1. Sports Medicine Mr. Smith

2.  Discuss arrival assessment  Discuss full head injury evaluation in HIPS format  Discuss deadly head injuries  Discuss second impact syndrome  Practice

3.  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

4.  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

5.  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

6.  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?

8. › 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

9.  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.

10. › Make sure the following have been checked  ABC’s  Vitals- heart rate, blood pressure, pulse  Pupils- P upils E qual A nd R eactive to L ight (PEARL) › Otorrhea, rhinorhea, Battle’s sign, raccoon eyes, hyphema, nystagmus= 911

19.  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.

20.  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.

21. › Balance/ coordination  Rhomberg’s test  Heel to toe walking › Reflexes  L4- L5 Patellar tendon reflex  PEARL  S1- S2 Achilles tendon reflex

22. › Cognitive Functioning- count backwards from 100 by 7’s or repeat the months backwards › Halo Test- for presence of CSF

23.  Cranial Nerve Assessment › Cranial Nerves 1-12 › Both sensory and motor › Need to be rechecked every 20 minutes until severity of trauma is established

24. #Cranial Nerve NameAcronim 1.IOlfactoryOn 2.IIOpticOld 3.IIIOcculomotorOlympus 4.IVTrochlearTowering 5.VTrigeminalTop 6.VIAbducensA 7.VIIFacialFin 8.VIIIAuditoryAnd A 9.IXGlossopharyngealGerman 10.XVagusViewed 11.XISpinal AccessorySome 12.XIIHypoglossalHops

26. Cranial NerveWhat action tests each nerve I- OlfactoryAsk if they can smell ammonia salts, tuft skin, perfume…. Etc. II- OpticAsk athlete to read the score board, look at cars in the distance III- OcculomotorPEARL IV- TrochlearRoll their eyes, follow your finger downward and inward V-TrigeminalBite down, clench jaw, sensation in cheeks VI- AbducensFollow your finger outward VII- FacialRaise eyebrows, smile, frown VIII- AuditoryClose eyes balance on both legs, balance one leg, close eyes balance on one leg, heel to toe walking, finger to nose IX-GlossopharyngealSwallowing X- VagusStick out tounge and say “ahhhh” XI- AccessoryResist the athlete doing a shoulder shrug XII-HypoglossalStick out tounge and wiggle it around

27. Grade or levelCantu (2001)Colorado Medical Society (1991) 1 st degreeNo LOC, postraumatic amnesia or postconucssion signs or symptoms lasting less than 30 minutes No LOC, confusion, no amnesia 2 nd degreeLOC 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 3 rd degreeLOC lasting more than 1 minute or posttraumatic amnesia lasting longer than 24 hours, postconcussion signs or symptoms lasting longer than 7 days LOC

28. 123456 EyesDoes not open eyes Opens eyes in response to painful stimuli Opens eyes in response to voice Opens eyes spontaneously N/A VerbalMake no sounds Incomprehensible sounds Utters inappropriate words Confused, disoriented Oriented, converses normally N/A MotorMakes no movements Extension to painful stimuli Abnormal flexion to painful stimuli Flexion/ withrawl to painful stimuli Localizes painful stimuli Obeys commands Severe coma, GCS < 8 Moderate coma, GCS 9-12 Minor coma, GCS > 13

29. Colorado Medical Society Return to Play Guidelines: GradeFirst ConcussionSecond 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

30. GradeFirst ConcussionSecond 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

31.  Intracranial Hemorrhage

33.  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

34.  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

36.  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

37.  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 2 nd 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?i d=5162747

38.  Questions? Comments? Concerns?  A lot of information to digest….. But with practice, it will become MUCH easier to understand  Practice time!!!