EMS Management of Catastrophic Cheerleading Injuries

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.

OBJECTIVES

• Outline cheerleader injury rates
• Discuss mechanism of injury
• Review trauma triage
• Discuss spinal cord injury management
• Explain assessment and prehospital management of traumatic brain injuries

   Thirty years ago, cheerleading was limited to energetic toe touch jumps, splits, claps and pom-pom shaking. Today, cheerleading routines include more technical tumbling, partner stunts, multilevel pyramids, lifts, catches and tosses. Likewise, the number and severity of injuries seen at all levels of cheerleading has increased. With over 3.6 million cheerleaders in the United States, it is reasonable to believe that many EMS providers will have the opportunity to respond to an emergency at a cheerleading event at some point during their careers.¹

Injury Rates

   Cheerleading begins at an early age. The All-Star Cheerleading organization lists its youngest age division as "5 years and younger." There are also youth recreational leagues, middle school, high school and collegiate divisions. Cheerleading is not limited to females, although only 4%-7% of cheerleaders in the United States are male.²

   According to Frederick O. Mueller, PhD, of the National Center for Catastrophic Sports Injury Research (NCCSIR), almost 26,000 cheerleaders presented to emergency departments in the United States for assessment of injuries in 2007,³ but this number only represented 22% of all injuries reported.⁴ Forty-eight percent of the injured cheerleaders were treated on scene or in an athletic trainer's office; 30% went to a physician's office or an urgent care center; and 98% of those who sought out emergency department care were treated and released.³ The article did not report the percentage of cheerleaders transported to the emergency department by EMS.

   A 2008 report from the NCCSIR claimed that fatal and life-altering injuries sustained while cheerleading were increasing at an alarming and unacceptable rate.³ Between 1982 and 2008 the report identified 10 deaths and 66 serious injuries, such as spinal cord injuries or head trauma, directly or indirectly related to cheerleading activities. The authors concluded that cheerleading was the leading cause of catastrophic injuries for all high school and college females and potentially more dangerous than football.

   Although the NCCSIR data was widely reported by the media, several cheerleading authorities refuted the information as inaccurate, incomplete and overstated. At the time, there was limited knowledge about the number of cheerleaders in the United States and what the overall injury rate was for the activity. Newer information demonstrates that high school and collegiate female cheerleaders suffer catastrophic injuries at a rate of 0.39 per 100,000 participants, compared with 1.41 for female gymnastics, 1.78 for male football, 2.76 for female ice hockey and 4.08 for male gymnastics.⁵ Other sources report that the overall injury rate for cheerleading is one injury for every 1,000 athletic encounters.⁴

Scene Survey

   As an EMS provider approaches the scene of an injury, he must assess the whole situation, which includes scene safety as well as mechanism of injury. While sports events and practices will generally not be considered dangerous environments, keep an eye open for ongoing activities that may produce fly balls, errant power kicks or players running out of bounds and into your scene.

   Scene assessment should also include the presence of coaches, parents and other bystanders who may or may not be providing helpful care, crowd control or other assistance. Experienced responders will welcome help holding C-spine, calming the patient or carrying equipment, but this scene could just as easily include hysterical teammates, friends or parents who will need to be respectfully but firmly managed so they do not interfere with your care or increase the patient's anxiety. As care is provided and the patient is prepared for transport to a hospital, you should make an effort to communicate what is going on with any coaches or parents present.

   Keep in mind that it is common to have numerous cameras taking video and photos at sporting events. Be professional at all times, and respect the patient's modesty as you assess him or her.

