Tia Dickson, RN, BSN

Primary Children's Hospital

Whether it's under the Friday night lights or on the soccer field, injuries can occur when kids play sports. Kid's brains and bodies are still growing and developing. The care EMS personnel provide at the time of an injury is crucial and can improve positive outcomes for athletes and their families. Take some time to review this great topic. Fall sports are right around the corner.

Podcast: EMS Timely Tips: Pediatric Sports Injury Management

On Scene Pediatric Sports Injury

Julia Rawlings, MD, Pediatric Emergency Medicine

University of Utah and Primary Children's Hospital

Excerpts from July 11th PETOS

More than 60 million children participate in organized sports each year and injuries are common. Most are minor but some do require transport to an emergency department.

Epidemiology of emergency transport incidents (ETI):

• For every 10,000 athlete exposures (1 game/practice) there is about 1 transport
• The sport with the most ETIs for high school is football (0.8)
• The sport with the most ETIs for college sports is women’s ice hockey (1.28)
• The most common mechanism of injury is player-to-player contact followed by contact with a surface
• The top diagnosis is "strain” (likely neck strain), followed closely by concussion and fractures.

Data collected since 1982 by the National Center for Catastrophic Sport Injury Research shows catastrophic injuries (those resulting in death, permanent disability or requiring long recovery) are those involving head/neck trauma, cardiac events, and heat-related illness.

Each year, emergency departments (ED) diagnose 750,000 concussions. Thirty percent of all pediatric concussions occur during sports; the 2 most common sports and recreation activities associated with ED visits for traumatic brain injury (TBI) are football and biking. In sports played by both sexes, girls sustain more concussions than boys.

What is a concussion?

• A subset of mild TBI
• Occurs at the neuro-metabolic level rather than a structural injury (so imaging is normal)
• Neurons are stretched which causes K+ to rush out of the injured cells and Ca2+ to rush in.
• Energy (ATP) is needed to re-establish homeostasis
• Cerebral blood flow decreases and less glucose is carried to the brain which leads to ENERGY CRISIS

Initial evaluation

For all acute head or neck injuries:

• ABCs (on field)
• Cervical spine precautions if needed (on field)
• Secondary survey (possibly sideline)
• Neurologic and cognitive evaluation (possibly sideline)
• Athletic trainers and team physicians may use Sideline Concussion Assessment Tool (SCAT5) to diagnose more subtle concussions

Visible concussion clues

• Loss of consciousness or responsiveness
• Lying motionless on ground or slow to get up
• Difficulty with balance or coordination
• Clutching of head
• Dazed, blank, or vacant look
• Confused / Not aware of events

• Players with shoulder pads, helmets, and face shields need special consideration.
• Face masks should be removed to access the airway but in nearly all situations which require cervical spine precautions leave BOTH the helmet and shoulder pads in place.
• If you remove one, you must remove both to avoid extension of the neck.
• If you must remove them it is important to do it the right way which requires 3 trained individuals. Rely on the coach and on-site athletic trainers.
• Stabilize the neck from below and remove both the pads and helmet simultaneously.
• You can intubate with the helmet and pads in place.
• NFL trainers routinely send players off the field without removing helmet and pads.

Patella dislocation

The patella (knee cap) dislocation in more common in younger patients. They almost always dislocate laterally.

Mechanism:

• Foot is planted, leg is rotated inward, and a valgus force is applied to the knee

• Direct blow to medial patella

• The patient's knee will be in a partially flexed position

On scene treatment:

• Any movement is very painful; give narcotics and splint as is
• Or try and splint in extension with some medial pressure, which may reduce it
  

Exertional heat illness (EHI)

• Heat stroke
• Heat exhaustion
• Heat cramps
• Exertional hyponatremia

Heat stroke is the #2 cause of death in sports after cardiac. About 9,000 high school athletes are treated for EHI annually (which is likely an underestimate). Between 1996 and 2018, 61 football players died from EHS (UNC Annual Survey of Football Injury Research). The rate in football players is 11.4 times higher than all other sports combined.

