Chapter 9 Notes
INJURIES TO THE HEAD, NECK, AND FACE
Anatomy Review.
A. Skull. The skull consists of 8 cranial bones and 14 facial bones (see Figure 9.1 on page 114). The cranial bones (cranium) form a protective rigid housing for the brain. Special articulations called suture joints hold the cranial bones together.
B. Soft-tissue structures that protect the cranium include the skin, dense connective tissue layer, galea aponeurotica, loose connective tissue, and the periosteum of cranial bone. (See Figure 9.2 on page 114.)
C. The Meninges. The cerebral meninges are located underneath the cranial bones. The meninges are 3 distinct layers of soft tissues that protect the brain.
1. The outermost layer, the dura mater, is a dense, fibrous connective tissue that is highly vascularized. The dura mater transports blood to and from cranial bones.
2. The middle layer, the arachnoid, is not as strong as the dura mater and does not have a blood supply. The arachnoid is separated from the dura mater by a small amount of fluid.
3. Beneath the arachnoid is the “sub-arachnoid space” that contains cerebrospinal fluid (CSF). CSF cushions the brain and spinal cord from external forces.
4. The innermost meningeal layer is the pia mater, a very thin, delicate membrane that is attached to the brain and provides a framework for an extensive vasculature that supplies the brain. The pia mater is very delicate tissue, and like the arachnoid, is more susceptible to trauma than the dura mater.
D. The Central Nervous System (CNS). The brain (encephalon) and spinal cord comprise the central nervous system (CNS).
1. The CNS is protected by the meninges, as well as the bones of the cranium and vertebrae.
2. The CNS consists of two distinct types of neural tissues, the gray and white matter.
3. The adult brain weighs 3.0-3.5 lb. and contains approximately 100 billion neurons.
a. The brain has three basic components: cerebrum, cerebellum, and brain stem. The cerebrum is the largest component and is involved in intellectual functioning. The cerebellum performs functions related to motor skills. The brain stem connects the brain to the spinal cord.
4. Neural impulses travel to and from the CNS via 12 pairs of cranial nerves and 31 pairs of spinal nerves.
a. The cranial, spinal, and autonomic nerves compose the peripheral nervous system.
5. A brief interruption of blood flow to the CNS can result in loss of consciousness. Neural cells may die when deprived of blood for only a few minutes.
E. The Face. The face is composed of skin placed loosely over underlying bones. Subcutaneous muscles, cartilage, and fat deposits provide minor protection from trauma.
1. Facial bones consist of the maxilla, R and L palatine, R and L zygomatic, R and L lacrimal, R and L nasal, R and L inferior nasal concha, the vomer, the mandible, and the hyoid. Some of these bones are shown in Figure 9.1 on page 114.
2. Several areas around the face are prone to injury. The orbits of the eyes, particularly the supraorbital regions, are vulnerable to contusions. The nasal bones are centrally located and vulnerable to blows that result in fractures. The mandible is also subject to external forces.
F. The Neck (Cervical Spine). The bones of the neck are 7 vertebrae that provide support for the head and provide protection for the upper portion of the spinal cord (see Figure 9.4 on page 116).
1. The first cervical (C-1) vertebra (atlas) articulates directly with the occipital bone to form right and left atlanto-occipital joints.
2. The skull and C-1 articulate as a unit with C-2 (axis) to form the atlantoaxial joint that allows for rotation of the head on the neck.
I. Head Injuries in Sports
A. Background Information. Even relatively minor head trauma can result in severe, sometimes life-threatening injury. Brain tissue is unable to repair itself, and any tissue loss results in some level of permanent disability. If the injury is severe, death can result.
1. With appropriate education, coaches can learn to recognize head injuries and render effective first aid when necessary.
2. A recent 3-year study indicated that high school and college football players experience approximately 300,000 traumatic head or brain injuries annually. Players who sustained a concussion had three times the risk of sustaining an additional concussion when compared to teammates who did not have concussions.
3. Cheerleading is a competitive sport. Cheerleaders are at risk of serious injuries because their routines are becoming increasingly difficult.
4. Recent data from the National Center for Catastrophic Sport Injury Research indicates that a relatively small percentage of injuries result in irreversible damage.
