Head Injuries
Injury Recognition and Emergency Procedures in Sports
The Athletic Trainer, Team Physician, or coach must make an accurate and comprehensive assessment of the injured athlete on the field of play and then again in the training room after the patient has been safely transported off of the field or has left under their own power.
The primary concern to begin any field assessment is to determine what is the patients' level of life support. This simply means to determine if they are breathing, is their heart pumping, and do they have an open airway. These are referred to as the A,B,C's of life support.
We call them the 4 B's for athletic training and sports medicine. "Breathing, beating, breaks, and bleeding."
Head Injuries
The popularity of athletics has grown at a steadily increasing rate over the last decade; so, too, has the technology of the athletic equipment manufacturers. Despite the modern helmets, the brain, head, and face are still subject to traumatic injury.
The head can be divided into two (2) anatomical groups: the cranium and face. The cranium contains the brain and spinal cord attachments. Laterally and inferior to the cranium are the temporal regions and the parietal region located posteriorly to the temple area.
The face includes the eyes, ears, nose, maxilla, mandible and mouth.
The majority of head injuries result from direct blows of a rigid object or from the sudden stopping of the head which allows the brain to rock forward and backwards inside the cranium.
The end result of such movement or contact is referred to as a concussion. A concussion causes a temporary loss of some or all of the brain function.
The brain is surrounded by a fluid cavity inside the cranium. A blow to the head can effect an injury to the brain either at the point of contact or on the opposite side. This causes a contrecoup type of injury. Thus, the blow could be to one side of the head while the pathological condition would affect the opposite side.
ANATOMY
Cranium - skull - 8 bones Skull Dura mater Arachnoid Cerebrospinal Fluid Pia mater
Dura mater - white, outermost covering produces cerebrospinal fluid
Arachnoid - membrane covering of brain
Pia mater - delicate, innermost covering
"Lucid Interval"
Patient is alert for a short time and then lapses into unconsciousness. This may be indicative of intracranial bleeding.
"Romberg Test"
Feet together, arms at side check balance, have the patient try to balance with their eyes closed and then touch their nose with their index finger. This helps test for an expanding clot within the cranium.
Epidural Hematoma
These occur between the skull and dura mater This is a very rapid, expanding problem due to arterial supply.
Subdural Hematoma
Between dura mater and arachnoid. Most common cause of death. May present with Dyspnea (uncontrolled breathing) May be slow in presenting as a result of venous damage.
Concussions can be divided into three (3) groups according to their severity or intensity.
1st Degree
If this athlete has no memory loss and his motor function is good, he may return to activity as soon as symptom free.
2nd Degree
The moderate concussion requires a blow, which is hard to cause other pathological conditions. This is a serious medical condition, and the patient should be placed under a physician's care.
This patient should not return to physical activity until all signs of dizziness and headache disappear (possibly 1 to 2 weeks).
3rd Degree
The 3rd degree concussion is a very serious medical condition and requires immediate care from qualified medical personnel.
When evaluating the patient with a possible head injury, any life threatening situations should first be ruled out. The vital signs should be monitored and a proper airway established if necessary.
The patient should be questioned in such a manner that detects the possible loss of memory. The athlete should be questioned with questions that require more than a "yes-no" answer.
In addition to the questioning, a small penlight can be used to check the dilation and constriction of the eye pupils. The pupils should constrict with light and dilate when taken away. They should also respond equally. Any discrepancy in size, or if the pupils are fixed, constitutes possible serious pathological changes. Care should also be taken not to position the athlete where the sun or stadium lights would interfere with the test results.
It should also be noted that repeated episodes of concussions to one individual present a problem, and referral to a physician and recommended. Repeat episodes can be dangerous even if they are of mild intensity.
RECOGNITION OF HEAD INJURIES
Ideally, an athlete should be placed under medical supervision after he has received physical trauma which causes him to deviate from normal neurological function.
SYMPTOMS - The following will enable you to superficially assess the individual and determine his need to see a physician. Positive findings in any one of the following areas is reason enough for an athlete to be referred to a physician. Seizures may follow head injuries.
