PART 1

TRIAGE AND ACTION PLANS

Most events in track and field have a low risk of serious or critical injury,
with the exceptions of events such as the pole vault, javelin, hammer, and
discus. When providing medical care for an athletics event, both athletes
and spectators should be considered. Therefore, planning should cover
various athletic medical conditions as well as sudden illness (heart attacks,
strokes, fainting, hypoglycemia, heat illness, asthma.
!ports medicine personnel must be ac"uainted with the principles of acute
care, as much depends on the initial response. #ersonnel carrying out first aid
must be familiar with the devices and medicines needed for primary care.
The following should be considered when providing medical support
for an athletics event$
1 Medical team and medical supplies
2 #lan of %ction (&mergency %ction #lan
3 Triage and first aid measures
A. Medical Team
The medical team providing medical services for an event should
include the following$
1. Medical physician with training in emergency medicine
2. !upport staff (athletic trainers'physiotherapists, nurses, emergency
medical technicians
3. (irst %iders ()ed *ross
4. %mbulance and driver on standby
5. %llied health care providers$ masseurs, chiropractors, acupuncturists, etc.
%s a guide, the number of (irst %id staff re"uired for an event would
vary from +,- for a small event involving about .// participants to 0/,.//
for a large event, e.g. a marathon involving more than +/// participants.
B. Planning and Logistics
#lanning and logistics for a major athletics competition include$
1. The need to have designated first aid stations, which could be in the
form of tents or other cool, shady areas to treat injuries'illnesses.
2. 1esignated parking spaces for the ambulances.
3. %de"uate first aid e"uipment and supplies including$
1. (irst aid kits
2. #ortable, lightweight, reliable stretchers
3. *oolers of water, towels, cold packs (or ice cubes in plastic bags
4. *ommunication sets (e.g. Walkie Talkie, cell phones
*2%#T&) 3, &M&)4&5*6 *%)&
4. 5otification of all local medical facilities regarding the upcoming competition.
5. 7n addition, the team physician should coordinate$
1. *ompliance with all local, state, and federal regulations
regarding storing and dispensing pharmaceuticals.
2. 1evelopment of a chain of command that establishes and
defines the responsibilities of all parties involved.
3. )egular rehearsal of the emergency response plan.
4. &stablishment of a network with other health care providers, including
medical specialists, athletic trainers'physiotherapists, and allied health
professionals covering all competition sites (polyclinics, field events.
5. &stablishment of a policy that includes the team physician and
athletic trainers'physiotherapist in the dissemination of any
information regarding the athlete8s health status.
C. Competition-Da Planning
.. 9ptimised Medical *are
*ompetition:day planning optimises medical care for injured or ill athletes.
The team physician should coordinate$
1. Medical operations and administrative medical policies.
2. #reparation of the stadium' field medical bags and station medical supplies.
;. %dministrative #rotocol
7t is essential for the team physiotherapist'athletic trainer to coordinate$
1. %ssessment of environmental concerns and playing conditions.
2. #resence of medical personnel at competition site with
sufficient time for pre:competition preparations.
3. #lan with the medical staff of the visiting teams for medical
care of the athletes.
4. 7ntroductions of the medical team to competition officials.
5. )eview of the emergency medical response plan.
6. *hecking and confirmation of communication e"uipment.
7. 7dentification of examination and treatment sites.
8. %rrangements for the medical staff to have convenient
access to the competition site.
9. #ost:meet review and necessary modifications to
medical and administrative protocols.
+. 9n:!ite Medical !upplies
The team physiotherapist'athletic trainer should have competition:day
on:site medical bags and stadium medical supplies (see %ppendix -, On-
Site Medical Supplies for Injury Prevention and First Aid.
*2%#T&) 3, &M&)4&5*6 *%)&
D. Eme!genc Action Plan
#lanning for any medical emergency is a must (<a failure to plan is the
same as a plan for failure=. #oints to note in planning include$
1. !pecific instructions for specific personnel.
2. The route of evacuation by ambulance.
3. Medical supplies re"uired.
4. !teps to take for likely serious problems e.g. collapse'unconsciousness,
fracture, bleeding, medical transport for head and spine.
