Transcript BCPS Concussion Management Program

BCPS Concussion Management
Program
August 2011
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
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
Latest Accepted Recommendations

Vienna, Prague, Zurich:
1.
2.
3.
4.
5.
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
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
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
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
Symptoms
 Four main categories
 Physical
 Cognitive
 Emotional
 Sleep
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
Cognitive Symptoms
 Feel mentally foggy
 Feel slowed down
 Difficulty concentrating
 Memory problems
 Confusion, particularly with recent events
 Answers slowly
 Repeats questions
Emotional Symptoms
 Irritability
 Sadness
 More emotional
 Nervousness
Sleep Symptoms
 Drowsiness
 Sleeping more or less than usual
 Difficulty falling asleep
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
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
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 autoregulation leading to cerebral edema.
 Intractable seizures, permanent
neurologic deficits, or death
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
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
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
Exclusion
 Coach MUST exclude
 New law requires
 Failure to exclude sets coach up for personal liability
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
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
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
Communication
 Procedures apply for all concussions in athletes
Graduated Return to Play
 Established protocols by MPSSAA
 Specific for football and soccer
 General protocol for other sports
 Progression over 5 + days
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