Concussion and Traumatic Brain Injury Quiz

Injuries to the Head, Face, Ears, Eyes, Nose, and Mouth

• Injuries to the head and face are common in sports
• Protective equipment reduces these injuries (helmets, facemasks, goggles, mouth guards)
• Protective gear protects soft tissues, not necessarily the brain

Anatomy

• The skull is composed of 22 bones joined by immovable joints
• The cranium protects the brain
• The scalp has 5 layers of soft tissue
• The brain is a vital part of the central nervous system
• The eye has a socket, eyelids, eyebrows, cornea, and pupil
• The ear has three parts: external, middle, and internal
• The nose has nasal bones and tissues
• The mouth contains the tongue, teeth, gums, cheeks, and jaw bones

Preventing Head and Face Injuries

• Protective equipment significantly reduces the risk of injuries to head, face, eyes, ears, and nose
• The goal is to protect the soft tissues, not just the brain

Injury Assessments of the Head and Face

• Priority First Aid for head injuries first addresses life-threatening conditions (loss of breathing, pulse, consciousness). Assume cervical spine involvement in all cases
• If no life-threatening injury is present, history and further assessment may follow.

Assessment Continued (History)

• Establishing whether a concussion has occurred and its potential severity is the primary purpose of the history evaluation
• Additional questions typically include pain locations, neck pain, ability to move extremities, knowledge of the situation, and more.

Observable Signs

• Note if the person was motionless
• Evaluate balance, gait, and general movement/coordination
• Assess whether there is disorientation, confusion, or inability to respond
• Look for vacant or blank stares

Concussions - Mild Traumatic Brain Injuries (MTBI's)

• Injuries to the brain cause immediate and sometimes long-lasting disruption of neurological function
• Concussions can result from direct blows, coup injuries (same side impact), contrecoup injuries (opposite side impact), acceleration/deceleration forces (whiplash), and sudden head/neck movements.
• Not all concussions cause unconsciousness, disorientation, cognitive deficits, amnesia, or motor/balance issues

MTBI's Continued (Red Flags)

• Red flags for potential severe injury include neck pain, double vision, weakness/numbness in extremities, severe headaches, seizures, loss of consciousness, worsening consciousness, vomiting, increasing agitation, and combative behavior.
• Amnesia may occur (anterograde—loss of memory from the time of injury and after; retrograde—loss of memory before the injury)

MTBI's Continued (Symptoms)

• Symptoms may appear immediately or take up to 24 hours to manifest
• Symptoms can include physical ones (headache, pressure, light sensitivity, sound sensitivity, dizziness, nausea)
• Emotional symptoms can include sadness, nervousness, and irritability
• Cognitive issues may include attention difficulties, memory problems, mental fog, fatigue, and slowed thinking
• Sleep disturbances can also occur—difficulty falling asleep or staying asleep, and changes in normal sleep patterns

Concussion Assessment

• Both subjective (symptoms) and objective measures are needed for concussion assessment
• One symptom is enough cause for suspicion of concussion and removal for further evaluation.
• NCAA guidelines require removal from activity and additional evaluation if concussion-like symptoms are present

Concussion Assessment (Cognitive Tests)

• Cognitive tests evaluate the impact of head trauma on cognitive function and provide objective measures to analyze patient status and improvement
• SCAT (Sport Concussion Assessment Tool) assesses neurocognitive impairment, using different tests
• ImPACT (Immediate Post-Concussion Assessment and Cognitive Test) is a computerized evaluation system, evaluating verbal and visual memory, reaction time, processing speed, and more.

Special Testing (SCAT6)

• SCAT6 includes cognitive assessment tests and eye function tests, particularly PERRLA (pupils equal, round, and reactive to light and accommodation)
• Balance testing, coordination testing (using finger to nose and tandem walking) are also included in SCAT6
• This tool helps identify concussion and refer athletes to medical professionals for appropriate actions.

