1. The Head, Face, and Neck Injuries and Prevention

2. Prevention of Injuries to the Head,
Head injuries are prevalent in sport, particularly in collision and contact sports
Education and protective equipment are critical in preventing injuries to the head and face
Head trauma results in more fatalities than other sports injury
Morbidity and mortality associated w/ brain injury have been labeled the silent epidemic
Morbidity—diseased state, disability, or poor health
Mortality—death

3. Bones of the Skull

4. Layers Under the Skull

5. Prevention Protective equipment
Mouthguards have benefit in prevention oral injury, but no evidence of concussion reduction
Head gear and helmets show reduction in biomechanical forces, but have not translated to a reduction in concussion incidence
Helmets reduce head and facial injury in skiing and snowboarding and are recommended for alpine sports
Helmets reduce other forms of head injury (e.g. fracture) in cycling, equestrian, motor sports

6. Head injuries

7. Injury Definition: Sports concussion
“Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include…”

8. Cerebral Concussion (Mild Traumatic Brain Injury)
Characterized by immediate and transient post-traumatic impairment of neural function with no focal lesions found on neuroimaging
Cause of Injury
Result of direct blow, acceleration/deceleration forces producing shaking of the brain
Signs of Injury
Altered level of consciousness post-traumatic amnesia are two factors that must be considered

9. Cerebral Concussion (Mild Traumatic Brain Injury)
Other signs & symptoms may include
Brief periods of diminished consciousness or unconsciousness that lasts seconds or minutes
Headache, tinnitus, nausea, irritability, confusion, disorientation, dizziness, anterograde amnesia, retrograde amnesia, concentration difficulty, blurred vision, photophobia, sleep disturbances
Classification grading systems of concussions have undergone extensive debate in recent years
No single system has been fully endorsed
The logical approach seems to be to focus on the presence and duration of various signs and symptoms

10. Cerebral Concussion (Mild Traumatic Brain Injury)
Care
The decision to return an athlete to competition following a brain injury is a difficult one that takes a great deal of consideration
If any loss of consciousness occurs
ATC must remove the athlete from competition
Cervical spine injury should be assumed
Objective measures (BESS and SAC) should be used to determine readiness to play

11. Cerebral Concussion (Mild Traumatic Brain Injury)
Care (continued)
All post-concussive symptoms should be resolved prior to returning to play -- any return to play should be gradual
Athlete must be cleared by the team physician
Recurrent concussions can produce cumulative traumatic injury to the brain
Following an initial concussion the chances of a second episode are 3-6 times greater

12. Postconcussion Syndrome
Cause of Injury
Condition which occurs following a concussion
May be associated w/ those concussions that don’t involve a LOC or in cases of severe concussions
Signs of Injury
Athlete complains of a range of post-concussion problems
Persistent headaches, impaired memory, lack of concentration, anxiety and irritability, giddiness, fatigue, depression, visual disturbances
May begin immediately following injury and may last for weeks to months

13. Postconcussion Syndrome
Care
ATC should treat symptoms to greatest extent possible
Return athlete to play when all signs and symptoms have fully resolved
Once the signs and symptoms have resolved, the athlete should be continually monitored in order to ensure that they have not returned.

14. Second Impact Syndrome
Cause of Injury
Result of rapid swelling and herniation of brain after a second concussion before symptoms of the initial injury have resolved
Second impact may be relatively minimal and not involve contact w/ the cranium
Impact disrupts the brain’s blood autoregulatory system leading to swelling, increasing intracranial pressure
50% mortality rate, 50% morbidity rate

15. Second Impact Syndrome
Signs of Injury
Often athlete does not LOC and may looked stunned
W/in 15 seconds to several minutes of injury athlete’s condition degrades rapidly
Dilated pupils, loss of eye movement, LOC leading to coma, and respiratory failure
Care
Life-threatening injury that must be addressed w/in 5 minutes w/ life saving measures performed at an emergency facility
Best management is prevention from the ATC’s perspective

16. Skull Fracture Cause of Injury Signs of Injury Care
Most common cause is blunt trauma
Signs of Injury
Severe headache and nausea
Palpation may reveal defect in skull
May be blood in the middle ear, ear canal, nose, ecchymosis around the eyes (raccoon eyes) or behind the ear (Battle’s sign)
Cerebrospinal fluid may also appear in ear and nose
Care
Immediate hospitalization and referral to neurosurgeon

17. Epidural Hematoma Cause of Injury
Blow to head or skull fracture which tear meningeal arteries
Blood pressure, blood accumulation and creation of hematoma occur rapidly (minutes to hours)

18. Subdural Hematoma Cause of Injury
Result of acceleration/deceleration forces that tear vessels that bridge dura mater and brain
Venous bleeding (simple hematoma may result in little to no damage to cerebellum while more complicated bleed can damage cortex)

19. Epidural or Subdural Hematoma
Hematoma Type
Epidural
Subdural  
Location
Between the skull and the dura
Between the dura and the arachnoid
Involved vessel
Bleeding Arteries
Bridging veins
Symptoms
Lucid interval followed by unconsciousness
Gradually increasing headache and confusion
CT appearance
Biconvex lens
Crescent-shaped

20. Evaluation

21. Detailed clinical assessment outlined in SCAT3 and Child SCAT3
NOTE: Developed by SCAT3 Subcommittee (Meeuwisse, McCrory, Dvorak, Echemendia, Guskiewicz Iverson, Johnston, McCrea, Putukian, Raftery, Schneider)

22. Assessment of Head Injuries
Observation (continued)
Inability to focus attention and is the athlete easily distracted?
Memory deficit?
Does the athlete have normal cognitive function?
Normal emotional response?
How long was the athlete’s affect abnormal?
Is there any swelling or bleeding from the scalp?
Is there cerebrospinal fluid in the ear canal?

