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EVALUATION AND MANAGEMENT OF HEAD AND NECK INJURIES

EVALUATION AND MANAGEMENT OF HEAD AND NECK INJURIES. MaryBeth Horodyski, EdD, ATC Associate Professor University of Florida. MINOR VERSUS MAJOR. Minor head injury is NOT always a minor injury!. INCIDENCE OF HEAD INJURY. Millions of “bumps” every year 500,000 significant records

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EVALUATION AND MANAGEMENT OF HEAD AND NECK INJURIES

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  1. EVALUATION AND MANAGEMENT OF HEAD AND NECK INJURIES MaryBeth Horodyski, EdD, ATCAssociate Professor University of Florida

  2. MINOR VERSUS MAJOR • Minor head injury is NOTalways a minor injury!

  3. INCIDENCE OF HEAD INJURY • Millions of “bumps” every year • 500,000 significant records • GCS 13 to 14 • 300,000 sports related • Thurman et al, 1998 • 70,000 with risks of long term deficits • GCS below 12

  4. DEMOGRAPHICS • Age groups with highest incidence • 15 to 24 • 65 to 75 • Males have higher incidence than females

  5. INJURY INCIDENCE • Football • mild concussions represent 85% - 90% • Albright et al, 1988 • 20 - 25% risk of head injury per number of athletes participating each year • nearly 3 times more likely to sustain second injury • Guskiewicz et al, 2000

  6. Without helmets soccer (m) 0.25 soccer (w) 0.24 field hockey 0.20 wrestling 0.20 lacrosse (w) 0.16 With helmets ice hockey 0.27 football 0.25 lacrosse (m) 0.19 softball 0.11 baseball 0.07 RATES OF CONCUSSION

  7. ADDITIONAL RISK FACTORS • Alcohol • Medications • Street drugs • Family issues • Anti-social behavior • History of previous head injury

  8. ANATOMY • Protection of the brain • bony structures • meninges • CSF • Areas of brain • cerebrum • parietal, frontal, occipital, temporal • cerebellum • brainstem

  9. SPECTRUM OF INJURY Correlations of symptoms and pathology is difficult

  10. SPECTRUM OF INJURY • Axonal disruption • Hemorrhage • Brain edema

  11. SPECTRUM OF INJURY • Focal • small concentrated area • high velocity-low mass • most head injuries that result in death are focal injuries. • Diffused • larger injury area • low velocity-high mass forces

  12. BIOMECHANICAL FORCES OF BHT • Coup: forceful blow to a • resting moveable head • Contracoup: moving head colliding • with a non-moving object

  13. BIOMECHANICAL STRESSES OF BHT • Compressive • Force that places direct pressure on a surface or soft tissue • Tensile • Force that tractions or pulls away from the surface • Shear • Force that is directed parallel to a joint or soft tissue surface

  14. SITES OF SHEARING FORCES • Dura mater: brain attachments impeding brain motion • Rough irregular surface contacts between brain and skull • Dissipation of CSF between the brain and skull

  15. MB: I can change the order in which these are presente - Let me know THE PATHOLOGY OF HEAD INJURY IS A DYNAMIC PROCESS • Excitotoxic reticular thalamus injury • Hypoxic-ischemia • Diffuse microvascular injury • Alteration of vascular activity • Focal injury • Diffuse axonal injury

  16. LOCATION OF HEMORRHAGE • Epidural • focal type injury • middle meningeal artery • sequence of events • trauma • initial LOC • lucid interval • lack of response • coma

  17. LOCATION OF HEMORRHAGE • Subdural • most cases the athlete is rendered unconscious at the time of injury • frequently remains unconscious • involved structure • superior cerebral vein

  18. LOCATION OF HEMORRHAGE • Intercerebral • between hemispheres of the brain • structure involved • branch of the middle cerebral

  19. CONCUSSIONImplies minimal structural damage despite interruption of function • Caused by an agitation or shaking of the brain • Often defined as a transient alteration in brain function without structural damage

  20. POST-CONCUSSION SYNDROME • Somatic • dizziness • Cognitive • poor concentration • Affective • depression

  21. SECOND IMPACT SYNDROME • Condition which is limited to adults (?) • Fatal brain swelling following minor head trauma in individuals who still have symptoms from a prior head injury • Autoregulation of the brain is lost • 50% mortality rate 

  22. Long-term cumulative effects if multiple concussive and subconcussive blows to the head Signs of CBI personality changes impaired intellectual functioning motor disturbances slurred speech ataxia CHRONIC BRAIN INJURY

  23. MALIGNANT BRAIN EDEMA SYNDROME • Occurs in the adolescent or pediatric athlete • Rapid neurologic deterioration • Pathologic injury • diffuse brain swelling with little or no brain tissue disruption

  24. TERMINOLOGY • Amnesia • loss of memory • Retrograde amnesia • loss of memory and inability to recall events before the traumatic event • Anterograde amnesia • loss of immediate memory and ability to recall events that have occurred since the injury

