Head, Neck, &
Facial Injuries
Concussion Defined
A brain injury caused by a blow to the
head, face, neck or body OR caused
by hitting a hard surface/object
(ground, bat, ball, opponent, etc)
CDC Fact Sheet for Coaches
Concussion Facts
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A concussion is a brain injury
All concussions are serious
Concussions can occur without a loss of consciousness
They can occur in any sport
It can be accompanied by one or more signs/symptoms
 Headaches are the most common symptom
Early recognition and proper management can prevent
further injury or even death
Concussions are most often associated with normal results
MRI/CT Scans
It is not necessary to lose consciousness to have a
concussion
Concussion Facts for Children
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Children are at higher risk of concussions due to
continued brain development and decreased
muscle tone and coordination
Children and teens are more likely to get a
concussion than adults
Children and teens take longer to recover than
adults
Youth athletes are at greatest risk of catastrophic
consequences from multiple concussions
Sports Related Concussions
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As many as 3.8 million sports-related concussions
per year
% of all sports related injuries:
6.5% (2002-2009)
 15% (2011)
NY Daily News.com
 20%-50%: Possible due to lack of reporting/hiding sx
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Rates of incidents (in order):
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FB, Girls SOC, Boys SOC, Girls BB, Wrestling, Boys
BB, Cheer, SB, VB, Baseball
75% classified as mild
Concussion Management
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What to look for:
 A forceful blow to the head or body
AND/OR
 Any change in their behavior, thinking,
or physical functioning
Concussion On-Field Evaluation
Neck Exam
 General Neurologic Exam
 Mental Status Exam
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On-Field Evaluation: Neck Exam
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Examine when appropriate:
 C-spine
tenderness
 Dermatomes/Myotomes
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Care of the spine takes
precedence over head injury
evaluation
Sideline Evaluation:
History Questions
 Previous
 Length
 Time
 Any
concussions
of symptoms
since fully asymptomatic
LOC or Amnesia
Sideline Evaluation: Concussion
Testing
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Determine their symptoms
Any athlete w/ symptom(s) is to be removed from
play until cleared by health care professional!
 “When in doubt…sit them out!”
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Determine their level of consciousness
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LOC >30sec OR decreased consciousness = 911
Determine their orientation
Evaluate their memory (before & after) and
their concentration
Sx’s & Symptoms
Severity, duration, & number of sx = most important
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Headache
Dizziness
Nausea/Vomiting
Blurred or double vision
Fatigue
Memory problems
Amnesia
Loss of consciousness
Sensitivity to noise or
light
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Vacant stare
Delayed responses
Decreased alertness &
concentration
Disorientation
Poor coordination
Inappropriate
emotionality
Behavior or personality
changes
Sideline Evaluation:
General Neurological Exam
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Cranial Nerves:
Pupillary evaluation
 Vision
 Balance
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Gait
Coordination & Fine Movements
Myotomes:
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Muscle Strength
Dermatomes:
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Sensation
12 Cranial Nerves
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I. Olfactory:
II. Optic:
III. Oculomotor:
IV. Trochlear:
V. Trigeminal:
VI. Abducens:
VII. Facial:
VIII. Vestibularcochlear:
IX. Glossopharangeal:
X. Vagus:
XI. Accessory:
XII. Hypoglossal:
Smell
Vision/sight
PEARL
Look up
Facial sensation/clench jaw
Lateral eye movement
Smile/frown/raise eyebrows
Hearing/balance
Swallow
Swallow/Say ahh
Resisted shoulder shrug
Stick out tongue
Myotomes
C5: Shoulder abduction
 C6: Elbow flexion/wrist extension
 C7: Elbow extension/wrist flexion
 C8: Ulnar deviation, thumb extension
 T1: Finger abduction/adduction
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Dermatomes
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C5: Lateral deltoid/arm
C6: Lat. Forearm/thumb/index finger
C7: Middle finger/forearm
C8: 4th/5th phalanx/medial forearm
T1: Medial arm
Sideline Evaluation Cont.
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Orientation
Where are we playing?
 Who are we playing?
 What is the score?
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Retrograde Amnesia
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Anterograde Amnesia
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What did they eat for breakfast that day?
