Kin 188 Head And Neck Evaluation And Injuries


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  • Kin 188 Head And Neck Evaluation And Injuries

    1. 1. KIN 188 – Prevention and Care of Athletic Injuries Head and Neck Evaluation and Injuries
    2. 2. Anatomy
    3. 3. Anatomy <ul><li>Bony anatomy </li></ul><ul><li>Brain </li></ul><ul><li>Meninges </li></ul>
    4. 4. Bony Anatomy <ul><li>Skull </li></ul><ul><ul><li>Provides protection for brain </li></ul></ul><ul><ul><li>Reduces forces transmitted to brain (thickness and shape) </li></ul></ul><ul><li>Occipital bone </li></ul><ul><ul><li>Inion – “bump of knowledge” </li></ul></ul><ul><li>Parietal bones </li></ul><ul><li>Frontal bone </li></ul><ul><li>Temporal bones </li></ul><ul><li>Sphenoid bones </li></ul>
    5. 5. Bony Anatomy
    6. 6. Brain <ul><li>Cerebrum </li></ul><ul><li>Cerebellum </li></ul><ul><li>Brainstem </li></ul>
    7. 7. Brain
    8. 8. Cerebrum <ul><li>Anatomy </li></ul><ul><ul><li>Two hemispheres separated by longitudinal fissure </li></ul></ul><ul><ul><li>Each hemisphere has frontal, parietal, temporal and occipital lobes </li></ul></ul><ul><ul><li>Sulci and fissures form contours </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Controls primary motor functions </li></ul></ul><ul><ul><ul><li>Gross and sequenced, coordinated movements </li></ul></ul></ul><ul><ul><li>Processes sensory information </li></ul></ul><ul><ul><ul><li>Temp, touch, pain, pressure, proprioception, vision, hearing, smell, taste </li></ul></ul></ul><ul><ul><li>Cognitive function </li></ul></ul><ul><ul><ul><li>Spatial relationships, behavior, memory </li></ul></ul></ul>
    9. 9. Cerebellum <ul><li>Located at posterior and inferior aspect of brain </li></ul><ul><li>Two hemispheres separated by fissure </li></ul><ul><li>Processing center for incoming and outgoing information relative to maintaining balance and coordination </li></ul><ul><ul><li>Quick link to cerebrum for processing sensory information </li></ul></ul><ul><ul><li>Quick link to musculoskeletal system to carry out proper muscular contractions and joint movements </li></ul></ul>
    10. 10. Brainstem <ul><li>Relays info to and from central nervous system and controls involuntary systems </li></ul><ul><li>Medulla oblongata </li></ul><ul><ul><li>Links cerebrum to brainstem and spinal cord </li></ul></ul><ul><ul><li>Regulates heart and respiratory rates, vascular changes, coughing, vomiting </li></ul></ul><ul><li>Pons (“bridge”) </li></ul><ul><ul><li>Links cerebellum to brainstem and spinal cord </li></ul></ul><ul><ul><li>Regulates respiratory rate </li></ul></ul>
    11. 11. Meninges <ul><li>Collectively, support and protect brain and spinal cord </li></ul><ul><li>Dura mater (“tough/hard mother”) </li></ul><ul><li>Arachnoid mater (spider web appearance) </li></ul><ul><li>Pia mater (“little mother”) </li></ul>
    12. 12. Meninges
    13. 13. Evaluation
    14. 14. Primary Survey <ul><li>Stabilize cervical spine </li></ul><ul><li>A – Airway </li></ul><ul><ul><li>Ensure that airway is clear (mouthpiece, tongue, etc.) </li></ul></ul><ul><li>B – Breathing </li></ul><ul><ul><li>Look, listen and feel </li></ul></ul><ul><li>C – Circulation </li></ul><ul><ul><li>Evaluate for presence carotid pulse </li></ul></ul><ul><li>D – Disorientation/Dysfunction </li></ul><ul><ul><li>Conscious vs. unconscious </li></ul></ul>
