{"id":9292,"date":"2020-07-08T08:59:03","date_gmt":"2020-07-08T07:59:03","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=9292"},"modified":"2020-07-08T19:27:52","modified_gmt":"2020-07-08T18:27:52","slug":"pitch-side-emergency-care-personal-protective-equipment-a-framework-for-elite-sport-during-the-covid-19-pandemic-part-2-of-3","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2020\/07\/08\/pitch-side-emergency-care-personal-protective-equipment-a-framework-for-elite-sport-during-the-covid-19-pandemic-part-2-of-3\/","title":{"rendered":"Pitch side emergency care &amp; personal protective equipment: a framework for elite sport during the COVID-19 pandemic: Part 2 of 3"},"content":{"rendered":"<p><strong><u>Rationale<\/u><\/strong><\/p>\n<ul>\n<li>Rightful concern is raised when returning the player population to training and competition in the context of suspected or confirmed COVID-19 infection; given that the infection is still relatively novel, much of the emerging evidence is difficult to contextualise in our player<\/li>\n<li>Adverse cardiac and respiratory outcomes have been acknowledged in COVID-19 infection. The prevalence of cardiac and respiratory injury in community infection is unknown.<sup>\u00a0 <\/sup>However, cardiac involvement\u00a0has been found in\u00a0up to 22% of hospitalised patients\u00a0compared to 1% for other viral illnesses<a href=\"#_ftn1\" name=\"_ftnref1\">[1]<\/a><sup>,<\/sup><a href=\"#_ftn2\" name=\"_ftnref2\">[2]<\/a>.<\/li>\n<li>Exercise in the context of a current or recentCOVID-19 infection poses the risk of viral myocarditis, with the potential for associated cardiac dysfunction and fatal arrythmia<a href=\"#_ftn3\" name=\"_ftnref3\">[3]<\/a>\u00a0. This is mitigated by investigations and detailed return to play protocol in clinical relevant presentations<a href=\"#_ftn4\" name=\"_ftnref4\">[4]<\/a><\/li>\n<li>Despite strict biosecurity measures implemented by various sports, as based on RTT Elite Sports guidance Stage 2<sup>1<\/sup>, it must be acknowledged this will act only as a risk mitigation measure for COVID-19 transmission; a zero risk environment cannot be achieved, even in the presence of frequent antigen testing for asymptomatic individuals<a href=\"#_ftn5\" name=\"_ftnref5\">[5]<\/a><\/li>\n<li>For most sports, a return to the sporting environment requires temporary breaching of social distancing measures during certain technical training, match play and essential medical care (see Table 2). Consequently, appropriate PPE will need to be utilised where indicated in these scenarios.<\/li>\n<li>Aerosol-generating procedures (AGPs) are recognised to be a high source of virus transmission, these also include situations where there is a high possibility of generating a cough or sneeze. Within sport there are many scenarios that are, or have the potential to become AGPs;\n<ul>\n<li>Cardiopulmonary resuscitation (CPR)<\/li>\n<li>Airway management: any suction of upper airway, use of airway adjuncts and emergency surgical airway procedures<\/li>\n<li>Breathing Management: any form of manual ventilation- mouth-to-mouth ventilation is not recommended in the current circumstance. Bag valve mask using a viral filter is preferable<a href=\"#_ftn6\" name=\"_ftnref6\">[6]<\/a>.<\/li>\n<li>Medical emergencies in the context of reduced and impaired consciousness, with a risk of or actual airway compromise, that would require the above interventions.<\/li>\n<li>Nose and throat procedures\u00a0such as\u00a0managing epistaxis or\u00a0oral lacerations<a href=\"#_ftn7\" name=\"_ftnref7\">[7]<\/a><sup>,<\/sup><a href=\"#_ftn8\" name=\"_ftnref8\">[8]<\/a><sup>,<\/sup><a href=\"#_ftn9\" name=\"_ftnref9\">[9]<\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>NB: Nebulising, high flow oxygen administration via facemask and nasopharyngeal swabbing are not considered AGPs.