Transcript Evaluation and Management of Head Injuries in Sports

Evaluation and Management of
Head Injuries in Sports
George S. Wham Jr., M.S., A.T.,C., S.C.A.T.
NATA Competencies concerning
Head Injuries




Recognize signs and symptoms of head trauma,
including loss of consciousness, changes in
neurological function, cranial nerve assessment,
and other symptoms that indicate brain injury
Explain and interpret signs and symptoms
associated with intracranial pressure
Define cerebral concussion and lists the signs and
symptoms used to classify cerebral concussion to
accepted grading scales: Cantu, Colorado, ANA
Assess a patient for possible closed-head trauma
Mechanisms of Injury

Coup

a forceful blow to resting
head, producing maximal
injury beneath the point of
impact

example: being hit with a
baseball or hockey puck
Mechanisms of Injury

Contrecoup

moving head hits an
unyielding object,
producing maximal brain
injury opposite the site of
impact as the brain
bounces within the
cranium
Example: head hits ground
when being tackled

Mechanisms of Injury

Repeated Subconcussive Blows

Many nontraumatic
blows overtime

Example: Soccer
players who head
the ball frequently
Types of Head Injuries in Sports

Cerebral Concussion

Cerebral Contusion

Cerebral Hematoma
Cerebral Concussion

Head trauma-induced alteration in mental
status that may or may not involve a loss of
consciousness
Cerebral Contusion




A bruise of the brain resulting from an impact of
the skull and an object causing bleeding from
injured vessels
May be associated with partial paralysis, one sided
pupil dilation, and altered vital signs
Progressive edema may further compromise brain
tissue not injured in original trauma
If basic life support, proper transport techniques,
and prompt expert evaluation are delivered, no
surgery is needed and prognosis is good
Cerebral Hematoma
Blood clot in the tissue surrounding the
brain causes pressure on the brain
 3 Types
 Epidural
 Subdural
 Intercerebral

Epidural Hematoma
Results from a severe blow to the head that
produces a skull fracture in the
temporoparietal region
 Neurological status may not be evident for
10 to 20 minutes after the injury
 Immediate surgery needed to decompress
the hematoma and control the bleeding
artery

Subdural Hematoma
A blow to the skull that causes subdural
blood vessels to tear resulting in venous
bleeding and the slow formation of a clot
 Symptoms may not appear for hours, days,
or even weeks
 Surgery is needed to drain the hematoma
and decompress the brain

Intracerebral Hematoma
Bleeding from a torn artery collects within
the brain itself
 Often results from a depressed fracture or
penetrating wound
 No lucid interval after the injury
 Hematoma progresses rapidly
 Death occurs before the athlete can be
moved to an emergency facility

Second Impact Syndrome
An athlete sustains a second concussion
before an earlier one has resolved
 Potential for occurrence with mild head
injuries
 Often the first concussion goes unreported
or unrecognized
 A major consideration when making return
to play decisions

Second Impact Syndrome (con’t)
Occurs within 1 week of initial injury
 Involves rapid brain swelling and herniation
 Brain stem failure develops within 2-5
minutes
 Causes rapid dilation of pupils, loss of eye
movement, respiratory failure, and coma
 Athlete must be intubated
 Mortality rate 50%

Frequency of Concussions




1 in 5 (250,000) high school
football players per year (Cantu
1986)
300,000 sport-related
concussions per year (Thurman
et al., 1998)
Player is 3 times more likely to
sustain a 2nd concussion after
the 1st (Guskiewicz 2000)
Only 1 in 100,000 high school
football players suffer
catastrophic injuries (Cantu
1999)
Who’s at Greatest Risk?
(Mueller, F.O. 2001).
Frequency of Head-Related Fatalities
(Mueller, F.O. 2001).
Cause of Death?
(Mueller, F.O. 2001).
It’s Getting Better …..
(Mueller, F.O., 2001).
OK, but isn’t it just football?.…
(Mueller, F.O., 2001).
Mouth Guards Decrease Concussions? How?
(Winters, J.E., 2001)
Grading Scales

Cantu (1984)

Colorado Medical
Society (1991)

American Academy of
Neurology (1997)
Cantu’s Scale (1984)
Grade 1 – no loss of consciousness
 Grade 2 – loss of consciousness < 5 minutes
 Grade 3 – loss of consciousness > 5 minutes

Revised in 1992
(Shultz et al., 2000)
Colorado Medical Society’s Scale

Grade 1 – confusion; no amnesia; no loss of
consciousness

Grade 2 – confusion; amnesia; no loss of
consciousness

Grade 3 – any loss of consciousness
American Academy of Neurology’s Scale

Grade 1 – confusion less than 15 minutes,
no loss of consciousness

Grade 2 – confusion greater than 15
minutes, no loss of consciousness

Grade 3 – any loss of consciousness
A.A.N.’s Recommendations for
Management of Concussions in Sports

