Epidemiology/Definitions Mechanism of Injury Brain physiology Who is at risk Signs and symptoms...

2013 UIL Coaches Concussion Training Course

Outline—Part 1

Epidemiology/Definitions

Mechanism of Injury Brain physiology Who is at risk Signs and symptoms

of concussion Sideline evaluation

Definition of concussion

“A complex pathophysiological process affecting the brain caused by traumatic physical force or impact to the head or body which may include temporary or prolonged altered brain function resulting in physical, cognitive, or emotional symptoms, or altered sleep patterns and may involve loss of consciousness.”

What sparked changes in concussion management?

NFL Depression Alzheimer’s disease Problems with memory

and concentration Led to congressional

hearings on the issue Players lawsuit UIL implementation

of guidelines/laws

Natasha’s Law

Natasha Helmick TX soccer player Multiple

concussions Headaches,

memory loss, anxiety, and depression

Advocate of concussion education

Concussion Epidemiology 1.6-3.8 million/yr

(cdc) 80-90% “mild”

“Ding” “Bell rung” Many likely

unrecognized/under-reported

Mechanism

Direct or indirect blow to the head or body causing impulsive forces transmitted to the brain

Pathophysiology

Functional problem (“software”) Change in ion flux

in brain cells No structural

(“hardware”) damage No skull fracture,

intracranial bleed, brain lesion

No MRI or CT changes are observed

Pathophysiology

Brain Energy Demand Brain Blood Flow

As mismatch corrects, symptoms improve

Grading/Classification

Many different guidelines and classification systems in the past.

There has been nearly one new guideline every year for the past 20 years.

As of the most recent International Symposia on Concussion in Sport, concussion is no longer graded or classified.

Who is at risk?

Gender Females increased risk Different symptoms

reported▪ Females: drowsiness,

noise sensitivity▪ Males: amnesia,

confusion Learning disabilities

Prolonged recovery Repeat concussions

Risk increases with prior concussion

Sport specific risks

Signs and Symptoms

Which child has a concussion?

Symptoms

• Drowsy• Sleeping less or

more • Trouble falling

asleep

•Memory• Poor

concentration• “Slowed down”• “Foggy

• Irritability• Sadness• Nervousness

• Headache• Fatigue• Dizziness• Balance problems• Light/noise

sensitivity• Nausea

Physical Emotional

SleepCognitive

Everyday Functional Effects Home

Difficulty completing tasks at home Reduced activity Irritability with challenges

School Concentration Remembering directions Disorganized Completing assignments Fatigue Fall behind, fail tests, reduced grades

Evaluation

If concussion suspected, remove from play immediately Coach Trainer Physician Parent/legal guardian

If in doubt, do not allow return to play

Evaluation

Initial assessment ABCs C-spine precautions Neurologic

evaluation▪ Cranial nerves▪ Strength/sensation▪ Balance testing▪ SCAT card

Evaluation: SCAT2

Neurologic Evaluation

Cranial nerves Strength Sensation Balance Reflexes

Evaluation

Red Flags (Emergency Room) Confusion > 30 minutes Loss of consciousness on field Focal neurologic deficit Deteriorating level of consciousness Severe, persistent headache (“the worst

headache of my life”) Persistent nausea/vomiting Seizure

Evaluation

NEVER ALLOW RETURN TO PLAY THE

SAME DAY

Evaluation

Medical referral Following injury, the athlete MUST be

evaluated by a physician Does not have to be the Concussion

Oversight Team’s physician Timing: prior to beginning phase 1 of

RTP protocol

SCAT2

SCAT2 (cont)

SCAT2

Recovery

“The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and return to play.” - Zurich consensus guidelines

Recovery

Complete rest until asymptomatic x 24h Athletic Academic Daily activities

Requires education Coaches Teachers Parents Athlete

Recovery

Physical Rest= No sports No jogging No weightlifting

Recovery

Cognitive Rest= No prolonged concentration No prolonged homework No prolonged classes No prolonged days

How Long Does Recovery Take?

Many recover in 1-2 weeks Delayed recovery: Post-concussion

syndrome Persistent symptoms: HAs, dizziness,

fatigue, irritability, impaired cognition 10% to 20% of athletes with concussion May last weeks to months...unrelated to

severity of injury.

What could happen if an athlete returns too soon?

