Head Injuries Of The Athtlete In Sport

Introduction Head injuries occur in all sports (Fig. 1) and are more common in contact sports, particularly where the aim of the sport is to inflict injury to the head (boxing, kick boxing) (Fig.2). Whilst most head injuries are minor there is the potential for every injury to lead to permanent disability or even death. The accurate assessment of the nature of the head injury and subsequent treatment can mean the difference between life, death or a lifetime of disability (Fig. 3). The brain’s susceptibility to injury is a function of its softness. It is basically a soft fluid structure enclosed within a very rigid box. The fact that the head is supported on a relatively long neck also allows injuring forces to be magnified. Injury can occur to the brain and neural pathways directly or the brain can be injured as a result of bleeding from arteries or veins in relation to it. Injury can also occur to structures attached or adjacent to the brain (the cranial nerves or brain linings) (Fig. 4). 1 Figure 4   Injury to Brain   ∙             Directly (to brain and neural  pathways)   ∙             Indirectly (from bleeding  arteries/veins)   ∙             Structures adjacent (cranial nerves,  meninges)             

Assessment Assessment of the severity of head injury is vital in allowing an accurate plan for the management of the injury and indicate what investigations and treatment is required. The history of the injury itself can suggest its severity as well as allowing an assessment to be made of whether the patient’s clinical condition is improving or deteriorating. It is important to remember that not all cases of reduced conscious state in sport are due to head injury, hence the importance of history taking in distinguishing head injury from other causes such as spontaneous intracranial haemorrhage or metabolic causes of unconsciousness (Fig. 5). It is important to collect information from witnesses to the

event. In particular, it is important to record the mechanism of injury , the extent of the reduction in conscious state and the length of any period of unconsciousness. Figure 5   Causes Reduced Conscious State    ∙             Head injury   ∙             Spontaneous Intracerebral Haemorrhage   ∙             Metabolic (diabetic/uraemic/hepatic/hypothermia)   ∙             Drugs (alcohol/narcotics/barbiturates/CO)   ∙             Epilepsy   ∙             Infection (meningitis)   ∙             Psychiatric (hysteria, catatonia)  

2 Even untrained witnesses are able to confirm whether the patient was talking or opening his eyes or obeying commands. They are also able to attest to the victim’s level of orientation or confusion. Witnesses are also able to give information in relation to the absence of jerking movements, changes in pattern of respiration or skin colour or loss of continence which may suggest seizure activity. Injuries are classified as focal or diffuse (Figs. 6 and 7). The most common head injury in sport (concussion) is further sub-classified to guide practitioners (Fig. 8). Figure 6   Classification of Head Injuries   Focal                  ­                cerebral contusion (ill­defined area damage/translational force/contre­ coup injury).  

­                                    intracerebral haematoma (deep/force over small area) ­                                    extradural haematoma (middle meningeal artery/temporal skull fracture/high  mortality/classic presentation ­                                    subdural haematoma (bridging veins torn/acute or subacute/70% mortality)   Diffuse               ­                  concussion (most common, see guidelines return to sport)                              ­                  diffuse axonal (severe brain dysfunction)

*

LOC – loss of consciousness 

Figure 8   Grading of Concussion  

 

 I  (mild)

Confusion/no LOC or amnesia Lucid 

 

in 5 – 15 mins

 

 

 

No LOC but confusion and retrograde 

  II  (moderate)      

amnesia (for few mins)   LOC, confusion and amnesia  (retrograde and post­traumatic)

III  (severe)

3 On-Field Management (First Aid) First aid treatment for head injuries is of importance as even a minor head injury has potential to be made significantly worse by coincident hypoxia, prolonged seizure activity, aspiration or other complications. In the acute injury state maintenance of an adequate airway is of critical importance. The patient should be rolled into the coma position so that the airway is not obstructed by the tongue. Likewise the airway should be cleared of any vomited material or foreign bodies (for example mouth guards). It is important to be aware of the possibility of coincident spine injury and the patient should be rolled and positioned so that the spine is not bent or twisted during the process. If the patient suffers seizure activity then the airway is further at risk. Most seizures are of short duration and self terminating. No effort should be made to lever the jaws apart. This can result in damage to the patient’s teeth or the bystander’s fingers.

