head injuries Flashcards
what does the research support in instances of head injuries? a change in protective equipment or a change in rules?
change in rules is more supported
- change in equipment may allow people to feel more invincible
- equipment can reduce impact forces but studies aren’t inclusive in demonstrating prevention
- athletes change their playing behaviours if they believe their equipment prevents all injuries
what are 4 examples of how helmets offer multiple layers of protection?
1) round, hard outer layer: deforms to chock and then rebounds forces (deflect)
2) layer of polymer: columns move in multiple directions to reduce force (absorbs)
3) face mask: spreads forces over larger area (dissipates)
4) soft layer of memory foam: for comfort and peoper fit (absorbs)
______ Canadians sustain brain injuries each year
165,000
50% of brain injuries in Canada are due to what?
falls or MVAs
30% of brain injuries are experiences by who?
children and youth while participating in sport or activities
there are currently over _____ people living with the effects of an acquired brain injury
1 million
are concussions more common in males or females?
more in males according to stats Canada in 2010
where are the peak times people get concussions?
peaks at teenagers/young adults and then again with middle aged groups
who has the highest risk of concussions? (which sport)
cheerleaders
-also very common in basket ball
concussion -def
“mild traumatic brain injury (mTBI)
- complex pathophysiological process brought on by traumatic biomechanical forces which affect the brain
- head injury that temporarily affects brain function
concussions - MOI
- direct blow to the head - head hit by moving object or moving head hits fixed object
- direct blow to the body - acceleration/deceleration force indirectly act on the brain
what is a coup vs countercoop injury
coup: impact at direct site
countercoop: shifting going back - impact on opposite side
concussion - S&S
- shearing forces disrupt axonal connections - not visivle lesions, can’t x-ray, MRI, CAT scan, etc.
- functional brain disturbance rather than a structural injury - fMRI and EEG may show slight alternations in brain activity patterns
variety of symptoms:
- disorientation or amnesia
- motor, coordination, balance deficits
- cognitive deficits
- loss of consciousness (may or may not occur)
what are the most common S&S of concussions?
- dizziness
- headache (#1 reported symptom)
- blurred vision
- nausea
may also have:
- altered LOC
- amnesia (retrograde: events prior; anterograde: loss after)
FOP concussion assessment: unconscious
1) assess scene safety
2) stabilize head and C-spine
3) assess UABC’s (primary survey) - if unconscious, call 911 and request AED
- open airway and look for obstruction and assess breathing
- assess pulse and scan for bleeding
- treat for shock
4) assess DEFG (secondary survey)
- vital signs
- full body scan
- SAMPLE history
- monitor vitals and treat shock
FOP concussion assessment: conscious
1) scene safety and ask permission to help
2) assess UABC’s (primary)
- R/O spinal and MSC injury
- treat shock
3) assess DEFG (secondary)
- vital signs
- SAMPLE and injury history
- focused scan of head and face - structural injury must be ruled out (numbness and tingling, muscle guarding, crepitus, deformity, pain), CAUTION be aware that some S&S may develop later
- removal from FOP - graded and controlled - look for balance and or gait disturbances, confusion, vacant look
- complete a sideline concussion assessment (SCAT5) remove them to somewhere quiet and private
- if noone on scene has training, send to hospital
what are red flags that are indications of severe head injury?
- neck pain or tenderness
- weakness, N/T or burning sensation in the arms and or legs
- increasingly restless, agitated, or combative
- high risk MOI - high velocity impact or vertical falls
- immediate or prolonged UNC or deteriorating LOC; GCS under 8
- evidence of a skull fracture or penetrating skull trauma - CSF and blood from ears, nose or mouth, raccoon eues, battle sign, deformity
- focal neurological signs - i.e problems with hearing, vision, or eye movements, paralysis, weakness in extremities, unequal pupil size, drooping eyelid, difficulty swallowing
- seizure(s) or convulsive movements
- persistent vomiting
- progressive worsening headache or intense pressure
- worsening of any S&S over time
- any difficulty encountered during assessment
what is the SCAT5?
a tool to help health care professionals assess for the possible presence of concussions immediately after an injury
- should not be used as a stand alone method for diagnosis
- baseline testing not necessary
SCAT5: symptom evaluation
- many S&S in isolation are not indicative of a concussion
- MOI and one symptoms indicates a possible concussion
SCAT5: cognitive screening
- orientation (time and place)
- memory (5 or 10 word recall)
- concentration (digits or months of the year repeated backwards
SCAT5: neurological screen and balance exam
- finger to nose, finger to finger, etc
- standing on single foot, tandem, semi tandem, etc.
