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ICSC01_1.TRANSCRIPT-Sports_Concussion

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ICSC01 Head Injuries
Section 1 – Sports Concussion
Instructor Brett Jarosz
Video Lesson: 21:12

My name is Brett Jarosz. I am a practicing sports chiropractor in Melbourne, Australia. I have a role as a casual academic at RMIT University in the discipline of chiropractic. I am a member of the FICS Education Commission, as well as part of the leadership team for functional neuro orthopedic rehabilitation, and doing some lecturing for the Carrick Institute of Clinical Neuroscience and Rehabilitation.

Today’s little presentation we are going to do here is on the topic of sports concussion. We are going to have a quick little overview, and I want to emphasize that word “overview” here. This topic is a very large topic that the information continues to grow at an almost exponential rate. What we want to try and do here today is do a quick bias towards some of the neuropathology in the concussive injury, as well as some of the assessments that we can do clinically, and we are going to bias that towards the vestibular and ocular mode of screening. Without further ado, let us move into some of these details.

You may be familiar with looking at that concept of coup and contrecoup type of injury. But one of the things we want to just look at here today is when we look at the nervous system and what is involved with a concussive mechanism, so if we look at just the details here, there is different types of head motions that can occur with concussion. If we think about the fact the skull is on the neck with seven vertebrae, and the fact that those vertebrae can move in all those various degrees of freedom, we have rotation that can occur, we have lateral bending that can occur, flexion, extension, etc. When we look at the actual concussive mechanism, there is two broad categories of forces. There is the contact and the inertial forces that can occur during the

concussions, and the primary cause of concussive injuries is the inertial acceleration loading experienced by the brain. I almost wanted to say think of more of it the brain and the brain stem, and if we just use those topics of nervous system rather than just saying the brain. Because we do have a picture of the brain hitting inside the skull. But what we want to start looking at now with the research that we are seeing is not only just the brain hitting inside the skull, but more of the rotation and the shearing forces that are occurring, in particular through the midline structures of the nervous system.

Now you saw that word there before, “acceleration.” and so if you also think of like an acceleration/deceleration injury, we often think of the word “whiplash.” That is occurring to the cervical spine, that whiplash mechanism. But we can also think of an acceleration/deceleration injury to the nervous system, and we can relate that to be a concussive type of injury. We have an acceleration/deceleration injury to the neck, to the orthopedic structures of the neck, that we start to consider as a whiplash type of injury, and we also have that acceleration/deceleration injury that can occur to the nervous system. We can relate that as a concussive type of injury.

 

There is a linear and a rotational acceleration that occurs with every concussion, and the brain tissue deforms more readily in response to the shear forces compared to other biological tissue. What is very unique, if you ever get a chance to get a brain that has not been embalmed, just in a cadaver, and we get a brain, that brain will adapt and change to its environment. The shape of the brain that we all have in our mind is because of the shape of the skull. But if you put a brain in a flat dish or a ball, that brain within minutes will start to adapt to the shape of that ball. The brain tissue can undergo those types of responses very, very quickly and the shear responses that can occur to the nervous system through that concussive mechanism.

I want you to picture a piece of towel. And you wet that towel, and then you are going to wring the towel out, and you are going to try and get the water out of the towel. When you think of where that water comes out of the towel, it comes out from the middle of the towel, and I want you to have that picture of the midline areas of the brain. I have got a couple of slides coming up soon to show that pathway that is involved in these concussive mechanisms.

What is important to remember in this acceleration injury to the nervous system is if you were able to constrain the head motion so that the skull and the head did not rotate, it is difficult to produce traumatic unconsciousness. That is very important. Whereas if you allow the head and the skull to rotate on the neck, that substantially increases the likelihood of an unconscious episode. These key things here that we wanted to think about is the fact that the neck allows our skull and our head to rotate is one of these key things that is involved in how people can get those concussive unconscious episodes, where we can lose that consciousness transiently or for even a few minutes, and in severe cases, obviously, for longer periods of time.

If we look here now at that neuropathology and the neurobiology of a traumatic brain injury or concussion, there is two main categories. There is the focal damage and the diffuse injury. When we look at focal injury, start to think about the idea of maybe having a direct contact to the head. So if we think of combat sports where we are getting knees and fists and elbows, etc, colliding with the skull, I could have a focal injury there, where I have a fracture or I cut the scalp or the face, or of course, I could have direct bleeding underneath that focal injury there, and we want to just picture that focal injury as more of that direct severe impact onto the brain, onto the skull.

Whereas we think of a diffuse injury, we want to think of the diffuse injury, and you look at that picture there with the skull showing that sort of rotation. We can see that rotation through the midline, and we want to think about the axons there. We want to look at the fact we have got our cell bodies, and then we have got our axons, and those axons, we can remember, think of the corticospinal pathway, we have got a pathway going from the cortex, that motor strip, all the way down the spinal cord. If this is, say as an example, going to go to dorsiflexion of your ankle, think about how long that axon is going from the cortex all the way down to L4, L5 in the spinal cord. Long, long axon.

 

So diffuse injuries caused by stretching and tearing of the brain tissue and we do not need a focal injury for that, so we do not need the skull fracture or the direct impact to cause that service. It is that shearing, that rotation injury, and this is seen in the cases of mild traumatic brain injury or concussion. The main form of diffuse injury is called diffuse axonal injury, and again, that is due to that acceleration/deceleration force that leads to the shearing of the axons. So again, we use those words acceleration/deceleration, we think of the injury that is occurring to the neck. We have got the orthopedic injury to the cervical spine, but we have also got the shearing of these tissues through the nervous system because of that acceleration/deceleration injury. Then if we look at the pathway, the midline pathway here that we have been referencing, is this cortico-reticulospinal pathway. The pathway going from the cortex into the reticular system within that brain stem. So when we look at the cortico-reticular pathway, it is beginning primarily from the premotor cortex frontal lobe, and then it terminates in the pontomedullary reticular formation, so obviously the pons and the medulla, the mid and the lower aspects of the brain stem and that reticular formation. When we start to look at that cortico-reticular spinal pathway, that is involved in the control of muscles of the extremities and the axial muscles. I have got a slide coming up for you next to show you also a lot of the other things that the reticular systems involved with.

But this particular research here by Lee et al showed that injury of that pathway when people had had a concussion, mild traumatic brain injury, these patients showed proximal weakness, so weakness of the shoulders and of the hips. When they did this particular study, they were indicating the importance of evaluating this cortico-reticular pathway. If we look at the image on the right of the slide there, we can see on the left that is showing a sort of the normal pathway. Whereas when we go to those three images on the right there, we can see thinning. Or we can see parts of the pathway being cut off, or we can see part of the pathways disappearing here. That pathway from the cortex to that reticular formation within the brain stem is one of these key pathways being involved in that concussion, those axons, that shearing due to that acceleration/deceleration injury.

If we look at the reticular formation, and you have a look at what structures are within that reticular formation and what those structures control, they control somatic motor control. We just talked about that, about how that cortico-reticular pathways involved primarily in these proximal muscles. The reticular formation in the brain stem’s involved tone, balance, and posture, and, as I said, in particular those proximal muscles showed by that last bit of research.

But what is also important is your eye and ear signals to your cerebellum are also being involved with that reticular formation. The motor nuclei for your gaze centers, so the ability for you to move your eyes left, right, up and down, to track objects, to find objects in space with your eyes, those come from the reticular formation. Cardiovascular control, your autonomic nervous system centers, your vital centers, are based in there. Pain modulation, a lot of us are familiar with our opioid mediated analgesic system, our serotonergic descending pain in the inhibitory system, that comes from that reticular formation. There are other functions as well, such as sleep and consciousness. These things are also from that reticular formation. So, when we look at what is going on in there, this becomes important, because what we are going to look at here today is that assessment of those ocular motor and vestibular centers. But keeping in mind, some other key things that are also occurring in concussion is dysautonomia, or dysfunction of the autonomic nervous system. Issues with people’s balance. Issues with people’s necks. Issues with people’s cognitive states. What we want to try and do when we think about concussion is we want to try and keep the neuroscience in mind when you are assessing sport-related concussion. I want you to keep in mind what is going on through that brain stem and that reticular formation, and understanding that balance, eye movements, autonomic nervous system. Start thinking about the symptoms that people are presenting with when they are talking about suffering a concussion, and start to think that back to the reticular formation in that brain stem and how those midline pathways are being sheared through that acceleration/deceleration mechanism.

If we then take a look at the Berlin Consensus Statement that was published in May (2018) this year in the British Journal of Sports Medicine by Paul McCrory et al, and what the concussion in sport group talked about is the 11 “Rs” in sport-related concussion management. Basically, you followed a logical flow to your management, which is

  • Recognize the concussion,
  • Remove the athlete from the field of play, R
  • e-evaluate, or of course, just evaluate, the re- obviously follows in with the Rest where appropriate.
  • Referring to appropriate practitioners, where appropriate for particular further assessments, or if it is outside of your knowledge base and skill.
  • Then we have got the Recovery
  • Returning to sport, Reconsider, Residual effects and sequelae, and Risk

What we want to look at here today is we just want to look at the third point, re-evaluate, and that re-evaluation, when we look at what the consensus statement showed is our examinations should encompass a comprehensive history and detailed neurological exam, a thorough assessment of mental status, cognitive functioning, sleep-wake disturbance, ocular function, vestibular function, gait, and balance. I just want to take that particular point there and recognize that you may not see athletes or a concussion on the field, or may not be there at the point of injury, and instead these athletes may be contacting you in your office as the first point of call following that injury.

When we look at that assessment, there is a lot in that concussion assessment. If we take a look at that neuropsychological assessment, that was previously described as the cornerstone. If we think of impact, injury, or mini mental status exams, and all these various forms of nerve psychological assessments, that should not be the sole basis of any management decisions. Should not be the sole basis of course about making a diagnosis of concussion. All athletes should have a clinical neurological assessment which includes your mental status and cognition, but should also include oculomotor function, gross sensorimotor, coordination, gait, vestibular function, and balance, as we alluded to on the previous slide.