9nce developed, the plan must be communicated to all concerned.
!ome other important points to note about emergency planning$
1. Must include personnel trained (and certified in *#), athletic
trainers' physiotherapists who are familiar with the first aid kit
available (training' practice re"uired.
2. Must include names and contact numbers of important
persons, e.g. physician in charge.
3. Must include a map that shows site of sports event'training ground,
evacuation route for ambulance (to nearest hospital, locations of
emergency telephone(s (and include emergency telephone
numbers, first aid kits. (or coin phones, the emergency plan should
include having coins available (if necessary.
4. 4et valuable input to the plan from physicians, facility
managers, local emergency medical service personnel.
5. #lans need to be reviewed and improved regularly, e.g. yearly.
E. T!iage and "i!st Aid Meas#!es
To ensure ade"uate and timely care of casualties, proper triage is
important. The steps would include primary survey (%>*1& ?airway, breathing,
circulation, disability'neurologic status, expose athlete@, resuscitation, and
secondary survey, as well as the other necessary first aid (for bleeding,
fractures, head and spine injury, see #art ; of this chapter, First Aid
Management of Acute Sports Injuries. *ommon causes for sudden collapse
include heart attack, stroke, heat exhaustion'stroke, and fainting.
1. %irway assessment is the first priority in any casualty. The airway must
be kept open and patent (remove foreign debris, chin lift or jaw thrust.
2. >reathing is then assessed with <look, listen and feel= method. 7f the
casualty is not breathing, then mouth:to:mouth resuscitation must be
instituted. Medical coverage staff for sports events should be *#): and
defibrillator:trained (see %ppendix A, CPR/Adult asic !ife Support.
3. #alpating peripheral pulse, e.g,. the carotid pulse at the angle of the
jaw next assesses circulation. 7f there is no pulse, then external cardiac
compressions are instituted, along with defibrillation where appropriate.
*2%#T&) 3, &M&)4&5*6 *%)&
4. 1isability is then determined with a very rapid and brief neurologic
assessment using the pneumonic <%B#C= (alert, responding to
vocal stimuli, responding to painful stimuli, unresponsive.
5. &xposure of the casualty must be ade"uate to allow for a
careful examination and assessment.
(ollowing the primary survey, the necessary resuscitative measures must be
implemented, e.g. continued *#), use of defibrillator when available'appropriate,
fluid replacement (if necessary with an intravenous line, cooling of the athlete (if
heat stroke'exhaustion suspected, stopping any bleeding (direct pressure is best
and ade"uate for almost all types of bleeding, splinting of suspected fractures.
!econdary survey may not always be feasible at the site of the event, and may
need to be done only at the hospital (or in the ambulance while on the way to
hospital. This involves surveying the whole body from head to toe to check for
injuries. #rocedures would include evaluating pupillary siDe, checking the fundi,
assessing possible cervical spine injury, chest injury (e.g. pneumothorax,
abdomen and extremities.
(or athletes who are stable and conscious, management should focus
on the injuries sustained or other medical conditions. The following section
describes common problems and their first aid management.
Re$e!ence
1. %merican 2eart %ssociation. ;//0 %merican 2eart %ssociation 4uidelines
for *ardiopulmonary )esuscitation and &mergency *ardiovascular *are,
;//0. http$''circ.ahajournals.org'content'vol..;';EFsuppl'
PART 2
"IRST AID MANAGEMENT O" AC%TE SPORTS IN&%RIES
!port is a potentially dangerous activityG fortunately, life:threatening injuries
are rare. % sports physician should be ac"uainted with the principles of acute
care, as much depends on first aid. 7t is very important to recognise injuries with
serious outcome, and transport the injured to the ade"uate institution after proper
first aid has been carried out. The physician carrying out first aid should be
ac"uainted with the devices and medications of primary care. 7n this section we
will deal with primary care during the pre:hospital phase of injury management.
A. Spinal In'#!ies
7njuries to the spine may occur when a faulty landing happens after jumping,
as a result of being struck by an implement, or during conditioning training.