SCAT5: delayed recall
-go back to see if they recall words from beginning
concussion: management
1) NO return to current game or practice
2) DO NOT leave athlete or individual alone
- regular monitoring for deterioration or post concussion symptoms is essential esp overnight and for next 24-48 hours
- no meds without medical supervision
- no sleeping tablets
- no aspirin or NSAIDs or stronger pain meds
- we want to monitor if symptoms are getting worse
- no alcohol
- no driving
3) a medical evaluation is a necessity, may involve neuropsychological testing to estimate recovery of cognitive function
what is the gradual RTP protocol for concussions?
1) symptom limited activity
2) light aerobic exercise
3) sport specific exercise
4) non contact training drills
5) full contact
6) return to sport
there should be at least 24 hours (asymptomatic) between each step in the progression
- if any symptoms worsen, go back to last step
- if symptoms persist for more than 10-14 days, refer to concussion specialist
what is the gradual return to school protocol for concussions?
1) daily activities at home that do not give the child symptoms
2) school activities
3) return to school part time
4) return to school full time
SCAT5 for ages 5-12
- may present with different symptoms, may require parents input to complete
- neuropsychological testing and timing requires adjustments at school and at home (due to development and or maturation of cognition)
- recovery time may be longer than adults
- cognitive rest is highlighted
- limited scholastic and other cognitive stressors (texting, computer, video games, reading)
- recommend to return to learning prior to RTP - but in some situations it could be computer screens that are irritating
- REQUIRES a more conservative approach for RTP
post-concussion syndrome
- poorly understood condition
- persistent S&S following a concussion - headaches, vision and balances problems, irritability, inability to concentrate
- S&S begin immediately or within days of injury
- may last weeks, months, or years
- occurs with both mild or severe concussions
post concussion syndrome: management
- no clear cut treatment - customized to each individual
- may experience increase anxiety regarding slow or no progression
- important to focus on what the athletes CAN do and not on what they can’t
what is a useful early strategy for the management of post concussion syndrome?
decreasing stimulation
- use of sunglasses
- limited use of monitors or screens or screen modifications and light settings
- earplugs, limited exposure to noisy environments
- sporting environments may be too stimulating however complete avoidance of these environments is not recommended due to the importance of peer support and maintaining routine - meet with teammates or staff in quiet
second impact syndrome (SIS)
rapid swelling and herniation of the brain after a 2nd head injury occurs before the symptoms of a previous head injury have resolved
-disrupted cerebrovascular auto-regulation leads to swelling, which significantly increases intracranial pressure and compromises the brain stem
what is the cause of second impact syndrome?
- caused by premature RTP
- 2nd impact may only be a minor blow to the head or body
- adolescents and child more susceptible
second impact syndrome: S&S
- often no LOC - patient may be able to leave FOP
- within seconds to minutes symptoms drastically worsen (dilated pupils, loss of eye movement, LOC leading to coma, respiratory failure)
- mortality rate is 50%
second impact syndrome: management
- PREVENTION IS KEY
- educate athletes, coaches, and parents
- follow graduated RTP protocol
chronic traumatic encephalopathy
- progressively degenerative brain disease; abnormal build up of tau protein
- may occur months, years, or decades after repetitive head trauma
- can only assess tau protein after death
- common in athletes with history of repetitive trauma
- leads to chronic mild cognitive impairments, depression, and other mental health problems (impulse control, aggression, dementia)
what are the three major types of cerebral contusions?
1) epidural hematoma (betwenn dura mater and skull)
2) subdural hematoma (under dura mater)
3) intracranial hematoma
which is more common? subdural or epidural hematoma?
subdural
what is the most common cause of death in athletes?
subdural hematoma
subdural hematoma: MOI
acceleration/deceleration forces tear vessels bridging dura mater and brain
-due to indirect blow to body (contrecoup injury)
acute subdural hematoma
rapid progression due to arterial bleed
chronic subdural hematoma
slow, low-pressure die to venous bleed
S&S of subdural hematoma
- simple: conscious
- complicated: unconscious
- dilated pupil (same side as injury)
- headache
- dizziness
- nausea
- sleepiness
management of subdural hematoma
- immediate medical attention
- CT scan or MRI for diagnosis
intracranial hematoma - def
-bleeding within cortex, brain stem, or cerebellum
intracranial hematoma - MOI
usually a direct blow to head
S&S of intracranial hematoma
- vary depending on extent and site of injury
- LOC, followed by alert and talkative
- headache, dizziness, nausea
management of intracranial hematoma
hospitalization for CT scan or MRI
skull fracture - MOI
blunt trauma to head or body
S&S of skull fracture
- severe headache and nausea
- altered LOC or UNCOC
- palpable deformity
- blood/CSF in ear and or nose (halo test)
- ecchymosis around the eyes (raccoon eyes)
- ecchymosis behind the ears (Battle’s sign)
what is a more serious secondary condition to skull fractures?
