Head Injuries / Concussions

1. Head Injuries / Concussions • Prevalent in collision and contact sports • Education and protective equipment are critical in preventing head injuries • Head trauma results in more fatalities than any other sports injury

2. Mild Head Injuries • Immediate and transient post-injury impairment of brain function • Mechanism of injury • Direct blow • Acceleration/deceleration forces • Shaking and/or shearing forces to the brain • Sudden snapping of the head • Forward • Backward • Rotating to the side

3. Signs and Symptoms • May present as • Life-threatening injury • Cervical injury (if unconscious) • Loss of consciousness (LOC) • May last seconds or minutes • Post-traumatic amnesia lasting < 24 hours • Other symptoms • Disorientation • Motor coordination or balance deficits • Cognitive deficits • Variety of scales and return to play criteria • Typically involve LOC or amnesia

4. Management • Any LOC requires the athlete be removed from competition • Assume a cervical spine injury with any LOC • Athlete should be referred to a physician for assessment • Athlete should not be left alone following a concussion for 24 hours or until a physician determines supervision is no longer necessary • Objective measures should be used to determine readiness for return to play • SAC Test (Standard Assessment of Concussion) • BESS Test (Balance Error Scoring System) • Return to normal baseline requires approximately 3-5 days • All post-concussive symptoms should be resolved • Return to play should be gradual

5. Second impact syndrome • Mechanism of injury • Recurrent concussions can produce cumulative injury to the brain • After 1st concussion the chances of a 2nd concussion are 3-6x’s greater • Occurs before symptoms of the initial injury have resolved • Second impact • May be relatively minimal • May not involve contact w/ the cranium • Result of rapid swelling and herniation of brain after a second head injury • Disrupts the brain’s blood autoregulatory system • Leading to swelling • Increasing intracranial pressure • Very serious condition

6. Second Impact Syndrome • Management • Life-threatening injury • Must be addressed w/in 5 minutes • Life saving procedures at trauma center • Activate 911 • Best management is prevention • Physician’s clearance for return to activity • Signs and Symptoms • Athlete may not have LOC • Athlete may looked stunned • Condition degrades rapidly w/in 15 secs. • Dilated pupils • Loss of eye movement • LOC leading to coma • Respiratory failure • May lead to death

7. History • Loss of consciousness and for how long? • Orientation (x’s 4) • Person (who you are / who MD is at hospital) • Place (where they are) • Time (day, month, year) • Event (more reliable test with athletes) • History of prior concussions • How many • Date of last one • Loss of consciousness (knocked out) • Medications • Use of blood thinners (anti inflammatory medications) • Alcohol use • Amnesia (memory deficit) • Retrograde amnesia (memory of events before the injury) • Can you remember who we played last week? • Antegrade amnesia (memory of events after the injury) • Can you remember walking off the field

8. History • Headache • Quantity (Severity of pain: 0 -10 scale) • Quality (sharp, stabbing, throbbing, ache) • Constant or intermittent • Neck pain • Evaluate motor function • Can you move your hands and feet? • Feelings of weakness • Wiggle fingers and toes • Sensory assessment • Nausea • Dizzyness / Vertigo / Balance problems • Change in sleep pattern / feeling sluggish • Visual disturbances • Blurry vision • Double vision • Red or purple haze to vision • Sensativity to light • Concentration or memory problems

9. Observation • General impression of the athlete • Is there a blank or vacant stare? • Can the athlete keep their eyes open? • Inability to focus attention • Is the athlete easily distracted? • Normal emotional response? • Speech • Slurred speech • Incoherent speech • Verbal response • Motor response • Gross disturbances to coordination? • Cognitive function?

10. Observation • Swelling or bleeding from the scalp? • Deformity • Cerebrospinal fluid leaking from • Ear canal • Nose • Discoloration • Behind the ears (Battle’s sign) • Under the eyes (Raccoon eyes) • Palpation for point tenderness and deformity • Neck • Skull • Special Tests • Vital signs • BP • Increase in systolic • Decrease in diastolic

11. Special Tests • Eye function • Pupils • Equal (same size or irregular) • And • Reactive to (constrict with increased light) • Light (Penlight or ambient room light or sunlight) • Accommodation • Ability of pupils to accommodate to light variance • Dilate for far away • Constrict for close up • Eye position • Strabismus • Eye tracking - smooth or unstable • Nystagmus • Vision up and down, side to side (bowtie pattern) • Convergence with close up focus • Visual acuity (Blurred vision / Eye chart) • Peripheral and tunnel vision • Close eyes tightly or open them widely

12. Special Tests • Ear function (test hearing by rubbing fingers together) • Nose (test smell with mild agent, ie soap or coffee) • Mouth • Smile or frown • Bite down hard • Hold mouth open against resistance • Tongue • stick tongue straight out (say ah) • Push tongue against cheek on each side • Uvula retracts as tongue sticks out • Gag reflex • Skin • Sensation 3 zones

13. Balance Tests • Romberg Test • Assess static balance • Determine individual’s ability to stand and remain motionless • Time (30 seconds) • Position • Feet together • Arms out in front at shoulder height • Head tipped all the way back • Eyes closed • Balance Error Scoring System • Coordination tests • Finger to nose • Heel-to-toe walking

14. Cognitive Tests • Obtains objective measures to assess patient status and improvement • On or off-field assessment • Serial 7’s • Months in reverse order • Counting backwards • Tests of recent memory • Score of contest • Breakfast • Prior game • 3 word recall

15. Balance Error Scoring System (BESS) • Positions • 1. On firm surface • a. Feet side by side • b. Single foot balance • c. One foot behind other • 2. On unstable surface • a. Feet side by side • b. One foot balance • c. One foot behind other • Quantifiable clinical battery of tests • Eyes are closed in all positions during test • Utilizes different stances on both firm and foam surface • Errors are tabulated when the athlete • Opens their eyes • Takes hands off hips • Steps/stumbles or falls

16. Loss of Consciousness Bleeding/Swelling Blood/CSF Ears or Nose Vital Signs Headache Nausea/vomiting Sleep Problems Amnesia Person Place Date Event Months Backward 7’s countdown Memory 3 Item Recall Medication Red/Purple Haze Photosensitive Pupil Size & Equality Light Reaction Eye Position Eye Tracking Tunnel/Peripheral Visual Acuity Smile Frown Eyes Open/Closed Sensation Smell Open Mouth Bite Tongue Out/Gag Tongue Strength Hearing Muscles of Expression Weakness or LossSensation Balance/Rhomberg Heel to Toe Walk Shoulder Shrug Finger to Nose Coordination Heel to Knee