1. BCPS Concussion Management Program August 2011

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. Symptoms • Four main categories • Physical • Cognitive • Emotional • Sleep

9. 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

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

11. Emotional Symptoms • Irritability • Sadness • More emotional • Nervousness

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

13. 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

14. 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

15. 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

16. 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

17. 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

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

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

20. 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

21. 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

22. 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

23. Communication • Procedures apply for all concussions in athletes

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

25. 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