Children s Hospital of the King s Daughters. Concussion Management Recommendations for Outreach Programs

Transcription

1 Children s Hospital of the King s Daughters Concussion Management Recommendations for Outreach Programs

2 CHKD is a leading provider of children s healthcare services. In the endeavor to deliver excellence in quality of care and service, these guidelines were established. CHKD recognizes that a concussion is a serious injury to the brain resulting from a force or jolt applied directly or indirectly to the head producing a set of signs and symptoms reflecting the brain s dysfunction. These recommendations are to aid in ensuring that athletes who sustain a concussion are properly identified and treated, and referred appropriately. These concussion management recommendations are to be utilized for all locations and events where CHKD provides athletic training services, except in school districts that have their own policy that meets the current standard of care. If an athlete exhibits or reports any sign or symptom of a concussion, he/she will be immediately removed from play and will not return the same day. The athlete will be evaluated by the Certified Athletic Trainer (ATC) on site. In the case of a minor, the parent/legal guardian or emergency contact will be notified on the day of the injury. The parent/legal guardian or the adult athlete will be responsible for obtaining further medical evaluation by a Licensed Health Care Provider (LHCP) knowledgeable in the care of sports concussions based on the athletic trainer s evaluation. In the Commonwealth of Virginia, an appropriate Licensed Health Care Provider means a physician, a physician assistant, osteopath or athletic trainer licensed by the Virginia Board of Medicine; a neuropsychologist licensed by the Virginia Board of Psychology; or a nurse practitioner licensed by the Virginia State Board of Nursing. Clearance to return to play is a medical decision. Written clearance to return to play provided by a Licensed Health Care Provider who has evaluated the athlete is recommended. The Licensed Health Care Provider cannot be the athlete s parent/legal guardian or other family member. This clearance must include a gradual return to play progression. The athlete will not be allowed to participate in a practice or game while experiencing any lingering or persisting symptoms of a concussion, no matter how slight. The athlete must be completely symptom free at rest and during physical and mental exertion. CHKD Concussion Clinical Management: 1. The athlete is suspected to have sustained a concussion by the coach, official, ATC, or facility/event personnel and removed from play. 2. The athlete is evaluated by the ATC on site using the SCAT 2 (SCAT 3 OR Child SCAT). 3. When referred by the Certified Athletic Trainer the athlete must be evaluated by a License Health Care Provider knowledgeable in the care of sports concussions. 4. Written clearance which includes a gradual return to play progression is recommended. 5. The athlete is recommended to turn written clearance into the facility/organization or medical personnel prior to participation in activity. Procedures for the Certified Athletic Trainer: CHKD Certified Athletic Trainers will follow these guidelines when assessing an athlete suspected of sustaining a concussion. Date 12/2015 CHKD Concussion Management Recommendations for Outreach Programs Page 1

3 1. The ATC will evaluate the athlete for a concussion using the SCAT 2 (SCAT 3 OR Child SCAT). The ATC will determine if immediate referral to the hospital is medically appropriate based on the information below in the Referral Procedures. 2. The Certified Athletic Trainer will notify the minor athlete s parent/legal guardian and give written and verbal home and follow-up care instructions. Written instructions will be given via the Concussion Information (Form #1). a. In the event that a minor athlete s parent/legal guardian cannot be reached, and the athlete is able to be sent home (rather than directly to a primary care provider or emergency department), the Certified Athletic Trainer must ensure that the athlete will be with an individual who has accepted responsibility and who is capable of monitoring the athlete and understands the home care instructions, before allowing the athlete to go home. The athlete cannot transport his/ herself. b. It is recommended that adult athletes do not transport his/herself. A responsible party should transport and monitor the athlete. c. If there is any question about the status of the athlete, or if the athlete cannot be monitored appropriately, the athlete must be referred to the emergency department for evaluation. The athlete cannot transport his/ herself. 3. The Certified Athletic Trainer will refer the athlete to their Primary Care Physician or a sports concussion specialist for medical clearance. This clearance should include a gradual return to play progression as outlined below. It is recommended that written clearance by use of the Medical Clearance (Form #2), and Gradual Return to Play Progression (Form #3), be obtained and given to the facility/ organization or medical personnel before the athlete returns to participation in physical activity. 4. Addendums for the Virginia Beach Field House. a. In addition to the procedures above, the Certified Athletic Trainer will fill out the Field House Accident Report and hand it in to the front desk, and complete the appropriate medical records. Procedures for Facility and Event Personnel: Facility and event personnel will use the Recognize, Remove, Refer procedure. 1. Recognize the signs and symptoms of a concussion in an athlete. 2. Any athlete who exhibits signs or symptoms of a concussion will be removed from play immediately. 3. The Facility or event personnel will refer the athlete to the Certified Athletic Trainer for assessment. 4. In the event that the Certified Athletic Trainer is not available: The facility or event personnel will contact the minor athlete s parent or guardian or the adult athlete s emergency contact. If they cannot be contacted the athlete will be sent to the emergency department via EMS. Referral Procedures: CHKD ATCs will use the following referral procedures with athletes suspected of having a concussion or brain injury: Date 12/2015 CHKD Concussion Management Recommendations for Outreach Programs Page 2

