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Unresponsive Unconscious Junior Player

Case Study

By Thomas Phillips

The incident occurred in the second last game of a large junior football league in suburban Melbourne, age group U16’s.

The Colbrow Medic location was on the sidelines with the sports trainers, who were volunteer parents of the junior players.

The game was close scoring and in the last quarter there was a heavy contest on the opposite side of the ground. It was difficult at distance to see what was happening as lots of players were involved. When the play moved on, there was a player lying prone and not moving on the ground.

It is important to watch a few seconds behind the play during the match for this reason. Please note this does happen often in junior football and players will often get up after a few seconds on the ground.

The sports trainers ran straight out with water as soon as he was seen.

After 15 seconds or so the player remained unmoved, so I decided to respond.

The trainers had put the player in the recovery position and said that he wasn’t breathing.

The patient presented unresponsive and centrally cyanosed with a snore and laboured, ineffective breathing. This is a common presentation for patients with loss of consciousness due to loss of tone in the airways. This is a life threatening complication. There was no response with significant nail bed pressure.

I instructed the trainers to roll the patient on his back. They had some concerns about spinal injuries and moving the patient but I explained that airway management must take precedence. A bystander was instructed to call the ambulance and report a GCS of 4.

Normally when there is an unknown mechanism for a loss of consciousness we take spinal precautions just in case. Therefore the triple airway manoeuvre (chin lift, head tilt, jaw thrust) to restore effective breathing is reduced to a double airway manoeuvre (without the head tilt to the cervical spine). A double airway manoeuvre was ineffective on this patient due to jaw trismus (locking of the jaw muscles). This usually happens when a patient sustains a significant head injury.

Having no other choice I performed a triple airway manoeuvre with an aggressive head tilt as the patient’s mouthguard was further complicating the situation. Due to trismus it could not be removed. I had an air-viva bag valve mask ready to breathe for the patient but with this manoeuvre his breathing was restored to normal. The patient was still unresponsive.

After a couple of minutes of proper breathing the patient began to respond and the jaw trismus ceased. We carefully removed the mouthguard to prevent obstruction. Conscious state assessment was GCS 9.

At this point the patient became agitated and tried to fight us off. It was important to reassure him and try to prevent movement in case of a spinal injury. The head had to be held still butcomfortable.

A couple of minutes later the patient had almost returned to normal. They were asking questions about what had happened. This was when the Ambulance Victoria Paramedics arrived, who immobilised the patient and transported the patient to hospital safely. The ambulance crew suspected a traumatic brain injury.

Outcome

  • The outcome for this patient was good.
  • While they had actually suffered a serious injury, the ambulance was on site within 15 minutes.
  • Successfully aligning the airway prevented serious complications such as brain damage or death.
  • Patient recovered within 15 minutes, presenting with concussion and retrograde amnesia. Airway and circulation effectively restored. Patient loaded into AV ambulance within 20 minutes and transported to major hospital for brain CT and further investigations.

Discussion

This case highlights the potential for serious injury in junior football. There are frequently high mechanisms of impact at a time when the body and brain are still developing.

The airway obstruction seen in this patient may have been life threatening. The recovery position and basic first aid were not enough to restore adequate breathing and advanced techniques were required. The patient had suffered a traumatic head injury, which is a serious condition. This explains the typical conscious state changes and jaw trismus seen. Without intervention this patient may have had ongoing neurological damage from hypoxia or in the worst case actually died.

The experience taught me not to underestimate the potential for injury in junior football and sport in general. Watching behind the play of the game helps to spot incidents early. Early recognition and early 000 call meant ambulance support within 15 minutes of the injury.

While medical services at junior football events may be more costly, the potential for serious injury provides obvious justification for the additional expertise and frees up club officials to manage the scene, contact emergency services and be reassured that the player is receiving a high level of pre-hospital healthcare.

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