Emergency Medicine School Sports Injuries Jordan Barnett, MD FACEP FAAEM 1
Statistics• Bruce and Coworkers report that football caused 66 percent of organized sports related cervical spine injuries• Diving 18 percent• Rugby 9 percent• High School football causes 20 to 30 quadriplegic injuries per year! 2
Cervical Spine injuries in Football• 72 percent of cervical cord injuries occur during tackling• 50% of college football players have experiences a paresthesia at least once 3
Rugby and other Sports in Comparison• In rugby, cervical injuries occur primarily when the scrummage collapses in the center and players behind keep pushing.• In rugby, injuries during tackling uncommon due to lack of a helmet and different tackling techniques• Soccer (most widely played team sport), low rate of spinal cord injuries.• Wrestling, horseback riding, gymnastics, and trampoline relative small number of cord injuries 4
Three Major Priorities• Ensure patient survival by following the ABCDEs of trauma care• Preserve Residual Spinal cord function by stabilizing the injured spinal column and avoiding secondary injury to the spinal cord• The Emergency Department should initiate treatments aimed at allowing the highest possible chance for the injured cord to recover. 6
Fourth Priority after stabilization• After completion of Emergency Care, restore the bony stability of the spinal column• Even the permanently quadriplegic patient needs bony vertebral stability. 7
Causes of Secondary Injury to Spinal Cord• Unnecessary motion of an unstable spinal column• Hypoxemia• Edema• Continued pressure on the cord by an extrinsic mass• Shock state reducing perfusion to the injured spinal cord 8
Spinal Neurogenic Shock• Hypotension• Paradoxical Bradycardia• Warm Dry Skin• Adequate Urine output• The ED/Medic will support the BP in a patient with neurogenic shock with an alpha 1 stimulating drug (i.e., Levophed). Optimal blood pressure to maintain is unknown, yet animal experiments suggest a pressure near normal might aid in perfusing injured area of the cord.• Somewhat controversial, ED may start high dose methylprednisolone as soon as practical after diagnosing a spinal cord injury 14
Whats with the Contraptions?• Key means of preserving and regaining cord function is removing any extrinsic source of pressure on the spinal cord• Thoracolumbar injuries usually reduce in the supine position on a rotary bed• Cervical injuries use the Gardner-Wells tongs with weight added in 5-10 lb increments up to certain weight limits (10 lbs with c1 or 2 injuries, 50 lbs or more with lower cervical segment injuries)• Excessive traction can permanently destroy cord or nerve root function. 15
Disposition?• Patient with significant Spinal Column or Cord injury should be managed at a regional trauma center or spinal cord injury center! 16
Cervical Spine Clearance in the ED• NEXUS or Canadian Rules• Post-traumatic pain or tenderness to neck• Loss of consciousness• Transient or persistent numbness or paresthesia• Impaired level of consciousness• Intoxication• Evidence of head injury• Distracting injuries 17
Closed-Head Injuries• Closed Head Injuries are divided into diffuse and focal lesion• Diffuse injuries are divided into concussion syndromes and prolonged traumatic coma• Concussion is a typically a transient loss of consciousness that occurs immediate following a nonpenetrating blunt impact to the head. LOC not necessary, however• Duration usually short, yet can last for hours
The CDC defines a concussion as "a complex pathophysiologic process affecting thebrain, induced by traumatic biomechanical forces secondary to direct or indirect forces tothe head."
Pathophysiology• LOC due to impairment of the reticular activating system caused by rotation of the cerebral hemispheres on the brainstem• It occurs when the head, while moving, strikes or is struck by an object
Recovery• Usually, recovery from concussion is complete without sequelae• Persistent headache and problems with memory, anxiety, insomnia and dizziness can persist in some patients for weeks and sometimes months.
Repeated concussions over time can lead to a conditionknown as dementia pugilistica, with long-term impairmentsto speech, memory and mental processing.
Diffuse Axonal Injury• Tearing or Shearing of nerve fibers occurring at the time of impact• Site and degree of DAI determined by direction, magnitude and duration of the angular force applied to the head• It can occur also in mild head injury diffusely or focally• Coma lasting for at least 6 hrs appears to result from DAI
Post Concussion Syndromes• Loss of memory, hearing problems, sensitivity to alcohol, depression and visual disturbances often present• Evidence of organic brain damage on neuropsychological testing• One study’s results- 34 percent of patients gainfully employed before an accident were unemployed 3 months after the injury. Probably due to problems with judgement, attention, concentration, and memory (litigation playing a role?)
Second Impact Syndrome• ImPACT Clinical Testing• A test given to athletes after a concussion to measure their performance in attention span, working memory, sustained and selective attention time, response variability, problem solving and reaction time. Comparing a "concussed" athletes performance on the test with a baseline measurement will help the physician decide if the brain has healed sufficiently.
The International Symposium on Concussion in Sport “document” states that neuropsychological testing should bepart of a comprehensive and systematic approach to concussion injury.
Returning an athlete to participation prior to complete recovery may greatly increase the risk of lingering, long-term, or catastrophic neurologic sequelae. As such, acute assessment of injury and determination of existingsymptoms that may indicate incomplete recovery proves critical to the safe management of the concussed athlete.In short, no athlete should return to participation until all signs and symptoms of concussive injury have completelyresolved
Cerebral Contusion• Usually over the crest of gyri• Usually hemorrhagic and surrounded by edema with overlying subarachnoid hemorrhage frequently present• Occur under the site of impact or on contralateral side• Typical locations are the frontal poles, subfrontal cortex and anterior temporal lobes.
Post-traumatic Seizures• Defined as as seizures occuring from 1 week to 1 year of time of injury• Usually associated with fractures with tear of the dura or brain with intracranial hematomas• Usually treated with anticonvulsants for two years seizure free interval has passed.