1. Recognition of Head Injuries

2. I. Head Injuries A. Initially –1. As a coach or first responder, your initial major task is to recognize that a head injury has occurred. –2. Once you have recognized it, your care decisions become very straight forward.

3. B. Severity –1. As a coach or first responder, you should always assume that the head injury is severe until proven otherwise. –2. Many times a small hit on the head when the victim is not expecting it is worse than a large blow to the head when the victim is expecting it. –3. Head weighs 20-25 pounds—unprepared for the force causes the force to only be dispersed over 20-25 pounds. –4. If prepared, then the force is dispersed over the entire body.

4. C. The injury will vary with the type of blow: 1. Even a relatively minor blow can cause a significant injury. 2. Countercoup injury: a. The athlete receives a blow from one side of the head and the brain hits the skull on the other side. b. Occurs most often when head hits an immovable object such as the ground.

5. II. Concussion/Head Injuries Signs and Symptoms

6. A. Consciousness –1. Any disturbance in an athletes level of consciousness is indicative of a head injury. –2. Being “knocked out” is one of the most recognized symptoms. However you don’t have to lose consciousness to have a significant head injury. –3. If an athlete has been rendered unconscious you must also assume a concurrent neck injury. –4. Do NOT use smelling salts as it will cause inappropriate neck motion. –5. Rather talk the unconscious person back to consciousness. –6. Any athlete who has an altered state of consciousness MUST see a physician.

7. B. Mental confusion –1. The athlete may appear mentally confused as to what is happening (i.e. get off the ground and goes to the opponents bench). –2. The mental confusion may be momentary or prolonged. –3. Any athlete who is mentally confused because of a head injury must see an MD. –4. A change from being flakey to being sharp as a tack is also a mental change and considered the same as from really sharp to being a flake.

8. C. Memory Loss 1. One of the most common symptoms. 2. Often occurs without symptoms. 3. Many times an athlete complains of this right after they made a mistake and have gotten scolded. The reason they may have made the mistake in the first place is a head injury. You MUST believe them.

9. 4. There are two types of memory loss: a. Retrograde—memory loss from point of injury and back—in the past. b. Anterograde—memory loss from point of injury forward. Anterograde is more serious as it may indicate a worsening situation. The athlete or person becomes very scared with this kind of memory loss and then becomes very anxious and agitated. They know they should remember something and can’t. It is possible that even with full recovery they may not remember everything.

10. 5. Any athlete with a memory loss of any kind MUST be evaluated by an MD.

11. D. Tinnitis 1. The presence of ringing in ears. 2. Occurs because of a cranial nerve disturbance. 3. May be momentary (no more than 1-2 minutes) or prolonged (greater than 1-2 minutes). 4. Any athlete with prolonged tinnitus should see an MD

12. E. Nystagmus: 1. The presence of “dancing eyes” 2. The movement of the eye and its muscles require a high level of neuromuscular controls. 3. To examine have the athlete follow pencil being moved from side to side (they don’t move head…just eyes). 4. If they have nystagmus, their eyes will bounce as they get to the sides. 5. Small percentage of people have it naturally. 6. The presence of nystagmus is indicative of head injury and athlete must be referred to MD.

13. F. Dizziness 1. Athlete may appear unsteady and dizzy after a blow. 2. It may be fleeting to prolonged. 3. Dizziness that is any longer than fleeting needs to be checked by a doctor.

14. G. Headache 1.Often will not be present initially but will show up after initial injury. 2.Headache combined with other symptoms is related to the head injury and needs MD evaluation. 3.Unexplained isolated headache should also see an MD.

15. H. Pupil Response: 1. Changes in pupil response in indicative of a head injury. 2. The pupils don’t respond to light or the response is slow. 3. The pupils may become unequal in size. 4. Remember, PEARRLA (pupils equal and round, regular in size/shape, react to light, accommodate).

16. I. Changes in Coordination –1. The ability to perform motor tasks in sports requires a high level of neurological function. –2. The inability to perform coordinated motor tasks is indicative of a head injury and requires MD evaluation. –3. There are numerous tasks and tests that as a coach you can do to check the athlete’s coordination and balance. –4. In these tests, a positive result is BAD and a negative result is GOOD.

17. 5. Rhomberg sign a. Have the athlete stand with feet together (they should be able to do so without faltering or wavering). b. Then have them close their eyes (again no movement). c. Finally, you gently tap the person on their chest to see if they can remain solid. d. Make sure you have someone stand behind them to catch them or help them catch their balance. e. You do not do the chest tap if they can’t stand steady with the first 2 steps of the test.

18. 6. Other tests: a. Finger to nose—Have the athlete repeatedly touch your index finger and their nose with the index finger. b. Rapidly alternate finger to finger—have the athlete touch your index finger with theirs as you move your finger around. 7. Once you recognize the symptoms, the athlete is DONE (with practice/game until cleared in writing by MD. 8. You are NOT qualified to make a return to play decision with the head injured athlete. 9. They MUST be evaluated by the MD prior to return. 10. They must have WRITTEN physician’s clearance. It should say, “Head injury” or “Concussion” is “resolved and OK to return to play.”

19. 11. What to do with the athlete after recognition: a. continue to monitor symptoms until they can see an MD. b. make sure they are not left alone. c. don’t let them travel home or to the MD alone. d. If signs and symptoms change you MUST get the athlete to an emergency facility—Don’t wait for the end of practice or Moms or Dads arrival.

20. III. Kinds of Brain Injuries

21. A. Expanding (Bleeding) Lesions 1.Bleeding in the head from injury (hematoma). 2.The bleeding causes increasing pressure. 3. Increased pressure leads to increased dysfunction. 4. This can be rapidly FATAL. 5. The bleeding is usually rapid enough that symptom changes are noticeable.

22. 6. Watch for changes in signs and symptoms that might indicate bleeding (expanding lesions). a. A deteriorating level of consciousness (they become less aware and less responsive). b. They become irritable, inappropriately emotional. c. They become tired and want to sleep (coma)—Don’t let them sleep. –1. Pinch ears. –2. Pinch below eyes (lightly).

23. d. Pupils change. e. Headache worsening. f. Coordination worsens. g. Heart rate changes. h. Memory changes—The athlete progresses toward anterograde amnesia. i. Nausea—May become nauseous and want to vomit. If they do, it is a rhythmic, projectile type of vomiting.

24. h. Weakness develops: 1. On one side of the body or the other. 2. Check by having them squeeze your fingers for grip strength. 3. Use 2 fingers and cross arms in front of yourself.

25. –7. Medical Emergency: If the athlete’s symptoms change such that they are deteriorating, it is a medical emergency and you MUST seek medical help immediately (911).

26. B. Second Impact Syndrome: Mortality is 50%. 1. Second concussion before recovered from the first. 2. Dramatically increases potential for serious problems such as an expanding lesion.

27. C. Post-Concussion Syndrome –1. After concussion, the CAT scan and MRI come out normal and yet the person’s symptoms remain. –2. Not uncommon for symptoms to be there for one year or longer. –3. As long as they have symptoms it means the athlete is not ready to return to the sport. –4. They may only return when symptom free for several days. –5. Length of time to heal continues to get longer as we learn more and there is no test to prove a healed brain.

28. D. Minimum Recovery Times

29. 1. Mild— Grade 1 is 1 week after symptoms are gone.

30. 2. Moderate— Grade 2 is 2-3 weeks.

31. 3. Severe— Grade 3 is 4-6 weeks.

32. 4.Two concussions in 1 season— Done for the season.

33. 5. Two Grade III concussions— Done for the year…May be done with sports forever.