Mechanism: The body's cooling mechanisms are overwhelmed by internal (metabolic) and external (environmental) heat factors. The athlete can no longer maintain a steady state. The uncompensated rise in internal temperature leads to exertional heat stroke. At temperatures >105.5 degrees F (40.83 degrees C), cells denature and membrane lipids liquify, which leads to multi-system organ failure. Damage becomes irreversible and ultimately fatal if hyperthermia isn’t quickly corrected.

Signs and symptoms:

• Nausea, vomiting
• Hot, wet skin
• Tachycardia
• Hypotension
• Hyperventilation
• Profound fatigue

When heat stroke treatment is started within 10 minutes it is 100% survivable. Begin with ABCs and obtain a set of vital signs including a core temperature (rectal temp is the most accurate). Remove excess equipment and cool them down.

Cool first, transport second. Cold water immersion (CWI) with ice is the best and fastest way to decrease body temperature. If CWI is not available, rotate ice towels to maximum surface area of the body every few minutes. Cooling should continue during transport.

** Note that hyperthermia protocols often warn against cooling quickly. These protocols address the general population. The above recommendations are for healthy athletes by the National Athletic Training Association. EMS should defer to local protocols but if you attend sports events frequently, consider updating your agency protocols for this special population.

• Organized events that require EMS coverage should have an EAP
• They prepare emergency responders for a catastrophic event
• The athletic trainer or covering physician should be your contact
• Trainers may have signals used to call emergency personnel onto the field
• Meet team staff and know the plan

A 14 year old “burn” victim was transferred from scene to the University of Utah in July. The PCR was firework explosion but there wasn't actually much thermal injury. This patient should have have been taken to Primary Children's Hospital. The reason stated for transfer was burn but as you can see from the current Pediatric Burn Treatment Clinical Guideline below, patients 14 and younger, who don't meet American Burn Association Referral Criteria, should first go to a pediatric level 1 center for evaluation..

On Topic:

• How extreme heat affects young athletes | PBS
  

• National youth sports safety month | Vanderbilt University Medical Center

• Traumatic brain injury prevention CDC heads UP | Centers for Disease Control and Prevention

• Sports injury prevention Mastering the topic, the message, and the delivery: Leveraging the social marketing mix to better implement sports injury prevention programs | Journal of Orthopaedic & Sports Physical Therapy

• Sports injury prevention Baseball-related craniofacial injury among the youth: A national electronic injury surveillance system database study | Journal of Craniofacial Surgery

Seasonal prevention

• Bicycle safety: Bicyclists of all ages should wear properly fitted bike helmets every time they ride.

• Heatstroke | Kids and car safety

Suicide prevention

• The first animated series for teen mental health | My life is worth living

• Adolescent athletes and suicide: A model for treatment and prevention | Aggression and violent behavior
  

Announcements

Primary Children's Hospital has joined the Pediatric Pandemic Network.

Reminder: NPRP assessment still available: Even though the official assessment period has ended, the National Pediatric Readiness Project (NPRP) assessment is still available online. Learn more.

EMSC is sad to report that our hard working medical director, Hilary Hewes is stepping down from that position in August.

Dr. Hewes received her BA in Spanish from the University of Oregon and her MD from the University of New Mexico School of Medicine in 2004. Her next stop was a 3-year pediatric residency at the University of Utah which was followed by a chief resident year.

In 2011, she finished her fellowship in pediatric emergency medicine at the University of Utah/Primary Children’s Hospital and was recruited to join the faculty in pediatric emergency medicine as assistant professor. Her interests include pediatric trauma, pediatric prehospital care, disaster preparedness, and injury prevention. She is actively engaged in research in these areas which has resulted in several peer-reviewed publications.

Hilary is a true juggler. She acted as the medical director for Utah EMSC, medical director for Emergency Management and Preparedness and Trauma for Primary Children's Hospital, and the principal investigator for NEDARC simultaneously. We are happy to note she intends to keep several of these hats which will keep her in close association with our program.

