Be suspicious of a traumatic brain injury any time an athlete has had any direct trauma to the head.
Photo credit: Nick Schuler, CAL FIRE-San Diego County Fire Authority
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- Discuss the frequency and significance of carotid artery dissection
- Explain the pathophysiology of carotid artery dissection
- Identify how to associate carotid artery dissection with prior neck injury
- Highlight the prevalence of mild traumatic brain injury in high school sports
- Explain assessment and prehospital management of mild traumatic brain injury
Rescue 195 had been providing stand-by EMS services at the local high school wrestling tournament. Throughout the day the crew had assisted with a few sprained knees and ankles, but had not treated any major injuries.
With the championship matches underway, the crew began closing up their BLS bags and moving some of their equipment to the ambulance. The two EMTs were discussing moving their backboard and stretcher to the rig when they suddenly realized the whole gymnasium had become quiet. Looking over to the wrestling mats, they saw one of the athletes lying on the mat with his coach at his side. When the boy did not get up after a few moments, the crew went over and asked if they could assist. The coach stood aside, stating that "Henry" had twisted his neck in a fall earlier in the week and was just now taken down in an awkward headlock. As the boy looked at the crew members with a scared half-smile, the senior EMT realized this 16-year-old had right-sided facial droop. A quick stroke assessment was performed, which the patient failed for inappropriate speech, arm drift and facial droop. He also complained about pain along the left side of his neck and a headache. The crew carefully performed complete spinal immobilization and transported him to the local emergency department, noting that his blood pressure was elevated during the transport.
Curious about how a 16-year-old male could present with stroke-like symptoms, the crew returned to the emergency department at the start of their shift the next morning and were told that the patient had been flown to the children's trauma center after a CT scan showed a carotid dissection.
Every year more than 2 million injuries occur to high school athletes, resulting in 500,000 physician visits and 30,000 hospital admissions.1 Many of these injuries are very minor and are treated by school athletic trainers with little to no involvement of EMS. More serious injuries can arise, however. This article looks at two serious sports-related injuries that are seen, yet can be difficult to evaluate, in high school sports: carotid artery dissection and traumatic brain injury.
CAROTID ARTERY DISSECTION
When an athlete's neck is twisted, hyperextended or hyperflexed, or sustains blunt trauma, the carotid artery is susceptible to injury. While relatively rare in the overall trauma picture (seen in 1% to 3% of blunt force trauma patients),2 it is much more common in high school athletes.3 When an injured artery experiences a tearing of the tunica intima, the innermost layer of the artery, pressurized blood is forced between the artery's layers, causing them to split.
Once the artery dissects (the layers split apart and the blood collects), a hematoma develops between the artery's layers, or an aneurysm develops. A dissection leads to clot formation, which can itself become large enough to interrupt cerebral blood flow, or it can break and emboli develop and drift into the cerebral arteries. More than half of patients with carotid artery dissection develop a stroke within days of the initial injury; in fact, dissection is one of the leading causes of stroke in young adults.2
Many different mechanisms can lead to a carotid dissection. Outside of trauma, dissections can occur spontaneously and as a result of connective tissue disorders, chronic hypertension, smoking and excessive coughing.
Dissection from penetrating trauma is rare; most dissections are caused by blunt force trauma. Major traumas, such as a motor vehicle crash, can cause dissections; however, the forces do not need to be excessive. Other less forceful mechanisms include:2
- Neck strain or manipulation
- Neck hyperextension
- Neck hyperflexion
- Yoga positions
- Wrestling neckholds
- Football tackles
- Diving accidents
- Any injury where the neck is impacted or twisted.
There are two carotid arteries deep within the neck structures. The left carotid artery arises from the arch of the aorta, while the right carotid artery branches off the brachiocephalic trunk--an artery that supplies blood to the head, chest and right arm. Passing out of the chest cavity just posterior of the clavicle and moving superiorly toward the head, the carotid arteries run parallel on each side of the trachea protected by deep connective tissue, the sternocleidomastoid muscle, fascia and several other deep muscles of the neck. These tissues protect the two arteries inside the carotid triangle, which is a space surrounded by muscle tissues. It is important to note that the carotid arteries are not actually against either the trachea or the cervical spinal column. Also protected inside the carotid triangle are internal jugular veins and the vagus nerve. When the carotid arteries pass the thyroid cartilage, they bifurcate, or divide, into internal and external carotid arteries, which both provide blood to the brain.