Trauma to the spine may result in injuries to the bone, cartilage, tendon, or spinal
cord. 7n severe vertebral or cordal injury, stability of the spine may be
compromised and there may be evidence of neurological findings. Whenever the
mechanism of injury or the clinical findings indicate bone or tendon involvement,
spinal cord injury should be taken into consideration, unless proven otherwise.
7f the patient is conscious, a fracture or cord injury is accompanied by
severe neck muscle spasm and pain, which indicates the nature of the
injury. 2owever, the unconscious athlete is open to further cord injury unless
the medical staff is not alert to this possibility. 7t is essential that no neck
manipulation be carried out on the field.
1uring the initial evaluation, proper preventive steps must be utilised in order to
prevent severe nervous system complications. These can occur, for example$
1. When nerve lesions remain unrecognised after bone:injury.
2. When first aid is delayed and irreversible nerve damage occurs.
3. When the unstable spine is improperly treated and
deterioration develops.
The following indicates spinal or spinal cord injury$
1. Tenderness to the spine
2. #alpable spinal deformity or haematoma
3. 5ervous system injury is suspected if there is$
1. %bnormality in chest breathing.
2. %bnormality of movements.
3. !egmental anaesthesia or numbness.
4. #ain that is referred to the limbs.
%ccording to the above:mentioned principles, first aid should be
carried out as follows$
.. &nsure breathing and circulation.
*2%#T&) 3, &M&)4&5*6 *%)&
(igure 3:.. #roper techni"ue for transferring a patient suspected of
having sustained a neck injury, in the absence of a stretcher.
2. When spinal injury is suspected, a thorough neurological
examination is to be performed as soon as possible, after
breathing and circulation have been maintained.
3. 7f the mechanism of injury is unknown and the patient is
unconscious, spinal injury must be assumed initially and treated
accordingly. The same is necessary if the patient is conscious
and spinal injury cannot be definitely ruled out.
4. 7f cervical injury cannot be ruled out, the neck should be stabilised
routinely in a neutral position with a rigid brace or collar,
sandbags, or with a !chantD:collar (but not a soft collar.
5. 2aving stabilised the neck, a vacuum mat is to be used as in spinal injuries.
The injured should be laid on a scoop or shovel:stretcher, or, if these are not
available, transfer should be carried out as shown in (igure 3:..
6. The seriously injured should be transferred to a hospital where
both modern diagnostic and therapeutic facilities are available.
Transfer should be carried out by helicopter if possible.
7. 7n case of a definite cord injury, high dose methyl:prednisolone should be
administered during the pre:hospital phase (+/mg'kg within .0 minutes,
0 mg'kg E0 minutes later, E mg'kgh for ;+ hours. !maller doses of
steroids are inade"uate, as only with high doses is oedema, which is
responsible for later neurological symptoms, prevented.
8. Bolume substitution may be necessary, because cross sectional
lesions of the spine may lead to vasodilation and shock.
Therefore infusion and alpha:adrenergic medication
(epinephrine or dopamine may be necessary.
9. The injured should be protected from being over:heated or cooled.
10. 5arcotic analgesics are contraindicated in case of spinal injury.
*2%#T&) 3, &M&)4&5*6 *%)&
Table 3:.. 4lasgow *oma !cale used to assess degree of head injury.
Reaction
Point
s
&ye opening
' !pontaneous E
' To speech +
' To pain ;
' 5o response .
Motor response
' (ollows commands -
' Hocalises pain 0
' Movement or withdrawal to pain E
' 1ecorticate flexion +
' 1ecerebrate extension ;
' 5o response .
Berbal response
' %lert and oriented 0
' 1isoriented conversation E
' !peaking but nonsensical +
' Moans or unintelligible sounds ;
' 5o response .
B. (ead In'#!ies
2ead injuries usually occur as a direct trauma to the head. 9ften concomittant
injury to the spine or spinal cord must be considered. 7njuries to the soft tissues of the
head are treated as in other soft tissue injuries (disinfection of the wound and
surroundings, sterile gauDe, and tetanus anti:toxin. 7f the athlete is unconscious, we
must proceed under the assumption that there is a fracture of the cervical spine.
