Head

1
Head Neck Trauma

• Brain Cervical Evaluation

2
Injuries to the Brain Skull

• Concussion
• Subdural Hematoma
• Epidural Hematoma
• Fracture

3
Injuries to the Neck

• Fracture
• Dislocation
• Contusions
• Spinal Cord Injuries

4
The Skull, Brain, Meninges

• Skull Frontal, Parietal, Occipital, Temporal,
  Mastoid process, Styloid process, Zygomatic
  process
• Skin ? blood supply

5
The Brain

• Cerebrum largest part communicates
  contralaterally w/ the body
• provides motor function - gross muscle
  contraction coordination of muscle contraction
• processes sensory info (touch, pain, temp.,
  pressure)
• processes special senses (vision, hearing, smell,
  taste)
• provides cognition - spacial relationships,
  behavior, association
• provides memory
•  Cerebellum -
• maintains balance coordination (if injured,
  uncoordinated, segmental, robotlike movements)
• provides for smooth, synergistic muscle control
• allows quick processing of both incoming/outgoing
  information (vision, tactile, hearing,
  proprioception info from cerebellum to cerebrum)

6
The Brain

• Diencephalon
• thalamus, hypothalamus, epithalamus
• routes afferent info to appropriate cerebral
  areas
• processing center for conscious unconscious
  brain output
• hypothalamus regulates hormones autonomic
  nervous system
• Sympathetic parasympathetic nervous system
  (body temp, H2O balance, hunger)
• controls emotion (anger fear)
•  Brain stem - medulla oblongata pons
• Relays info to from CNS controls involuntary
  systems such as respiratory rate, heart rate,
  blood vessels (vasodilation vasoconstriction),
  coughing, vomiting

7
Meninges

• Inner coverings of the brain (arterial
• venous blood supplies are provided
• through these)
• Dura Mater (hard mother)
• Meningeal arteries - supply cranial bones
• Subdural Space
• Arachnoid Mater (spider)
• Subarachnoid Space contains
• Cerebrospinal fluid (CSF)
• Pia Mater (tender mother)

8
The Brain CSF Blood Supply

• Cerebrospinal fluid (CSF) circulates around the
  brain spinal cord within the subarachnoid space
  
• Blood
• 2 vertebral arteries
• 2 common carotid arteries

9
Terminology

• Concussion agitation of the brain impairment of
  neural functions
• Anterograde amnesia inability of athlete to
  recall events after the injury loss of memory
  after an injury (post traumatic)
• Retrograde amnesia memory loss of events
  occurring prior to injury loss of memory prior
  to an injury
• Tinnitus ringing sound in the ear
• Epistaxis hemoorhage from nose (nosebleed)
• Raccoon Eyes periorbital ecchymosis (black eye
  in both eyes underneath eyes)
• Nystagmus rapid, uncontrollable movement of
  eyeballs from left to right, up down

10
The Evaluation Process

• Is the athlete conscious and responsive?
• Is the athlete walking towards you or are you
  going to the athlete?
• Is the athlete unconscious?
• Is the athlete prone or supine?
• Is the athlete breathing or not?
• Does the athlete have a pulse?
• ANY UNCONSCIOUS ATHLETE MUST BE SUSPECTED TO HAVE
  A FRACTURE OR DISLOCATION OF THE NECK!!!

11
The Evaluation Process

• Where is the athlete positioned?
• Is this an on-field or off-field eval?
• Is the athlete positioned in-line?
• Decerebrate - rigid extension, brain stem lesion
• Decorticate - rigid flexion of upper body, lesion
  above brain stem
• Is the athlete conscious responsive?
• Level of consciousness
• Can the athlete communicate is it legible?
• Alert, Lethargic, Stuporous, Semicomatose,
  Comatose
• Primary survey
• ABCs
• Secondary survey
• Check for fractures other trauma
• Nausea, vomiting, seizure

12
The Evaluation Process - History

• MOI of brain
• Coup direct hit
• Contrecoup injury occurring to opposite side
• Was there any rotational or shear forces?
• Where is the pain?
• What is the head pain like?
• Severity Pain Scale
• Previous history of trauma or concussions
• Second Impact Syndrome

• MOI of cervical spine
• Is there any cervical pain?
• Was there axial loading?
• Is there any weakness?
• What type of activity?
• Is it repeated trauma?

