Head Injury Management Concussion Evaluation

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Head Injury ManagementConcussion Evaluation
Sports Medicine Mr. Smith
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Todays Agenda

• Discuss arrival assessment
• Discuss full head injury evaluation in HIPS
  format
• Discuss deadly head injuries
• Discuss second impact syndrome
• Practice

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Arrival Assessment

• 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

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On Field Assessment

• When you get to the athlete
• One immediately stabilizes the head, while
  another performs the evaluation
• Check ABCs- 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

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On Field Assessment

• If theyre conscious and moving their limbs as
  you are approaching, should you still immediately
  stabilize the head and neck?
• If theyre 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

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HIPS Evaluation

• History
• Mechanism- Ask them how they got hurt and then
  ask someone else who witnessed the trauma, if you
  didnt, 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?

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Mechanism of Injury Coup and Contrecoup
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Signs and Symptoms of a Concussion

• 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

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HIPS Evaluation

• 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.

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HIPS Evaluation

• Make sure the following have been checked
• ABCs
• Vitals- heart rate, blood pressure, pulse
• Pupils- Pupils Equal And Reactive to Light
  (PEARL)
• Otorrhea, rhinorhea, Battles sign, raccoon eyes,
  hyphema, nystagmus 911

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Pupillary Response
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Ottorrhea
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Basal Skull Fracture
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Battles Sign
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Racoon Eyes
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Hyphema
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Subconjunctival Hemorrhage
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Nystagmus
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HIPS Evaluation

• 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.

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HIPS Evaluation

• 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 (gt30 minutes) antero
  amnesia 911
• Keep asking questions- date, location, who scored
  last point, what they ate for breakfast etc.

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HIPS Evaluation

• Balance/ coordination
• Rhombergs test
• Heel to toe walking
• Reflexes
• L4- L5 Patellar tendon reflex
• PEARL
• S1- S2 Achilles tendon reflex

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HIPS Evaluation

• Cognitive Functioning- count backwards from 100
  by 7s or repeat the months backwards
• Halo Test- for presence of CSF

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HIPS Evaluation

• Cranial Nerve Assessment
• Cranial Nerves 1-12
• Both sensory and motor
• Need to be rechecked every 20 minutes until
  severity of trauma is established

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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
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(No Transcript)
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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
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Grading systems for the severity of a concussion
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
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Glasgow Coma Scale
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 lt 8
• Moderate coma, GCS 9-12
• Minor coma, GCS gt 13

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• 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
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Cantu Return to Play Grading System
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
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Normal Concussions

• Intracranial Hemorrhage

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Quick Brain Anatomy
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Dangerous Concussions

• 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

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Very Dangerous Concussion

• 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

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Epidural vs. Subdural
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Consequences of returning to athletic
participation too soon

• Second Impact Syndrome
• Deadly!! Can take only minor blow the second time
  to create life threatening situation
• Loss of auto regulation of the brains 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

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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?id5
  162747

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Whewww.

• Questions? Comments? Concerns?
• A lot of information to digest.. But with
  practice, it will become MUCH easier to
  understand
• Practice time!!!