CONCUSSION RECOGNITION AND MANAGEMENT

Toggenburg Ski Patrol

R Eugene Bailey, MD

January 22, 2012

OBJECTIVES

• Head Injury – review of treatment• What is a concussion?• Extent of the problem • Recognition and triage• Define concussion management team• Education / Promotion• Our Return to play protocol at ESM• Discuss protocol for Toggenburg

Feb 2, 2011 – Lindsey Vonn – concussion during practice.

15-4

Head Injuries

Suspect a Head or Spinal Injury With any unresponsive trauma patient When wounds or other injuries suggest large

forces involved Observe patient carefully during the initial

assessment

Injuries to the Head

May be open or closed Bleeding may be profuse Closed injuries may involve swelling/

depression at site of skull fracture Bleeding inside skull may occur with any

head injury

General Signs and Symptoms

Lump or deformity in head, neck, or back Changing levels of responsiveness Drowsiness Confusion Dizziness Unequal pupils

General Signs and Symptoms continued Headache Clear fluid from nose or ears Stiff neck Inability to move any body part Tingling, numbness, or lack of feeling in feet

or hands

Assessing an Unresponsive Patient If no life-threatening condition perform limited

physical examination for other injuries Do not move patient unless necessary Check for serious injuries Stabilize head and neck

Assessing an Unresponsive Patient

Ask those at scene: What happened Patient’s mental status before becoming

unresponsive

Assessing a Responsive Patient If nature of injuries suggests potential spinal

injury, carefully assess for spinal injury during physical examination

Ask patient not to move more than you ask during the examination

Assessing a Responsive Patient

Ask: Does your neck or back hurt? What happened? Where does it hurt?

Physical Examination

Perform standard examination When checking torso, look for impaired

breathing or loss of bladder/bowel control Compare strength from one side of body to

other Assess both feet and both hands at same

time

Physical Examination

Perform standard examination Don’t assume patient without symptoms has

no spinal injury. Consider forces involved When in doubt, keep head immobile while

waiting for additional EMS

15-15

Skill: Head and Spinal Injury Assessment

Check the victim’s head.

Check neck for deformity, swelling, and pain.

Check sensation in feet.

Ask victim to point toes.

Ask victim to push against your hands with feet.

Check sensation in hands.

Ask victim to make a fist and curl it in.

Ask victim to squeeze your hands.

15-24

Brain Injuries

Brain Injuries

Occur with blow to head with/without open wound

Brain injury likely with skull fracture Brain swelling/bleeding

Signs and Symptoms of a Brain Injury

Severe or persistent headache Altered mental status (confusion,

unresponsiveness) Lack of coordination, movement problems

Signs and Symptoms of a Brain Injury Continued Weakness, numbness, loss of sensation,

paralysis Nausea and vomiting Seizures Unequal pupils Problems with vision or speech Breathing problems or irregularities

Concussion

Brain injury involving temporary impairment Usually no head wound or signs and

symptoms of more serious head injury Victim may have been “knocked out” but

regained consciousness quickly

Signs and Symptoms of Concussion Temporary confusion Memory loss about event Brief loss of responsiveness Mild or moderate altered mental status Unusual behavior Headache

Medical Evaluation

Concussion patient may recover quickly Difficult to determine injury severity More serious signs and symptoms may occur

over time Patients with suspected brain injuries require

medical evaluation

Emergency Care for Head Injuries Perform standard patient care Use the jaw-thrust to open airway Follow local protocol re: oxygen Manually stabilize the head and neck Don’t let patient move

Emergency Care for Head Injuries continued Closely monitor mental status Control bleeding. No direct pressure on skull

fracture Monitor vital signs Expect vomiting Provide additional care for skull fracture

Skull Fracture

Check for possible skull fracture before applying direct pressure to scalp bleeding Direct pressure could push bone fragments into

brain Skull fracture is life threatening

Signs of a Skull Fracture

Deformed area Depressed or spongy area Blood or fluid from ears or nose Eyelids swollen shut or becoming discolored

(bruising)

Bruising under eyes (raccoon eyes) Bruising behind ears (Battle’s sign) Unequal pupils An object impaled in skull

Signs of a Skull Fracture

Emergency Care for Skull Fractures Care as for any head/spinal injury Don’t clean wound, press on it, or remove

impaled object Cover wound with sterile dressing

Emergency Care for Skull Fractures

• If bleeding, apply pressure only around edges of wound. Use a ring dressing

• Do not move victim unnecessarily

CONCUSSION MANAGEMENT

What is a Concussion?

