Tuesday, April 15, 2014

On-ice evaluation and management of head and neck injuries

In last night's final regular season game for the Vancouver Canucks, a scary incident occurred towards the end of the second period. While going to retrieve the puck in the defensive zone, Daniel Sedin skated towards the end boards and took a hit from behind from Calgary Flames forward Paul Byron, going head-first into the glass.

Sedin lay still on the ice for several minutes before the Canucks physician and medical staff were able to complete the thorough neurological protocol. Sedin was taken to Vancouver General Hospital in stable condition on a stretcher and underwent further evaluation. Byron was assessed a five-minute major for boarding and a game misconduct.

The video below recaps the whole situation, including Sedin being stretchered off the ice:

The good news is that Sedin was released from the hospital later that night. He acquired a CT scan and is apparently injury free. He recaps the situation here on Canucks clean-out day:

Following a head or neck injury like Sedin's last night, there is strict protocol medical staff must follow.  I'll try to detail that as much as possible.

Head and neck injuries are usually the result of either direct (hit to the head) or indirect contact (hit causing the head/neck to be injured, a la Sedin). Head and neck injuries are the most serious in all of sports, as consequences of neurological injuries have a potentially high incidence of morbidity and mortality. Studies have estimated that 70% of traumatic deaths and 20% of permanent disability in sports-related injuries are due to head and neck injuries (Van Camp et al, Mueller et al.).

Head and neck injuries require immediate assessment and action. The initial assessment of an injury is important, but challenging for physicians. If an injury is fatal, it causes immediate neurological consequences that are easy to identify (ex: Professor Sid Watkins account of Aryton Senna's death from the documentary Senna). The most challenging aspect of assessing a neurological injury is identifying athletes with a 'mild' injury without immediate symptoms. Often, it takes concussion symptoms up to 24 hours to manifest. When initially assessing the injury, the mechanism and amount of force are considered in the diagnosis.

There are five steps to managing a head or neck injury that occurs during play. Physicians will always err on the side of caution. They are:

  1. Preparation for any neurological injury (assembling paramedics, equipment, worst-case scenarios)
  2. Suspicion and recognition (no official diagnosis made, based on observation and patient reporting)
  3. Stabilization and safety (depending on severity, could mean securing the body on a stretcher or just moving to a better location off-ice in a safe manner).
  4. Immediate treatment and possible secondary treatment (CPR if necessary, etc.)
  5. Evaluation for return to play (long-term...players suffering a possible concussion should NOT return to play the same day)

A physician will start with a basic safety evaluation which includes the ABC (Airway, Breathing and Circulation) evaluation. If the athlete doesn't have the normal ABC's (not breathing, no pulse) CPR should be initiated immediately (this is what happened with Peverley a few months ago).

Additionally, if there is any suspicion of a head or neck injury, the athlete should immediately be assessed for level of consciousness. The most extensively used tool that provides a prognostic indicator for recovery is the Glascow Coma Scale:

A score of >11 is associated with a good prognosis for recovery, while <7 is quite serious with a less favorable prognosis. These 'scales' are debated among the neurological community, however. Is there such a thing as 'mild' head injury if it has lifelong effects?

After checking the ABCs, if an athlete is conscious and alert, the physician will caution them to remain still; they will also ask them what is wrong and if they feel any pain. If an athlete has any head, neck, or back pain, they should not be moved until the spine is stabilized. The player's helmet and padding should not be removed; removal can cause unwanted motion or worsening of the fracture which could result in permanent nerve damage/paralysis. Players should not be moved until trained paramedics are able to assist. If players are in the prone position, proper log rolling technique is used to move them into a supine position for better assessment.

A hard cervical collar and a spine board should always be used to prevent further injury until a cervical injury can definitely be excluded. As seen in the image below from last night, Sedin is completely immobilized. He is strapped securely to the spine board, is wearing a neck brace (after having his helmet carefully removed by a trainer), and his head is strapped down.

Unlike in Sedin's situation, if a cervical spine injury is excluded but there is still fear of a head injury, the player can be slowly assisted to a sitting position which could help decrease intracranial pressure. If the athlete is stable while sitting, they can be assisted to help stand and then escorted to the locker room for further evaluation. During this time, the physician should conduct a complete neurological exam and evaluation. If a head injury is suspected, the player should not return. If the athlete is in unstable condition or is at risk for a deterioration in condition, they should be transported to the hospital.


Mueller FO, Cantu RC. Catastrophic injuries and fatalities in high school and college sports, fall
1982 – spring 1988. Med Sci Sports Exerc 1990;22(6):737 – 41.

G. Ghiselli et al. / Clin Sports Med 22 (2003) 445–465.

Van Camp SP, Bloor CM, Mueller FO, et al. Nontraumatic sports death in high school and
college athletes. Med Sci Sports Exerc 1995;27(5):641 – 7.

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