Like all arteries, the carotid arteries have three tissue layers. The innermost layer, known as the tunica intima, is made of smooth endothelial cells and provides the arteries with a smooth and non-stick passage for blood components. The middle layer, or tunica media, provides muscle strength and elasticity. The tunica media is made of elastic tissues which allow arteries to flex and stretch, while smooth muscle tissues, also in the tunica media, constrict to cause vasoconstriction and relax to allow for vasodilation. Finally, the outermost arterial layer, the tunica externa, provides the artery stability and protection and is made of collagen-based connective tissues that hold the artery in place in relation to surrounding structures and organs. The hollow canal within an artery is known as the lumen.
When a carotid artery experiences blunt force trauma, such as squeezing, or is stretched too far, small tears can develop within the tunica intima. When the tunica intima completely tears, high-pressure arterial blood begins to force itself between the tunica intima and tunica media. A dissection occurs when the blood forces the separation of the tunica intima and media along a length of the artery. An aneurysm forms when the tunica media also tears and the tunica externa balloons outward. This latter event can cause compression, also known as mass effect, to adjacent structures.2
A carotid dissection affects the body in several ways. Blood clots form inside the dissection and pieces of the clots can break off, causing emboli in the brain. These clots can become large enough to narrow the carotid artery's lumen, which reduces blood flow through the artery. Fortunately, because there are two carotid arteries, collateral circulation allows the brain to maintain adequate perfusion in most circumstances. In situations where adequate cerebral perfusion cannot be maintained, such as when large emboli develop, cerebral ischemia and injury may occur. When trauma causes a dissection, 58% of patients are eventually discharged from the hospital with some form of permanent neurological deficit.2
A carotid dissection might be recognized at two different time periods. How an assessment is driven depends on when the patient interacts with EMS. A patient may present at the time of injury, or several hours to days later when neurological symptoms caused by the dissection begin to develop. Regardless of when a patient presents to EMS, the foundation for suspecting a carotid artery dissection requires obtaining a thorough and complete history.
Accurately evaluate and ask questions about the mechanism of injury. Ask direct questions to determine if the patient's head and neck were flexed or stretched in any direction. Determine if there were any direct blows to the front or sides of the neck, and ask the patient if there is any pain in the neck's soft tissues. Pain is one of the earliest symptoms of a dissection. Consider the potential for a carotid dissection any time the patient's neck experiences hyperextension or hyperflexion.
ACUTE INJURY ASSESSMENT
If you are managing a patient with an acute injury, assess the airway, breathing, circulation and disability, as you would any other trauma patient. During the secondary assessment, perform a careful neck assessment. Bruising and swelling can be found, and the patient will typically have pain that is often instant and constant, but may gradually worsen and be described as throbbing or sharp. The strength of carotid pulses will not change; however, immediately after injury, a bruit develops. Take time to listen with a stethoscope for bruit along the carotid arteries. Bruit is the sound of blood passing through a narrowed and non-smooth lumen. The presence of associated neck and face injuries greatly increases the potential for carotid dissection.2
SUB-ACUTE INJURY ASSESSMENT
Medic 4 was called to the home of a 17-year-old male who awoke during the night with a severe headache and numbness on the right side of his body. The crew found Michael in bed, awake but anxious, with slurred speech and complaining that his headache woke him two hours ago. The crew asked Michael if he had any previous injuries, and he stated that he had a neck stinger two nights ago during football practice.
Physical signs of dissection do not disappear in a few days. Patients will still have bruit, complain of neck pain, and may have bruising or a hematoma. Neurological symptoms following a carotid artery dissection can take several days to develop. When symptoms do develop, they can be subtle or obvious. Patients may complain of:
- Blurred vision
- Pulsatile tinnitus (ringing in the ears)
- Loss of taste sensation or difficulty swallowing
- Visual field disturbances.2
Nearly all patients with neurologic symptoms complain of some sort of headache, which may include facial discomfort. They are often ipsilateral (on the same side) to the dissection and usually present prior to the patient developing stroke-like symptoms. Some patients may complain of cluster headaches behind or in the eyes.
