1. PHED 120 Krzyzanowicz – Fall ‘12
Head Injuries
PHED 120
Krzyzanowicz – Fall ‘12

2. Cerebral Concussion Injury associated with virtually every sport
A thorough and consistent approach to evaluate patients suspected of a concussion will aid in improving diagnosis and return-to- play decisions
Must identify severity in order to develop a treatment plan
Early detection, diagnosis and follow-up are critical

3. Pathomechanics
Transient neurological dysfunction resulting from applied force to the head
Forceful blow to the resting movable head produces brain injury beneath point of cranial impact
Coup injury
Forceful blow to the moving head produces brain injury opposite site of cranial impact
Contrecoup injury
Differences are the result of brain lag and distribution of cerebrospinal fluid (CSF)
Concussion experienced in sports tends to be a combination

4. Pathomechanics Stresses Applied to Brain Types of Pathology
Compressive
Tensile
Shearing
Types of Pathology
Traumatic brain injury
Focal = post-traumatic intracranial mass lesions that include subdural hematomas, epidural hematomas, cerebral contusions, intracerebral hemorrhages and hematomas
Diffuse = disruption of neurological function, not usually associated with macroscopic brain lesions
Result of brain being “shaken”
Tissue damage, the result of acceleration-deceleration
Includes cerebral concussions (mild traumatic brain injury)

5. Concussions
No universal agreement on definition or nature of concussions
Caused by direct blow to head, resulting in sudden mechanical loading of head
Impact between cortex and bony skull walls results in immediate/short-term neurological impairment
Long-term effects = post-concussion syndrome
May cause neuropatholgical changes or temporary tissue deformation

6. Concussions Causes a gradient of clinical syndromes including LOC
Most often associated with normal results during conventional neuroimaging
Is “getting his bell rung” a concussion?
Important for AT to recognize and classify concussive injury
Athlete must also understand signs and symptoms and their negative consequences

7. Classification of Cerebral Concussion
Grading concussions
Clinicians should focus on the duration of symptoms associated with injury
Important to emphasize other signs and symptoms, in addition to LOC and amnesia
Athlete’s condition should be graded after symptoms have resolved

8. Classification of Cerebral Concussion
Mild Concussion
Most frequent and most difficult to recognize and diagnose
Transient aberration in brain electrophysiology results in impaired mental status
No LOC; impaired cognitive function (post-traumatic amnesia)
Dizziness, tinnitus, possible decline in coordination (Romberg test), headache
Headache can be used to determine if condition is improving or worsening

9. Classification of Cerebral Concussion
Moderate Concussion
Associated with transient mental confusion, tinnitus, moderate dizziness & unsteadiness, prolonged post- traumatic amnesia (>30 minutes)
Momentary loss of consciousness (up to 1 minute)
Blurred vision, balance disturbances, nausea
Requires careful consideration and clinical observation
Must also be cautious and use skillful judgment when making return-to-play decisions

10. Classification of Cerebral Concussion
Severe Concussion
Signs and symptoms last considerably longer than those of mild and moderate concussions
Will likely include more significant LOC
Post-traumatic amnesia lasting >24 hours; retrograde amnesia (memory loss of events prior to injury)
Decreased neuromuscular coordination
Serial observations should be conducted
Management
Serial observations
Rest
Evaluation by physician in the event of prolonged LOC
Should consider neuroimaging of the brain
Athletes should not be returned to participation while still experiencing symptoms

11. Cerebral Contusion
Brain tissue suffers bruising when an object hits the skull
Results in injured vessels, internal bleeding, and LOC
May be associated with partial paralysis or hemiplegia; one-sided pupil dilation, altered vital signs
Progressive swelling may continue to compromise brain tissue & cerebral function
Prognosis is dependent on care

12. Cerebral Hematoma
Little space for swelling and blood clots between brain and skull
Results in increased intracranial pressure and possible shifting of cerebral hemispheres
Causes a decline in neurologic function
Two types
Epidural
Subdural