4 1. Immediate Transportation by Emergency Vehicle. Any athlete who has symptoms of a concussion, and who is not stable (i.e., condition is changing or deteriorating), is to be immediately transported to the nearest emergency department via emergency vehicle. Also any athlete who exhibits any of the following symptoms should be transported immediately: a. deterioration of neurological function; b. decreasing level of consciousness; c. decrease or irregularity in respirations; d. decrease or irregularity in pulse; e. unequal, dilated, or unreactive pupils; f. any signs or symptoms of associated injuries, spine or skull fracture, or bleeding; g. mental status changes: lethargy, confusion or agitation or difficulty maintaining arousal; h. seizure activity; and/or i. cranial nerve deficits. 2. Transported to Emergency Department privately. Any athlete, who is symptomatic but stable, may be transported by his/her parent/legal guardian or emergency contact. The athlete cannot transport his/herself. The transporting party should be advised to contact the athlete s primary care physician, or seek care at the nearest emergency department, on the day of the injury. THE OPTION OF EMERGENCY TRANSPORTATION SHOULD ALWAYS BE GIVEN. 3. Referral to Primary Care Physician or Sports Concussion Specialist. If the Certified Athletic Trainer has determined that the athlete does not need to see a physician on the day of the incident, then the athlete will be referred to their Primary Care Physician or a Sports Concussion Specialist. a. The Certified Athletic Trainer will give verbal home and follow-up care instructions as well as written instructions using the document of the Concussion Information (Form#1) to the minor athlete s parent/guardian, the adult athlete or the adult athlete s emergency contact. b. The Certified Athletic Trainer will provide the minor athlete s parent/guardian, the adult athlete or the adult athlete s emergency contact with the Medical Clearance (Form #2), and Gradual Return to Play Progression (Form #3). These forms are to be completed by a License Health Care Provider. c. The Certified Athletic Trainer will verbalize that the medical clearance must include a gradual return to play progression and be returned in written form before the athlete returns to participate in activity. 4. If the minor athlete or adult athlete is a student and plays a sport at their school, the Certified Athletic Trainer will recommend that the athlete sees their school Certified Athletic Trainer and/or school nurse. Return to Play Criteria 1. It is recommended that any athlete who sustains a concussion obtain a written clearance that includes a gradual return to play progression before they participate in activity. Date 12/2015 CHKD Concussion Management Recommendations for Outreach Programs Page 3