Repeat words & try to recall (girl, dog, green)
Concentration
Repeat days of week backward, start with today
 Repeat these #s backward: 419 (914)
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Post Concussion – General Care
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Any symptomatic athlete must be held from play
Have concussed athlete sit & monitored
Do not give them or let them take pain medication
Contact parent(s)/guardian(s)
Check every 5 min for at least 15 min
Must be released to parent/guardian, or other
responsible adult party in their absence, with take
home instructions
Do not leave athlete unattended!
 Do not let them drive home, especially by themselves
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Neuroimaging Studies
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Consider for:
Prolonged LOC (30 sec+)
 Neurological deficits
 Post-traumatic seizures
 Worsening symptoms
 Persistent symptoms > one week
 Any suspected structural injury
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CT (acute bleeding) vs MRI (2-3 days: swelling)
scans
Any positive imaging findings mandates
termination of season
Seek Immediate Medical Care If:
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LOC
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> 30 sec at time of injury, or any LOC after initial
trauma
Severe or worsening headache
Persistent nausea/vomiting
Unusual behavior/Persistent mental status
alterations
Visual disturbances
Worsening concussion symptoms
Seizures
Post Concussion Treatment
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Complete Physical and Mental Rest:
No exercise
 Absence from school?
 Decreased school work/postpone reading,
homework, and tests
 No texting, reading, or computer use
 Communicate about return to learn & play protocols
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Concussion Risks
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3-5x’s more likely to get a subsequent
concussion after receiving at least one previous
head injury
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Repeated mild brain injuries occurring over an
extended period (i.e., months or years) can result
in cumulative neurologic and cognitive
deficits
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Repeated mild brain injuries occurring within a
short period (i.e., hours, days, weeks) can be
catastrophic or fatal
Concussion Risks
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A recent study found that NFL players who
suffer multiple concussions are 30% more likely
to suffer clinical depression later in life
Concussion Risks
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Cerebral Edema:
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Epidural/Subdural Hematoma:
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Brain swelling
Increases intracranial pressure which can cut off oxygen
supply to brain
Can be fatal if not treated quickly
Bleeding in/around the brain
Increases intracranial pressure
Can be fatal if not treated quickly
Signs:
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Severe headache, dizziness, vomiting, increased size of
one pupil, or sudden weakness in an arm or leg
Concussion Risks
 Second
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impact syndrome:
Rare, but fatal condition
Occurs when a second head injury is sustained
before the first has time to completely heal
Rapid brain swelling, which can result in fatal
complications
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50% chance of death
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100% chance of morbidity
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One or more of their senses may be impaired either
temporarily or permanently
Story of Death: Case 1
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October 1991, a 17-year-old HS FB player was tackled on the
last play of the first half of a varsity game and struck his head on
the ground.
During half-time, he told a teammate that he felt ill and had a
headache; he did not tell his coach or athletic trainer.
He played again during the 3rd quarter and received several
routine blows to his helmet during blocks and tackles.
He then collapsed on the field and was taken to a local hospital
in a coma.
A CT-Scan revealed diffuse swelling of the brain and a small
subdural hematoma.
He was transferred to a regional trauma center, where attempts
to reduce elevated intracranial pressure were unsuccessful, and
he was pronounced dead 4 days later.
Story of Death: Case 2
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August 1993, a 19-year-old college football player
reported a headache to family members after a full
contact-practice during summer training.
During practice the following day he collapsed on the
field approximately 2 minutes after engaging in a
tackle.
He was transported to a nearby trauma center where a
CT scan showed diffuse brain swelling and a thin
subdural hematoma.
Attempts to control the elevated intracranial pressure
failed, and he was pronounced brain dead 3 days later.
E:60 explores Preston Plevretes'
life after tragedy
Plevretes, then a 19-year-old sophomore at
La Salle, received a second concussion
while still symptomatic from his first
 He was briefly knocked unconscious but
then awoke and was combative for 3-5
minutes before lapsing into a coma
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http://espn.go.com/video/clip?id=espn:516315
1
Concussion Grading
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Based on severity AND duration of
symptoms
The more symptoms and the more severe the
symptoms are reported = more severe concussion
 Typically, the more sx the person reports and higher
severity dictates a longer recovery
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A concussion cannot be truly graded until
the symptoms have stopped
How long will it take to recover?
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A recent 2011 study looked at how long it took
high school athletes symptoms to resolve/clear
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23.5% - less than 24 hours
33.8% - 1 to 3 days
20.6% - 4 to 6 days
19.6 - 1 week to 1 month
2.8% - more than a month
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Post Concussion Syndrome (PCS)
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Weeks to Months of persistent symptoms
Exercise can trigger or aggravate symptoms
Symptoms at 3 months:
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Headache
Memory dysfunction
Fatigue
Irritability
Dizziness
Impaired concentration
Sleep disturbance
Depressed mood
42%
36%
30%
28%
26%
25%
20%
9%
Pharmacotherapy for PCS
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Acetominophen, NSAIDs, Excedrin (Only
Tylenol post acute concussion)
Tricyclic
Antidepressants
Anti-nausea Medication
Sleep Aids
Beta-Blockers
Calcium Channel Blockers
Baseline & Sideline Tests
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ImPact ®
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Neurocognitive Test
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~20 min test; Computerized; Cost Associated w/ Test
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Verbal and Visual Memory
Reaction time
Concentration
Symptom Checklist
$350-$750/year depending on number of athletes/concussions
Limitations: no balance score, cannot be used post-injury on
sidelines, long test, no 1-on-1 tester interaction
Used by many professional, collegiate, and high school teams
Baseline & Sideline Tests – Cont.
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SAC
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SCAT3
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Cognitive Test (Memory, concentration, orientation)
~5 min test; 1 page; Free
Cognitive Test, Balance, Symptom Checklist, Other Evaluation
Tools, & Take Home Instructions
~7 min test; 3-4 pgs or use App; Free
Standard test for FIFA, Olympic Games, Rugby, & many others
NFL Form (NEW)
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Revised SCAT2 – No take home instructions
~5 min test; 1-2 sheets of paper; Free
Standard for all NFL teams
Concussion Evaluation Materials
Concussion Research
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University of Pittsburgh Medical Center
Neuropsychological Testing (IMPACT)
 Tests indicated cognitive deficits in
asymptomatic athletes following 4 days post
concussion
 Deficits also found in reaction time and
processing speed when asymptomatic
Research Continued
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64 high school athletes with mild concussions (“bell
ringers”)
2 groups:
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< 5 min signs/sx
5-15 min signs/sx
Used IMPACT for baseline, 2, 4 & 7 days post injury
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< 5min signs/sx group: had deficits that gradually improved
days 2-7. Back to baseline at day 7
5-15 min signs/sx group: had signif. deficits that gradually
improved days 2-7. No return to baseline at day 7!
Concussion Legislation
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50 states, D.C., & Chicago have adopted
concussion laws (2014)
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Washington State's concussion law became
effective in July 2009, named for Zachery
Lystedt
Zachery Lystedt
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Late in the first half after a big play, his head hit
the ground and he grabbed his helmet in
obvious pain as he struggled to get up.
He made it to the sideline, sat out for about 15
min, and then went back in for the remainder of
the game.
http://espn.go.com/video/clip?id=7525526
Lystedt Law & WIAA Guidelines
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Removal of any athlete suspected of having a
concussion from practice/game
Athletes cannot return to practice/game until evaluated
by a licensed healthcare professional trained in the
management of concussions and given written medical
authorization
Parents and athletes are required to sign a concussion
information sheet each year
School districts are required to work with the (WIAA)
to develop guidelines for safe play
Private non-profit youth leagues using public fields
must comply as well
Who Can Authorize RTP?
Medical Doctors (MD)
 Doctor of Osteopathy (DO)
 Advanced Registered Nurse Practitioner
(ARNP)
 Physicians Assistant (PA)
 Licensed Certified Athletic Trainers
(ATC/L)
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Concussion Prevention
Teach proper technique/mechanics
 Ensure proper equipment is worn and that
it fits properly
 Recommend/require mouth guards
 Teach good sportsmanship
 Ensure your athletes are in good physical
shape (Neck strength!)