What we just want to look at here now is a brief screening straight from the literature of how we can start to look at some vestibular function and ocular function in that assessment of concussion. If we take this clinical assessment, and we are going to use this work here by Mucha et al from 2014, a Vestibular Ocular Motor Screening for Concussion. Now what this assessment involves is getting the baseline symptoms of your patient, recording what their headache is out of 10, with 10 being severe and 0 being no symptoms. We are going to do headache, dizziness, nausea, and fogginess. We are just going to ask the patient about those symptoms, if they have got them, and to rate them out of 10.

Then what we are going to do is we are going to perform these particular tests. Smooth Pursuits, Saccades, Convergence, or accommodation, the Vestibular Ocular Reflex, and a Visual Motion Sensitivity Test, also sometimes referred to info from a laboratory testing is called SHIMP, or Suppression Head Impulse Procedure. When we look at the VOMS assessment, that Vestibular Ocular Motor Screening, here is a chart that we can enter. We are going to record headache, dizziness, nausea and fogginess symptoms on a 0 to 10 scale prior to performing the tests, and then what you will do is you will perform the tests and ask them, “how is your headache, dizziness, nausea, or fogginess out of 10” after you perform each of the tests, and we can record that in this particular table here.

Let us start by looking at the smooth pursuits part of this test. What we do is we have the patient sitting in front of us, and the practitioner can hold a finger or a pen or a target that that patient’s going to focus their eyes on. We are going to have that target approximately three feet away from the patient, or basically having the patient have their arm up in front, and you are going to be at least arm’s distance away from the patient. Then you as the examiner are going to slowly move that target, whether it is your finger, whether it is a pen. You are going to move it smoothly left to right, in a range of about 1 and 1/2 feet to the right and 1 and 1/2 feet to the left of the midline. And that target is going to basically move. It is going to take you a second to get from the midline to the right, and then a second to get back to the middle, and then another second to get to the left. It should take you two seconds to get from right all the way across to left. What you will do is you will get two repetitions. You are going to go to the right, to the left, to the right, to the left, and then you will do the same thing vertically. You will go up, down, up, down. As you do those movements, you as the practitioner are watching the patient’s eyes to see if they have any jerky eye movements. The eyes should be following your fingers smoothly. If you see any jerky eye movements, saccadic eye movements, or, of course, if you see a blatant palsy, where you do not see the eye abduct or adduct or elevate or depress, we make that observation. Then we, of course, record any symptoms– out of 10, headache, dizziness, nausea, and fogginess. I have got horizontal pursuits, and I have got vertical pursuits. Two seconds to move horizontally left to right, two seconds to move vertically up and down, with two repetitions.

After I have recorded my findings and my symptoms from the pursuits, I then move on to the saccades. Same principle. I have got my targets, which can be my thumbs, could be my fingers. And I set those up at least arm’s distance away from the patients, or about three feet. I set my two targets about 1 and 1/2 foot to the right, 1 and 1/2 feet to the left of the midline. If we look at the picture there on the top right, we can see that 1 and 1/2 to the right and to the left, 1 and 1/2 feet to the right and to the left, and then what we are going to do is ask the patient to look from one finger to the other, so from one target to the other, as quick as possible. They do 10 repetitions. Again, at the end of the 10 repetitions, you are recording any headache, dizziness, nausea, and fogginess symptoms out of 10 – 0 being no symptoms to 10 being severe.

When they are doing the saccade test, you are observing to see are they accurate. Do their eyes look directly to the target? Do they look directly to your finger? Or do they stop short? Or do they overshoot, and then come back to your finger? We are also looking to see are there more than two movements to get to your fingers. If they were looking to the right, can they look to your finger in one movement accurately? Or do they take three movements to get to your finger? We want to look for any of those abnormalities in their eye movements. Once again, do both eyes move conjugately? So does the right and the left eye move together? Or is one eye moving delayed? Or is one eye moving and the other one not? We want to observe for those gross palsies, disconjugate movements, as well as those saccadic errors.

Recording the symptoms again after the test. So again, 10 repetitions looking left and right. We then would move our fingers so that they are in a vertical plane, again, 1 and 1/2 feet above the midline, 1 and 1/2 foot below the midline, and, again, we ask the patient to look up and down, 10 repetitions as quickly as possible. Record the symptoms of the headache, dizziness, nausea, and fogginess at the end of the test, and again, observing the patient’s eyes for any of those gross disconjugate movements or saccadic errors overshooting.

We can then move on to the next test, the near-point convergence, or also you might remember it as accommodation. But what we are looking at here is the ability for both eyes to converge. We are going to have the patient have a small target. We could use, say, a bit of a stick, and we could put a dot on the end of the stick, or again a pen, or a stick with a little ball on the end of it. We can then ask the patient to bring that stick in towards the tip of their nose nice and slow.

You ask the patient to stop moving that stick, that target, when they see two distinct images, so when they get double vision or when you as a practitioner observe the fact that both of their eyes are no longer converging. We see both eyes slowly coming in together. They are coming in together, and then all of a sudden, one eye deviates out. When you observe that, you get them to stop the stick. That should be at the time when the patient also would start to see double. The patient may see double before that, whichever occurs first, they stop the movement. And then you measure the distance from the tip of the nose to that target. If you look at the picture on the right, we can see the far-right picture showing the measurement from the tip of the nose to that target. Repeat that test three times. Again, at the end of those three performances of those tests ask for the symptoms of headache, dizziness, nausea, and fogginess out of 10. Record those symptoms. But you as a practitioner with your measurements are looking to see can the eyes, of course, converge, and then another thing that you are looking for is on your measurements, are the eyes able to get to 6 centimeters or closer to the tip of the nose? An inability to get closer than 6 centimeters is considered an error with this test.

So again, we are looking for convergence. Seeing double vision or seeing one eye diverge. Record that distance from the tip of the nose to the target, and we are, again, looking for a greater than 6-centimeter distance being considered an error. Recording as symptoms as per all of our VOMS– Vestibular, Ocular, Motor, Screening– tests. We record those symptoms out of 10.

 

The next test in the VOMS is the VOR. With this particular VOR test, what the patient is going to do is they will be looking at a target that is positioned in front of them, again, three feet away or at least arm’s distance away, and we are going to ask the patient to move their head right and left. What they are going to do is they are going to have a metronome set up, and the metronome will be set to 180 beats per minute. So that way the patient is going to time the movement of their head in time to the beat. When they hear the beat, they should be to the left. When they hear the next beat, they should be to the right.

At 180 beats per minute, they are going to be moving their head at about a range of 20 degrees. Left, right, left, right, at 180 beats a minute, keeping their eyes on the target in front of them. They are going to do 10 repetitions left and right. Once again, at the end of that test, you are going to record. We are going to ask and then record any symptoms, headache, dizziness, nausea, and fogginess out of 10 again. Record those symptoms.

As the practitioner, while they are doing the test, you are going to be observing their eyes. Can the patient maintain their eyes being fixed on the target throughout the test? If you see that their eyes are losing fixation from the target, what you want to do is see if you can note is it one side that they keep losing fixation. Is it if they turn their head to the right, do they lose fixation? Or if they turn their head to the left, do they lose fixation? Or is it both? See if you can observe for that. After you have done the horizontal VOR testing, you then do it vertical. You are going to get them to nod their head up and down. Same again, 180 beats per minute. 10 repetitions. You are going to observe the eyes to see if they can maintain fixation, and you are going to again record headache, dizziness, nauseousness, fogginess symptoms at the end of each test.

The final test is the visual motion sensitivity test, and what the patient will do here is they will stand with their feet shoulder width apart. You will try to have the patient positioned so that there is movement around them. If you are in a private room, a consultation room, maybe you have it where there is books or a bookshelf or computer screen or things that are in the background to make it a little bit busy in the visual area. You do not want a plain white wall as a background. You want things to be in the patient’s background.

The patient will extend their thumb out in front of them. I like to put both hands out in front and overlap the thumbs. The patients are going to stare at their thumbs, and then what they are going to do is they are going to rotate from their ankles. They are going to move their head, their body, their legs together as a whole unit. Imagine the whole body is a log locked together. They are going to rotate at a range of 80 degrees to the right and to the left, and their eyes are staying fixed on their thumb the whole time. This time the metronome is set to 50 beats per minute to maintain the speed. They get to the right, they get to the left, they get to the right, they get to the left in time with the beats, so again, one beat in each direction, and with this one, they perform five repetitions. At the end of this test, you are recording symptoms again of headache, dizziness, nauseousness, and fogginess out of 10. For those that have further training in this area, and they want to go further into this, we can also then look at this test to look at the ability for the eyes to remain fixed on that thumb, and we want to look and see how much movement occurs from the eyes from the thumb, if any. With this test, when we look at the literature, we are just recording symptoms. But if we look at some of the other literature with this test in laboratory settings, we could also look at the ability for the eyes to maintain gaze fixation. But the key thing again at the end of this test is recording the symptoms of headache, dizziness, nauseousness, and fogginess, if there is any, from 0 to 10.

When we look at this VOMS assessment, it is designed for the use in patients age 9 to 40. If we have got someone outside of that age range, the interpretation of these tests can vary. What is important with this VOM screening is that any abnormal findings or provocation of their symptoms– so if we do any of these tests and the headache worsens, or the dizziness worsens, or their fogginess or nauseousness worsens, this may indicate dysfunction, and that dysfunction should trigger a referral to the appropriate health care professional for more detailed assessment and management.

Now some of you may have further training in that world of clinical neuroscience and rehabilitation, or vestibular rehabilitation. If not, this is where that relationship’s set up with a practitioner who has got further training in this field, whether it is ENT, whether it is audiologist, whether it is a chiropractor with further training in clinical neuroscience and rehabilitation, a physical therapist with further training in rehabilitation. Getting this patient to the appropriate person for further assessment and management.

