HEAD INJURY EVALUATION: Etiology and Symptoms



HEAD INJURY EVALUATION: Etiology and Symptoms

Concussions are head injuries and most often are the result of a blow to the head, either direct contact with something, or indirect contact such as jarring of the brain against the skull from deceleration. Many are grade 1, or mild concussions with no loss of consciousness and a short duration of symptoms. Every head injury is unique, so all should be fully evaluated and treated individually.

Any blow to the head which results in the student-athlete needing assistance should be thoroughly evaluated before further activity is permitted. The normal progression for a grade 1 concussion is that symptoms (such as headache, dizziness, minimal disorientation) will be present initially and will fade in a relatively short period of time. The student-athlete should be carefully evaluated and watched for several minutes after a head injury. Once the student-athlete feels better then a decision can be made. Deviation from this pattern is cause for concern. Any worsening of symptoms is a sign of emergency action. This indicates that bleeding into the cranial cavity is causing increased pressure on the brain.

Factors for MDs and Certified Athletic Trainers to consider in return to play decisions:

1. Potential for disaster. Injuries to the head account for more fatalities than to any other area of the body. Many of these are due to Second Impact Syndrome.

2. Second Impact Syndrome - occurs when a student-athlete sustains a force to the head/brain while still experiencing symptoms from a previous head injury. The mortality rate for Second Impact Syndrome is 50%. Those who survive often have permanent impairment in neurological and mental function.

3. History of Concussion. A student-athlete with a history of multiple concussions has an increased chance of sustaining another concussion with a blow of relatively lesser force. If the student-athlete has sustained three concussions in a season, she should be referred for further medical care.

4. The nature of the sport. High risk/contact vs. low risk/contact sports. Soccer, lacrosse, volleyball, softball, diving, basketball, and field hockey are sports with a higher risk of head trauma than tennis, crew, golf, swimming, fencing, and cross country, which carry a lower risk.

5. The student-athlete’s style of play. Some student-athletes put their bodies at risk to make a play. While this style of play may be praised by coaches and fans, it can greatly increase the risk of head injury. These student-athletes are also the ones who will minimize their symptoms and not inform medical staff of symptoms of headache or dizziness, thus they increase their risk for second impact syndrome.

SIGNS AND SYMPTOMS:

Concussions are graded on many different scales. Many of the signs and symptoms are subjective and thus can be difficult to evaluate. The student-athlete must be relied upon to tell the truth. If confronted with a head injury, seek out a certified athletic trainer to evaluate it.

NO student-athlete should be returned to play with any of the following symptoms…

• Headache

• Dizziness

• Blurred or otherwise impaired vision

• Loss of function

• mental - assess by asking student-athlete questions requiring concentration (count backwards from 100 by seven's)

• motor – student-athlete should have good balance and should pass the following tests: finger to nose coordination test, Rhomberg sign (balance with feet together and eyes closed), heel/toe walking

• Amnesia - this is assessed by asking questions related to the game, the student-athlete's name, the score, etc. Amnesia may vary with time; student-athlete may be fully lucid for a period of time, then unable to remember most recent events.

The following symptoms are indicators of emergency action….

• Nausea and vomiting (indicates increasing intracranial pressure)

• Loss of consciousness – (Grade III).

AN UNCONSCIOUS STUDENT-ATHLETE SHOULD ALWAYS BE TREATED AS IF A CERVICAL SPINE INJURY IS PRESENT.

Neurological signs – Signs of increasing intracranial pressure…

a. Inequality in pupil size and/or reaction to light

b. nystagmus - involuntary eye movement

Student-athlete must be observed 24 hours for signs of increasing intracranial pressure:

increasing headache

nausea and vomiting

pupil inequality

progressive impairment of consciousness

disorientation

slowing of pulse

If the student-athlete appears completely normal after the game, a friend or roommate can be asked to wake her up every few hours that night to check for the above. It is recommended that student-athletes who have sustained concussions should not take aspirin, as it may increase the bleeding. A regular Tylenol dose can be taken for a headache. The increase in pain from increased intracranial pressure will not be masked by a recommended dose of Tylenol. If in any doubt, send the student-athlete to the infirmary following the game. Campus Police will transport if necessary.