    15. 15. Unconscious Athlete <ul><li>Activate EMS </li></ul><ul><li>Must assume that athlete has head and/or cervical spine injury </li></ul><ul><li>If ABCs not intact, must initiate rescue breathing or CPR </li></ul><ul><li>If ABCs intact: </li></ul><ul><ul><li>Establish and monitor vital signs </li></ul></ul><ul><ul><li>Evaluate pupil response (PEARL) </li></ul></ul><ul><ul><li>Palpate skull and c-spine for deformity, swelling, etc. </li></ul></ul>
    16. 16. Conscious Athlete – Secondary Survey <ul><li>Assumes ABCs intact – establish and monitor vital signs </li></ul><ul><li>History </li></ul><ul><ul><li>Loss of consciousness, mechanism of injury, symptoms (pain, numbness/tingling, etc.) </li></ul></ul><ul><ul><li>Orientation x 4 (self, others, place, time) </li></ul></ul><ul><li>Inspection </li></ul><ul><ul><li>Skull/c-spine alignment </li></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>For bony deformity, swelling, muscle spasm (guarding) </li></ul></ul><ul><li>Neurological screening </li></ul><ul><ul><li>Sensory testing (dermatomes) compared bilaterally </li></ul></ul><ul><ul><li>Motor testing not performed clinically – if all other symptoms negative, may ask to wiggle fingers and toes to establish distal motor function </li></ul></ul>
    17. 17. History <ul><li>Location of symptoms </li></ul><ul><li>Mechanism of injury/etiology </li></ul><ul><ul><li>Head vs. cervical spine </li></ul></ul><ul><li>Loss of consciousness </li></ul><ul><li>Prior history of head injury </li></ul><ul><li>Complaints of weakness </li></ul>
    18. 18. Location of Symptoms <ul><li>Cervical pain or muscle spasm </li></ul><ul><ul><li>More concerning if accompanied by numbness, tingling, burning sensations and/or radiating pain </li></ul></ul><ul><li>Head pain </li></ul><ul><ul><li>If localized, may indicate contusion, skull fracture and/or intracranial bleeding </li></ul></ul><ul><ul><li>Most common complaint is headache </li></ul></ul>
    19. 19. Mechanism of Injury <ul><li>Head injuries </li></ul><ul><ul><li>Coup – stationary skull struck by high velocity object, results in trauma at site of impact </li></ul></ul><ul><ul><li>Contrecoup – moving skull strikes a non-moving object, brain “floats” and strikes skull opposite impact causing trauma </li></ul></ul><ul><ul><li>Repeated subconcussive forces – cumulative neurological deficits </li></ul></ul><ul><ul><li>Rotational or shear forces – sudden acceleration/deceleration forces, can disrupt CNS activity and result in concussive symptoms </li></ul></ul><ul><li>Cervical spine injuries </li></ul><ul><ul><li>May involve any ROM (flexion, extension, lateral flexion and/or rotation – may be combined) </li></ul></ul><ul><ul><li>If flexed ~30 degrees, lordotic curve is lost and cervical spine most susceptible to axial load injury (unable to dissipate forces) </li></ul></ul>
    20. 20. Other Historical Elements <ul><li>Loss of consciousness </li></ul><ul><ul><li>Component of memory evaluation </li></ul></ul><ul><ul><li>Can athlete or others establish whether there was or was not momentary loss of consciousness </li></ul></ul><ul><li>History of concussion </li></ul><ul><ul><li>Recent history of prior concussion increases risk of second impact syndrome </li></ul></ul><ul><li>Complaints of weakness </li></ul><ul><ul><li>Reports of weakness in extremities may indicate brain, spinal cord and/or nerve root injury </li></ul></ul>
    21. 21. Inspection <ul><li>Bony structures </li></ul><ul><li>Eyes </li></ul><ul><li>Nose and ears </li></ul><ul><ul><li>Otorrhea </li></ul></ul><ul><ul><li>Rhinorrhea </li></ul></ul>
    22. 22. Bony Injuries
    23. 23. Eye Ecchymosis
    24. 24. Palpation