A concussion is a mild traumatic brain injury (MTBI) that interferes with normal function of the brain

Evolving knowledge “dings” and “bell ringers”

are serious brain injuries Do not have to have loss of

conciousness Young athletes are at

increased risk for serious problems

The Problems in the Medical Field There is much variation in

the knowledge of health care providers managing concussed athletes Physicians (MD/DO) Physician assistants Nurse practitioners Chiropractors Athletic trainers School nurses

New and emerging research and technologies will lead to a continuing evolution of care

Problems for Athletes-Post-Concussion Syndrome 85-90% of concussed

young athletes will recover within 1 to 2 weeks

The remainder may have symptoms lasting from weeks to months interfering with school and daily life

Subtle deficits may persist a lifetime

Extent of the Problem Professional athletes get a

great deal of attention 1600 NFL players

Much more common in high school than any other level- due to large number of participants HS Sports Participants

Football- 1.14 million Boys Soccer- 384,000 Girls Soccer- 345,000 Boys Hoops- 545,000 Girls Hoops- 444,000

NFHS 2008-09

Extent of the Problem

19.3% of all FB injuries in 2009!!!

Likely at least 100,000 concussions in HS athletes yearly based on CDC estimates

Not Just a Football Problem

Injury rate per 100,000player games in highschool athletes

Football 47 Girls soccer 36 Boys soccer 22 Girls basketball 21 Wrestling 18 Boys basketball 7 Softball 7

Data from HS RIO JAT, 2007

What has happened to make this such a big deal? Increasing awareness

and incidence Number of high profile

athletes over the past 20 years Steve Young, Troy

Aikman, Eric Lindros, etc

Bigger and faster kids, increased opportunities

What has happened to make this such a big deal? High profile cases

Second Impact Syndrome Death or devastating

brain damage when having a second injury when not healed from the first

Long-term effects Possible long-term

effects- dementia, depression

NFL and long-term complications

Prevention

“Concussion prevention” has become the “holy grail” for sports equipment marketers

Soccer head gear Girl’s Lacrosse head

gear/helmets Pole vaulting helmet

New football helmets, soccer head pads, mouth guards- NO PROVEN PROTECTION FROM CONCUSSION!!

Multiple flaws in a study looking at “Riddell Revolution” helmet

Neurosurgery, 2006

Prevention

Concussion Diagnosis & Management 3rd statement following the 1st (Vienna - 2001)

and 2nd (Prague -2004) International Symposia

2010 – 2011 NFHS Rule Book Changes on Concussion Any athlete who exhibits signs, symptoms, or behaviors

consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion, or balance problems) shall be immediately removed from the contest and shall not return to play until cleared by an appropriate health care professional. (Please see NFHS Suggested Guidelines for Management of Concussion). Approved by NFHS Sports Medicine Advisory Committee –

October 2009 Approved by the NFHS Board of Directors – October 2009

Staying Ahead of the Issue

Need to take initiative Several meetings to

review our policy and procedure

Major campaign for awareness

Revised recognition and management

RTP protocol Establishment of the

concussion management team

CONCUSSION MANAGEMENT TEAM

1. IDENTIFY THE PROBLEM

2. DEFINE OUR CONCUSSION MANAGEMENT TEAM

3. DEVELOP PROTOCOLS

4. INVOLVE COMMUNITY

5. EDUCATE ATHLETES, COACHES Ski Patrollers, PARENTS,PHYSICIANS

Concussion Management Team (Family, School, Medical personnel)

Family: Parents/guardians, siblings, grandparents

Medical: Primary care doctor, neurologist, concussion specialist.

School Physical: School Physician, Athletic Trainers, School Nurse, Coaches.

School Academic: Teacher, Counselors, Administrator

Toggenburg: Ski Patrol / Admin

Community based Multi disciplinary Concussion Management Team

Family Team

Medical TeamToggenburg Ski Patrol

Concussion Management- The Basics Coach Education

Awareness and Recognition

When in doubt, sit ‘em out!!

Policies No return to activity on

the same day of a concussion

No return to activity if having symptoms of a concussion

What are we doing at ESM?

Educating athletes, coaches and parents Field-side concussion evaluation form Follow up ESM Concussion Evaluation form

for Physicians Return to play protocol

HEAD INJURY ASSESSMENT HEADACHE NAUSEA VOMITING BALANCE/ STABILITY ISSUES DIZZINESS FATIGUE TROUBLE FALLING ASLEEP SLEEPING MORE THAN USUAL SLEEPING LESS THAN USUAL DROWSINESS SENSITIVITY TO LIGHT SENSITIVITY TO NOISE IRRITABILITY SADNESS EMOTIONAL SENSITIVITY NUMBNESS/ TINGLING SENSATION IN EXTREMITIES FEELING “SLOW” FEELING “FOGGY” DIFFICULTY WITH CONCENTRATION DIFFICULTY WITH MEMORY BLURRED VISION DOUBLE VISION

Education / Promotion Who?