But on top of the VOMS testing, there is also a couple more clinical assessments that we can do at the bedside. The antisaccade test is one. This can be done computerized, but it can also just be done via fingers. Very similar to the saccade test that you did in the VOMS screening. We set, again, the patient up at least arm’s distance away, so about three feet away. We have the target set up about 1 and 1/2 feet to the right of midline, 1 and 1/2 feet to the left of midline. And then you as a practitioner wiggle your finger. With this test, the patient is instructed to look to the finger that does not move. When you wiggle the right finger, the patient is supposed to look to your left finger. What you want to do is make that test random. You might do two snaps of your right finger, then three of your left, then one on your right, one on the left, and you make it completely random. And what you are looking for is any errors that are made. If you wiggle your right finger and they look to the right, you make a note of that error. When we look at that particular test, two sets of 10 random finger snaps, and we get an average of the errors made.

When we look at some of the research that is been done in a computerized laboratory and standardized testing for this, so we have got eye measurements and we have got some very specific numbers. When we look at a concussive group that have suffered a concussion, the antisaccade tests we are seeing groups have between 15 to 18 errors out of the total of 20 snaps. You can see there is a lot of errors that are occurring in a concussion group. So out of your 20 snaps, we are seeing, and expecting to see, maybe up to 15 errors made in the concussion group. This antisaccade test can be another nice test to help in that assessment and diagnosis of ocular motor dysfunction in concussion.

The final test to add in here is the head impulse test, also referred to as the Halmagyi test, or the head thrust test. What we want to do with this particular test is you want to position yourself right in front of the patient. You going to grasp the patient’s head on either side, so right hand on the patient’s side of their head and your left hand on the patient’s side of their head. You want to bring the patient’s head into about 30 degrees of flexion. This is to try and make the horizontal canals of the vestibular system line up with the horizon.

Then what you want to do is just very slowly rotate the patient’s head from side to side, telling the patient to keep their eyes fixed on your nose. We are going to rotate left and right slowly, just in the way the patients’ neck muscles stay relaxed. Their eyes are staying on your nose, and then randomly and suddenly, you want to quickly turn the patient’s head very rapidly about 10 degrees from the midline to the left or to the right, and you are observing the patient’s eyes. If we look at the picture on the right of the slide again, the top sequence there is showing you what should happen. When you rapidly thrust that patient’s head to the right, we should see that their eyes go to the left and maintain fixation on your nose. If we look at the bottom three pictures, we can see with that rapid thrust of the head to the right, the patient’s eyes in the middle moved with the head, and then they had a corrective saccade to look back to your nose. That is considered an error. If we thrust someone’s head to the right and they lose fixation, that would be considered hypofunctioning of the right vestibular system. Vice versa, if I turn the patient’s head rapidly to the left and I saw the patient’s eyes lose fixation of my nose and catch up, then that would be hypofunctioning of the left vestibular system.

 

When we look at the antisaccades and that head impulse test by Balaban et al, that work allowed that group to identify some oculomotor, vestibular, and reaction time characteristics of concussion, and to show that a small subset of the panel, so they did multiple oculomotor tests. They did saccades, and pursuits, and VOR, and a number of other tests, and you can look up the references for this test. But what they showed is that that small subset of tests that they did, which the three tests were saccades, antisaccades, and that Halmagyi, or the head impulse test, those three tests can be utilized to achieve a high specificity and sensitivity for the diagnosis of concussion. That objective, oculomotor, vestibular, reaction time, pattern can then be utilized to help confirm the diagnosis of concussion.

When we look at the research, and we look at a clinical assessment summary, in concussion we should be looking at our mental status and cognition. The SCAT5, that is freely accessible from the British Journal of Sports Medicine that was developed through the Berlin Consensus Statement, that SKAT5 gives you a complete overview of things you should be looking for in your assessment of concussion, the mental status and cognition. They will also be your balance testing in there, as well as symptom testing, as well as other forms of clinical assessment to be performed.

You have also got other mini mental status exams there, as well as depressive types of questionnaires that have all been shown in the literature to be reliable and valid within concussed patients. There is also the world of this autonomic dysregulation and looking and testing for autonomic dysfunction, and then what we have alluded to here today is that vestibular ocular assessment, so looking at the head impulse tests, looking at smooth pursuits, looking at your accommodation, saccades, antisaccades, as well as looking at that visual motion sensitivity. You can also see there is other tests such as gaze holding, dynamic visual acuity in there, as well as other tests such as balance, coordination, testing subpostural stability, tandem gait, as well as all of our neck testing.

So just in summary, what we want to look at here is when we think of assessing a concussion patient, we want to make sure that we are addressing all of these particular topics and assessing all of these particular fields, and if you do not have the skills and the training in this field, we want to make sure that we are part of a team that can allow the appropriate assessment and diagnosis to take place in all of these various fields.

But three very key important areas that have come from the Berlin Consensus Statement are the fields of dysautonomia; or the autonomic dysregulation; vestibular ocular rehabilitation; and cervical spine rehabilitation.

These are three key areas within the world of concussion that we can form part of that multi- disciplinary management team to apply the appropriate patient-centered care and work as part of that team for the patient to get best outcomes.

I hope today has been able to allow you to have a little bit of a different insight into some of the nervous system involvement in the injury, as well as some of those reticular areas, those vestibular, oculomotor areas, that can be involved in a concussive injury, and how we can assess it clinically at the bedside, how to record that, and then from that, that can start formulating our management strategies or the appropriate referral strategies.

Here are some slides of references for you for some further reading on today’s presentation, and I hope that has helped you in the clinical assessment of concussion. Any questions, please feel free to make contact.

 

References:

 

  • Balaban C, Hoffer ME, Szczupak M, Snapp H, Crawford J, Murphy S, et al. Oculomotor, Vestibular, and Reaction Time Tests in Mild Traumatic Brain Injury. Janigro D, editor. PLoS ONE. 2016 Sep 21;11(9):e0162168.
  • Blennow K, Hardy J, Zetterberg H. The Neuropathology and Neurobiology of Traumatic Brain Injury. Neuron. Elsevier Inc; 2012 Dec 6;76(5):886–99.
  • Brandt T, Strupp General vestibular testing. Clin Neurophysiol. 2005;116:406- 426.
  • Casa Della E, Affolter Helbling J, Meichtry A, Luomajoki H, Kool J. Head-Eye movement control tests in patients with chronic neck pain; Inter-observer reliability and discriminative validity. BMC Musculoskelet Disord. 2014;15(1):16.
  • Ellis MJ, Cordingley D, Vis S, Reimer K, Leiter J, Russell K. Vestibulo-ocular dysfunction in pediatric sports-related J Neurosurg Pediatr. 2015 Jun 2;:1–8.
  • Hellmuth J, Mirsky J, Heuer HW, Matlin A, Jafari A, Garbutt S, et al. Multicenter validation of a bedside antisaccade task as a measure of executive function. Neurology. 2012 Jun 5;78(23):1824–31.
  • Hides JA, Franettovich Smith MM, Mendis MD, Treleaven J, Rotstein AH, Sexton CT, et al. Self- reported Concussion History and Sensorimotor Tests Predict Head/Neck Injuries. Med Sci Sports Exerc. 2017 Jul 13;:1.
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ICSC01_2.TRANSCRIPT-CTE_Head-Injury_Rob Reid

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ICSC01 Head Injuries
Section 2 – CTE
Instructor Rob Reid
Video Lesson: 18:05

I am going to be talking today about Chronic Traumatic Encephalopathy.  We are using the term CTE because that is too long. The question we have is what if we were wrong about CTE and concussion? We’ll talk about that a bit later and you will see where I am going with that. We need to talk about the definition mechanism of injury, and the histological process as much as we could, we know about, but also, we also need to make sure that we look at a potential problem. I have been around for a long time; 40 years and I am a Sports and Exercise Physician in Australia. I have been Chief Medical Officer for a lot of different sports and I have always used a team approach when I look at these.  Whether I am working with an athletic trainer or a sports trainer or another doctor or a chiropractor, or an osteopath, it really doesn’t matter to me. I think the athlete’s well-being is the most important part of the thing, and I am just part of the team. There is no “I” in team.

Let us recap on concussion itself. Sports-related concussion is traumatic brain injury induced by mechanical forces. Now, those forces may be direct to the brain, or they may be to the face neck or somewhere else in the body that transmitted to the brain. As I see it means if there is a rapid short-term impairment of neurological function that results spontaneously. This is important because it means that it is a functional problem, not a structural problem. It does mean that it doesn’t last for a long time or do we don’t have consequences? It just means the definition is that, so, they cannot be explained by things like drugs alcohol, medication use, the interesting, they probably maybe in some cases, be able to be described by cervical injuries, but that may be the cranio-cervical junction but that is not very well recognized in the medical profession, but you guys know much more about this than we do.

