Head Injuries / Concussions Prevalent in collision and contact sports Education and protective equipment are critical in preventing head injuries Head trauma results in more fatalities than any other sports injury

Mild Head Injuries Immediate and transient post-injury impairment of brain function Mechanism of injury Direct blow Acceleration/deceleration forces Shaking and/or shearing forces to the brain Sudden snapping of the head Forward Backward Rotating to the side

Signs and Symptoms May present as Life-threatening injury Cervical injury (if unconscious) Loss of consciousness (LOC) May last seconds or minutes Post-traumatic amnesia lasting < 24 hours Other symptoms Disorientation Motor coordination or balance deficits Cognitive deficits Variety of scales and return to play criteria Typically involve LOC or amnesia

Management Any LOC requires the athlete be removed from competition Assume a cervical spine injury with any LOC Athlete should be referred to a physician for assessment Athlete should not be left alone following a concussion for 24 hours or until a physician determines supervision is no longer necessary Objective measures should be used to determine readiness for return to play SAC Test (Standard Assessment of Concussion) BESS Test (Balance Error Scoring System) Return to normal baseline requires approximately 3-5 days All post-concussive symptoms should be resolved Return to play should be gradual

Second impact syndrome Mechanism of injury Recurrent concussions can produce cumulative injury to the brain After 1st concussion the chances of a 2nd concussion are 3-6 x’s greater Occurs before symptoms of the initial injury have resolved Second impact May be relatively minimal May not involve contact w/ the cranium Result of rapid swelling and herniation of brain after a second head injury Disrupts the brain’s blood autoregulatory system Leading to swelling Increasing intracranial pressure Very serious condition

Second Impact Syndrome Signs and Symptoms Athlete may not have LOC Athlete may looked stunned Condition degrades rapidly w/in 15 secs. Dilated pupils Loss of eye movement LOC leading to coma Respiratory failure May lead to death Management Life-threatening injury Must be addressed w/in 5 minutes Life saving procedures at trauma center Activate 911 Best management is prevention Physician’s clearance for return to activity

History Loss of consciousness and for how long? Orientation (x’s 4) Person (who you are / who MD is at hospital) Place (where they are) Time (day, month, year) Event (more reliable test with athletes) History of prior concussions How many Date of last one Loss of consciousness (knocked out) Medications Use of blood thinners (anti inflammatory medications) Alcohol use Amnesia (memory deficit) Retrograde amnesia (memory of events before the injury) Can you remember who we played last week? Antegrade amnesia (memory of events after the injury) Can you remember walking off the field

History Headache Neck pain Nausea Quantity (Severity of pain: 0 -10 scale) Quality (sharp, stabbing, throbbing, ache) Constant or intermittent Neck pain Evaluate motor function Can you move your hands and feet? Feelings of weakness Wiggle fingers and toes Sensory assessment Nausea Dizzyness / Vertigo / Balance problems Change in sleep pattern / feeling sluggish Visual disturbances Blurry vision Double vision Red or purple haze to vision Sensativity to light Concentration or memory problems

Observation General impression of the athlete Speech Verbal response Is there a blank or vacant stare? Can the athlete keep their eyes open? Inability to focus attention Is the athlete easily distracted? Normal emotional response? Speech Slurred speech Incoherent speech Verbal response Motor response Gross disturbances to coordination? Cognitive function?

Palpation for point tenderness and deformity Observation Swelling or bleeding from the scalp? Deformity Cerebrospinal fluid leaking from Ear canal Nose Discoloration Behind the ears (Battle’s sign) Under the eyes (Raccoon eyes) Palpation for point tenderness and deformity Neck Skull Special Tests Vital signs BP Increase in systolic Decrease in diastolic

Special Tests Eye function Pupils Equal (same size or irregular) And Reactive to (constrict with increased light) Light (Penlight or ambient room light or sunlight) Accommodation Ability of pupils to accommodate to light variance Dilate for far away Constrict for close up Eye position Strabismus Eye tracking - smooth or unstable Nystagmus Vision up and down, side to side (bowtie pattern) Convergence with close up focus Visual acuity (Blurred vision / Eye chart) Peripheral and tunnel vision Close eyes tightly or open them widely

Special Tests Ear function (test hearing by rubbing fingers together) Nose (test smell with mild agent, ie soap or coffee) Mouth Smile or frown Bite down hard Hold mouth open against resistance Tongue stick tongue straight out (say ah) Push tongue against cheek on each side Uvula retracts as tongue sticks out Gag reflex Skin Sensation 3 zones

Balance Tests Romberg Test Balance Error Scoring System Assess static balance Determine individual’s ability to stand and remain motionless Time (30 seconds) Position Feet together Arms out in front at shoulder height Head tipped all the way back Eyes closed Balance Error Scoring System Coordination tests Finger to nose Heel-to-toe walking

Cognitive Tests Obtains 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 Prior game 3 word recall

Balance Error Scoring System (BESS) Quantifiable clinical battery of tests Eyes are closed in all positions during test Utilizes different stances on both firm and foam surface Errors are tabulated when the athlete Opens their eyes Takes hands off hips Steps/stumbles or falls Positions 1. On firm surface a. Feet side by side b. Single foot balance c. One foot behind other 2. On unstable surface b. One foot balance

Person Place Date Event Months Backward 7’s countdown Loss of Consciousness Bleeding/Swelling Blood/CSF Ears or Nose Vital Signs Headache Nausea/vomiting Sleep Problems Amnesia Person Place Date Event Months Backward 7’s countdown Memory 3 Item Recall Medication Red/Purple Haze Photosensitive Pupil Size & Equality Light Reaction Eye Position Eye Tracking Tunnel/Peripheral Visual Acuity Hearing Smell Open Mouth Bite Tongue Out/Gag Tongue Strength Smile Frown Eyes Open/Closed Sensation Muscles of Expression Weakness or Loss Sensation Shoulder Shrug Finger to Nose Coordination Heel to Knee Balance/Rhomberg Heel to Toe Walk