5 2. Gradual return to play progression: a. The gradual return to play progression cannot start until the athlete has been completely symptom free for a minimum of 24 hours. b. The athlete must be going to school or work for full days and complete their work and activities of daily living without any symptoms (or back to their previous academic baseline) prior to starting the progression. c. The gradual return to play progression is recommended to follow the stages as outlined in the table below. d. At least 24 hours between each progression stage is recommended. e. If the athlete experiences any symptoms, at any point during the rehabilitation stages, the progression will stop immediately and the cycle will resume at the previous asymptomatic rehabilitation stage after a minimum of 24 hours of rest. If symptoms continue to occur, the athlete will be referred back to the physician for a follow up evaluation. Rehabilitation Stage Function Exercise Objective 1. No Activity Complete physical and cognitive rest Recovery 2. Light Exercise Walking, swimming, stationary cycling Increased heart rate keeping intensity below <70%maximum heart rate; no resistance exercises 3. Moderate, Sportspecific Running or sport specific drills, NO head Add movement Exercise impact 4. Noncontact Training Drills More complex drills, light resistance exercises Exercise, Coordination, Cognitive load 5. Full-contact Practice Normal training Restore confidence, Assess functional skill by coaches 6. Return to Play Normal game play Written Medical Clearance: 1. It is recommended that the minor athlete s parent or guardian or the adult athlete submits their written medical clearance and gradual return to play progression forms to the facility/organization or medical personnel. It is the facility s/organization s responsibility to ensure that medical clearance and gradual return to play progression forms are properly submitted from each athlete who sustained a concussion. 2. If the minor athlete s parent or guardian or the adult athlete asks for assistance with the gradual return to play progression, if availability allows the Certified Athletic Trainer will assist with the progression. If the Certified Athletic Trainer does not have the availability, they will refer the athlete to physical therapy. The Certified Athletic Trainer will give the Medical Clearance (Form #2) and Gradual Return to Play Progression (Form#3) to the minor athlete s parent or guardian or the adult athlete. Date 12/2015 CHKD Concussion Management Recommendations for Outreach Programs Page 4

6 3. If the minor athlete s parent or guardian or the adult athlete asks for use of the ImPACT test, the Certified Athletic Trainer will refer the athlete to a sports concussion specialist. Date 12/2015 CHKD Concussion Management Recommendations for Outreach Programs Page 5

7 Appendix A Useful websites regarding concussions: CHKD Sports Concussion program CDC Concussion in Sports American Academy of Pediatrics (AAP) Sport-Related Concussion in Children and Adolescents Virginia High School League (VHSL) National Federation of State High School Associations (NFHS) Free online course NFHS Parent s Guide to Concussion in Sports Appendix B References 1. Brenner, J. (2011). Medical Clearance for Gradual Return to Sports Participation Following Concussion form 2. Brenner, J, Callis, M, Martin, W, and Cleavenger, J (2012). Chesapeake Public Schools Sports Concussion Management Plan 3. Children s Hospital of the King s Daughters (2011) Sports Medicine. Head Injury Assessment Form 4. Como-Lesko, N, Rhodes, D, Desk, W, and the Concussion Management Team. Virginia Beach City Public Schools Protocol and Procedures for Management of Sports-Related Concussion 5. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, Clinical Journal of Sports Medicine Guskiewicz, K, Bruce S, Cantu, R, Ferrara, M, Kelly, J, McCrea, M, Putukian, M, & Valovich McLeod, T (2004). National Athletic Trainers Association Position Statement: Management of Sport- Related Concussion.Journal of Athletic Training; 39(3); Halstead, M. Walters, K, and the American Academy of Pediatrics Council on Sports Medicine and Fitness (2010). Sport-Related Concussion in Children and Adolescents, Pediatrics; 126; Date 12/2015 CHKD Concussion Management Recommendations for Outreach Programs Page 6

8 Children s Hospital of the King s Daughters Concussion Information Form 1 While participating in athletics on (date) (name) sustained a head injury that appears to be a concussion or brain injury. This fact sheet should answer your questions about concussions and how to treat them. Athlete safety is our main priority. An athlete should not return to activity until a licensed healthcare provider has determined that it is safe to do so with written clearance. It is recommended that the athlete complete a gradual return to play progression prior to competing. The athlete should go to his/ her primary care physician or you can call CHKD Sports Medicine (668-PLAY) to see their pediatric concussion specialists, Dr. Joel Brenner or one of his colleagues. If you have any questions or concerns please call us at the number listed below. Sincerely, (Signature) Joel Brenner, MD Director, CHKD Sports Concussion Program Office: (757) 668-PLAY (7529), ATC Certified Athletic Trainer Cell Phone: (757) What is a concussion? A concussion is a brain injury which results in a temporary disruption of normal brain function. A concussion is caused by a bump, blow or jolt to the head or body. Even what seems to be a mild bump to the head can be serious. An athlete does not have to lose consciousness ( knocked-out ) to suffer a concussion. A concussion may cause multiple symptoms. Many symptoms appear immediately after the injury, while others may develop over the next several days or weeks. The symptoms may be subtle and are often difficult to fully recognize. Physical Cognitive Emotional Sleep Headache Visual Problems Feeling mentally foggy Irritability Drowsiness Nausea/vomiting Fatigue/feeling tired Feeling slowed Sadness Sleeping less than usual down Dizziness Sensitivity to light or Difficulty More emotional Sleeping more than usual noise remembering Balance Problems Numbness/tingling Difficulty concentrating Nervousness Trouble falling asleep Date 12/2015

