August 2011

BCPS Concussion Management Program

Case14 yo high school female varsity soccer

goalie dives to save a shot. During dive, strikes top of her head against

goal postNo loss of consciousness but she

experienced brief disorientation upon standing.

During halftime, experienced headaches and blurry vision

Concussion Science

Significant advances since 2001International symposia (2001, 2004, 2008)Eliminated grading scales (e.g., Cantu,

Colorado Medical Society, AAN)

TerminologyConcussion 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

ConcussionNo fracture or bleeding in the brainDamage comes from chemical changes in

the brain cells (neurons) – considered an “energy crisis” at the cell level

ConcussionsBrain Injury caused by shaking of the brain

inside of the cranial vault.Can be caused by direct blow, sudden

change in directionDoes not need to include loss of

consciousness

Clinical Management 2011

Decisions based on symptomsGoal is for student to be and remain

symptom-freeRequires a gradual and monitored return to

playRequires close collaboration between

classroom, home and field

SymptomsFour main categories

PhysicalCognitiveEmotional Sleep

Physical Symptoms

Headache – most commonly reportedLoss 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 SymptomsFeel mentally foggyFeel slowed downDifficulty concentratingMemory problemsConfusion, particularly with recent eventsAnswers slowlyRepeats questions

Emotional SymptomsIrritabilitySadnessMore emotionalNervousness

Sleep SymptomsDrowsinessSleeping more or less than usualDifficulty falling asleep

Post-Concussion ManagementGoal is to prevent against cumulative

effects of injuryCumulative neurocognitive deficitsCumulative behavioral deficitsLess biomechanical force causes extension of

injuryPrevent Post-Concussive SyndromeDetermination of Asymptomatic status

is essential to reducing repetitive and chronic morbidity of injury

Post Concussive SyndromePresence 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 AthletesCoach trainingParent & Athlete trainingExclusion of all athletes with possible

concussionsCommunication between coaches and

school nurseCommunication with health care providersGraduated return to playThroughout – close monitoring

Coach TrainingStandardized training to be provided at

coaches meetingsReviews signs and symptoms of head injuryStresses requirement to exclude athletes’

with probable head injury from play until evaluated

Overview of return to play protoocol

Athlete and Parent TrainingAthletic Directors to receive standardized

training via emailProvide at “meet the coaches” nightCoaches must provide power point training

to student athletesTraining of parents and athletes is

mandatory

ExclusionCoach MUST excludeNew law requiresFailure to exclude sets coach up for

personal liability

CommunicationSchool nurse alerted that day or next

morningSchool nurse interviews athlete

Checks for symptomsEducates about need for physical & cognitive

restSchool nurse communicates with athlete’s

familyMakes sure family has paperworkMakes sure family understands need for

medical clearance

CommunicationSchool nurse alerts teachersSchool nurse excuses student from PE

(need MD note after 1 week)Teachers

Make minor accommodationsRefer student to nurse if symptomatic

School nursePermits student to restSends student homeCommunicates with parents and health care

provider re: observations

CommunicationNurse alerts AD when medical clearance

receivedCoach notifies AD if medical clearance

received (AD notifies nurse)Athlete begins graduated return to playStudent monitored for 1-2 weeks for school

symptoms – if present, coach/parent/health care provider alerted

CommunicationProcedures apply for all concussions in

athletes

Graduated Return to PlayEstablished protocols by MPSSAASpecific for football and soccerGeneral protocol for other sportsProgression over 5 + days

School AccommodationsMinor accommodations for 1-3 weeks

Cognitive restExcused absencesReduced workload/extended deadlines

If symptoms persist beyond 3 weeks, need medical documentation