Pope John Paul II Catholic High School Athletic Department Protocol and Procedures for Management of Sports- Related Concussion

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1 Pope John Paul II Catholic High School Athletic Department Protocol and Procedures for Management of Sports- Related Concussion The following policy and procedures on neurocognitive baseline testing and subsequent assessment and management of concussions as well as return to play guidelines has been developed in accordance with the goal of the Pope John Paul II Catholic High School Athletic Department (JP II) to provide the appropriate healthcare and assure the well-being of each student-athlete at JP II. Purpose Pope John Paul II Catholic High School Athletic Department recognizes that sports-related concussions pose a significant health risk for JP II student-athletes. Therefore Pope John Paul II Catholic High School has implemented policies and procedures to deal with the assessment, management, and return to play (RTP) considerations for student-athletes who have sustained a concussive episode. In establishing this protocol it provides education about concussions for athletic department staff and other school personnel. The protocol outlines procedures for staff to follow in managing head injuries and outlines school policy as it pertains to return to play issues after concussion. Pope John Paul II Catholic High School seeks to provide a safe return to activity for all athletes after injury, particularly after a concussion. In order to effectively and consistently manage these injuries, procedures have been developed to aid in insuring that concussed athletes are identified, treated and referred appropriately, receive appropriate follow-up medical care during the school day, including academic assistance, and are fully recovered prior to returning to activity. In addition JP II also recognizes the importance of baseline testing on studentathletes who participate in sports which are recognized as contact or collision and/or who have a history of concussions upon entering athletic participation at JP II. Baseline concussion testing will consist of neurocognitive testing; this information will be extremely useful in RTP decisions. The baseline data along with physical exam, diagnostic testing, symptom scaling, follow up testing, and a gradual RTP protocol will all be used in conjunction with sound clinical judgment and on an individualized basis to determine when it is safe for an athlete to return to competition. This protocol will be reviewed on a yearly basis, by JP II Athletic Director and the assigned Huntsville Hospital SportsCenter Certified Athletic Trainer. Any changes or modifications will be reviewed and given to athletic department staff and appropriate school personnel in writing.

2 Concussion Related Information and Definition Concussions are one of the most commonly reported injuries in children and adolescents who participate in sports and recreational activities. The Centers for Disease Control and Prevention estimates that as many as 3,900,000 sports and recreation-related concussions occur in the United States each year. Concussions represent 9% of all sports injuries. Some other concussion factors that we consider at JP II are: 10% of all contact sport athletes sustain a concussion annually. 63% of all concussions occur in football. Estimated that 20% of all football players sustain a concussion per season. An athlete who sustains a concussion is 4 to 6 times more likely to sustain a second concussion. Effects of concussion are cumulative in athletes who return to play prior to complete recovery. The best way to prevent problems with concussion is to manage them effectively when they occur. What this means is that young athletes are particularly vulnerable to injury and even death if they continue to play after the initial concussion or head injury. So for our purposes we define a concussion as the temporary impairment of brain function caused by a violent shaking or jarring action to the brain, usually as a result of impact directly/indirectly with an object or the ground. Concussions injure the brain (traumatic brain injury (TBI)) and can range from mild to severe and can disrupt the way the brain normally works. They can occur in organized/unorganized sport or recreational activities along with the possibility of auto mobile accidents. Concussions can occur with and without loss of consciousness (LOC), but the vast majority of them occur without LOC. Post Concussion Syndrome A set of symptoms which may last for weeks, months, or years following a concussion Second Impact Syndrome Rare condition when an athlete sustains a second head injury before symptoms from the first have resolved, often fatal How Long Can a Concussion Last? There is no standard length of concussion. Concussions can take days, weeks, or months to resolve. It is important to treat each concussion individually because not all concussions act the same. A concussion in one person will probably not act the same as a concussion in another person. The average time for a concussion to resolve in an adolescent is between 2-4 weeks, but total symptom resolution at rest and with exertion is paramount when managing concussions. Proposed Concussion Grading Scale The following Concussion Grading Scale is a combination of the University of North Carolina and Dr. Robert Cantu. The JP II Concussion Grading System is as follows: Grade 0 No loss of consciousness. Mild confusion but asymptomatic in 20 minutes; passes functional tests without recurrence of signs or symptoms. Headache may develop later.