There are other co-morbidities that are as well, and we need to keep that in mind. The concussions resulting in neuropathological changes, but the signs and symptoms should reflect its functional disturbance, rather than a structural injury, there is a range of clinical signs and symptoms that may or may not involve consort loss of consciousness, and what we need to remember is that only 10% of concussions are associated with the loss of consciousness. That doesn’t mean that they are not all severe, but it just means that the concussive episode that produces a lot of consciousness is not present in all of them. What about the definition? Well, The Concussion in Sports Group, we met in Zurich in 2016, sorry in 2012, but also in Berlin in 2016 and so it is defined as not having any structural abnormalities. It is a historical term that representing low-velocity injuries of corner because our brain shaking, as you can see there.  It is a subset of traumatic brain injuries and that’s what I am going to talk about. In Europe, they sometimes talk about commotio cerebri as the definition, but we’ll talk about concussion.

mTBI which is Minimally Traumatic Brain Injury is not a concussion. It means by definition, it means that there is some structural damage and this is out of the context of concussion itself. It is used interchangeably in some of the U.S. literature and offering that confusing and they should not be used interchangeably. It is a clinical diagnosis made or presumed at the time of the injury. You cannot go back later and say he did not have a concussion, it is very, very difficult. You cannot go back on a Monday or Tuesday after an injury on the weekend and say, well, he didn’t have a concussion because it is made at the time of the injury, not when you see them later on, that is whether you are a medical doctor or chiropractor, or anybody else. It can be over diagnosed, but mild concussions are more commonly under-diagnosed, it is symptoms of mild can be delayed, they can be delayed for 24 hours. So, you need to be aware of all of these sorts of things. Tim Stark made an interesting comment,  We need a higher level of competency in the outcome clinicians to investigate these things deeper because some of the things that we see in the Medical Profession and not explained by concussion itself but maybe by other problems that Sports Chiropractic can diagnose better and so Sports Chiropractor is should be one of the opinions especially when we’ve got these difficult ones that don’t follow the protocol that they are supposed to. So, Sports Chiropractic should be one of the opinions and I agree with them.

Whiplash, these are interesting. Whiplash has been defined as an acceleration-deceleration force transferring energy to the cervical spine. We have got a head sitting on top of that and the problem is that whether it is the cervical spine, or the head, sometimes it is both and some of the problems associated with concussion, some of the symptoms and signs can be problems with the upper cervical spine, and the cranio-cervical junction. There is some very interesting work in this area done by Dr. Scott Rosa in the United States, looking at changes at the cranio-cervical junction, which I find very fascinating. I cannot do it. Well, I can diagnose it, but I think it is fantastic.

The mechanism of injury for concussion. A blow to the brain sets off a flood of all sorts of things that occur, there is an injury to the brain, it is that the whole of the brain that’s affected and because of that there are all sorts of problems associated. Changes with an influx of calcium into the neurons and then because of this an extra energy that is required by the neurons to try to get better, but the changes also limit the supply of the brain fuel, which is glucose. So, the higher energy demand restricted flow and oxygen debt, and glucose debt create an energy crisis. This leads to the mental confusion failed memory and may take days to restore the balance. We need a full recovery before athletes return to play, but we need a full recovery which might take longer than we think.

CTE is defined as a progressive degenerative, disease of the brain. When people with a history of repetitive brain trauma often athletes, but not always. It is symptomatic concussions but also, we think that asymptomatic is sub-concussive hits, play a part as well. It has been known to affect boxers, it was called the punch-drunk syndrome would dementia pugilistica, but we think it is because of these concussive episodes and Boston University CTE Center is doing a lot of work on this. Obviously, this is a big, big thing in the states. So, the NIH had a CTE Conference in March 2015 and the neuropathology which is pathognomonic of CTE is an accumulation of tau which is a protein in the neurons and the glia at the depth of the cortical sulci.  The problem with that is that it can only be diagnosed after death because post-mortem, you’re a pathological analysis is required to find this tau protein. We cannot use any of the normal methods likes MRI, CT or anything like that to diagnose CTE during life. The concerns that we have is this, we cannot diagnose it during life, but we don’t really want to get to death before we diagnose it. People are not going to donate their brains to science when they are still using them. It is a difficult conundrum that we face, but Boston University CTE Center and a lot of others are doing a lot of work in this area. Tau protein aggregation has been implicated as a result of amyloid protein aggregation, but it is interesting that we actually, we are going to come onto the difference between this and parkinsonism or Parkinson’s disease later on.

A cause-and-effect has not been confirmed we would like to, but we think that repeated brain trauma triggers this Progressive degeneration including the build-up of tau but it takes too long for this to occur to make it easy for us to make the connection. It could be decades after the last brain trauma or the end of the act that led to even caught involvement before somebody really shows the problems with CTE. We do not know the number of head injuries or the type or the amount of head injuries that are required to produce CTE and we also have found that not everyone with a history of repeated brain trauma has it makes it difficult.

When we look at this picture of Parkinson’s disease, we can see that the substantia nigra is a lot smaller in somebody with Parkinson’s. We see something similar in somebody with CTE. So, obviously, it is different to normal, but again, we need to pull the brain apart before we could find it. So, the degeneration in the brain is associated with the common symptoms and these can be all of those that are also post-concussive syndrome or symptoms that we can see.  Parkinsonism is not one, but confusion, headache, depression, impulse control problems and things like that are all seen through all of these. Eventually, we get a progressive dementia and that is probably something that finally has these patients die, but again, we cannot describe it during life, unfortunately. The post-mortem analysis indicated that the symptoms are associated with the neuropathological changes, but their changes because there is atrophy of certain structures as well as degeneration of myelinated neurons. We have a difficulty in trying to describe this or define this during life, other changes with the degeneration of the neurons, etc. We have enlargement of the lateral at the ventricles and septi fenestrations and things that we again cannot define during life. We must have a brain on a table to be able to have a look at these.

Microscopically. There is accumulation in the neurons of tau protein, as I said before these aggregations and filaments called neurofibrillary tangles, but you don’t need to know all of that. But there are other small vessels in the frontal and temporal lobes but also they are prominent in the basal ganglia. When we talk about parkinsonism, we talk about the basal ganglia as well, but this is a bit more diffuse and so, when we look at this and even if we look at Alzheimer’s there is a very different look to these.  Alzheimer’s. Well, again is similar because the tau protein is increased, but they are different, they are amyloid plaques. What we see in CT is a very diffuse amyloid and tau protein aggregation. So, there are similar other brain problems, it is difficult to define whether they are on your genetic factors or whether it is just because of brain injury.

When we assess these, it is difficult there is a lot of different things that we look at difficulty thinking it involves behavior, depression, memory loss, difficulty planning, the executive functions of one of the things that that are important, but again, it makes it difficult for the person who has it because they don’t have the executive function to follow it up, emotional stability. The problem is this can occur in other neuropathological problems or other diagnoses, which don’t include CTE. We cannot make a definitive diagnosis on these because these are the functions but not CTE’s defined as a structural problem. It is almost the opposite of a concussion.

What about prevention? Yes, it is important really important. Can we prevent it? We don’t have a treatment for CTE. We cannot make these brains better when we can prevent them and we think that the way to do that is, because it is associated with a recurrent concussion, we need to do something about that. If somebody’s had one concussion, we know that they are more likely to have another head injury. We don’t know how long they will likely have another head injury, but we do know that there is some association, we don’t know whether it is because they have not really fully recovered from the first one, or whether they have set themselves up, if you like for a second heading toward the recurrent, current recommendation is to prevent the mild traumatic brain injuries, but don’t play sport that that project can produce these things, but we also need to prevent additional injury after a concussion. If somebody is completely back to normal before a return to sport, they are more likely to have any other injury that includes another concussion. We need to make sure that the concussion’s treated properly.

Can we treat it any other ways? There are some interesting things happening at the cervical cranial junction or creating a cervical Junction I should say, some interesting studies done by Dr. Scott Rose in the States which a lot of you may be familiar with. He is talking about the change in some in this Junction, which may make a difference to some of the things that we see in CTE because of a change in CSF flow. The medical symptom system doesn’t really understand what the CSF flow is or why we can sort of semi-define it, but there is some interesting studies done by Scott Rosa and by a number of other people too, who may be able to change some of the early symptoms and signs of CTE, but this is still in the early stages and we not sure that we have definitive changes that we can do with that yet.   There are a few references there one is the Rosa Clinic by Scott Rosa also the two BJSM references are for the Berlin CIS, The Concussion in Sport Group meeting in 2016, and 2012 and Bruckner and Khan’s book, which has some good information in it as well.

[END]

 

ICSC01_3.TRANSCRIPT_Facial Injuries_ Warren McDonald

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ICSC01 Head Injuries in Sport
Section 3 – Facial Injuries
Instructor Warren McDonald
Video Lesson: 53:18

Injuries to the ear, mouth, and eye. We are going to talk about some of the common things that we see when dealing with injuries in that area. My name is Dr. Warren McDonald. I am a sports and exercise physician from Australia. I have worked in both Olympic sports with water polo in particular and was lucky enough to go to Olympic Games with the Australian Olympic team. I have also worked extensively in rugby, and I am currently the chief medical officer of Rugby Australia. Just for clarity, I have no competing interests or conflicts that I am aware of in undertaking this presentation.

During this presentation, we will cover some of the common injuries we see in the ear, the mouth, and teeth, as well as the eye and surrounding tissues. Let us start with the ear. In simple terms, just recalling our ear anatomy, the ear is divided into the outer ear, the middle ear, in which we will talk about the tympanic membrane a little bit later on, and then the inner ear, which is responsible for the fine-tuning of hearing and for balance as well. We are going to discuss how we assess an ear and obviously, the first thing to do when you have got an injury to the ear is to look at the outer ear and see if there is any obvious trauma, which we will talk about in a few minutes.

Do not forget to look at the surrounding tissues. There may well be some bruising or other injuries in the area. Then potentially, if it is appropriate, feel the earlobe. I have to say if there are any areas of significant pain and again the surrounding tissues, looking for both pain swelling but also sometimes you can feel crepitus which is a crackling sensation if there is a significant injury to the region. Special tests of the ear are really best left to doctors, particularly looking inside the ear with the use of an otoscope, and obviously, more sophisticated tests of hearing and balance require much more significant investigation. But I think if you have got a significant injury to an ear, do not forget that they could well be associated injuries, and in particular, thinking about concussion. Any trauma that is severe enough to damage the ear could also cause injury further inside the skull.

In the outer ear, we will often see things like hematomas and lacerations. In the middle ear, we will commonly see, there is rupture of the tympanic membrane or the eardrum. Inner ear injuries are much less common but it should not be missed. Let us start with the outer ear and think about hematomas of the outer ear or auricular hematomas. A hematoma is simply a collection of blood, and given the anatomy of the ear, the pathology associated with this is an accumulation of blood very close to the cartilage of the ear.