9 Children s Hospital of the King s Daughters Concussion Information Form 1 What should I do the first hours? Your athlete should not be left alone and should be checked throughout the night. It is OK to let them go to sleep. You only need to wake them up if you are concerned about their breathing or how they are sleeping. Your athlete should not drive while they are still having symptoms. Check with your doctor before giving your child any pain medicine. It is OK to use an ice pack on the head and neck for comfort. When should I take my child to the doctor? All athletes who sustain a concussion need to be evaluated by a licensed health care professional who is familiar with sports concussion diagnosis and management. You should call your athlete s physician and explain what has happened. A follow up appointment should be scheduled with your primary care doctor or a sports concussion specialist if directed by your personal physician. If any of your athlete s signs or symptoms are worsening they should be taken to the emergency department IMMEDIATELY. Additional symptoms to watch for that would require you to call your doctor or go to the emergency department IMMEDIATELY include: Headaches that worsen Very drowsy, can t be awakened Can t recognize people of places Seizures Repeated vomiting Increasing confusion Neck pain Slurred speech Weakness/numbness in arms/legs Unusual behavior change Significant irritability Less responsive that usual When can a youth athlete return to play following a concussion? After suffering a concussion, no athlete should return to play or practice on that same day. Studies have shown us that a young brain does not recover quickly enough for a youth athlete to return to activity in such a short time. Your young athlete should not participate in any HIGH risk activities that may result in head injury such as physical education class, recess, ride a bike or skateboard until cleared by a licensed health care professional. Once an athlete no longer has symptoms of a concussion for a minimum of 24 hours and is cleared to return to physical activity by a licensed health care professional knowledgeable in the care of sports concussions, he or she should proceed with activity in a supervised step-wise fashion to allow the brain to re-adjust to exertion. This should occur over a minimum of 5 days. (See Medical Clearance (Form #2) and Gradual Return to Play Progression (Form #3)) *The Medical Clearance(Form #2) and the Gradual Return to Play Progression (Form #3) is recommended to be signed and returned to the facility/organization or medical personnel prior to participating in activity. How can a concussion affect schoolwork? Following a concussion, many student-athletes will have difficulty in school. These problems may last from days to months and often involve difficulties with short and long-term memory, concentration, and organization. In many cases it is best to lessen the student-athlete s class load early on after the injury. This may include staying home from school for a few days, followed by a lightened schedule for a few days, or perhaps a longer period of time, if needed. Decreasing the stress on the brain early on after a concussion may lessen symptoms and shorten the recovery time. Date 12/2015

10 Children s Hospital of the King s Daughters Concussion Information Form 1 Why is it so important that an athlete not return to play until they have completely recovered from concussion? A second concussion that occurs before the brain recovers from the first can slow recovery or increase the chances of long-term problems. In rare cases, brain swelling can result leading to permanent brain damage or even death ( second impact syndrome ). What is the best treatment to help my athlete recover more quickly from a concussion? The best treatment for a concussion is rest, both physically and mentally. There are no medications that can speed the recovery from a concussion. Exposure to loud noises, bright lights, computers, video games, television and phones (including text messaging) all may worsen the symptoms of a concussion. You should allow your athlete to rest as much as possible in the days following a concussion. As the symptoms lessen, you can allow increased use of computers, phone, video games, etc., but the access must be lessened if symptoms worsen. How long do the symptoms of a concussion usually last? The symptoms of a concussion will usually go away within one week of the initial injury. However, in some cases symptoms may last for several weeks, or even months. Is a CT scan or MRI needed to diagnose a concussion? Diagnostic testing, which includes CT ( CAT ) and MRI scans, are rarely needed following a concussion. While these are helpful in identifying life-threatening brain injuries (e.g. skull fracture, bleeding, swelling), they are not normally utilized, even by athletes who have sustained severe concussions. A concussion is diagnosed based upon the athlete s description/story of the injury/event and the licensed health care provider s physical examination. When should the athlete see a sports concussion specialist? Any athlete who has had significant or recurrent head injuries or the symptoms persist beyond 5-7 days may benefit from a specialty evaluation from a sports concussion program. Your personal physician may also recommend a specialty evaluation if they have any concerns or need further assistance with your athlete s concussion management. Neuropsychological testing, which should be part of the evaluation when possible, can be helpful to assist with return to academic and physical activity. (2010 AAP Sport-Related Concussion in Children and Adolescents) Some of this information has been adapted from the CDC s Heads Up: Concussion in High School Sports and the NFHS s Sports Medicine Advisory Committee. Please go to for more information. Date 12/2015

