Head InjuriesHead Injuries

Managing the Unconscious AthleteManaging the Unconscious AthleteWhy is this so scary?Why is this so scary?

Can not collect Can not collect symptoms so must rely symptoms so must rely on signson signs

Always treat as though Always treat as though have cervical spine have cervical spine injuryinjury

Always stay calmAlways stay calm

Mechanisms for Rendering an Mechanisms for Rendering an Athlete UnconsciousAthlete Unconscious

Blow to headBlow to head

Diabetic ComaDiabetic Coma

HypoglycemiaHypoglycemia

Electric ShockElectric Shock

Heat IllnessHeat Illness

DrowningDrowning

Psychogenic ShockPsychogenic Shock

SyncopeSyncope

IllnessIllness

Substance AbuseSubstance Abuse

Epileptic SiezuresEpileptic Siezures

RhabdomyolysisRhabdomyolysis

Others?Others?

Remember what you have learned Remember what you have learned thus far!!thus far!!

Check Check

CallCall

CareCare

Conduct life-threatening measuresConduct life-threatening measures

Treat severe Treat severe bleedingbleeding

CPRCPR

AEDAED

HistoryHistoryKnow/get past Know/get past medical historymedical history

MechanismMechanism– If you missed, what If you missed, what

should you do?should you do?

InspectionInspectionOtorrheaOtorrhea

RhinorrheaRhinorrhea

Battle’s SignBattle’s Sign

Raccoon EyesRaccoon Eyes

Body PositionBody Position– Decorticate rigidityDecorticate rigidity

Arms flexed, legs Arms flexed, legs extendedextended

– Decerebrate rigidityDecerebrate rigidityArms & legs extendedArms & legs extended

Swelling, Deformity, Swelling, Deformity, Bleeding, Bleeding, DiscolorationDiscoloration

Determine Quality of LifeDetermine Quality of LifePulsePulse

RespirationsRespirations

PupilsPupils

Blood PressureBlood Pressure

Record with timeRecord with time

Establish State of ConsciousnessEstablish State of Consciousness

Glasgow Coma Glasgow Coma ScaleScale– Coma DefinitionComa Definition– Assesses depth and Assesses depth and

duration of comaduration of coma– Grades a wide Grades a wide

variety of variety of conditionsconditions

Glasgow Coma ScaleGlasgow Coma ScaleEye Opening Response

Spontaneous – opening with blinking at baseline 4 points

To verbal stimuli, command, speech 3 points

To pain only (not applied to face) 2 points

No response 1 point

Verbal Response

Oriented to place, time, etc 5 points

Confused conversation, but able to answer questions 4 points

Inappropriate Words 3 points

Incomprehensible speech 2 points

No response 1 point

Motor Response

Obeys commands for movement 6 points

Purposeful movement to painful stimulus 5 points

Withdraws in response to pain 4 points

Flexion in response to pain (decorticate posturing) 3 points

Extension in response to pain 2 points

No response 1 point

Head Injury Classification ScoresHead Injury Classification Scores

Sever Head InjurySever Head Injury

Moderate Head InjuryModerate Head Injury

Mild Head InjuryMild Head Injury

PalpationPalpationHead to toe evaluationHead to toe evaluationGeneral information seekingGeneral information seekingHead structuresHead structuresCervical structuresCervical structuresUpper ExtremityUpper ExtremityArmsArmsChestChestAbdomenAbdomenLower ExtremityLower Extremity

Oh no, What do I do?Oh no, What do I do?STAY CALMSTAY CALM““Know that you are in control of the Know that you are in control of the controllable but YOU CANNOT controllable but YOU CANNOT DICTATE THE OUTCOME”DICTATE THE OUTCOME”Be the leaderBe the leaderPractice, Practice and more Practice, Practice and more PRACTICEPRACTICE– SOMEONE’S LIFE MAY BE IN YOUR SOMEONE’S LIFE MAY BE IN YOUR