There is not a lot of space within the ear obviously, so the significant bleeding can both be a sign of damage to the cartilage or potentially cause damage to the cartilage. The mechanism of injury is either a direct blow or recurrent rubbing of the ear which can happen in quite a few different sports. Things like wrestling, the martial arts, boxing, rugby, and particularly those players that play in the front row or second row of the rugby scrum can get significant rubbing of these, and then other sports like water. polo.

Usually, if a player has injured their ear, they may present acutely after a direct trauma or they might present sometime later after an accumulation of rubbing or blows. Signs and symptoms of an irregular hematoma and, well, it is quite a painful swollen mess, and it can be quite tense when you touch it. It is quite done stretching the tissues above it. There is often a very small soft spot or at least an area of softness that indicates that there is fluid within the ear. You obviously need to make sure that the middle ear and inner ear have not been damaged if there is trauma, and likewise, make sure that you have not missed trauma or there has no associated trauma to the face or to the skull or elsewhere.

Sometimes, and in fact, quite commonly in sports people who have been around for some period of time, there will be a combination of new injury and old injury and the recurrent bleeding of a hematoma may compromise the cartilage over time leading to permanent damage, and that is known as a cauliflower ear. The diagram at the top here shows an acute hematoma, but the diagram at the bottom shows damage to the tissue and the cartilage that is quite permanent and that is known as a cauliflower ear. How do we treat a hematoma? Well, it usually requires aspiration if you can get it early. Aspiration using sterile technique. If you can pick the softest spot, you can often drain the blood from the region quite straightforwardly. Often there is not a large volume of blood that comes out, but removing that blood makes a significant difference to the appearance of the ear almost immediately. The biggest or the hardest part is actually maintaining pressure once you have aspirated the bleeding because they are notorious for regathering. You can see the bottom diagram here shows a person who has had their ear drained with a compression bandage over the top and this needs to be left in place for well, preferably a few days to prevent re-accumulation of the hematoma which is very common and come, unfortunately.

The other one, returning to sports, obviously, the ear needs to be protected and this is best done either with a bandage but to protect it from either rubbing again or often get further blows, then an appropriate helmet should be worn. In a sport like water polo shown at the top here, those headgears are mandatory and must be worn and they have protection for the ears. In other sports like rugby or rugby league, as shown in these players here, there are a variety of headgear that can be worn in those sports and others that will protect the ears from further damage. I would recommend that players that have trauma to the year wear them for some period of time.

Of course, the ear can also be lacerated with a trauma and it is not that common an injury, but the skin of the ear is very thin and especially at the front of the ear. Direct blow or contact with a sharp object will lead to a laceration which can be full thickness and involve the cartilage of the ear or just involve the skin of the ear as we can see in the lower picture there, and that usually presents quite acutely with a painful bleeding earlobe.

As the skin is very thin in some parts, you need to ensure that the underlying cartilage is intact and it has not been damaged but the ear can be sutured quite straightforwardly. But the complication is that you need to be aware of the infection and then slow or poor healing can also eventuate, so they need to be managed and monitored quite closely as they recover. Obviously, any significant laceration should be assessed by a doctor to ensure that the wound is healing and whether it needs to be sutured or when fact, in some situations when there is a very significant injury, surgery may be required. It is best not to return to sport until after the laceration is well and truly healed.

Moving from the outer ear to the middle ear, one of the classic injury in this region is a rupture of the tympanic membrane or a rupture of the eardrum. Just recalling our anatomy, the tympanic membrane is a thin layer of tissue stretched across the ear canal. You can see where it is located on the diagram here at the end of the ear canal. Then when we look inside, it is a very thin layer of tissue that is a crucial component of the process of hearing and also provides a barrier for water or fluid to enter into the inner ear from the outside. How does that get injured? Well, the tympanic membrane is usually damaged following a blow to the side of the head and especially if the ear is hit with a cupped hand. What that does is force a rush of air into the middle ear region and that will rupture the tympanic membrane.

I mentioned water polo earlier on, and it is an injury that we not uncommonly see in water polo but can happen in plenty of sports as well where a cupped hand over the ear will cause problems. The diagram on the right here is showing where the membrane has ruptured. That can be quite painful and cause a loss of hearing and sometimes a sensation that air is moving through the ear as well. The mechanism blow to the head and then immediate symptoms come on with pain and potentially a loss of hearing, not necessarily complete loss, but some loss of hearing potentially ringing in the ears which is known as tinnitus and sometimes bleeding from the ear as well. The player should be assessed by a doctor in this situation to view the tympanic membrane which they can do with an otoscope. You can see here that this diagram on the right shows the rupture or the tear in the tympanic membrane and you can usually see that relatively straightforwardly.

Usually, it heals fairly well, if allowed to. It usually heals over a period of a few days to weeks and antibiotics may be required because obviously, you do not want this potentially a risk of infection getting beyond the tympanic membrane in particularly into the middle ear. But yeah, you do need to make sure that it does heal and is given the appropriate chance to do so.

What do we do if we are faced with one of what we suspect is a ruptured eardrum and they should be assessed by a doctor in the first 24 hours after injury? Just get the assessment right and confirm the diagnosis and then commence treatment. Then once the ruptures heal, they can return to sport, and again, the use of headgear is very helpful and I know I have mentioned water polo a couple of times, but the design of the water polo cap is designed as such to protect from this injury so that the player because of the nature of the sport and the fact that the blows to the head and the ear are not uncommon, then the water polo caps are designed to actually prevent that this injury from happening.

The damage to the inner nearly not right along is much less common in sport but may result if you are unlucky enough to damage the components of the inner ear. It can result in either permanent hearing or balance disturbance. The very structure can be damaged by trauma including the semicircular canals and the small bones of the inner ear and that can happen with a direct blow, usually a very, very significant blow. People will present with hearing loss or balance disturb in following such trauma. They may also have tinnitus. They may have problems with vertigo with the world spinning around them. So, this needs to be assessed by a doctor and they possibly need to undertake significant scanning and potentially hearing tests as well.

The other thing to remember is that if a trauma has been significant enough to damage the inner ear, then again, other injuries may be associated with it such as concussions so the player certainly needs a thorough assessment to make sure that you have covered all the possible diagnosis. These players or these participants should be referred to a doctor immediately, and return to sport should not occur until all symptoms of settled. Unfortunately, with a damage to the inner ear, that will take some time for both the assessment and then treatment to occur. It is not uncommon for these people to be out of sport for months at a time.

Moving on from the ear to the mouth. The significant features we are going to talk about here, we are going to talk about some simple lacerations but also injuries to dentition as well. So, when you are assessing the mouth or the mouth region, then you should look obviously at the mouth both inside and out. I am not a fan of anyone putting their hands inside someone’s mouth without a pair of gloves on but you should assess and look to see where the injury has occurred in the mouth, whether it be the tongue, the cheek, or the other parts of the mouth, whether it is the lips or the teeth that are injured. You can then sort of gently just feel the area to see if there is significant pain. Usually, I do not recommend touching the teeth unless you really know what is going on.

If a player or an injured athlete is complaining that they feel like their teeth are loose for example, then do not go touching them to see that. Let that be in the hands of a professional. Then the special tests of looking at someone with a mouth injury, see if they can move their jaw, both open and close their mouth. Can they move it from side to side? Does it feel normal?  Does their bite feel normal? Are there any unusual clicks or any other sensations that they are feeling? Of course, the mouth is part of the upper airway so do not forget to keep an eye on someone with significant mouth trauma to keep an eye on their airways, their breathing, and their circulation. If they have taken a significant blow to the mouth, do not forget that they can have injuries to the nose or to the eyes, or other parts of the face as well so they do need to be assessed thoroughly.

We are going to have a quick chat about the lacerations within the mouth. We will have a look at teeth injuries and then we will talk about fractures to the face and to the jaw as well in covering this. Then to finish off, we are just going to have a quick chat about temporomandibular joint injuries as well. Lacerations inside the mouth or around the mouth are usually a result of direct trauma or potentially by biting the tongue or soft tissues or from a fall such as from a bike. A child riding a bike or anyone riding a bike, they are going to fall off and unfortunately have direct trauma to the mouth.

Lacerations can occur in both the lips and the soft tissues, such as the inner cheek or the tongue itself and you can see on the diagram on the right shows a quite deep and nasty laceration inside the inner lip. But the good news is, the mouth has a very good blood supply. Lacerations in the mouth will usually, they will bleed profusely but they will also heal very well as well. It is an upside and a downside to that. The initial presentation of someone is obviously that they will, following a fall or trauma of some sort, they are complaining with pain, bleeding, swelling, and a potentially altered speech. They might not be able to talk normally because of either the pain or the swelling in and around their mouth.

See if they can open their mouth, their jaw and move side to side. If a patient happens to be unconscious for whatever reason is part of the trauma, do not put your fingers inside their mouth at any stage. Even if they are semi-conscious, you should avoid that because there is a risk that they can go into trismus and lock their teeth on your fingers and that is not a good outcome for either person.  Assess what you can and obviously be aware of other injuries. You can see that the diagram here shows a significant laceration to the tongue, but that would have been caused by the teeth, for example, jamming down, biting the tongue. It is possible that the teeth are also injured as well. We will talk more about teeth injuries in a minute. If there are certain blows that are that significant that cause injuries in this region, do not forget that they can be associated with things such as concussion as well.

How do we intervene? Do not forget the airways, breathing and circulation need to be assessed in these patients to make sure that the big picture items are intact. Usually, I mentioned before, this is a nice diagram here of someone who has had their inner lip sutured. Because of that good blood supply, you would expect that to heal very nicely for that person. They should not return to sport in general, until it has completely healed. But generally, the healing does occur in a relatively quick time. I am a big believer that people playing sports should wear mouth guards particularly if there is a high risk of contact. These injuries often occur because the tooth goes through the lip or whatever. Certainly, the tongue injury I showed on the last slide could have been prevented in a contact sport situation by wearing mouthguard.

