Athletic Training and Sports Health Care

Quick Questions in Sports Medicine 

What Are the Red Flags During a Sideline Assessment for Immediate Referral to the Emergency Department?

Kristina Wilson, MD, MPH, CAQSM, FAAP

Abstract

The most important role that a medical professional covering a sporting event plays is reducing morbidity and mortality from a secondary injury by early identification of the initial injury and appropriate management. Fortunately, the majority of sport-related injuries are injuries to the extremities. Although injuries to the head and neck in sports are not as common, they account for 70% of mortality and 20% of morbidity with permanent disability.1 For this reason, it is important for medical professionals working with athletes to be knowledgeable about the signs and symptoms of a more severe intracranial or cervical spine injury that may be associated with the concussion. Head and neck injuries generally occur simultaneously; therefore, any suspected concussion should include suspicion of a cervical spine injury.

During the on-field assessment, the most important evaluation is to determine the extent of the initial injury and to evaluate for associated cervical spine injury or focal or posttraumatic intracranial mass lesions. Fortunately, posttraumatic intracranial injuries are infrequent but include such abnormalities as subdural hematomas, epidural he-matomas, cerebral contusions, in-tracerebral hematomas, or hemorrhages. The leading cause of death related to head injury in sport is from subdural hematomas.1 Sub-dural hematomas occur when the bridging veins between the brain and dura are torn. These athletes typically present with a loss of consciousness with focal neurologic findings and may have a lucid interval similar to those athletes with epidural hematomas. Intracranial injuries often manifest over time, which is why it is critical that the athlete have serial evaluations after the injury. Reevaluation on the sideline every 5 to 7 minutes immediately after the injury provides you with the opportunity to monitor for any change in his or her examination or deterioration in his or her condition that would warrant immediate transfer to the emergency department. An associated intracranial injury should be suspected if there is a loss of consciousness, lethargy, vomiting, or change in mental status.

The decision to transport is primarily based on whether the athlete needs further evaluation with radiographic imaging due to concerns of a more extensive head or neck injury. In addition, if the athlete is unable to be monitored for deterioration in an environment with a responsible adult after sustaining a head injury, he or she should be transported for further evaluation with imaging and observation. There are several studies that have evaluated the signs and symptoms that are most predictive of an intracranial injury. These prediction rules for when to image with computed tomography (CT) scans are helpful in on-field assessments as well. These studies indicate that vomiting, physical examination signs of an underlying skull fracture, confusion (altered mental status), posttraumatic amnesia (specifically longer than 15 minutes), and loss of consciousness are most predictive of finding abnormalities with CT scan evaluation.2 Most prediction algorithms suggest that two of these risk factors should indicate head imaging. The CT in Head Injury Patients (CHIP) prediction rule supports obtaining CT scans after minor head injury if the patient presents with vomiting, posttraumatic amnesia of 4 hours or longer, clinical signs of skull fracture, altered mental status as noted by a Glascow Coma Score (GCS) of less than 15, or posttraumatic seizure.3

Head and neck injuries generally occur simultaneously. Another indication for immediate transport to and evaluation in the emergency department is concern for cervical spine injury. Cervical spine injury is often1 associated with head injury. Annually, there are 10,000 cervical spine injuries in the United States, with 10% of these injuries being sport related. Cervical spine injury is seen in all sports, particularly diving, skiing, and surfing. Athletes can have neck pain associated with their…

The most important role that a medical professional covering a sporting event plays is reducing morbidity and mortality from a secondary injury by early identification of the initial injury and appropriate management. Fortunately, the majority of sport-related injuries are injuries to the extremities. Although injuries to the head and neck in sports are not as common, they account for 70% of mortality and 20% of morbidity with permanent disability.1 For this reason, it is important for medical professionals working with athletes to be knowledgeable about the signs and symptoms of a more severe intracranial or cervical spine injury that may be associated with the concussion. Head and neck injuries generally occur simultaneously; therefore, any suspected concussion should include suspicion of a cervical spine injury.

During the on-field assessment, the most important evaluation is to determine the extent of the initial injury and to evaluate for associated cervical spine injury or focal or posttraumatic intracranial mass lesions. Fortunately, posttraumatic intracranial injuries are infrequent but include such abnormalities as subdural hematomas, epidural he-matomas, cerebral contusions, in-tracerebral hematomas, or hemorrhages. The leading cause of death related to head injury in sport is from subdural hematomas.1 Sub-dural hematomas occur when the bridging veins between the brain and dura are torn. These athletes typically present with a loss of consciousness with focal neurologic findings and may have a lucid interval similar to those athletes with epidural hematomas. Intracranial injuries often manifest over time, which is why it is critical that the athlete have serial evaluations after the injury. Reevaluation on the sideline every 5 to 7 minutes immediately after the injury provides you with the opportunity to monitor for any change in his or her examination or deterioration in his or her condition that would warrant immediate transfer to the emergency department. An associated intracranial injury should be suspected if there is a loss of consciousness, lethargy, vomiting, or change in mental status.