13. Cerebral Hematoma Epidural Hematoma
Result of severe blow to head, producing skull fracture in temporoparietal region
Tend to be isolated injuries (skull sustains major impact forces and absorbs resultant kinetic energy)
Accumulation of blood between dura mater and inner surface of skull due to arterial bleed from middle meningeal artery
Fast developing, which cause neurologic deterioration in 10 – 120 minutes
Possible LOC; period of lucidity
Slow accumulation of blood resulting in neurologic compromise as hematoma becomes critically large = compresses brain tissue
Clinical manifestation is dependent on type and amount of energy transferred, time course of hematoma formation, concurrent brain injuries

14. Epidural Hematoma

15. Cerebral Hematoma Subdural Hematoma
Caused by blow to head resulting in brain being thrust against point of contact
Subdural vessels stretch and tear leading to hematoma in subdural space
Typically venous in origin resulting in slow developing hematoma
Acute = hours development
Chronic = later time frame, variable clinical manifestations
Signs & symptoms will develop slowly
Altered consciousness (coma or major focal neurological deficits)
Treatment
Prolonged observation and monitoring due to the risks associated with slowly developing brain bleeds and deterioration in mental status
Surgical intervention may be necessary to evacuate hematoma and decompress brain

16. Second Impact Syndrome
Occurs when an athlete sustains a second head injury prior the symptoms resolving from a previous injury
Often first injury was unreported or unrecognized
Results in rapid brain swelling & herniation; brain stem failure occurs in 2-5 minutes; pupil dilation and loss of eye movement, respiratory failure and ultimately coma
Mortality of SIS is 50% and morbidity is 100%

17. Immediate Management of Sport-Related Concussion
Recognize injury & severity
Determine if athlete requires additional attention/assessment
Decide when it is safe for the athlete to return to sports activity
Well-developed protocol is key to successful initial evaluation

18. Initial On-Site Assessment
Athlete down vs. Ambulatory conditions
Primary survey
Assess basic life support needs
Secondary survey
History
Observation
Palpation
Special tests
Active/passive range of motion
Strength tests
Functional tests

19. Initial On-Site Assessment
History
Must be thorough
Determine level of mental confusion, LOC and amnesia (anterograde vs. retrograde)
Consider cervical spine involvement
Monitor vital signs at regular intervals
Observation & Palpation
Check for deformities and abnormal facial expressions (cranial nerve involvement)
Speech patterns, respiration patterns, movement of extremities
Palpation of skull and C-spine
Exercise additional caution if patient is unconscious

20. Sideline Assessment More detailed examination Cranial nerve assessment
Check for basilar skull fractures
Battle’s sign, otorrhea, rhinorrhea, raccoon eyes
Continue to monitor vital signs
Slowing heart rate or changes in blood pressure could suggest intracranial involvement

21. Special Tests for Assessment of Coordination
Balance Error Scoring System (BESS)
Provides objective, rapid and cost-effective means of assessing postural stability
Reliable and valid assessment tool
Utilizes three stances on both firm and foam surfaces
Results from test are best used when compared to a baseline
Other tests
Sensory Organization Testing & force plate recommended for return-to-play decisions
Finger-to-nose test also considered a good means of assessing cognitive processing and balance

22. Special Tests for Assessment of Cognition
Begin with giving athlete 3 unrelated words
Ask athlete to repeat words at end of assessment
Standardized Assessment of Concussion (SAC)
Used to assess mental status
Brief screening for those with no expertise in neuropsychological testing
Assesses 4 domains of cognition (orientation, immediate memory, concentration, delayed recall)
Most helpful when baseline scores have been obtained prior to injury

23. Special Tests for Assessment of Cognition
Computerized Neuropsychological Test
Automated Neuropsychological Assessment Metrics
CogState
Concussion Resolution Index
Immediate Post-concussion Assessment and Cognitive Testing (ImPACT)
Primary advantages
Ability to assess reaction time
Establishing baselines for large number of athletes in short period of time
Multiple forms within testing paradigm
Challenges
Best follow-up assessment protocol
Interpretation of results
Cost
Clinicians should be trained in administration of test
Must identify neuropsychologist that will aid in clinical interpretation of post-injury test results

24. Return to Competition Grading scales
Lack of consensus as many scales have been based on anecdotal literature and clinical experience
Cantu Evidence Based Grading Scale is recommended because it emphasizes all signs and symptoms without placing undue emphasis on LOC and amnesia
Athlete should not return to play if still symptomatic