Power Point Presentation
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Head InjuriesHead Injuries
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Managing the Unconscious AthleteManaging the Unconscious AthleteWhy is this so scary?Why is this so scary?
Can not collect Can not collect symptoms so must rely symptoms so must rely on signson signs
Always treat as though Always treat as though have cervical spine have cervical spine injuryinjury
Always stay calmAlways stay calm
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Mechanisms for Rendering an Mechanisms for Rendering an Athlete UnconsciousAthlete Unconscious
Blow to headBlow to head
Diabetic ComaDiabetic Coma
HypoglycemiaHypoglycemia
Electric ShockElectric Shock
Heat IllnessHeat Illness
DrowningDrowning
Psychogenic ShockPsychogenic Shock
SyncopeSyncope
IllnessIllness
Substance AbuseSubstance Abuse
Epileptic SiezuresEpileptic Siezures
RhabdomyolysisRhabdomyolysis
Others?Others?
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Remember what you have learned Remember what you have learned thus far!!thus far!!
Check Check
CallCall
CareCare
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Conduct life-threatening measuresConduct life-threatening measures
Treat severe Treat severe bleedingbleeding
CPRCPR
AEDAED
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HistoryHistoryKnow/get past Know/get past medical historymedical history
MechanismMechanism– If you missed, what If you missed, what
should you do?should you do?
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InspectionInspectionOtorrheaOtorrhea
RhinorrheaRhinorrhea
Battle’s SignBattle’s Sign
Raccoon EyesRaccoon Eyes
Body PositionBody Position– Decorticate rigidityDecorticate rigidity
Arms flexed, legs Arms flexed, legs extendedextended
– Decerebrate rigidityDecerebrate rigidityArms & legs extendedArms & legs extended
Swelling, Deformity, Swelling, Deformity, Bleeding, Bleeding, DiscolorationDiscoloration
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Determine Quality of LifeDetermine Quality of LifePulsePulse
RespirationsRespirations
PupilsPupils
Blood PressureBlood Pressure
Record with timeRecord with time
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Establish State of ConsciousnessEstablish State of Consciousness
Glasgow Coma Glasgow Coma ScaleScale– Coma DefinitionComa Definition– Assesses depth and Assesses depth and
duration of comaduration of coma– Grades a wide Grades a wide
variety of variety of conditionsconditions
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Glasgow Coma ScaleGlasgow Coma ScaleEye Opening Response
Spontaneous – opening with blinking at baseline 4 points
To verbal stimuli, command, speech 3 points
To pain only (not applied to face) 2 points
No response 1 point
Verbal Response
Oriented to place, time, etc 5 points
Confused conversation, but able to answer questions 4 points
Inappropriate Words 3 points
Incomprehensible speech 2 points
No response 1 point
Motor Response
Obeys commands for movement 6 points
Purposeful movement to painful stimulus 5 points
Withdraws in response to pain 4 points
Flexion in response to pain (decorticate posturing) 3 points
Extension in response to pain 2 points
No response 1 point
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Head Injury Classification ScoresHead Injury Classification Scores
Sever Head InjurySever Head Injury
Moderate Head InjuryModerate Head Injury
Mild Head InjuryMild Head Injury
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PalpationPalpationHead to toe evaluationHead to toe evaluationGeneral information seekingGeneral information seekingHead structuresHead structuresCervical structuresCervical structuresUpper ExtremityUpper ExtremityArmsArmsChestChestAbdomenAbdomenLower ExtremityLower Extremity
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Oh no, What do I do?Oh no, What do I do?STAY CALMSTAY CALM““Know that you are in control of the Know that you are in control of the controllable but YOU CANNOT controllable but YOU CANNOT DICTATE THE OUTCOME”DICTATE THE OUTCOME”Be the leaderBe the leaderPractice, Practice and more Practice, Practice and more PRACTICEPRACTICE– SOMEONE’S LIFE MAY BE IN YOUR SOMEONE’S LIFE MAY BE IN YOUR
