Approach to Pitchside Injury Care

DEFINITION OF PRIMARY SURVEY

• A rapid, structured assessment.
• Performed to identify life- or limb-threatening injuries.
• When present, immediate intervention must be carried out.
• Designed to enable clinicians to perform evaluations efficiently.

PROTOCOL SELECTION — FOCUSED VS COMPLETE 1° SURVEY

PRE-SURVEY SCAN & SAFETY CHECKS

1 · PPE

Don personal protective equipment before entering the pitch or assessing.

2 · Danger

Check for immediate environmental hazards.

3 · 5-second rapid scan

Signs of upper airway obstruction · central pulse · catastrophic haemorrhage.

A — AIRWAY & CERVICAL SPINE

Look

Facial trauma: wounds, swelling, haematoma, bleeding, deformity, foreign bodies.

Listen

Upper airway obstruction: stridor, gurgling, snoring, choking, hoarseness.

Feel

Facial tenderness, swelling or structural deformity.

Quickest method

Speak directly to the player to assess airway patency.

If obstruction is present:

• Manual opening: jaw thrust (preferred in trauma — no neck movement). Head-tilt/chin-lift is contraindicated with suspected trauma.
• Suction bleeding, secretions or vomitus while evaluating the gag reflex with the suction catheter.
• Adjuncts: OPA if the gag reflex is absent; consider an NPA if a gag reflex is present (best tolerated). NPA: relative contraindication with suspected base-of-skull fracture.
• High-flow oxygen via BVM or non-rebreather mask at 15 L/min — as soon as it arrives; do not wait for the survey to finish.
• Advanced: consider an i-gel LMA pitchside in cardiac arrest; intubation / RSI later at the medical base, ambulance or hospital.

FIFA: fix each problem before moving on — an obstruction is treated (jaw thrust, suction, adjunct) before assessing breathing. Never let players put fingers in a player's mouth. See the airway skill films on the Films page.

Cervical spine management:

• Initiate Manual In-Line Stabilisation (MILS) and palpate for cervical spine tenderness.
• Early collar application is not required if the player is conscious and alert — alert players naturally splint their neck.
• Apply a cervical collar if you are unable to clear the cervical spine — as part of extrication, not early in the survey (FIFA). Clearing can wait until the primary survey is done.
• Use the NSAID mnemonic to decide whether the spine can be cleared on-field.

N

Neurological deficit (numbness, weakness)

S

Spinal midline tenderness (on palpation)

A

Altered mental status (GCS < 15)

I

Intoxication

D

Distracting injury (severe enough to mask spinal pain)

FIFA: a player shouting or screaming has a patent airway. Signs of obstruction: gurgling, snoring, choking, stridor, cyanosis, no breathing effort — treat at once and give oxygen. Head-tilt/chin-lift only if there is no suspicion of trauma.

FIFA — clearing the cervical spine (all needed)

1 No midline tenderness · 2 GCS 15 · 3 No distracting injury · 4 No neurology · 5 No concerning mechanism (e.g. fall onto the head, axial load) · 6 Active rotation of 45° to each side. The manual adds a seventh: no intoxication.

B — BREATHING

Pitchside breathing assessment is limited — use a focused “hands-on 1, 2, 3” approach.

1 observation

Respiratory rate — plus chest movement, deformity, flail segment, bruising, open wounds.

2 hands on 3 places

1. Neck · 2. Anterior chest wall · 3. Posterolateral chest wall.

Assess

Pain, surgical emphysema (crackling under the skin), swelling, asymmetry.

Listen as you approach: gurgling / stridor = upper airway; wheeze = lower airway; coughing is reassuring. Watch the trend. Auscultation has no value inside a noisy stadium. No respiratory effort → cardiac arrest protocol (skill module 2).

C — CIRCULATION & HAEMORRHAGE CONTROL

Check for active haemorrhage and evaluate CCTVR (Colour, Capillary refill, Temperature, Voluntary movement / pulse, Response).

1 observation

Pulse — rate, volume and trend. Exercise tachycardia should settle; a worsening tachycardia is concerning.

2 hands · Abdomen

Inspect and palpate all 4 quadrants.

2 hands · Pelvis

Feel posterior → lateral → anterior. No downward pressure — DO NOT SPRING THE PELVIS.

2 hands · Long bones

Femurs down to the ankles. A fractured femur can lose up to 1.5 L of blood.

• Direct pressure to control active bleeding — this takes priority in the survey.
• Splint suspected fractures (reduces bleeding and pain).
• Utilise a scoop stretcher to minimise movement during handling (~15° tilt vs a 90° log roll onto a board).
• Capillary refill centrally: press the sternum for 5 seconds; skin should pink up within 2 seconds. A normal CRT does not exclude bleeding.
• On-pitch BP has almost no value — measure it off the pitch with a properly fitted cuff.
• Radial pulse: it relates to blood pressure, but studies differ and no single pressure figure can be attached to it. An ABSENT radial pulse is extremely concerning — think cardiac arrest.
• Check blood glucose in any confused or collapsed player.

D — DISABILITY & NEUROLOGICAL STATUS

• Pupils: size and reactivity — a baseline. A unilateral fixed, dilated pupil with a falling GCS = emergency transfer to neurosurgery.
• Rapidly scan for unilateral neurological deficits.
• Ask about numbness or weakness.
• Observe limb movements and ask the player to move their limbs.
• Assess balance and gait when returning the player to standing, if appropriate.

FIFA “Hands On 1, 2, 3” for D: 1 observation = AVPU · 2 pupils (equal and reactive?) · 3 places — sensation and movement in the arms, upper legs and lower legs.

E — EXPOSURE & EXTRICATION

Complete necessary exposure and safely extricate the player from the pitch.

EXTRICATION KIT BELOW THE FEET, IN LINE WITH THE PLAYER

Set up below the feet (FIFA): basket in line with the player, 2–3 basket lengths from the feet; scoop out of the basket, extended and split, laid between the feet and the basket.