3 Grade 1 Grade 2 No loss of consciousness. Either post-traumatic amnesia or postconcussive symptoms clear in less than 30 minutes. Headache present. Loss of consciousness lasting less than 1 minute; post-traumatic amnesia or post-concussive symptoms lasting longer than 30 minutes but less than 24 hours. Headache present. Grade 3 Loss of consciousness lasting longer than 1 minute or posttraumatic amnesia lasting longer than 24 hours; post-concussive signs or symptoms lasting longer than 7 days. Headache present. CONCUSSION SIGNS AND SYMPTOMS Early Signs and Symptoms (minutes/hours) Headache Dizziness or vertigo Lack of awareness of surrounding Nausea or vomiting Late Symptoms (days/weeks) Persistent low grade headache Light-headedness Poor attention & concentration Memory dysfunction Easy fatigability Irritability & low frustration tolerance Intolerance of bright lights or difficulty focusing vision Intolerance to loud noises, sometimes ringing in the ears Anxiety and/or depressed mood Sleep disturbance Loss of balance Behavior change Pressure in the head Just don t FEEL RIGHT! Vacant Stare Delayed verbal & motor responses Slurred or incoherent speech Loss of appetite Numbness or weakness in extremities Convulsions Fluid from ear or nose Abnormal pupil size Any period of loss of consciousness Gross observable in coordination

4 Symptoms (reported by athlete) Headache Fatigue Nausea or vomiting Double vision, blurry vision Sensitive to light or noise Feels sluggish Feels foggy Problems concentrating Problems remembering CONCUSSION MANAGEMENT AND RETURN TO PLAY GUIDELINES BASELINE ASSESSMENT Pope John Paul II Catholic High School recognizes the seriousness of concussions and knows that using neurocognitve testing in the assessment of concussions is of great importance. JP II will use the Standardized Assessment of Concussion (SAC), which is a series of questions that tests orientation, immediate memory, concentration, and delayed memory to measure immediate neurocognitive effects of a student-athlete. The use of this SAC test will provide a baseline for the student-athlete s normal pre-injury performance. During the first year of the implementation of these guidelines, all athletes who fall into the following sport-participation categories will undergo baseline SAC testing. The following years/seasons, only incoming freshmen, transfers, or athletes who have been assessed as having a concussion will undergo baseline SAC testing. The following sports will be required to submit to baseline SAC testing: Football M/W Basketball Cheerleading (Competition) Baseball Softball M/W Soccer Volleyball Track & Field (only athletes whose events require them leaving the ground) MANAGEMENT In any circumstance where a concussion is suspected in an athlete, the first priority is to remove the athlete from further competition until a thorough sideline assessment can be made. Furthermore, if there is a question about the state of mental clearing it is best to err in the direction of conservative assessment and withhold the athlete from further competition until a physician assessment can be arranged. The recommendations in this document for the management of concussion are based on review of the medical literature including, but not limited to, statements by the American Academy of Neurology, Robert C. Cantu, MD, Colorado Medical Society and the NCAA Manual of Sports Medicine.

5 I. Management and Referral Guidelines for All Staff A. Suggested Guidelines for Management of Sports-Related Concussion i 1. Any athlete with a witnessed loss of consciousness (LOC) of any duration should be spine boarded and transported immediately to nearest emergency department via emergency vehicle. 2. Any athlete who has symptoms of a concussion, and who is not stable (i.e., condition is changing or deteriorating), is to be transported immediately to the nearest emergency department via emergency vehicle. 3. An athlete who exhibits any of the following symptoms should be transported immediately to the nearest emergency department, via emergency vehicle. 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, difficulty maintaining arousal, confusion or agitation h. seizure activity i. cranial nerve deficits 4. An athlete who is symptomatic but stable, may be transported by his or her parents. The parents 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. **ALWAYS give parents the option of emergency transportation, even if you do not feel it is necessary. II. Sideline Evaluation (ATC/Physician) Grade 0 and 1 Conscious at all times but dazed, foggy, or fuzzy. 1. Administer confusion/orientation, memory, balance, and concentration tests. No return to play even if normal later on in the contest/practice. 2. Administer the neurologic tests (SAC Test). Athlete must pass all components of the neurologic tests. There is no return to play even if normal later in the contest/practice. If pupils are unequal in size, send to an emergency room immediately. Grade 2 Conscious at all times but dazed, blank stares, clueless, or amnesia of any kind. If the athlete gives wrong answers to more than two questions on the confusion/orientation or memory tests the first time tested, immediately remove him or her from play and seek emergency medical attention. The athlete should not return to play for at least five to seven days and should be cleared by his or her doctor first.

