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Evaluation and Management of Head Injuries in Sports George S. Wham Jr., M.S., A.T.,C., S.C.A.T.

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Presentation on theme: "Evaluation and Management of Head Injuries in Sports George S. Wham Jr., M.S., A.T.,C., S.C.A.T."— 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 injury 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 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 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 Assess a patient for possible closed-head trauma

3 Mechanisms of Injury Coup Coup a forceful blow to resting head, producing maximal injury beneath the point of impact a forceful blow to resting head, producing maximal injury beneath the point of impact example: being hit with a baseball or hockey puck example: being hit with a baseball or hockey puck

4 Mechanisms of Injury Contrecoup Contrecoup moving head hits an unyielding object, producing maximal brain injury opposite the site of impact as the brain bounces within the cranium 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 Example: head hits ground when being tackled

5 Mechanisms of Injury Repeated Sub- concussive Blows Repeated Sub- concussive Blows Many nontraumatic blows overtime Many nontraumatic blows overtime Example: Soccer players who head the ball frequently Example: Soccer players who head the ball frequently

6 Types of Head Injuries in Sports Cerebral Concussion Cerebral Concussion Cerebral Contusion Cerebral Contusion Cerebral Hematoma Cerebral Hematoma

7 Cerebral Concussion Head trauma-induced alteration in mental status that may or may not involve a loss of consciousness Head trauma-induced alteration in mental status that may or may not involve a loss of consciousness

8 Cerebral Contusion A bruise of the brain resulting from an impact of the skull and an object causing bleeding from injured vessels 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 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 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 If basic life support, proper transport techniques, and prompt expert evaluation are delivered, no surgery is needed and prognosis is good

9 Cerebral Hematoma Blood clot in the tissue surrounding the brain causes pressure on the brain Blood clot in the tissue surrounding the brain causes pressure on the brain 3 Types 3 Types Epidural Epidural Subdural Subdural Intercerebral Intercerebral

10 Epidural Hematoma Results from a severe blow to the head that produces a skull fracture in the temporoparietal region 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 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 Immediate surgery needed to decompress the hematoma and control the bleeding artery

11 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 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 Symptoms may not appear for hours, days, or even weeks Surgery is needed to drain the hematoma and decompress the brain Surgery is needed to drain the hematoma and decompress the brain

12 Intracerebral Hematoma Bleeding from a torn artery collects within the brain itself Bleeding from a torn artery collects within the brain itself Often results from a depressed fracture or penetrating wound Often results from a depressed fracture or penetrating wound No lucid interval after the injury No lucid interval after the injury Hematoma progresses rapidly Hematoma progresses rapidly Death occurs before the athlete can be moved to an emergency facility Death 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 resolved An athlete sustains a second concussion before an earlier one has resolved Potential for occurrence with mild head injuries Potential for occurrence with mild head injuries Often the first concussion goes unreported or unrecognized Often the first concussion goes unreported or unrecognized A major consideration when making return to play decisions A major consideration when making return to play decisions

14 Second Impact Syndrome (cont) Occurs within 1 week of initial injury Occurs within 1 week of initial injury Involves rapid brain swelling and herniation Involves rapid brain swelling and herniation Brain stem failure develops within 2-5 minutes Brain stem failure develops within 2-5 minutes Causes rapid dilation of pupils, loss of eye movement, respiratory failure, and coma Causes rapid dilation of pupils, loss of eye movement, respiratory failure, and coma Athlete must be intubated Athlete must be intubated Mortality rate 50% Mortality rate 50%

15 Frequency of Concussions 1 in 5 (250,000) high school football players per year (Cantu 1986) 1 in 5 (250,000) high school football players per year (Cantu 1986) 300,000 sport-related concussions per year (Thurman et al., 1998) 300,000 sport-related concussions per year (Thurman et al., 1998) Player is 3 times more likely to sustain a 2 nd concussion after the 1 st (Guskiewicz 2000) Player is 3 times more likely to sustain a 2 nd concussion after the 1 st (Guskiewicz 2000) Only 1 in 100,000 high school football players suffer catastrophic injuries (Cantu 1999) Only 1 in 100,000 high school football players suffer catastrophic injuries (Cantu 1999)

16 Whos at Greatest Risk? (Mueller, F.O. 2001).

17 Frequency of Head-Related Fatalities (Mueller, F.O. 2001).

18 Cause of Death? (Mueller, F.O. 2001).

19 Its Getting Better ….. (Mueller, F.O., 2001).

20 OK, but isnt it just football?.… (Mueller, F.O., 2001).

21 Mouth Guards Decrease Concussions? How? (Winters, J.E., 2001)

22 Grading Scales Cantu (1984) Cantu (1984) Colorado Medical Society (1991) Colorado Medical Society (1991) American Academy of Neurology (1997) American Academy of Neurology (1997)

