epidemiology/definitions mechanism of injury brain physiology who is at risk signs and symptoms...
TRANSCRIPT
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 [email protected]
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?