<\/p>\n<p>&nbsp;<\/p>\n<p><strong><u>PPE in the context of cardiopulmonary resuscitation<\/u><\/strong><\/p>\n<p>The UK government guidance as published by the\u00a0New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG)<a href=\"#_ftn10\" name=\"_ftnref10\">[10]<\/a>\u00a0have detailed that they do not consider chest compressions or the use of an Automatic External Defibrillator (AED) as AGPs. However, this view is not shared by\u00a0the Resuscitation Council UK (RCUK<a href=\"#_ftn11\" name=\"_ftnref11\">[11]<\/a>), the European resuscitation council (ERC<sup>20<\/sup>), the International Liaison Committee on Resuscitation (ILCOR)<a href=\"#_ftn12\" name=\"_ftnref12\">[12]<\/a> and the World Health Organistaion<a href=\"#_ftn13\" name=\"_ftnref13\">[13]<\/a>. This view is also supported by the British Medical Association\u00a0(BMA)<a href=\"#_ftn14\" name=\"_ftnref14\">[14]<\/a>. All have taken the position that chest compressions themselves are an potentially aerosol generating and thus\u00a0requiring Level 3 PPE. In the context of a shockable\u00a0cardiac\u00a0arrest,\u00a0RCUK advise 3 stacked\u00a0shocks be administered in a monitored arrest in Level 2\u00a0PPE,\u00a0in the absence of compressions and airway management, whilst additional support is\u00a0donning the appropriate PPE<a href=\"#_ftn15\" name=\"_ftnref15\">[15]<\/a>.<\/p>\n<p>Given that\u00a0sport typically follows the professional guidance of the Royal Colleges and\u00a0RCUK, we felt it\u00a0unwise to contradict these organisations in these unprecedented times of the COVID-19 pandemic.\u00a0 This is due to the relative lack of current evidence, and a desire not to increase the exposure risk for\u00a0medical\u00a0staff\u00a0 in the event of an arrest [see Figure 2]. We acknowledge that most sports environments utilise AEDs, \u00a0and thus the sports\u2019 guidance has been\u00a0adapted\u00a0to suit the required needs.\u00a0In summary:<\/p>\n<ul>\n<li>AED use is not considered an AGP<\/li>\n<li>Compressions are considered potntially aerosol generating, and can only be commenced in the absence of Level 3 PPE with a cover over the player\u2019s face (e.g.a non-rebreather mask with oxygen attached or a towel) such as there is a minimal delay to the start of compressions<\/li>\n<li>Medical responders are ideally already in Level 2 PPE<\/li>\n<li>Awaiting support responders who are in Level 3 PPE<\/li>\n<\/ul>\n<p>It is important that all medical teams\u00a0amend\u00a0their EAP to reflect these changes during this period.<\/p>\n<p>The response time\u00a0for\u00a0a medical emergency in individual sports needs to be appropriately risk assessed with the new addition of time taken to don appropriate PPE; this is imperative when considering airway interventions, chest compressions and all clinically relevant scenarios.\u00a0As time is critical in determining successful outcomes,\u00a0it\u00a0is\u00a0recommended that\u00a0during both\u00a0training and matchday\u00a0activities\u00a0trained staff\u00a0should either be wearing or have access to\u00a0Level 3 PPE\u00a0in a time frame that will not detrimentally affect the outcome of the clinical situation. Individual donning times will vary according to experience and the availability of \u201cdonning buddies\u201d.<\/p>\n<p>It must be remembered hat, once any\u00a0AGP\u00a0is commenced, all involved that are not in Level 3 PPE must step back 2m when\u00a0outdoors, and\u00a0vacate the room if indoors.