Presentation on theme: "Evaluation and Management of Head Injuries in Sports"— Presentation transcript:
1 Evaluation and Management of Head Injuries in Sports George S. Wham Jr., M.S., A.T.,C., S.C.A.T.
2 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 injuryExplain and interpret signs and symptoms associated with intracranial pressureDefine cerebral concussion and lists the signs and symptoms used to classify cerebral concussion to accepted grading scales: Cantu, Colorado, ANAAssess a patient for possible closed-head trauma
3 Mechanisms of Injury Coup a forceful blow to resting head, producing maximal injury beneath the point of impactexample: being hit with a baseball or hockey puck
4 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 craniumExample: head hits ground when being tackled
5 Mechanisms of Injury Repeated Sub-concussive Blows Many nontraumatic blows overtimeExample: Soccer players who head the ball frequently
6 Types of Head Injuries in Sports Cerebral ConcussionCerebral ContusionCerebral Hematoma
7 Cerebral ConcussionHead trauma-induced alteration in mental status that may or may not involve a loss of consciousness
8 Cerebral ContusionA bruise of the brain resulting from an impact of the skull and an object causing bleeding from injured vesselsMay be associated with partial paralysis, one sided pupil dilation, and altered vital signsProgressive edema may further compromise brain tissue not injured in original traumaIf basic life support, proper transport techniques, and prompt expert evaluation are delivered, no surgery is needed and prognosis is good
9 Cerebral HematomaBlood clot in the tissue surrounding the brain causes pressure on the brain3 TypesEpiduralSubduralIntercerebral
10 Epidural HematomaResults from a severe blow to the head that produces a skull fracture in the temporoparietal regionNeurological status may not be evident for 10 to 20 minutes after the injuryImmediate surgery needed to decompress the hematoma and control the bleeding artery
11 Subdural HematomaA blow to the skull that causes subdural blood vessels to tear resulting in venous bleeding and the slow formation of a clotSymptoms may not appear for hours, days, or even weeksSurgery is needed to drain the hematoma and decompress the brain
12 Intracerebral Hematoma Bleeding from a torn artery collects within the brain itselfOften results from a depressed fracture or penetrating woundNo lucid interval after the injuryHematoma progresses rapidlyDeath occurs before the athlete can be moved to an emergency facility
13 Second Impact Syndrome An athlete sustains a second concussion before an earlier one has resolvedPotential for occurrence with mild head injuriesOften the first concussion goes unreported or unrecognizedA major consideration when making return to play decisions
14 Second Impact Syndrome (con’t) Occurs within 1 week of initial injuryInvolves rapid brain swelling and herniationBrain stem failure develops within 2-5 minutesCauses rapid dilation of pupils, loss of eye movement, respiratory failure, and comaAthlete must be intubatedMortality rate 50%
15 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)
22 Grading Scales Cantu (1984) Colorado Medical Society (1991) American Academy of Neurology (1997)
23 Cantu’s Scale (1984) Grade 1 – no loss of consciousness Grade 2 – loss of consciousness < 5 minutesGrade 3 – loss of consciousness > 5 minutesRevised in 1992(Shultz et al., 2000)
24 Colorado Medical Society’s Scale Grade 1 – confusion; no amnesia; no loss of consciousnessGrade 2 – confusion; amnesia; no loss of consciousnessGrade 3 – any loss of consciousness
25 American Academy of Neurology’s Scale Grade 1 – confusion less than 15 minutes, no loss of consciousnessGrade 2 – confusion greater than 15 minutes, no loss of consciousnessGrade 3 – any loss of consciousness
26 A.A.N.’s Recommendations for Management of Concussions in Sports For a grade 1Remove from activityExamine immediately and at 5 minute intervalsAllow to return only if post-concussive symptoms resolve within 15 minutesIf a 2nd grade 1 concussion occurs on the same day then remove until asymptomatic for 1 week
27 A.A.N.’s Recommendations for Management of Concussions in Sports For a Grade 2Remove from activityExamine frequently to assess the evolution of symptoms, with more extensive diagnostic evaluation if symptoms worsen or persist for more than 1 weekAthlete may return to play after 1 week asymptomatic
28 A.A.N.’s Recommendations for Management of Concussions in Sports For a Grade 3Remove from activity for 1 week if loss of consciousness is brief, or for 2 weeks if prolongedIf unconscious at time of initial evaluation or if neurological signs are abnormal, the athlete should be transported by ambulance to ERIf a 2nd grade 3 occurs, the athlete should not return to sport until asymptomatic for 1month
