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Concussion

In this Chapter

  • What is a Concussion?

  • What are the Signs and Symptoms of Concussion?

  • When to Seek Immediate Medical Attention

  • Complications of Concussion

    • Second Impact Syndrome

    • Chronic Traumatic Encephalopathy (CTE)

  • Management of the Student with a Concussion

  • Responsibilities of the Core Team

    • Health Care Provider

    • Parent /Guardian

    • Student with a Concussion

    • School Registered Nurse

    • School Health Room Aide

    • School Administrator

    • Educational Personnel

    • Training - PE Teachers, Before- or After- School Program Physical Activity Staff

  • Coaches Section

    • Education on Management of Concussion

    • Recognition and Management

    • NFHS Rules Book Language

    • Definition of Appropriate Health-Care Professional

    • Mechanics for Removal from Athletic Contest

    • Return to Play (RTP) Criteria: Suggested Concussion Management

    • Reporting of Head Injuries

  • Resources

  • References

A concussion is a type of brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head but can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth. The brain is not a fixed structure within the skull, and any sudden impact to the head or body will cause the brain to bounce or twist within the skull, which can cause damage and stretching of the brain cells.  Such damage causes neurochemical changes in the brain that triggers the symptoms often associated with concussion.  A concussion (also known as mild traumatic brain injury (MTBI) is a metabolic injury affecting brain chemistry and function. 

Most concussions do not involve gross structural injury to the brain which is why most CT and MRI scans of the brain following concussion are read as NORMAL. A person does not need to lose consciousness (black out) to suffer a concussion. In fact, less than 10% of athletes who have concussions lose consciousness.

     

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?

Children and teens are more likely to get a concussion and overall take longer to recover than adults. While most children and teens with a concussion recover quickly and fully, some will have concussion symptoms that last for days, weeks, or even months. (CDC)

Symptoms of a concussion usually fall into four categories. Symptoms may not develop immediately after the injury and may appear hours or even days later.

Thinking/Remembering:

  • Difficulty thinking clearly

  • Feeling slowed down

  • Difficulty concentrating

  • Difficulty remembering new information 

Physical:

  • Headache

  • Fuzzy or blurry vision

  • Nausea or vomiting (early on)

  • Dizziness

  • Sensitivity to noise or light

  • Balance problems

  • Feeling tired, having no energy

Emotional/Mood:

  • Irritability

  • Sadness

  • More emotional

  • Nervousness or anxiety

Sleep:

  • Sleeping more than usual

  • Sleepless than usual

  • Trouble falling asleep


WHEN TO SEEK IMMEDIATE MEDICAL ATTENTION

DANGER SIGNS (CDC) 

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. 

Contact your doctor or emergency department right away if you have any of the following danger signs after a bump, blow, or jolt to the head or body:

  • A headache that gets worse and does not go away

  • Weakness, numbness or decreased coordination

  • Repeated vomiting or nausea

  • Slurred speech

The people checking on you should take you to an emergency department right away if you:

  • Look very drowsy or cannot be awakened

  • Have one pupil (the black part in the middle of the eye) larger than the other

  • Have convulsions or seizures

  • Cannot recognize people or places

  • Are getting more and more confused, restless, or agitated

  • Have unusual behavior

  • Lose consciousness (a brief loss of consciousness should be taken seriously and the person should be carefully monitored)

DANGER SIGNS – YOUNG CHILDREN
Take your child to the emergency department right away if they received a bump, blow, or jolt to the head or body, and:

  • Have any of the danger signs  listed above

  • Will not stop crying and cannot be consoled

  • Will not nurse or eat

COMPLICATIONS OF CONCUSSION

SECOND IMPACT SYNDROME

Second Impact Syndrome (SIS) is a rare but dangerous condition that occurs when a person who has suffered a concussion sustains a second head injury while the brain is still vulnerable.  If a person receives a second blow to the head (even a relatively minor one) before the symptoms of the initial concussion have cleared, the consequences can be permanently disabling or even deadly. These devastating injuries seem to occur primarily in children and adolescents under 20 years of age, not adults.