7n cases of head injury, attention must be focused on potential
intracranial lesions (cerebral concussion, cerebral contusion, subdural, or
epidural haematomas. Treatment should be carried out as follows$
1. % thorough neurological assessment should be made. 1uring the
examina:tion, signs and symptoms of possible neurological deficiencies
are sought. !ymptoms of increased intracerebal pressure should be
looked for. The seriousness of head injury can be estimated by the
4lasgow *oma !cale as seen in Table 3:., which is also useful as an
indicator for intratracheal intubation or for later assessment.
.

2. *omplete *#) if necessary (see %ppendix A, CPR/Adult asic !ife Support.
3. 7n case of increased intracranial pressure, the following should be initiated$
1. The patient8s head should be placed at +/I.
2. 7ntravenous diuretics should be administered (E/ mg of furosemide.
3. Mannitol /.;0,. g'kg 7B.
*2%#T&) 3, &M&)4&5*6 *%)&
The signs and symptoms of intracranial pressure should be sought for
carefully$ (headache, vomiting, tachycardia, hyperventilation, hypertension,
meningeal signs (>rudDinki, Jernig:sign, stiffness of the neck, drowsiness,
stupor, wide:, non:reacting pupils, anisocoria, coma, Jussmaul:breathing,
convulsions, increase in muscular tone, bradycardia, hypotension, flaccid
muscles, hyperpyrexia, slow breathing, brady:arrhythmias, no
circulation, no breathing.
4. 7f inade"uate circulation or breathing are noticed, oxygen
should be administered.
5. %n 7B line should be ensured and intravenous crystalloids
should be given, so that mean pressure of K/mm 2g is
maintained. 7n the later stage, reduced cerebral perfusion
pressure is necessary in order to prevent cerebral oedema.
6. The patient should be transferred to a hospital where
neurosurgery is available.
Please note: 7f the examiner notices symptoms of brain concussion (transient
unconsciousness, diDDiness, nausea, vomiting, paleness, the patient should be admit:
ted to the hospital, because an intracranial lesion should be suspected. 7t is possible
that, in case of head injury, the patient will regain consciousness and be symptomless.
2owever, small veins around the dura may rupture causing a haematoma, which will
present with late neurological symptoms. This is called the lucid state (status lucidum.
C. "!act#!es
(ractures may result from several causes, including direct trauma, such as a blowG
from twistingG or as the end result of an unrecognised incomplete stress fracture.
The diagnosis can often be made from the history, plus physical findings.
The physical examination will reveal the classical signs and symptoms of
fractures (local oedema, pain, deformity, restriction of movement.
(irst aid in case of fractures$
1. 1o not move the patient until the injury is totally immobilised. 1o not
attempt to straighten a misshapen bone or joint to change its position.
2. (ractures should be stabilised (most commonly pneumatic
devices are used. 7f the ends of these fractures are not
stabilised, secondary injuries to the nerves and vessels may
occur. % compartment syndrome may also develop.
3. 7f a broken bone pierces the skin, take steps to prevent infection.
4. Take steps to prevent shock. Hay the patient flat, elevate the
feet ;/,;0 cm and cover with a coat or blanket. Jeep flat if a
head, neck, or back injury is suspected.
5. %nalgesics may be administered if there is severe pain (see
!oft Tissue 7njuries, below.
6. The patient may need to be admitted to the hospital for final care.
*2%#T&) 3, &M&)4&5*6 *%)&
D. &oint Dislocation and S#)l#*ations
%lways keep in mind that dislocations or subluxations of the joint may injure the
surrounding area (vessels, nerves, tendons, as well as the capsule of the joint.
7n case of joint injury the following is recommended$
1. The joint should be examined thoroughly. %n unstable joint and
haematoma indicate capsule injury. &very joint has its own method
of examination, which will not be discussed in this text.
2. The joint should be put at rest and stabilised with a splint or bandage.
3. 7n case of pain, local or general anaesthetics are necessary.
