Transcript Athletic Injuries ATC 222

Athletic Injuries ATC
222
Head, Face, Eyes, Ears, Nose, and
Throat
Chapter 27
Facial Injuries
• Mandible Fracture
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deformity
malocclusion
malalignment
bleeding around teeth/gums
lower lip anesthesia
pain with biting
• Treatment
Facial Injuries
• Mandible
Dislocation/Subluxation
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commonly from lateral force
malalignment
malocclusion
open, locked jaw
Dental Injuries
• Types
– fracture
– dislocation/subluxation
• Treatment
– realign subluxation
– replace/preserve dislocation or
fracture
– 30 minute survival rate
Nasal Injuries
• Fracture or Cartilage Separation
– S/S
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deformity
profuse bleeding
immediate swelling
crepitus
– treatment
• control hemorrhaging
• referral
• most return to activity in 3-4 days
Nasal Injuries
• Epistaxis (nosebleed)
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sit upright
ice (nose and ipsilateral carotid)
direct pressure on nostril
cotton/gauze plug
refrain from nose blowing for 2 hours
Eye Injuries
• Causes and Prevention
• S/S or Serious Eye Injury
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prolonged blurred vision
loss of part/all of visual field
sharp, stabbing, throbbing pain
double vision
embedded object
blood in anterior chamber (hyphema)
Treatment of Serious Eye
Injury
• immediate referral
• cover both eyes with
embedded object
• ice only to surrounding tissue
• no pressure applied to eyes
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Orbital Blowout Fx
Blunt trauma
Inability to look upward
Diplopia
Sunken eye
What is wrong with this
picture?
Orbital Hematoma
• “Black Eye”
• Bleeding in orbit area and poss. Sclera
• Rule out serious eye injury
Foreign Body in Eye
• Embedded?
• Removal
– Close eye
– eye rinse
– removal with gauze pad
The ole finger in the eye
play!!!!
Ear Injuries
• Hematoma Auris (cauliflower ear)
– causes
– S/S
• swelling
• redness, warmth
• pain
– treatment
• ice
• protection
• aspirate
Otitis Media and Externa
• Etiology
• Signs and Symptoms
• Treatment
Neurological System and
Evaluation
Neuron (Nerve Cell)
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dendrites
cell body
axon
Schwann cells
motor end plate
Functional Classification of
Neurons
• Sensory
• Associational
– Inter-neurons
• Motor
– Upper motor neuron
– Lower motor neuron
Synapse
• Functional connection between 2
neurons
– chemical or electrical
• Neurotransmitters
– acetylcholine
– norepinephrine
• Motor Unit
Nervous System Divisions
• Central Nervous System (CNS)
– Brain
– Spinal Cord
• Peripheral Nervous System (PNS)
– Cranial Nerves
– Spinal Nerves
• R.T.D.C.B.
PNS
– Somatic NS
– Autonomic NS
• sympathetic
• parasympathetic
• enteric NS
Somatic Nervous System
• Functions
– voluntary control of skeletal muscle
– convey conscious/unconscious sensory
(afferent) information
• vision, pain, touch, unconscious muscle
sense
Autonomic Nervous System
• Functions
• convey sensory input from visceral organs,
glands and cardiovascular system
• involuntary control of smooth and cardiac
muscle
• maintain homeostasis
• Divisions of ANS
– Sympathetic Nervous System
• thoracolumbar
– Parasympathetic Nervous System
• craniosacral
– Enteric Nervous System
Sympathetic Nervous System
• Dominates in stress conditions
– physical and psychological
– very rapid effects
• “Fight or Flight” theory
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increased sweating, HR, RR
blood diverted to skeletal muscles
pupil dilation
conversion of glycogen to glucose
Parasympathetic Nervous
System
• Opposite actions of sympathetic
nervous system
• dominates in relaxed states
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decreased HR and RR
increased peristalsis
increased saliva and intestinal secretions
pupil constriction
Enteric Nervous System
• innervates GI tract, pancreas, gall
bladder
CNS
• Gray matter = nerve cell bodies
• White matter = axons
• Efferent neurons
– motor neurons
• Afferent neurons
– sensory neurons
Meninges
• Dura Mater
– tough, inelastic membrane
– adheres to inner part of cranium
• Arachnoid Mater
– delicate, web-like tissue
– avascular
• Pia Mater
– thin, delicate tissue hugging brain
– no space between pia mater and brain
– capillary rich to supply brain with blood
Meninges Cont.
• Epidural Space
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“potential space”
between cranium and dura mater
space created due to epidural hematoma
middle meningeal artery
• Subdural Space
– filled with a serous lubricant
– prevents dura mater and arachnoid from
adhering to each other
• Subarachnoid Space
– relatively large
– filled with cerebrospinal fluid
– ventricles
Cerebrum
• Basal Ganglia
• Limbic system
Cerebrum
• general appearance and behavior
• level of consciousness (loc)
• intellectual performance
– short term memory (STM)
– long term memory (LTM)
• amnesia?