To prevent Second Impact Syndrome, all symptoms of a concussion should be completely resolved and a student should be cleared by a physician/health care provider before returning to sports/physical activity.  

 

CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE)

Chronic Traumatic Encephalopathy (CTE) is a progressive neurodegenerative disease (tauopathy) caused by total brain trauma, and is not limited to athletes who have reported concussions. The incidence and prevalence is unknown. Chronic Traumatic Encephalopathy is diagnosed only after death by distinctive immunoreactive stains of the brain for Tau protein, and is not the same disease as Alzheimer’s disease. Typical signs and symptoms include a decline of recent memory and executive function, mood and behavioral disturbances (especially depression, impulsivity, aggressiveness, anger, irritability, suicidal behavior and eventual progression to dementia). Initial signs and symptoms do not typically manifest until decades after trauma received  (ages 40-50).

 

CDC Heads Up to Clinicians: Addressing Concussion in Sports among Kids and Teens

MANAGEMENT OF THE STUDENT WITH A CONCUSSION

The safety of the student with a concussion is the primary consideration in the delivery of all health-related services provided in the school. Upon identification of a student with a concussion, the Return to School Release Post-Concussion Diagnosis Form should be completed by a physician and returned to the school nurse. Concussion management is best done using a core team approach.  Members of the core team implement these guidelines and take responsibility for their role as outlined.

RESPONSIBILITIES OF THE CORE TEAM

Healthcare Provider

The Physician/Healthcare Provider should provide information and guidance to the School RN to use in developing a Health Care Plan.   The Physician/Health Care Provider should take into consideration the resources available in the school to assist with the student’s care.

To safeguard the student’s health, the Physician/Healthcare Provider should:

  • Provide the School RN with all medical documentation as requested, including written orders on the Return to School Release Post-Concussion Diagnosis Form.  

  • Be accessible by phone or FAX to review the written medical orders. 

  • Educate the student and the parent/guardian regarding concussion management.

Parent/Guardian

According to the School Health Services Act (s. 381.0056 F.S.), school health services supplement rather than replace parental responsibility. 

In order for children to receive the services they need in the safest possible manner while in school, it is important for parents and guardians to:

  • Inform the School RN as soon as possible when a student is newly diagnosed as having a concussion. 

  • Provide the school with accurate and current emergency contact information. 

  • Accept financial responsibility for 911 calls and transportation to the hospital, if needed. 

  • Provide the school with the Physician’s/Healthcare Provider’s written medical orders related to the student’s concussion management. 

  • Provide the School RN with any new written medical orders when there are changes in the medical management that must be implemented in school. 

  • Sign appropriate written permission for authorization of treatment and sharing of necessary health-related information.

  • Provide and transport to the school any medications, if needed.

  • Work with health care providers, staff, and the student to promote safe concussion management and when to return to play. For more information and to download a fact sheet for parents, follow- http://www.cdc.gov/headsup/pdfs/schools/tbi_factsheets_parents-508-a.pdf

Student with a Concussion

To remain active and healthy, the student should:

  • Learn about signs and symptoms of a concussion. 

  • Tell their coach and/or parent if they suspect a concussion.

  • Get a medical exam by a physician/health care provider to diagnose a concussion.

  • When diagnosed with a concussion rest and give the brain time to heal. 

  • Work with health care providers, staff, and their parents to promote safe concussion management and when to return to play.

Physical and cognitive rest is critical to the healing process and is essential within the first few days of the concussion and throughout the recovery period. A repeat concussion that occurs before the brain heals from the first, usually within a short amount of time (hours, days, weeks), can slow recovery or increase the chances for long-term health problems.  For more information and to download a fact sheet for student athletes, click on Middle School Athletes or High School Athletes.

School Registered Nurse 

The School RN has the knowledge and skills to provide concussion prevention education to parents, students and staff; identify suspected concussions; and help guide the student’s post-concussion graduated academic and activity re-entry process. (NASN Position Statement-Concussions)

The School RN may be the only full or part-time licensed health care professional in the school setting.  When the School RN is assigned to multiple schools, the nurse should recognize the need to be informed of any student who has had a concussion and to follow- up with the student. 

