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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