Concussions

1. Concussions by Katherine Rice Frey, BSRN, MAEd, LSN with contributions from Bea Benda, BSRN, MSN, Licensed School Nurse Jessica Findell, BSRN, Licensed School Nurse Karen Thill, BSRN, Licensed School Nurse Minneapolis Public Schools

2. Dedicated to Scott Sacco, Coaches Bob Bancroft and John Deehan Whitman-Hanson Regional High School, Whitman, Massachusetts Coach and Hero Bob Bancroft Coach and Hero John Deehan Scott Sacco Class of ‘80

3. Scott’s Story Scott Sacco, a 6’2” 225 pound defensive and offensive end was tackled during a football game. Hit in the shoulder, Scott’s head rotated so violently he sustained a concussion. For the next 2 weeks Scott’s coaches noted his complaints of headaches. Scott’s parents were unaware of the seriousness of this. Coaches Bancroft and Deehan took Scott to the Emergency Room where a CAT Scan was performed. The CT revealed a subdural hematoma, (brain bleed). Scott had emergency surgery to relieve the pressure on his brain. The doctors told Scott that his coaches saved his life. Coaches Bob Bancroft and John Deehan are heroes.

4. “Concussions can trigger a chemical chain reaction in brain neurons that leaves an athlete disoriented, unconscious or dead. They can also impair learning over a period of years.”

5. Outline I. Introduction and Goals II. Definition of Concussions, Signs and Symptoms III. Management of Concussions IV. Guidelines for Return to Play V. Recovery Considerations V. Prevention and Prevalence VI. Results of Studies and Case Studies VIII. Resources and Works Consulted

6. Introduction Since a concussion can be an immediate life-threatening condi- tion with potential long-term effects, a working knowledge of this injury is essential for physical education teachers, coaches, and anyone who works with athletes.

7. Goals • Understand concussions, recognize signs and symptoms • Understand management, be aware of possible life threatening/changing complications • Incorporate preventative and safety measures into your program • Implement an ACTION PLAN for a suspected concussion • Know when it is safe to return to play • Know which sport and positions are most susceptible

8. A concussion can happen anytime there is a blow to a person that causes the brain to move rapidly inside the skull. II. Concussions Defined

9. Concussion: Head trauma which causes an alteration in mental status which may or may not include LOC (loss of consciousness) Alters how the cells in the brain work Three grades of concussion, 1,2,and 3 Treatment varies based on the severity of the injury Can be fatal if the head is hit several successive times in a short time span

10. Three Categories of ConcussionsLOC= Loss of Consciousness Grade 1 transient confusion, no LOC, mental status abnormalities for < 15 minutes Grade 2 transient confusion, no LOC, mental status changes for > 15 minutes Grade 3 ANY LOC, brief or prolonged, seconds, minutes or longer

11. Recognizing a Concussion Watch for the following two things among your athletes: • A forceful blow to the head OR BODY that results in rapid movement of the head • Any change in an athlete’s behavior, thinking, or physical functioning

12. Signs reported by athlete: • Headache or “pressure” in head • Nausea or vomiting • Balance problems or dizziness • Double or blurry vision • Sensitivity to light • Sensitivity to noise • Feeling sluggish, hazy or foggy • Concentration or memory problems • Confusion • Does not “feel right”

13. Signs observed by others: • Appears dazed or stunned • Is confused about what to do • Forgets plays • Moves clumsily • Answers questions slowly • Loses consciousness (even briefly) • Shows behavior changes • Cannot recall events prior to injury • Cannot recall events after injury

14. Management of Concussions The AAP (American Academy of Pediatrics) recommends calling the physician for anything more than a light bump on the head. • A doctor or health care professional can determine if a concussion occurred. • A second head injury during the recovery phase of the initial injury can be catastrophic or fatal. Follow physician activity restrictions and recommendations CLOSELY.

15. Management (cont.) No one should return to play or vigorous activity while signs or symptoms of a concussion are present. If signs or symptoms last 15 minutes or longer or include loss of consciousness or amnesia, according to the Mayo Clinic physicians, it is not safe to return to play for at least one week.Mayo Clinic, 3/09.

16. An Action Plan for Suspected Concussion • Remove athlete from play, look for signs and symptoms of a concussion • Have athlete evaluated by physician • Report cause of injury and force of blow • Any loss of consciousness • Any memory loss • Any seizure activity after injury • Number of previous concussions (if any) • Inform parents of possible concussion, give concussion fact sheet (see end of PowerPoint) • Allow athlete to return to play with physician permission

17. Return to Play Guidelines The American College of Sports Medicine, (ACSM), The Colorado Medical Society and the American Academy of Neurology have achieved consensus on the following guidelines. These have been adopted by the NCAA (National Collegiate Athletic Association).

18. Return to Play LOC= Loss of Consciousness; PTA= Post Traumatic Amnesia Athletes should NOT return to play while symptoms of concussion are present. Grade 1: Symptoms < 15 minutes, (“Bellringer” or “Ding”), no LOC or PTA, then return to play after 15-20 minutes Grade 2: Symptoms > 15 minutes, or any PTA, then remove from play for 1 week Grade 3: Any LOC, remove from play for 1 week, see physician

19. Communication is CriticalRE: Recovery and Return to Play • Communication between the athlete, parents, teachers, coaches, school nurses, athletic trainer, and the athlete’s physician is critical for recovery from a concussion. • If teachers, coaches, or school nurses see or hear students struggling in school or complaining of symptoms after a concussion , let the parents, athletic trainer and coaches know! 