    25. 25. Palpation of Bony Structures <ul><li>Skull </li></ul><ul><ul><li>Palpate all cranial bones for pain and deformity </li></ul></ul><ul><li>Spinous processes </li></ul><ul><ul><li>Palpate cervical spinous processes for pain and crepitus associated with fracture </li></ul></ul>
    26. 26. Palpation of Soft Tissues <ul><li>Musculature </li></ul><ul><ul><li>Palpate sternomastoid and upper trapezius muscles for spasm secondary to strain, sprain, fracture and/or dislocation </li></ul></ul><ul><li>Throat </li></ul><ul><ul><li>Palpate thyroid cartilage, cricoid cartilages and hyoid bone to rule out larynx and tracheal injury </li></ul></ul>
    27. 27. Special Tests
    28. 28. Special Tests <ul><li>Range of motion </li></ul><ul><li>Functional testing – evaluates function of central nervous system (CNS) </li></ul><ul><ul><li>Orientation x 4 </li></ul></ul><ul><ul><li>Memory </li></ul></ul><ul><ul><li>Cognitive function </li></ul></ul><ul><ul><li>Balance and coordination </li></ul></ul><ul><ul><li>Vital signs </li></ul></ul>
    29. 29. Range of Motion <ul><li>Active/passive/resistive neck flexion </li></ul><ul><ul><li>Chin to chest </li></ul></ul><ul><li>Active/passive/resistive neck extension </li></ul><ul><ul><li>Look directly above head </li></ul></ul><ul><li>Active/passive/resistive neck rotation </li></ul><ul><ul><li>Chin almost in line with shoulder </li></ul></ul><ul><li>Active/passive/resistive neck lateral bending </li></ul><ul><ul><li>Approximately 45 degrees to each side </li></ul></ul>
    30. 30. Orientation <ul><li>Orientation x 4 </li></ul><ul><ul><li>Self </li></ul></ul><ul><ul><ul><li>Own name </li></ul></ul></ul><ul><ul><li>Place </li></ul></ul><ul><ul><ul><li>General sense of location </li></ul></ul></ul><ul><ul><li>Time </li></ul></ul><ul><ul><ul><li>General sense, use point in game practice </li></ul></ul></ul><ul><ul><li>Others </li></ul></ul><ul><ul><ul><li>Athletic trainer, coaches, teammates, etc. </li></ul></ul></ul>
    31. 31. Memory <ul><li>Retrograde amnesia </li></ul><ul><ul><li>Difficulty or inability to remember events preceding the injury – more severe if can’t remember events of day before as opposed to more recent events </li></ul></ul><ul><ul><li>Some assessed with orientation x 4, pre-game meal?, who played last game? </li></ul></ul><ul><li>Anterograde amnesia </li></ul><ul><ul><li>Difficulty or inability to remember events after the onset of injury </li></ul></ul><ul><ul><li>Athlete given verbal list of items and asked to repeat them serially over time </li></ul></ul>
    32. 32. Cognitive Function <ul><li>Brain injury can present as abnormal behavior, personality changes, inability to process information accurately </li></ul><ul><li>Behavior </li></ul><ul><ul><li>May become violent, belligerent, etc. - abnormal </li></ul></ul><ul><li>Analytical ability </li></ul><ul><ul><li>Typically assessed with serial number repetitions or spelling forward/backward </li></ul></ul><ul><li>Information processing </li></ul><ul><ul><li>Cannot follow simple instructions </li></ul></ul>
    33. 33. Balance and Coordination <ul><li>Evaluation for possible cerebellar injury affecting muscle coordination </li></ul><ul><ul><li>Romberg test – single leg stance with shoulders abducted 90 degrees, eyes closed and head back </li></ul></ul><ul><ul><li>Tandem walking – heel to toe walking forward and backward along straight line </li></ul></ul><ul><ul><li>Finger to nose – rapid alternating movements </li></ul></ul>
    34. 34. Vital Signs <ul><li>Pulse rate, respiratory rate, blood pressure taken early in evaluation process to establish baseline and repeated serially for comparison </li></ul>
