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Concussions

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nikki devlieger

on 9 July 2015

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Transcript of Concussions

Anatomy
Common Injuries
Skull Fractures
Mechanism of Injury

• Concussions may be caused by a direct blow to the head, face, neck, or elsewhere on the body, with a force transmitted to the head

• It can be due to a fall in which the patient hits their head, or from an object in motion such as a shot put or baseball.

•There’s usually a rapid onset of short lived impairment or neurological function that resolves spontaneously


Signs and Symptoms
Cerebral Concussions
The Basics
“A type of mild traumatic
BRAIN
injury.”
It effects
THE BRAIN
.
It happens when
ANY
violent moving of the brain occurs...not necessarily by a direct hit to the head.
What to Watch for
Concussions
Blunt trauma
Does what is says
Cerebral Concussion
Mild Trauma Brain Injury
MTBI
Direct blow to head
Either by an object, like equipment or player, or strike a fixed object
Involves shaking of the brain
Contact Points
A direct blow to the head
A contact that causes the head to snap forward, backwards, or rotate to the side. Whip Lash
Coup- occurs on the site of impact with an object and Countercoup- occurs on the side opposite the area that was impacted.
Onset- usually sudden
Level of Consciousness- Confusion or unconsciousness
Pulse- weak irregular
Respiration- shallow and irregular
Skin- Pale and cold
Eyes- Pupils are equal. No Paralysis
Convulsions- None
Breathing- Nothing special

Severe headache
Nausea
Blood in the middle ear or in the canal, nose, and around the eyes
.
Possible cerebrospinal fluid

Postconcussion Syndrome
Not very well understood
Condition that follows a concussion
May occur in cases that do not involve loss of consciousness
Second-Impact Syndrome
After a second head injury occurs
Occurs because of rapid swelling and herniation
Disruption of the brain's blood auto regulation system, increases intracranial pressure, and leads to herniation.
Blow does not have to be directly to the head
Cerebral Contusion
Occurs because of an impact injury where the head strikes a stationary object
The cerebrum is mainly impacted
Small hemorrhages/intercerebrum bleeding within the cortex, brain stem, or cerebellum.
3 Types
Malignant Brain Edema Syndrome
Occurs in the younger population.
Brain swelling resulting in vascular engorgement with little to no immediate injury to the brain.
Serious because the internal pressure continues to rise
Epidural Hematoma
Occurs because of a blow to the head/skull that tears the meningeal arteries.
Arterial blood pressure rises
Blood accumulates and hematoma forms
Only takes about 2-3 hours
Subdural Hematoma
Result of accelerating and decelerating forces that tear vesicles that bridge the dura matter and the brain.
Occurs more frequently than Epidural Hematomas
Most common cause of death in Athletes
1. Acute- occurs rapidly.
2. Association- happens along with other types of brain contusions and skull injuries
3. Chronic- occurs due to venous bleeding. (Veins are torn)
Skull Fractures
Postconcussion Syndrome
Second-Impact Syndrome
Stunned face
Seem 'okay' at first
Conditions drastically plummet
Pupils dilate and lose movement
Loss of consciousness leading to coma
Life threatening with a mortality rate of 50%
Cerebral Contusion
Vary case to case
Experience loss of consciousness
Once consciousness is regained, patient is talkative and alert
Neurological exam will be normal
Headaches, dizziness, and nausea will be persistent.
Three types
Malignant Brain Edema Syndrome
At first they are at a normal alert state
Rapid neurological deterioration that progresses to a coma within minutes to hours
Epidural Hematoma
Usually there is loss of consciousness. Patient could regain consciousness.
At first, show none of the signs of a serious head injury.
Gradually symptoms worsen
Dilation of ONE pupil
Sleepiness
Neck rigidity and depression of pulse and respiration.
Convulsions
'Deteriorating consciousness'
Subdural Hematoma
Signs & Symptoms
Persistent headache
Impaired memory
Lack of concentration
Anxiety, irritability, fatigue and depression.
Can appear immediately after incident, several days or months after.

Usually there is NOT loss of consciousness
If there is loss of consciousness, then is it a complicated subdural hematoma.
Dilation of one pupil
Headache, dizziness, nausea and sleepiness.
Epidural Hematoma
Subdural Hematoma
Intracerebral Hematoma
(intracerebral)
Cerebrum
(Cortex)
1)Frontal:
Problem solving, intellect, judgment, behavior, attention, abstract thinking, physical reactions, voluntary muscle movements, coordinated movements.
2)Parietal:
Comprehension (focus), monitors visual functions, language, reading, internal stimuli, tactile sensation and sensory comprehension.
3)Temporal:
Visual and auditory memories, helps manage some speech and hearing capabilities, behavioral elements, and language.
4)Occipital:
Helps to control vision. (back)
Cerebellum:
"The little brain", balance, posture, coordination.

Pons:
Sleep, posture, respiration, swallowing, and bladder.

Medulla Oblongota
(lowest stem): maintains vital body functions, heart rate, breathing.
The Brain
The Scalp
The Bones
• Unconsciousness (not likely)
• Disorientation or Amnesia
• Motor, Coordination, or Balance deficits
• Cognitive deficits

Prentince Definition
The AT is responsible for primary and secondary on the field evaluations.
Tests/Evaluation for Concussions:
History

– The AT uses this to obtain more information from the patient to understand what happened

Observation

– the AT is looking for abnormalities, signs of instability

Palpation

– the AT is touching the patient to feel for abnormalities

Special tests
– this will help the AT further evaluate balance and cognition

HOPS
Is the patient disoriented and unable to tell where he/she is, what time it is, what date it is, who the opponent is?