20. The Athlete Needs: • To rest completely from everything that strains the brain including studying, watching tv, reading • To be honest and not hide his/her symptoms  • To GRADUALLY return to play with light activity (such as biking) first before any contact and high intensity drills are allowed • To report if any symptoms return (they must stop activity and return to rest) 

21. However, There is a lack of agreement about how to manage second or third concussions in the same athlete. In addition, no guidelines are offered for the management of serial concussions of different grades. "When in doubt, sit them out."

22. Considerations/Complications during Recovery • Second Impact Syndrome (SIS) • Post Concussion Syndrome (PCS) • Epidural or Subdural Hematoma (brain bleed)

23. Second Impact Syndrome (SIS) If a 2nd concussion occurs before the brain has fully recovered from the first one, even if the first one is mild, it can be catastrophic or fatal. SIS can trigger vascular congestion, swelling and cause widespread, permanent damage.

24. Post Concussion Syndrome (PCS) A complex disorder in which a combination of symptoms such as headaches and dizziness last for weeks and sometimes months after the con- cussion. Learning can be impaired.

25. Post Concussion Symptoms • Fatigue and Headaches • Dizziness • Irritability • Anxiety • Insomnia • Loss of concentration and memory • Noise and light sensitivity • Memory, mood and attention deficits • Intellectual dullness • Personality changes

26. Subdural or EpiduralHematoma (brain bleed) Hematoma- collection of blood Dura- membrane covering the brain Sub- below Epi- on top of After a blow to the head or a violent shaking motion, a blood vessel may rupture on top of 0r beneath the dura. The blood (hematoma) compresses brain tissue, which is LIFE THREATENING. Treatment is often times surgery .

27. Prevention Follow the rules for safety and of the sport Practice good sportsmanship at all times Wear the right protective equipment (helmets, mouth and eye guards, padding, shin guards) Fit protective equipment properly, maintain equipment and wear consistently Learn the signs and symptoms of a concussion

28. Mouth Guards and Helmets A proper fitting helmet and mouth guard can minimize or prevent concussions. • Studies indicate that the triple layered, vacuum fitted mouth guards may lead to a decrease in concussions (Shock Doctor, Brain Pad, etc.). • Studies show a 10 % reduction in concussions with improved high tech helmets.

29. The Evolution of the Helmet

31. High Tech Mouth Guards Fabricated vacuum fitted mouth guards are the most effective mouth guards for preventing concussions (Shock Doctor, Brain Pad, Power Gel) etc.

32. Prevalence of Concussions In a study conducted comparing the 3 sports with the highest rate of concussions, (hockey, soccer and football), it was determined that football players had the highest incidence of concussions. The mechanism of injury is head-to-head contact. According to this study, the defensive backs had the high- est rate of concussions due to their smaller size combined with multiple high impact collisions.

33. What do Studies Show? • Concussions are underreported in high school • Athletes, adults and some coaches think that a concussion requires a loss of consciousness • Athletic trainers report 5 percent of high school players suffer a concussion per season • Surveys of players STRONGLY suggest that number is much higher • Anonymous questionnaires show 15% of football players had at least one concussion per season • When the word “concussion” is omitted and a description of symptoms provided, nearly 50 percent of players say they had one, with 35 percent reporting two or more concussions per season

34. Final thoughts: • It is critical that coaches, players and parents understand the medical issues involved in concussion. • Athletes are more likely to follow recommendations and seek medical attention if they know that premature return to play could result in death. • It is helpful when players understand that not every concussion results in automatic removal from athletic participation.

35. Case Studies • John is tripped outside at recess. He falls and lands on his head. In the health office, he complains of nausea and dizziness which does not abate after 1 hour. Physician confirmed diagnosis? Concussion. Treatment? No activity for 7 days (avoid SIS). • Will falls playing football at recess hitting his head. He comes to the health office for first aid. During the nurse’s assessment, she notes he’s unusually sleepy and mentally groggy. He went to bed at the normal hour the night before. Physician confirmed diagnosis? Concussion. No activity for 7 days. • Inside the athlete’s brain (NFL outstanding video, works when PowerPoint is in the slide show mode)

36. Free Fact Sheets, Coaches Toolkit and other Resources (Gillette Children’s Brain Injury Department) http://www.cdc.gov/ncipc/tbi/CGToolKit/CoachGuide. pdf http://www.cdc.gov/concussion/pdf/coaches_Engl.pdf http://www.cdc.gov/concussion/pdf/poster_Eng.pdf http://www.cdc.gov/concussion/pdf/parents_Eng.pdf http://www.cdc.gov/concussion/pdf/parents_Span.pdf

37. Works Consulted http://www.nytimes.com/2010/01/31/sports/31concussions.html Orr, M., and Schwartz, A. High School Football’s Hidden Glory, 2007 CDC- Concussions http://www.healthsystem.virginia.edu/internet/neurogram/neurogram1_4_concussion.cfm http://www.headinjury.com/sports.htm http://www.mayoclinic.com/health/post-concussion-syndrome/DS01020 http://beyondthesideline.com/Documents/Microsoft%20Word%20-%20ATR%20490%20Concussions%20Paper.pdf http://www.aafp.org/afp/990901ap/887.html http://www.aan.com/professionals/practice/guidelines/pda/Concussionsports.pdf http://www.nytimes.com/2007/09/15/sports/football/15concussions.html?pagewanted=1&_r=3 http://www.cnn.com/2009/HEALTH/01/26/athlete.brains/index.html#cnnSTCVideo McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy, M., & Cantu, R. (2009). Consensus Statement on Concussion inSport 3rd International Conference on Concussion in Sport . Clinical Journal of Sport Medicine, 19, 185-195.

38. Scott Sacco TodayPermission is granted by the author (Kathy Frey) and the people featured to share this PowerPoint with whomever might benefit.