CONCUSSION MANAGEMENT PROCEDURE & TREATMENT PLAN
RECOGNITION OF CONCUSSION
A sports related concussion usually results from a blow to the head, though it can follow a body blow resulting in a shaking up of the brain. The following signs and symptoms are commonly seen with concussions.
- Loss of consciousness
- Nausea or vomiting
- Athlete appears dazed or stunned
- Confusion (about assignments, plays, etc.)
- Forgets plays
- Unsure about game, score, opponent
- Moves clumsily (altered coordination)
- Balance problems
- Personality or behavior changes
- Responds slowly to questions
- Forgets events prior to hit
- Forgets events after hit
- Nausea or vomiting
- Double vision, blurry vision
- Sensitive to light or noise
- Feels sluggish
- Feels foggy
- Problems concentrating
- Problems remembering
- An athlete with a witnessed loss of consciousness (LOC) of any duration should be spine boarded and transported immediately to the nearest emergency department via emergency vehicle.
- An athlete who has symptoms of a concussion and is not stable (condition is deteriorating) is to be transported to the nearest emergency department via emergency vehicle.
- An athlete who exhibits any of the following signs is unstable and should be transported to the nearest emergency room via emergency vehicle:
- Deterioration of neurological function
- Decreasing level of consciousness
Decrease or irregularity of respirations or pulse
- Unequal, dilated or nonreactive pupils
- Any signs or symptoms of associated injuries, spine or skull fractures
Fluid (clear or blood) from the eyes, ears, nose, and mouth
- Seizure activity
- Cranial nerve deficits
- Mental status change: lethargy, difficulty maintaining arousal, increasing confusion,
- An athlete who is symptomatic but stable (not exhibiting any signs of instability listed above), may be transported by his or her parents. The parents should be advised to contact the athlete’s primary care physician within 24 hours. If they feel the athlete’s condition is worsening, they should be advised to go to the emergency room.
- If the parents are not available, a responsible individual may be allowed to transport the athlete home if the individual understands the home care instructions and is able to monitor the athlete. Efforts should continue to be made to contact the parents.
- Parents should always have the option of emergency transportation, even if it is not deemed necessary.
GUIDELINES FOR THE CERTIFIED ATHLETIC TRAINER (ATC)
- The ATC will assess the injury or provide guidance to the coach if unable to physically attend to the athlete.
- The ATC will perform serial assessments using SAC (Standardized Assessment of Concussion), SACT2 (Sport Assessment Concussion Tool 2), or BESS (Balance Error Scoring System).
- Immediate referral to the hospital will be made when medically appropriate as outlined above.
- The ATC will notify the athlete’s parents as soon as possible and offer the appropriate medical referral and follow-up care.
- The ATC will encourage follow-up with the athlete’s primary care physician.
- The ATC will give the parents written and verbal home care instructions.
- The ATC will give the parents follow-up care instructions.
- The ATC will maintain communication with the parents regarding the athlete’s status including return to play until the athlete is fully recovered.
- The ATC will notify the school nurse of the injury as soon as possible. The school nurse will then initiate appropriate follow-up in the school immediately upon the athlete’s return to school.
- The ATC will continue to coordinate care of the athlete with the school nurse.
GUIDELINES FOR COACHES
- Any athlete who exhibits signs or symptoms of a concussion should be removed from play immediately and should not be allowed to return to activity that day. All coaches should be familiar with the signs and symptoms of a concussion.
- If a coach suspects the athlete has sustained a concussion, the athlete should be removed from activity until medically evaluated.
- Refer the athlete for medical evaluation.
- Coaches should report all head injuries to the certified athletic trainer (ATC) as soon as possible for medical assessment, management, home instructions, and follow-up care.
- Coaches should seek assistance from the host site ATC if at any away contest.
- If the ATC is not available, the coach is responsible for notifying the athlete’s parents of the injury.
- The coach should contact the parents, inform them of the injury, and make arrangements for the parents to pick the athlete up at school. The coach is to remain with the athlete until the parents arrive.
- The coach should encourage the parents to follow-up with the athlete’s primary care physician.
- The coach should instruct the athlete to report directly to the school nurse the day he or she returns to school after the injury.