On physical exam, signs identical to acute stroke can appear. Hemiparesis may be seen, but may not present with complete paralysis. Evaluate the patient for any unilateral motor weakness. Abnormal speech and facial droop are common as well. More than 10% of patients develop cranial nerve impairment and present with impaired eye movement or facial muscle control. Performing a stroke assessment, such as the Los Angeles Prehospital Stroke Screen or Cincinnati Stroke Scale, is reasonable and accurately identifies neurological deficits.
Manage any acute injuries in a trauma patient as trained. Protect and manage the patient's airway, breathing and circulation, and provide complete spine immobilization as necessary. Prehospital providers cannot repair a carotid artery dissection or reverse its symptoms, so no special interventions are necessary. However, any time it is suspected, vigilant cervical spine protection is indicated--even if the spine was previously cleared following the trauma. Eliminating unnecessary spine movement helps prevent any blood clots from excess movement. Even though no specific treatment can be provided by EMS caregivers, simply recognizing a carotid artery dissection presence or introducing a high index of suspicion for the injury can greatly improve the patient's long-term care.
At the hospital, the patient will receive a CT scan and often a MRI. The exact location and size of dissection determine how it is managed. In-hospital management ranges from anticoagulation only, usually with heparin or warfarin, to surgical repair and stent placement. Current research suggests that patients can also be managed conservatively with long-term aspirin therapy.4 Providing prehospital anticoagulation to these patients can be dangerous until other injuries and cerebral aneurysm can be ruled out.
MILD TRAUMATIC BRAIN INJURIES
Every year, more than 1.1 million people are treated for traumatic brain injuries (TBIs) in emergency departments across the United States.5 Of all age groups, high school teenagers have the second highest TBI rate.5 Research has also shown that when teenagers experience a traumatic brain injury, they take longer to recover than adults.6 The Departments of Defense (DoD) and Veterans Affairs recognize that repeated concussions, also known as mild traumatic brain injuries, can have long-term consequences, particularly in sports, including boxing, football and hockey.7 To emphasize the seriousness of TBI, the state of Oregon passed a law in January 2010 requiring high school athletic coaches to be able to recognize concussion in athletes.7
By definition, a traumatic brain injury has occurred whenever trauma to the head causes an alteration in mental status with or without loss of consciousness. In other words, it is a physiologic interruption of normal brain function that can present as loss of consciousness, memory loss, mental status changes, personality changes or focal neurological deficit.8
BLS Squad 22 was on stand-by at a high school hockey game. Late in the second period, one of the players tripped and was hit in the head by another athlete's stick as he was attempting a slap-shot. The crew watched the player get hit and fall face-first onto the ice. Wasting no time, they made their way onto the ice to help the coaches evaluate the player. When they reached his side, he was awake but appeared confused, asking what had happened and why everyone was standing over him. A few questions later, the crew realized the player had no recollection of the event or the hockey game.
Be suspicious of a traumatic brain injury any time an athlete has had any direct trauma to the head. If a patient presents less than awake on AVPU, assume traumatic brain injury. When the patient is awake, begin assessing for TBI by asking him to tell you everything he remembers from the minutes before the event until EMS arrived at his side. If the patient cannot remember what has happened for a part of that time, the memory loss is considered diagnostic for TBI. There are two forms of memory loss, or amnesia: Retrograde amnesia is the inability to remember information or events prior to the trauma; antegrade amnesia is the inability to maintain new memory following the event. Retrograde amnesia is more common and usually only covers a brief period of time; antegrade amnesia suggests a more serious injury may be present.
Ask the patient to describe how he is feeling. Following a TBI, it is common for patients to need a few extra moments to gather their thoughts, and they often experience headache and dizziness. Seeing stars, blurred vision and double vision are common as well.
Perform a complete physical exam to rule out other injuries. Examine the head and neck carefully, looking for evidence of fractures to the skull, facial bones, mandible and cervical spine. In our opinion, any patient experiencing any form of traumatic brain injury should receive cervical spine protection until a spine assessment can be performed. Many EMS systems are now performing spine assessments. Consider it if the assessment is within your scope of practice and the patient is awake and reliable.
Finally, determine if the patient has a history of previous traumatic brain injuries or concussion. Repetitive traumatic brain injuries increase the chances for long-term neurologic impairment and development of more serious injuries.
