs, the examiner may assume that a severe cervical injury is less likely to have occurred. However, movement of the head in relation to the cervical spine should be kept to a minimum. Keeping in mind the possibility of a cervical injury, the examiner should position the patient so that airway clearance and resuscitation can easily be accomplished. This change in position must be performed carefully to ensure that movement of the cervical spine is kept to a minimum. If the patient is reasonably comfortable in the side-lying or prone position and there is no problem with cardiac function or breathing, it is not necessary to move the patient to the supine position.

After the airway has been established, whether by the use of an airway device, by proper head or jaw positioning, by the use of tongue forceps, or by a tracheotomy, the examiner must ensure that the airway is maintained and that the patient continues breathing. If respiration is not spontaneous, assisted ventilation (e.g., mouth-to-mouth, bagging) should be instituted. Ventilation can be compromised by a flail chest or pneumothorax (tension or open).^8,21 Endotracheal intubation is necessary if nasopharangeal bleeding, laryngeal trauma, secretions, or aspirations prevent maintenance of an adequate airway or end-ventilation.^16,20,25 Transtracheal ventilation is the treatment of choice for patients with breathing problems caused by brain, cervical spine, or maxillofacial injuries. An endotracheal tube may cause straining and venous hypertension, leading to increased brain edema, and extension of the head and neck to open upper airways may aggravate cervical spine injuries. Also, hemorrhage in maxillofacial injuries prevents the effective use of a breathing mask and does not allow adequate visualization.¹⁷

While the examiner is determining whether breathing is normal, the patient’s circulation should be checked for 10 or 15 seconds using the carotid (preferred), brachial, radial, or femoral pulse (Figure 18-6). For a sedentary adult, the normal heart rate is 60 to 90 beats per minute. For children, the rate is 80 to 100 beats per minute. In the highly trained athlete of either sex, the rate may be as low as 40 beats per minute. With activity, the heart rate will be above these levels, and the examiner should take this fact into account when taking the pulse. Depending on the type and level of the individual’s activity, the heart rate for a fit person should decrease to slightly above normal values within 5 minutes. The examiner should note whether the pulse is absent, rapid and rebounding, or weak and diminishing.

The pulse is most often checked at the carotid artery, because this artery is large and easy to locate. Therefore, the examiner has less chance of missing the pulse and does not have to move from the area of the patient’s head to perform palpation. If a pulse cannot be detected, it should be assumed that the patient does not have a heartbeat, and CPR should be initiated using either manual methods or an automated external defibrillator. The use of the defibrillator increases the chance of survival in cardiac arrest.²⁶ Although cardiac arrest is rare in athletes, sudden death or commotio cordis resulting from low-impact blunt trauma is always a possibility in sports.²⁷ When the pulse is assessed, the examiner should estimate its rate, strength, and rhythm to obtain an indication of the cardiac output. Circulatory sufficiency may also be determined by squeezing the nail bed or hypothenar eminence. Capillary refill is delayed if the pink color does not return to the nail bed or hypothenar eminence within 2 seconds after release of the pressure.²⁸ Squeezing the hypothenar eminence is a better indicator if the patient is hypothermic.

The pulse may also be used to determine the patient’s blood pressure. If a carotid pulse can be palpated, systolic blood pressure is 60 mm Hg or higher. If the femoral pulse is palpable, systolic blood pressure is 70 mm Hg or higher. If the radial pulse can be palpated, the systolic blood pressure is 80 mm Hg or higher.^12,19,28 Like heart rate, blood pressure should drop to almost normal levels within 5 minutes following termination of exercise.

A weak or rapid pulse usually indicates shock, heat exhaustion, hypoglycemia, fainting, or hyperventilation. A slowing pulse is sometimes seen when there is a large increase in intracranial pressure, which usually indicates a severe lower brain stem compression.²⁹ A pulse that is rebounding and rapid is often the result of hypertension, fright, heat stroke, or hyperglycemia.

