Sports Medicine

Mr. Smith

Discuss arrival assessment Discuss full head injury evaluation in

HIPS format Discuss deadly head injuries Discuss second impact syndrome Practice

What you should observe as you are approaching the downed athlete› Are they moving? Limbs? Eyes?› Body position?

Decerebrate and decorticate rigidity? Prone? Supine? Neck angle?

› Level of consciousness: Unconscious and not breathing Unconscious and breathing Conscious

When you get to the athlete:› One immediately stabilizes the head, while

another performs the evaluation› Check ABC’s- begin CPR? AED?› Determine level of consciousness (LOC)

If unconsc and not breathing- begin CPR/ AED If unconsc and breathing- treat as if a neck fx If consc- continue with eval

› Check ears and nose- presence of CSF› Quick body visual for gross deformities and/ or

bleeding› Check vitals- respiration, pulse, blood

pressure, pupils

If they’re conscious and moving their limbs as you are approaching, should you still immediately stabilize the head and neck?

If they’re conscious and you stabilize the head and neck, how long should you continue to stabilize?

If they are unconscious ALWAYS treat like a cervical fracture with head trauma

History› Mechanism- Ask them how they got hurt

and then ask someone else who witnessed the trauma, if you didn’t, to confirm their memory

› Previous concussion(s)?› Any unusual sensations? Pain, numbness?

Can they move their hands and feet? Headache, nausea, blurred vision, tinnitus? Where is pain located? Head, neck?

› Headache› Balance problems› Dizziness› Concentration

difficulties› Loss of

consciousness (LOC)› Lightheadedness› Delayed motor/

verbal response› Memory or cognitive

dysfunction

› Disorientation› Amnesia› Blurred vision› Vacant stare› Photophobia› Tinnitus› Nausea› Vomiting› Emotionality› Slurred speech

Inspection› Working with these athletes daily give you the

advantage, because you know how each person NORMALLY acts and what their normal personality is.

› Visual inspection of athletes disturbances in coordination, orientation, attention, emotional response, verbal and motor response, and physical deformity such as swelling, bleeding, fluid from ears or nose… etc.

› Make sure the following have been checked ABC’s Vitals- heart rate, blood pressure, pulse Pupils- Pupils Equal And Reactive to Light

(PEARL)

› Otorrhea, rhinorhea, Battle’s sign, raccoon eyes, hyphema, nystagmus= 911

File_Optokinetic_nystagmus.htm

Palpation› Skull- feel for tenderness, depressions› Cervical spine- pain over the spinous

processes?› Sensation in extremities?

› This is point in which you completely rule out a cervical fracture

IF this is deemed within normal limits, you can stop stabilizing the head

IF pain or numbness occurs, stabilize head until paramedics arrive. Do not give head to anyone.

Special Tests› Memory Check- retrograde, anterograde amnesia

Anterograde amnesia- after the brain injury Example: Remember these three words….

Have athlete repeat words back to you every five minutes Retrograde amnesia- before the brain injury

Example: What team are you playing?

Presence of sustained (>30 minutes) antero amnesia = 911

Keep asking questions- date, location, who scored last point, what they ate for breakfast… etc.

› Balance/ coordination Rhomberg’s test Heel to toe walking

› Reflexes L4- L5 Patellar tendon reflex PEARL S1- S2 Achilles tendon reflex

› Cognitive Functioning- count backwards from 100 by 7’s or repeat the months backwards

› Halo Test- for presence of CSF

Cranial Nerve Assessment› Cranial Nerves 1-

12› Both sensory and

motor

› Need to be rechecked every 20 minutes until severity of trauma is established

# Cranial Nerve Name Acronim

1. I Olfactory On

2. II Optic Old

3. III Occulomotor Olympus

4. IV Trochlear Towering

5. V Trigeminal Top

6. VI Abducens A

7. VII Facial Fin

8. VIII Auditory And A

9. IX Glossopharyngeal German

10. X Vagus Viewed

11. XI Spinal Accessory Some

12. XII Hypoglossal Hops

Cranial Nerve What action tests each nerve

I- Olfactory Ask if they can smell ammonia salts, tuft skin, perfume…. Etc.