– calculation
– reasoning
• emotional control
• language skills
• voluntary movement (cerebral cortex)
Basal Ganglia and Limbic
System
• Basal Ganglia
– part of extra-pyramidal system
– inter-connects several part of CNS
– fine tune motor control
• Limbic System
– emotion, hunger, biological rhythms,
smell
Diencephalon
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epithalamus
thalamus
hypothalamus
subthalamus
Thalamus/Hypothalamus
• Thalamus
– receives input from every sensory system
– sensory and motor integration
• Hypothalamus
– homeostasis (temp), hunger, thirst,
emotions
Cerebellum
• Coordination
– control of timing, speed, and direction of
movement
• Equilibrium
– balance, posture
Brain Stem
• midbrain
– eye tracking; voluntary movement
• medulla
– decussation of UMN
• pons
– relay info. from cortex to cerebellum;
respiration
• medulla oblongata
– reflexes for vomiting, swallowing,
coughing, salivation, pupils
• cranial nerves III, IV, V, VI, VII, VIII,
IX, X, XI, XII
Movie Time
Rated PG
Reticular Formation
• Extends throughout the length of the
brain stem
• Reticular activating system
– wakefulness
– modification of sensory input
– controls motor function via reticulospinal
tract
– receives input from hypothalamus and
limbic system (emotion)
Vestibular Nuclei
• located in brain stem
• receive input from labyrinthine
system, reticular formation, and
cerebellum
• controls/interprets balance, head
control, and eye tracking
Spinal Cord
• Function
– pathway for efferent and afferent nerve
fibers
• ascending and descending spinal tracts
– connects peripheral and spinal nerves to
brain
– center for spinal (monosynaptic) reflexes
• Location
– foramen magnum to app. L2
• Gives rise to 31 pair of spinal root
nerves
• Cauda equina
– lumbrosacral plexus from L2 on down
Spinal Nerves
• 31 pair
– dorsal spinal root = afferent = sensory
– ventral spinal root = efferent = motor
• Doral and ventral root join to form the
peripheral nerve
• Spinal nerves exit below respective
vertebral level except for cervical
• Myotome
– voluntary muscle group receiving motor
innervation from a specific spinal nerve
• Dermatome
– section of skin that receives sensory
innervation from a specific spinal nerve
– adjacent dermatomes overlap
– partial loss = peripheral complete loss
= cord
Descending Tracts
“Motor”
• corticospinal (Pyramidal Tract)
– voluntary skilled movement in
extremities
• reticulospinal
– facilitate or inhibit motor neurons;
– posture
• tectospinal
– postural reflexes of head for vision
• rubrospinal
– facilitate/inhibit motor neurons
– posture
• vestibulospinal
– facilitate/inhibit postural muscles of
abdomen, back, neck
Ascending Tracts
• Exteroceptive, Proprioceptive, and
Interoceptive
• ventral and lateral spinothalamic
– pain and temperature
• spinocerebellar
– proprioceptive and exteroceptive
– vestibular nuclei and joint receptors
• spinoreticular
– muscle, joints, and skin
• gracile and cuneate
– touch, pressure, conscious joint sense
Cranial Nerves
• Sensory and/or Motor Function
– 12 pairs
• On Old Olympus’ Towering Top A Fin
And German Viewed Some Hops
• Oh Oh Oh To Touch and Feel a
Girl/Guy Very Sexy and Hot
• Motor and/or Sensory Function
– Some say marry money but my brother
says bad boys marry money.
Cranial Nerves
• I. Olfactory
• function: smell
• testing: identify common odors
• II. Optic
• function: vision
• testing: check visual fields, check vision
• III. Oculomotor
• function: eye movement, pupil reflex
• testing: tracking, direct/consensual pupil
reflex, accommodation, nystagmus, drooping
eyelid
• IV. Trochlear
• function: eye movement
• testing: tracking, nystagmus
Cranial Nerves Cont.
• V. Trigeminal
• function: muscles of mastication, facial
sensation, corneal reflex
• testing: check facial sensation, muscles of
mastication
• VI. Abducens
• function: eye movement
• testing: tracking, nystagmus
• VII. Facial
• function: muscles of facial expression, taste
to anterior tongue
• testing: facial expressions, taste
• VIII. Vestibulocochlear
• function: hearing, equilibrium
• testing: hearing, check for tinnitus, check
balance
Cranial Nerves Cont.
• IX. Glossopharyngeal
• function: taste to posterior tongue, muscles
of larynx/pharynx
• testing: taste, gag reflex, speak/swallowing,
coughing
• X. Vagus
• function: swallowing, phonation, taste
• testing: speak/swallowing, gag reflex, taste,
cough
• XI. Spinal Accessory
• function: motor control of upper trap and
sternocleidomastoid
• testing: SMT/DMT of trap and SCM
• XII. Hypoglossal
• function: tongue movement
• testing: tongue protrusion (deviation?)