Mechanism of Injury

   Mechanism factors to appreciate include the type of stunt, fall height and the type of floor. Sixty percent of all injuries and 96% of concussions and closed head injuries occur during stunts,⁶ which may include pyramids, lifts, tosses and catches. Not surprisingly, 83% of injuries occur during practice.⁴

   When a cheerleader falls from a height, it is important to assess the height of the fall and the type of surface fallen on. Serious injuries can occur with falls from as little as 6 inches above a concrete surface to 11 feet above spring floors. Ninety percent of serious fall-related injuries in one study were from heights between 4 and 11 feet and occurred on artificial turf, grass, wood or traditional foam floors.⁷ To prevent injury, many cheerleading groups now follow guidelines that prohibit any two-level stunts like pyramids or tosses on any surface other than spring floors or traditional foam floors with 4-inch landing mats.

Common Injury Types and Regions

   Types of injuries and anatomical structures involved are similar to gymnastics and dance team injuries. Ankles are the most frequently injured and account for 16% of cases, while knees are involved 9% of the time. Neck trauma makes up 9% of injuries, head trauma accounts for 7% and low back injuries are seen in 7% of patients.⁴

   Fifty-three percent of cheerleader injuries are sprains and strains;10% are classified as fractures. Concussions or closed head injuries are limited to 4% of cases, but are typically more serious.⁴

   EMS may occasionally be called to sports facilities for orthopedic injuries of the lower extremities, but the remainder of this article focuses on the more critical scenarios, referred to as catastrophic injuries. These include fatalities, nonfatal but permanently disabling injuries and other traumas that are serious but do not cause long-term disability.³

   Examples of catastrophic injuries include cervical spine fractures, head injuries including traumatic brain injuries, facial and skull fractures, other spinal fractures and spinal cord injuries, and, less frequently, internal chest and abdominal injuries. We will specifically review traumatic brain injury (TBI) and spinal cord injury (SCI) assessment and management.

Primary Survey

   As with any trauma incident, assessment of an injured cheerleader starts with a thorough primary survey. Most of these cases involve falls and other forms of blunt trauma, so cervical spine immobilization should be considered. Once life threats and distracting injuries are ruled out, the patient may be further assessed with a selective spinal immobilization protocol to determine if full immobilization is needed.

   While establishing manual stabilization, assess the airway for patency. Typical threats would be vomiting after a head injury or soft-tissue obstruction resulting from an altered level of consciousness (LOC). Bleeding, broken teeth or soft tissue swelling may be present, especially if facial trauma was sustained.

   Any compromise of a patient's airway must be immediately managed by manual basic life support techniques, such as a modified jaw thrust or oropharyngeal airway. Portable manually operated or battery-powered suction must be readily available for use.

   Assessment of the patient's breathing includes a quick but careful check of respiratory rate, volume and pattern. Be watchful for alterations in respiratory function from a TBI or blunt trauma to the chest. Respiratory changes from spinal cord injuries may not be obvious immediately after an injury, but keep in mind that an injury above the level of C-3 or C-4 may interrupt the phrenic nerve. The diaphragm is innervated by the phrenic nerve; without it the patient may only be using intercostal muscles to breathe. Conversely, injury to the spinal cord in the thoracic region may interrupt use of the intercostal muscles, leaving the patient breathing with only the diaphragm and neck muscles.⁸ Functioning on their own, any of these muscles may fatigue minutes or hours after an injury.

   Any significantly injured patient with signs of hypoxia and/or respiratory distress should receive high-flow oxygen by non-rebreather mask (NRB). If the patient's breathing is inadequate, begin assisting ventilations with a bag-valve mask (BVM).

   The circulatory check consists of pulse, skin condition and inspection for any major hemorrhage. An abnormally strong or slow pulse or an abnormal pulse rhythm may be an indication of a closed head injury. A spinal cord-injured patient may present with cool, moist, pale skin above the level of injury and warm, dry, normal-colored skin below the injury. The vasodilation that creates these skin signs may also create a relative hypovolemia, referred to as neurogenic shock.

   The next step in a primary survey is to assess the patient's level of consciousness. The Glasgow Coma Scale (GCS) is an effective way to record what stimulus patients respond to and how they respond. The GCS is used by hospitals and included in trauma registries, as it is considered an important baseline measure and predictive of patient outcome.⁹ All trauma patients should have a prehospital GCS assessment recorded.