Moving up to just the other injuries around the mouth and the face. The zygomaticomaxillary complex or the area of the cheek can certainly be damaged in with trauma. Fractures of the cheekbone occur from a direct blow, which can be a fall, but it could also be a fist such as a punch, it can be a hockey stick injury or a cricket ball hitting them on the appropriate region. Do not forget that a fracture is a crack through the bone and that it can be either displaced or non-displaced, they can be separated or not and it can extend into the orbit of the eye from its location.

Generally, fractures to the cheek occur from a direct blow to that region. They present with a very painful tender area. Perhaps there is going to be some swelling, some bruising as we can see in the picture here on the right. It may be looking a bit flat compared to the other side, so they may be asymmetry between the two sides. There may be some crepitus or crackling of the skin when touched, and there may be, again, unusual, again, extension of symptoms to involve the eye. There may be double vision, there might be numbness of the cheek because of the involvement of the nerves underneath that have some swelling and therefore some pressure on them. Movements of the eyes may be limited and asymmetry as I mentioned. The player needs a thorough assessment in that situation for the generalized facial illness and injuries, I should say, and do not forget the ABC, the airways, the breathing, and the circulation.

Anyone with a significant injury needs to be referred to a doctor for review and then X-rays and scans. Often, I will need more than just plain X-rays because the intricacies of the bones in that region sometimes make it hard to determine whether there is a fracture. So, things like CT scans may be more appropriate. At the top there, I have got other injuries such as eye injuries and other fractures and concussions as we have mentioned. Depending on how bad those injuries are, the treatment ranges from rest at the time or on some occasions, surgeries are required if there is a displaced fracture to relocate the fracture and then allow it to heal over time. When returning to sports, that should only happen when all injuries are healed.

Other fractures around the maxillary and the facial bones, well, yeah, they usually occur from a direct blow, and again, the things I mentioned before. A fall, a fist, a hockey stick, or a cricket ball or baseball. Again, remembering that there might be greater fractures extending to the whole face and affecting the palate or the orbit as well. True facial fractures as shown in the diagram down below, usually require a large amount of force. Things like falling from a height, falling from a bike onto your face can cause these sorts of injuries. They are significant injuries and usually need to be, well, in the vast majority of cases, will need surgical treatment.  Someone who has really damaged the maxillary or the facial bones will have a lot of pain and a very tender touch. There may be swelling, there may be flatness in the cheek, there may be crepitus, there may be double vision, numbness again, and movements of the eyes might be limited, there might be asymmetry in movements in the eyes, and the patient’s face might look asymmetrical or unusual, and there may be a malocclusion. When they bite down, it just does not feel like their teeth a lining up the way it should be. These people need to be thoroughly assessed for facial injuries and again, with significant trauma to the face. Remember that their airways and their breathing, in particular, may be compromised. So, they often want to sit up these people and are probably better managed sitting up because lying down will potentially compromise their airways. But that is obviously only if they are alert enough and awake to be able to assist you in that situation.

Significant fractures and other injuries like to the eye, to other fractures in the face or elsewhere, concussion in the airways and breathing, they need to be referred to a hospital for doctor’s review and X-rays and scans and further management. In many cases, they need ambulance transfer for significant injury. They cannot return to sport and would not be returning to sport until after all their injuries are healed, which may be many months down the track. Mandibular fractures are more common and we see the fractures of the mandible of the lower jaw. In many sports, and again, on the other pictures here we see sports like boxing, the rugby sports, any other contact sports.

Mandibular fractures are not that uncommon but it can also occur from a blow from a ball as well, whether it be a baseball, cricket ball, or any other way, other hard ball that strikes the right place. Most commonly, the jaw will fracture at what we call the angle of the jaw or up at the condyle at the temporomandibular joint. The mandible fractures it often fractures in more than one place. You need to thoroughly assess the mandible if you suspect there is a fracture. The mechanism of injury usually results from a direct blow or from a fall. A painful, tender swelling and malocclusion are common. When assessing these, there may be bruising on the floor of the mouth. You will see malalignment of the teeth and that is what the diagram on the right is showing. The teeth do not line up completely as they should. There is a significant malalignment there on the mandible. There might be tingling or numbness of the lower lip and of the chin as well. Do not forget your first aid approach, the ABC. The airways may be compromised and again, what we spoke about with the other facial fractures, they might feel more comfortable sitting forward which helps maintain their airway if they are conscious.

The complications or potential problems, airway complications can be considered. Concussion needs to be considered and other head and neck injuries. They need urgent referral to a hospital. An ambulance might be required to do that quickly. They need X-rays and scans and they may need surgery. Obviously, the X-ray on the right-hand side, the white arrow shows the line of the fracture. That is relatively easy to see. Often, they are not quite so easy so sometimes you need further scanning such as a CT to ensure that there are no fractures there. They should not return to sports until all the injuries are healed, and that they may be for some months before everything is settled.

Temporomandibular joint injuries are not uncommon in sports. There is a range of injuries from the very mild to the very severe. Generally, any blow to the mandible can injure the temporomandibular joint but the range of injuries can vary from a dislocation of the joint, bleeding into the joint, which is a hemarthrosis to a meniscal displacement to an intracapsular fracture out of the head of the condyle. The diagram on the right there shows a small fracture through the condyle and within the joint.

The mechanism of injury is usually a blow to the jaw. The person will present with pain, tenderness, limited opening of the jaw, they potentially cannot open it properly, they might have malocclusion, their bite does not feel right, they might be unable to close their bite. If they cannot properly close their mouth, that might indicate dislocation and there might be asymmetry as well. When you are assessing them, you need to assess the tender areas and movement of the jaw and the occlusion of the teeth, and you can remember that there may be other injuries associated with it as well. These people should be referred to us for assessment which may include X-rays or scans.

Dislocations or fractures occasionally may need surgery, many times, they do not. But remember that these people again should not return until it is completely healed, which may take some weeks. I know I have spoken a few times around fractures around the mouth area. You can see that the majority of the cases involve the condylar process. That is the most common reason for fractures. Then around the angle of the jaw is the second most common. These are the areas where it will commonly fracture, and as I said, always consider that there might be more than one place where this happens.

Dental injuries are very common in sporting instances and they can range from anything from a small chip of a tooth to loosening of teeth or complete avulsion of a tooth. An avulsion is where the tooth is completely removed from its socket and that is what you can see clearly here on this upper diagram. The lower diagram shows a picture from an Australian rules football where you can see quite clearly the tooth sort of sitting and have been accidentally blown. It received a blow to the face that it actually popped right out of the mouth and will need to be found.

Usually, teeth injuries occur with a collision with an [inaudible] or trauma from an equipment of some sort such as a hockey stick or a fall onto the face from a bike. They will present with pain, bleeding, swelling, and an uneven bite. The signs and symptoms are usually pretty obvious, and especially if you have lost a tooth as that last diagram showed, then the first thing is to find the tooth. Even if that takes some time, it is worth doing. If a tooth can be found and replaced into its socket, then that will potentially have the best outcome. So, if someone loses a tooth, it is worth spending the time to try and find it.  When touching the tooth, you should have some gloves on. It is best to just handle the tooth by the tooth proper, not by the root of the tooth, which is the area that goes into the jawline. Basically, the tooth should be, if it is intact and if it is possible, then as this diagram at the top is showing, it is ideal if it can be replaced quickly, then do so. Wash the tooth down and then replace it before getting to emergency care. If it cannot be easily replaced, then a couple of options. One is to pop it into milk or there are some special solutions that are produced. The worst thing you can stick it in is water. Saliva is better. You can sit in the, I would say, at the cheek of the person whilst they are transferred to emergency dental care. Now, obviously, you do not want the person to swallow the tooth, and that is the point that is made here in the script here. If a tooth or fragment of a tooth cannot be found, then do not forget that it not only might be swallowed but it could be aspirated as well. Obviously, if a tooth gets into the lungs, then that can be a real problem. So, if you cannot find a fragment of tooth or a full tooth that is gone missing, then the person should have a chest X-ray and especially in children to make sure that the tooth is not somehow made its way into the lungs.

To all significant teeth injuries like the ones that I have shown here, they require immediate specialist treatment. You need to get them to a dentist as quickly as you possibly can. But it is worth the effort because you cannot quite often save the tooth and, basically, that will then require weeks and sometimes months of treatment, to get things back to normal. But basically, once the teeth have been healed, then they can return to sport.

Moving right along the eyes. The eye anatomy is very complex. I am not going to go into much detail, but it obviously sits in the bony orbit, which is shown at the bottom here. But the eye itself is a very delicate and complex organ whose purpose is to provide vision. That is a key feature obviously. One of the keys of assessment is making sure that the person has the ability to see out of the eye. If you have got someone with an eye injury, then obviously you need to look at the eye and at the surrounding tissues to ensure to discover what you can. You can feel around the eye to see if there is significant tenderness or numbness and then you can move the eye to see that its movements are full and equal.  The eyes move together usually, but if there is asymmetry in movement, then that is important and we will discuss that in a couple of minutes. Is there any pain with the movement of the eye, and importantly, does light bother the eye as well? The other important thing you might just see here on the diagram on this page is the person here has one red injured eye. The other eye, again, we cannot see clearly, but it looks relatively normal in what we can see. There is an old saying in medicine, “Beware of the one red eye.”