To ensure the safety of the student, the School RN should: 

  • Perform a nursing assessment on the student based on a school health room visit to obtain health and psycho-social information.

  • Develop a Health Care Plan in cooperation with the student, parent/guardian, health care provider, athletic trainer, and other school-based staff, as necessary. 

  • Regularly review and update the Health Care Plan whenever there is a change in medical management or the student’s response to care, as necessary.

  • Communicate pertinent health-related information to teachers and staff.

  • Act as a resource to the principal and other school-based personnel, providing or arranging for in-service concussion education appropriate to their level of involvement.

  • Establish and maintain a working relationship with the student’s parent/guardian and health care provider and act as a liaison between the student‘s health care provider and the school.  

  • Participate in Individualized Education Planning or Section 504 planning meetings and provide relevant health information as needed. 

  • Serve as the student’s advocate. Respect the student’s confidentiality and right to privacy.

School Health Room Aide

The Health Room Aide (HRA) performs under the administrative supervision of the School Principal and the guidance and direction of the School RN for health-related issues.  The HRA performs services within the school health services program according to the written policies and procedures in the School Health Services Manual.

The HRA should:

  • Be trained (by the School RN) about the signs and symptoms of concussion. 

  • Notify the School RN if a student is diagnosed with a concussion. 

  • Provide emergency treatment as necessary - Refer to MEDICAL CONDITIONS, ILLNESS & INJURY Chapter of School Health Manual (Head Injury).

  • Maintain accurate student health records.

  • Maintain student confidentiality.

School Administrator

The principal should set the example for the rest of the school-based staff to create a safe environment for the student with a concussion. 

The principal should:

  • Provide leadership for all school-based personnel to ensure that all health policies related to concussion management at school are current and implemented. 

  • Require that necessary staff complete concussion-specific training and meet the locally designed competency requirements. 

  • Facilitate problem solving among members of the school team and the student’s family. 

  • Provide physical resources on campus to safely execute all accommodations and activities.

  • Respect the student’s confidentiality and right to privacy.

Educational Personnel - Teachers, P.E. Teachers, Aides, Before-or After-School Physical Activity Staff

Management of concussion requires that there be an equal partnership between the members of the school team who manage physical activity reduction and those who manage cognitive activity reduction. Educational personnel should be aware of a student with a concussion in order to follow physician’s /healthcare provider’s orders for concussion management. While the brain is vulnerable, it is important for the student to avoid activities that make concussion symptoms (e.g. headache, fatigue) worse.

Concussion management may include the following:

  • No/limited cognitive activity such as; computer use, homework, testing, reading, video games, texting and TV as directed by the physician/healthcare provider.  

  • No physical activity until released by physician/healthcare provider with gradual return to play guidelines. 

Educational personnel should:

  • Recognize the signs and symptoms of concussion. 

  • Be aware of the student with a concussion and cooperate with the accommodations listed in the Health Care Plan and/or Section 504 Plan. 

  • Leave a clear message for any substitute regarding the special needs of the student. 

  • Respect the student‘s right to confidentiality and privacy.

Training - PE Teachers, Before- or After- School Physical Activity Staff

Safety of all students participating in activities in the school setting is the primary consideration, whether it is a student on the PE field or a school sponsored before- or after- school physical activity.

All PE teachers and before-or after-school physical activity staff are required to view a FREE online education course. “Heads Up: Concussion in Youth Sports.” This course can be viewed online at: http://www.cdc.gov/headsup/youthsports/training/index.html .  At the completion of the course a certificate will be issued. 

  • Log into the Professional Development system and submit a request for inservice credit.

  • Elementary School and Middle School PE Teachers/Staff – A copy of the certificate must be on file with the Principal or designee.

  • High School PE Teachers/Staff –  A copy of the certificate must be on file with the Athletic Director.

