How to treat winter sports injuries

Winter signals the return of winter sports, as well as the return of injuries associated with slamming onto hard surfaces while travelling at speeds approaching that of a moving motor vehicle.

All this while strapped to various pieces of equipment that prevent you from falling gracefully.

Since many of us respond to the recreational areas and resorts where these injuries occur, a short review of common winter sports-related injuries and their treatment is warranted.

Scope of the problem
The number of people injured during winter sports are significant; a quick query of the National Electronic Injury Surveillance System reveals the following 2010 injury rates on a few common winter sports:

• Snow skiers: 144,000
• Snowboarders: 148,000
• Ice skaters: 23,000
• Snowmobiles: 11,000

Common injury patterns
The majority of injuries are orthopedic in nature. Knee injuries are common, along with shoulder dislocations, lower leg fractures and injuries to the wrist and forearm.

While fewer in frequency, head injuries are often more serious, sometimes with catastrophic outcomes. Even though more skiers and snowboarders are wearing helmets today, it is crucial to quickly — yet carefully — evaluate and manage the potentially evolving brain injury.

Accessing the patient
The winter environment presents unique challenges to the EMS provider — terrain can make access to the patient more difficult and time-consuming.

If you are not trained or prepared to travel to the patient's side, you will need to rely upon ski patrollers and other expert rescuers to bring the patient to you.

If you are prepared to perform an outdoor rescue, the assessment and care you provide will be fairly austere.

Frigid temperatures and atmospheric moisture can rapidly cause hypothermic conditions for the victim who is no longer able to move about and create enough body warmth to maintain homeostasis.

It is crucial to maintain the patient's body temperature while basic care is delivered on scene. As soon as logistically possible, moving the patient to a pick-up point becomes the primary mission goal.

Brain injury
Head trauma disproportionately kills more people in winter sports than other injury patterns. The well-publicized deaths of Sonny Bono and, more recently, actress Natasha Richardson increased awareness about the use of helmets; however, a majority of skiers and snow boarders still do not use them.

Begin your assessment by evaluating the mechanism carefully. If possible, find witnesses who may be able to better describe the crash mechanism.
If a helmet was worn, inspect it carefully for signs of damage, not only on the exterior of the helmet but also for any potential deformation of the foam inside the helmet itself.

Consider whether to immobilize the patient's cervical spine. Recall that mechanism alone does not dictate spinal precautions; a combination of clinical signs such as an altered level of mentation, the complaint of cervical discomfort, the presence of neurological deficits, the presence of alteringsubstances such as alcohol or drugs, and/or the presence of distracting pain may indicate the need for immobilization.

If the patient requires spinal immobilization, and is wearing a helmet, evaluate the need to remove it. If the patient can maintain airway patency on his or her own, leave it in place and pad the shoulders accordingly. Continue with normal spinal precautions.

You will likely recall that the classic signs of an evolving brain injury involves Cushing's Triad, which includes a rapidly rising blood pressure, decreasing heart rate, and increasingly irregular respiratory rate.

However, evaluate for more subtle signs that may be present initially. Headaches, tinnitus (ringing in the ear), retrograde (before the event) and antegrade (after the event) amnesia may be early signs.

Work closely with the patient, family and medical direction to convince a patient to seek further care if he or she is refusing your assistance.

If the patient is rapidly deteriorating from the brain injury, prepare to ventilate the patient appropriately. Providing positive pressure ventilation at a controlled rate (20 breaths per minute for adults, 25 for children (PHTLS textbook 7th edition)) is indicated only for patients with signs of brain herniation (altered mental status, unequal pupil size, and hypertension).

Intubation will be necessary to control an airway if the patient is vomiting and suctioning does not maintain a patent airway; medication assistance such as sedation or induction can be helpful.

If at all possible, use waveform capnography to maintain a slightly lower than normal carbon dioxide gas level in the exhaled air. (PHTLS textbook 7th edition)

Orthopedic injuries
The vast majority of musculoskeletal injuries are minor and patients typically self transport to a medical facility. Most of these injuries consist of sprains, strains and occasional bone fractures.

Remember to evaluate the mechanism of injury and confirm that no other, more serious injuries exist. Once you have determined that the injury is isolated, evaluate the limb to make sure there is adequate blood flow to the distal end.

Angulated fractures and severe dislocations can compress major arteries, and you may need to straighten the limb in an attempt to re-establish blood flow.
Splinting is both an art and science. Basic principles include:

• If in doubt, splint. It is difficult to differentiate between a strain, sprain and a fracture.
• Check for distal circulation, motor and sensory function before and after the application of the splint.
• Pad the extremity as much as possible so that the splint fits snugly, but not so tight as to constrict blood flow.
• In general, secure the splint above and below the break, and then restrict the motion of the joints above and below the break. For example, a rigid, padded cardboard splint along with a sling and swath will provide adequate stabilization for a radius/ulnar injury.
• Applying a cold pack can help reduce soft tissue swelling around the injury site and reduce pain. Paramedics can consider the administration of an analgesic such as morphine sulfate to also help improve patient comfort.

Summary
Winter time sports are a lot of fun and are a great way to get exercise. Unfortunately injuries are common and EMS providers must be ready to manage both critical and non-life threatening injuries when they occur.

With some modifications, basic rules of assessment and care still apply for these situations.

References