5. There are three general categories of head injuries: concussion, intracranial hemorrhage, and skull fracture.
B. Mechanism of Injury
1. Vast majority of head injuries involve either direct or indirect mechanisms. Direct mechanisms involve a blow to the head that causes an injury at the site of impact, which is a coup injury.
a. A contrecoup injury occurs when the head is moving and abruptly stops, but the brain keeps moving within the skull, and becomes compressed on the side that’s opposite from the initial impact.
b. Indirect injury mechanisms involve damaging forces traveling from other parts of the body, such as blows to the face. Rapid and violent movement of the cervical spine also may result in indirect injury to the brain.
c. “Treat every head injury as if there is a neck injury, and every neck injury as if there is also a head injury.”
C. Concussion (Mild Head Injury). Jordan defines a concussion as “a clinical syndrome characterized by immediate and transient impairment of neurologic function secondary to mechanical forces.”
1. The clinical manifestations can include unconsciousness or other neurologic signs listed in Time Out 9.1 on page 117. Any external blow can cause temporary disruption of neurologic function, and in some cases, structural damage has occurred.
a. Brain cells that survive the trauma are vulnerable to subsequent injury.
1. There are various systems for classifying cerebral concussions; most base the level of severity on the duration of unconsciousness as well as the presence or absence of post-traumatic amnesia (PTA).
2. Cantu developed an “evidence-based” system for grading concussion. (See Table 9.1 on page 117 for signs and symptoms of each grade of concussion.)
a. Grade 1 concussions are a common sports injury, and they are the most difficult to identify.
b. Grade 2 involves loss of consciousness lasting less than one minute and/or PTA lasting longer than 30 minutes.
c. Grade 3 involves loss of consciousness for more than a minute or PTA for longer than 24 hours. According to Cantu’s research, the majority of sports injuries involve less than one minute of unconsciousness, but PTA lasting more than 24 hours, which indicates most concussions are grade 3.
d. The two types of PTA resulting from head injury are anterograde and retrograde. Anterograde amnesia is the inability to recall events that transpired since the time of injury. Retrograde amnesia is characterized by the inability to recall events that happened just prior to the injury. Retrograde amnesia is thought to be indicative of more severe forms of head injury.
e. Level of consciousness is qualitative and is determined as soon as possible after the head injury occurs.
A. First determine if athlete is alert and will respond to simple questions such as those that evaluate the athlete’s recognition of time and place to determine the presence of retrograde amnesia. Two minutes later, repeat the questioning to determine the presence of retrograde amnesia.
B. Unconsciousness is usually identified when the athlete fails to respond to verbal stimuli or is obviously knocked out. Consciousness does not always indicate that a serious head injury has not occurred.
3. Second Impact Syndrome (SIS). Second impact syndrome has raised concern among the sports medicine community that there needs to be a more cautious approach to the care and management of athletes who have sustained concussions.
1. SIS results when an athlete who has sustained a head injury receives another head injury prior to the resolution of the symptoms related to the first injury.
2. SIS involves a rapid and catastrophic swelling of the brain, specifically in the uncus region of the temporal lobes, putting pressure on the brain stem. (Refer to Figure 9.5 on page 118.).
3. Since death can result from SIS, any athlete sustaining a head injury, no matter how minor, should be monitored carefully by a physician before being cleared to return to participation. It may take weeks to recover from concussion.
4. Intracranial Injury. These injuries are potentially life threatening.
1. Intracranial injuries can result from direct blows to the head, rapid deceleration, and rapid rotational motions of the head. The most common cause is blunt trauma to the head.
2. These injuries involve disruption of blood vessels that result in a hematoma or swelling within the cranium that applies pressure to the brain tissues.
3. Major forms of intracranial injury are epidural hematoma, subdural hematoma, intracerebral hematoma, and cerebral contusion.
a. Epidural hematoma involves arterial bleeding with signs and symptoms of injury usually developing rapidly.
b. Subdural hematoma involves rapid arterial bleeding or more slow venous bleeding. Thus, the development of signs and symptoms can occur more slowly in some cases.
c. Any of these injuries can result in some degree of permanent neurologic damage and even death.
