Head injuries

In many sports serious head injury is an unlikely event, but when it happens and no one knows where any of the medical equipment is stored then disaster looms; so through preparation at the venue is important. Even if the venue is foreign, it is important to know the whereabouts of the stretchers, preferably a scoop stretcher, and semi-rigid, lock-on, cervical collars. It is always important to have doctors or paramedics near when team training occurs, or at least to have a telephone number of the nearest institution. Remember, first two minutes are crucial for injured athlete.

Airway or neck protection

The airway is vital, and its restoration must take precedence, even in the presence of spinal injury. Concusion and cervical spine injuries often coexist, and the possibility of cervical spine injury in an unconscious patient must never be overlooked.

Signs of concussion are present if:

a)      there has been even the shortest time of unresponsiveness

b)      the athlete fails the Maddocks questions( will be described later)

c)      there is post-traumatic amnesia( this may begin 30s after the injury)

d)     the athlete is unsteady walking heel to toe, or unable to hold the ball

e)      the athlete complains of giddiness, double vision, or is vomiting

f)       the athlete has been unconscious, has spasms, or convulsions

AVPU: record a base line and monitor at 5 minute intervals

A  Alertness

V  responds to Verbal commands

P   responds to Pain

U  Unconscious

Check for possible complications

a)      Lacerations, scalp tenderness, haemathoma, and blood or cerebral spinal fluid from nose or ears for underlying fractures. A small skin wound can hide a fracture

b)      Subconjunctival haemorrhage

c)      Signs of neck injury such as paraesthesia

During transport if serious injury

a)      Note rising blood pressure or falling pulse, head down position may aggravate the blood pressure

b)      Treat with continuos oxygen

c)      Label the athlete with name and birth date if known

Return to competition or training

This should not occur until the athlete has passed full neurological examination. Some sports have an arbitrary time to match fitness. If neurological examinations are ok, doctor will prescribe how much player has to rest. In some cases, player can return on the pitch very soon, depending of injury type and damage. Concussions are common in contact sports of any type.

Prevention

In soccer, if player suffered head injury, it should be warn about close game, free kick situations, corner kicks, heading, and especially during jumping elbows should be in position up, cause easily an opponent can hit the athlete during jump and create serious head injury. Remember, arms are always near the face and head!

Now there are other things that can help injured player to protect, which will be discussed in this thema later.

Suspected concussion?

PROCESS

IS ATHLETE UNCONSCIOUS NOW?

YES – protect cervical spine in an unconscious patient

NO – ask Maddock’s questions, for soccer:

1)      At which half time are we?

2)      How far is into the half time, start, middle, or end?

3)      Which side kicked the last goal?

4)      Result at the moment?

5)      Which team did we play last week?

6)      Did we win last week?

POSITIVE ANSWERS – check other signs of other injuries, including cervical spine

YES – remove from play or training for further medical examinations

NO – return to play

NEGATIVE ANSWERS TO MADDOCK’S QUESTIONS:

Remove from game/event for full assessment on stretcher. Remove gum shield and clear airway.

Indications for urgent transport:

-          Fractured skull

-          Penetrating skull injury

-          Loss of consciousness longer than 5 min

-          Focal neurological signs

-          Deteriorating conscious state

-          Any convulsive movement

-          More than one concussion in a match or in a day

-          Any assessment difficulty

-          High- risk athletes(greater potential for bleeding)

-          Impairment of consciousness > 30 min

-          High – risk injury(high speed or missile)

-          Persistent vomiting/increasing headache

-          Inadequate post-injury supervision

Eyes

Protection

  

    Snow blindness can be stopped by any glasses that don’t reflect sun rays… prescription glasses may be made with polarized, or photochromic material, and polarized shields may clip onto normal lenses. In badminton or squash, there are specially designed eye guards.

    These should be plastic polycarbonate, have sprund ear clips, and have a nose bridge that holds the glasses away from the face to prevent misting up.