23. Assessment of Head Injuries
Palpation
Neck and skull for point tenderness and deformity
Special Tests
Neurologic exam
Assess cerebral testing, cranial nerve testing, cerebellar testing, sensory and reflex testing
Eye function
Pupils equal round and reactive to light (PEARL)
Dilated or irregular pupils
Ability of pupils to accommodate to light variance
Eye tracking - smooth or unstable (nystagmus, which may indicate cerebral involvement)
Blurred vision

24. Assessment of Head Injuries
Special Tests
Balance Tests
Romberg Test
Assess static balance - determine individual’s ability to stand and remain motionless
Tandem stance is ideal
Coordination tests
Finger to nose, heel-to-toe walking
Inability to perform tests may indicate injury to the cerebellum

25. Assessment of Head Injuries
Special Tests
Cognitive Tests
Used to establish impact of head trauma on cognitive function and to obtain 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 game, 3 word recall)
Neuropsychological Assessments
Standardized Assessment of Concussion (SAC) provides immediate objective data concerning presence and severity of neurocognitive impairment

26. Assessment of Head Injuries
Brain injuries occur as a result of:
Direct blow, or sudden snapping of the head forward, backward, or rotating to the side
May present as life-threatening injury or cervical injury (if unconscious)
May or may not result in
Loss of consciousness
Disorientation or amnesia
Motor coordination
Balance deficits
Cognitive deficits

27. Assessment of Head Injuries
History
Determine loss of consciousness and amnesia
Additional questions (response will depend on level of consciousness)
Do you know where you are and what happened?
Can you remember who we played last week? (retrograde amnesia)
Can you remember walking off the field (antegrade amnesia)
Does your head hurt?
Do you have pain in your neck?
Can you move your hands and feet?

28. Assessment of Head Injuries
Observation
Is the athlete disoriented?
Is there a blank or vacant stare?
Can the athlete keep their eyes open?
Is there slurred speech or incoherent speech?
Are there delayed verbal and motor responses?
Gross disturbances to coordination?

29. Management

30. Recovery Majority (80-90%) resolve in short (7-10 day) period
May take longer in children and adolescents

31. Management
CORNERSTONE = initial period of rest until acute symptoms resolve
Physical Rest
No training, playing, exercise, weights
Beware of exertion with activities of daily living
Cognitive Rest
No television, extensive reading, video games?
Caution re: daytime sleep

32. Management Expect gradual resolution within 7-10 days
Gradual return to school and social activities that does not result in significant exacerbation of symptoms
Proceed through step-wise return to sport / play (RTP) strategy

33. Graduated RTP Protocol
Rehabilitation stage
Functional exercise at each stage of rehabilitation
Objective of each stage
1. No activity
Symptom limited physical and cognitive rest.
Recovery
2.Light aerobic exercise
Walking, swimming or stationary cycling keeping intensity < 70% MPHR
No resistance training.
Increase HR
3.Sport-specific exercise
Skating drills in ice hockey, running drills in soccer. No head impact activities.
Add movement
4.Non-contact training drills
Progression to more complex training drills e.g. passing drills in football and ice hockey.
May start progressive resistance training
Exercise, coordination, and cognitive load
5.Full contact practice
Following medical clearance participate in normal training activities
Restore confidence and assess functional skills by coaching staff
6.Return to play
Normal game play
24 hours per step (therefore about 1 week for full protocol)
If recurrence of symptoms at any stage, return to previous asymptomatic level and resume after further 24 hr period of rest

34. Same day return to play? NO!
Unanimously agreed that no RTP should occur on the day of concussive injury

35. Return to Play / Sport Must pass graded exertion first
=remain asymptomatic
Is the athlete confident to go back?
New helmet/head gear?
Other “protective” equipment / behaviors / factors?
Consider implications of multiple/recent injury

36. “Difficult” or persistently symptomatic concussion patient
Persistent symptoms (>10 days) in about 10-15%
Important to consider other issues
Should be managed in multidisciplinary manner by healthcare providers experienced in sport concussion
In order to consider sub-symptom threshold exercise and other forms of therapy /rehabilitation

37. Psychological & Mental Health issues
Psychological approaches may have application especially in selected situations (modifiers)
Evaluate for affective symptoms (depression, anxiety) as common in all forms of traumatic brain injury
Depression-may be consequence of concussion, underlying pathophysiological abnormality, may be multifactorial but should be considered in management

38. Management Pharmacotherapy
Prolonged symptoms (sleep disturbance, anxiety)
Modify underlying pathophysiology
Upon return to play should not be on medication that could mask symptoms
Antidepressants?