Parents Coaches Students Administrators Nurses Teachers Guidance Councilors Ski Patrollers

Education / Promotion How will this information be promoted?

Parent Meetings Posters Handouts Training classes for coaches In service presentations Access to online power point, and

references What can Toggenburg do?

STEP BY STEP SCENARIO Athlete sustains head injury Evaluated on-field by AT, coach, or opposing team’s AT(if available)

1. Remove from play2. Use Head Injury evaluation instrument3. Minimum 20 minutes out of action, check athlete every 5 minutes4. Athlete MAY NOT RETURN TO PLAY while ANY symptoms are present

Decision- is a concussion suspected? Physician Referral, Parents contacted Athlete or parents given concussion information, including ESM

concussion evaluation form Athlete seen by physician, in ER or by family physician Once athlete is symptom free and cleared by physician, Return To

Play protocol begins under the supervision of an Athletic Trainer

STEP BY STEP SCENARIO Athlete sustains head injury Evaluated on-field by AT, coach, or opposing team’s AT(if available)

1. Remove from play2. Use Head Injury evaluation instrument3. Minimum 20 minutes out of action, check athlete every 5 minutes4. Athlete MAY NOT RETURN TO PLAY while ANY symptoms are present

Decision- is a concussion suspected? Physician Referral, Parents contacted Athlete or parents given concussion information, including ESM

concussion evaluation form Athlete seen by physician, in ER or by family physician Once athlete is symptom free and cleared by physician, Return To

Play protocol begins under the supervision of an Athletic Trainer

ESM Stepwise Return to Play Protocol

This protocol correlates with the Zurich guidelines as well as the NYSPHAA

It allows a gradual increase in volume/intensity of exercise

It will take several days to complete

No full activity until all steps have been completed and remains symptom free

Each step will take a day to complete and must remain symptom free before moving to next step

ESM Return to Play ProtocolStep 1: Rest / No Physical Activity

Step 2: Light aerobic activity(Walking, swimming, stationary bike 10-15 min)

Step 3: Sport specific exercise(running drills, 20-30 min, no weight lifting)

Step 4: Non-contact training drills(More progressive training drills, may start progressive resistance

training)

Step 5: Full contact practice(Participate in normal practice/training activities)

Step 6: Return to play

ESM Return to Play Protocol

If a step is failed, the athlete will drop back to the previous step and try again after 24hrs of rest.

If the athlete continues to have symptoms after failing any 2 steps the athlete should be referred back to his/her physician.

Conclusions

Educate Everyone dealing with

young athletes must be aware of the signs, symptoms, and ramifications of concussions

Mandate or Legislate? Concussion management

policies must be in place at every level

If you don’t do it, someone will do it for you

What can Toggenburg do?

Discussion

Heat Index Procedures

Use the following link from NYSPHSAA for heat index procedures: http://www.nysphsaa.org/safety/pdf/

HeatIndexProcedure.pdf Go to accuweather.com put in the area

code for the location of your game If the Real Feel (heat index)

temperature is above 96 the contest will be suspended.

Lightning Policy

Hear it, see it, flee it. Find shelter for your team (school, bus,

etc.) 30 minute wait period after the last

sound or sight of lightning. The clock resets if seen or heard.

Use the following link from NYSPHSAA for Thunder/Lightning procedures: http://www.nysphsaa.org/safety/pdf/ThunderLight

ningPolicy.pdf

Referenceshttp://www.nysphaa.org

http://www.nfhs.org

http://accuweather.com

http://cdc.gov/concussion/

http://extras.mnginteractive.com/live/media/site36/2010/1102/20101102_071347_RMHC%20REAP%20Final%207-10.pdf

(Rocky Mountain Youth Sports Medicine Institute)

P.McCrory, W.Meewise, K. Johnston, J. Dvorak, M. Aubry, M. Molloy, &R. Cantu. (2009). Consensus statement on concussion in sport – The 3rd International Conference on concussion in sport, held in Zurich, November 2008. Journal of Clinical Neuroscience. 16. 755-763.

THANK YOUs!!!!!!

Dr. Desiato and our Board of Education Bill McEachron – Athletic Director Dan Rancier, MD – ESM School Physician Eugene Bailey, MD- ESM School Physician Mark Powell, MS, ATC, CSCS Paul Houck, MS, ATC Paul Manfredo, BS, ATC And all parents in attendance tonight!

Feel free to contact us or

go to the ESM Athletics website

with any questions