    35. 35. Injuries
    36. 36. Injuries <ul><li>Head injuries </li></ul><ul><ul><li>Concussion </li></ul></ul><ul><ul><li>Post-concussion syndrome </li></ul></ul><ul><ul><li>Second impact syndrome </li></ul></ul><ul><ul><li>Intracranial hemorrhage </li></ul></ul><ul><ul><ul><li>Epidural hematoma </li></ul></ul></ul><ul><ul><ul><li>Subdural hemtoma </li></ul></ul></ul><ul><ul><li>Skull fracture </li></ul></ul><ul><li>Cervical spinal cord injuries </li></ul><ul><ul><li>Cervical spine fracture/dislocation </li></ul></ul><ul><ul><li>Quadraplegia </li></ul></ul>
    37. 37. Concussion <ul><li>Cerebral concussion = mild traumatic brain injury (MTBI) </li></ul><ul><li>Hallmark symptoms include mental confusion, altered mental status, amnesia and potential loss of consciousness </li></ul><ul><li>Multiple occurrences may produce cumulative degenerative effects </li></ul><ul><li>Ultimate assessment based upon duration of loss of consciousness (if any) and neuropsychological findings </li></ul>
    38. 38. Concussion <ul><li>Additional symptoms of concussion may include but are not limited to: </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Tinnitus </li></ul></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><ul><li>Motor impairment </li></ul></ul><ul><ul><li>Memory loss </li></ul></ul>
    39. 39. Concussion Rating Systems <ul><li>Guidelines for identifying concussion severity and determining return to play timeline – often considered conservative for athletic population </li></ul><ul><li>Significant differences between scales – be consistent with scale utilized </li></ul><ul><li>American Academy of Neurology </li></ul><ul><li>Cantu Concussion Rating Guidelines </li></ul><ul><li>Colorado Medical Society Concussion Rating Guidelines </li></ul>
    40. 40. Return to Play Criteria <ul><li>Multiple factors to consider include whether or not loss of consciousness occurred, duration of symptoms, total number of concussive episodes, exertional testing </li></ul><ul><li>Universal agreement that individual who lost consciousness for any period of time should not be allowed to return to activity on the same day even if all symptoms have resolved </li></ul>
    41. 41. Post-Concussion Syndrome <ul><li>Individuals may present with concussion symptoms long after “normal” resolution would have occurred </li></ul><ul><li>Common symptoms include </li></ul><ul><ul><li>Decreased attention span </li></ul></ul><ul><ul><li>Difficulty concentrating </li></ul></ul><ul><ul><li>Memory impairment </li></ul></ul><ul><ul><li>Prolonged headaches </li></ul></ul><ul><ul><li>Balance impairments </li></ul></ul><ul><ul><li>Decreased cognitive function </li></ul></ul>
    42. 42. Second Impact Syndrome <ul><li>Defined as symptoms resulting from second concussive episode before symptoms of first concussive episode have resolved </li></ul><ul><ul><li>Entirely preventable, return to play considerations </li></ul></ul><ul><li>Second trauma typically not as violent as initial injury – thought to affect brain blood supply causing increased intracranial pressure which impacts brainstem function </li></ul><ul><li>Quick progression from mild concussive symptoms to comatose state </li></ul><ul><li>Even if treated appropriately, has ~50% mortality rate </li></ul>
    43. 43. Intracranial Hemorrhage <ul><li>Named for location relative to meningeal layers </li></ul><ul><ul><li>Epidural hematoma </li></ul></ul><ul><ul><li>Subdural hematoma </li></ul></ul><ul><li>Caused by injury to blood vessels supplying brain blood supply </li></ul><ul><li>Increased pressure from bleeding in confined space compresses neural tissue </li></ul><ul><li>Onset of symptoms associated with nature of bleeding – venous vs. arterial (lucid interval) </li></ul>