For EMSC she headed a number of quality improvement projects. Most recently she assisted in the early development of a rural telehealth network, worked with the Utah EMS Protocol Guidelines steering committee, and compiled data points for our Handtevy QI initiative. Dr. Hewes has been a key part of the executive team of the UPTN (Utah Pediatric Trauma Network) since its inception and helped develop multiple pediatric trauma-based protocols for emergency providers across the state and region.

Dr. Hewes attended our many retreats and conferences and always made herself available to individual EMS providers and agencies (even while on vacation).

We are truly grateful to Dr. Hewes and look forward to working with her in a new capacity!

Monkeypox is a rare disease with symptoms similar to smallpox but milder, less contagious, and rarely fatal. The virus spreads from person-to-person through direct contact with an infectious rash, scabs, or body fluids. Unlike COVID-19, which is airborne, the reported cases of monkeypox appear to spread by skin-to-skin contact with infected lesions. It can also spread by touching items, such as clothing or linens, that previously touched the infectious rash or body fluids. Wearing PPE when caring for monkeypox patients effectively prevents transmission in the healthcare environment.

While there’s no specific treatment for monkeypox, the condition typically goes away by itself within about two weeks. There are two vaccines licensed by the U.S. Food and Drug Administration (FDA) that are available to prevent monkeypox infection—JYNNEOS (also known as Imvamune or Imvanex) and ACAM2000. Currently there’s a limited supply of JYNNEOS, although more is expected in coming weeks and months. There’s also an antiviral drug called tecovirimat (TPOXX) that’s FDA-approved for treatment of smallpox and is expected to be effective against monkeypox virus infection as well. Tecovirimat is being made available to healthcare providers by the Centers for Disease Control and Prevention (CDC), via state health departments, for treatment of certain patients with monkeypox infection whose illness is severe or complicated, or who are at risk for severe or complicated disease. Intermountain infectious disease and pharmacy leaders are working with the CDC and local health departments to provide this therapy. More details are expected next week.

This FAQ from the CDC provides quick, helpful information about monkeypox. Here’s more in-depth information. Here’s an informative CDC slide set for providers, which includes clinical updates and patient assessment tools.

Steve Christiansen

Intermountain's Office of Patient Experience and Related Communications.

PECCs, are you receiving a frequent email titled PECC—Hot topics and updates?

Doctors Hewes and Miller along with the pediatric surge team send out a monthly email to all Utah PECCs. While this resource is aimed at our hospital PECCs, EMS PECCs will also find the information useful. Be sure mail coming from Annette is added to your safe senders and contact tdickson@utah.gov if you are a PECC and not on this direct email list.

Annette Newman MS, RN, CCRN

Disaster Preparedness Consultant

Utah Hospital Association

435-901-1425

annettenewman2020@gmail.com

PECCs, please educate

PECCs please use the story about the burn patient above to improve pediatric transfer decisions. Use these guidelines to educate your agencies and hospitals. Encourage leadership to look at your transfer protocols and be sure they are up to date with these recommendations.

https://www.utahptn.org/pediatric-guidelines-for-burn-treatment-utah/

https://www.utahptn.org/wp-content/uploads/2022/05/2021-Pediatric-Trauma-Expedited-Transport.pdf

Did you know that Primary Children's is offering general and in-depth case review?

You have a right to close the loop! PCH has recently put together a process to give you feedback on your patients. Agency PECCs please print out the PDF below. Post it around your agency, send it out to your providers. If they want to know what happened to that MVA kid or you want to know why the kid was unconscious; these are the peopld you should contact (the QR codes should work from the print out).

EMS Agency & Hospital PECC's are invited to our annual PECC conference!

When: Friday September 16, 2022

Where: Utah Valley Convention Center, 220 West Center Street, Provo, UT 84601

Time: 12:00-16:00

Presentations will be a hybrid of virtual and in-person presentations and would like to know how you would like to participate. Please RSVP so we can plan accordingly.

Please RSVP by clicking on the link https://tinyurl.com/ywcjw854

Questions - JaredWright@Utah.gov

Do you have a question for our EMSC medical director, Sarah Becker, MD, PCH, ER attending physician about this newsletter topic or anything related to pediatrics? Email tdickson@utah.gov.

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth