Transcript 2012 Concussion Training Course

Epidemiology/Definitions
Mechanism of Injury
Brain physiology
Who is at risk
Signs and symptoms of
concussion
 Sideline evaluation
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“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.”
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NFL
 Depression
 Alzheimer’s disease
 Problems with memory
and concentration
Led to congressional
hearings on the issue
 Players lawsuit
 UIL implementation of
guidelines/laws
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Natasha Helmick
TX soccer player
Multiple concussions
 Headaches, memory
loss, anxiety, and
depression
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Advocate of
concussion education
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1.6-3.8 million/yr (cdc)
80-90% “mild”
 “Ding”
 “Bell rung”
 Many likely
unrecognized/underreported
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Direct or indirect blow
to the head or body
causing impulsive
forces transmitted to
the brain
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Functional problem
(“software”)
 Change in ion flux in
brain cells
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No structural
(“hardware”) damage
 No skull fracture,
intracranial bleed, brain
lesion
 No MRI or CT changes
are observed
Brain Energy Demand
Brain Blood Flow
As mismatch corrects, symptoms improve
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Many different guidelines
and classification systems
in the past.
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There has been nearly one
new guideline every year
for the past 20 years.
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As of the most recent
International Symposia on
Concussion in Sport,
concussion is no longer
graded or classified.
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Gender
 Females increased risk
 Different symptoms
reported
▪ Females: drowsiness, noise
sensitivity
▪ Males: amnesia, confusion
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Learning disabilities
 Prolonged recovery
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Repeat concussions
 Risk increases with prior
concussion
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Sport specific risks
Which child has a concussion?
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Headache
Fatigue
Dizziness
Balance problems
Light/noise
sensitivity
• Nausea
• Irritability
• Sadness
• Nervousness
Physical
Emotional
Sleep
•Memory
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• Poor concentration
• “Slowed down”
• “Foggy
• Sleeping less or more
• Trouble falling asleep
Drowsy
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
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If concussion suspected, remove from play
immediately
 Coach
 Trainer
 Physician
 Parent/legal guardian
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If in doubt, do not allow return to play
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Initial assessment
 ABCs
 C-spine precautions
 Neurologic evaluation
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Cranial nerves
Strength/sensation
Balance testing
SCAT card
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Cranial nerves
Strength
Sensation
Balance
Reflexes
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Red Flags (Emergency Room)
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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
NEVER ALLOW RETURN
TO PLAY THE SAME DAY
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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
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“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
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Complete rest until asymptomatic x 24h
 Athletic
 Academic
 Daily activities
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Requires education
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Coaches
Teachers
Parents
Athlete
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Physical Rest=
 No sports
 No jogging
 No weightlifting
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Cognitive Rest=
 No prolonged concentration
 No prolonged homework
 No prolonged classes
 No prolonged days
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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.
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 engorgementincreased ICPBrainstem
herniation
 50% mortality
 ~100% morbidity rate
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E:60 Preston Plevretes: videoE:60 Second Impact -YouTube
RTP protocol
Required RTP
documentation
 Educational
considerations
 Prevention strategies
 Questions
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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
Determined by the COT for the applicable ISD
 Step-wise return to activity
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 No activity, complete rest until asymptomatic x 24h
 Light aerobic exercise (walking)
 Sport-specific training
 Non-contact training drills
 Full contact training
 Game play
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If athlete becomes symptomatic at any level, drops
back to previous level
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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
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Asymptomatic completion of each step of the
protocol must be documented
 Athletic trainer
 Coach
▪ Superintendent or his/her designee supervises
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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
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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
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Signed RTP progression form
 Each step initialed by trainer, supervising
administrator, or nurse
 Parent signature
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Collect all forms WITH signatures (including
parent) before student returns to play
Minimize risk secondary to lack of
documentation
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Athlete should stay home if:
 Able to concentrate < 20 minutes
 Headache/other symptoms with attempted
concentration
 Bedrest or light mental activity only
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Return to school once able to concentrate 2030 min without symptoms
 May require return for half days initially
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Equipment
 Headgear
▪ Do not eliminate risk of concussion, but likely decrease risk
 Mouthpiece
▪ No decreased risk of concussion
▪ Prevention of maxillofacial injuries
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Teach Proper Technique
Education!!
 Athlete education---athlete must be honest about
symptoms
 Parent/Teacher/Coach education
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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
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Wade Krause
 Cell: 210-264-1776
 Office: 830-393-0235
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Dr. Sheldon Gross (Pediatric Neurologist)
 Office: 210-614-3737
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UIL
 512-471-5883
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Billy Marshall
 830-743-6839
 [email protected]
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Athletes who have had a concussion are at no
higher risk of a second concussion?
False
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Second impact syndrome is a deadly
complication after concussion which can be
avoided by allowing the athlete to completely
recover before returning to play
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True
1.
2.
3.
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5.
Unequal pupils
Severe headache
Seizure
Increasing confusion
None of the above
Answer: 5
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Concussions can be detected on CT and MRI?
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Answer: False
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Answer: sleep
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Texas licensed physician
One or more of the following:
 Athletic trainer
 Nurse
 Neuropsychologist
 PA
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No
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No
Must be seen by a physician of the
parents/guardians choosing
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No
The treating physician must provide a written
statement that in his/her judgment it is safe
for the athlete to return to play
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Physician clearance form
Completed RTP protocol form
 Each step must be initialed by supervising school
official
 Signed by parent
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Consent form signed by parent
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Yes
But…the superintendent or his/her designee
has supervisory responsibilities of the coach
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Every 2 yrs
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Yes, every 2 yrs
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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
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Questions?