11 Children s Hospital of the King s Daughters Medical Clearance Form 2 NAME DATE DOB DATE OF INJURY This form is to be completed by a Licensed Health Care Provider. Criteria for Medical Clearance for Gradual Return to play (Check each) The athlete must meet all of these criteria to receive medical clearance. No Symptoms at rest for minimum 24 hours/ no medication used to manage symptoms (e.g., headaches) No return of symptoms with typical physical and cognitive activities of daily living Neurocognitive functioning at typical baseline Normal Balance and coordination No other medical/neurological complaints/findings Detailed Guidance SPORT 1. Symptom checklist: None of these symptoms should be present. Assessment of symptoms should be broader than athlete report alone. Also consider observational reports from parents, teachers, others. Physical Cognitive Emotional Sleep Headache Visual Problems Feeling mentally foggy Irritability Drowsiness Nausea/vomiting Fatigue/feeling tired Feeling slowed down Sadness Sleeping less than usual Dizziness Sensitivity to light or noise Problems remembering More emotional Sleeping more than usual Balance Problems Numbness/tingling Problems concentrating Nervousness Trouble falling asleep 2. Exertional assessment (Check): The athlete exhibits no evidence of return of symptoms with: Cognitive activity: concentration on school tasks, home activities (e.g. TV, computer, pleasure reading) Physical activity: walking, climbing stairs, activities of daily living, endurance across the day 3. Neurocognitive Functioning (Check): The athlete s cognitive functioning has been determined to have returned to its typical pre-injury level by one or more of the following: Appropriate neurocognitive testing Reports of appropriate school performance/ home functioning (concentration, memory, speed) in the absence of symptoms listed above 4. Balance & Coordination Assessment (Check): The athlete is able to successfully perform: Romberg Test OR SCAT2 (Double leg, single leg, tandem stance, 20 secs, no deviations from proper stance) 5 successive Finger-to-Nose repetitions < 4 sec I certify that: I am aware of the current medical guidance on concussion evaluation and management; the above-named athlete has met all the above criteria for medical clearance for his/her recent concussion. The athlete may start the return to play progression. LHCP Name (PRINT) Phone # Signature Date: Date 12/2015

12 Children s Hospital of the King s Daughters Gradual Return to Play Progression Form 3 NAME DATE OF INJURY DATE SPORT This form is to be completed by a Licensed Health Care Provider. I understand that each step of this gradual return to play progression must be completed prior to returning to full contact activity. I understand: Prior to starting the gradual return to play progression, the athlete must be completely symptom free at rest and during typical physical and cognitive activities of daily living. Each stage of the concussion rehabilitation should last no less than 24 hours. The athlete must remain symptom free after each stage of the progression. If symptoms return after any stage of the progression the stage will have to be repeated after a 24 hour asymptomatic period. If symptoms return and continue, the athlete must contact their Licensed Health Provider {If symptoms recur during progression rehabilitation, STOP IMMEDIATELY.} Initial/Date Type Example Exercises Light Aerobic Activity Walking, biking, swimming Keep heart rate <70% Moderate Aerobic Activity Noncontact, Complex drills Full-contact Practice Running drills, sport specific drills, passing, dribbling No Head Impact Complex footwork, complex passing drills, light resistance training No Live Scrimmages I certify that: I am aware of the current medical guidance on concussion evaluation and management; the above-named athlete has completed a Gradual Return to Play Progression as outlined above after receiving medical clearance. The athlete is able to return to full sports participation. LHCP Name (PRINT) Phone # Signature Date: Date 12/2015