If the patient remains unconscious for more than a few minutes an ambulance should be summoned and the patient transferred to the nearest appropriate hospital for further management. Medical Management Most head injuries are minor and will require no medical treatment. If the patient has not lost consciousness then it is probably safe for them to return to competition once any symptoms have resolved. They should not complete if they suffer with dizziness, headache, are poorly orientated or have any neurological symptoms. There are now uniform guidelines in this area (Figs. 9 and 10). Figure 9   (IMPORTANT)Guidelines to Return to Sport After Concussion  

 

 

 

1  episode

2  episode

3rd episode

 

 

 

 

 

 

 

  I

 Asymptomatic

   asymptomatic

  asymptomatic

 

 > 20 mins

> 1 week

> 3 months

 

 

 

 

 II

Asymptomatic

   asymptomatic

  next season if

 

> 1 week

> 1 month

  Asymptomatic

 

 

 

 

III

asymptomatic

   off for season

  off for season

st

  nd

2 weeks

 

Boxing, especially Amateur boxing, is carefully regulated in Australia and at the Olympics. Each boxer must keep diary of fights and incidents. Such a record does not exist in other sports. Eg in rugby, many players experience post concussion dizzy spells on the field and are sent off OR return in an arbitrary manner. 4 Figure 10   Take­Away Head Injury Guide (To go with patient and carer)     1.            No play for 24 hours.

  2.            Liquid diet 8­24 hours.   3.            Ice to head (15 mins/of every 60 mins)   4.            Panadol (Tylenol) only.   5.            Awaken patient 2 hourly x 24 hours.   6.            Report any of following to doctor:   Nausea/vomiting/visual problem./ear ringing/confusion/disorientation/lack co­ ordination/drowsiness/worse headache/persistent headache (<49 hours)/unequal or slowly reacting pupils/convulsions/tremors.   7.      Follow­up with usual doctor.    

If the sportsman has lost consciousness then they should not be allowed to compete in a situation where further head injury is possible for a period of one week or until any symptoms have resolved. The patient should be seen by a medical practitioner so that any evidence of post concussion symptoms can be assessed and appropriate investigation and treatment undertaken. If the patient has been rendered unconscious for longer than five minutes then hospital admission, observation and if necessary further investigation and treatment are required. Hospital Management Upon hospital admission the patient should have their level of consciousness formally assessed and assessment made of for the presence of any other injuries. The most widely accepted scheme for assessment of the level of consciousness is the Glasgow Coma Scale (Fig. 11). The coma scale has been shown to be a reliable indicator of severity of injury and gives good information in terms of the likelihood of significant intra-cranial pathology being present and the patient’s prognosis. 5 Figure 11 Figure 10

Glasgow Coma Score is used to  Assess the severity of head injury    

 

 

Best

  Spontaneously

  4

Open

  To speech

  3

 

  To pain

  2

 

  None

  1

 

 

 

 

 

 

Best

  Orientated

  5

Verbal

  Confused

  4

Response   Inappropriate

  3

Sound

    Words

 

  Incomprehensible

  2

  None

  1

   

 

 

 

 Obey commands

  6

Best

  Localises pain

  5

Motor

  Flexion to pain

  4

Response   Abnormal flexion

  3

  None

  2

 

  1

   

If the Glasgow Coma Score (the sum of numeric values assigned to levels on the coma scale) is greater than 8 then the patient should be admitted for neurological observation. If their coma score fails to return to 15 within 12 hours or if it deteriorates then have a CT scan performed. The patient should be observed until their coma score has returned to 15 and once the coma score has been at 15 for a period of time they should be discharged into the charge of a responsible adult with warnings given to return to the hospital should the level of consciousness deteriorate, should headache recur or persist, or should the patient develop any neurological symptoms.