If the pulse rate is beginning to weaken, the patient may be going into shock (Figure 18-7). Shock is characterized by signs and symptoms that occur when the cardiac output is insufficient to fill the arterial tree and the blood is under insufficient pressure to provide organs and tissues with adequate blood flow. It should be noted, however, that patients who maintain pink skin, especially in the face and extremities, are seldom hypovolemic after injury. If the skin of the face or extremities turns ash-gray or white, this usually indicates blood loss of at least 30%.⁸ Common types of shock and their causes are shown in Table 18-4. A patient going into shock becomes restless and anxious. The pulse slowly becomes weak and rapid, and the skin becomes cold and wet, often clammy. Sweating may be profuse, and the face is initially pale and later cyanotic (blue) around the mouth. Respirations may be shallow, labored, rapid, or possibly irregular and gasping, especially if a chest injury has occurred. The eyes usually become dull and lusterless, and the pupils become increasingly dilated. The patient may complain of thirst and feel nauseated or vomit. If shock develops quickly, the patient may lose consciousness. To prevent or delay the onset of shock, the examiner may cover the patient, elevate the patient’s legs, or attempt to eliminate the cause of the problem.

Circulatory collapse in trauma patients is caused primarily by blood loss from vascular damage or fracture, or hypovolemic shock, but the examiner must remember that shock in trauma may also be caused by tension pneumothorax, central nervous system injury, or pericardial tamponade (heart compression resulting from blood in the pericardium)—all emergency conditions that require physician intervention.³⁰ By the time hypovolemic shock becomes evident, blood loss may be as high as 20% to 25%. The normal range of blood pressure is 100 to 120 mm Hg for systolic pressure and 60 to 80 mm Hg for diastolic pressure. With shock, the blood pressure gradually decreases. If the blood pressure can be measured, it is best to assume that shock is developing in any injured adult whose systolic blood pressure is 100 mm Hg or less.

If the examiner is caring for a dark-skinned person, it may be difficult to determine from observation whether the patient is going into shock. A healthy person with dark skin usually has a red undertone and shows a healthy pink color in the nail beds, lips, and mucous membranes of the mouth and tongue. A dark-skinned patient in shock, however, has a gray cast to the skin around the nose and mouth, especially if experiencing respiratory shock. The mucous membranes of the mouth and tongue, the lips, and the nail beds have a blue tinge. If the shock is caused by hypovolemia, the mucous membranes of the mouth and tongue will not be blue; rather they will have a pale, graying, waxy pallor.³¹

If no pulse is present, then the cardiac portion of CPR techniques should be initiated. Sports equipment (such as, shoulder pads or rib pads) should be removed, at least anteriorly, to give the examiner clear access to the anterior chest wall. CPR provides only approximately 25% of normal cardiac output, so it is imperative that it is performed properly by knowledgeable persons.³² CPR is maintained until the patient recovers or EMS personnel arrive. If a cervical spine injury is suspected, CPR must be done with care, because compression to the heart can cause repeated flexion-extension of the cervical spine.¹⁷

The examiner should look for any signs of external bleeding or hemorrhage (Table 18-5). The types of wounds in which external bleeding or hemorrhage may be seen are incisions, which are clean cuts, or lacerations that have jagged edges. A contusion may produce internal bleeding, whereas a puncture or abrasion may also show bleeding or oozing on the surface. Major traumatic injuries, such as fractures (e.g., pelvis, femur), can cause a great deal of internal bleeding. Of the five types of wounds, the puncture wound is probably the most difficult to treat, because it has the highest probability of infection. The examiner should watch for bleeding from the lungs, the stomach, the upper bowel, the lower bowel, the kidneys, or the bladder. If the liver, spleen, or kidney is injured, serious internal bleeding may result; the blood will not be visible because it is contained within the abdominal cavity. In this case, the patient may experience abdominal rigidity, pain, and difficulty breathing (pressure on diaphragm).

When inspecting a bleeding structure, the examiner should note the type of vessel affected. For example, an artery spurts blood, whereas a vein provides an even flow. Capillaries tend to ooze bright blood (Figure 18-8).¹⁸ Because arterial bleeding is of greatest concern, the examiner must be aware of the pressure points in the body (see Figure 18-6) so that he or she will know where to apply proper treatment. The examiner chooses the pressure point closest to the area of bleeding and applies pressure to the artery to slow or stop the bleeding. Tourniquets should be used only with extreme caution and in selected instances (e.g., accidental amputation of a limb, very severe bleeding from a major artery, or the need to apply CPR with no assistance available) and then only with enough pressure to stop bleeding. If a tourniquet is used, the time of tourniquet application should be noted carefully to prevent unnecessary tissue damage. Hemodynamic stability is best maintained by applying direct pressure to an open wound, keeping the patient in a recumbent position, and minimizing the number of times the patient is moved.¹⁶

