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 3-6 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

6. Second Impact Syndrome
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
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

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 Neck pain Nausea
Quantity (Severity of pain: 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 Speech Verbal response
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. Palpation for point tenderness and deformity
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 Balance Error Scoring System
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)
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
b. One foot balance

16. Person Place Date Event Months Backward 7’s countdown
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
Hearing
Smell
Open Mouth
Bite
Tongue Out/Gag
Tongue Strength
Smile
Frown
Eyes Open/Closed
Sensation
Muscles of Expression
Weakness or Loss Sensation
Shoulder Shrug
Finger to Nose
Coordination
Heel to Knee
Balance/Rhomberg
Heel to Toe Walk