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Kin 188  Head And Neck Evaluation And Injuries
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Kin 188 Head And Neck Evaluation And Injuries

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