If signs and symptoms of shock are present but visible bleeding is minimal, the examiner should suspect hidden bleeding within the abdomen, chest, or extremities.^19,33 If bleeding is suspected in the abdomen, the examiner should palpate the abdominal wall for shape and distention. To check for bleeding in the chest or extremities, the examiner should look for deformities (e.g., fractures). The fingers may be used to percuss the chest area, noting any loss of hollow sounds, to help locate the presence of fluid or blood. Hyporesonance may indicate a solid organ or the presence of fluid or blood; hyperresonance usually indicates air- or gas-filled spaces.¹⁹

After the ABCs systems have been assessed and controlled, the examiner can proceed to the remainder of the primary assessment. The examiner should check the ears and nose for the presence of cerebrospinal fluid. If blood or cerebrospinal fluid leaks from the ear, this may indicate a skull fracture. The examiner should incline the head toward the affected side to facilitate drainage, unless a cervical injury is suspected. The examiner can place a gauze pad over the patient’s ear or nose where the bleeding is occurring to collect the fluid on the gauze (Figure 18-9). The examiner should look for an orange halo forming on the pad (see Figure 2-42). The halo is cerebrospinal fluid, the presence of which is a good indication of a skull fracture.³⁴

The examiner checks the pupils for shape and for response to light by using a penlight or by covering the eye with one hand and then taking it away. The pupil normally reacts to the intensity of light or focal distance. The pupils dilate in a dark environment or with a long focal distance, and they constrict in a light environment or with a short focal distance. Normally, the pupils are equally or almost equally dilated (diameter range, 2 to 6 mm; mean of 3.5 mm), but injury to the central nervous system (e.g., head injury) may cause the pupils to dilate unevenly. Some people normally have unequal pupil sizes, and the health care professional must be aware of this possibility. In a fully conscious, alert person who has sustained a blow near the eye, a dilated, fixed pupil is most likely the result of trauma to the short ciliary nerves of that eye rather than the result of third cranial nerve compression caused by brain herniation.16 Drugs may also affect the pupillary size. For example, opiate drugs cause pinpoint pupils, whereas amphetamines may cause dilated pupils.¹⁹

To test pupil reaction, the examiner holds one hand over one eye and then moves the hand away quickly, or shines the light from a penlight into the eye, and observes the pupil’s reaction when the light is shone on the eye (normal reaction: constriction) or when the light source is removed (normal reaction: dilation). The examiner tests the other eye in a similar fashion and compares the results. The pupillary reaction is classified as brisk (normal), sluggish, nonreactive, or fixed. An ovoid or slightly oval pupil or a fixed and dilated pupil indicates increasing intracranial pressure.¹⁹ If both pupils are midsize, midposition, and nonreactive, midbrain damage is usually indicated. The fixation and dilation of both pupils is a terminal sign of anoxia and ischemia to the brain.^19,35

Spinal cord injuries can have catastrophic and irreversible neurologic consequences, so early recognition of the problem is essential.36 If the athlete walks off the field before notifying the medical staff of a potential neck injury, he or she should be examined using a regular cervical assessment (see Chapter 3). If the player appears to have or communicates a neck injury on the field or is unconscious, then a neck or head injury should be assumed, and he or she is treated as indicated below. The cervical assessment is modified so as much of the examination as possible is done without moving the athlete. After examination, the athlete is immobilized and transported to a medical facility.³⁷

An upper spinal cord injury should be suspected, at least initially, if the patient has neck pain; the patient’s head position is asymmetric or abnormal; the patient is having respiratory difficulty, especially if the chest is not moving (absence of abdominal or diaphragmatic breathing); the patient is demonstrating priapism (erection of the penis); or the patient is unconscious after a fall or other contact activity. Other indications of neurological injuries in the conscious patient include numbness, tingling, or burning, especially below the clavicles; muscle weakness; twitching; or paralysis of the arms or legs, especially bilaterally (flaccid paralysis).¹⁹

The examiner may ask the patient to stick out the tongue, wiggle the toes, move the feet or arms, or squeeze the examiner’s fingers.¹² This quick test provides a rapid assessment of the brain and spinal cord by showing whether the patient can follow instructions and can do the activity.

