A 16-year-old boy is injured during a high school football game in a helmet-to-helmet collision. When the team physician reaches him, the patient is unconscious and lying prone on the field. He is breathing spontaneously, and respirations are 12/min. A radial pulse is palpable and pulse is 82/min. Emergency medical personnel arrive to transport the patient to the nearest emergency department. Which of the following is the best next step in management of this patient?

Question

A 16-year-old boy is injured during a high school football game in a helmet-to-helmet collision.  When the team physician reaches him, the patient is unconscious and lying prone on the field.  He is breathing spontaneously, and respirations are 12/min.  A radial pulse is palpable and pulse is 82/min.  Emergency medical personnel arrive to transport the patient to the nearest emergency department.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This athlete who experienced a blow to the head (ie, helmet-to-helmet collision) forceful enough to cause unconsciousness may also have sustained a cervical spine injury. Therefore, his cervical spine motion should be restricted and his neck maintained in a neutral, midline position until injury is ruled out clinically or radiographically. The following sequence can limit cervical spine motion while allowing for patient evaluation (eg, airway, breathing, circulation) and transport: Logroll to the supine position: One provider stabilizes the head and neck while three other providers bring the patient's arms to his sides and the legs together. The neck is kept in a neutral position relative to the body, and a coordinated roll is executed, usually onto a rigid longboard.Airway access: The face shield and mouthguard are removed to allow access to the airway.Spinal stabilization: A rigid cervical collar (ideally high cut, with multiple points of support [eg, chin, angle of the jaw, occiput]) is typically applied. However, if the uniform or equipment (eg, helmet, shoulder pads) cannot be removed to allow cervical collar application without significant risk of spinal manipulation, stabilization can be achieved through other means (eg, towel rolls, foam head blocks). Logroll to the supine position: One provider stabilizes the head and neck while three other providers bring the patient's arms to his sides and the legs together. The neck is kept in a neutral position relative to the body, and a coordinated roll is executed, usually onto a rigid longboard. Logroll to the supine position: One provider stabilizes the head and neck while three other providers bring the patient's arms to his sides and the legs together. The neck is kept in a neutral position relative to the body, and a coordinated roll is executed, usually onto a rigid longboard. Airway access: The face shield and mouthguard are removed to allow access to the airway. Airway access: The face shield and mouthguard are removed to allow access to the airway. Spinal stabilization: A rigid cervical collar (ideally high cut, with multiple points of support [eg, chin, angle of the jaw, occiput]) is typically applied. However, if the uniform or equipment (eg, helmet, shoulder pads) cannot be removed to allow cervical collar application without significant risk of spinal manipulation, stabilization can be achieved through other means (eg, towel rolls, foam head blocks). Spinal stabilization: A rigid cervical collar (ideally high cut, with multiple points of support [eg, chin, angle of the jaw, occiput]) is typically applied. However, if the uniform or equipment (eg, helmet, shoulder pads) cannot be removed to allow cervical collar application without significant risk of spinal manipulation, stabilization can be achieved through other means (eg, towel rolls, foam head blocks). (Choice A) Administering a noxious stimulus to arouse this unconscious patient may facilitate the neurologic examination; however, doing so would be dangerous while the patient is still in the prone position and without spinal immobilization because his unpredictable movements could worsen a potential cervical spine injury. (Choice C) Spinal traction is sometimes used in the treatment (eg, closed reduction) of cervical spine injury (eg, facet dislocation) but is performed only under radiographic guidance by an expert provider (eg, spine surgeon). (Choice D) The exact timing (ie, in the field vs in the hospital) of helmet removal depends on the helmet type; however, it is always performed with the patient in the supine (vs prone) position, typically with one provider manually maintaining in-line spinal immobilization while another provider removes the helmet. (Choice E) Transporting this patient in the prone (vs the supine) position does not allow for adequate evaluation and protection of the airway. Educational objective: Athletes with possible cervical spine injury should have their cervical spine motion restricted (eg, logroll technique, application of a rigid cervical collar) until injury is ruled out clinically or radiographically. References: Management of the helmeted athlete with suspected cervical spine injury. (http://www.ncbi.nlm.nih.gov/pubmed/15262662) Face mask removal is safer than helmet removal for emergent airway access in American football. (http://www.ncbi.nlm.nih.gov/pubmed/24216399)

A 16-Year-Old Boy Is Injured During a High School Football