SABCDE

S - Safe Approach
A - AIRWAY with C-spine control
B - BREATHING with adequate ventilation
C - CIRCULATION with bleeding control
D - Neurological dysfunction
E - Exposure and Environment

Life depends upon oxygen being pumped around the body. Therefore, in order to stay alive, we need to be able to get oxygen into the body through an OPEN AIRWAY. The oxygen needs to get deep into the lungs and bloodstream through effective BREATHING and then pumped around the body by the CIRCULATION. If you don’t have A, you will not have B and C for long. Achieving an open airway is the absolute priority in all casualties. Without it, the injured player will probably die.

Safe Approach

It is essential that the first aiders ensure that it is safe to approach the injured player. The SAFE approach is as follows:

• Shout for help
• Assess the scene
• Free from danger
• Evaluate the player

Initial assessment – primary survey

Injured or critically ill players should be assessed and their first aid priorities established based from on their injuries, signs and symptoms and/or on the mechanism of injury. 

This process constitutes of the ABCDEs of first aid care and identifies life threatening conditions by adhering to the following sequence.

1. Catastrophic bleeding management
2. Airway maintenance with C- spine protection
3. Breathing with adequate ventilation
4. Circulation with bleeding control
5. Disability: neurological status
6. Exposure & environment control

During the initial primary assessment  life threatening conditions should be identified and first aid management commenced. Early call for help is essential.

Catastrophic haemorrhage control

In the very rare circumstance of a player presenting with catastrophic haemorrhage the application of a pressure dressing should be considered in attempt to stop the bleeding before moving on to assess and maintain the player’s airway. 

Airway maintenance with C- spine protection

In a suspected injured player if there is any possibility of a cervical spine injury, the neck must be controlled by manual in-line immobilisation as part of the initial approach before talking to the player. The airway assessment begins by assessing if the player is able to respond to your voice with a clear voice and no added sounds. 

If there are any concerns about the player’s airway, this must be assessed and managed according to the principles outlined in the airway chapter. 

It is essential to identify airway compromise early and manage where appropriately to minimise low oxygen levels. It is important that the airway is regularly re-evaluated since some airway problems are progressive in nature and may not be apparent during the first initial assessment.

Breathing with adequate ventilation

The next priority is to assess the player’s breathing. It is important to determine if there is any breathing distress by looking at the respiratory rate, breathes per minute and to check for equal expansion of the chest wall. A cursory brief palpation of the chest wall at this time may reveal any areas of tenderness. 

Life threatening conditions should be identified and appropriate help summoned urgently. 

Circulation with haemorrhage control

The next priority is to assess the player’s circulatory status. This initial assessment includes:

• Pulse – presence of the radial pulse
• Pulse – rate and volume
• Colour of the player – noting pallor
• Mental status - conscious level and agitation
• Evidence of external bleeding
• Evidence of internal bleeding

The presence of external bleeding should be managed by direct pressure to the wound and the application of dressings to stem the bleeding. Call for help.

Neurological Dysfunction

The on pitch baseline observation of the neurological status of the player involves the use of the ACVPU system:

• A = Alert
• C = Confusion
• V = Responding to voice
• P = Responding to painful pressure stimulus
• U = Unresponsive

If there is any suspicion of a spinal cord or head injury a check of the player’s peripheral neurology should be undertaken. This will also be required if contemplating  as part of clearing the player's spine.

Once in the medical room the neurological Assessment ACVPU should be repeated frequently and recorded along with all observations in the primary survey to identify improvement or deterioration in the player.

Exposure & environment control

A top to toe check should be undertaken to check for any other injuries, checking for swelling, deformity, crepitus, pain and ensuring normal sensation and movement of limbs.

For the initial on pitch assessment, there should be limited exposure and the player protected from the environment.

Once in a more protected environment, the player may will need to be exposed facilitating a thorough examination and assessment if time allows. Do not delay transfer to definitive care. Care should be taken to cover the player at the earliest opportunity to respect their dignity and protect them from the elements.

Re-evaluation

Continuous monitoring of vital signs and neurological status are essential. Players with significant injuries or illness must be re-evaluated constantly to ensure that new findings are not overlooked and to identify deterioration. 

Re-evaluation of the player should be undertaken after any:

• Intervention
• Deterioration
• Cause for concern
• Uncertainty

Secondary Survey

A player with a time- critical illness or injury should never be detained in the pre- hospital setting in order to perform a secondary assessment if transport to the appropriate hospital is available.

Proceed only to the secondary survey when:

• Initial primary survey with appropriate resuscitation has been completed
• ABCDE have been reassessed
• Vital signs are normalising

A full secondary survey includes obtaining a full history of the incident, the player’s past medical history and a systematic head to toe examination of the patient designed to detect all of the player’s injuries. A rapid pre- hospital head to toe examination involves includes palpating for areas of pain, tenderness, deformity, swelling, and or evidence of blood loss, and  neurological compromise.

The secondary survey history allows for documentation of the mechanism of injury, signs and symptoms, details of the player’s past and current medical history, current medications, allergies and when the player last ate or drank. A useful mnemonic for this is SAMPLE:

• S: Signs and symptoms
• A: Allergies
• M: Medications
• P: Past medical history
• L: Last meal and drink
• E: Events and environment of the injury or/illness

The recording of this information can be aided by the medical team having pre- prepared documentation including the players personal details, contact details including a next of kin and the AMP parts of SAMPLE history already completed, allowing for the other sections SLE just to be added at the time of the assessment.

Definitive Care

On completion of the initial primary it is important to understand that the player’s clinical condition may continue to change, therefore and regular re-evaluation is important.

It is equally important that assessments of vital signs are documented to allow for trends to be identified. This information along with the above mentioned clinical documentation (including the SAMPLE history) should accompany be sent with the player to the hospital.

The transport of critically injured or ill players should be undertaken by appropriately qualified ambulance crews with appropriate equipment immediately available in case of any deterioration in the player’s condition. 

The mnemonic ATMIST has now been widely adopted by the ambulance services and pre- hospital care medical teams for the handover of patients. 

A - Age of the player (sex of player often also included)
T - Time of the injury / Illness starting
M - Mechanism of injury / progression of illness
I - Injuries / illness present and/or suspected
S - Signs including vital signs
T - Treatment provided