Cerebrum Higher thought, mvmt & sensation Cerebellum - Balance & coordination Brainstem - Life-sustaining functions i.e.

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1 H. Head Injuries Skull Bones: frontal, 2 temporals, 2 parietals, 1 occipital, sphenoid, ethmoid (mastoid process & foramen magnum) The Brain: Cerebrum Higher thought, mvmt & sensation Cerebellum - Balance & coordination Brainstem - Life-sustaining functions i.e. breathing/heartbeat Meninges 1. Dura mater 2. Arachnoid mater 3. Pia mater "Potential Spaces" Adjacent to Meninges 1. Epidural Space Between Skull & Dura Mater 2. Subdural Space Between Dura Mater & Arachnoid Mater 3. Subarachnoid Space Between Arachnoid Mater & Pia mater "Cerebrospinal Fluid"(CSF) Straw Colored Fluid that circulates through spaces in brain & spinal cord Layers in the Head Superficial to deep: Skin Skull Epidural space Dura mater Subdural space Arachnoid mater Subarachnoid space Pia mater Cerebral cortex

2 I. Scalp Contusions, Lacerations, Hematomas S&S: Laceration profuse bleeding; Contusion ecchymosis & swelling; Hematoma - goose egg Rx: Laceration - Locate source & control bleeding with pressure (unless skull fx suspected!!!); Apply antiseptic; If wound > ½ " long & 1/8 " deep, see M.D.; Contusion/Hematoma Ice & compression see MD if hematoma not improved in 1 day. SCALP LACERATION J. Skull fractures S&S: Blood or clear fluid (CSF) leaking from nose or ear; Unequal pupil size; Discoloration around eyes (raccoon eyes) or behind ears (Battle's sign); Swelling or dent on any part of the head; Headache, Nausea A skull fx should be suspected if concussion has occurred with LOC. Rx: Immobilize. Activate EMS - Bone fragments can lacerate brain! Treat shock. Light pressure with sterile gauze to control bleeding. Clearance: MD must clear CSF leakage K. Brain Injuries Battle's Sign (Temporal Bone Fx) MOI: Direct Impact - "coup" injury; Indirect Impact - Acceleration & deceleration brain mvmt in skull = "countercoup" injury (injury on side opposite of impact); Cumulative trauma can lead to brain injury. Diffuse shearing of brain structures can also occur

3 1. Brain Contusion (intracranial bleeding) S&S: HA, Dizziness, nausea, numbness, weakness, loss of memory, aphasia (loss of speech/comprehension), LOC & later athlete becomes very alert & talkative. More symptoms may emerge hours to days after injury!!! Rx: Activate EMS 2. Concussion Disturbed neural function due to trauma. Diffuse brain injury. Shear force can tear axons. S&S: Tons possible!!! (see below for a few) Rx: VARIABLE depending on severity. Some Post Concussion Symptoms Headache Nausea/Vomiting Drowsiness Numbness/Tingling Loss of Consciousness Hearing Disturbance Light Sensitivity Noise Sensitivity Increased Emotions (Labile) Irritability Sadness Nervousness Disturbed Balance Feeling "Slowed Down" or "in Fog" Visual Disturbance Disturbed Concentration Retrograde Amnesia = loss of memory of events prior to injury Altered Sleep (+ or -) Impaired Memory Anterograde Amnesia = Loss of memory of events after injury What should ATC do for athlete with loss of consciousness after impact? o If alone, call 911 Suspect spine injury & skull fx until cleared. Use spine board if move athlete Note time, note body position (abnormal postures may indicate severe head injury, Determine level of consciousness & responsiveness (Glascow Coma Scale) Assess ABCs. Unscrew face mask; Remove dentures/mouthguards. Don't remove helmet until skull fracture & spine injury are cleared!!! If prone, roll over ONLY if not breathing. Ensure spine is stabilized! Monitor vitals (HR/Breathing/Temp/BP)