   The final step in the primary assessment is to expose the patient (as appropriate for the situation) to rule out any other life-threatening injuries. Palpate the chest, abdomen, pelvis and long bones, such as the femurs and humeri, at this time. Be sure to cover the patient and insulate them from a cold surface after you finish the primary assessment to preserve body heat. Even in environments we consider warm, trauma patients quickly lose body heat. Hypothermia is a significant complication in trauma care and is largely preventable.

Trauma Triage

   Once the primary survey is completed, determine if the patient shows signs of a critical injury. Refer to the National Trauma Triage Protocol (www.cdc.gov/fieldtriage/) for a full list of criteria. Critical findings/vitals potentially seen in cheerleading injuries include: GCS < 14, respiratory rate > 29, new onset paralysis or open skull fracture. These patients should be transported emergently to the closest, most appropriate trauma care facility. Limit any further care on scene and prepare the patient for transport.

   If there are no physiological findings or anatomical field trauma triage criteria, a more thorough on-scene secondary assessment and management of injuries are warranted. The secondary assessment includes a full set of vital signs, an AMPLE history, and a head-to-toe, hands-on physical examination.

   In cases of catastrophic injuries (CHI and SCI), it is likely that a life-threatening or serious condition will be recognized in the primary survey. If life threats are found, only lifesaving interventions such as hemorrhage control, basic airway control and BVM ventilations should be done on scene. Other therapies, like starting IVs or more advanced airway management, can usually be completed en route to the hospital. It is well established that critical trauma patients who have shortened scene times and early transport to an appropriate trauma center have better outcomes. Be sure to contact the trauma center early so they will be prepared for your arrival. Even in the highest level trauma centers, the trauma team must be activated and may take time to assemble. Giving them early notice is in the best interest of your patient.

Spinal Immobilization

   In most protocols, the combination of blunt trauma mechanism and a critical injury dictate that you take full spinal immobilization precautions, including C-collar and a long backboard. Assess motor and sensory nerve function in each limb before and after application of the longboard. If a deficit is present, make careful note of which parts of the limb are affected, as well as whether the deficit is sensory or neurological. Examples include muscle weakness, full paralysis, tingling, shooting pains, limited or absent sensation or any other abnormal sensations.

   Pad the longboard with either a blanket or a commercial padding device like the Turley Backboard Pad or a Back Raft. Thirty-two percent of patients with SCI develop some form of pressure ulcer or skin lesion within 24 hours.⁸ While this skin breakdown is not something we typically consider during our brief time with the patient, it is a major source of complications including pain, infection and increased hospital stays.

   Once en route to the hospital, attention is turned to continued assessment and support of the patient's ABCs. A quick primary survey is a good way to reassess the patient after the move from the scene to the ambulance, after any intervention and when a change in condition is noted.

Spinal Cord Injury Management

   If transporting a cheerleader with a spinal cord injury, closely monitor the patient's respiratory function. As mentioned earlier, intercostal muscles unassisted by the diaphragm, or vice-versa, may tire and lead to respiratory failure. End-tidal capnography waveform analysis is helpful to observe early respiratory rate and volume changes, as well as build-up of carbon dioxide, indicating respiratory failure.

   Be prepared to assist the patient's ventilation with positive pressure (BVM) and 100% oxygen. The PHTLS curriculum recommends ventilating an adult patient at 10 breaths per minute (20 for children), with just enough volume to cause chest rise.⁹ Continue to monitor the patient with pulse oximetry and capnography.

   Indications for advanced airway management in SCI include inability to control or protect the airway with basic techniques and worsening respiratory failure. Depending on your scope of practice, protocols, skill level and experience, advanced airway techniques may include nonvisualized or multilumen airways, orotracheal intubation, rapid sequence intubation, blind nasotracheal intubation, or, if necessary, a surgical airway like cricothyroidotomy. Regardless of the method chosen, C-spine immobilization must be maintained at all times.