13
The Evaluation Process - Inspection

• Discoloration
• Eyes
• Is there a dazed, distant appearance?
• Nystagmus
• Pupil size
• Pupillary reaction to light
• (PEARL)

• Position of head
• Cervical vertebrae
• Mastoid process
• Battles sign
• Skull scalp
• Nose
• Ears
• Any discharge

14
The Evaluation Process - Palpation

• Spinous processes
• Skull
• Musculature
• Throat

15
The Evaluation Process Functional Testing

• Memory
• Retrograde amnesia Anterograde amnesia
• What happened before after the event? What is
  their first memory after injury? What were the
  events leading up to the injury
• How did you get here? Where are you?
• Who am I?
• How old are you?
• What did you eat for breakfast?
• Where is your home town?
• What is your name?
• Remember these three things.

16
The Evaluation Process Functional Testing

• Cognitive Function
• Behavior
• Are they acting normal or are they way off?
• Has their mood changed drastically?
• Analytical skills
• Serial 7s
• Other math functions
• Information processing
• Are they confused?
• How slowly are they functioning?
• How are they reacting to simple complex
  activities?

17
The Evaluation Process Functional Testing

• Neuropsychological Testing p. 621
• Trail Making Test A B
• Wechsler Digit Span Test
• Stroop Color Word Test
• Hopkins Verbal Learning Test
• Symbol Digit Modalities Test
• Controlled Oral Word Association Test

18
The Evaluation Process Functional Testing

• Balance Coordination
• Romberg Test
• Tandem Walking
• Balance Error Scoring System
• Vital Signs
• Respiration
• Blood Pressure
• Pulse

19
Neurologic Testing - Cranial Nerve Assessment

• Name S, M, B Function
• I. Olfactory S smell  
• II. Optic S vision
• III. Oculomotor M eye movements
  (adduction, downward
• movement), elevation of upper
  eyelid constriction of pupils
• IV. Trochlear M eye movements (upward)
• V. Trigeminal B motor muscles of mastication
  (chewing)
• sensation face
• VI. Abducens M eye movements (laterally)
• VII. Facial B motor muscles of expression
  (from hairline to clavicle)
• sensation taste
• VIII. Auditory S equilibrium, hearing
• (vestibulocochlear)

20
Cranial Nerve Assessment

• IX. Glossopharyngeal B motor pharyngeal
  muscles (tongue throat) (speech) BP, gag
  reflex,
• swallow
• sensory tongue, pharynx, external ear temp
• X. Vagus B motor swallow
• sensory gag reflex, hunger, fullness,
  intestinal discomfort
• XI. Spinal Accessory M movement of head
  shoulders
• (trapezius sternocleidomastoid)
• XII. Hypoglossal M tongue movement
• On Old Olympus Towering Top A Finn And German
  Viewed Some Hops. 
• Some Saps May Marry But My Brother Says Bad
  Business, My Man.

21
Quick Cranial Test

• Eyes - Vision (II), Light (III), Movement (II,
  IV, VI)
• Eyebrows, forehead, smile, frown (VII)
• Clench jaw (V)
• Swallow (IX, X)
• Stick out tongue (XII)
• Ears hearing (VIII)
• Nose smell (I)
• Voice, head/shoulder movement (XI)
• Balance (VIII)

22
General Signs Symptoms

• Brain
• Headache - if it becomes more severe, may
  indicate additional intracranial involvement,
  indicates damage has not subsided, cessation of
  headache probably most reliable indicator of
  adequate recovery
• Lack of awareness of surroundings confusion
• Disorientation
• Irritability and low frustration tolerance
• Dizziness or vertigo
• Incoordination
• Poor attention concentration
• Light-headedness
• Memory dysfunction
•  
• Ears
• Ringing in ears (tinnitus)
• Dizziness
• Intolerance of loud noises

23
General Signs Symptoms

• Eyes
• Blurred/double vision
• Sensitive to light (photophobia) or difficulty
  focusing vision
• Nystagmus
• Stomach
• Nausea or vomiting
• Other
• Numbness/tingling
• Weakness muscular
• Fatigued
• Anxiety and/or depressed mood
• Sleep disturbance

