August 2011 BCPS Concussion Management Program

Case 14 yo high school female varsity soccer goalie dives to save a shot. During dive, strikes top of her head against goal post No loss of consciousness but she experienced brief disorientation upon standing. During halftime, experienced headaches and blurry vision

Concussion Science Significant advances since 2001 International symposia (2001, 2004, 2008) Eliminated grading scales (e.g., Cantu, Colorado Medical Society, AAN) Terminology Concussion versus mild TBI

Latest Accepted Recommendations Vienna, Prague, Zurich: 1. Abandonment of graded scale approach, recommend individualized management of injury and determination of severity after sx have resolved 2. Any athlete exhibiting any sx should be removed from competition and not allowed to return that day. 3. Objective assessment via sideline assessment tools, balance testing and neurocognitive testing significantly increasing understanding of proper recovery 4. Role of physical and cognitive exertion is important to recovery and Stepwise RTP should begin only when asymptomatic 5. RTP is always a clinical decision

Pathophysiology Concussion No fracture or bleeding in the brain Damage comes from chemical changes in the brain cells (neurons) – considered an “energy crisis” at the cell level

Concussions Brain Injury caused by shaking of the brain inside of the cranial vault. Can be caused by direct blow, sudden change in direction Does not need to include loss of consciousness

Clinical Management 2011 Decisions based on symptoms Goal is for student to be and remain symptom-free Requires a gradual and monitored return to play Requires close collaboration between classroom, home and field

Symptoms Four main categories Physical Cognitive Emotional Sleep

Physical Symptoms Headache – most commonly reported Loss of consciousness – occurs in less that 10% Other symptoms: nausea, vomiting, balance problems, visual problems, fatigue, sensitivity to light and/or sound, stunned or dazed appearance

Cognitive Symptoms Feel mentally foggy Feel slowed down Difficulty concentrating Memory problems Confusion, particularly with recent events Answers slowly Repeats questions

Emotional Symptoms Irritability Sadness More emotional Nervousness

Sleep Symptoms Drowsiness Sleeping more or less than usual Difficulty falling asleep

Post-Concussion Management Goal is to prevent against cumulative effects of injury Cumulative neurocognitive deficits Cumulative behavioral deficits Less biomechanical force causes extension of injury Prevent Post-Concussive Syndrome Determination of Asymptomatic status is essential to reducing repetitive and chronic morbidity of injury

Post Concussive Syndrome Presence of symptoms for greater than two weeks Time for imaging if not done previously during evaluation Time to consider possible medication for symptom management Statistically shown to increase long term morbidity than pts with less than two weeks of symptoms

Second Impact Syndrome Worst Case Scenario Occurs only in pts with developing brains, has never been seen an adult patient. Second brain injury when recovering from initial can lead to massive abnormality in cerebral vascular auto- regulation leading to cerebral edema. Intractable seizures, permanent neurologic deficits, or death

BCPS Protocol for Student Athletes Coach training Parent & Athlete training Exclusion of all athletes with possible concussions Communication between coaches and school nurse Communication with health care providers Graduated return to play Throughout – close monitoring

Coach Training Standardized training to be provided at coaches meetings Reviews signs and symptoms of head injury Stresses requirement to exclude athletes’ with probable head injury from play until evaluated Overview of return to play protoocol

Athlete and Parent Training Athletic Directors to receive standardized training via Provide at “meet the coaches” night Coaches must provide power point training to student athletes Training of parents and athletes is mandatory

Exclusion Coach MUST exclude New law requires Failure to exclude sets coach up for personal liability

Communication School nurse alerted that day or next morning School nurse interviews athlete Checks for symptoms Educates about need for physical & cognitive rest School nurse communicates with athlete’s family Makes sure family has paperwork Makes sure family understands need for medical clearance

Communication School nurse alerts teachers School nurse excuses student from PE (need MD note after 1 week) Teachers Make minor accommodations Refer student to nurse if symptomatic School nurse Permits student to rest Sends student home Communicates with parents and health care provider re: observations

Communication Nurse alerts AD when medical clearance received Coach notifies AD if medical clearance received (AD notifies nurse) Athlete begins graduated return to play Student monitored for 1-2 weeks for school symptoms – if present, coach/parent/health care provider alerted

Communication Procedures apply for all concussions in athletes

Graduated Return to Play Established protocols by MPSSAA Specific for football and soccer General protocol for other sports Progression over 5 + days

School Accommodations Minor accommodations for 1-3 weeks Cognitive rest Excused absences Reduced workload/extended deadlines If symptoms persist beyond 3 weeks, need medical documentation