HANDSHANDS
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ConcussionsConcussions
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DefinitionDefinitionClinical syndrome Clinical syndrome characterized by characterized by immediate and transient immediate and transient impairment of impairment of neurological function neurological function secondary to mechanical secondary to mechanical forcesforcesStatistic on Brain InjuryStatistic on Brain Injury– 750,00 total injuries750,00 total injuries
85,000 brain injuries85,000 brain injuries– NFL= 3.5 brain NFL= 3.5 brain
injuries/gameinjuries/game– 10% college and 20% HS 10% college and 20% HS
football players suffer brain football players suffer brain injuriesinjuries
– 5% soccer players suffer 5% soccer players suffer brain injuriesbrain injuries
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MechanismMechanism
Coup InjuryCoup Injury
Contrecoup InjuryContrecoup Injury
Types of forces Types of forces causing brain causing brain injuryinjury
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Acute Concussion Sign and Acute Concussion Sign and SymptomsSymptoms
HeadacheHeadache
Consciousness LevelsConsciousness Levels
Memory ImpairmentMemory Impairment– Retrograde amnesiaRetrograde amnesia– Anterograde amnesiaAnterograde amnesia
Cognitive Function Cognitive Function DeficitsDeficits
Behavioral ChangesBehavioral Changes
Balance and Balance and CoordinationCoordination
TinnitisTinnitis
Pupil SizePupil Size– AniscoriaAniscoria
NystagmusNystagmus
Vision AcuityVision Acuity
NauseaNausea
PulsePulse
Blood PressureBlood Pressure
RespirationsRespirations
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Injury ClassificationInjury ClassificationEpidemiologyEpidemiologyAmerican Academy of Neurology Grading American Academy of Neurology Grading ScaleScale– Grade 1Grade 1– Grade 2Grade 2– Grade 3Grade 3– Advantage/DisadvantagesAdvantage/Disadvantages
Cantu Evidence Based Grading ScaleCantu Evidence Based Grading Scale– Grade 1Grade 1– Grade 2Grade 2– Grade 3Grade 3– Advantage/ DisadvantagesAdvantage/ Disadvantages
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NATA Position StatementNATA Position StatementAvoid grading Avoid grading scalesscalesFocus on RecoveryFocus on RecoveryIs the athlete Is the athlete symptomatic ofor symptomatic ofor asymptomaticasymptomaticOnce Once asymptomatic asymptomatic focus on focus on progresssionprogresssion
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Post-concussion SymtpomsPost-concussion SymtpomsPhotophobiaPhotophobia
SensitivitySensitivity
Seeing stars or flashing lightsSeeing stars or flashing lights
Poor concentrationPoor concentration
IrritabilityIrritability
DepressionDepression
AnxietyAnxiety
FatigueFatigue
HeadacheHeadache
Sleep disturbance Sleep disturbance
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Post-concusion AssessmentPost-concusion Assessment
Mental Testing AssessmentMental Testing Assessment
Postural-stability TestsPostural-stability Tests
Neuropsychological TestsNeuropsychological Tests
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Post-concussion AssessmentPost-concussion AssessmentMental Status TestingMental Status Testing– Standardized Assessment of Concussion TestStandardized Assessment of Concussion Test
OrientationOrientationImmediate memoryImmediate memoryConcentrationConcentrationDelayed recallDelayed recallAlso measuresAlso measures
– StrengthStrength– SensationSensation– CoordinationCoordination– Neurological examNeurological exam– LOC and anmnesia also recordedLOC and anmnesia also recorded
Max scoreMax scoreLow scores?Low scores?Need good baseline dataNeed good baseline data
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Post-concussion AssessmentPost-concussion Assessment
Postural-stability AssessmentPostural-stability Assessment– Romberg or Stork TestsRomberg or Stork Tests– Balance Error Scoring System (BESS)Balance Error Scoring System (BESS)
3 stance positions3 stance positions
2 different surfaces2 different surfaces
Test PositionTest Position
Count errorsCount errors– What counts as an errorWhat counts as an error
There is a practice effect from multiple trialsThere is a practice effect from multiple trials