24
Concussion Rating Scale (p. 631)

• Grade 1
• Transient confusion
• No loss of consciousness
• Concussion symptoms or mental status
  abnormalities on exam RESOLVE IN LESS THAN 15
  MINUTES.
• Grade 2
• Transient confusion
• No loss of consciousness
• Concussion symptoms or mental status
  abnormalities on exam LAST MORE THAN 15 MINUTES.
• Grade 3
• Any loss of consciousness, either brief or
  prolonged

25
Treatment

• Grade 1
• Remove from contest/practice.
• Examine immediately and at 5 min. intervals for
  further development of problems.
• May return to contest if normal/symptoms clear
  within 15 minutes.
• A second Grade 1 concussion in the same contest
  eliminates the player from further activity that
  day. May return if asymptomatic for one week at
  rest and with exercise.
• Grade 2
• Remove from contest/practice.
• Examine on site.
• Reexamine the following day.
• MD perform exam to clear for return after 1 week
  asymptomatic at rest and with exertion.
• CT/MRI if headache or other symptoms worsen or
  persist.
• Following 2nd Grade 2, athlete must be
  asymptomatic x 2 weeks.
• Termination of seasion if abnormal CT/MRI.

26
Treatment

• Grade 3
• Transport to ER if unconscious or worse.
• Thorough neurological eval.
• If normal findings during exam, patient may be
  sent home with written instructions to athlete
  and someone staying with the person.
• If not normal, hospital admission.
• Neurological assessment daily.
• After a brief (seconds) Grade 3 concussion,
  athlete should be withheld from play until
  asymptomatic x 1 week at rest and exertion.
• After a prolonged (minutes) Grade 3 concussion,
  athlete should be withheld from play x 2 weeks.
• Following a 2nd Grade 3, athlete should be
  withheld a minimum of 1 asymptomatic month.
• CT/MRI recommended.
• Termination of season if abnormal CT/MRI.

27
Neck Evaluation

• Always think the worst scenario could happen and
  hopefully it doesnt!
• History
• Where is the pain located?
• Do they have any numbness or paresthesia?
• Do they have any stinging, burning, numbness,
  tingling down the arm? How far does it travel
  down the arm?
• What position was their head/neck in?
• Determine level of consciousness

28
Neck Evaluation

• Observation
• DO YOU NEED TO STABILIZE THE NECK AT THIS TIME?
  You may already be stabilizing it.
• ABCs
• Do they have any movement? Seizure?
• What is the body position posture?
• Observe the ears nose for any fluids
• Halo effect, Orange Halo effect
• Note for any other secondary injuries

29
Neck Evaluation

• Neurological Testing
• Sensory testing
• C4 Superior shoulder
• C5 Lateral humerus
• C6 Lateral forearm
• C7 Middle finger
• C8 Medial forearm
• T1 Medial elbow
• L1, L2, L3 Lat. thigh
• L4 Medial low leg foot
• L5 Lateral low leg foot
• S1 Lateral low leg plantar foot

• Palpation
• Bony Soft tissue
• Feel for any gross deformities, swelling, and
  painful areas

30
Neck Evaluation

• Neurological testing
• Motor testing ONLY do this if no other
  signs/symptoms of cervical injury exists
• Active motion is performed first to small joints
  (fingers, toes) and then move to larger joints
• Each movement must be performed bilaterally

31
Neck Evaluation

• Spurling Test
• Brachial Plexus Traction Test
• Cervical Compression Test
• Cervical Distraction Test

32
Now What Do You Do?

• If you have a head or neck injury, this
  individual should be referred to the physician.
• You may have to activate EMS. Make sure everyone
  knows your emergency action plan procedures.

33
Concussion Grading Scales
34
Glasgow Coma Scale (LOC)

• gt13 possible mild brain injury
• 9-12 moderate injury
• lt 8 severe brain injury

35
References

• www.images.google.com
• www.merck.com/mmhe/ sec06/ch076/ch076b.html
• catalog.nucleusinc.com/ generateexhibit.php?ID
• Agur Dalley (2005). Grants Atlas of Anatomy,
  11th ed.