F. Cranial Injury. Cranial injuries involve the skull bones. In the majority of cases, these injuries also damage the scalp. Skull fractures can be simple with no damage to underlying tissue, and in many cases, few neurologic problems result.
1. More severe cranial injuries involve depressed skull fractures in which bone fragments are pushed into the cranial region.
II. Initial Treatment of a Suspected Head Injury: Guidelines. Any athlete who sustains a head injury should be treated as if a neck injury is present and every neck injury should be treated as though a head injury is present, because the injury mechanisms for both are similar. At least 50% of all cases of permanent neurologic consequences from head trauma resulted from inappropriate first aid care.
A. Initial Survey
1. First step in treating suspected head injuries is to determine if the athlete is either in respiratory or cardiac arrest by executing the primary survey.
2. When approaching the athlete, note body position, presence or lack of movement, limb positions, as well as positions of the helmet, face mask, and mouth guard.
3. If the athlete appears to be unconscious, attempt to arouse him or her by placing your hands on the athlete’s shoulders, chest, or upper back and speaking loudly, directly at the injured person.
4. If conscious, the athlete will probably have an open airway.
5. If unconscious, make a note of the approximate time of the injury.
6. The coaching staff should be trained and rehearsed with respect to their emergency plan.
7. The head and neck should be immobilized immediately by having a person stationed at the athlete’s head to stabilize it with both hands. (See Figure 9.6 on page 120.)
a. It is not necessary to remove a helmet from a football player to determine if the athlete is breathing.
b. Breathing can be detected by placing your ear near the athlete’s face and listening for typical breathing as well as gagging, wheezing, or choking sounds.
c. Movements of the thorax and abdomen can also indicate normal breathing.
8. Circulation Assessment. In an unresponsive victim, determine if signs of circulation are present by looking for breathing, coughing, and movement in response to breaths.
A. If no signs of circulation are present, begin CPR and summons EMS.
B. Following accepted guidelines, logroll the athlete to a supine position while stabilizing the head and maintaining an airway.
B. Physical Exam. Once the initial survey has been completed (which can be accomplished with practice in around 30 seconds), and the athlete’s vital signs have been ascertained, the coach can perform the physical exam.
1. The physical exam must include assessments of consciousness or unconsciousness, extremity strength without moving the neck (if conscious), mental function (if conscious), eye signs and movements, neck pain, and neck spasm.
2. If head injury is suspected:
a. Don’t remove a football player’s helmet.
b. Don’t move the athlete.
c. Don’t use ammonia capsules, because the athlete may aggravate a neck injury.
d. Don’t rush through the physical exam.
3. To determine if any significant neurologic damage has happened to a conscious athlete, place two fingers in the athlete’s hand and ask the athlete to squeeze them as hard as possible. Then test the athlete’s other hand and compare grip strength. You can also check bilateral strength by asking the athlete to dorsiflex his or her feet.
4. Check sensations on both sides of the athlete’s body by pinching the skin on the insides of the arms, thorax, and legs.
5. Monitor the athlete’s eyes by noting the size of the pupils and their responsiveness to light, as well as, their ability to follow a moving object while moving it slowly from side to side. Most people have pupils that are the same size, but some normal persons have pupils that are not equal in size (anisocoria).
A. Note any loss of peripheral vision and also any jerking eyeball movements.
6. Gently palpate the athlete’s neck, beginning at the base of the skull and working slowly down to the bottom of the neck. Note any deformity, such as protrusions or spasms. Ask athlete to indicate if pain occurs during the evaluation.
7. Based on this assessment, you should be able to determine the level of concussion. Athlete with grade 1 concussion will be able to walk to the sideline or courtside with assistance.
a) Athlete with grade 2 or 3 concussion should not be moved from site of injury. In these cases, the coach should monitor vital signs and summon EMS.
b) Athlete with grade 1 concussion and normal vital signs can be moved, using great care. If the athlete is lying down, two people assist the athlete into a sitting position by providing support on both sides of the athlete’s body. While the athlete is sitting, monitor his or her vital signs and behavior for 1 to 2 minutes.