The decision to transport is primarily based on whether the athlete needs further evaluation with radiographic imaging due to concerns of a more extensive head or neck injury. In addition, if the athlete is unable to be monitored for deterioration in an environment with a responsible adult after sustaining a head injury, he or she should be transported for further evaluation with imaging and observation. There are several studies that have evaluated the signs and symptoms that are most predictive of an intracranial injury. These prediction rules for when to image with computed tomography (CT) scans are helpful in on-field assessments as well. These studies indicate that vomiting, physical examination signs of an underlying skull fracture, confusion (altered mental status), posttraumatic amnesia (specifically longer than 15 minutes), and loss of consciousness are most predictive of finding abnormalities with CT scan evaluation.2 Most prediction algorithms suggest that two of these risk factors should indicate head imaging. The CT in Head Injury Patients (CHIP) prediction rule supports obtaining CT scans after minor head injury if the patient presents with vomiting, posttraumatic amnesia of 4 hours or longer, clinical signs of skull fracture, altered mental status as noted by a Glascow Coma Score (GCS) of less than 15, or posttraumatic seizure.3

Head and neck injuries generally occur simultaneously. Another indication for immediate transport to and evaluation in the emergency department is concern for cervical spine injury. Cervical spine injury is often1 associated with head injury. Annually, there are 10,000 cervical spine injuries in the United States, with 10% of these injuries being sport related. Cervical spine injury is seen in all sports, particularly diving, skiing, and surfing. Athletes can have neck pain associated with their head injury from meningeal irritation, but neck pain at time of injury should be taken seriously. Athletes with cervical spine pain should be immobilized with cervical spine precautions and transported by emergency medical services.

The last indication for immediate referral to the emergency department is signs of skull fracture. Physical examination signs concerning for skull fracture include expanding hematoma on any area of the head other than the forehead, palpable depression, bruising behind the ears (Battle's sign, raccoon eyes), or hemotympanum. Examination of the tympanic membranes is often not performed on the sideline, but it should be if there is a high index of suspicion for an associated skull fracture.

Fortunately, most concussions are not associated with more severe intracranial injuries or cervical spine injuries. Unfortunately, these types of injuries are associated with the highest rates of morbidity and mortality in sport-related injury. Outcomes related to these injuries can be impacted by early identifica-tion and appropriate intervention with referral of these athletes for definitive diagnosis and treatment. Therefore, it is imperative that in the setting of any of the red flags in Table 1, suspicion of a more severe head or neck injury be raised and managed appropriately.


Red Flags for Immediate Referral to Emergency Department

Table 1:

Red Flags for Immediate Referral to Emergency Department

References

  1. Ghiselli G, Schaadt G, McAllister DR. On-the-field evaluation of an athlete with a head or neck injury. Clin Sports Med. 2003;22:445–465. doi:10.1016/S0278-5919(02)00109-6 [CrossRef]
  2. Saboori M, Ahmadi J, Farajzadegam Z. Indications for brain CT scan in patients with minor head injury. Clin Neurol Neu-rosurg. 2007;109:399–405. doi:10.1016/j.clineuro.2007.01.013 [CrossRef]
  3. Smits M, Dippel D, Steyerberg E, et al. Predicting intracranial traumatic find-ings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Int Med. 2007;146:1–55. doi:10.7326/0003-4819-146-6-200703200-00004 [CrossRef]
  4. US Centers for Disease Control and Prevention. Concussion: When to Seek Medical Attention. Available at: http://www.cdc.gov/concussion/signs_symptoms.html. Published March 8, 2010. Accessed December 3, 2014.

Red Flags for Immediate Referral to Emergency Department

Amnesia lasting longer than 15 minutes
Deterioration of neurological function
Motor deficit—weakness
Sensory deficit—numbness
Balance deficit
Increasing confusion
Decreasing level of consciousness
Difficult to arouse
Increasing lethargy
Decrease or irregularity in respiration
Decrease or irregularity in pulse
Increase in blood pressure
Unequal, dilated, or unreactive pupils
Cranial nerve deficits
Vomiting
Any signs of skull or neck trauma
Seizure activity
Worsening postconcussion symptoms
Unusual personality or mood changes
Significant irritability
Can't recognize people or places
Authors

From Primary Care Sports Medicine, Center for Pediatric Orthopaedics, Phoenix Children's Hospital, Phoenix, Arizona; Neurotrauma/Concussion Program, Barrow Neurologic Institute at Phoenix Children's Hospital, Phoenix, Arizona; and the Department of Child Health, University of Arizona School of Medicine–Phoenix, Phoenix, Arizona.

The author has no financial or proprietary interest in the materials presented herein.

Reprinted with permission from Valovich McLeod T. Quick Questions in Sport-Related Concussion. Thorofare, NJ: SLACK Incorporated; 2015:65-68. To purchase: http://healio.com/books/at

Correspondence: Kristina Wilson, MD, MPH, CAQSM, FAAP, Phoenix Children's Hospital, 1919 E. Thomas Road, Department of Orthopaedics and Sports Medicine, Main Building, Clinic B, Phoenix, AZ 85016. E-mail: kwilson@phoenixchildrens.com

10.3928/19425864-20161004-01

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