HANDSHANDS

ConcussionsConcussions

DefinitionDefinitionClinical syndrome Clinical syndrome characterized by characterized by immediate and transient immediate and transient impairment of impairment of neurological function neurological function secondary to mechanical secondary to mechanical forcesforcesStatistic on Brain InjuryStatistic on Brain Injury– 750,00 total injuries750,00 total injuries

85,000 brain injuries85,000 brain injuries– NFL= 3.5 brain NFL= 3.5 brain

injuries/gameinjuries/game– 10% college and 20% HS 10% college and 20% HS

football players suffer brain football players suffer brain injuriesinjuries

– 5% soccer players suffer 5% soccer players suffer brain injuriesbrain injuries

MechanismMechanism

Coup InjuryCoup Injury

Contrecoup InjuryContrecoup Injury

Types of forces Types of forces causing brain causing brain injuryinjury

Acute Concussion Sign and Acute Concussion Sign and SymptomsSymptoms

HeadacheHeadache

Consciousness LevelsConsciousness Levels

Memory ImpairmentMemory Impairment– Retrograde amnesiaRetrograde amnesia– Anterograde amnesiaAnterograde amnesia

Cognitive Function Cognitive Function DeficitsDeficits

Behavioral ChangesBehavioral Changes

Balance and Balance and CoordinationCoordination

TinnitisTinnitis

Pupil SizePupil Size– AniscoriaAniscoria

NystagmusNystagmus

Vision AcuityVision Acuity

NauseaNausea

PulsePulse

Blood PressureBlood Pressure

RespirationsRespirations

Injury ClassificationInjury ClassificationEpidemiologyEpidemiologyAmerican Academy of Neurology Grading American Academy of Neurology Grading ScaleScale– Grade 1Grade 1– Grade 2Grade 2– Grade 3Grade 3– Advantage/DisadvantagesAdvantage/Disadvantages

Cantu Evidence Based Grading ScaleCantu Evidence Based Grading Scale– Grade 1Grade 1– Grade 2Grade 2– Grade 3Grade 3– Advantage/ DisadvantagesAdvantage/ Disadvantages

NATA Position StatementNATA Position StatementAvoid grading Avoid grading scalesscalesFocus on RecoveryFocus on RecoveryIs the athlete Is the athlete symptomatic ofor symptomatic ofor asymptomaticasymptomaticOnce Once asymptomatic asymptomatic focus on focus on progresssionprogresssion

Post-concussion SymtpomsPost-concussion SymtpomsPhotophobiaPhotophobia

SensitivitySensitivity

Seeing stars or flashing lightsSeeing stars or flashing lights

Poor concentrationPoor concentration

IrritabilityIrritability

DepressionDepression

AnxietyAnxiety

FatigueFatigue

HeadacheHeadache

Sleep disturbance Sleep disturbance

Post-concusion AssessmentPost-concusion Assessment

Mental Testing AssessmentMental Testing Assessment

Postural-stability TestsPostural-stability Tests

Neuropsychological TestsNeuropsychological Tests

Post-concussion AssessmentPost-concussion AssessmentMental Status TestingMental Status Testing– Standardized Assessment of Concussion TestStandardized Assessment of Concussion Test

OrientationOrientationImmediate memoryImmediate memoryConcentrationConcentrationDelayed recallDelayed recallAlso measuresAlso measures

– StrengthStrength– SensationSensation– CoordinationCoordination– Neurological examNeurological exam– LOC and anmnesia also recordedLOC and anmnesia also recorded

Max scoreMax scoreLow scores?Low scores?Need good baseline dataNeed good baseline data

Post-concussion AssessmentPost-concussion Assessment

Postural-stability AssessmentPostural-stability Assessment– Romberg or Stork TestsRomberg or Stork Tests– Balance Error Scoring System (BESS)Balance Error Scoring System (BESS)

3 stance positions3 stance positions

2 different surfaces2 different surfaces

Test PositionTest Position

Count errorsCount errors– What counts as an errorWhat counts as an error

There is a practice effect from multiple trialsThere is a practice effect from multiple trials

