Head

Injuries
 Coup Injury
• A coup injury refers to the brain
damage that occurs directly under
the point of impact.
 Countre coup injury

• A moving head hitting against an

unyielding object usually produces
maximum brain injury opposite the
site of cranial impact as the brain
rebounds within the cranium.
 Stationary head prior to
impact
• No brain lag

• No change in distribution of CSF

• Absence of countrecoup injury

• Coup injury.
 Moving head before
impact

• Brain lags

• Squeezing away the cerebrospinal fluid (CSF)

• Countrecoup injury

• Lack of coup injury in the moving head injury

 Cerebral Concussion
• Cerebral concussion, the most common sport-related TBI,
classified as a mild diffuse injury and is often referred to as
mild traumatic brain injury (MTBI).

• The injury involves an acceleration–deceleration

mechanism in which a blow to the head or the head
striking an object results in one or more of the following
conditions:
Post Concussion Syndrome
• Post-concussion syndrome is a complex disorder in which
various symptoms — such as headaches and dizziness —
last for weeks and sometimes months after the injury that
caused the concussion.

• In most people, post-concussion syndrome symptoms occur

within the first seven to 10 days and go away within three
months, though they can persist for a year or more.
Post-concussion symptoms
include:
• Headaches

• Dizziness

• Fatigue

• Irritability

• Anxiety

• Insomnia

• Loss of concentration and memory

• Noise and light sensitivity

 Mild Concussion
• Frequent(85%)

• Altered mental status

• No unconsciousness

• Impaired cognitive function e.g. Post Traumatic amnesia

• Dizziness and Tinnitus

• Rare loss of coordination that is evident on Romberg Test

• Headache
 Moderate Concussion

• Transient mental confusion, tinnitus, moderate dizziness.

• Prolonged post-traumatic amnesia (30 minutes).

• A momentary loss of consciousness often results, lasting

from several seconds up to 1 minute.

• Blurred vision, dizziness, balance disturbances, and nausea

 Severe Concussion
• Headache

• Loss of consciousness

• Slurred speech, numbness, nausea

• Decreased co-ordination, increased confusion

• Post Traumatic amnesia > 24 hrs

• Retrograde amnesia
 Second Impact Syndrome
When an athlete who has sustained an initial head trauma, most
often a concussion, sustains a second injury before symptoms
associated with the first have totally resolved.

SIS usually occurs within 1 week of the initial injury and

involves rapid brain swelling as a result of the brain losing
autoregulation of its blood supply.
Brain stem failure develops in 2 to 5 minutes, causing rapidly
dilating pupils, loss of eye movement, respiratory failure, and
eventually coma.

On-field management of SIS should include rapid removal of

any helmet or pads so the athlete can be rapidly intubated.

Unfortunately, the mortality rate of SIS is 50%, and the

morbidity rate is 100%.
 Immediate Management of
Sport-Related Concussion
• Easy to recognize concussion if athlete is unconscious.

• Of all cerebral concussions, 90% to 95% involve no loss

of consciousness but rather only a transient loss of
alertness or the presence of mental confusion.
 Three primary objectives
1. Recognizing the injury and its severity

2. Determining if the athlete requires additional attention

and/or assessment

3. Deciding when it is safe for the athlete to return to sports

activity.
Initial On-Site Assessment
• Primary survey of athlete:
 A primary survey involving basic life support should be
performed first. This is easily performed and usually
takes only 10 to 15 seconds as respiration and cardiac
status are assessed to rule out a life-threatening condition.
Once life-threatening conditions have been ruled out, the
secondary survey can begin.
• Secondary survey:

 During the secondary survey, a seven-step protocol

(history, observation, palpation, special tests,
active/passive range of motion, strength tests, and
functional tests) should be strictly followed to ensure that
nothing has been overlooked.
Amnesia testing
The clinician can perform amnesia testing by first asking the
athlete simple questions directed toward recent memory and
progressing to more involved questions.
Asking the athlete for the first thing he or she remembered after
the injury will test for length of post-traumatic amnesia, also
known as anterograde amnesia.
Asking what the play was before the injury or who the opponent
was last week will test for retrograde amnesia. Retrograde
amnesia is generally associated with a more serious head injury.
Sideline Assessment
• Quick cranial nerve assessment

• Visual acuity (cranial nerve II: optic) read / identify

selected objects (at near range and far range).

• Eye movement (cranial nerves III and IV: occulomotor

and trochlear) should be checked for coordination and a
purposeful appearance by asking the athlete to track a
moving object.
 Pupils

The pupils also should be observed to determine if they are

equal in size and equally reactive to light; the pupils should
constrict when light is shined into the eyes.
The clinician should also look for any signs

Otorrhea
CSF draining from the ear canal.

Rhinorrhea
CSF draining from the nose.
Battle’s sign

Battle's sign consists of bruising over

the mastoid process.
 Raccoon eyes
Bilateral periorbital ecchymosis also known as "raccoon
eyes".
• Bilateral = "both sides"
• Periorbital = "around the orbit"(eye)
• Eccyhmosis = "bruise".
• Bruising around the eyes on both sides.
Special Tests for the Assessment
of Coordination
The inclusion of objective balance testing in the assessment of
concussion is recommended. Balance Error Scoring System
(BESS) is recommended over the standard Romberg test,
which for years has been used as a subjective tool for the
assessment of balance.
Research has found the BESS to be a reliable and valid
assessment tool for the management of sport related
concussion.
Three different stances (double, single, and tandem) are
completed twice, once while on a firm surface and once
while on a 10-cm–thick piece of medium density foam
for a total of six trials.
The total test time is approximately 6 minutes—the
athlete is asked to assume the required stance by placing
their hands on the iliac crests and on eye closure the 20-
second test begins.
 Finger-to-Nose test
The finger-to-nose test is also considered to be a good test for
combining cognitive processing and balance. The clinician asks
the athlete to stand with his or her eyes closed and arms out to the
side. The athlete is then asked to touch the index finger of one
hand to the nose and then to touch the index finger of the other
hand to the nose. The athlete is then asked to open his or her eyes
and touch the index finger of the evaluator (placed at varying
ranges in the peripheral view) to test acuity and depth of
perception. Inability to perform any of these tasks may be an
indication of physical disorientation.
 SAC (Cognition Testing)
Standardized- assessment-of-concussion

The SAC requires approximately 5 minutes to administer and

assesses four domains of cognition, including orientation,
immediate memory, concentration and delayed recall. A
composite total score of 30 possible points is summed to
provide an overall index of cognitive impairment and injury
severity.
The SAC includes measures of functions most sensitive to concussion:
Orientation; (month, date, day of week, year, time)
Immediate memory; (recall of 5 words in 3 separate trials)
Neurological;
• Loss of consciousness; (occurrence, duration)
• Amnesia; (either retrograde or anterograde) (recollection of events pre- and
post-injury)
• Sensation
• Coordination
• Strength
• Concentration
• Delayed recall (5 word)
Medications
Aspirin or non-steroidal anti-inflammatory drugs, which
decrease platelet function and potentially increase
intracranial bleeding, are contraindicated because it leads to
a more severe injury.
It is also recommended that acetaminophen (Tylenol) be
used sparingly in the treatment of headache-like
symptoms in the athlete with a concussion because of its
pain-relieving effect.
Other medications to avoid during the acute post-
concussion period include those that adversely affect central

nervous function—in particular, alcohol and narcotics.