Evaluation head injuries
Head, Face, Eyes, Ear, Nose, and Throat
History
Location of the pain
Onset
Activity

 
Eipstaxis (by hot, dry environment)
Injury mechanism
- Coup; trauma on the side that was struck
  - Countercoup; trauma on the opposite side that was struck
  - Repeated subconcussive forces; repeated nontraumatic blows to head (e.g., boxing, heading a soccer ball)

- Flexion of the cervical spine is the mechanism most likely to produce catastrophic injury
Other symptoms
Equiblium, Tinnitus, dizziness

Level of Consciousness
  - Trainer should note whether the athlete is moving or not, while approaching the scene.
  - If communication is not present, trainer should check the athlete’s responsiveness to painful stimuli.


Inspection

Ear
  Auricle
  Tympanic membrane
  Periauricular area -
Battle’s sign (ecchymosis around the mastoid process)
Nose
  Alignment
  Epistaxis
  Septum and mucosa
  Saddle nose deformity –
Raccoon eyes (Following nasal fracture blood lost  because of hemorrhage)
Face and Jaw
  Bleeding
  Ecchymosis – Black eye
  Symmetry
  Muscle tone –
Bell’s palsy (unilateral paralysis of facial muscle)
Oral Cavity
  Lips
  Teeth
  Tongue
  Lingual frenulum
  Gums (laceration, abscess, gingivitis)
Throat
  Thyroid cartilage
  Cricoid cartilage

Palpation
  - Should not be performed over areas of obvious deformity, or suspected fracture, especially in the cervical
     spine and skull.
Nasal bone
Nasal cartilage
Zygoma
Maxilla
Temporomandibular joint
Periauricular area
External ear
Teeth
Mandible
Hyroid bone
Cartilages

Functional tests
Ear
  Hearing
  Balance
Nose
  Smell (olfactory)
Jaw and throat

Ligamentous tests
Not applicable

Neurologic tests
Facial muscles (CN I, II, V, VII)
Ear
  Hearing (CN VIII)
  Balance (CN VIII)
Nose
  Smell (CN I)

Special tests 
Mandibular Fracture
  Tongue blade test

Neurologic exam
- The goal of functional tests is to assess the status of the CNS
Cerebral testing (assess cognitive function)
Cranial nerve testing
Cerebellar testing (assess coordination and motor function)
Sensory testing
Reflex testing

Eye function
Checking eye signs can yield cranial information about possible brain injury
  Pupils equal and reactive to light (PEARL)
  Eyes track smoothly
  Vision blurred
  - General state of the eyes should be tested
  - Nystagmus, the involuntary cyclical movement of the eyes, should be noted if present
  - Equality of the size of pupils should be noted.

Balance test
Rhamberg test

Coordination test
Finger-to-nose test
Heel-to-toe walking
Standing heel to knee test

Cognitive test
(Serial 7s)
1. Hopkins verbal Learning Test
2. Digit span (WMS-R)
3. Trail-Making test
4. Stroop test
5. Controlled Oral Word Association Test
6. Symbol Digit Modalities
7. Grooved Pegboard test

Memory
  - Retrograde amnesia; inability to recall events prior to the onset of the injury
  - Anterograde amnesia; inability to recall events following the onset of injury
Prevention of injuries to the head, face, eyes, ears, nose and throat
Helmets or protective headgear
Face masks
     In football, ice hockey, lacrosse, wrestling, and baseball
     Decrease injuries to head, face, eyes, ears, and nose
     Helmet can prevent injury only to the brain
To teach the athletes to use correct techniques when initiating contact

Assessment of Head Injuries
  - Injuries to the brain may or may nor result in;
   
o Unconsciousness
     o Disorientation or amnesia
     o Motor, coordination, or balance deficits
     o Cognitive deficits


Unconscious Athlete
   -
Athletic trainers must be adept at recognizing and interpreting the signs that an unconscious athlete presents.
   - If neck injuries are suspected in unconscious athlete, jaw is brought forward but neck is not hyperextended to clear airway.

   -
All unconscious athletes must be managed as if fracture or dislocation of cervical spine exists until presence of these injuries
     can be definitively ruled out.