If someone presents with one red or potentially injured eye, they really need to be thoroughly assessed so that we understand the pathology that is going on. There are a range of pathologies, and as a result, we need to fully assess them. There is the specialist test around, can the person see out of both eyes, can they see in all directions, and can they see all of the visual fields at a full? Each eye needs to be examined individually. Is their vision blurred at all? Are there unusual spots? Obviously, looking inside the eye requires specialist equipment such as an ophthalmoscope and also some specialist drops some time to help you such as anesthetic drops, but also down here I am showing fluorescein drops or fluorescein strips, which are very important in helping assess the other services of the eye which again, we will talk about it in a second. Do not forget the associated injuries such as fractures of the nose or the face and concussions, which can also occur as well. There will be a consideration of a few different injuries here, things like corneal abrasion, subconjunctival hemorrhage, hyphema, retinal detachment, and orbital fractures as well. So, let us have a look at these. Corneal abrasions are very common. The cornea is the outer layer of the eye. Basically, it is a common injury in which that outer layer of the cornea is scratched and that can occur with a multitude of things. It could be a foreign body, it can be a fingernail accidentally in a sporting context. It can be things such as metal fragments in people who are working with metal or whatever it might be.

Usually, the person presents with pain, irritation in the eye, a sensation that there is something in the eye, and they might have blurred vision. For anyone who has had something in their eyes, it can be quite an annoying sort of sensation, and you can see on the diagram, the fluorescein drops which are typically orange, sort of show a scratch running across the eye. They should be referred to a doctor for assessment because this is potentially a serious injury and you do not strongly recommend against messing around with eyes. They have one job and if people are not able to see properly then, they need to be assessed as soon as possible.  Basically, the complications of corneal abrasion, usually they will heal, they will often need antibiotics drops to prevent infection and maybe those drops to actually see the inflammation. If it does not heal, just occasionally, you will get scarring if not treated appropriately, but the vast majority will heal quite comfortably with the right treatment. They should be referred to a doctor on the same day to be seen as soon as possible and then usually they can return to their sport after a few days after all symptoms have settled.

Subconjunctival hemorrhages are also very common. The conjunctiva is in the outer layer of the eye away from the cornea. A trauma can lead to bleeding under the conjunctiva and that can happen from either a direct blow, a scratch, a finger in the eye, or a range of things can cause that to occur. Often, it will present as a bright red area, much like what I am showing here in this diagram, a small area of bleeding. Sometimes they just happen spontaneously as well, which often scares people, but is usually, thankfully, not too much to be concerned. But they are not always quite simple as this nice little simple red area. They can be quite extensive as the diagrams here show and so much larger. If they are small, it is usually of no concern. But if they are large, they can cause visual symptoms and photophobia, which is irritation from light, and they should be assessed in that situation. The other important issue is if you cannot see behind a hemorrhage, then it may indicate that there is further injury to the bony structures, particularly the zygomatic bone or the zygomatic arch, but also the orbit as well. What do I mean you cannot see behind it? Well, on the diagram on this page shows the subconjunctival hemorrhage and you can see as we move away from the iris, we cannot ever see this clearer at the back of this eye in this region here. We can just see blood all the way around. So, that is always a concern. There is also obviously a fair bit of bruising around this person’s orbit. The concern is that there is something else going on or significant with this person.

You have got to be aware of fractures and significant injury in the eye. A doctor’s referral for anyone with some subconjunctival hemorrhage if their vision is impaired, you cannot completely see behind the hemorrhage. The good news, unless there is some other significant injury, if it is just a simple subconjunctival hemorrhage, then they can usually return to the sport very, very quickly. In fact, almost immediately. So, that is the good news. A hyphema is an unusual injury but it does occur occasionally where you get bleeding into what we call the anterior chamber of the eye. It is right at the front of the eye, and you can see the picture here shows a fluid level. It shows just fluid sitting in that anterior chamber starting to really block out the iris of the eye. That potentially comes from a blow. It is usually a blow to the orbit or blunt trauma. Sometimes they can be a lot smaller, and I will show you a smaller one on the next page. But these need to be referred immediately to an eye specialist for review. You certainly do not mess around with these. If you see this injury, this person needs to be treated appropriately because if you do not get it right and treated appropriately, then you can have permanent visual problems in this person.

You can see in this case, there is a much smaller fluid level than on the last diagram but again, that person still needs to be referred. It is bleeding, as I said that has gone in there, and if it is not treated appropriately, then they can end up with significant scarring in that anterior chamber and can further damage the cornea. You do not give them aspirin, you do not give them anti-inflammatories because they can both increase the risk of bleeding. They need bed rest. It is what they need but they also need referral to an ophthalmologist to be seen urgently, and then further treatment will be guided by the ophthalmologist depending on their particular preferences. But in most cases, the bed rest will allow the bleeding to settle, and without any scarring, it will allow people to move forward.

Retinal detachments are an uncommon injury, but a very, very significant injury and there are a couple of keys here that sort of make you think, wow, is this person telling me that their retina is detaching? Now, the retina obviously is the sensitive part of the eyeball where the light is directed, and from the retina, the signals are taken to the optic nerve and to the brain for interpretation of our sight. If the retina detaches from the orbital wall, then we break this mechanism, we damage the mechanism and therefore, we can end up with permanent visual impairment. The pathology here is, as I said, the retina is stripped or lifted off the posterior wall of the orbit and it can follow a blunt trauma or a perforating trauma, and sometimes it occurs sometime after a trauma as well. It is almost like the area becomes weakened and then a relatively small event can accelerate what is happening there to go forward.

There are a couple of key things that the patient will tell you in this situation. They often report that they potentially had a trauma, but then they will report flashing lights in their eye, and which worries them. Sometimes, they will say it feels like there is a curtain coming down across the field of vision and that is a bit of a giveaway. If you look at the diagram on the lower diagram here on the right, you can see that the picture above is relatively normal, what normally the inside of the eye will look like. But on this occasion, it just looks abnormal at least you can imagine. It looks like the tissue back there, the retina, is actually sort of sitting and almost sort of waving in the background.

Do not expect to be able to see those. That takes a specialist to be able to identify these issues. But if you think about the tissue sort of sitting forward and therefore damaging the line of the signal, then that explains why they present either with the flashing lights or with a sense that they vision curtain is coming across it. It needs an immediate referral to an eye specialist. You do not mess around with this one at all. If it is not treated immediately, it may result in permanently lost or impaired vision. Even if it is treated immediately, there can still be some loss of vision. But the sooner it is seen and dealt with, then the better. The emergency care protocol is, get them referred immediately. Unfortunately, for the vast majority of people, this needs for the future, that they need to avoid risky or contact sports. Not uncommonly, these people have to retire from the sports that they have been involved in such as contact sports because there is a risk that it could happen again. Having had one retinal detachment usually means that the person should reduce all risks that have been happening again.

Orbital fractures are not uncommon and obviously, the orbit is the bony structure around the eye. The walls of the orbit are very thin both inferiorly, the floor of the orbit, and medially. They can be quite easily fractured with a direct trauma. It results in what we call a blowout fracture. In this situation, a trauma, a blow to the eye region or the orbit, the contents of the orbit, or the eye structures can be compressed and damage the bony structures around them. Then the contents of the orbit can herniate through the fracture line and possibly be trapped by the fracture, which is quite uncomfortable.

People will usually present with these injuries following a direct blow to the eye such as with a squash ball, which is well known for potentially causing these issues. Anything else that directly blows onto the orbit or creates a blow onto the orbit will potentially cause this injury. The person will complain of pain, blurred, or altered vision, they will often be a lot of swelling around the orbit and quite scarily, these people will sometimes present where they have had a trauma, and they feel as if there is something not right. They feel sometimes like they have got to blow their nose, and then they blow their nose, they get an enormous amount of swelling around the eye and sometimes report that they feel like the eye is going to fall out of the socket.  That Is a key giveaway. If someone presents with that story, then in my mind they have got a fractured orbit until proved otherwise.

The other thing I present with is restricted eye movements and that is because of, the muscles around the eye will get trapped in the fracture. If you would have a look down at the diagram at the bottom right, you can see that person is trying to look up and the one eye is going up and the injured eye is not going up there because the muscles have been trapped. The person above that, there is significant swelling and bruising around the eye here and much more than you might just expect to see with a non-fractured injury. This person has had a CT scan which shows the fracture line where the arrows are pointing to.

You need to be a little careful here as a doctor if you order X-rays of this area because the X-rays are often inadequate to see the fracture and the CT scan as this is showing is much better required. If they have the right story and they have history of a blow to the eye, the sense that the eye is blowing up, that maybe crepitus if it feels like it is jumping out of their eyes or out of their eye socket then they do not need to do that but do if you suspect that they have got a fracture of the orbital floor or the medial wall of the orbit.

Complications that are potentially there, well, they can get infected, they will often have impaired vision if the fracture is not reduced and stabilized. Depending on how big the fracture is, these people sometimes need surgery to put it back together. They should be referred to a doctor as soon as possible for assessment and X-rays and scans as I have described. Then they can return to their sport after appropriate treatment and surgery, but it usually takes, you know, several weeks to months for this to settle down. The good news is that usually they will heal quite successfully, and people can return to their previous sports.

That is just a quick skip through some of the injuries we see around the ear, the eye, and the mouth and face. I guess we need to make sure that we take a team approach to the treatment of any athlete. In the absence of any emergency services in an event, the emergency care goals are to first stabilize the patient and provide basic life support, which is the importance thing here. You will notice that quite a few times through the presentation, I referred to going back to the simple ABC. Do not forget those things because the injuries around the head and the face can certainly cause compromise to the airways, the breathing, and circulation.

If there are other sports medicine members, who are emergency care certified workers who are working at an event, they should be the primary care providers in the event of life-threatening trauma. Then finally, any rapid return to a sport may compromise the long-term health of the athlete. It is always wise in my books to just take a little bit longer, make sure you have got them right, and then you will do the best thing you will and not harm the athletes.

If in doubt, sit them out and then see how things progress from there.