Concussion Assessment (BESS Test)

• The BESS test assesses static balance and measures an individual's ability to stay motionless while performing specific standing tests (double leg stance, single leg stance, tandem stance) in a set amount of time (20 seconds), counting errors

Concussion Assessment (ImPACT)

• ImPACT, a computerized concussion evaluation tool, measures verbal and visual memory, processing speed, reaction time, and symptoms.
• It provides a summary of the patient's results in relation to baseline results and established norms

ImPACT Procedure

• ImPACT involves pre-season baseline testing, along with player/team education
• In the event of a suspected concussion, further testing and determination of whether an athlete is ready for non-contact activity
• Determining a safe timeline for return to play involves a series of steps, including post-injury testing and treatment plans

Immediate Care

• Suspected concussions require removal from activity and rest.
• Return to activity is only appropriate after all signs and symptoms of the concussion have resolved
• Patients can be cared for by a caretaker/support person
• It is often recommended that patients be evaluated in 24 hours, or as clinically appropriate by the physician providing care

Long-Term Care

• Continued check-ins with athletic trainers or medical professionals are necessary
• Ongoing symptom evaluation and removal from classes or activity, as necessary, are important steps
• Activity levels should be symptom limited
• Gradual return to play is crucial following concussion

Post-Concussion Syndrome

• Symptoms of concussion that last months or years are considered Post-Concussion Syndrome.
• Symptoms are not related to initial injury severity
• Individuals experience a wide array of concussion-like symptoms
• Treatment should involve symptom management and referral to a physician for further evaluation
• Return to play is not appropriate until all signs and symptoms of post-concussion syndrome fully resolve

Second Impact Syndrome

• A rapid swelling of the brain after a second concussive force before symptoms from the initial injury have resolved
• The injury may be relatively minimal and may not directly involve contact to the head
• The condition disrupts the brain's autoregulatory system—leading to swelling, increasing intracranial pressure
• Symptoms often include dilated pupils, loss of eye movement, loss of consciousness, and respiratory failure
• Treatment requires immediate medical attention to address the life-threatening issues involved

Second Impact Syndrome Continued

• Life-threatening issues must be handled with urgent, life-saving measures
• Prevention should be emphasized—the athlete should never return to play while experiencing concussion-like symptoms.

Chronic Traumatic Encephalopathy (CTE)

• A progressive degenerative brain disease that occurs in individuals with a history of repetitive brain trauma (multiple concussions or sub-concussive blows)
• Changes in brain tissue occur
• CTE can lead to memory loss, confusion, depression, impaired judgment, aggression, and dementia
• CTE is diagnosed by examining the brain after death (post-mortem)

CTE Continued (Prevention)

• Education for players and coaches is crucial for injury prevention
• Proper equipment fitting and consistent use of protective gear is essential
• Improving technique, including tackling and body checking for players, can also help to reduce the incidences of head and neck injury
• Implementing rule adjustments, for example, can help reduce the likelihood of these injuries

Skull Fracture

• Blunt trauma is the most frequent cause
• Symptoms include severe headaches, nausea, and potential blood in the middle ear, ear canal, nose, or behind the ear (Battle's sign).
• Echymosis (bruising) around the eyes (raccoon eyes) is another possible symptom.
• Patients need immediate hospitalization and neurosurgery referral

Epidural Hematoma

• This is caused by a tear in arteries due to a blow to the head or skull fracture.
• Rapid blood accumulation and hematoma formation follow.
• Symptoms include loss of consciousness, followed by brief periods of consciousness with few initial symptoms that gradually worsen (headaches, dizziness, nausea, pupil dilation on the side of the injury, deteriorating consciousness, neck rigidity, decreased respiration, and convulsions)
• Urgent neurosurgical care is required to relieve the pressure

Subdural Hematoma

• Acceleration/deceleration forces tear blood vessels which connect the dura mater and the brain
• Venous bleeding forming a simple hematoma may cause little to no brain damage while more significant damage to the cerebellum or brain cortex can occur.