  25. TERMINOLOGY • Cheyne-Stokes respiration • breathing pattern characterized by a rhythmic fluctuation between hyperpnea and apnea

  26. TERMINOLOGY • Decerebrate posturing • a rigid extension of all 4 extremities with the arms internally rotated and pronated • upper brain stem injury • Decorticate posturing • a rigid extension of the legs and flexion of the arms, wrist, and hands toward the chest • injury above the brain stem

  27. DOCUMENTATION • Person is oriented yet presents with altered mental state and/or loss of motor tone • Person is mentally unresponsive • inability to obey commands • Evidence of post traumatic amnesia NATA-REF, 1994

  28. DOCUMENTATION • Evidence of post concussion symptoms • headaches, nausea, dizziness, fatigability, loss of concentration • Person reports or was observed to have had LOCNATA-REF, 1994

  29. The initial assessment and management of the head injury may have as great an impact as follow-up neurosurgical procedures!

  30. EVALUATION • Stabilization • ABCs • Glasgow Coma Scale • Concussion grading system • Vital signs • Heart rate • Respiration rate • Blood pressure

  31. CONCUSSION GRADING SYSTEMS • Glasgow Coma Scale • GCS-E • Colorado Medical Society • Cantu Grading System • Galveston Orientation and Amnesia Test • AAN

  32. GLASGOW COMA SCALE • Eyes • Best motor response • Best verbal response • Total: 3-15

  33. GALVESTON ORIENTATION AND AMNESIA TEST • Based on error points • Personal information • Location • Activity before and after injury • Date, time

  34. Grade 1 Confusion without amnesia No LOC Remove from event pending further evaluation Grade 1 RTP - No symptoms at rest/exertion after 20 minutes of observation COLORADO MEDICAL SOCIETY

  35. Grade 2 Confusion with amnesia No LOC Disallow early return to activity Grade 2 RTP Remove from activity One week after the athlete is asymptomatic at rest/exertion COLORADO MEDICAL SOCIETY

  36. Grade 3 LOC Remove from activity Appropriate medical facility Grade 3 RTP Remove from activity One month Asymptomatic for at least two weeks COLORADO MEDICAL SOCIETY

  37. Grade 1 transient confusion no LOC concussion symptoms or mental status abnormalities on examination resolve in less than 15 minutes Grade 1 RTP serial examination every 5 minutes for 15 minutes no lingering symptoms 4 grade 1 concussions in season termination of season AAN

  38. Grade 2 transient confusion no LOC concussion symptoms or mental status abnormalities on examination last more than 15 minutes any persistent grade 2 symptoms lasting more than 1 hour warrants medical observation Grade 2 RTP serial examination including 24 hours post injury may RTP after full week of not symptoms at rest or exertion termination of season with 3 or more grade 2 concussions AAN

  39. Grade 3 LOC brief (few seconds) prolonged (minutes) Grade 3 RTP transport to appropriate medical facility brief withheld until asymptomatic for 1 week prolonged asymptomatic for 2 weeks 2 grade 3 concussions asymptomatic for 12 months AAN

  40. STANDARDIZED ASSESSMENT OF CONCUSSION • Developed in accordance with CMS and AAN • 3 main sections to sideline evaluation • mental status testing • neurological examination • exertional provocative testsMcCrea et al, 1998

  41. CARE OF THE ATHLETE • Stabilization of cervical spine • ABCs • Establish level of consciousness • Decision for additional medical care • Serial examination • Sending the athlete home • information for the parent/guardian

  42. ADDITIONAL ASSESSMENTS • Vital signs • PEARL • Six cardinal fields of gaze • tests cranial nerves III, IV, and VI • lateral movements • vertical movements • combination of movements

  43. ADDITIONAL ASSESSMENTS • Cranial nerves • identification of odors (I) • peripheral vision (II) • pupil size, upward eye movement (III) • downward eye movement (IV) • clench teeth (V) • lateral eye movement (VI) • facial expressions (VII) • hearing, equilibrium (VIII) • swallowing (IX) • voice quality (X) • shoulder shrug (XI) • tongue protrusion (XII)

  44. ADDITIONAL ASSESSMENTS • Motor skills • assess unilateral weakness • ability to follow commands • Reflexes • upper and lower extremities

  45. ADDITIONAL ASSESSMENTS • Special tests • Serial 7 Test • concentration • Romberg • cerebellum dysfunction • Tandem Walking • balance and equilibrium • Finger to Nose Test • upper extremity coordination • Babinski • lower brain stem injury

  46. SEQUELAE OF BHT • Neurological • Psychiatric/psychological • Medical

  47. HEAD INJURY REDUCTION • Improved medical care • Improved conditioning • Equipment • Changes/implementation of rules • Changes in coaching techniques

  48. CERVICAL INJURIES

  49. NECK INJURIES • NCAA and NFHSAA • 1976 rule changes • prevent the use of the head in tackling • Injury rate • 0.3 overall neck injuries/1,000participants • Equipment improvements • Potential of injury still exists

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