Post-concussion AssessmentPost-concussion Assessment

Neuropsychological TestingNeuropsychological Testing– Most require licensed and board Most require licensed and board

certified psychologistcertified psychologist– Tests includeTests include

AttentionAttention

ConcentrationConcentration

Memory functionMemory function

Return to Play DecisionsReturn to Play Decisions

Some guideline require 7 day of Some guideline require 7 day of symptom freesymptom free

Begins with progressionBegins with progression

SACSAC– Both rest and exertional assessmentBoth rest and exertional assessment

All tests baseline or betterAll tests baseline or better

NATA Position StatementNATA Position Statement– Minimum 7 days after asymptomatic Minimum 7 days after asymptomatic

Guidelines for RTP after several ConcussionsGuidelines for RTP after several Concussions

Prentice, Principles of AT, 13th ed

When do you refer to physician?When do you refer to physician?Any LOCAny LOCDecr. LOCDecr. LOCAmnesia >15 minAmnesia >15 min*Decr. neurological function*Decr. neurological function*Decr. or irregularity of *Decr. or irregularity of respirationsrespirations* Decr. Or irregularity of pulse* Decr. Or irregularity of pulseIncrease in BPIncrease in BP*Mental status changes*Mental status changes*Seizures*Seizures

*Unequal, unresponsive or *Unequal, unresponsive or dilated pupilsdilated pupilsCranial nerve deficitsCranial nerve deficits*Injuries associated with *Injuries associated with spine, skull fracturesspine, skull fracturesSubsequent to Initial EvalSubsequent to Initial Eval– Motor deficitsMotor deficits– Sensory deficitsSensory deficits– Balance deficitsBalance deficits– Cranial nerve deficitsCranial nerve deficits– Post-concussion symptoms Post-concussion symptoms

that worsenthat worsen

* Indicates that patient be transferred immediately to nearest emergency facility

Secondary Impact SyndromeSecondary Impact Syndrome

What is it? What is it?

SignsSigns

TreatmentTreatment

Epidermal HematomaEpidermal Hematoma

Bleeding Bleeding between scalp between scalp and skulland skull

Little concern Little concern unless have S/S unless have S/S of head spine of head spine injuriyinjuriy

Epidural HematomaEpidural HematomaEtiologyEtiology– Associated with Associated with

skull fracturesskull fractures– Tear in meningeal Tear in meningeal

arteriesarteries

S/SS/S

ManagementManagement– Medical Emergency Medical Emergency

Subdural HematomaSubdural HematomaEtiologyEtiology– Acceleration/Acceleration/

deceleration forcedeceleration force– 3 kinds3 kinds

S/SS/S

ManagementManagement– ReferralReferral

Skull FractureSkull FractureMechanismMechanism– Blunt traumaBlunt trauma– Types of fracturesTypes of fractures

S/SS/S

ManagementManagement– ABC’sABC’s– CSF leakageCSF leakage

Putting it TogetherPutting it TogetherHistoryHistory– Ask peopleAsk people– Establish level of Establish level of

consciousnessconsciousness– HeadacheHeadache– SensesSenses– MemoryMemory

InspectionInspection– LOCLOC– ABC’sABC’s– Head PositionHead Position– SkullSkull– Mastoid ProcessMastoid Process– Eyes, ears, noseEyes, ears, nose– Body PositionBody Position– MovementsMovements– BehaviorBehavior– Facial expressionsFacial expressions

PalpationPalpation– Head/ScalpHead/Scalp– Cervical spineCervical spine– Soft TissueSoft Tissue– Vital signsVital signs

Functional TestsFunctional Tests– Cognitive Function Cognitive Function

(Subjective)(Subjective)– Cognitive Function Cognitive Function

(Objective)(Objective)SACSAC

– Balance and CoordinationBalance and CoordinationNeurological TestsNeurological Tests– Dermatomes Dermatomes – MyotomesMyotomes

Continue MonitoringContinue Monitoring– Every 5 minutesEvery 5 minutes