All right, good afternoon, everybody. Bobby, thanks for having me on to kind of share this information that I think, particularly at this time of year, is so valuable. In the interest of time, we'll try to move through things pretty quickly. I've outlined this in a series of cases in which we'll talk through the initial stabilization and evaluation management. Some of the more common sideline emergencies you'll see as you go out into covering sports threats and fellowship year. Let's see. So again, our primary goal is just to review the evaluation, emergency stabilization, and diagnostic considerations for any sideline management for the most catastrophic injuries that are frequently encountered in athletes. So we have a high school football player, stands with helmet to helmet, hit, immediately complains of headache and blurred vision. No LOC, but he is amnestic to the event. So we'll talk about closed head injuries with the understanding that the popular thing to focus on is concussions, but the more worrisome things tend to be intracranial bleeds. And so we'll kind of rest through how you evaluate that and some of the diagnostic considerations you can make as well. So head injuries are the leading cause of traumatic deaths in sports. It's estimated that 300,000 sports-related brain injuries occur annually, with 250,000 occurring in high school football players. Concussions are the most likely, but you also have to consider these potentially life-threatening events. So your classic epidural hematoma here, a subarachnoid and, I'm sorry, subdural and subarachnoid hemorrhage here. Concussions are caused by direct or indirect transmitted forces, primarily due to rotation, but also due to acceleration and deceleration forces. And you may have heard the term coup-contrecoup. This is one where you see the athlete kind of fall back, strike their head on the turf, and they kind of bounce back. It produces cellular damage and changes that can have long-standing impact. As most of you probably are well aware, a concussion is a clinical diagnosis. There is no single diagnostic test. Imaging does not help you diagnose a concussion. The other thing to keep in mind is that sometimes these symptoms are delayed in onset, and so you'll have multiple categories, physical symptoms, mental, sleep, emotional, et cetera. And a big part of understanding concussions, particularly at the high school level, is giving anticipatory guidance to the families so that they know what to watch for. The thing that you'll want to know is obviously when to remove an athlete from the field of play and when to refer to an ER for a more emergent workup and evaluation. So if you see somebody and they're suspected of having a head injury, immediately remove them from the field of play. If they're conscious, do your ABCs, so airway, breathing, circulation, followed by a C-spine evaluation, as Dr. Kloskowski was talking about in his previous talk. Your Glasgow Coma Scale will be an adjunct to your thorough neurological assessment, but in essence, it's a way that you can quickly and methodically assess what is this patient or this athlete's level of neurological function, taking note of their eye movements, their speech, and their motor function. Any unconscious player should be assumed to have a C-spine injury and immediately stabilize, as we said, in a hard collar, but also on a spine board. The two big things to be mindful of are when to refer them to an ED. If there's any focal neurological deficit or if they have any worsening clinical status, you need to send them in. The classic one where you hear tragically about athletes, particularly high school athletes that die, is with these epidural hematomas. They sustain an injury. They may have a brief loss of consciousness, get on the sidelines, say after a while. They have this lucid interval where they're functioning, and nothing seems to be wrong, and they compensate quickly. And in that moment, you've kind of lost your window. You worry about brain and uncle herniation, and eventually they arrest from a respiratory standpoint. But to prevent that, if you send them to ER, you're basically doing that to get imaging of both their CT and classically their C-spine. And we use a set of diagnostic guidelines and criteria to help with that on the back end. You're Canadian, or you're new on this head CT rule. As we talked about through Glasgow Coma Scale, again, a quick way to screen what their level of alertness is, looking at eye, verbal, and motor responses. I won't go through those in detail this way, save you time. The Canadian head CT rule. It's important to recognize what your inclusion and exclusion criteria are. And so if somebody has a DCS less than 13, this doesn't apply, and they need to be shipped anyway. But what you're looking for is in high-risk conditions that may require neurosurgical intervention, whether that's a bone hole, whether that's decompression. And so if they have a DCS score of less than 15 at two hours after the injury, suspected open or depressed skull fracture, any sign of a basal skull fracture. That may be hemotympanum when you look in the ear, battle signs behind the ear, raccoon eyes around the eyes, representative of intracranial bleed and sign of basal skull fracture. If they have multiple repeated episodes of vomiting, age greater than 65 won't apply as much, but then these lower risk, but still relatively significant, amnesia, dangerous mechanism, et cetera. If any of these things are present, then you should get a head CT. The New Orleans head CT rules are a different set of guidelines, maybe not quite as relevant for your athletic population, but it's good to know how these decisions are made either way. So all symptomatic players should not allow to return. Once you're getting off the sideline, you're putting it through computerized neuropsychological testing, so there's an impact. But that said, the SCAT find remains the standard of care in most settings, particularly acutely. Prevention revolves around screening to aid modification and protective equipment.

2nd Edition, CASE 38

2nd Edition

Neurology

concussions

intracranial bleeds

Glasgow Coma Scale

preventative measures

neuropsychological testing