Head, Face, Eyes, Ears, Nose and Throat. Neurological Exam. Eye Function 12/11/2017. Oak Ridge High School Conroe, Texas

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1 Head, Face, Eyes, Ears, Nose and Throat Oak Ridge High School Conroe, Texas Neurological Exam Consists of Five Major Areas: 1. cerebral testing cognitive functioning 2. Cranial nerve testing 3. Cerebellar testing coordination 4. Sensory testing 5. Reflex testing Eye Function Pupils equal and reactive to light (PEARL) Dilated or irregular pupils. Check with penlight. Some individuals normally have pupils that differ in size. Inability of the pupils to accommodate rapidly to light variance. Cover with card or hand and expose to light. Slow response may indicate cerebral injury. 1

2 Eye Function Eyes track smoothly. Looking for smooth movement and any sign of pain. A constant involuntary back and forth, up and down, or rotary movement of the eyeball is called nystagmus and indicates possible cerebral involvement. Vision blurred. Have them read a game program or the scoreboard. Balance Test Also known as Rhomberg test, can be used to assess static balance. Original test is to stand on one leg with eyes closed. Coordination Tests These test include the finger to nose test, heel to toe walking, and the standing heel to knee test. Inability to perform any of these test may be indicative of injury to the cerebellum. 2

3 Cognitive Tests The purpose is to establish the effects of head trauma on various cognitive functions and to obtain an objective measure for assessment of the patient s status and improvement. Serial of 7s, in which one counts backward by 7s Name of the months in reverse order Careful about questions you ask, make sure you know the answer Skull Fracture Occur most often form blunt trauma such as a baseball, shot put to the head or a fall. Signs include severe headache and nausea. Palpation may reveal defect such as indentation. May be bleeding in the middle ear, blood in the ear canal, bleeding through the nose, ecchymosis around the eyes or behind the ears. Cerebrospinal fluid may appear in the ear canal or the nose. Skull Fracture Management includes immediate hospitalization. The fracture is not the main problem, rather complications that stem form intracranial bleeding and bone fragments embedded in the brain and infection. 3

4 Concussions Has been defined as clinical syndrome characterized by immediate and transient posttraumatic impairment of neural functions such as alterations of consciousness, disturbance of vision, loss of equilibrium, and so on due to brain stem involvement. A concussion is a disturbance in brain function that occurs following either a blow to the head or as a result of the violent shaking of the head. Concussion In the United States, the annual incidence of sports related concussion is estimated at 300,000. Estimates regarding the likelihood of an athlete in a contact sport experiencing a concussion may be as high as 19% per season. 4

5 Concussions Signs observed Appears to be dazed or stunned Is confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness (even temporarily) Shows behavior or personality change Forgets events prior to hit (retrograde amnesia) Forgets events after hit (anterograde amnesia) Signs reported by athlete Headache Nausea Balance problems or dizziness Double or fuzzy vision Sensitivity to light or noise Feeling sluggish Feeling "foggy" Change in sleep pattern Concentration or memory problems Concussion Assessment Upon ruling out more severe injury, acute evaluation continues with assessment of the concussion. First, the clinician should establish the presence of any loss or other alteration of consciousness (LOC). LOC is relatively rare and occurs in less than 10% of concussions. Concussion Assessment The identification of LOC can be very tricky, as the athlete may lose consciousness very briefly and this event may not be directly observed by others. By definition, LOC represents a state of brief coma in which the eyes are typically closed and the athlete is unresponsive to external stimuli. LOC is most obvious when an athlete makes no attempt to brace his or her fall following a blow to the head. Any athlete with documented LOC should be managed conservatively, and return to play is contraindicated. 5

6 Concussion Assessment Although helpful in identifying more serious concerns (e.g. skull fracture, hematoma, contusion), traditional neurological and radiologic procedures, such as CT, MRI, and EEG, are not useful in identifying the effects of concussion. Such tests are typically unremarkable or normal, even in athletes sustaining a severe concussion. The reason for this issue is that concussion is a metabolic rather than structural injury. Thus, structural neuroimaging techniques are insensitive to the effects of concussion. Concussion Management At the forefront of proper concussion management is the implementation of baseline and/or post injury neurocognitive testing. Such evaluation can help to objectively evaluate the concussed athlete's post injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussion. In fact, neurocognitive testing has recently been called the "cornerstone" of proper concussion management by an international panel of sports medicine experts. Concussion Management Current management guidelines (i.e. Grade 1, 2, 3 of concussion) are not evidenced based and little to no scientific data support the arbitrary systems that are in place to manage concussion. As a result, there are currently 19 different management criteria available for concussion management, which are often misused and misinterpreted. 6

7 Previous Concussion Grading Chart Postconcussion Syndrome Is a poorly understood condition that occurs following concussion. It may occur in cases of mild head injury that do not involve loss of consciousness or in cases of severe concussions. Post Concussion Syndrome Chronic headaches Fatigue Sleep difficulties Personality changes (e.g. increased irritability, emotionality) Sensitivity to light or noise Dizziness when standing quickly Deficits in short term memory, problem solving and general academic functioning 7

8 Postconcussion Syndrome Management includes making an effort to treat the symptoms. The athlete should not be allowed to return to play until all symptoms have resolved. Second Impact Syndrome Occurs because of rapid swelling and herniation of the brain after a second head injury that occurs before the symptoms of a previous head injury have resolved. It may not take a blow to the head, it may be to the chest or the back. The symptoms occur because a disruption of the brain s blood autoregulatory system leads to swelling of the brain, which significantly increases intracranial pressure, and to herniation. Second Impact Syndrome Signs include the athlete not losing consciousness, and may looked stunned. The athlete may remain standing and be able to leave the playing surface under his or her own power. Conditions will worsen rapidly, with dilated pupils, loss of eye movement, loss of consciousness leading to coma, and respiratory failure. 8

9 Second Impact Syndrome This is a life threatening emergency that must be addressed within approximately five minutes by dramatic life saving measures performed in an emergency care facility. Prevention is the best way to treat this emergency. Do not allow an athlete to return too soon to competition. Concussion Recommendations According to the Vienna Concussion Conference Recommendations, athletes should complete the following step wise process prior to return to play following concussion: Removal from contest following signs and symptoms of concussion No return to play in current game Medical evaluation following injury Rule out more serious intracranial pathology Concussion Recommendations Step wise return to play 1. No activity rest until asymptomatic 2. Light aerobic exercise 3. Sport specific training 4. Non contact drills 5. Full contact drills 6. Game play 9

10 Tooth Fractures Any impact to the lower or upper jaw or direct trauma can potentially fracture the teeth. Three types of fractures can occur Uncomplicated crown fracture Complicated crown fracture Root fracture Tooth Fractures Uncomplicated fracture there is a small portion of the tooth broken, no bleeding and the pulp chamber is not exposed Complicated fracture there is bleeding and the pulp chamber is exposed and there is great deal of pain. Root fracture occurs below the gum line so diagnosis is difficult. X Ray needed and it is very painful. 10

ImPACT Concussion Management Program

ImPACT Concussion Management Program Carver Athletic Department * Information obtained in this presentation came directly from the Impact website at www.impacttest.com What is a Concussion? A concussion