more serious problems are the possible secondary complications such as intracranial bleeding, bone fragments on brain, and infection
management of skull fractures
- recognize S&S asap and activate EMS immediately
- monitor vital signs and treat for shock
- control any bleeds: bandage skins wounds as necessary; carefully with padding
TBI’s often require surgery to repair:
- epidural: decompression
- subdural: drainage via shunts
- intra-cranial: decompress, drainage, and repair
scalp injuries are usually due to ____ or ____ traum
blunt, penetrating
-ex: collision or equipment
what are two different scalp injuries
Lacerations: extensive bleeding because highly vascularized
Contusion: little to no bleeding, visible hematoma
-both localized pain and swelling
management of scalp injuries (ex: lacerations, contusions)
- clean and control bleeding; apply sterile dressing; refer to physician
- prevent contamination
- assess for associated skull fracture, concussion or cerebral hematoma
what are three different methods used to close wounds?
- dermabond: superficial lacerations; facial lacerations
- suture: most lacerations
- staples: scalp or huge lacerations; faster, lower infection, reduced inflammation; greater tensile strength
what is the most common facial fracture?
nasal
MOI - nasal fracture
-direct or lateral blow
S&S of nasal fracture
- immediate swelling and deformity (from lateral blow)
- often accompanied by epitaxis (nosebleed)
management of nasal fracture
- sit upright in “sniffing position”, ice bridge of nose, pressure against septum or cotton in nostrils
- septal hematoma - bleeding between the mucosal layers of septum and can cause blockages; requires drainage and packed
what is the second most common facial fracture?
mandible
MOI - mandible fracture
direct trauma in collision sports - often at the frontal angle
S&S of mandible fracture
- deformity
- loss of normal occlusion
- pain biting down
- trismus (guarding of muscles)
- bleeding around teeth
- lower lip anesthesia
management of mandible fracture
-reduction and fixation by physician (4-6 weeks)
what is the third most common facial fracture
zygomatic
MOI - zygomatic fracture
-direct blow to cheekbone
nondisplaced zygomatic fracture
- 1-2 suture lines affected
- pain and swelling
- trismus and or numbness
- ice and anti-inflammatories; refer to physician
displaced (tripod fracture) zygomatic fracture
- all 3 suture lines affected
- obvious facial deformity
- referral to hospital
what is the fourth most common facial fracture
maxillary
MOI maxillary fracture
direct blow to upper jaw - typically hockey puck or stick
mild maxillary fracture
- front wall of maxilla fractures
- swelling and numbness between eyes and mouth
- rarely epistaxis
severe maxillary fracture
- lower part of maxilla and associated teeth separate from skull (“Lefort fracture”
- significant malocclusion and epistaxis
facial lacerations - MOI
- common in contact and collision sports
- direct impact with sharp object or indirect compression force
management and S&S of facial lacerations
- pain and substantial bleeding
- lip, oral, ear, cheek, and nasal often contaminated
- require carefully cleaning to avoid infection
- apply sterile dressing and ice
- assess for concussion
- refer to physician for sutures - need to get it done within 24 hours
what are the 3 types of tooth fractures?
1) uncomplicated - small portion of tooth broken
- no bleeding from tooth
- pulp chamber not exposed
2) complicated - portion of tooth is broken
- bleeding from fracture
- pulp chamber exposed = pain
3) root fracture - below gum line - requires x-ray
- tooth appears normal
- bleeding around gum
management of uncomplicated and complicated fracture
- place fractured piece in plastic bag
- athlete can continue to play - gauze over fracture if bleeding
- see dentist within 24-48 hours - cap with synthetic composite
management of root fracture
athlete can continue to play
- see dentist immediately after
- re-position and brace for 3-4 months
- wear mouth guard while competing
what are the three types of tooth dislocation
1) subluxation - tooth in normal place, slightly loose
- little or no pain, feels different or sensitive
2) luxation - tooth very loose and moved slightly outward/inward
3) avulsion - tooth is knocked completely out of mouth
treatment of tooth subluxation
-refer to dentist within 48 hours
treatment of tooth luxation
- move tooth to normal position
- refer to dentist immediately
treatment of tooth avulsion
- rinse tooth and re-implant OR
- store tooth in saliva, milk, or saline - or between cheek and gum
- refer to dentist immediately