   

COACHES

Education on Management of Concussions 

All FHSAA member school head coaches and paid/supplemented coaches are required to view a FREE online education course. Sarasota County coaches are required to view the FREE online education course “Heads Up:  Concussion  in Youth Sports”. This course can be viewed online at  http://www.cdc.gov/headsup/youthsports/training/index.html .   At the completion of the course a certificate will be issued. A copy of the certificate must be on file in the Athletic Department for all paid/supplemented coaches. The FHSAA, at any time, can audit member schools to determine compliance. Fines will be assessed for non-compliance. All member school personnel, contest officials, student-athletes and parents are encouraged to educate themselves by viewing the FREE online education course as well.

 

Recognition and Management 

If an athlete exhibits any signs, symptoms, or behaviors that make you suspicious that he or she may have had a concussion, that athlete must be removed from all physical activity, including sports and recreation. Continuing to participate in physical activity after a concussion can lead to worsening concussion symptoms, increased risk for further injury, and even death. 

Symptoms reported by Athlete:

  • Headache

  • Nausea

  • Balance problems or dizziness

  • Double or fuzzy vision

  • Sensitivity to light or noise

  • Feeling sluggish

  • Feeling foggy or groggy

  • Concentration or memory problems

  • Confusion

Coaches are not expected to be able to “diagnose” a concussion. That is the role of an appropriate health-care professional. However, you must be aware of the signs, symptoms and behaviors of a possible concussion, and if you suspect that an athlete may have a concussion, then he or she must be immediately removed from all physical activity.

Signs Observed by Parents/Others:

  • Appears dazed or stunned

  • Is confused about what to do

  • Forgets plays

  • Is unsure of game, score, or opponent

  • Moves clumsily

  • Answers questions slowly

  • Loses consciousness

  • Shows behavior or personality changes

  • Can’t recall events prior to hit

  • Can’t recall events after hit

WHEN IN DOUBT, SIT THEM OUT!
When you suspect that a player has a concussion, follow the “Heads Up” 4-step Action Plan:

  • Step 1 - Remove the athlete from play.  

  • Step 2 - Ensure that the athlete is evaluated by an appropriate health-care professional. 

  • Step 3 - Inform the athlete’s parents or guardians about the possible concussion and give them information on concussion. 

  • Step 4 - Keep the athlete out of play the day of the injury and until an appropriate health-care professional says he or she is symptom-free and gives the okay to return to activity.

The signs, symptoms, and behaviors of a concussion are not always apparent immediately after a bump, blow, or jolt to the head or body and may develop over a few hours or days. An athlete should be observed following a suspected concussion and should never be left alone for at least 2 hours following the injury. If symptoms do progress/worsen, the player should be taken to the Emergency Department immediately.

DANGER SIGNS THAT REQUIRE EMERGENCY TRANSPORT TO THE HOSPITAL:

  • One pupil (the black part in the middle of the eye) is larger than the other

  • Drowsiness or cannot be awakened

  • A headache that gets worse and does not go away

  • Weakness, numbness or decreased coordination

  • Repeated vomiting or nausea

  • Slurred speech

  • Seizures or convulsions

  • Difficulty recognizing people or places

  • Increasing confusion, restlessness or agitation

  • Unusual behavior

  • Loss of consciousness (even a brief loss of consciousness should be taken seriously)  

Current medical advice is that it is not dangerous to allow an athlete to sleep after a head injury, once they have been medically evaluated. Parents do not need to awaken an athlete every 2 hours who falls asleep after a head injury. The best treatment for a concussion is sleep and rest. 

Athletes must know that they should never try to “tough out” a suspected concussion. Teammates, parents and coaches should never encourage an athlete to “play through” the symptoms of a concussion. In addition, there should never be an attribution of bravery to athletes who do play despite having concussion signs or symptoms. The risks of such behavior must be emphasized to all members of the team, as well as coaches and parents.

If an athlete returns to activity before being fully healed from an initial concussion, the athlete is at risk for a repeat concussion. A repeat concussion that occurs before the brain has a chance to recover from the first can slow recovery or increase the chance for long-term problems. In rare cases, a repeat concussion can result in severe swelling and bleeding in the brain that can be fatal.

