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

• 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

– 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

– 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

• 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 3-6 x’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

• 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

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

• 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

• 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

• 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?

• 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

• 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

• 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

– 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

– 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

Balance Error Scoring System (BESS)

•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

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

Loss of Consciousness

Person Place Date Event Medication

Headache

Amnesia

Weakness or Loss Sensation

Sleep Problems

Red/Purple Haze Photosensitive

Coordination

Bleeding/Swelling Blood/CSF Ears or Nose Vital Signs

Pupil Size & Equality Light Reaction Eye Position Eye Tracking Visual Acuity

Hearing Smell SmileOpen Mouth Bite Tongue StrengthTongue Out/Gag Sensation

Balance/RhombergFinger to Nose Heel to Toe Walk

Nausea/vomiting

7’s countdown Memory 3 Item Recall

Shoulder Shrug

Muscles of Expression

Heel to Knee

Months Backward

Eyes Open/ClosedFrown

Tunnel/Peripheral