4. 7ce packs should be administered to prevent eventual later
conse"uencesG they also lessen pain.
5. The patient should be referred to a clinic or hospital, where diagnostic
procedures including L:ray, ultrasound, or M)7 are available to diagnose
fractures or intra:articular lesions and cartilage and soft tissue involvement.
5. Ligament St!ains
!trains of the ligaments usually take place on the proximal and distal
endings, rarely along the whole ligament.
7n case of strains, the following is recommended$
1. % thorough physical examination, which will reveal the degree
of the injury of the ligaments as follows$
1. First degree" swelling and tenderness is possible, the joint is stable.
2. Second degree" under loading the ligament is loose, but
there is a stable end:point.
3. #$ird degree" the whole ligament is disrupted, movement is
lax (no endpoint.
2. 7n case of first degree injury, treatment is as for soft tissue
injuries (see below.
3. !econd and third degree injuries should be treated in hospital after
exact diagnostics. Third degree injury is usually treated surgically.
6. M#scle St!ains
Muscle strain is the most fre"uent injury in sports. 7t usually occurs due to
bad techni"ue$ while strengthening the agonist muscular group, the
antagonist group is not relaxed accordingly, due to ionic imbalance or fatigue.
!trains usually occur where the muscle attaches to the bone, or in the muscle
itself at the musculo:tendinous junction. 7n children, the muscle may avulse
the apophysisG for example, the hamstring attachment at the ischial tuberosity
7n case of strains, the following is recommended$
1. (or muscle strains, determine the degree of the injury
according to its anatomic and functional status.
*2%#T&) 3, &M&)4&5*6 *%)&
1. First degree" the muscle fibres are partially injured. There is
local swelling and tenderness if the patient contracts the
muscle against resistance.
2. Second degree" more fibres are injured. Minor contraction will
cause pain or the muscle cannot contractG the injury is palpable.
3. #$ird degree" the tendon of the muscle is detached from its
adhesion point or a large amount of the muscle is damaged.
The muscle is functionless, the lesion can be palpated,
haematoma results within a short time.
2. #rinciples of first aid for muscle strains are the same as for
soft tissue injuries (see below.
G. So$t Tiss#e In'#!ies (see also *hapter K, Soft #issue %amage and &ealing
There are many mechanisms that may cause soft tissue injury in athletics, from
overload of soft tissues (e.g. overextension of the muscle to direct trauma. !oft
tissue injury is accompanied by surrounding oedema, haematoma, and tissue
necrosis. The accumulated blood sets off an inflammatory cascade that results in
further swelling. This leads to increased pressure on the surrounding tissues
causing hypoxia, which will increase the degree of the injury. 7n case of inade"uate
first aid, the injured area and its surrounding develop scarring and muscle atrophy
due to haematoma, tissue necrosis and oedema.
!oft tissue treatment is performed according to the mnemonic PRICES$
1. # M protection$ protect the injured area from further damage.
2. ) M rest$ the limb should be put at rest (this should be done
before examination, the degree of injury should be "uickly
assessed because the least load may result in deterioration.
3. 7 M ice$ icing of the injury has many benefits$
1. Hessens the pain, so the surrounding muscle tone will decrease.
2. 7ncreases vasoconstriction, which reduces bleeding.
3. 2ypothermia reduces the oxygen and nutrition demands
of the injured tissues.
4. Hocal inflammatory reaction decreases.
Please note: 7n case of minor injuries the athlete should be instructed to cool
the injury. 7n case of extensive injury, an ice bath should be used. %fter
training, it is recommended that ice be applied to the muscles, because
loading leads to microtraumas. 7f chemical ice packs are used, they should be
applied through a layer of clothes or wrap in order to prevent freeDing. Csually
cold packs are used for ./,;/ minutes every ; hours, during the first
; days.
4. * M compression$ compression raises the tissue pressure, which reduces
bleeding and swelling. *ompression should be used during and after ice
therapy. The bandage should be applied firmly, from distally to proximally,
*2%#T&) 3, &M&)4&5*6 *%)&
with an overlap of one:half the bandage8s width. %n ice pack can be
placed over a layer of compression wrap.