   Administration of the steroid methylprednisolone (Solu-Medrol) for SCI remains controversial among the medical specialties.⁹ In 2004, the National Association of EMS Physicians issued a position paper recommending against administration of steroids for SCI in the prehospital setting.¹⁰

Traumatic Brain Injury Management

   Care of the cheerleader with any form of traumatic brain injury also focuses on effective airway monitoring and ventilation management based on the severity of the head injury.

   The TBI patient's airway is at risk from vomiting, which is frequently associated with head trauma, as well as tongue occlusion secondary to reduced level of consciousness.⁹ Management of airway compromise in TBI is similar to SCI.

   As the airway is maintained, turn your attention to the patient's ventilatory status. TBI may lead to an inadequate breathing rate or volume, which must be corrected immediately. Positive pressure ventilation may also be used to treat increasing intracranial pressure (ICP) or herniation syndrome. Controlled hyperventilation may be used when the patient begins to show herniation signs like GCS drop of 2 or more points, development of a sluggish or nonreactive pupil, development of hemiplegia or hemiparesis or Cushing's phenomenon.⁹

   Without signs of herniation, a TBI patient is treated with 100% oxygen via NRB at a minimum. When assisted ventilations are needed, ventilate at a rate of 10 breaths per minute (20 for children). If signs of increasing ICP or herniation are present, increase the rate of ventilations to 20 breaths per minute (30 for children).⁹ This "controlled hyperventilation" is not needed for patients unless they are actively herniating, as it may actually worsen a head injury. "Blowing off" too much carbon dioxide causes vasoconstriction, which limits cerebral perfusion at a time when the brain tissue needs good blood flow and oxygenation. Consult your local protocol or online medical control for specific direction as needed for hyperventilation of any TBI patient.

   Although recent evidence questions the reliability of ETCO²'s correlation to PaCO₂ in multisystem trauma patients, capnography may be used to help guide ventilation of the patient with an isolated TBI. Without signs of increasing ICP, aim for a range of 35-40 mmHg. With herniation, decrease the ETCO2 to 30-35 mmHg.¹¹

   Establishing one or two large-bore IVs remains a mainstay in trauma care and is appropriate in SCI and TBI cases. Unless hypotension is present, set the IV fluids to a keep-vein-open (KVO) rate. Even one episode of hypotension in the setting of a head injury can double the mortality rate, so be prepared to administer IV fluid boluses to maintain a systolic blood pressure of 90 mmHg or greater.¹¹ Hypotension caused by neurogenic shock is also managed by IV fluid boluses to maintain a similar blood pressure.⁹

   If a cheerleader suffers a seizure, treat immediately with a benzodiazepine. Unlike febrile or epileptic seizures, seizures during a TBI can lead to increased ICP and should be halted as quickly as possible.

   Other considerations to reduce increases in ICP include providing adequate sedation and pain control medications, and use of a long-acting neuromuscular blocking agent if the patient's airway is secured. Keep in mind that patients need adequate sedation and pain control even if they are pharmacologically paralyzed.

   Patients with isolated head trauma may be transported with the head of the cot slightly elevated (<30 degrees), but if hypotension or other multisystem trauma is involved, transport the patient flat.⁹

   Once at the hospital, give the trauma team a brief report using the MIVT format:

   M - Mechanism of Injury

   I - Injuries found in your assessments

   V - Vital signs including neurological assessment

   T - Treatments given.

   Complete your patient care report and leave a copy with the patient for inclusion in the hospital's records and trauma registry.

The Role of Athletic Trainers

Oftentimes, when an EMS crew arrives on the scene of an athletic event at a school, there will be an athletic trainer already tending to the patient. Certified Athletic Trainers (ATCs) have a minimum of a bachelor's degree from an accredited athletic training curriculum and are well-versed in the prevention, diagnosis and management of injuries and conditions related to sports and recreational activities. They have specific criteria for activation of the EMS system, which include potential neck, back and head injuries.