Medical eye injury kit:

a)      small mirror

b)      pencil torch

c)      ophthalmoscope

d)     sterile washout fluid

e)      local anaesthetic eye drops (amethocaine)

f)       fluorescein

g)      antibiotic drops or ointment – check expiry dates regularly

h)      eye patches, and micropore or clear tape

i)        visual acuity chart

j)        contact lens fluid

Cuts around the eye

Allow 3-4 weeks for adequate soft tissue healing:

a)      Acute – remove from field or play; cover the wound

b)      Subacute – subcuticular suturing and enzyme creams

Corneal abrasion

Application of amethocaine and fluorescein will allow adequate examination of the eye where corneal abrasion or a foreign body is suspected. An antibiotic cream or drops can be applied. Remove loose foreign bodies. Close the eyelid and keep the eye shut by covering with an eye patch for 24-48 hours.

Puncture wound of eye

Note any history of a penetrating wound. Signs of hyphaemia, per-shaped iris, enlarged or poorly reacting pupil, cloudy vision and impaired visual acuity should be referred for an ophthalmic opinion.

Blow to the eye

Large (elbow,fist, cricket ball) – check for hyphaemia and orbital fractures, especially of the inferior orbit. Note diplopia may also occur as a late sequela.

Small (squash ball, knuckle, part of the elbow) – small ball will fit the orbit and may be catastrophic, causing a blow out fracture of the orbit and loss of an eye. However, one third of orbital blow out fractures are sustained in sport. Though visual acuity recovery is complete, almost universal loss of binocular vision occurs.

Subconjunctival haemorrhage

If the haemorrhage appears segmental and in the anterior aspect of the sclera, it is probably of no consequence. But if the posterior aspect cannot be visualized, refer for further opinion.

Ears

Prevention is better than cure. Scrum caps, or taping of the ears, prevents damage to the pinna, and ear muffs and ear plugs should reduce acoustic trauma.

Haemathoma of the pinna(cauliflower ear)

Acute – aspirate and apply a compression bandage. The aspiration must be aseptic and will probably require repeating on several occasions

Chronic – no effective treatment is available until cosmetic surgery can be advised, when the playing days are over. Perichondral tears should be well aligned, sutured and covered by antibiotics

Mouth

Gumshields should be cast made, to allow maximum compression thickness over the teeth cusps but cause the least interference with the palate, which enables easy mouth breathing. They should be warn in all sports where potential impact may occur.

Displaced teeth should be replaced and splinted. Avulsed teeth and crown fragments should be kept, but handled only by the crown. They should be replaced in 60 minutes if urgent – or stored in buccal sulcus until dentist arrives, or placed in a sterile surround, or milk, if not urgent, than dentist should be consulted within two hours. Fractured teeth are painful on air sufflation and require dental review. Athletes should also go to X-ray to see if the teeth are swallowed.

Nose bleeds

The patient should be sat up and the head tipped forwards, and compression applied externally over Little’s area, preferably for 5 minutes, by a person other than a patient.

THE PRESENCE OF CLEAR CEREBROSPINAL FLUID FROM NOSE IS DIAGNOSTIC OF CRANIAL FRACTURE.

Fractured nose

Undisplaced – may be treated by managing the bleeding and soft tissue injury

Displaced – should be reduced, especially in the young, as a fracture may reduce the size of the nasal passage and increase the likelihood of sinusitis

SEPTAL HAEMATHOMA MAY BE DIAGNOSED BY INCREASING PAIN, FEVER AND LOCALIZED REDNESS AND SWELLING OF THE SEPTUM, WHICH REQUIRES EVACUATION AND ASPIRATION.

Nose clips

Sprung – the idea is to close the external nares; this is used in syhcnronized swimming

Strips – the idea is to open the nares and ease respiration. There is an effect at rest but they do little or nothing to aid respiration during exercise, as this is predominantly by mouth breathing. However, nose strips during the recovery phase produce a feeling of more controlled and easy respiration

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English