Sports Medicine Mr. Smith. Discuss arrival assessment Discuss full head injury evaluation in HIPS...
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Transcript of Sports Medicine Mr. Smith. Discuss arrival assessment Discuss full head injury evaluation in HIPS...
Sports Medicine
Mr. Smith
Discuss arrival assessment Discuss full head injury evaluation in
HIPS format Discuss deadly head injuries Discuss second impact syndrome Practice
What you should observe as you are approaching the downed athlete› Are they moving? Limbs? Eyes?› Body position?
Decerebrate and decorticate rigidity? Prone? Supine? Neck angle?
› Level of consciousness: Unconscious and not breathing Unconscious and breathing Conscious
When you get to the athlete:› One immediately stabilizes the head, while
another performs the evaluation› Check ABC’s- begin CPR? AED?› Determine level of consciousness (LOC)
If unconsc and not breathing- begin CPR/ AED If unconsc and breathing- treat as if a neck fx If consc- continue with eval
› Check ears and nose- presence of CSF› Quick body visual for gross deformities and/ or
bleeding› Check vitals- respiration, pulse, blood
pressure, pupils
If they’re conscious and moving their limbs as you are approaching, should you still immediately stabilize the head and neck?
If they’re conscious and you stabilize the head and neck, how long should you continue to stabilize?
If they are unconscious ALWAYS treat like a cervical fracture with head trauma
History› Mechanism- Ask them how they got hurt
and then ask someone else who witnessed the trauma, if you didn’t, to confirm their memory
› Previous concussion(s)?› Any unusual sensations? Pain, numbness?
Can they move their hands and feet? Headache, nausea, blurred vision, tinnitus? Where is pain located? Head, neck?
› Headache› Balance problems› Dizziness› Concentration
difficulties› Loss of
consciousness (LOC)› Lightheadedness› Delayed motor/
verbal response› Memory or cognitive
dysfunction
› Disorientation› Amnesia› Blurred vision› Vacant stare› Photophobia› Tinnitus› Nausea› Vomiting› Emotionality› Slurred speech
Inspection› Working with these athletes daily give you the
advantage, because you know how each person NORMALLY acts and what their normal personality is.
› Visual inspection of athletes disturbances in coordination, orientation, attention, emotional response, verbal and motor response, and physical deformity such as swelling, bleeding, fluid from ears or nose… etc.
› Make sure the following have been checked ABC’s Vitals- heart rate, blood pressure, pulse Pupils- Pupils Equal And Reactive to Light
(PEARL)
› Otorrhea, rhinorhea, Battle’s sign, raccoon eyes, hyphema, nystagmus= 911
File_Optokinetic_nystagmus.htm
Palpation› Skull- feel for tenderness, depressions› Cervical spine- pain over the spinous
processes?› Sensation in extremities?
› This is point in which you completely rule out a cervical fracture
IF this is deemed within normal limits, you can stop stabilizing the head
IF pain or numbness occurs, stabilize head until paramedics arrive. Do not give head to anyone.
Special Tests› Memory Check- retrograde, anterograde amnesia
Anterograde amnesia- after the brain injury Example: Remember these three words….
Have athlete repeat words back to you every five minutes Retrograde amnesia- before the brain injury
Example: What team are you playing?
Presence of sustained (>30 minutes) antero amnesia = 911
Keep asking questions- date, location, who scored last point, what they ate for breakfast… etc.
› Balance/ coordination Rhomberg’s test Heel to toe walking
› Reflexes L4- L5 Patellar tendon reflex PEARL S1- S2 Achilles tendon reflex
› Cognitive Functioning- count backwards from 100 by 7’s or repeat the months backwards
› Halo Test- for presence of CSF
Cranial Nerve Assessment› Cranial Nerves 1-
12› Both sensory and
motor
› Need to be rechecked every 20 minutes until severity of trauma is established
# Cranial Nerve Name Acronim
1. I Olfactory On
2. II Optic Old
3. III Occulomotor Olympus
4. IV Trochlear Towering
5. V Trigeminal Top
6. VI Abducens A
7. VII Facial Fin
8. VIII Auditory And A
9. IX Glossopharyngeal German
10. X Vagus Viewed
11. XI Spinal Accessory Some
12. XII Hypoglossal Hops
Cranial Nerve What action tests each nerve
I- Olfactory Ask if they can smell ammonia salts, tuft skin, perfume…. Etc.