If the patient is unconscious (Table 18-6), the examiner should reassess the level of unconsciousness if possible and treat the patient as though a spinal injury has occurred. In the unconscious patient, the examiner should watch for spontaneous limb movement, especially after the application of a painful stimulus, because movement indicates that the patient is less likely to have suffered a severe cervical injury.¹⁹ In addition, the examiner should look for tonic posturing that indicates a severe head injury. The fencing response may occur at the time of impact with one limb extending and the other flexing regardless of position or gravity (Figure 18-10).³⁸ Decerebrate rigidity is evidenced by all four extremities being in extension. With decorticate rigidity, the lower limbs are in extension and the upper limbs are in flexion (see Figure 2-33).

The patient’s level of consciousness is then reassessed. The examiner should now institute a Neural Watch (Figure 18-11) or a similar observation scheme to note any changes in the patient over time. The Neural Watch should initially be performed every 5 to 15 minutes, because it also facilitates monitoring of the patient’s vital signs.¹⁹ After the patient has stabilized, Neural Watch recordings may be made every 15 to 30 minutes.²⁹ If possible, reassessment by the same examiner allows the detection of subtle changes.

The examination should include an evaluation of the patient’s facial expression; a determination of the patient’s orientation to time, place, and person; and the presence of both posttraumatic amnesia and retrograde amnesia. Signs and symptoms that demand emergency action in a patient who has sustained a blow to the head are increased headache, nausea and vomiting, inequality of pupils, disorientation, progressive or sudden impairment of consciousness, gradual increase in blood pressure, and diminution of pulse rate.

Reaction to pain and the level of consciousness can be determined by the use of physical and verbal stimuli. If there is no cervical injury, the verbal stimuli may include calling the patient’s name and shaking and shouting at the patient. Physical stimuli (see Figure 2-32) include squeezing the Achilles tendon, squeezing the trapezius muscle, squeezing the soft tissue between the patient’s thumb and index finger, squeezing an object (pen or pencil) between the patient’s fingers, squeezing a fingertip, or applying a knuckle to the sternum. (This must be done with caution because it may cause bruising.) In comatose patients, a motor response to a painful stimulus to an extremity may indicate intact pain appreciation from that site, especially if it is accompanied by a more remote response, such as a grimace or a change in respiration or pulse.¹⁶

The level of consciousness can best be determined with the use of the Glasgow Coma Scale (GCS) (see Table 2-20).^39–41 The sooner the patient is tested with the scale, the better, because the initial assessment can be used as a baseline for improvement or deterioration in the patient. The GCS is often used in conjunction with the Neural Watch. For a description of the test, see Chapter 2.

Deterioration of consciousness may result from many conditions, such as increased intracranial pressure caused by an expanding intracranial lesion, hypoxia (which can aggravate cerebral edema and increase the intracranial pressure), epilepsy, meningitis, or fat embolism. The examiner should always look for signs of expanding intracranial lesions (see Chapter 2), especially if the patient is conscious. These lesions are emergency conditions that must be attended to immediately because of their potentially high mortality rate (up to 50%).

If the patient experiences loss of consciousness or appears to have disturbed senses, is seeing stars or colors, is dizzy, or has auditory hallucinations or a severe headache, the patient should not be left alone or allowed to return to activity (Table 18-7). In addition, nausea, vomiting, lethargy, increasing blood pressure, disturbed sensation of smell, or a diminished pulse should lead the examiner to the same conclusion. Amnesia, hyperirritability, an open wound, unequal pupils, or leaking of cerebrospinal fluid or blood from the ears or nose also indicates an emergency condition. Numbness on one side of the body or a large contusion in the head area should likewise lead the examiner to handle the patient with care. If the frontal area of the brain is affected, the patient may experience lapses of memory, personality changes, or impairment of judgment. If the temporal lobe has been affected, the patient may experience feelings of unreality, déjà vu, or hallucinations involving odors, sounds, or visual disturbances, such as macropsia (seeing objects as larger than they really are) or micropsia. The literature indicates that head injury depends not only on the magnitude and direction of impact and the structural features and physical reactions of the skull but also on the state of the head/brain at the moment of impact.^6,42,43

If the examiner suspects a heat-type injury with no cervical injury, only heat exhaustion and heat stroke need be considered as life-threatening.10,44 Heat fatigue or exhaustion occurs when a person is exposed to high environmental temperature or humidity and perspires excessively without salt or fluid replacement. Heat stroke can occur when a non-acclimatized person is suddenly exposed to high environmental temperature or humidity. The thermal regulatory mechanism fails, perspiration stops, and the body temperature increases. Above 42° C oral body temperature, brain damage occurs, and death follows if emergency measures are not instituted. The diagnostic keys in this situation are the high body temperature and the absence of sweating. Initial signs of heat injury include muscle cramps, excessive fatigue or weakness, loss of coordination, decreased reaction time, headache, decreased comprehension, dizziness, and nausea and vomiting.

