Brain Injuries

• 3 major parts of the brain: cerebrum/cortex, cerebellum, brain stem
• meninges and cerebrospinal fluid are also included with the brain
• 4 lobes of the cerebrum are the frontal, parietal, occipital, and temporal lobe
• brain stem is made up of the pons, midbrain, and medulla oblongata
• what is between the dura mater and the skull?

  epidural space
• what is between the dura mater and arachnoid mater?

  subdural space
• what is between the arachnoid and pia mater?

  subarachnoid space
• cerebrospinal fluid is contained between the arachnoid and pia mater membranes
• head injury MOI:

  • direct blow to the head or body
  • causes the head to snap
  • coup vs contrecoup
• cerebral concussion (mTBI) is caused by direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head
• cerebral concussion (mTBI) results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously

  • In some cases, signs and symptoms evolve over a number of minutes to hours
• cerebral concussion (mTBI) may result in neuropathological changes

  • acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury
• cerebral concussion results in a range of clinical signs and symptoms that may or may not involve loss of consciousness

  • Resolution of the clinical and cognitive features typically follows a sequential course
  • In some cases, symptoms may be prolonged
• mTBI signs observed by coaching staff:

  • appears dazed or stunned
  • is confused about assignment
  • forgets plays
  • is unsure of game, score or opponent
  • moves clumsily
  • answers questions slowly
  • loses consciousness
  • shows behavior or personality changes
  • can't recall events prior to hit
  • can't recall events after hit
• mTBI symptoms reported by athlete:

  • headache
  • nausea
  • balance problems or dizziness
  • double or fuzzy vision
  • sensitivity to light or noise
  • feeling sluggish
  • feeling foggy or groggy
  • concentration or memory problems
  • confusion
• observable red-flag signs for concussion that warrant emergency care:

  • decreasing level of consciousness
  • increasing confusion
  • increasing irritability
  • loss of or fluctuating level of consciousness
  • numbness in the arms or legs
  • pupils becoming unequal in size
  • repeated vomiting
  • seizures
  • slurred speech or inability to speak
  • inability to recognize people or places
  • worsening headache
• for an unconscious individual, always suspect and treat as a cervical neck injury
• for an unconscious individual, if no immediate life-threatening conditions are present, maintain in-line stabilization and wait for EMS
• history for conscious victim, ask:

  • Can you tell me what happened?
  • Can you remember the score or who we played last week?
  • Do you remember walking off the field?
  • Does your head hurt?
  • Do you have any pain in your neck
  • Can you move your hands and feet
  • Have you experienced any tinnitus?
• Ask conscious victim about amnesia, anterograde and retrograde
• observation of victim:

  • Orientation of individual
  • Vacant stare? Inability to focus?
  • Memory deficits
  • Cognitive function
  • Slurred speech
  • Delayed verbal and/or motor responses
  • Physical coordination
  • emotional responses
  • straw-colored fluid in the ears
• For concussion, palpate the skull and cervical spine and feel for:

  • points of tenderness
  • deformities
• concussion neurological exams test:

  • eye function
  • balance testing
  • coordination testing
  • cognitive tests
• testing for eye function:

  • PEARL
  • Eyes should track smoothly
  • Nystagmus (when eyes make repetitive, uncontrolled movement)
  • check vision
• Balance Test:

  • Balance Error scoring system
  • 6 total trials with 3 different stances and 2 surfaces
  • 20 second trials (count errors)
  • Eyes closed, hands on hips
• Balance Error Scoring System Scoring Errors:

  • Moving hands off the hips
  • Opening eyes
  • Step, stumble or fall
  • Hip flexion or abduction greater than 30 degrees
  • Lifting the forefoot or heel off of the testing surface
  • Remaining out of testing position for more than 5 seconds
• Cognitive Test for concussion:

  • standardized assessment of concussion
  • delayed memory recall
  • concentration
• neuropsychological testing for concussion:

  • computerized tests (ImPACT)
• how to assess previous concussions:

  • date(s) and circumstances; presence and duration of loss of consciousness, amnesia and symptoms with each injury


  preparticipation examination
• how to assess concussion-related personal history:

  • mood disorder, learning disability, attention-deficit hyperactivity disorder, epilepsy or seizures, sleep apnea, skull fracture, migraine headaches

  preparticipation examination
• how to assess family history:

  • mood disorder, learning disability, attention-deficit hyperactivity disorder, dementia, migraine headaches, complications from concussions?

  preparticipation examination
• how to assess symptoms: current and recurrent?

  symptom checklist or scale
• how to assess mental status:

  • level of consciousness, attention and concentration, orientation, memory


  standardized assessment of concussion
• how to assess eye examination:

  • eye movements with smooth pursuit (cranial nerves III, IV, VI), nystagmus (VII), pupillary reflex (CN II, III)


  clinical examination
• how to assess muscle strength:

  • strength evaluation of deltoids, biceps, triceps, wrist and finger flexors and extensors; pronator drift?

  clinical examination
• how to assess motor control: balance assessment?

  balance error scoring system
• how to assess cognitive function: reaction time, working memory, delayed recall?

  neurocognitive testing
• Any suspicion of mTBI, the individual must be removed from activity
• predictor of slower recovery is the severity of initial symptoms
• prior to RTP, all signs and symptoms must be resolved