<\/p>\n<p>&nbsp;<\/p>\n<p><strong><u>Special considerations for youth sport<\/u><\/strong><\/p>\n<p>As cardiac arrest in children occurs for a variety of \u00a0reasons, ventilation is often crucial to a child\u2019s chance of survival. If the decision is made to perform rescue breathing [due to compression only CPR being less effective if a respiratory problem is the cause] despite the risk to the responder, a bag valve mask<sup>25,<\/sup><a href=\"#_ftn16\" name=\"_ftnref16\">[16]<\/a> is preferable.<\/p>\n<p><strong><u>\u00a0<\/u><\/strong><\/p>\n<p><strong><u>Optimised pitchside<\/u><\/strong><strong><u>\u00a0<\/u><\/strong><strong><u>medical cover at all training and matches would consist of:<\/u><\/strong><strong><u>\u00a0<\/u><\/strong><\/p>\n<ul>\n<li>One appropriately trained responder* in Level 2 PPE with the ability to don Level 3 with minimal delay, if required. Forexample\u00a0having additional\u00a0available\u00a0PPE on person or in the emergency pitchside bag.<\/li>\n<li>One appropriately trained responder* who is either already wearing or has immediate access to Level 3 PPE and can respond immediately<\/li>\n<li>Additionalsupport\u00a0personnel\u00a0that can don the appropriate level of PPE to\u00a0assist\u00a0in a medical emergency with minimal delay, when required.<\/li>\n<\/ul>\n<p>Additional (support) personnel that can don\u00a0the appropriate level of\u00a0PPE to assist with extrication<\/p>\n<p>*<em>Appropriately trained responders are those with a current <\/em><em>ATMMiF<\/em><em>\/IMMOFP\/PHICIS\/ICIR\/UEFA FDEP\/ITMMiF or equivalent qualification<\/em>.<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><a href=\"#_ftnref1\" name=\"_ftn1\">[1]<\/a>Clerkin \u00a0KJ, Fried \u00a0JA, Raikhelkar \u00a0J, \u00a0et al. \u00a0Coronavirus disease 2019 (COVID-19) and cardiovascular disease.\u00a0\u00a0\u00a0Circulation. Published online March 21, 2020.<\/p>\n<p><a href=\"#_ftnref2\" name=\"_ftn2\">[2]<\/a> Driggin \u00a0E, Madhavan \u00a0MV, Bikdeli \u00a0B, \u00a0et al. \u00a0Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic.\u00a0\u00a0\u00a0J Am Coll Cardiol. Published online March 18, 2020.<\/p>\n<p><a href=\"#_ftnref3\" name=\"_ftn3\">[3]<\/a> https:\/\/jamanetwork.com\/journals\/jamacardiology\/fullarticle\/2766124<\/p>\n<p><a href=\"#_ftnref4\" name=\"_ftn4\">[4]<\/a> https:\/\/journals.sagepub.com\/doi\/full\/10.1177\/2047487320930596<\/p>\n<p><a href=\"#_ftnref5\" name=\"_ftn5\">[5]<\/a> https:\/\/www.acpjournals.org\/doi\/pdf\/10.7326\/M20-1495<\/p>\n<p><a href=\"#_ftnref6\" name=\"_ftn6\">[6]<\/a> https:\/\/www.erc.edu\/covid<\/p>\n<p><a href=\"#_ftnref7\" name=\"_ftn7\">[7]<\/a> https:\/\/www.entuk.org\/sites\/default\/files\/files\/COVID%2019%20Epistaxis%20Management.pdf<\/p>\n<p><a href=\"#_ftnref8\" name=\"_ftn8\">[8]<\/a> https:\/\/www.nature.com\/articles\/s41415-020-1552-4.pdf<\/p>\n<p><a href=\"#_ftnref9\" name=\"_ftn9\">[9]<\/a> https:\/\/www.fgdp.org.uk\/sites\/fgdp.org.uk\/files\/editors\/FGDP%20CGDent%20Implications%20of%20COVID-19%20for%20the%20safe%20management%20of%20general%20dental%20practice%2016%20June%202020%20ed1.1.pdf<\/p>\n<p><a href=\"#_ftnref10\" name=\"_ftn10\">[10]<\/a> <a href=\"https:\/\/www.gov.uk\/government\/publications\/wuhan-novel-coronavirus-infection-prevention-and-control\/phe-statement-regarding-nervtag-review-and-consensus-on-cardiopulmonary-resuscitation-as-an-aerosol-generating-procedure-agp\">https:\/\/www.gov.uk\/government\/publications\/wuhan-novel-coronavirus-infection-prevention-and-control\/phe-statement-regarding-nervtag-review-and-consensus-on-cardiopulmonary-resuscitation-as-an-aerosol-generating-procedure-agp<\/a><\/p>\n<p><a