It is important for Coaches to work with health care providers, staff, parents and the student to promote safe concussion management and when to return to play.  For more information and to download a fact sheet for coaches, follow -http://www.cdc.gov/headsup/pdfs/custom/headsupconcussion_fact_sheet_coaches.pdf 

NFHS Rules Book Language

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 in the Appendix in the back of each NFHS Rules Book).

Definition of Appropriate Health-Care Professional

“An interscholastic student-athlete who has been removed from play may not return to play until the student-athlete is evaluated by a licensed health-care professional familiar in the evaluation and management of concussion and receives written clearance to return to play from that health-care professional.” 

In Florida, the FHSAA Sports Medicine Advisory committee for concussion management defines an appropriate health-care professional (AHCP) as either a licensed physician (MD, as per Chapter 458, Florida Statutes) or a licensed osteopathic physician (DO, as per Chapter 459, Florida Statutes).

Mechanics for Removal from Athletic Contest

The NFHS concussion rule calls for the immediate removal of the participant from the contest.  The revised language reflects an increasing focus on safety, given that the vast majority of concussions do not involve a loss of consciousness.  However, the revised language does not create a duty that officials are expected to perform a medical diagnosis.  The change in this rule simply calls for officials to be cognizant of athletes who display signs, symptoms or behaviors of a concussion (see NFHS Suggested Guidelines for Management of Concussion) and remove them from play.  At that point, the official’s job is done.  It is important to note that the responsibility of the official is limited to activities that occur on the field, court, or mat. 

Once the participant has been removed from a contest due to a suspected concussion, the coach and appropriate health-care professional(s) assumes full responsibility for that athlete’s further evaluation and safety.  If available, a certified athletic trainer (ATC) under the direct supervision of a MD/DO can assist with the sideline evaluation of a student-athlete when a student-athlete is sent out of a competition or practice, but cannot provide written clearance to return to play (refer to above).  

Return To Play (RTP) Criteria:  Suggested Concussion Management

  • No athlete should return to play (RTP) or practice on the same day of a concussion.  "When in doubt, sit them out!"

  • Any athlete suspected of having a concussion must be evaluated by an appropriate health-care professional (as defined above) as soon as possible and practical.

  • Any athlete who has sustained a concussion must be medically cleared by an appropriate health-care professional (as defined above) prior to resuming participation in any practice or competition.

  • After medical clearance, return to play should follow a step-wise protocol with provisions for delayed return to participation based upon the return of any signs or symptoms. 

This plan was recommended at the Sports Medicine Advisory Committee Meeting on September 1, 2010 and revised at the Sports Medicine Advisory Committee Meeting on March 14, 2012.  The FHSAA Board of Directors adopted the policy in June, 2011.  Gary Pigott, FHSAA Senior Director of Athletics, is a member of the Florida Concussion Task Force.

Reporting of Head Injuries

If the Certified Athletic Trainer is not on site to evaluate the injured athlete it is the responsibility of the coach to determine what steps need to be taken, referring to the signs and symptoms and behaviors of a possible concussion.

All suspected head injuries will be reported to the Certified Athletic Trainer as soon as possible. The Certified Athletic Trainer will then alert the sports medicine team (Physician, Athletic Director, School Nurse, Administration) about the injury and the steps that need to be taken for the management of the injury.

RESOURCES

Take the free online concussion training :

 

REFERENCES

  • Centers for Disease Control and Prevention, Concussion and Mild TBI,   http://www.cdc.gov/headsup/index.ht

  • McAvoy K. REAP (Reduce, Educate, Accommodate, Pace): The Benefits of Good Concussion Management. 2016

  • McCrory, P.M et al. “Consensus Statement on Concussion in Sport- the 5th International Conference on Concussion in Sport Held in Berlin, October 2016. BR.J. Sports Med 2017;0:1-10. 1136/bjsports-2017-097699.

  • National Association of School Nurses - NASN Position Statement. Concussions-The Role of the School Nurse. June 2016