A Synopsis of AFP's "Management of Head and Neck Injuries by the Sideline Physician"

Management of Head and Neck Injuries by the Sideline Physician
JOHN W. WHITESIDE, M.D., Mayo Clinic, Scottsdale, Arizona 
Am Fam Physician. 2006 Oct 15;74(8):1357-1364.
http://www.aafp.org/afp/2006/1015/p1357.pdf

     A sideline physician must be well trained in detecting and managing sports injuries. This article focuses on concussions and head injuries. It is important to document the time of injury and how long symptoms and loss of consciousness lasts.
     The neck should be evaluated in a certain order and if any of the tests are positive, then the testing can stop and the patient's neck needs to be immobilized. The patient should first be assessed for a loss of consciousness.  If the patient is unconscious, then ACLS should be implemented.  If the patient is suspected to have neck instability, it is important not to move the neck. Helmet and shoulder pads should be kept on. The patient should be immobilized and put on a backboard.
     The next step is to assess the patients peripheral strength and sensations. The clinician should evaluate the paraspinal muscles and document any symmetrical spasm and tenderness. The patients isotonic neck strength should be evaluated. The neck should not be moved during this part of the test. Then, the active range of motion of the neck can be assessed.  Next, the Spurling test, which compresses the cervical foramina is done. Pain or radiculopathy is a positive sign. If the test is negative, then the clinician can evaluate the patients neurological status. Questions should be asked to assess orientation and recent memory. A list of questions that may be asked include;
Where are we playing?
Who are we playing against?
How far into the game are we?
What is the score, who is winning, and who scored last?
Who did we play last week and who won?
Postural stability can be assessed with the balance error scoring system. The test is conducted by having the patient stand on either the ground or foam, while having his or her eyes closed. The patient is instructed to either stand with both feet side by side, one in front of the other, or with one foot in the air. Hands can be placed on the waist. Positive signs of balancing errors are stumbling, opening eyes, moving hands from waist, or moving out of testing position. A patient with usually make at least 12 errors after a concussion. The last step is to ask about symptoms such as headaches, nausea, dizziness, and blurred vision.
     Sometimes the patient will complain of a "burner" or "stinger". This is described as a short period of weakness or numbness along the C5/C6 dermatome. They are unilateral and are not associated with any weakness or range of motion problems. Patients can usually return to play if the symptoms resolve quickly.
     A concussion is defined as a quick, transient impairment of neural function after trauma to the brainstem. Symptoms include alterations in memory, blurred vision, fatigue, headache, coordination problems, loss of consciousness, nausea, vomiting, tinnitus, and sleep problems.  Assessing for concussion is a little easier than for assessing the neck. The four steps are
1. asses for loss of consciousness
2. ask about symptoms
3. evaluate recent memory
4. evaluate postural stability.
     According to the American Academy of Neurology Guidelines, there are three grades of concussion. Grade 1 has no loss of consciousness, transient confusion, and concussion symptoms lasting less than 15 minutes. These patient should be pulled out of the game and evaluated every 5 minutes on the sideline. They can return to play if they are symptom free for 15 minutes. If they get another grade 1, they should be held out for one week. A grade 2 concussion will present with symptoms lasting longer than 15 minutes. The patient should be pulled from the game for the day. The patient should be evaluated that day as well as the next day. The patient can return to play if asymptomatic for one day. Imaging can be done if the symptoms persist beyond a week. If the patient has a repeat grade 2 concussion, he or she cannot return until asymptomatic for two weeks. Any patient with loss of consciousness is considered to have a grade 3 concussion. These patients should be transported to the hospital if the loss of consciousness is prolonged, if there is persistent confusion. or if the neurological exam is abnormal. Imaging can be done if the patient is symptomatic beyond a week. The patient can return to play after 2 weeks of being symptom free. If the patient gets a second grade 3 concussion, they need to sit out for a month.