Monitor the patient carefully for signs that he may be experiencing increasing intracranial pressure (ICP). Early indications include persistent vomiting, a severe headache and mental status changes. A complete discussion of increasing ICP is not included in this article.
As with carotid artery dissection, begin managing any traumatically injured patient by protecting the airway, breathing and circulation. Once this is done and spine precautions are taken, complete an exam to determine the extent of neurological impairment. Unless specifically trained by a medical control physician, it is beyond the scope of EMS care to evaluate an athlete for the ability to return to the athletic event if they have experienced a traumatic brain injury. A spine assessment is appropriate, if allowed by medical control, as most patients with a TBI have had a significant enough mechanism where it is reasonable to assume the cervical spine has been injured. See the sidebar below to see the spine assessment utilized by EMS in Maine.
Whether or not a spine assessment is performed, a patient with a traumatic brain injury should be evaluated by a physician. Transport to the hospital by some means is indicated. Patients should be evaluated to rule out intracranial hemorrhage, monitored for increasing ICP, and counseled on when to return to sports and the signs of postconcussion syndrome.
Postconcussion syndrome is a constellation of symptoms that patients can experience starting about 24 hours following the initial injury. Symptoms include recurrent headache, difficulty sleeping, intermittent dizziness, ataxia, light sensitivity, attention and concentration problems and depression.8
Of the myriad different injuries high school athletes experience, a traumatic carotid artery dissection and mild traumatic brain injury can be easily missed during evaluation. Without proper treatment, both can cause long-term damage. By performing a careful patient evaluation of the head and neck, EMS providers can recognize the subtle symptoms of both injuries and influence their long-term management, potentially preserving the patient's neurological function and preventing permanent damage.
SIDEBAR: SPINE ASSESSMENT FOR BLUNT FORCE TRAUMA
- Free of distracting Injuries
- Free of intoxication (drugs or alcohol)
- Free of acute stress reactions (anxiety)
- Awake and calm, cooperative, sober and alert
- Free of spine pain
- Free of numbness and tingling in the body
Clear physical exam
- Free of spine tenderness
- Intact motor and sensory exam
- Distinguishes light touch from pain sensation in all extremities
- Equal bilateral finger abduction or finger/wrist extension against resistance
- Equal bilateral dorsiflexion and plantar flexion of the foot or great toe9
Carotid dissection is only one cause of bruit. There are many others, including plaque and fatty build-up. The presence of bruit following trauma should cause suspicion for carotid dissection, but not be treated as diagnostic.
A traumatic brain injury has occurred any time a patient experiences a blow to the head and any temporary alteration from their baseline neurological condition.
1. CDC. Sports-related injuries among high school athletes--United States, 2005-2006 school year. Morbidity & Mortality Weekly Report 55(38):1037-1040, 2006.
2. Zohrabian D. Carotid Artery Dissection. http://emedicine.medscape.com/article/757906-overview.
3. Iskander G. Personal communication on June 2, 2010. Dr. Iskander is director of trauma services for the Level II trauma centers at St. Joseph's Hospital and St. Joseph's Children's Hospital in Marshfield, WI.
4. Arnold MJ. Aspirin or Anticoagulation? Preventing Cerebral Ischemic Events after Carotid Artery Dissection. www.medscape.com/medline/abstracts19321846.
5. CDC. Nonfatal traumatic brain injuries from sports and recreation activities. Morbidity & Mortality Weekly Report 56(29):733-737, 2007.
6. CDC. How Many People Have TBI? www.cdc.gov/traumaticbraininjury/statistics.html.
7. Wilner A. Mild Traumatic Brain Injury/Concussions-New Department of Defense Guidelines. firstname.lastname@example.orgXehaK9wuIc@.29f95ecb!comment=1&cat=All.
8. Bernhardt DT. Concussion. http://emedicine.medscape.com/article/92095-overview.
9. Burton JH, Dunn MG, Harmon NR, et al. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma 61:161-167, 2006.
Kevin T. Collopy, BA, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also a flight paramedic for Spirit Ministry Medical Transportation in central Wisconsin and a lead instructor for Wilderness Medical Associates. Contact him at email@example.com.
Greg Friese, MS, NREMT-P, is director of education for CentreLearn Solutions, LLC. He is an educator, instructional designer, author, presenter and podcaster. Connect with Greg on Facebook, Twitter, or e-mail him at firstname.lastname@example.org.