23 Cantus Scale (1984) Grade 1 – no loss of consciousness Grade 1 – no loss of consciousness Grade 2 – loss of consciousness < 5 minutes Grade 2 – loss of consciousness < 5 minutes Grade 3 – loss of consciousness > 5 minutes Grade 3 – loss of consciousness > 5 minutes Revised in 1992 (Shultz et al., 2000)

24 Colorado Medical Societys Scale Grade 1 – confusion; no amnesia; no loss of consciousness Grade 1 – confusion; no amnesia; no loss of consciousness Grade 2 – confusion; amnesia; no loss of consciousness Grade 2 – confusion; amnesia; no loss of consciousness Grade 3 – any loss of consciousness Grade 3 – any loss of consciousness

25 American Academy of Neurologys Scale Grade 1 – confusion less than 15 minutes, no loss of consciousness Grade 1 – confusion less than 15 minutes, no loss of consciousness Grade 2 – confusion greater than 15 minutes, no loss of consciousness Grade 2 – confusion greater than 15 minutes, no loss of consciousness Grade 3 – any loss of consciousness Grade 3 – any loss of consciousness

26 A.A.N.s Recommendations for Management of Concussions in Sports For a grade 1 For a grade 1 Remove from activity Remove from activity Examine immediately and at 5 minute intervals Examine immediately and at 5 minute intervals Allow to return only if post-concussive symptoms resolve within 15 minutes Allow to return only if post-concussive symptoms resolve within 15 minutes If a 2 nd grade 1 concussion occurs on the same day then remove until asymptomatic for 1 week If a 2 nd 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 2 For a Grade 2 Remove from activity 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 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 Athlete may return to play after 1 week asymptomatic

28 A.A.N.s Recommendations for Management of Concussions in Sports For a Grade 3 For a Grade 3 Remove from activity for 1 week if loss of consciousness is brief, or for 2 weeks if prolonged 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 If unconscious at time of initial evaluation or if neurological signs are abnormal, the athlete should be transported by ambulance to ER If a 2 nd grade 3 occurs, the athlete should not return to sport until asymptomatic for 1month If a 2 nd 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 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

32 Evaluation

33 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

34 Thorough Evaluation Before an Athlete Is Allowed to Return to Play On-field Assessment On-field Assessment Primary Survey Primary Survey Secondary Survey Secondary Survey Off –field Assessment Off –field Assessment

35 On-field Assessment Primary survey Primary survey check ABCs check ABCs Secondary survey Secondary survey H.O.P.S. protocol H.O.P.S. protocol determine if the athlete can go to the sideline for further evaluation or needs an ambulance determine 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 Battles Sign – posterior auricular hematoma Battles Sign – posterior auricular hematoma Ottorrhea – CSF draining from ears Ottorrhea – CSF draining from ears Rhinorrhea – CSF draining from nose Rhinorrhea – CSF draining from nose Raccoon Eyes – periorbital ecchymosis resulting from blood leaking from anterior fossa of skull Raccoon 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, irritability 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) Only 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 Assessment Obtain information about mental confusion, any loss of consciousness, and amnesia 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 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? 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 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 (cont) Ask athlete if his ears are ringing, he has blurry vision, or nausea Ask athlete if his ears are ringing, he has blurry vision, or nausea Check for any facial abnormalities Check for any facial abnormalities While asking questions, observe speech patterns, respirations, and movement of the extremities While asking questions, observe speech patterns, respirations, and movement of the extremities Palpate the athletes cervical spine and skull to rule out fracture, assuming neck injury has been ruled out Palpate the athletes cervical spine and skull to rule out fracture, assuming neck injury has been ruled out Walk to sideline for further assessment Walk to sideline for further assessment

41 Glasgow Coma Scale Used to assess level of consciousness Used to assess level of consciousness (Shultz et al., 2000)

42 Cranial Nerve Assessment Rule out problems with II, III, IV, VI first Rule out problems with II, III, IV, VI first II – check vision by read scoreboard and fingers 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 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)

43 Further Cranial Nerve Assessment I – check smell I – check smell V – check by clinching jaw V – check by clinching jaw VII – check by raising eyebrows, smiling VII – check by raising eyebrows, smiling VIII – check balance and hearing VIII – check balance and hearing IX and X – check by swallowing IX and X – check by swallowing XII – check by sticking out tongue XII – check by sticking out tongue XI – check by neck rotation/extension and shoulder shrug XI – check by neck rotation/extension and shoulder shrug

44 (Shultz et al., 2000)

45 Test Sensory/Motor Function Dermatome Testing Dermatome Testing Myotome Testing Myotome Testing ROM Testing ROM Testing Strength Testing Strength Testing