For a grade 1
 Remove from activity
 Examine immediately and at 5 minute intervals
 Allow to return only if post-concussive
symptoms resolve within 15 minutes
nd grade 1 concussion occurs on the same
 If a 2
day then remove until asymptomatic for 1 week
A.A.N.’s Recommendations for
Management of Concussions in Sports

For a Grade 2
 Remove from activity
 Examine frequently to assess the evolution of
symptoms, with more extensive diagnostic
evaluation if symptoms worsen or persist for
more than 1 week
 Athlete may return to play after 1 week
asymptomatic
A.A.N.’s Recommendations for
Management of Concussions in Sports

For a Grade 3
 Remove from activity for 1 week if loss of
consciousness is brief, or for 2 weeks if
prolonged
 If unconscious at time of initial evaluation or if
neurological signs are abnormal, the athlete
should be transported by ambulance to ER
nd grade 3 occurs, the athlete should not
 If a 2
return to sport until asymptomatic for 1month

If any abnormality exists on the MRI or CT
scan the athlete should be removed from
activity for the season and discouraged from
a future return to contact sports
Another Classification Scale to Consider?
(Oliaro, S., et al. 2001).
More
Return to
Play
Guidelines
(Oliaro, S., et al. 2001).
Evaluation
Signs of Severe Brain Damage
•Damage above brain stem.
•Rigid extension of legs and
flexion of the arms, wrist,
and hands towards the chest
•Damage below brain stem
•Rigid extension of all 4
extremities with arms
internally rotated and pronated
Babinski Sign
Thorough Evaluation Before an
Athlete Is Allowed to Return to Play


On-field
Assessment
 Primary Survey
 Secondary
Survey
Off –field
Assessment
On-field Assessment


Primary survey
 check ABC’s
Secondary survey
 H.O.P.S. protocol
 determine if the athlete can go to the sideline
for further evaluation or needs an ambulance
**Often there is no “player down” assessment**
Check for Signs of Skull Fracture




Battle’s Sign – posterior
auricular hematoma
Ottorrhea – CSF
draining from ears
Rhinorrhea – CSF
draining from nose
Raccoon Eyes –
periorbital ecchymosis
resulting from blood
leaking from anterior
fossa of skull
Symptoms of a Concussion


Headache, nausea,
vomiting, dizziness, poor
balance, sensitivity to noise
or light, ringing in the ears,
blurred vision, poor
concentration, memory
problems, trouble sleeping,
sleepiness, depression,
irritability
Only 8.9% result in a loss
of consciousness
(Guskiewicz et al., 2000)
Method to Rate Severity of Signs & Sx
(Oliaro, S., et al. 2001).
Initial Assessment

Obtain information about mental confusion, any
loss of consciousness, and amnesia



Confusion: dazed, stunned, or glassy-eyed facial
expression; behaviors like running to the wrong
huddle
Unconscious: assume a cervical spine injury exists,
athlete spine boarded sent to ER; If conscious ask if
he has any tingling, numbness, or neck pain. Also,
can he move his fingers and toes?
Amnesia: test for post-traumatic amnesia by asking
what he remember about the last play; test for
retrograde amnesia by asking name, date, place
Initial Assessment (con’t)





Ask athlete if “his ears’ are ringing”, he has blurry
vision, or nausea
Check for any facial abnormalities
While asking questions, observe speech patterns,
respirations, and movement of the extremities
Palpate the athlete’s cervical spine and skull to
rule out fracture, assuming neck injury has been
ruled out
Walk to sideline for further assessment
Glasgow Coma
Scale

Used to assess
level of
consciousness
(Shultz et al., 2000)
Cranial Nerve Assessment

Rule out problems with II,
III, IV, VI first
II – check vision by read
scoreboard and fingers
 III, IV, VI – check eye
movement by asking athlete
to track a moving object,
check pupils for equal size
and light reactivity with a
penlight

** problems indicate increased
intracranial pressure**
(Shultz et al., 2000)
Further Cranial Nerve Assessment







I – check smell
V – check by clinching jaw
VII – check by raising eyebrows, smiling
VIII – check balance and hearing
IX and X – check by swallowing
XII – check by sticking out tongue
XI – check by neck rotation/extension and
shoulder shrug
(Shultz et al., 2000)
Test Sensory/Motor Function

Dermatome Testing

Myotome Testing

ROM Testing

Strength Testing
Upper Extremity Dermatome Testing





C1: Top of head
C2: Temporal,
Occipital
C3: Neck, Posterior
Check
C4: Superior Shoulder
C5: Deltoid patch




C6: Lateral forearm,
thumb, fore finger
C7: posterior forearm,
middle finger
C8: Lower medial
forearm, 4th and 5th
fingers
T1: Medial forearm
Upper Extremity Myotome Testing