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Return To Play Protocol
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Assess initial injury, remove athlete from play, sideline
SCAT2?, complete rest until sx free
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DAY 1: 20 min Light Aerobic Activity
DAY 2: 30 min Sport Specific Activity
DAY 3: Non-Contact Practice with team
DAY 4: Full Contact Practice with no return of sx
DAY 5: Full Release by school ATC or team physician w/
a return to baseline SCAT2* and symptom free throughout
all exertional testing
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Concussion Education Videos
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espn.go.com/video/clip?id=5163151
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http://vimeo.com/15026404
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Preston Plevretes E60 Video
NATA’s Educational Video
http://www.youtube.com/watch?v=VH2KjItY
XUY
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CNN Big Hits, Broken Dreams
Additional Resources
 CDC
Heads
 NATA
 NCAA
 WIAA
Up Sport
Anatomy: Spine
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Spinous Process
C4-C7
Disc
Nerve Root
ROM: Neck & Trunk
Flexion
 Extension
 Lateral Bending
 Rotation
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Postural Malalignments: Spine
Spinal Injuries:
Bulging/Herniated Disc
Neck Injuries: Axial Loading
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A force applied to the top of the head when the
neck is partially flexed, which aligns the cervical
vertebrae in a straight column
Neck is unable to handle the force causing the
cervical vertebrae to compress
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Results in a fracture or dislocation
Neck Injuries: Axial Loading
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Primary cause for catastrophic cervical spine
injuries (CSIs) resulting in paralysis.
Head-down contact: initiating contact with the
top of the helmet
Neck Injuries: Axial Loading
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Spearing: intentional use of a head-down contact
technique.
Unintentional head-down contact: is the dropping
of the head just before contact.
Catastrophic CSIs from axial loading are not
prevented by players’ standard equipment.
Eric LeGrand:
http://www.youtube.com/watch?v=NMklSv_VlxE
 Anthony Conner:
http://www.youtube.com/watch?v=ITzuLkpb44k
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Neck Injuries: On-Field Acute
Management
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Subjective:
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Observation:
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Look for crown of helmet or head contact
Look at body posture and movement capabilities
Palpation:
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Hx, MOI, C/O, Med/All
Red Flags: Tingling, numbness, motor loss, neck pain over spinous process
Palpate spinous processes of cervical vertebrae
Special Tests:
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Active ROM:
 Move hands and feet
Resisted ROM/Myotomes:
 Exp: Grip hand, resisted plantar flexion
Dermatomes
Dermatomes
Neck Injuries: On-Field Acute
Management
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Initial Care for Suspected Neck Injury:
Stabilize C-Spine
 Call 911/Get AED???
 Remove face mask
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If athlete is NOT wearing shoulder pads, remove helmet
Monitor A, B, C’s
 Check for signs of concussion?
 If face down and not breathing…log roll and begin
CPR
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Facial Injuries: Eye
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Basketball & baseball are most common sports
Most sports related eye injuries are from blunt
trauma
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Exp: Golf ball to the eye
Corneal abrasions
Exp: Finger to eye during basketball
 (Seen under blue light w/ stain)
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Eye Injury – Immediate Referral
Sudden decrease in or
loss of vision
 Loss of field of vision
 Pain w/ movement
 Diplopia
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Proptosis of the eye
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Double Vision
Forward Displacement of Eye
Light flashes or floaters
Irregularly shaped pupil
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Foreign-body
Red eye
Blood in/around eye
Halos around lights
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Corneal edema
Laceration of the eye lid
 Broken contact lens or
shattered eyeglasses
 Unable to look up
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Orbital floor fx possible
Facial Injuries: Laceration
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Seen in basketball, field hockey, baseball,
softball, martial arts/boxing, etc
Management:
Stop bleeding
 Clean wound
 Apply Steri-strips
 Cover wound
 Refer to Urgent Care for F/U
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Facial Injuries: Nose
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Deviated Septum
Fracture of Nasal Bone
Management:
Stop bleeding
 Observe & Palpate
 Refer for x-rays
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Facial Injuries: Avulsed Tooth
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“Knocked-Out Tooth”
Management:
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Pick up tooth by the crown (the chewing surface) not the root ASAP
If dirty, gently rinse tooth with water or saline
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Replace tooth in socket ASAP(if possible)
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Hold the tooth in place with fingers or by gently biting down on it
Keep tooth moist at all times.
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Do not use soap or chemicals
Do not scrub, dry, or wrap up the tooth
Emergency tooth preservation kit
Milk
Cup of saliva
Mouth (next to cheek)
Go to nearest available dentist within 30-60 minutes
Cauliflower Ear
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Caused by blunt trauma or repeated friction
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Causes a hematoma which restricts blood flow to the cartilage,
leads to cartilage death/scarring & possible infection
As it heals it can shrivel up giving it a cauliflower-like
appearance
Tx: Drain blood from hematoma, antibiotics, & reduce
inflammation
Without tx it is permanent, w/ prompt/aggressive tx
deformity is unlikely
Common in wrestlers, boxers, & martial artists