3.3 Cardiac Emergencies, Head Injuries, and First Aid

3.3 Cardiac Emergencies, Head Injuries, and First Aid

Introduction to Cardiac and Traumatic Emergencies in Schools

School nurses serve as primary responders for acute life-threatening traumatic injuries, head trauma, and unexpected cardiovascular catastrophes. Sudden Cardiac Arrest (SCA) is the leading cause of exercise-related death in young athletes, while traumatic brain injuries (TBIs) and severe musculoskeletal injuries occur frequently during school athletics, physical education classes, and playground activities. Mastery of immediate life support, evidence-based concussion protocols, hemorrhage control, and systematic injury triage is essential for the Nationally Certified School Nurse.

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Sudden Cardiac Arrest (SCA) and School CPR/AED Protocols

Sudden Cardiac Arrest (SCA) in school-aged youth is most commonly caused by underlying structural or electrical cardiovascular abnormalities, including hypertrophic cardiomyopathy (HCM), anomalous origin of coronary arteries, Long QT Syndrome (LQTS), Wolff-Parkinson-White syndrome, myocarditis, and commotio cordis (ventricular fibrillation triggered by a direct non-penetrating blow to the precordium during the vulnerable repolarization phase of the cardiac cycle).

The School Cardiac Chain of Survival

1. Early Recognition & Call 911: Immediate identification of sudden unresponsiveness and abnormal breathing (agonal gasps). Dispatch EMS and retrieve the Automated External Defibrillator (AED).
2. High-Quality CPR: Initiate chest compressions immediately.
   • Compression Rate: 100 to 120 compressions per minute.
   • Compression Depth: At least 2 inches (5 cm) in children and adolescents; 1.5 inches (4 cm) in infants.
   • Technique: Allow complete chest recoil after each compression; minimize interruptions in compressions to <10 seconds; 30 compressions to 2 ventilations for single rescuer (15:2 for two healthcare providers in children).
3. Rapid Defibrillation: Apply AED as soon as available. Early defibrillation within 3 to 5 minutes of collapse yields survival rates exceeding 50% to 70%.
4. Advanced Life Support & Post-Arrest Care: Paramedic transport and specialized intensive care.

AED Application Technical Standards

• Pad Placement (Adult/Standard Pads for ≥8 Years or ≥25 kg):
  • Upper Right Pad: Placed on the bare chest below the right clavicle, lateral to the sternum.
  • Lower Left Pad: Placed on the lower left chest wall, mid-axillary line below the nipple line.
• Pediatric Placement (<8 Years or <25 kg): Use pediatric attenuated pads. If pediatric pads are unavailable, standard adult pads may be used, ensuring they do not touch or overlap. If the pads would overlap on the chest, utilize an Anterior-Posterior (A-P) placement (one pad centered on the middle of the chest, the other centered on the back between the scapulae).
• Safety Protocol: Ensure no personnel are touching the student during rhythm analysis and shock delivery.

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Concussion Assessment and Traumatic Brain Injury Triage

A concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces (direct blow to head, neck, or body with impulse force transmitted to the head). It results in a functional neurometabolic crisis (potassium efflux, glutamate release, ionic mismatch, and transient cellular energy failure) rather than structural axonal damage visible on standard neuroimaging (CT/MRI).

Clinical Symptom Domains

• Somatic: Headache, nausea, vomiting, dizziness, balance disruption, phobophobia (sound sensitivity), photophobia (light sensitivity).
• Cognitive: Feeling in a fog, slowed thinking, difficulty concentrating or remembering, executive dysfunction.
• Emotional / Mood: Irritability, sadness, emotional lability, anxiety.
• Sleep / Energy: Drowsiness, fatigue, sleeping more or less than usual, difficulty falling asleep.

Standardized Assessment Frameworks: SCAT6 and Child SCAT6

School nurses utilize the Sports Concussion Assessment Tool 6th Edition (SCAT6) for students aged 12 and older, and the Child SCAT6 for children aged 5 to 11. Key components include:

1. Red Flag Assessment: Neck pain/tenderness, double vision, weakness/tingling in arms/legs, severe or increasing headache, seizure, loss of consciousness, deteriorating conscious level, repeated vomiting, increasing confusion/agitation. (Presence of ANY red flag requires immediate emergency EMS transport).
2. Maddocks Score / Cognitive Screening: Orientation and immediate memory tests.
3. Symptom Evaluation: Self-reported symptom severity score.
4. Neurological Screen & Balance Assessment: Modified Balance Error Scoring System (mBESS) and tandem gait.

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Return-to-Learn (RTL) and Return-to-Play (RTP) Protocols

When a student sustains a suspected concussion, the school nurse enforces the cardinal rule: "When in doubt, sit them out." The student must be removed from physical activity immediately and prohibited from same-day return to play.

Step-wise Return-to-Learn (RTL) Framework

Academic recovery must precede complete physical return to competition. RTL proceeds through gradual stages with school nurse coordination:

• Step 1: Daily Activities at Home: Rest, cognitive rest (minimal screen time, no reading/testing).
• Step 2: School Activities at Home: 15-30 minute segments of reading or light screen work.
• Step 3: Return to School Part-Time: Modified schedule, rest breaks in health office, no testing, reduced homework.
• Step 4: Full-Time School: Full academic days with accommodations as needed.
• Step 5: Full Academic Load: Complete catch-up work and standardized testing without accommodations.

Step-wise Return-to-Play (RTP) Progression

Once the student is asymptomatic at rest and has successfully navigated RTL, they may enter the 6-step RTP protocol under medical direction. Each step requires a minimum of 24 hours. If symptoms recur at any stage, the student must stop activity, rest for 24 hours, and revert to the previous successful step.

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Severe Hemorrhage Control, Fracture Immobilization, and Burn Triage

Hemorrhage Control Protocols

In major traumatic extremity wounds with severe arterial bleeding:

1. Apply firm, direct pressure over the wound with sterile gauze or clean cloth.
2. If bleeding is uncontrolled by direct pressure on a limb, apply a commercial windlass tourniquet (e.g., CAT):
   • Position tourniquet 2 to 3 inches proximal to the wound site (never directly over a joint).
   • Tighten the windlass rod until arterial bleeding and distal pulse cease.
   • Secure the windlass rod and record the exact time of application ("T: HH:MM") on the tourniquet strap or student's forehead.
   • Never cover or loosen a tourniquet once applied.

Musculoskeletal Fracture Immobilization

• Immobilize suspected fractures in the position found using splints that extend above and below the joint adjacent to the fracture site.
• Assess and document distal neurovascular status (Circulation, Movement, Sensation - CMS) before and after splint application. If distal pulse is absent or limb is cold/cyanotic, treat as a vascular emergency.
• Open (Compound) Fractures: Cover exposed bone and wound with sterile, saline-moistened dressings. Do not attempt to push exposed bone fragments back into the tissue.

Burn Classification and Triage

• Superficial (1st Degree): Erythema, dry, painful, no blisters (e.g., sunburn). Cool with cool running tap water for 10-15 minutes; apply soothing lotion.
• Partial-Thickness (2nd Degree): Blisters (bullae), severe pain, moist red dermis. Cool with water, cover with sterile non-adherent dressing. DO NOT rupture blisters.
• Full-Thickness (3rd Degree): Leathery, white/charred appearance, painless due to destroyed sensory nerve endings. Emergency EMS triage required; cover loosely with clean dry sheet; maintain body heat to prevent hypothermia.
• Chemical Burns: Immediately flush affected tissue with large volumes of running water for a minimum of 15 to 20 minutes while removing contaminated clothing.