Case14 yo high school female varsity soccer
goalie dives to save a shot. During dive, strikes top of her head against
goal postNo loss of consciousness but she
experienced brief disorientation upon standing.
During halftime, experienced headaches and blurry vision
Concussion Science
Significant advances since 2001International symposia (2001, 2004, 2008)Eliminated grading scales (e.g., Cantu,
Colorado Medical Society, AAN)
TerminologyConcussion versus mild TBI
Latest Accepted Recommendations Vienna, Prague, Zurich:
1. Abandonment of graded scale approach, recommend individualized management of injury and determination of severity after sx have resolved
2. Any athlete exhibiting any sx should be removed from competition and not allowed to return that day.
3. Objective assessment via sideline assessment tools, balance testing and neurocognitive testing significantly increasing understanding of proper recovery
4. Role of physical and cognitive exertion is important to recovery and Stepwise RTP should begin only when asymptomatic
5. RTP is always a clinical decision
Pathophysiology
ConcussionNo fracture or bleeding in the brainDamage comes from chemical changes in
the brain cells (neurons) – considered an “energy crisis” at the cell level
ConcussionsBrain Injury caused by shaking of the brain
inside of the cranial vault.Can be caused by direct blow, sudden
change in directionDoes not need to include loss of
consciousness
Clinical Management 2011
Decisions based on symptomsGoal is for student to be and remain
symptom-freeRequires a gradual and monitored return to
playRequires close collaboration between
classroom, home and field
Physical Symptoms
Headache – most commonly reportedLoss 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 SymptomsFeel mentally foggyFeel slowed downDifficulty concentratingMemory problemsConfusion, particularly with recent eventsAnswers slowlyRepeats questions
Post-Concussion ManagementGoal is to prevent against cumulative
effects of injuryCumulative neurocognitive deficitsCumulative behavioral deficitsLess biomechanical force causes extension of
injuryPrevent Post-Concussive SyndromeDetermination of Asymptomatic status
is essential to reducing repetitive and chronic morbidity of injury
Post Concussive SyndromePresence 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 auto-regulation leading to cerebral edema.
Intractable seizures, permanent neurologic deficits, or death
BCPS Protocol for Student AthletesCoach trainingParent & Athlete trainingExclusion of all athletes with possible
concussionsCommunication between coaches and
school nurseCommunication with health care providersGraduated return to playThroughout – close monitoring
Coach TrainingStandardized training to be provided at
coaches meetingsReviews signs and symptoms of head injuryStresses requirement to exclude athletes’
with probable head injury from play until evaluated
Overview of return to play protoocol
Athlete and Parent TrainingAthletic Directors to receive standardized
training via emailProvide at “meet the coaches” nightCoaches must provide power point training
to student athletesTraining of parents and athletes is
mandatory
CommunicationSchool nurse alerted that day or next
morningSchool nurse interviews athlete
Checks for symptomsEducates about need for physical & cognitive
restSchool nurse communicates with athlete’s
familyMakes sure family has paperworkMakes sure family understands need for
medical clearance
CommunicationSchool nurse alerts teachersSchool nurse excuses student from PE
(need MD note after 1 week)Teachers
Make minor accommodationsRefer student to nurse if symptomatic
School nursePermits student to restSends student homeCommunicates with parents and health care
provider re: observations
CommunicationNurse alerts AD when medical clearance
receivedCoach notifies AD if medical clearance
received (AD notifies nurse)Athlete begins graduated return to playStudent monitored for 1-2 weeks for school
symptoms – if present, coach/parent/health care provider alerted
Graduated Return to PlayEstablished protocols by MPSSAASpecific for football and soccerGeneral protocol for other sportsProgression over 5 + days