II- Optic Ask athlete to read the score board, look at cars in the distance

III- Occulomotor PEARL

IV- Trochlear Roll their eyes, follow your finger downward and inward

V-Trigeminal Bite down, clench jaw, sensation in cheeks

VI- Abducens Follow your finger outward

VII- Facial Raise eyebrows, smile, frown

VIII- Auditory Close eyes balance on both legs, balance one leg, close eyes balance on one leg, heel to toe walking, finger to nose

IX-Glossopharyngeal Swallowing

X- Vagus Stick out tounge and say “ahhhh”

XI- Accessory Resist the athlete doing a shoulder shrug

XII-Hypoglossal Stick out tounge and wiggle it around

Grade or level

Cantu (2001) Colorado Medical Society (1991)

1st degree No LOC, postraumatic amnesia or postconucssion signs or symptoms lasting less than 30 minutes

No LOC, confusion, no amnesia

2nd degree LOC lasting less than 1 mintues, postraumatic amnesia or postconcussion signs or symptoms lasting longer than 30 mintues but less than 24 hours

No LOC, confusion, amnesia

3rddegree LOC lasting more than 1 minute or posttraumatic amnesia lasting longer than 24 hours, postconcussion signs or symptoms lasting longer than 7 days

LOC

1 2 3 4 5 6

Eyes Does not open eyes

Opens eyes in response to painful stimuli

Opens eyes in response to voice

Opens eyes spontaneously

N/A N/A

Verbal Make no sounds

Incomprehensible sounds

Utters inappropriate words

Confused, disoriented

Oriented, converses normally

N/A

Motor Makes no movements

Extension to painful stimuli

Abnormal flexion to painful stimuli

Flexion/ withrawl to painful stimuli

Localizes painful stimuli

Obeys commands

Severe coma, GCS < 8Moderate coma, GCS 9-12Minor coma, GCS > 13

Colorado Medical Society Return to Play Guidelines:

Grade First Concussion Second Concussion

Third Concussion

Grade 1 (mild)

May return to play if without symptoms for at least 20 minutes

Terminate contest or practices, may return to play if without symptoms for at least 1 week

Terminate season, may return to play in 3 months if asymptomatic

Grade 2 (moderate)

Terminate contest or practices, may return to play if without symptoms for at least 1 week

Consider terminating season, may return to play in 1 month if without symptoms

Terminate season, may return to play next season if without symptoms

Grade 3 (severe)

Terminate contest or practice and transport to hospital, may return to play on 1 month, after 2 consecutive weeks without symptoms

Terminate season, may return to play next season if without symptoms

Terminate season, strongly discouraged to return to contact or collision sports

Grade First Concussion Second Concussion

Third Concussion

Grade 1 (mild)

May return to play if asymptomatic for 1 week; terminate season if CT or MRI abnormality

Return to play in 2 weeks if asymptomatic at the time for 1 week

Terminate season; may return to play next season if asymptomatic

Grade 2 (moderate)

Return to play after asymptomatic for 2 weeks; terminate season if CT or MRI abnormality

Minimum of 1 month; may return to play then if asymptomatic for 1 week; consider terminating season

Terminate season; may return to play next season if asymptomatic

Grade 3 (severe)

Minimum of 1 month; may return to play then if asymptomatic for 1 week

Terminate season; may return to play next season if asymptomatic

Consider no further contact sports

Intracranial Hemorrhage

Epidural Hematoma› Sits outside of dura mater in between

skull Signs and Symptoms include:

Altered state of consciousness, nystagmus, pupil inequality, irregular eye movement, slowing of heart rate, irregular respirations, severe headache, vomiting, unable to perform coordination tests, decreased muscle strength, seizures, cranial nerve assessment tests are all not normal

Subdural Hematoma:› Collection of blood between the dura and

the arachnoid space of the brain› Commonly delayed onset of symptoms (2

days- 2 weeks) High mortality rate

› Signs and Symptoms: LOC, irritability, seizures, numbness,

headache, dizziness, disorientation, amnesia, weakness, nausea, vomiting, personality changes, inability to speak, slurred speech, difficulty walking, blurred vision, deviated gaze or abnormal movement of eyes

Second Impact Syndrome› Deadly!! Can take only minor blow the second

time to create life threatening situation› Loss of auto regulation of the brain’s blood

supply; vascular engorgement in the cranium; increased intracranial pressure; the second blow bursts the engorged area

› Death in nearly 50% of all cases, disability in almost 100% of all cases… 911… maintain vitals if possible

› THIS IS WHY WE TREAT ALL CONCUSSIONS CONSERVATIVELY

Preston Plevretes

Second Impact Syndrome-› Second Impact Syndrome happened to young man

while in freshman year of college during football game Sustained initial injury 4 days before 2nd injury

› Four and a half years later, Plevretes struggles to walk and talk and needs round-the-clock care ALL BECAUSE CONCUSSION WENT UNDIAGNOSED!!!

http://sports.espn.go.com/espn/e60/news/story?id=5162747

Questions? Comments? Concerns?

A lot of information to digest….. But with practice, it will become MUCH easier to understand

Practice time!!!