    44. 44. Epidural Hematoma <ul><li>Arterial bleeding between skull and dura mater </li></ul><ul><li>Initially may present with concussive symptoms </li></ul><ul><li>Short lucid interval (typically <48 hours)– individual appears “OK” </li></ul><ul><ul><li>Due to arterial nature of bleeding </li></ul></ul><ul><li>Subsequently may c/o disorientation, confusion, drowsiness, increasing headache intensity, signs of cranial nerve changes (esp. pupil changes) </li></ul><ul><li>If untreated, can be fatal </li></ul>
    45. 45. Subdural Hematoma <ul><li>Venous bleeding between brain and dura mater </li></ul><ul><li>May not present with symptoms of concussion </li></ul><ul><li>Longer lucid interval – may be hours, days or weeks before symptoms present </li></ul><ul><ul><li>Due to venous nature of bleeding </li></ul></ul><ul><li>Subsequent development of headaches, confusion, changes in cognitive/motor abilities, cranial nerve changes </li></ul><ul><li>More likely to cause death due to lack of recognition of nature/source of symptoms and delay in subsequent treatment </li></ul>
    46. 46. Skull Fractures <ul><li>Minimal risk with head protection, but may still suffer bony injury </li></ul><ul><li>May cause CSF leakage from nose/ear, may have residual/secondary ecchymosis </li></ul><ul><li>Linear </li></ul><ul><ul><li>Hairline fractures in bone </li></ul></ul><ul><li>Comminuted </li></ul><ul><ul><li>Multiple fracture fragments </li></ul></ul><ul><li>Depressed </li></ul><ul><ul><li>Easier to identify on evaluation – gross deformity </li></ul></ul><ul><ul><li>Potential for fragments to injure meninges/brain </li></ul></ul>
    47. 47. Cervical Spinal Cord Injuries
    48. 48. Cervical Spinal Cord Injuries <ul><li>Risk minimized with rules and coaching emphasis changes </li></ul><ul><li>Spinal cord injury caused by </li></ul><ul><ul><li>Impingement/laceration from bony displacement </li></ul></ul><ul><ul><li>Compression from bleeding, swelling, ischemia to cord </li></ul></ul><ul><li>Mechanism of injury is key to decisions on management </li></ul><ul><ul><li>Must assume worst case scenario until proven otherwise </li></ul></ul><ul><li>Trauma at spinal cord level affects function distal to level of injury </li></ul><ul><ul><li>At or above C4 level – death is likely due to impact on brainstem and vital functions </li></ul></ul>
    49. 49. Cervical Fracture/Dislocation <ul><li>Spinal cord injury typically secondary to actual bony injury from swelling, bony fragment displacement, etc. </li></ul><ul><li>With dislocation, diameter of canal for spinal cord is impacted and can compress spinal cord </li></ul><ul><li>Must differentiate between spinal cord symptoms and brachial plexus injury symptoms (longer duration vs. transient symptoms) </li></ul><ul><li>Often treat with steroid injections to limit swelling and subsequent pressure on spinal cord with these injuries </li></ul>
    50. 50. Quadriplegia <ul><li>Transient quadriplegia often results from cervical hyperextension, hyperflexion and/or axial loading </li></ul><ul><li>Several predisposing factors </li></ul><ul><ul><li>Cervical stenosis </li></ul></ul><ul><ul><li>Cervical spine instability </li></ul></ul><ul><ul><li>Posterior arch abnormalities of cervical spine </li></ul></ul><ul><li>If truly transient, symptoms often resolve within 48 hours </li></ul>