29 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
30 Another Classification Scale to Consider? (Oliaro, S., et al. 2001).
31 More Return to Play Guidelines (Oliaro, S., et al. 2001).
33 Signs of Severe Brain Damage Damage below brain stemRigid extension of all 4 extremities with arms internally rotated and pronatedDamage above brain stem.Rigid extension of legs and flexion of the arms, wrist, and hands towards the chestBabinski Sign
34 Thorough Evaluation Before an Athlete Is Allowed to Return to Play On-field AssessmentPrimary SurveySecondary SurveyOff –field Assessment
35 On-field Assessment Primary survey check ABC’s Secondary survey H.O.P.S. protocoldetermine if the athlete can go to the sideline for further evaluation or needs an ambulance**Often there is no “player down” assessment**
36 Check for Signs of Skull Fracture Battle’s Sign – posterior auricular hematomaOttorrhea – CSF draining from earsRhinorrhea – CSF draining from noseRaccoon Eyes – periorbital ecchymosis resulting from blood leaking from anterior fossa of skull
37 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, irritabilityOnly 8.9% result in a loss of consciousness (Guskiewicz et al., 2000)
38 Method to Rate Severity of Signs & Sx (Oliaro, S., et al. 2001).
39 Initial AssessmentObtain information about mental confusion, any loss of consciousness, and amnesiaConfusion: dazed, stunned, or glassy-eyed facial expression; behaviors like running to the wrong huddleUnconscious: 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
40 Initial Assessment (con’t) Ask athlete if “his ears’ are ringing”, he has blurry vision, or nauseaCheck for any facial abnormalitiesWhile asking questions, observe speech patterns, respirations, and movement of the extremitiesPalpate the athlete’s cervical spine and skull to rule out fracture, assuming neck injury has been ruled outWalk to sideline for further assessment
41 Glasgow Coma Scale Used to assess level of consciousness (Shultz et al., 2000)
42 Cranial Nerve Assessment Rule out problems with II, III, IV, VI firstII – check vision by read scoreboard and fingersIII, 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)
43 Further Cranial Nerve Assessment I – check smellV – check by clinching jawVII – check by raising eyebrows, smilingVIII – check balance and hearingIX and X – check by swallowingXII – check by sticking out tongueXI – check by neck rotation/extension and shoulder shrug
48 Check Vital SignsIncreased pulse, increased systolic blood pressure, and a decreasing diastolic blood pressure indicates increasing intracranial pressureA decrease in systolic bp denotes shock
49 Check for Post-traumatic Amnesia (Anterograde) Give the athlete 3 unassociated words to remember, and periodically ask for recallExample: Red, Explorer, Clemson
50 Check for Retrograde Amnesia Ask questions likeWhere are we playing?Which quarter is it?What did we have for pre-game meal?Who did we play last week?
51 Check for Concentration Have athleteRecite days of the week or months of the year backwardCount backward from 100 by 7’s (Serial 7’s)Multiple/Addition facts
52 SAC (Standardized Assessment of Concussion) Designed to detect impaired concentrationSideline or follow-up evaluation toolTakes 5 minutes to assess:OrientationImmediate memoryNeurological fxnConcentrationDelayed recallSx during exertional testing(McCrea et al., 1997)
54 Neurocognitive Assessments Trail-Making Test B: (working memory and rapid visual processing) Connect circles containing letters (A-L) 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)
55 Check Balance, Coordination, and Depth Perception Romberg’s TestFinger-to-Nose TestFinger-to-Finger TestHeel-to-Toe WalkingSupine Heel-to-Knee Test
56 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 concussionExpensive and immobile(Guskiewicz, K. M. et al., 2001)
57 NeuroCom Smart Balance Master vs BESS (Guskiewicz, K. M. et al., 2001)Strong Correlation between the two tests!
58 Balance Error Scoring System (BESS) Quantifiable modified Rhomberg3 tests lasting 20s eachDouble-legSingle-legHeel-toeEyes ClosedPerform once on ground and once on foamTally number of errors(Guskiewicz, K. M. et al., 2001)
59 6 Types of Errors in BESS(Guskiewicz, K. M. et al., 2001)
60 Test Equilibrium and Balance (Oliaro, S., et al. 2001).
62 How long do symptoms linger? Post Concussion Syndrome(Guskiewicz, K. M. et al., 2001)
63 Functional Testing Must be asymptomatic Designed to see if activity will cause symptomsSit-upsPush-upsJoggingRunningSports Specific Tasks
64 Return to Play Protocol 95% of baseline on cognitive and balance tests(Oliaro, S., et al. 2001).
65 Return to PlayAssuming the athlete passes the complete exam he/she may return to play
66 Take Home MessageWhile experts argue over specifics of the guidelines all agree –NO ATHLETE EXPERIENCING SYMPTOMS SHOULD PARTICIPATE!
67 ReferencesGuskiewicz, 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,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),McCrea, M, Kelly, J.P., Kluge, J., Ackley, B., and Randolph, C. (1997). Standardized assessment of concussion in football players. Neurology, 48, (3),Mueller, F.O. (2001). Catastrophic head injuries in high school and collegiate sports. Journal of Athletic Training 36, (3),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),Shultz, S.J., Houghlum, P.A., Perrin, D.H. (2000). Assessment of Athletic Injuries. (1st Ed., pp ). 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),