Subdural Hematoma (Signs and Care)

• Loss of consciousness, pupil dilation, headaches, nausea, dizziness, or sleepiness are signs
• Immediate medical attention, including CT or MRI to determine the extent of the damage, is necessary

Facial Fractures

• Facial fractures often result from direct blows
• Signs include deformity, pain with biting, bleeding around teeth, and misalignment of the jaw
• Immobilization if possible and referral to a physician or emergency room are necessary treatments

Types of Facial Fractures

• Mandible fracture (often breaks at the front angle): Splint if applicable and seek medical care
• Cheekbone fracture often manifests with nosebleeds—immediate attention needed
• Nasal fracture typically leads to swelling, misalignment, and may require control of bleeding.
• All fractures need medical attention

Nosebleeds (Epistaxis)

• Nosebleeds can result from direct blows, sinus infections, high humidity, allergies, foreign objects, or serious facial injuries.
• Minor nosebleeds generally bleed from the anterior septum and resolve spontaneously. Severe bleeding needs intervention.
• Treatment: sit upright, apply cold compress to the nose, apply pressure to the affected nostril, insert gauze between the upper lip and gum, use gauze or cotton plugs to encourage clotting if bleeding continues; avoid blowing nose and contact a physician if bleeding does not stop

Recognizing and Managing Dental Injuries

• Mouth guards should be used during sports involving contact
• Regular dental checkups are important for preventative care

Tooth Fractures

• Tooth fractures are often caused by jaw impact or direct trauma-
• Signs include tooth fragments, bleeding, and pain
• Treatment: fractured pieces can often be bagged according to the doctor's directions; bleeding can be controlled by a gauze; athlete can continue play but must follow up immediately after competition
• Potential tooth repositioning may occur, along with need for bracing and/or mouthpieces

Tooth Subluxation, Luxation, and Avulsion

• These injuries result from direct blows
• Signs of subluxation include a loose tooth; luxation involves a tooth that is loose and displaced; avulsion involves a tooth being knocked out
• Save a Tooth Kit, milk, or saline can be used; referral to a dentist is also necessary for these injuries

Recognizing and Managing Ear Injuries

• Auricular hematoma (Cauliflower ear) results from compression or shear injury to the ear, causing subcutaneous bleeding; symptoms appear as an elevated, white, round nodular formation that resembles a cauliflower ear.
• Tympanic membrane rupture typically results from a fall, slap to the ear, or sudden shifts in underwater pressure, leading to pain in the ear, nausea, vomiting, dizziness, and hearing loss. Often self-resolves but medical follow up is still important.
• Swimmer's ear (otitis externa) may occur after exposure to water and bacteria; symptoms include pain, dizziness, itching, partial hearing loss, and potential discharge

Recognizing and Managing Eye Injuries

• Black eye (orbital hematoma) is caused by a blow to the area surrounding the eye resulting in capillary bleeding; symptoms include swelling and discoloration; treatment includes ice and restriction from play if vision is impaired
• Orbital fractures are caused by a blow to the area around the eye pulling the eyeball back and causing damage to the floor of the orbit—symptoms include diplopia (double vision), restricted eye movement, downward displacement of the eye, swelling, and potential hemorrhaging; numbness is possible if infraorbital nerve is affected; care includes X-rays, antibiotics, and surgical or spontaneous resolution
• Corneal abrasions often result from foreign object removal causing severe pain, watering, photophobia, and eyelid spasm - patching and physician referral is needed
• Hyphema is blood in the anterior chamber of the eye caused by direct impact to the eye-
• Symptoms include blood accumulation in the anterior chamber of the eye, reddish/greenish discoloration, and/or vision impairment. Care includes bed rest and elevation (30-40 degrees), patching both eyes, and possible sedation or medication
• Retinal detachment occurs when the retina separates from underlying tissues; symptoms include painless early symptoms that progress to specks, flashes of light, or blurred vision, as well as a "curtain falling" in the field of vision -care includes immediate ophthalmologist referral, bed rest, and patching both eyes
• Conjunctivitis (Pinkeye): caused by bacteria or allergens, resulting in eyelid swelling, purulent/itchy discharge, and burning; highly contagious, so a physician referral is needed for treatment