4 History If conscious ask about symptoms & MOI ("What happened?" "Do you feel OK?" "Does your head or neck hurt?" "Can you move your hands and feet?" "How's your vision, hearing, sensation?") (Seeing stars/flashing lights, blurred vision, double vision = "diplopia", ringing in ears = "tinnitus") If unconscious ask other athletes about MOI. Observation Note Loss of Consciousness (LOC), Seizures, Vomiting, Abnormal Gait/Balance. Signs of Skull fracture - Battle's sign, "raccoon eyes", Blood or CSF drainage (straw colored fluid) from nose {rhinorrhea} or ears {otorrhea} Pupil Abnormalities Palpation (PEARL = pupils equal, accommodate ( size when object approaches), round & reactive to light) Visual tracking (up/down/right/left). Nystagmus Vision have read scoreboard or small eye chart Gently/systematically palpate skull/face/ cervical spine for abnormality Special Tests - Neurological Screening Cognition (thinking) Note confusion, speed of response, distractibility and incorrect responses Orientation (time, place, person, & circumstances of injury) Concentration ("Serial 7s" = count bkwd from 100 by 7s; Name months in backward order) Immediate memory ("who's the opponent", "what's the score") Delayed recall (recall of 3 words at 0 and 5 minutes) Note amnesia Sensation (light touch, pain) Motor (muscle) function Strength Exertional Tests (jogging - 40-yard sprint, sit-ups, push-ups, knee bends) Balance Romberg (arms cross chest and hands touch opposite shoulders. Do with feet together, tandem stance or single limb stance; Test is + (meaning abnormal) if marked sway, balance, or inability to keep eyes closed Coordination Finger to nose to examiner's finger; Heel to toe walking; standing heel to knee test. Rapidly alternating movements

5 NOTE: If intracranial pressure increases, responses will change, so monitoring every 5 minutes must continue until condition improves!!! If S&S worsen rather than improve, assume increasing ICP(intracranial pressure) ---activate EMS Monitor Post concussive athletes closely after return to play. Reevaluate after the playing & at 24 & 48 hours post-injury to identify any delayed onset of symptoms. (Give parents/roommate written & verbal instructions in what to look for) If athlete has LOC or >15 min of amnesia see MD on day of injury Don't let the athlete return to play if he/she continues to have symptoms of concussion at rest or during exertion!!! Glascow Coma Scale (GCS) Rates brain function Score: 3-8 = Severe Impairment; 9-12 = moderate impairment; = mild impairment AREA TESTED GRADE RESPONSE Eye Opening 4 Spontaneous 3 To Loud Voice 2 To Pain (pinch trap/axilla etc ) 1 No response Motor Response 6 Follows Simple Commands 5 Localizes to Pain by moving examiner's hand etc 4 Withdraws from Pain 3 Flexes body inappropriately to pain 2 Rigid Extension to pain 1 No Response to Pain Verbal Response 5 Oriented correctly converses re place, self, time 4 Confused Conversation 3 Inappropriate (no sense) 2 Sounds 1 No noise How does an ATC grade a concussion's severity? There are many concussion grading systems. Below are a few.

6 Cantu, Colorado & AAN Concussion Grading Guidelines: Grade Cantu Colorado AAN 1 Mild No LOC Amnesia or other S & S clear in < 1 hr No LOC Transient confusion No Amnesia No LOC Transient confusion S&S last <15 min 2 Moderate LOC <1 min & amnesia & Post concussive S&S last > 1/2 hr & < 1 day 3 Severe LOC> 1 min or Amnesia >1 day or Post concussive S&S > 1 week No LOC Confusion with amnesia Any LOC No LOC S&S last > 15 min Any LOC Generally speaking: A Mild concussion has no LOC and any other S&S clear in less than ½ hour. A Moderate concussion has no LOC (or only LOC for seconds) and other S&S last greater than ½ hour. A Severe concussion has LOC (longer than seconds) and S&S last greater than a day. How does an ATC decide when an athlete who's had a concussion can return to sport? There are many "return to play" guidelines. Generally speaking, Mild concussion After a 1 st concussion, the athlete can return to play after 20 minutes of no S&S (at rest and with exertion!) After the 2 nd concussion, the athlete can return to play after 1 week of no S&S After the 3 rd, he/she is out for the season. Moderate Concussion After a 1 st, the athlete can return after 1 week symptom free After a 2 nd, the athlete can return after 1 month if symptom free for 1 week After a 3 rd, end season Severe Concussion After a 1 st, the athlete can return after 1 month if symptom free for 2 weeks After a 2 nd, end season After a 3 rd, consider ending career