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ICSC01 Head Injuries in Sport
Section 4 – Intracanial Bleed & Haematomas
Instructor Rob Reid
Video Lesson: 16:49

Intracranial bleeds and hematomas are a consequence of head injuries but not really of concussions, although it can be a consequence of the head injury that we can’t diagnose. We will talk about the definition, mechanism of injury, histological processes, and potential problems as last time.  Firstly, its definition. I found this from Wikipedia, and it was quite a good definition, so I am not going to really change anything. This is nothing abnormal or nothing unusual for a lot of you. ICH is also known as intracranial bleed, because of bleeding in the skull obviously but I am going to talk about it as a bleed rather than a hemorrhage. I just don’t like the term. The subtypes, you can get into intraventricular bleeds and intraparenchymal bleeds, but these tend to be not associated with injury, so I am just going to talk about the ones that are associated with injuries. The bleeding can occur when obviously, a blood vessel leaks or is ruptured, which are two different things from a medical point of view and it can result from physical trauma, but also can occur in hemorrhagic strokes, people with high blood pressure. I am only going to talk about trauma-related ones today.

These bleeds, they are much more likely at high-speed impact. So, a low-speed impact has less of a chance of doing this but it is still a bit unclear because I will talk a bit about some of the ones that we see, which are unfortunate, I will just mention them, but downhill mountain biking, motor vehicle racing is common, and equestrian events. It is quite common because of the link that how far they fall, ice hockey and it can occur in other sports but less common in more common sports, if that makes any sense.

Complications make it a serious medical emergency. This is important for everybody to remember. It is a buildup of blood within a fixed volume of the skull. It occupies space and it makes a difference both to the brain tissue and whether somebody can in fact survive, so increasing intracranial pressure is not a good place to be. The ICP increase can cause the brain to be pushed out of the foramen magnum, which puts more pressure on the mid-brain and brainstem, and an increase in blood pressure is one of the signs that we see but also a decrease in heart rate and these two are important symptoms or signs I should say because they can lead to death.

Early symptoms and signs similar statistics to those of a concussion. You can’t tell the difference. I cannot tell the difference as a medical practitioner, and I dare say that you won’t either. If you can, then you are better than I am. There is nothing to distinguish them, so any head injury, whether it is a concussion, a mild traumatic brain injury, or severe traumatic brain injury has to be treated with respect. It is a medical emergency, and we need to treat these on a presumptive diagnosis. You don’t need to do a CT scan to start appropriate treatment for these people. If you know the force of the injury, then you’ve got a better chance of making this decision early. You should have a high level of suspicion when there is a serious head injury or concussion or would you think is a concussion, so early recognition and prompt management are vital. We need a referral to an appropriate facility. The CT scan is in fact the definitive tool for a diagnosis of an intracranial hemorrhage. Sometimes MRI scan can also be used but a CT scan shows the difference in the bleeding area and the brain tissue better than it sometimes an MRI, so a CT scan is the way to go.

Symptoms. Same as for concussion. Headache, dizziness, amnesia, disorientation, tinnitus or ringing in the ears, lightheadedness, emotional changes, sometimes you might some changes and irritability, I [inaudible]. I had one athlete who is we really had to get him off the field because he was quite irritable and although he was sort of thinking okay, he is very irritable. We must take that into account. Double vision, memory loss. They are all symptoms. Signs include loss of consciousness. These people with a bleed will often have a loss of consciousness because the injury is a high-speed injury. Vomiting is common, and they are always drowsy and want to go to sleep. Fainting, loss of balance, slurred speech, slower reaction [inaudible]. The other stuff is there as well but if you can, you need to look at the blood pressure and the pulse, even adjusting the pulse will give you some idea. What about the classification? Well, when we look at these, it is a focal brain injury. Traumatic ones are what we call a focal brain injury. Something that is a localized spot in the brain that may or may not directly involve the brain. Tissue, it might just push it out of the way. There are three different categories. The Extradural, Subdural, and Subarachnoid Hemorrhages. I will talk it to them one by one.

An extradural is sometimes called an epidural, although that’s normally left to a hemorrhage that would occur in the spinal cord occurs between the dura mater and the skull. It is caused by trauma, but it is an artery. Laceration of an artery means that they bleed quickly, so there is a rapid increase in the size of the bleed which means they rapidly go downhill. It is very uncommon because you almost need to have a skull fracture because of mostly the middle meningeal artery but you still see in 1% to 3% of these significant head injuries. Vomiting, agitation, and loss of consciousness are common. The clinical onset occurs over minutes sometimes hours quite often minutes but they have a history of head trauma but then a lucid period and then the increasing symptoms, these are the ones that go off quickly, so you got to keep an eye on them. You must keep an eye on these guys because if they have got one of these, they can go off very quickly. It doesn’t cross suture lines on a CT scan, and you can see it on the CT scan quite easily, but we need to evacuate that bleeding. It can push the brain out of the foramen magnum and the brain doesn’t like going there. Its potential complication is death but normally It is pretty good, and these are often recognized quite early and treated early. We certainly hope so.

A subdural is almost more difficult because it is a tearing of a bridging vein and because of that, It is a low-pressure system, it doesn’t occur as fast. They may still have a loss of consciousness, but they are usually associated with cerebral cortex injury because it is underneath the dura mater, and so, they can be associated with long-term problems, but the problem is that they don’t hit you in the face like an extradural. Depends on the side of the injury as well but they quite often get knocked out or have a loss of consciousness and they get better for a while but then over hours, they just become worse and worse. This is the reason why we tend to get people to who’ve had a head injury really watch for 4-8 hours. If you go to the hospital, they will nearly always keep somebody in 4 hours, sometimes 8 hours, because we don’t want these subdural to come up later when somebody’s asleep because this is the sort of person who can fall asleep after they have had a head injury and they just never wake up. We would like to prevent that. A crescent-shaped hemorrhage compressing the brain on the CT, shows quite well on a CT scan.

The management, same thing. We need a surgical evaluation. The problem is that these can still produce a significant pressure effect on the brain with all its problems. It just is not as fast as an extradural. Unfortunately, there are people quite often who’ll be left with long-term consequences of this because some of the brain tissue because it is almost within the brain. Some of the brain tissue can be affected by this and so, although, the herniation through the foramen magnum is not as common, we still need to make sure that these people are treated properly so that we minimize the amount of long-term brain damage they have.

Subarachnoid hemorrhage. This is uncommon with a head injury. It is mostly older middle-aged people and It is bleeding into the subarachnoid space obviously, subarachnoid hemorrhage, but they quite often start with a sudden severe headache often at the back of the head and quite often nausea, yes, but vomiting is prominent and neck stiffness is actually very common in these. Confusion, a lowered level of consciousness, and seizures occur but these are normally the severe ones, not the ones you see very often. The rapid headache sometimes called the thunderclap headache is the prime thing with these. It is diagnosed clinically, again, confirmed with a CT, occasionally by lumbar puncture. If somebody’s got a sudden severe headache, we would prefer not to do a lumbar puncture because it changes the pressure inside the CSF area, and therefore, if somebody has a significant brain bleed or a bleed around the brain, then it can cause more problems. The CT scan is fairly typical when you see these, you can diagnose them very and they look very different on the CT scan.

Management. It is actually treated by surgery of neurosurgery or angiography because it is an arterial defect but because of the way the arterial defect is, it is a form of stroke, considered a form of stroke, and so, the spontaneous ones require further investigations as the source of the bleeding by either putting a clip in with neurosurgery or a stent in through angiography, these can be treated very extremely. Well, again, you’ve got to have the correct facility.

Basic Emergency Care. This is the same as everything. Now, in Australia, we use this DRABCD. Danger. You look for any dangers surrounding the player/athlete. This is stuff that you should do. It should be just there all the time. Response. You need to respond early. Now, you need to know your sport, if you are dealing with a sport, because, in some situations, you can come onto the field straight away and in some situations, you must wait until the referee or [inaudible] calls you onto the field. Let’s say you need to know your sport but if you see it happen or see you are potentially worried about these things, the earlier, the better. You need to respond very early. Airways. Always with cervical spine control. We need to maintain an airway because if somebody doesn’t have an airway, they are not going to survive anyway. We need to make sure that if we don’t know if it is a high-speed impact, we don’t know what the problem is, then we maintain cervical spine control. It doesn’t fix and prevent all cervical spine injuries, but we want to try to make sure that we don’t do any further damage. Breathing. Circulation or Compressions. It depends on where you are. Some jurisdictions called circulations; some people called compression. The D is the Defibrillator or Drugs. If somebody has collapsed and you don’t know whether they have had a head injury or if they don’t have a pulse, then a defibrillator is important. It may be some drugs that are important as well and this is where the emergency services or paramedics are excellent at looking after they sort of [inaudible], but you also need to remove and refer them to an appropriate facility. A facility that can look after them because if we suspect that they have got an intracranial hemorrhage, then you really need it somewhere we can get something mechanical done about that because it is a mechanical problem.

Luckily, FICS Doctors are trained and certified as primary contact practitioners which means you have a duty of care. This means that if you are the only person there, you are the one to take control and provide basic life support. If there are other people around, we need to work as a team. We need to make sure that the athlete is looked after appropriately. It might be somebody in the crowd who’s emergency trained, it might be a sports trainer or something like that, or an athletic trainer who’s working with you. It might be a physiotherapist or another chiropractor or a doctor. Doctors don’t necessarily know all of these things, but you need to train in this to keep up to date. If there is any question, whether it is an intracranial hemorrhage, it needs a prompt referral, early diagnosis, and treatment are the key to looking after these people. We really need to make sure that these people get the appropriate help quickly.

This is an interesting one. Return to Sport. The problem with any sort of intracranial hemorrhage is It is likely to cause long-term problems. We need to take a considered approach within an appropriate time frame. Again, this is a team approach to do the best thing for the athlete to make sure that they don’t end up in the same situation again. Sometimes they won’t be able to return to the sport because it is too dangerous and you need to make sure that they don’t return rapidly because that make compromise their long-term health. One of the things that, as I said, with concussions before is that we need to make sure that they are completely back to normal before they return to sport. Now, sometimes, after an intracranial bleed does never occur but we need to make sure that they are ready to return to the sport because we don’t want to put them in danger of other injuries as well. I hope this is helpful and thank you very much for listening to me.

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