46 Upper Extremity Dermatome Testing C1: Top of head C1: Top of head C2: Temporal, Occipital C2: Temporal, Occipital C3: Neck, Posterior Check C3: Neck, Posterior Check C4: Superior Shoulder C4: Superior Shoulder C5: Deltoid patch C5: Deltoid patch C6: Lateral forearm, thumb, fore finger C7: posterior forearm, middle finger C8: Lower medial forearm, 4 th and 5 th fingers T1: Medial forearm

47 Upper Extremity Myotome Testing C1/C2: Cervical flexion C1/C2: Cervical flexion C3: Lateral neck flexion C3: Lateral neck flexion C4: Shoulder Shrug C4: Shoulder Shrug C5: Shoulder Abduction C5: Shoulder Abduction C6: Elbow flexion, wrist extension C6: Elbow flexion, wrist extension C7: Elbow extension, wrist flexion C7: Elbow extension, wrist flexion C8: Ulnar deviation, thumb extension, finger flexion & abduction C8: Ulnar deviation, thumb extension, finger flexion & abduction T1: Finger abduction/adduction T1: Finger abduction/adduction

48 Check Vital Signs Increased pulse, increased systolic blood pressure, and a decreasing diastolic blood pressure indicates increasing intracranial pressure Increased pulse, increased systolic blood pressure, and a decreasing diastolic blood pressure indicates increasing intracranial pressure A decrease in systolic bp denotes shock A 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 recall Give the athlete 3 unassociated words to remember, and periodically ask for recall Example: Red, Explorer, Clemson Example: Red, Explorer, Clemson

50 Check for Retrograde Amnesia Ask questions like Ask questions like Where are we playing? Where are we playing? Which quarter is it? Which quarter is it? What did we have for pre-game meal? What did we have for pre-game meal? Who did we play last week? Who did we play last week?

51 Check for Concentration Have athlete Have athlete Recite days of the week or months of the year backward Recite days of the week or months of the year backward Count backward from 100 by 7s (Serial 7s) Count backward from 100 by 7s (Serial 7s) Multiple/Addition facts Multiple/Addition facts

52 SAC (Standardized Assessment of Concussion) Designed to detect impaired concentration Designed to detect impaired concentration Sideline or follow-up evaluation tool Sideline or follow-up evaluation tool Takes 5 minutes to assess: Takes 5 minutes to assess: Orientation Orientation Immediate memory Immediate memory Neurological fxn Neurological fxn Concentration Concentration Delayed recall Delayed recall Sx during exertional testing Sx during exertional testing (McCrea et al., 1997)

53

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 Rombergs Test Rombergs Test Finger-to-Nose Test Finger-to-Nose Test Finger-to-Finger Test Finger-to-Finger Test Heel-to-Toe Walking Heel-to-Toe Walking Supine Heel-to-Knee Test Supine Heel-to-Knee Test

56 Nerurocom Smart Balance Master System SOT (Sensory Organization Test) SOT (Sensory Organization Test) Forceplate system measures postural sway by quantifying balance deficits and sensory organization problems resulting from a concussion Forceplate system measures postural sway by quantifying balance deficits and sensory organization problems resulting from a concussion Expensive and immobile Expensive 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 Rhomberg Quantifiable modified Rhomberg 3 tests lasting 20s each 3 tests lasting 20s each Double-leg Double-leg Single-leg Single-leg Heel-toe Heel-toe Eyes Closed Eyes Closed Perform once on ground and once on foam Perform once on ground and once on foam Tally number of errors Tally 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).

61 (Shultz et al., 2000)

62 How long do symptoms linger? (Guskiewicz, K. M. et al., 2001) Post Concussion Syndrome

63 Functional Testing Must be asymptomatic Must be asymptomatic Designed to see if activity will cause symptoms Designed to see if activity will cause symptoms Sit-ups Sit-ups Push-ups Push-ups Jogging Jogging Running Running Sports Specific Tasks Sports Specific Tasks

64 Return to Play Protocol (Oliaro, S., et al. 2001). 95% of baseline on cognitive and balance tests

65 Return to Play Assuming the athlete passes the complete exam he/she may return to play Assuming the athlete passes the complete exam he/she may return to play

66 Take Home Message While experts argue over specifics of the guidelines all agree – While experts argue over specifics of the guidelines all agree – NO ATHLETE EXPERIENCING SYMPTOMS SHOULD PARTICIPATE!

67 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 trainers perspective. Journal of Athletic Training, 36, (3), 257-262. Shultz, S.J., Houghlum, P.A., Perrin, D.H. (2000). Assessment of Athletic Injuries. (1 st 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.


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