7 OTHER RULES OF THUMB FOR POST CONCUSSION CLEARANCE If athlete has any Post concussive S&S during exertion or rest, do not allow to return to contact/collision sport!!!! & keep monitoring-- don't leave alone!!! When athlete is asymptomatic, gradually increase activity. Back off to previous level for a day if symptoms occur at a more strenuous level. Comparison of Cantu, Colorado and AAN Concussion Return to Play Guidelines: Grade # Concussions Cantu Colorado AAN 1 Mild 1 st No S&S x 1 wk Abnormal MRI/CT = END SEASON 2 nd Out 2 wks+ No S&S 20 min No S&S within 15 min No S&S x 1 wk No S&S x 1 wk No S&S x 1 wk 3 rd END SEASON May return next season if no S&S END SEASON May return in 3 mo if no S&S 2 Moderate 1 st No S&S x 1 wk No S&S x 1 wk No S&S x 1 wk 2 nd No play x 1 mo & No S&S x 1 wk 3 rd END SEASON Next season if no S&S No play x 1 mo May return if no S&S END SEASON Next season if no S&S No S&S x2 wks Abnormal MRI/CT = END SEASON 3 Severe 1 st No play x 1 mo & No S&S x 1 wk EMS No play x 1 mo May Return if no S&S x 2 wks EMS if LOC/neuro abnormality Return in 1 wk if no S&S (& LOC secs) Return if no S&S x 2 wks (if LOC mins) 2 nd END SEASON END SEASON Return if no S&S x 1 mo 3 rd END SEASON & DISCOURAGE RETURN

8 3. Post Concussion Syndrome Persistent headache, dizziness, fatigue, irritability, & impaired memory or concentration which can persist for months after a concussion No treatment. No return to sport until resolved 4. Secondary Impact Syndrome Rapid swelling & herniation of brain which can result in DEATH when 2 nd head injury is sustained prior to resolution of S&S of 1 st head injury. S&S athlete looks stunned; can't walk off field on their own; within 15 seconds to minutes LOC; Coma; Dilated pupils, loss of eye movements; respiratory failure; ½ die Rx Activate EMS!!! ASAP 5. Hemorrhage Damage to BVs resulting in hematoma (pooling of blood in a space); Damaged Arteries = fast bleed; Damaged Veins = slow bleed 6. Epidural Hematoma MOI: Direct Blow to head resulting in tear of BVs between the dura mater & skull. S&S: LOC. Few/no S&S immediately upon regaining consciousness. Gradual worsening of S&S within minutes as hematoma size s. HA, dizziness, nausea, unequal pupil dilation; contralateral weakness, decerebrate posturing, sleepiness decreased consciousness, neck (nuchal) rigidity, decreased HR, decreased breathing, convulsions Rx: Activate EMS - intracranial pressure must be decreased! 7. Subdural Hematoma - Most frequent cause of death from sport trauma. MOI: Tear of BVs between dura mater & brain (usually veins ---slow bleeding & slow onset of sxs i.e. several hours to days); Due to acceleration forces not impact! S&S: Unconsciousness, uneven pupils; HA, dizziness, sleepiness, nausea/vomiting, decreased pulse, gradual increase in BP, dypsnea (shortness of breath) Rx: Medical Emergency Activate EMS

9 8. Skull Fractures -Suspect with trauma to head. Complication = septic meningitis (torn Dura mater allows bacterial infection to enter site) SKULL FRACTURE IS MORE COMMON THAN SUBDURAL HEMATOMA WHICH IS MORE COMMON THAN EPIDURAL HEMATOMA a. Eyebrow fracture S&S - Raccoon eyes; Bony fragments can damage olfactory & optic nerves resulting in blindness and diminished sense of smell b. Basilar Fracture - Fx to base of skull S&S May have Hearing Loss, Facial Paralysis, Battle's sign (discoloration behind ear); Blood/CSF leakage from nose/ ear. "Halo test" - Absorb some fluid on sterile gauze, then see if there is a separation of the CSF from the blood. It determines if CSF is present in add'n to blood; Signs of Fracture o Visible Deformity ("Goose egg" may mask) o Deep Laceration/Bruise to Scalp o Palpable Depression/Crepitus (Grating) o Unequal Pupils o Raccoon Eyes/Battle's Sign o CSF/Bleeding from Nose/Ear o Anosia (Loss of Smell) o Visual Changes o LOC > 2 minutes Treatment for Suspected Skull Fracture o Activate EMS o Stabilize Head/Neck o Monitor ABCs o Take Vitals (Heart rate/breathing Rate/Blood Pressure/Temperature) o Inspect for Swelling/Discoloration (Raccoon Eyes, Battle's Sign) o Inspect for Blood/CSF leakage ("Halo Test") o Assess Pupils/Eye Movement o Palpate(Gently) for depressions, blood, crepitus o Palpate (Gently) c/s for neck injury o Rx by covering wounds with sterile gauze, but don't apply pressure if suspect fx o Rx by elevating head/upper body only if there are no signs of shock o Rx shock and continue to monitor ABCs o Recheck vitals every 5 minutes until EMS arrives