The body temperature varies according to the site at which the measurement is taken. The oral body temperature is 37° C (98.6° F). Taken in the armpit or axilla, the temperature is 36.4° C to 36.7° C (97.5° F to 98.1° F), and in the rectum, it is 37.3° C to 37.6° C (99.1° F to 99.7° F).

The examiner may palpate the skin to get some idea of the external temperature of the body and possible pathology (Table 18-8). Hot and dry skin is often caused by heat stroke, high fever, or hyperglycemia. Cold and clammy skin is caused by hypoglycemia, shock, fainting, or hyperventilation. Cool and moist skin is often caused by heat exhaustion, whereas cool and dry skin is caused by exposure to cold.

Skin color can also play a significant role. Pallor, or whitish skin, indicates circulatory disturbance or decreased circulation and is most often associated with trauma and shock. Cyanosis, or a blue tint to the skin, indicates respiratory distress, as does a gray tint. Redness indicates an increase in blood flow as a result of fever, heat stroke, or exercise.

While doing the initial assessment, the examiner should also be considering how the patient will be moved and immobilized (e.g., self-ambulation, stretcher, spinal board) depending on the severity of the injury, and whether the patient can move him or herself or can move only with assistance.45

If the patient has not already done so, the examiner asks the patient to move the limbs to reassess for a cervical spine injury and look for major trauma (e.g., fracture, dislocation, third-degree strain, third-degree sprain). At the same time, the examiner may palpate the areas of potential injury, noting any pain, abnormal bone or joint alignment, swelling, hypersensitive or hyposensitive areas, or palpable defect (third-degree strain).⁴ If movement is relatively normal, the examiner quickly checks the myotomes of the upper or lower body for any possible motor involvement or motor impairment. Changes in limb power may be caused by a contractile tissue injury, a neurological injury, or an expanding intracranial lesion, which will be displayed as progressive weakness in the contralateral arm or leg.²⁹ Decreased limb power can also be caused by reflex inhibition as a result of previously unrecognized limb injury. In these cases, contractions are weak and painful. These types of injuries are placed in the low-priority group (see Table 18-1) because they represent a threat to the limb rather than to the life of the patient.¹⁷

Normally, a patient is left in the position in which he or she is found until the primary assessment is completed. However, if the patient is having difficulty breathing or there is no pulse, the patient must be positioned to do CPR. If the conscious patient is prone and in respiratory difficulty, the examiner, with assistance, should log-roll the patient (Figure 18-12) onto a spinal board so that an attempt can be made to restore the airway. During any movement of the patient, the examiner should apply traction of about 4.5 kg (10 lbs) to the cervical spine to maintain stability. The patient should be reassured that others are going to carefully move the patient while he or she remains still. Before any movement is attempted, the patient and those who are going to assist the examiner should know what the examiner plans to do and what their jobs are. This requires frequent practicing of emergency procedures. The sequence of movement and positioning of the extremities and body of the patient should be thought out beforehand so that everyone is aware of what is going to happen and in what order. The proper procedure for moving the patient should be practiced often to ensure competency.

To roll the patient, at least three assistants are needed. There should be two-way communication between the examiner and the patient at all times to continually evaluate the patient’s comfort level and neurological signs. The assistants should place the spinal board beside the patient and then kneel beside the spinal board and patient (see Figure 18-12, A). They should reach over the patient and hold the patient’s shoulder, hip, and knees (see Figure 18-12, B). On command from the examiner, the assistants roll the patient toward them while the examiner stabilizes the head (see Figure 18-12, C) until the patient is lying supine on the spinal board (see Figure 18-12, D). Only rolling—not lifting—should occur. With the patient in the supine position, proper CPR techniques may be applied, or the patient may be transported. The patient may also be covered with a blanket to provide warmth.