- The coach should contact the ATC and provide the athlete’s name and home phone number so follow-up can be initiated.
- In the event the athlete’s parents cannot be reached and the athlete is able to be sent home (rather than directly to medical evaluation):
- The coach should insure that the athlete will be with a responsible individual who is capable of monitoring the athlete and understands the home care instructions before allowing the athlete to go home.
- The coach or ATC should continue efforts to reach the parents.
- If there is any question about the status of the athlete, or if the athlete is not able to be monitored appropriately, the athlete should be referred to the emergency department for evaluation. A coach, ATC, or designated school administrator should accompany the athlete and remain with the athlete until the parents arrive.
- Athletes with suspected head injuries should not be permitted to drive home.
- A Clarence School District accident report form must be completed and given to the athletic director/school nurse as soon as possible.
FOLLOW-UP CARE DURING THE SCHOOL DAY
- Responsibilities of the school nurse after notification of a student’s concussion.The athlete will be instructed to report to the school nurse upon his or her return to school. The school nurse will:
Responsibilities of the student’s guidance counselor:
- Re-evaluate the athlete using a graded symptom checklist.
- Notify the student’s guidance counselor and teachers immediately and include an individualized health care plan as needed.
- Notify the student’s physical education teacher that the athlete is restricted from all physical activity until further notice.
- If the school nurse receives notification from someone other than the ATC (parent, athlete, physician note) that the student has sustained a concussion, the ATC should be notified as soon as possible.
- Monitor the athlete on a regular basis during the school day.
- Monitor the student athlete closely and recommend appropriate academic accommodations to the student athlete’s teachers.
- Communicate any changes made to the student athlete’s individual education plan to the school nurse.
RETURN TO PLAY GUIDELINES AFTER CONCUSSION
- Returning to play on the same day of injury:
- An athlete who exhibits signs or symptoms of a concussion, or has abnormal cognitive testing shall not be permitted to return to play on the day of the injury. Any athlete who denies symptoms but has abnormal sideline cognitive testing should also be held out of activity.
- Return to play after concussion:
An initial post-injury ImPACT test will be done within a few days of the injury. Subsequent tests will be done roughly weekly at the discretion of the school physician.
- The athlete must meet all of the following criteria in order to return to activities:
- Asymptomatic for at least 24 hours.
- Cognitive testing (ImPACT) has returned to the athlete’s baseline testing.
- Graduated progression back to full activity, with no resumption of symptoms during the process.
- The athlete’s primary care physician’s wishes with regard to returning to school and accommodations in school will be honored. However, returning an athlete to athletic activity is the sole responsibility of the school physician.
- Once the athlete is asymptomatic for 24 hours and his/her ImPACT test is back to baseline, the athlete may begin a graduated progression of activity leading to full activity.
- This process will be supervised by the ATC.
- The progression of activity will be individualized based on the athlete’s concussion history, the duration of symptoms, the age of the athlete, and the specific sport the athlete is returning to.
- The graduated progression (following the guidelines of the Zurich Progressive Exertion Protocol):
Phase 1: low impact, non-strenuous, light aerobic activity such as walking or riding a stationary bike. If tolerated without a return of symptoms over a 24 hour period, proceed to:
Phase 2: higher impact, higher exertion, and moderate aerobic activity such as running or jumping rope. No resistance training. If tolerated without return of symptoms over a 24 hour period proceed to:
Phase 3: sport specific non-contact activity. Low resistance weight training with a spotter. If tolerated without a return of symptoms over 24 hours proceed to:
Phase 4: sport specific activity, non-contact drills. Higher resistance weight training with a spotter. If tolerated without a return of symptoms over a 24 hour period, proceed to:
Phase 5: full contact training drills and intense aerobic activity. If tolerated without return of symptoms over a 24 hour period proceed to:
Phase 6: Return to full activities without restriction.
If the athlete experiences post-concussion symptoms during any phase, the athlete drops back to the previously tolerated phase and resumes activity after 24 hours.7. The ATC and the athlete will discuss daily appropriate activities. The athlete should see the ATC and/or school nurse daily for reassessment and instructions until back to full activity. After return to full activity the ATC should continue to monitor the athlete for a few days for the return of symptoms or signs.