Cranial Nerve Quick Test
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Vision
Visual Fields
Eye Tracking
Facial Sensation
Muscles of Facial Expression
Muscles of Mastication
Hearing/Balance
Swallowing
Upper Trap/SCM Strength
Tongue Protrusion
Pupil Reflexes
Movie Time
Rated PG
Proprioception
• The awareness of posture, movement,
muscle length/tension, changes in
equilibrium, weight, resistance of
objects, and speed/range,angle of
movement
• Proprioceptors
– muscle spindle
– Golgi tendon organ (GTO)
– mechanoreceptors
Muscle Spindle
• Detects length and rate of length
• Extrafusal vs. Intrafusal fibers
• extrafusal = skeletal muscle fibers
– innervated by alpha motor neurons
• intrafusal = muscle spindle fibers
– innervated by gamma motor neurons
Muscle Spindles
• Intrafusal fibers
– located within muscle belly
– stretching a muscle also stretches the
muscle spindle
– most sensitive to rapid stretching
• Types
– Nuclear Bag 1 (Dynamic)
• rate of change in length
• Ia afferent; fires rapidly but adapts quickly
– Nuclear Chain (Static)
• overall length
• II afferent; slow firing and non-adapting
Golgi Tendon Organ
– located within tendons
– Ib afferent
• slow firing and non-adapting
– most sensitive to excessive stretch
– sensitive to excessive tension due to
muscle contraction
– excessive tension will cause a reflexive
inhibition of alpha mn
Myotatic or Stretch Reflexes
• Deep Tendon Reflex
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biceps brachii: C5-C6
brachioradialis: C5-C6
triceps brachii: C7
infrapatellar: L3-L4
posterior tibialis: L5
achilles: S1
• Jendrassik Maneuver
– increases facilitative activity of spinal
cord
Superficial Reflexes
• Abdominal
– upper: T6-T9
– lower: T9-T12
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Cremasteric: L1-L2
Plantar: S1-S2
Gag
Corneal
Visceral Reflexes
• Pupillary reflex
– direct
– consensual
– accommodation
• Blink reflex
Pathological Reflexes
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Babinski sign
Oppenheim sign
Decorticate rigidity **
Decerebrate rigidity **
• ** due to lack of cortical/cerebral
control
Lower Motor Neuron
Lesions
• weakness/paralysis/paresis of a
voluntary motor group
• decreased tone (flaccidity) of involved
motor group
• decreased/absent deep tendon reflex
(hyporeflexia or areflexia)
• atrophy of muscle/muscle group
• radicular pain specific to a spinal
nerve path
• decreases/absent sensation of specific
dermatomes (hypoesthesia or
anesthesia)
Upper Motor Neuron Lesion
• pathological reflex present (eg:
Babinski sign)
• weakness distal to lesion
• hemiplegia/paraplegia
• increased deep tendon reflex
(hypereflexia) **
• hypertonicity
– spasticity
– rigidity
• decreased/absent superficial reflexes
• ** due to lack of cortical control
Reflex Grading Scale
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0 =
1+ =
2+ =
3+ =
4+ =
Absent
Decreased (elicited with reinforcement)
Normal
Increased
Clonus
Movie Time
Rated R
Head Injuries
• Incidence of serious injury
has decreased
– neck injuries?
– protective gear
• Appr. 250,000
concussions/year
• Focal vs. Diffuse Injuries
Concussion
• Definition
– clinical syndrome characterized
by immediate and transient
impairment of normal
neurological function
• Causes
– coup Vs. contrecoup
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Grades
Return to Play Criteria
Post-concussion Syndrome
Second Impact Syndrome
Intracranial
Hemorrhaging
• Epidural hematoma
– arterial bleeding
– rapid onset (poss. 10-20 min.)
• Subdural hematoma
– venous/capillary bleeding
– slow onset
• Intracerebral hematoma
– compressive
mechanism/aneurysm
– rapid onset
Evaluation Process
• Primary Assessment?
– ABC’s
• Secondary Assessment
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Mental Status
Cranial Nerve Exam
Motor System Exam
Proprioception, balance, and
coordination
– Sensory Exam
– Reflex Examination
Cranial Nerve Exam
• Test for:
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Vision
Tracking
Visual Fields
Pupil Reflex
Hearing
Swallowing
Shoulder Shrug
Facial Sensation
Facial Expression
Tongue Protrusion
Mastication
Other Signs and
Symptoms
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headache
nausea, vomiting
seizures
unequal pupils
tinnitus
unusual drowsiness
Treatment
• Recheck athlete on regular basis
• Refer if in doubt or in more severe
cases
• Monitor throughout the night
• No alcohol, aspirin, ibuprofen
• No activity until asymptomatic
• No new s/s or no worsening of
current s/s