5/16/2014 Disclosures Football Protective Equipment Designs - Effects on Cervical Spine Injury Management and Acute Airway and Cardiovascular Care in Medical Emergencies Current Funding: NFL Charities, NFL Erik E Swartz, PhD, ATC, FNATA Professor, Clinical Coordinator Evidence Based Medicine What is Evidence? David L Sackett “the integration of best research evidence with clinical expertise and patient values.” “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” Creating High Level Evidence Level Type of evidence I Large RCTs with clear cut results II Small RCTs with unclear results III Cohort and case-control studies IV Historical cohort or case-control studies V Case series, studies with no controls The Problem 1 5/16/2014 Creating High Level Evidence  Full face-mask removal using established tools and techniques27-29 is executed once the decision has been made to immobilize and transport.  Evidence Category: C Face Mask Removal The objective in removing a facemask is to create little or no movement and finish in as short a time as possible. “Yes” Face Mask Removal is Safer than Helmet Removal….Right? No research comparing facemask and helmet removal have been published How do you know? 2 5/16/2014 Facemask Removal Compared to Helmet Removal Results Recent changes in facemask and shoulder pad designs allow for full quick-release removal.  Facemask removal—regardless of helmet type—resulted in less motion than helmet removal  FMR: sagittal=3.9°±0.2°; frontal=2.4°±0.1°; transverse=2.7°±0.1°  HR: sagittal=18.5°±0.9°; frontal=7.4°±0.4°; transverse=10.3°±0.4°  Facemask removal was 20 15 FMR HR 10 5 0 Sag Front Trans completed in less time (37.4±1.3sec) than helmet removal (96.1±6.1sec). Funding: Eastern Athletic Trainers’ Association 3 5/16/2014 Full QR Helmet Options Full QR Helmet Options 4 5/16/2014 Methods Range of Motion  4 conditions: 18  FMR of Schutt Ion4D 16  FMR of Riddell 360 14  Removal of Schutt Ion4D and Traditional shoulder pads 12  Removal of Riddell 360 and RipKordTM shoulder pads 10 Sagittal Frontal 8 Transverse  2 participants in each session 6  Participants performed each condition 2 times 4 2 0 RS360-FMR Time ION-FMR RS360-HR ION-HR Major Findings 35  As hypothesized, FMR induced less motion than HR when accessing the airway, validating current clinical recommendations. PHEW!! 30 25  Quick-release loop straps allow FMR to be completed in clinically acceptable times with less motion in all planes. 20  Helmet removal may be removed in clinically acceptable times 15 10 5 0 RS360-FMR ION-FMR RS360-HR ION-HR Chest Access Major Findings Variable Traditional RipKord t P Sagittal ROM, º 14.10 (2.90) 12.84 (2.17) 1.63 0.119 Frontal ROM, º 6.84 (1.55) 6.49 (1.21) 0.80 0.435 Transverse ROM, º 6.92 (1.22) 6.52 (1.24) 1.10 0.285 Time, sec 29.22 (4.45) 21.96 (3.08) 9.80 <0.0001* RPE 2.13 (0.87) 2.28 (0.70) 0.80 0.435  The new RipKordTM design allows ATs to remove shoulder pads more quickly, without compromising cervical spine motion or introducing additional difficulty to the task. 5 5/16/2014 Rapid Fire Considerations for Clinical Techniques Riddell Quick Release System Facemask Removal Schutt Facemask ‘Hanger’ Remove Cheek Pads Helmet and Shoulder Pad Removal Removal of Cheek Pads from Traditional Helmets is not easy 6 5/16/2014 Cheek Pad Removal Riddell Revolution, Speed, 360 Deflate Bladders Cheek Pad Removal Schutt ION4D Which bladder does each valve connect? Which Bladders (valves) are Accessible? Chin Strap Removal Head Stabilization Open Shoulder Pads 7 5/16/2014 Face Mask Removal The reason for removing a facemask is to establish access to the airway. “Yes” Face Mask Removal Allows for adequate ventilations….Right? No research has established that an airway can be viably supported with a football helmet in place How do you know? 8 5/16/2014 Research Design- CPR Scenarios  Independent Variables:  Shoulder pad status: On, Lifted, Open, Trad Off, RipKord Off  Face mask: On, Lifted  Dependent Variables:     Research Design- Airway Scenarios  Independent Variables:  Airway: Pocket Mask (PM) vs. Bag Valve (BV) Compression Depth Compression Recoil Compression Rate AED placement Preliminary Impressions  Bag valve > pocket mask  No Helmet > Helmet  Number of rescuers: 1 vs. 2  Helmet: On vs. Off  Chin Strap: On vs Off  Dependent Variables:  (MV) Mean Volume  (TV) Total AdeqVentilations  (AV) Adequate Ventilations (% of total attempted) Preliminary Impressions Implications  Chin Strap greatly reduces ventilatory effectiveness 9 5/16/2014 Question No matter what, at some point the equipment has to come off, in order to effectively diagnosis and treat the athlete. “should we remove protective athletic equipment prior to transport…?” What if the Equipment has to come off Here?? Pre-Hospital Equipment Removal 1. Experienced and Trained Personnel 2. Full medical access to airway and chest 3. Immediate use and proper application of AED 4. Ability to utilize cervical collar 5. Ability to conduct x-ray/ MRI on arrival Do we WANT the equipment to come off here?? Question “should we remove protective athletic equipment prior to transport…?” 10 5/16/2014 Our Current Recommendations Concluding Thoughts A spineboard provides better immobilization than a collar and stretcher alone….Right? “Yes” How do you know? Prevention of Head Impacts The best way to manage a catastrophic head or neck injury is to prevent it from happening in the first place 11 5/16/2014 What’s Causing the Problem? The Rise of Catastrophic Spine Injury? 1969-1972 Tackling without Head Contact Just sayin’... Thank you! 12