1. Unconsciousness - "Knocked Out" - this criteria is most commonly--but not correctly associated with head injuries. - can vary from no loss to transitory fleeting loss to prolonged loss of consciousness. - any athlete who is rendered unconscious should be referred to a physician.
2. Mental confusion - individual is confused as to what is going on. - can vary from showing slight to complete disorientation. This can be momentary to prolonged. - any athlete who is confused mentally as a result of trauma is a physician's responsibility.
3. Memory loss - storage and recall of information is a high level neurological process. - most common symptom - commonly seen even without any loss of consciousness
2 types -
Anterograde (beware of this type) - extending forward
Retrograde - varies from transient to prolonged loss of memory - any athlete with a memory deficit should see a physician. However, some patients may present with automatism. This is where they may act normal but have no memory of what they are doing .
4. Tinnitus - ringing of ears - if it persists for an hour or more, the athlete should be examined by a physician
5. Nystagmus - "dancing eyes" - if present, see a physician
6. Dizziness - fleeting to prolonged - if any more than fleeting - see physician
7. Coordination - coordinating the many small and large muscle actions to provide for an athletic type movement is a complex process. - agitation of the CNS may influence one's ability to do this: therefore, if an athlete cannot perform basic coordinated movements up to par, he should be examined by a physician.
The above assessments can be made by anyone. If a symptom is present, ideally the athlete should be managed by a trained medical person. The field assessment does not have to assess the level or degree of the above - merely the presence of head injury.
MANAGEMENT (in the absence of a physician)
One must constantly reassess the conscious state of an individual who has had a head injury--not with the idea of returning him to participation that day since that is out of the area of your responsibility--but rather to determine if the athlete has a serious head injury in the form of an expanding lesion. -If you must coach, assign a mature, responsible kid to the responsibility of watching the injured kid--informing you of any changes in him.
The following SIGNS may indicate an EXPANDING LESION:
1. a deteriorating level of consciousness
2. eyes
3. heart
4. bilateral strength comparison
5. coordination
6. nausea
7. head
THESE SITUATIONS SIGNIFY A MEDICAL EMERGENCY & YOU MUST GET INDIVIDUAL TO A HOSPITAL
Levels of Consciousness
A - alert V - verbal
P - pain
U - unresponsive
Return To Participation following a concussion
If the athlete has a headache, he may not return.
The return of an individual to participation following a head injury is up to a physician. A physician may allow a kid to return after he clears of all symptoms. Get written or verbal confirmation from the physician--do NOT take the students word for it.
If an athlete is hurt in the first half--perhaps he can go in the second. This is a PHYSICIAN'S DECISION ONLY--have one on the sidelines.
Do NOT risk the future of an athlete for the sake of one practice.
Also realize that even though a kid may appear to be completely OK, he may not be as sharp, agile, quick, reactive, or strong. Thus he is more vulnerable to another injury--THIS HAPPENS QUITE OFTEN.
Beware of incoming athletes with a history of previous head injury. - put him in the best helmet that you can--our experience has been that the air or liquid filled type are the best - do not be afraid to seek the medical expertise of a specialist - be aware that the AMA recommends disqualification of an athlete from a contact sport following the third concussion within a one year period of time.
PREPARE FOR EMERGENCIES
If a player is unconscious:
1. maintain airway, Do not remove the headgear
2. try to arouse--talk in ear, pinch armpit, sternal rub
3. do not move without stabilizing neck
4. collar
5. no ammonia capsules
Always have on the field or courtside:
1. tongue forceps
2. oral screw
3. artificial airway
4. jaw block
5.face mask removal tools
Have a "PLAN"
1. access to a phone--unlocked, open line
2. phone numbers posted and carried
3. pay phone quarters or cellular phone
4. know who is to do what
5. names of Sports Medicine Advisory Team - if possible, utilize a specialist
6. know how your physician wants situations handled--get to know your doctors
7. do not give aspirin, it causes an inhibition of platelet formation in bleeding