5. & M elevation$ the injured area should be elevated above the
level of the heart. This will decrease swelling by enhancing
drainage via lymphatic channels, and reducing venous stasis.
6. ! M support$ use braces, splints, etc. to support the injured area.
(. Medical T!eatment
&ffective medication should be administered throughout the entire treatment
process, taking into account banned drugs. 7f in spite of local measures the patient
still has pain, the first drug of choice is paracetamol (0// mg,.g. 7f paracetamol is
not enough, more effective drugs should be administered. 5!%71s are useful and
popular$ diclofenac 0/ mg given parenterally (maximum daily dose .0/ mg,
ibuprofen 3// mg (maximum daily dose ;E// mg, indomethacin 0/ mg (maximum
daily dose .// mgG in addition to their analgesic effect they are also good anti:
inflammatory drugs. 5!%71s can cause stomach irritation for some individuals. 7n
this case, an 2
;
:blocker may be used to reduce the amount of gastric acid
secretion. 7f the injury is accompanied by extreme bleeding, the administration of
an 5!%71 should be considered carefully, as they reduce platelet aggregation and
increase bleeding. *orticosteroids have no place in first aid treatment.
Please note: #ain is a good indicator of the status of the injury. %nalgesics
and anti:inflammatory drugs should never mask pain in an effort to allow an
athlete to continue to compete or train, which may lead to severe conse"uences.
I. "ollo+-%p Management
1epending upon the site of injury and its extent, additional treatment
may be utilised as a part of the treatment'rehabilitation process (see
*hapter K, Soft #issue %amage and &ealing, for additional details.
.. #rotected Mobilisation
#rotective taping and bracing permits the injured area to be mobilised
actively and passively while damaged tissue is protected. This prevents
excessive stress on muscles, joints, and ligaments during the healing process.
;. &lectro:Therapeutic Modalities
&lectrical therapies are an additional means of providing heat energy to deep
tissues, mobilising lymphatic and capillary circulation, and promoting healing. These
modalities include$ interferential current, ultrasound, and magnetic field therapy.
Cltrasound should be used with caution around children8s physes.
+. Manual Therapy
Manual techni"ues are useful in the healing process and in reducing the se"uelae
of injury. !tretching is valuable in reducing tissue contraction and muscle
*2%#T&) 3, &M&)4&5*6 *%)&
spasm, and preserving muscle and ligament length. (riction massage is
helpful in decreasing scar tissue contraction that follows the inflammatory
reaction. Mobility exercises, both passive and active, are essential for
maintaining joint range of motion and muscle length.
E. (itness Maintenance
1uring the acute phases of the healing process, as well as during
rehabilitation, cardiovascular fitness must be maintained. This can be
accomplished in a variety of ways, depending upon the site of the injury. %n
exercise bicycle can be used if the lower extremity can bear weight. 9therwise,
swimming, or running in a swimming pool with a flotation jacket, can be used. %t
first, the athlete can <run= in deep water, and then progress to shallower water
with partial weight bearing. !trength and range of motion of all the uninjured
parts must be maintained with appropriate stretching and resistive exercises.
&. E,al#ation o$ T!eatment
The clinician should constantly assess each treatment8s effectiveness
by comparing symptoms and signs prior to and after treatment. *ontinual
evaluation leads to the most appropriate treatment course for the specific
injury and allows the programme to be adapted to the individual8s needs.
Re$e!ences
1. >ambi, !., and 4. >ecattini$ Cse of devices for spine immobiliDation for trauma
patients at the emergency department, %ssistenDa infermieristica e ricerca
, %7)'7taly, ;; (.$ 0:.; 7!!5$ .0K;,0K3-, ;//+.
2. >anerjee, )., M. %. #alumbo, and #. 1. (adale. *atastrophic cervical
spine injuries in the collision sport athlete, part ;$ principles of
emergency care. %m. N. of !ports Medicine +; (A$.A-/,E, ;//E.