If a spinal injury is suspected and the conscious patient is in the prone position but has no difficulty breathing, the patient is log-rolled halfway toward the assistants while another assistant slides the spinal board as close as possible to the patient’s side. The patient is then rolled directly onto the spinal board in the prone position. Similarly, if a spinal injury is suspected and the patient is in the supine position and breathing normally, the patient is rolled toward the assistants while another assistant slides the spinal board under the patient as far as possible. The patient is then rolled back onto the spinal board in the supine position. If a spinal injury is suspected and the patient is in side lying, the patient is log-rolled directly onto the spinal board and into the supine position. In each of these cases, the examiner controls the head, applies traction, and instructs the assistants. The patient’s head is then stabilized and immobilized with sandbags, a head immobilizer, or triangular bandages, and the patient is strapped to the spinal board with restraining belts. If a collar is used to stabilize the spine, it must do so during movement as well as when the patient is stationary; it must not hinder access to the carotid pulse, airway, or performance of CPR; it must be easy to assemble and apply; it must be adaptable to patients of all ages and sizes; and it must allow radiological examination without removal.^46,47 Any major injury (such as, a head injury, a spinal injury, or a fracture) requires appropriate handling, slow and deliberate management, and proper transportation to provide a satisfactory outcome. These techniques must be practiced repeatedly.

If possible and if time permits, especially if the assistants are not used to working together, a simulated roll and transport using an uninjured person should be attempted before moving the patient to ensure that all involved know what they are doing in terms of patient positioning, movement sequence, and specific handling (e.g., head, hands, feet) so that any transfer or movement of the patient is effective and organized.

During the emergency assessment, if the patient is nauseated, is vomiting, or has fluid draining from the mouth, and provided breathing and circulation are normal, the patient should be placed in the recovery position (Figure 18-13) as long as there is no suspicion of a spinal injury. This side lying position enables the patient to be continually monitored (ABCs) and allows the examiner to easily observe any change in condition while waiting for emergency personnel. The patient’s head should be positioned to keep the airway open and to allow drainage from the throat and mouth. If the blood flow to the heart and brain has diminished, circulation can be improved by elevating the lower limbs, provided that the position change can be accomplished without causing further pain or breathing problems or aggravating an injury. If the patient has breathing difficulties or a chest injury or has experienced a heart attack or stroke, it may be desirable to lower blood pressure in the injured parts by elevating the upper part of the body slightly, if the position change can be accomplished without causing further pain or breathing problems.

If the patient is unconscious and the cardiac and circulatory functions are not compromised, the patient should be left in the original position until consciousness is regained. However, if the patient is unconscious and lying supine, the examiner should always watch for the possibility that the patient may “swallow” the tongue and obstruct the airway. Also, an unconscious patient loses the cough reflex, and if vomiting or bleeding occurs, vomitus, mucus, or blood may enter and obstruct the airway. Therefore, the examiner may elect to put the patient in the recovery position.

If the patient is unconscious and in respiratory or cardiac distress, the examiner must quickly assess the patient and attempt to restore respiratory and cardiac function. This patient is then treated the same as the conscious patient.

If the patient’s spine is twisted or flexed and the patient is reasonably comfortable, the patient should be stabilized in that position until a spinal injury is ruled out. If there has been a loss of breathing or cardiac function, the examiner must carefully correct the deformity, place the patient in the supine lying position, and perform the appropriate measures to deal with the problem.

If a cervical spine injury has occurred to a child of 7 years of age or younger, the examiner should realize that in these children, the head is normally larger in proportion to the rest of the body. If the child is positioned on a spinal board without modification, the neck will be forced into some flexion. To alleviate this problem, the spinal board should have a cutout for the head, or a pad for the chest or rest of the body should be added to elevate it in relation to the head.⁴⁸

If the patient is in the water and unconscious, he or she must be reached as quickly as possible. The rescuer should not jump into the water, because this action creates waves that may rock the victim’s head and could cause severe consequences if a neck injury has occurred. The examiner should approach the patient head-on and place an extended arm down the middle of the patient’s back with the patient’s head in the examiner’s axilla. The examiner then grasps the patient’s biceps with the forearm around the patient’s forehead, slowly lifts the arm, and turns the patient face up. The examiner’s forearm locks the patient’s head in the examiner’s axilla during the turn. Once the patient is supine, both of the examiner’s arms support the patient’s head and spine in the water. An assistant then slides the spinal board under the patient in the water and blocks the patient’s head with towels. The patient is next strapped to the spinal board with restraining straps and is lifted out of the water.⁴⁹ If a spinal board is not available and a cervical injury is suspected, the patient should be supported in the water until emergency personnel arrive.