II- Optic Ask athlete to read the score board, look at cars in the distance
III- Occulomotor PEARL
IV- Trochlear Roll their eyes, follow your finger downward and inward
V-Trigeminal Bite down, clench jaw, sensation in cheeks
VI- Abducens Follow your finger outward
VII- Facial Raise eyebrows, smile, frown
VIII- Auditory Close eyes balance on both legs, balance one leg, close eyes balance on one leg, heel to toe walking, finger to nose
IX-Glossopharyngeal Swallowing
X- Vagus Stick out tounge and say “ahhhh”
XI- Accessory Resist the athlete doing a shoulder shrug
XII-Hypoglossal Stick out tounge and wiggle it around
Grade or level
Cantu (2001) Colorado Medical Society (1991)
1st degree No LOC, postraumatic amnesia or postconucssion signs or symptoms lasting less than 30 minutes
No LOC, confusion, no amnesia
2nd degree LOC lasting less than 1 mintues, postraumatic amnesia or postconcussion signs or symptoms lasting longer than 30 mintues but less than 24 hours
No LOC, confusion, amnesia
3rddegree LOC lasting more than 1 minute or posttraumatic amnesia lasting longer than 24 hours, postconcussion signs or symptoms lasting longer than 7 days
LOC
1 2 3 4 5 6
Eyes Does not open eyes
Opens eyes in response to painful stimuli
Opens eyes in response to voice
Opens eyes spontaneously
N/A N/A
Verbal Make no sounds
Incomprehensible sounds
Utters inappropriate words
Confused, disoriented
Oriented, converses normally
N/A
Motor Makes no movements
Extension to painful stimuli
Abnormal flexion to painful stimuli
Flexion/ withrawl to painful stimuli
Localizes painful stimuli
Obeys commands
Severe coma, GCS < 8Moderate coma, GCS 9-12Minor coma, GCS > 13
Colorado Medical Society Return to Play Guidelines:
Grade First Concussion Second Concussion
Third Concussion
Grade 1 (mild)
May return to play if without symptoms for at least 20 minutes
Terminate contest or practices, may return to play if without symptoms for at least 1 week
Terminate season, may return to play in 3 months if asymptomatic
Grade 2 (moderate)
Terminate contest or practices, may return to play if without symptoms for at least 1 week
Consider terminating season, may return to play in 1 month if without symptoms
Terminate season, may return to play next season if without symptoms
Grade 3 (severe)
Terminate contest or practice and transport to hospital, may return to play on 1 month, after 2 consecutive weeks without symptoms
Terminate season, may return to play next season if without symptoms
Terminate season, strongly discouraged to return to contact or collision sports
Grade First Concussion Second Concussion
Third Concussion
Grade 1 (mild)
May return to play if asymptomatic for 1 week; terminate season if CT or MRI abnormality
Return to play in 2 weeks if asymptomatic at the time for 1 week
Terminate season; may return to play next season if asymptomatic
Grade 2 (moderate)
Return to play after asymptomatic for 2 weeks; terminate season if CT or MRI abnormality
Minimum of 1 month; may return to play then if asymptomatic for 1 week; consider terminating season
Terminate season; may return to play next season if asymptomatic
Grade 3 (severe)
Minimum of 1 month; may return to play then if asymptomatic for 1 week
Terminate season; may return to play next season if asymptomatic
Consider no further contact sports
Intracranial Hemorrhage
Epidural Hematoma› Sits outside of dura mater in between
skull Signs and Symptoms include:
Altered state of consciousness, nystagmus, pupil inequality, irregular eye movement, slowing of heart rate, irregular respirations, severe headache, vomiting, unable to perform coordination tests, decreased muscle strength, seizures, cranial nerve assessment tests are all not normal
Subdural Hematoma:› Collection of blood between the dura and
the arachnoid space of the brain› Commonly delayed onset of symptoms (2
days- 2 weeks) High mortality rate
› Signs and Symptoms: LOC, irritability, seizures, numbness,
headache, dizziness, disorientation, amnesia, weakness, nausea, vomiting, personality changes, inability to speak, slurred speech, difficulty walking, blurred vision, deviated gaze or abnormal movement of eyes
Second Impact Syndrome› Deadly!! Can take only minor blow the second
time to create life threatening situation› Loss of auto regulation of the brain’s blood
supply; vascular engorgement in the cranium; increased intracranial pressure; the second blow bursts the engorged area
› Death in nearly 50% of all cases, disability in almost 100% of all cases… 911… maintain vitals if possible
› THIS IS WHY WE TREAT ALL CONCUSSIONS CONSERVATIVELY
Preston Plevretes
Second Impact Syndrome-› Second Impact Syndrome happened to young man
while in freshman year of college during football game Sustained initial injury 4 days before 2nd injury
› Four and a half years later, Plevretes struggles to walk and talk and needs round-the-clock care ALL BECAUSE CONCUSSION WENT UNDIAGNOSED!!!
http://sports.espn.go.com/espn/e60/news/story?id=5162747
Questions? Comments? Concerns?
A lot of information to digest….. But with practice, it will become MUCH easier to understand
Practice time!!!