C1/C2: Cervical flexion
C3: Lateral neck flexion
C4: Shoulder Shrug
C5: Shoulder Abduction
C6: Elbow flexion, wrist extension
C7: Elbow extension, wrist flexion
C8: Ulnar deviation, thumb extension, finger
flexion & abduction
T1: Finger abduction/adduction
Check Vital Signs

Increased pulse,
increased systolic
blood pressure, and a
decreasing diastolic
blood pressure
indicates increasing
intracranial pressure

A decrease in systolic
bp denotes shock
Check for Post-traumatic Amnesia
(Anterograde)


Give the athlete 3
unassociated words to
remember, and
periodically ask for
recall
Example: Red,
Explorer, Clemson
Check for Retrograde Amnesia

Ask questions like
 Where are we
playing?
 Which quarter is it?
 What did we have
for pre-game meal?
 Who did we play
last week?
Check for Concentration

Have athlete
 Recite days of the
week or months of
the year backward
 Count backward
from 100 by 7’s
(Serial 7’s)
 Multiple/Addition
facts
SAC (Standardized Assessment of Concussion)



Designed to detect impaired concentration
Sideline or follow-up evaluation tool
Takes 5 minutes to assess:
 Orientation
 Immediate memory
 Neurological fxn
 Concentration
 Delayed recall
 Sx during exertional testing
(McCrea et al., 1997)
Neurocognitive Assessments
Trail-Making Test B: (working
memory and rapid visual processing)
Connect circles containing letters (AL) to numbers (1-13) in alternating
numeric fashion as fast as possible.
Wechsier Digit Span Test:
(concentration and memory recall)
Subjects presented w/ a series of
numbers and must repeat digits in
same order or reverse order.
(Guskiewicz, K. M. et al., 2001)
Check Balance, Coordination,
and Depth Perception

Romberg’s Test

Finger-to-Nose Test

Finger-to-Finger Test

Heel-to-Toe Walking

Supine Heel-to-Knee
Test
Nerurocom Smart Balance Master System



SOT (Sensory
Organization Test)
Forceplate system
measures postural
sway by quantifying
balance deficits and
sensory organization
problems resulting
from a concussion
Expensive and
immobile
(Guskiewicz, K. M. et al., 2001)
NeuroCom Smart Balance Master vs BESS
Strong Correlation between the two tests!
(Guskiewicz, K. M. et al., 2001)
Balance Error Scoring System (BESS)





Quantifiable modified
Rhomberg
3 tests lasting 20s each
 Double-leg
 Single-leg
 Heel-toe
Eyes Closed
Perform once on ground and
once on foam
Tally number of errors
(Guskiewicz, K. M. et al., 2001)
6 Types of Errors in BESS
(Guskiewicz, K. M. et al., 2001)
Test Equilibrium and Balance
(Oliaro, S., et al. 2001).
(Shultz et al., 2000)
How long do symptoms linger?
Post
Concussion
Syndrome
(Guskiewicz, K. M. et al., 2001)
Functional Testing


Must be asymptomatic
Designed to see if
activity will cause
symptoms
 Sit-ups
 Push-ups
 Jogging
 Running
 Sports Specific Tasks
Return
to Play
Protocol
95% of baseline
on cognitive and
balance tests
(Oliaro, S., et al. 2001).
Return to Play

Assuming the athlete
passes the complete
exam he/she may
return to play
Take Home Message

While experts argue
over specifics of the
guidelines all agree –
NO ATHLETE
EXPERIENCING
SYMPTOMS
SHOULD
PARTICIPATE!
References
Guskiewicz, K.M., Weaver, N.L., Padua, D.A., Garrett, W.E. (2000). Epidemiology of concussion in
collegiate and high school football players. American Journal of Sports Medicine, 28, 643-650.
Guskiewicz, K.M., Ross S.E., Marshall, S. W. (2001). Postural stability and neuropsychological deficits
after concussion in collegiate athletes. Journal of Athletic Training. 36 (3), 263-273.
McCrea, M, Kelly, J.P., Kluge, J., Ackley, B., and Randolph, C. (1997). Standardized assessment of
concussion in football players. Neurology, 48, (3), 586-588.
Mueller, F.O. (2001). Catastrophic head injuries in high school and collegiate sports. Journal of Athletic
Training 36, (3), 312-315.
Oliaro, S., Anderson S., and Hooker, D. (2001). Management of cerebral concussion in sports: the athletic
trainer’s perspective. Journal of Athletic Training, 36, (3), 257-262.
Shultz, S.J., Houghlum, P.A., Perrin, D.H. (2000). Assessment of Athletic Injuries. (1st Ed., pp.345-371).
Human Kinetics. Champaign IL.
Thurman, J.D., Branche C.M., Sniezek, J.E. (1998). The epidemiology of sports-related traumatic brain
injuries in the United States: recent developments. Journal of Head Trauma Rehabilitation, 13, 1-8.
Winters, J.E. (2001). Commentary: Role of properly fitted mouthguards in prevention of sport-related
concussion. Journal of Athletic Training, 36 (3), 339-341.