Disclosures Evidence Based Medicine What is Evidence? Creating

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
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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?
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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
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Full QR Helmet Options
Full QR Helmet Options
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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.
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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
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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
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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?
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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
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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…?”
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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
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5/16/2014
What’s Causing the Problem?
The Rise of Catastrophic Spine Injury?
1969-1972
Tackling without Head Contact
Just sayin’...
Thank you!
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