WITH ANY LOSS OF CONSCIOUSNESS AN AMBULANCE SHOULD BE CALLED...

X5555- "The athletic trainer is requesting an ambulance to the “soccer/field hockey field for an unconscious student-athlete”.

HEAD INJURY EVALUATION: Assessment

Primary Survey

a. ABC's-should continue throughout entire evaluation

(A-airway, B-breathing, C-circulation) Take pulse, temperature, blood pressure and record them

Secondary Survey

History - determine the mechanism of injury and direction of force

Level of Consciousness

1. What is your name?

2. Where are you?

3. Do you know who I am?

4. Headache?

5. Dizzy?

6. Ringing in your ears?

7. Nauseous?

8. Blurry or cloudy vision?

9. Any pain in your neck?

10. Numbness, tingling, or weakness in any part of your body?

Determine Mental Function – Note the manner of response, is the student-athlete’s speech slow or slurred? Is she overly emotional? Disoriented?

1. What happened?

2. Who are you playing today?

3. What is the score?

4. What did you have for breakfast today?

5. Count backwards from 100 by 7's

6. Remember 3 objects (ball, truck, fence)

Retrograde amnesia -inability to remember events leading up to the injury. Usually found with a Grade III concussion.

Observation - watch the student-athlete carefully during the history portion of the evaluation to see if the condition improves or worsens. CALL AMBULANCE IMMEDIATELY IF ANY OF THESE ARE PRESENT.

a. Pupils - pupils should be equal in size and reaction to light, any inequality is a sign of a severe head injury

b. Blood or fluid from ears– indicates skull fracture

c. Irregular respirations

d. Seizures

e. Decreasing level of consciousness

f. Obvious deformities/abnormal positions of body parts

g. Examine head, neck, face for deformity, bruising, lacerations

Palpation

a. pulse - pulse should decrease after activity and should remain level. If the pulse decreases and slows it could indicate a severe head injury

b. palpate cervical spinous processes, skull, and facial bones for deformity, swelling, tenderness

If signs and symptoms indicate a severe head or spinal cord injury, your evaluation should STOP HERE. Call for Ambulance.

Special Tests

Neurological Function

1. cranial nerve testing

2. upper quarter screening

3. Babinski/Oppenheim tests

Motor Function

1. thumb to forefinger

2. touch heel to opposite knee

3. touch nose with fingers

If the student-athlete has no gross symptoms that indicate the need for emergency action, she may sit up. Check again for increase in headache, dizziness, nausea. If no increase in symptoms, she may stand. If symptoms do not worsen, she may be removed from the field. If symptoms such as headache, dizziness, nausea increase with changes in position, wait a moment and try again. If symptoms still increase, have student-athlete lie back down and call the ambulance.

Once on the sideline, the SAC (Sideline Assessment of Concussion) should be performed. The SAC score is a good indicator of neurological deficits that may not be evident in the above tests. Note all results on the card for immediate tests. Exertional maneuvers should only be performed if student-athlete is free of physical symptoms.

A score of 25 or above on the SAC is an indicator of good mental and neurological function. Before returning a student-athlete to play, perform a sport specific functional test to see in the increase in activity precipitates any symptoms related to a head injury.

If it is decided NOT to return the student-athlete to play, continue to monitor the student-athlete for any decrease in neurological function or increase in signs and symptoms. If there is an increase in any symptoms, call for an ambulance.

It is always better to be overcautious than risk permanent injury or death. After a Grade I, II, III (mild, moderate, severe) a student-athlete must be symptom free for a one week period and have clearance from a physician or neurologist in order to return to play.

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