If the Glasgow Coma Score is 8 or less there is a high chance that significant intracranial pathology is present. Immediate steps should be taken to stabilise the patient’s condition and to reduce the chance of further brain injury. The patient shoulder anaethetised, intubated and slightly ventilated (pCO2 25-30 mmHg). A brain shrinking agent such as Mannitol (one gram per kilogram body weight 20%) should be administered and an indwelling catheter inserted. The patient should have an emergency CT scan. 6 The pathology present can vary from extra-dural haematoma with blood clot forming between the skull and the dural lining of the brain compressing eh underlying brain. These haematomas give a classic lentiform appearance on CT scanning (Figure 12). Sub-dural haematomas lie between the dura and the brain (Fig. 13) and can arise from either tearing of dural vascular structures or disruption of the underlying brain tissue with haemorrhage in the sub-dural space. The so called diffuse axonal injury is also relatively common ion patients with a grossly depressed level of consciousness.

Small petechial haemorrhages

can be seen on CT scanning throughout the brain substance. Surgical treatment is dependant on the pathology that has been displayed. Significant sized haematomas (generally speaking more than 25 cc or with more than 5 mm shift of the midline structures) should be treated by evacuation. In most cases these require craniotomy, removal of the blood clot and haemostasis. In life-threatening situations when neurosurgical treatment is not immediately available as an emergency measure a burr hole can be cut over the haematoma and evacuation begun. Control of the intra-cranial pressure after surgery is also of importance, and efforts should be made to keep the intra-cranial pressure less than 25 mm of mercury. Treating physicians should also be vigilant of the complications in relation to such severe head injuries (electrolyte imbalance, seizure activity, sepsis, recurrent haematoma). Rehabilitation All patients who have lost consciousness for more than 5 minutes or have persisting symptoms should be assessed by a medical practitioner for, just as soft tissue and musculoskeletal injuries can require rehabilitation so can neurological injuries. Symptoms such as headaches, poor memory, poor concentration, personality change such as irritability or unusual placidity, dizziness or double vision and poor mental and physical stamina are common following significant head injuries. Such symptoms can be devastating for work and family situations and intervention from rehabilitation providers can be beneficial in both allowing full recovery from such symptoms and for the provision of aids and coping strategies to minimize their impact. Prognosis for Post Concussion Syndrome Symptoms are variable but usually resolve. The prognosis for patients who have been afflicted with severe head injuries is likewise variable. Whilst complete recovery is possible the progress is often slow and fluctuating. A

program of physiotherapy, occupational therapy, speech therapy and psychological intervention supervised by a trained rehabilitation specialist is generally speaking of benefit but even so, some patients will remain significantly disabled (sometimes to the point of requiring institutional care). 7 Second-impact Syndrome (after Hughston) A syndrome of rapid brain swelling (may be fatal) from a second minor head injury whilst athlete is still suffering from the initial injury. It is characterized by the rapid development of diffuse brain swelling following a second impact to the head. Within seconds to minutes of this second impact, the initially but stunned athlete collapses. It is because of this syndrome that there are guidelines for the return to play of athletes with head injuries. Dementia Pugilistica The “Punch Drunk” syndrome was first described amongst boxers in 1928. It results from repeated punches to the head (chronic closed head trauma). Its severity correlates with neruo anatomical changes (hydrocephalus, scarring) and presents with cerebellar (Parkinsonian) features, dysarthria, personality changes and deteriorating mental capacity. Modification of activities, head protection, changes to the boxing code and supportive care are required.   Prevention of Head Injuries     ∙                    Wear helmets in contact sports (football,  cricket, boxing)     ∙                    Use mouth guards     ∙                    Improved strength of neck extensor  muscles may reduce incidence head injuries     ∙                    Monitor necessary games regulation/rules  to change dangerous play (scrumming in rugby,  speartackling made illegal)

    ∙                    Supervise children’s games (and  encourage to wear helmets, Figs. 14 and 15)