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
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.