href=\"#_ftnref11\" name=\"_ftn11\">[11]<\/a> <a href=\"https:\/\/www.resus.org.uk\/media\/statements\/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation\/statement-on-phe-ppe-guidance\/\">https:\/\/www.resus.org.uk\/media\/statements\/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation\/statement-on-phe-ppe-guidance\/<\/a><\/p>\n<p><a href=\"#_ftnref12\" name=\"_ftn12\">[12]<\/a> https:\/\/costr.ilcor.org\/document\/covid-19-infection-risk-to-rescuers-from-patients-in-cardiac-arrest<\/p>\n<p><a href=\"#_ftnref13\" name=\"_ftn13\">[13]<\/a> https:\/\/apps.who.int\/iris\/bitstream\/handle\/10665\/331695\/WHO-2019-nCov-IPC_PPE_use-2020.3-eng.pdf<\/p>\n<p><a href=\"#_ftnref14\" name=\"_ftn14\">[14]<\/a> <a href=\"https:\/\/www.bma.org.uk\/advice-and-support\/covid-19\">https:\/\/www.bma.org.uk\/advice-and-support\/covid-19<\/a><\/p>\n<p><a href=\"#_ftnref15\" name=\"_ftn15\">[15]<\/a> <a href=\"https:\/\/www.resus.org.uk\/media\/statements\/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation\/covid-community\/\">https:\/\/www.resus.org.uk\/media\/statements\/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation\/covid-community\/<\/a><\/p>\n<p><a href=\"#_ftnref16\" name=\"_ftn16\">[16]<\/a> <a href=\"https:\/\/www.gov.uk\/government\/publications\/novel-coronavirus-2019-ncov-interim-guidance-for-first-responders\/interim-guidance-for-first-responders-and-others-in-close-contact-with-symptomatic-people-with-potential-2019-ncov\">https:\/\/www.gov.uk\/government\/publications\/novel-coronavirus-2019-ncov-interim-guidance-for-first-responders\/interim-guidance-for-first-responders-and-others-in-close-contact-with-symptomatic-people-with-potential-2019-ncov<\/a><!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Rationale Rightful concern is raised when returning the player population to training and competition in the context of suspected or confirmed COVID-19 infection; given that the infection is still relatively novel, much of the emerging evidence is difficult to contextualise in our player Adverse cardiac and respiratory outcomes have been acknowledged in COVID-19 infection. The [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bjsm\/2020\/07\/08\/pitch-side-emergency-care-personal-protective-equipment-a-framework-for-elite-sport-during-the-covid-19-pandemic-part-2-of-3\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[16129],"class_list":["post-9292","post","type-post","status-publish","format-standard","hentry","category-uncategorized","tag-covid"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Pitch side emergency care &amp; personal protective equipment: a framework for elite sport during the COVID-19 pandemic: Part 2 of 3 - BJSM blog - social media&#039;s leading SEM voice<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bjsm\/2020\/07\/08\/pitch-side-emergency-care-personal-protective-equipment-a-framework-for-elite-sport-during-the-covid-19-pandemic-part-2-of-3\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Pitch side emergency care &amp; personal protective equipment: a framework for elite sport during the COVID-19 pandemic: Part 2 of 3 - BJSM blog - social media&#039;s leading SEM voice\" \/>\n<meta property=\"og:description\" content=\"Rationale Rightful concern is raised when returning the player population to training and competition in the context of suspected or confirmed COVID-19 infection; given that the infection is still relatively novel, much of the emerging evidence is difficult to contextualise in our player Adverse cardiac and respiratory outcomes have been acknowledged in COVID-19 infection. 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