Does the patient have slurred or incoherent speech?

Does the patient have gross coordination disturbance?
(stumbling, inability to walk in a straight line, can’t touch finger to nose)


Observation



Can you tell me what happened?

Can you remember what you had for dinner last night?
this question will determine whether there is retrograde amnesia

Can you remember whom we’re playing? this question will determine whether there is anterograde amnesia

Does your head hurt?



History

The AT should palpate both the neck and skull to identify tender points or deformity.

Deformities of either structure can indicate a fracture which would require immediate and advanced medical care


Palpation

Special Tests



If the patient falls out of formation they are to make any adjustments to return to testing formation as quickly as possible
These trials are assigned a max error score of 10
Test is incomplete if the patient cannot sustain the stance for longer than 5 seconds

Balance Error Scoring System - Interactive


Currently the most widely used on the field test for assessing concussion related signs and symptoms, cognition, balance, and coordination

SCAT2 Developed in 2008 and modified in 2012, SCAT3

In the new version there were some changes made such as:
Changing the age group from 10 years old to 13 years old
There is a child SCAT3 for ages 5-12
Adding a tandem gait to the BESS section
A measure of reaction time
There is no longer an overall composite SCAT score. An individual who exhibits a deficit on any single part of the assessment will be considered to have a concussion and should be treated accordingly.


SCAT3

Rest
No participation in physical activity such as running, biking, weight training etc.
Limit high thinking activities such as homework, job related activities and video games
Eat right, drink plenty of fluids and eat carbohydrates and protein to maintain appropriate blood sugar levels

Rehab

Computerized tests


Retrograde amnesia- refers to loss of memory for information acquired before the onset of amnesia

Anterograde amnesia- Anterograde amnesia is the loss of the ability to create new memories


Eye Function Test
Neurological Exam

Balance tests
Coordination tests
Cognitive tests
SCAT3
Paper and pencil tests
Tests the cerebrum,cranial nerves,cerebellum,sensory,reflex and motor functions
PEARL-Pupil Equal And Reactive to Light
Eyes track smoothly
Vision is blurred
Romberg Test
Balance Error Scoring System (BESS)
Finger to nose
Heel to toe walking
Glasgow Coma Scale (GCS)
Maddocks Coordination scale
graded symptom scale
Standard Assessment of Concussion (SAC)
Modified BESS
Loss of Consciousness scale (LOC)
Spelling a word backwards
naming the months in reverse order
Stroop Color Word Test
Hopkins Verbal Learning Test
Concussion Resolution Index (CRI)
CNS Vital Signs
The patient gets error points for falling out of formation.
1 error point is added for any of the following:
Hands lifted off hips
Opening eyes
Step, stumble, or fall
Moving hip into >30 degrees
Lifting forefoot or heel
Remaining out of testing position >5 seconds
Things to keep in mind
Points
Rules
Get in pairs
One person will be the observer and the other the patient
The patient will do each of the 3 poses for 20 seconds with their eyes closed and hand on their hips
The observer will keep time and record any error points
Sport Concussion Assessment Tool
After ruling out a life- threatening condition, the AT should move on to the secondary on the field evaluation
"The covering of the skull"
5
soft tissue layers
Skin, connective tissue, aponeurosis epicranius, connective tissue layer, periosteum.
3 to 2
Aponeurosis epicranius
Composed of
22
bones.

Sutures (
*
mandible)

Cranial vault:
"
House of the brain
"

Frontal, Ethmoid, sphenoid, 2 parietal, 2 temporal,occipital
C can
S she
P please
S say
C cheese
I in
E every
S snap
There are 5 Main types of Concussions:
Cerebral Concussion
Skull Fracture
Post Concussion
Second Impact
Cerebral Contusion
Intracerebral
Epidural
Subdural
Return To Play
Research

• Concussions may be caused by a direct blow to the head, face, neck, or elsewhere on the body, with a force transmitted to the head

• It can be due to a fall in which the patient hits their head, or from an object in motion such as a shot put or baseball.

•There’s usually a rapid onset of short lived impairment or neurological function that resolves spontaneously.
Transient Paraplegia, Blindness,Migrainous Phenomena: Adams and Victor's

"With falls or blows on top of the head, both legs may become temporarily weak and numb, with wavering bilateral Babinski signs and sometimes with sphincteric incontinence. Impact over the occiput may cause temporary blindness. The symptoms disappear after a few hours."
References
AMA Citation
Prentice E. William: Ch.26-The Head, Face, Eyes,
Ears, Nose and Throat. In: Principles of Athletic Training, A Competency-Based Approach. 15th ed. New York, NY: McGraw-Hill; 2014: 806-842.

Ropper AH, Samuels MA, Klein JP. Chapter 35.
Craniocerebral Trauma. In: Ropper AH, Samuels MA, Klein JP. eds. Adams & Victor's Principles of Neurology, 10e. New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com/content.aspx?bookid=690&Sectionid=50910886. Accessed July 08, 2015.
"The blindness and paraplegia are usually followed by a throbbing, vascular type of headache."

"Possibly all of these phenomena are the result of an attack of migraine induced by a blow to the head. These focal syndromes can be perplexing for a few hours, especially if it is the first such attack of migraine in a child."
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