Evaluation of the athlete’s position
   - A supine athlete is in the optimal position for subsequent evaluation and management.
   - Sidelying or prone position athlete is more difficult position for evaluation.
   - When athlete is prone or sidelying, absence of vital signs takes precedence over possibility of spinal fracture. Athlete must be
      rolled into the supine position in the safest manner possible.

Determination of Consciousness

   - Level of consciousness
       o Alert (Able to respond appropriately to questions)
       o Verbal (responds appropriately to verbal stimuli)
       o Painful (Only responds to painful stimuli)
       o Unresponsive (Does not respond)
    - Primary survey
       o If the athlete is unconscious or unable to communicate, check athlete’s ABCs by looking, listening, and feeling for breathing.
    - Secondary survey
       o Inspect the extremities and torso for bleeding or indications of fractures or dislocations.



                                                               
The Head
      o Head injuries occur from direct and blunt forces to the skull.
      o 30-40 major head injuries during sport-related activities each year.

Anatomy
Bones (skull/cranium)
22 bones
Sutures; all bones of the skull are jointed together in immovable joints (except mandible)
· In infants & children, sutures are more pliable because they are continually being remodeled during growth.)

Scalp
5 layers of soft tissue
· Skin (connective tissue)
· Aponeurosis epicranalis (thick connective tissue sheet that acts as attachment for occipitalis & frontalis muscles)
· Loose connective tissue layer
  Skin greatly increases skull’s strength, increasing its breaking force from 40 lb per square inch to 425 to 490 lb per square inch.

Brain
   Cerebrum

   · Motor function
   · Sensory information (touch, pain, pressure, temperature)
   · Special senses (vision, hearing, smell, taste)
   · Cognition
   · Memory
Cerebellum
   · Balance and coordination
   · Smooth, synergistic muscle control
Diencephalon (thalamus, hypothalamus, and epithalamus)
   · Routing of afferent information to the appropriate cerebral areas
   · Body temperature regulation
   · Maintenance of the necessary water balance
   · Emotional control (anger and fear / sympathetic and parasympathetic nervous system))
Brain stem (medulla oblongata and pons)
   · Heart rate regulation
   · Respiratory rate regulation
   · Control over the amount of peripheral blood flow
Meninges (protect the spinal cord & brain)
 
Dura mater: outermost, consisting of a dense, fibrous and inelastic sheath.
   Falx cerebri is a fold in the dura mater in the longitudinal fissure between the two cerebral hemispheres.
   Falx cerebelli fills the void between the two-cerebellar hemispheres.
   Meningeal arteries are primarily supply blood to the cranial bones.
   Venous sinuses serve as a drainage conduit to route used blood into the internal jugular veins in the neck.
   Arachnoid mater: extremely delicate sheath
   Subdural space separates the arachnoid mater from the dura mater
   Subarachnoid space is a wider separation beneath the arachnoid, containing the CSF.
 
Pia mater: thin, delicate, and highly vascularized membrane
 
Cerebrospinal fluid
- Originating from the choroids plexuses deep within the brain and secreted by cells surrounding the cerebrum’s blood vessels,  
    CSF slowly circulates around the brain and spinal cord within the subarachnoid space.

Blood circulation in the Brain
- Brain demands 20 % of the body’s oxygen uptake (rest).
- For each degree (centigrade) the body’s core temperature increase, the brain’s need for oxygen increases by 7 %.
- The two vertebral arteries and the two common carotid arteries provide blood supply to the brain.
- Each common carotid artery diverges to form an internal carotid artery and an external carotid artery.
- The two internal carotid arteries and  two vertebral arteries converge to form a collateral circulation network, the circle of Willis.

Sports with the most risk potential
  1. Boxing
  2. Ice hockey
  3. Football
  4. Rugby

Concussion Grades
  - Many different grade systems are available. Slight differences among them
  - Two of the most widely accepted are;
     o Cantu and Kelly (same as American Academy of Neurology)
  - AMA has one out that is also common

Return to Play guidelines
  - Vary from immediate return to play to transport to the emergency room

Follow up Guidelines
  - Overnight considerations
  -
Document
  - Retest

All unconscious athletes should be managed as if a fracture or dislocation of the cervical spine exists until the presence of these injuries can be definitively ruled out.
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