2. History ABCs Level of Consciousness (ask simple questions) Determine MOI (or ask bystander) Ask about headache Ask about nausea Ask about paralysis/numbness/weakness Ask about tinnitus (ringing in the ears)

3. ABCs C – Circulation Pulse Adult and Child: Carotid artery Infant: Brachial Artery Begin CPR if needed A – Airway Remove face mask (if needed) Chin tilt Jaw thrust B – Breathing Look, Listen, and Feel 2 breaths

4. Levels of Consciousness Levels Alert and Oriented? Responsive to Verbal Stimuli? Responsive to Painful Stimuli? Lethargy: Drowsiness Stupor: responsive only to vigorous stimulus Coma: unresponsive to verbal or physical stimulus

5. Observation Unequal Pupils PERRLA (Pupils equal, round, and reactive to light and accommodation) Respiratory Rate Face color (red or pale) Abnormal body position Discharge from ears and nose Spinal Fluid

6. Palpation Rate and quality of pulse 60 – 100 bpm Rapid and weak? Strong and slow? Brachycardia (bpm < 60) Tachycardia (bpm > 100) Signs of Trauma to head and neck LOC Amnesia (retrograde and antrograde) Unable to wake sleeping victim Confusion Vomiting Dizziness Very high blood pressure Very slow pulse Numbness, tingling, pain

7. Cranial Nerves I - Olfactory II - Optic III - Oculomotor IV - Trochlear V - Trigeminal VI - Abducens VII - Facial VIII – Vestibulocochlear /Auditory IX - Glossopharyngeal X - Vagus XI – Spinal Accessory XII - Hypoglassal O - On O - Old O - Olympus T - Towering T - Top A - A F - Famous V - Vocal G - German V - Viewed S - Some H - Hops O - Oh O - Once O - One T - Takes T - The A - Anatomy F - Final V - Very G - Good V - Vacations A - Are H - Heavenly

8. Cranial NerveWhat?How? 1 OlfactorySmellPlace a strong, identifiable odor under the nose; ammonia capsule 2 OpticVisionRead something 3 OculomotorMvmt of eyelidElevate eyelid; cross eyes 4 TrochlearMvmt of eyeElevate the eye 5 Trigeminal Touch/pain of face; muscles of mastication Sensory: Touch the skin around the face Motor: Elevate, depress, protrude, retract, lateral deviate mandible 6 Abducens Lateral mvmt of eye Abduct or laterally move the eye 7 Facial Mvmt of facial muscles Motor: close eyelid; scrunch face 8 VestibulocochlearHearing/balance Stand w/eyes closed no support; snapping 9 GlossopharyngealMvmt of pharynx Swallow 10 Vagus Not Tested 11 Spinal AccessoryMvmt of Sternocleidomastoid and trapezius muscle Shrugging of shoulders 12 Hypoglassal Mvmt of tongue Stick tongue out

10. Special Tests (Concussion Tests) Cranial Nerve Testing Blurred Vision (Optic nerve) Pupillary Response (PERRLA) Tracking (Trochlear, Abducens, and Oculomotor) Romberg Sign (Vestibulocochlear) Finger-to-nose test Babinski Test (reflex test) Oppenheim Test Opposition Amnesia

11. Babinski Test Tests Babinski Response Either Present or not How? Lightly rub thumb up the bottom of the sole from the heel up to the base of the toe Normal response: Infants: Great toe extends and fanning of other toes Disappears as infant matures (1yr or less) Adults and children (1 yr or older) Toes curl under (flex)

12. Oppenheim Test Tests for cranial irritation Either present or not How? Rub antro/medial side of tibia Noxious Stimulus Abnormal response: Similar to Babinski Extension of great toe/toes

13. Finger-to-Nose Test Tests Spacial awareness or proprioception How? Instruct athlete to close eyes and attempt to touch finger to nose Positive test Athlete is unable to touch their nose without the eyes open

14. Romberg Test Testing balance through the Romberg Sign How? The essential features of the test are as follows: the subject stands with feet together, eyes open and hands by the sides. the subject closes the eyes while the examiner observes for a full minute. Because the examiner is trying to elicit whether the patient falls when the eyes are closed, it is advisable to stand ready to catch the falling patient. For large subjects, a strong assistant is recommended. Positive if, and only if, the following two conditions are both met: The patient can stand with the eyes open; and The patient falls when the eyes are closed. The test is not positive if either: The patient falls when the eyes are open; or The patient sways but does not fall when the eyes are closed.

15. Opposition The ability to touch and hold the thumb and another finger together. How? Instruct athlete to touch each finger to the thumb Then instruct the athlete to hold the two fingers together while you pull them apart. Positive finding Athlete is unable to touch fingers together or hold the two fingers together.

16. PERRLA Pupils Equal, Round and Reactive to Light and Accommodation How to test? If in a bright area Cover one eye and remove cover May also use a pen light Pen lights are used starting from the lateral side and moving medial Repeat on other eye If in a darker area Same steps but use Pen Light Positive if Pupils: Do not constrict Do not constrict equally Are difference sizes Are not round Positive = Brain Injury