In some sports (e.g., ice hockey, lacrosse, motor car or motorcycle racing, football), the athletes wear helmets. Whether the helmet should be removed to institute emergency procedures is a controversial issue and often depends on the type of training (EMS versus sports therapy) and experience of the health care professional.^2,45,50–53 Generally, if the patient is unconscious, the helmet should not be removed unless the examiner is absolutely certain that there has not been a neck injury. In the patient who wears both helmet and shoulder pads, both should be left on the patient, because they help to maintain the cervical sagittal alignment close to normal. Ideally, the helmet and shoulder pads should be removed in a controlled setting, such as the emergency department.^2,54,55 Helmets should be removed only if the facemask or visor interferes with adequate ventilation;^54,56 if the facemask interferes with the clinician’s ability to restore an adequate airway;^54,56 if the helmet is so loose that it does not provide adequate immobilization of the head when secured to the spinal board;^54,56 if life-threatening hemorrhage under the helmet cannot be controlled;^54,56 if, in children, the helmet is too large and causes flexion of the neck when used as part of the immobilization;^48,54,56 or if it is necessary to defibrillate the patient. In the last case, the shoulder pads must be removed, so the helmet should be removed to maintain spinal position.⁴ If the patient is in respiratory distress, facemasks can usually be easily removed with the use of an X-Acto knife or similar device to release the restraining straps while holding the mask in place.

If, for whatever reason, the decision is made to remove the headgear, the neck and head must be held as rigid as possible. Therefore, at least two people are needed: one to stabilize the head and neck and one to remove the facemask. One person, usually the assistant, first applies in-line traction is to the helmet to ensure initial stability. A second person, usually the examiner, then stands at the side of the patient and employs in-line traction by applying a traction force through the patient’s chin and occiput. The assistant stops applying traction and, if the helmet is a football helmet, first removes the cheek pads by sliding a flat object (e.g., scissors handle) between the cheek pad and helmet, twisting the object to cause the pads to unsnap. After the pads are removed, the assistant applies bilateral expansion to the helmet so that the ears are cleared as the helmet is removed.⁴ After the helmet has been removed, the assistant reapplies in-line traction from the head, and the examiner then releases the traction and continues the primary examination.⁴³ If desired, the examiner may apply a cervical collar, such as the Stifneck collar, but this should be done with caution because cervical collars do not completely eliminate movement in the cervical spine.⁵⁷

If the helmet is removed and the patient is wearing shoulder pads, the person holding the head must ensure that the head does not fall back into extension, and a modification must be made to the spinal board. The shoulder pads should be removed only if it is impossible to do this or if defibrillation is necessary.

If the patient is conscious and there appears to be no cervical injury or other severe injury, the patient may be moved to another area for a more appropriate and complete secondary assessment. If the injury is in the upper limb and the injured part is immobilized, the patient may first be moved from a supine to a sitting or kneeling position, then from sitting or kneeling to supported standing, to unsupported standing, and finally the person may walk off the field. During these changes in position, the examiner or assistants are positioned to provide support and assistance if the patient feels dizzy or unsteady. If the injury is in the lower limb, the athlete may be helped off the field by teammates, stretcher, or cart. Spinal injuries require greater care and the use of a spinal board and cervical collar with support. Again, assistance may be required, and everyone, including the patient and assistants, should be aware of the movement sequence before it is attempted.

During the primary assessment, the examiner must use some method of determining the severity of injury. There are several scales that may be used to test the severity of injury or to triage the patient, including the Galveston Orientation and Amnesia Test,58 which tests for posttraumatic amnesia; the Abbreviated Injury Scale;⁵⁹ the Injury Severity Score;^59–61 the Trauma Score;⁶² the Triage Index;^63,64 the Circulation, Respiration, Abdomen, Motor, and Speech (CRAMS) Scale;^65,66 and the Trauma Index.⁶⁷ Of these, the Trauma Score illustrates the ease of scoring (Figure 18-14) and the survival probabilities (Table 18-9) that can be expected in trauma patients. This tool provides a dynamic score that monitors changes in the patient’s condition and is useful in making triage decisions. The CRAMS scale illustrates a similar scoring pattern (Table 18-10).