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Post-concussion AssessmentPost-concussion Assessment
Neuropsychological TestingNeuropsychological Testing– Most require licensed and board Most require licensed and board
certified psychologistcertified psychologist– Tests includeTests include
AttentionAttention
ConcentrationConcentration
Memory functionMemory function
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Return to Play DecisionsReturn to Play Decisions
Some guideline require 7 day of Some guideline require 7 day of symptom freesymptom free
Begins with progressionBegins with progression
SACSAC– Both rest and exertional assessmentBoth rest and exertional assessment
All tests baseline or betterAll tests baseline or better
NATA Position StatementNATA Position Statement– Minimum 7 days after asymptomatic Minimum 7 days after asymptomatic
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Guidelines for RTP after several ConcussionsGuidelines for RTP after several Concussions
Prentice, Principles of AT, 13th ed
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When do you refer to physician?When do you refer to physician?Any LOCAny LOCDecr. LOCDecr. LOCAmnesia >15 minAmnesia >15 min*Decr. neurological function*Decr. neurological function*Decr. or irregularity of *Decr. or irregularity of respirationsrespirations* Decr. Or irregularity of pulse* Decr. Or irregularity of pulseIncrease in BPIncrease in BP*Mental status changes*Mental status changes*Seizures*Seizures
*Unequal, unresponsive or *Unequal, unresponsive or dilated pupilsdilated pupilsCranial nerve deficitsCranial nerve deficits*Injuries associated with *Injuries associated with spine, skull fracturesspine, skull fracturesSubsequent to Initial EvalSubsequent to Initial Eval– Motor deficitsMotor deficits– Sensory deficitsSensory deficits– Balance deficitsBalance deficits– Cranial nerve deficitsCranial nerve deficits– Post-concussion symptoms Post-concussion symptoms
that worsenthat worsen
* Indicates that patient be transferred immediately to nearest emergency facility
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Secondary Impact SyndromeSecondary Impact Syndrome
What is it? What is it?
SignsSigns
TreatmentTreatment
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Epidermal HematomaEpidermal Hematoma
Bleeding Bleeding between scalp between scalp and skulland skull
Little concern Little concern unless have S/S unless have S/S of head spine of head spine injuriyinjuriy
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Epidural HematomaEpidural HematomaEtiologyEtiology– Associated with Associated with
skull fracturesskull fractures– Tear in meningeal Tear in meningeal
arteriesarteries
S/SS/S
ManagementManagement– Medical Emergency Medical Emergency
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Subdural HematomaSubdural HematomaEtiologyEtiology– Acceleration/Acceleration/
deceleration forcedeceleration force– 3 kinds3 kinds
S/SS/S
ManagementManagement– ReferralReferral
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Skull FractureSkull FractureMechanismMechanism– Blunt traumaBlunt trauma– Types of fracturesTypes of fractures
S/SS/S
ManagementManagement– ABC’sABC’s– CSF leakageCSF leakage
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Putting it TogetherPutting it TogetherHistoryHistory– Ask peopleAsk people– Establish level of Establish level of
consciousnessconsciousness– HeadacheHeadache– SensesSenses– MemoryMemory
InspectionInspection– LOCLOC– ABC’sABC’s– Head PositionHead Position– SkullSkull– Mastoid ProcessMastoid Process– Eyes, ears, noseEyes, ears, nose– Body PositionBody Position– MovementsMovements– BehaviorBehavior– Facial expressionsFacial expressions
PalpationPalpation– Head/ScalpHead/Scalp– Cervical spineCervical spine– Soft TissueSoft Tissue– Vital signsVital signs
Functional TestsFunctional Tests– Cognitive Function Cognitive Function
(Subjective)(Subjective)– Cognitive Function Cognitive Function
(Objective)(Objective)SACSAC
– Balance and CoordinationBalance and CoordinationNeurological TestsNeurological Tests– Dermatomes Dermatomes – MyotomesMyotomes
Continue MonitoringContinue Monitoring– Every 5 minutesEvery 5 minutes