Second-Impact Syndrome Second brain injury which occurs before

symptoms associated with the first have fully cleared

Death usually follows rapidly (2-5 minutes) due to brainstem herniation

Disordered cerebral autoregulation of cerebral blood flow vascular engorgementincreased ICPBrainstem herniation

50% mortality ~100% morbidity rate

Second Impact Syndrome

E:60 Preston Plevretes: videoE:60 Second Impact - YouTube

2013 Concussion Training:Part 2

Part 2 Outline

RTP protocol Required RTP

documentation Educational

considerations Prevention

strategies Questions

Return to Play Outline

1. Evaluation by physician 2. Completion of Return to Play

Protocol 3. Written statement by physician

clearing athlete 4. Parent must consent (written) for

player to return to play

Return to Play Protocol

Determined by the COT for the applicable ISD

Step-wise return to activity No activity, complete rest until asymptomatic x 24h Light aerobic exercise (walking) Sport-specific training Non-contact training drills Full contact training Game play

If athlete becomes symptomatic at any level, drops back to previous level

RTP protocol

To begin the protocol Athlete must be completely

asymptomatic▪ No headache▪ Normal concentration/cognitive skills▪ Normal balance

If time to reach asymptomatic state is > 7 days revisit physician; possible referral to pediatric neurologist

RTP Protocol: Monitoring

Asymptomatic completion of each step of the protocol must be documented Athletic trainer Coach▪ Superintendent or his/her designee

supervises

Documentation for Return to Play

Physician note After completing the RTP progression,

the athlete must be evaluated/cleared by the treating physician

Treating physician can be the:▪ COT physician▪ PCP▪ Pediatric neurologist

Documentation for Return to Play

Parent/Guardian Consent Form The athlete’s parent/guardian must sign

the consent for return to play form, which indicates the parent/guardian:▪ Understands of the risks of returning to play▪ Consents to disclosure of medical information

pertaining to concussion▪ Understands the immunity provisions

Documentation for Return to Play

Signed RTP progression form Each step initialed by trainer,

supervising administrator, or nurse Parent signature

Documentation for Return to Play

Collect all forms WITH signatures (including parent) before student returns to play

Minimize risk secondary to lack of documentation

Educational Considerations

Athlete should stay home if: Able to concentrate < 20 minutes Headache/other symptoms with

attempted concentration Bedrest or light mental activity only

Return to school once able to concentrate 20-30 min without symptoms May require return for half days initially

Prevention Strategies

Equipment Headgear▪ Do not eliminate risk of concussion, but likely decrease

risk Mouthpiece▪ No decreased risk of concussion▪ Prevention of maxillofacial injuries

Teach Proper Technique Education!!

Athlete education---athlete must be honest about symptoms

Parent/Teacher/Coach education

Prevention Strategies

Education (cont) UIL required documentation of

concussion education▪ Athlete/Parent▪ Acknowledgment form must be signed by athlete

and parent stating that they have received and read written information that explains concussion prevention, symptoms, treatment, and oversight▪ Must be signed every year of athletic

participation

Coaches must complete concussion training every 2 years

Contact Information

Wade Krause Cell: 210-264-1776 Office: 830-393-0235

Dr. Sheldon Gross (Pediatric Neurologist) Office: 210-614-3737

UIL 512-471-5883

Billy Marshall 830-743-6839 bmarshall@fisd.us

Questions

True/False

Athletes who have had a concussion are at no higher risk of a second concussion?

False

True/False

Second impact syndrome is a deadly complication after concussion which can be avoided by allowing the athlete to completely recover before returning to play

True

Which of the following is not an indication to send an athlete to the ER after sustaining a concussion?

1. Unequal pupils2. Severe headache3. Seizure4. Increasing confusion5. None of the above

Answer: 5

True/False

Concussions can be detected on CT and MRI?

Answer: False

The 4 symptom categories of concussion are physical, cognitive, emotional, and _____________?

Answer: sleep

Who must serve on the Concussion Oversight Team (COT)?

Texas licensed physician One or more of the following:

Athletic trainer Nurse Neuropsychologist PA

Can administrators, coaches, or other school officials serve on the COT?

No

Are student athletes required to see the COT’s physician?

No Must be seen by a physician of the

parents/guardians choosing

Is the COT’s physician required to approve or certify the athlete’s return to play from concussion?

No The treating physician must provide

a written statement that in his/her judgment it is safe for the athlete to return to play

What forms must be obtained prior to allowing the athlete to return to play?

Physician clearance form Completed RTP protocol form

Each step must be initialed by supervising school official

Signed by parent Consent form signed by parent

Can a coach monitor a student athlete’s compliance with the RTP protocol?

Yes But…the superintendent or his/her

designee has supervisory responsibilities of the coach

How often will coaches be required to complete 2 hrs of concussion education?

Every 2 yrs

Will the non-physician licensed health care professionals (nurses, etc) on the COT be required to document completion of concussion continuing education?

Yes, every 2 yrs

Summary

Athlete safety #1 priority If in doubt, sit them out Follow the protocol…this is now LAW Make sure you have ALL

documentation before the athlete returns Get the required signatures from the

parents Questions?