3. >aron, >. N., and T. M. !calea. !pinal cord injuries. In &mergency
Medicine (!ixth &dition, Nudith &. Tintinalli (ed., pp. .0-K,.03;. 5ew
6ork$ Mc4raw 2ill, ;//+.
4. 4arcia:!ola, )., #. #ulido, and #. *apilla. The immediate and long:term
effects of mannitol and glycerol. % comparative experimental study.
%cta 5eurochir. (Wien ./K$(+,E$ ..E,.;., .KK..
5. 2aller, #.). *ompartment !yndromes. In &mergency Medicine (!ixth &dition,
Nudith &. Tintinalli (ed., pp. .AE-:.AEK. 5ew 6ork$ Mc4raw 2ill, ;//+.
6. Jakarieka, %., ). >raakman, and &. 2. !chakel. !ubarachnoid
hemorrhage after head injury. *erebrovasc. 1is. 0$E/+:E/-, .KK0.
7. Jirsch, T. 1., and *. %. Hipinski. 2ead injury. In &mergency Medicine
(-th &dition, Nudith &. Tintinalli (ed., pp. .00A:.0-K. 5ew 6ork$
Mc4raw 2ill, ;//+.
*2%#T&) 3, &M&)4&5*6 *%)&
8. Harson, N. H., Nr. 7njuries to the spine. In &mergency Medicine$ %
*omprehensive !tudy 4uide (-th &dition, Nudith &. Tintinalli (ed., pp.
.A/;:.A... 5ew 6ork$ Mc4raw 2ill, ;//+.
9. Mower, W. )., %. >. Wolfson, N. ). 2offman, and J. 2. Todd. The
*anadian *:spine rule. 5ew &ngland Nournal of Medicine +0/
(.E$.E-A,KG author reply .E-A,K, ;//E.
10. MuiDelaar, N. #., &. #. Wei, and 2. %. Jontos. Mannitol causes
compensatory cerebra vasoconstriction and vasodilatation in response
to blood viscosity changes. N. 5eurosurgery 0K$3;;:3;3, .KK+
11. #ickard, N. 1., and M. *Dosnyka M. Management of raised intracranial
pressure. N. 5eurol. 5eurosurg. #sych. 0-$ 3E0:303, .KK+
12. !ancheD 7i, %.)., M. T. !ugalski, and ). (. Haprade. (ield:side and
prehospital management of the spine:injured athlete. *urr. !port Med.
)ep. E (.$0/:0, ;//0.
13. !tiell, 7. 4., et al. The *anadian *:!pine )ule versus the 5&LC! How:
)isk *riteria in patients with trauma. 5ew &ngland Nournal of Medicine
+EK$;0./:3, ;//+.
"ootnote
.
The 4lasgow *oma !cale is the most widely used scoring system for
"uantify:ing the level of consciousness following traumatic brain injury. 7t is
used primarily because it is simple, has a relatively high degree of
interobserver reliability, and correlates well with outcome following brain injury.
The !cale is easy to use, particularly with a table such as shown in Table 3:.
(page + of this section. 9ne determines the best eye opening response, the best
verbal response, and the best motor response. The score represents the sum of the
numeric scores of each category. % *oma !core of .+ or higher correlates with a
mild brain injury, K,.; is a moderate injury, and 3 or less a severe brain injury.
2owever, there are limitations to a simple application of the table. 7f there is an
endotracheal tube in place, the patient cannot talk. 2ence, it is important to
document the score by its individual components. (or example, a 4lasgow *oma
!core of .0 would be detailed as follows$ &:E, B:0, M:-. %n intubated patient would
be documented as &:E, B intubated, M:-. 9f these factors, the best motor
response is probably the most significant.
9ther factors that alter the patient8s level of consciousness will interfere
with the !cale8s ability to reflect the severity of the brain injury. 2ence,
shock, hypoxemia, drug or alcohol use, or metabolic disturbances may alter
the !cale independently of brain injury. % spinal cord injury will invalidate the
motor score, and an orbital injury may impair the ability to open the eye.
For more information on t$e 'lasgo(
Coma Scale) see
(((*trauma*org/scores/gcs* $tml*