Athletic trainers have training on and protocols for full spinal immobilization techniques, but, due to limited resources, they often simply maintain manual C-spine immobilization while awaiting EMS. Exceptions to this would be some of the larger collegiate events where other trainers are available and immobilization equipment is maintained. Unfortunately, many cheerleading teams have no or limited access to athletic trainers. Only 28% of teams report having regular access to a trainer.⁴ Some sports organizations, including the NCAA, do not consider cheerleading a sport and as such do not require athletic trainer coverage for the teams.

Glossary

• Athletic encounter (AE): Also known as athletic exposure. Generally defined as one cheerleader participating in one event that includes games, pep rallies, cheerleading competitions and practices.⁴
• Cushing's phenomenon: Ominous combination of greatly increased arterial blood pressure and the resultant bradycardia that can occur with severely increased ICP.⁹
• Fall height: Distance between the surface on which the victim was standing to the surface on which he/she fell. Note: The actual distance a part of the patient's body (e.g., head) falls is generally greater than the fall height.⁷
• Hemiplegia: Paralysis on one side of the body.⁹
• Hemiparesis: Weakness limited to one side of the body.⁹

Conclusion

   Regardless of the rate of injury or average number of catastrophic cases, cheerleading associations and safety advocates view even one case as too many and have set out to prevent injuries through better coach training, safety rules, competency levels and general safety awareness. Cheerleading safety groups advocate increased access to athletic trainers, development of emergency plans, first aid training for coaches, and recognition of cheerleading as a sport so standardized safety rules will be required across the leagues. These improving injury prevention initiatives will decrease the number of 9-1-1 calls, but when the pager goes off, EMTs or paramedics will be in a critical position to provide lifesaving care and transportation.

REFERENCES

1. American Sports Data Inc. The Superstudy of Sports Participation: Volume II. Recreational Sports 2003. Hartsdale, NY: American Sports Data Inc: pp. 14,43, 2004.

2. Pratt S. Cheerleading: One giant leap for mankind. https://observer.guardian.co.uk/osm/story/0,,803079,00.html.

3. Mueller FO, Cantu RC. National Center for Catastrophic Sports Injury Research: Twenty-fifth Annual Report, fall 1982-spring 2007. www.unc.edu/depts/nccsi/AllSport.htm.

4. Shields BJ, Smith GA. Cheerleading-related injuries in the United States: A prospective surveillance study. J Athl Train 44(6):567-577, 2009.

5. American Association of Cheerleading Coaches and Administrators. Annual Sports Injury Study. https://aacca.org.

6. Shields BJ, Smith GA. Epidemiology of cheerleading stunt-related injuries in the United States. J Athl Train 44(6):586-594, 2009.

7. Shields BJ, Smith GA. The potential for brain injury on selected surfaces used by cheerleaders. J Athl Train 44(6):595-602, 2009.

8. Caroline NL. Emergency Care in the Streets. Sudbury, MA: Jones and Bartlett, 2008.

9. Salomone JP, Pons PT. PHTLS: Prehospital Trauma Life Support, 6th Ed. St. Louis, MO: Mosby Elsevier, 2007.

10. Bledsoe BE, et al. NAEMSP Position Statement: High-dose steroids for acute spinal cord injury in emergency medical services. Prehosp Emerg Care 8(3):313-316, Jul/Sep 2004.

11. Stiver SI, Manley GT. Prehospital management of traumatic brain injury. Neurosurg Focus 25(4):E5, 2008.

   Michael Fraley, BS, NREMT-P, is coordinator of the North Central (Wisconsin) Regional Trauma Advisory Council, EMS coordinator for Portage County (Wisconsin) EMS and affiliate faculty for PHTLS. He has also worked as a flight paramedic, EMS service manager and assisted living facility owner/administrator. E-mail fraleym@charter.net.