6 Grade 3 Any loss of consciousness, no matter how brief, is a grade 3 concussion requiring immediate medical attention. No need for you to perform any exams, but you must do the following: If the athlete wakes up within one minute and does not have any neck pain, you may move the athlete to the sideline, where you should keep him or her calm and quiet. Call an ambulance or ask a responsible adult to take the player directly to an emergency room. If the athlete is unconscious longer than one minute, does not wake up, or complains of neck pain after returning to consciousness, assume the athlete has a neck/spine injury. Do not move the athlete. Make sure that he or she is breathing. Do not allow others to move the athlete. Call an ambulance. While waiting for the ambulance to arrive, keep the athlete s head from being moved. In either case, expect the athlete to be prohibited from taking part in the activity for a minimum of two weeks to one month. Resist well-meaning adults who unknowingly want their child returned to athletic activity. An athlete who is symptomatic but stable, may be transported by his or her parents. The parents 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. ** ALWAYS give parents the option of emergency transportation, even if you do not feel it is necessary. III. TESTS FOR CONCUSSION Remember to tailor your questions to the age of your athletes. Confusion/Orientation: What s your name? Where are you? What month or year is it? Who are we playing? What sport are we playing? Who s winning? Memory: Who was our last opponent? Who won that game? When was the last major holiday? What is the next one? What has happened so far in this game? Who is the president of the United States? Give the athlete three objects (cat, book, tree) to remember, then ask him or her to tell you what they are after three minutes.

7 Balance Test: Rhomberg Test Alternating single leg stance with eyes closed and arms at side- positive test consists of athlete swaying, cannot keep eyes closed, or obviously losses their balance all together. Tandem Stance(heel to toe)- same as above for positive tests. Have the athlete walk heel-toe in straight line, forward and backward -- fails test if wavers or line is not straight Concentration: Repeat these numbers backward (4-3-6, , ). Beginning with December, say the months of the year backwards. Tell me a multiplication table forwards. Neurologic Tests Pupils should be of equal size. If not, call an ambulance. Generally while assessing a patient who has a suspected head injury, an assessment of the pupils' size and responsiveness to light with respect to each other can indicate the severity of the injury. A person who had PEARL is unlikely to have suffered severe brain trauma or succumb to increasing intracranial pressure whereas a person with brain trauma's pupils will often be oddly dilated or each eye will respond differently to light IV. Procedures for the Certified Athletic Trainer (ATC) A. The ATC will assess the injury, or provide guidance to the coach if unable to personally attend to the athlete. 1. Immediate referral to the JP II s overseeing team physician (Dr. John Greco) or the athlete s primary care physician or to the hospital ER will be made when medically appropriate. 2. The ATC will perform serial assessments following recommendations in the NATA Statement. a. The ATC will notify the athlete s parents and give written and verbal home and follow-up care instructions. B. The ATC will also initiate appropriate follow-up in school immediately upon the athlete s return to school. 1. The ATC will communicate with the athlete s guidance counselor (who will notify the athlete s teachers and let them know that the athlete might need special consideration until they have fully recovered from their concussion) regarding the athlete s neurocognitive and recovery status, if needed. 2. The ATC will notify the student s P.E. teacher immediately that the athlete is restricted from all physical activity until further notice. 3. The ATC is responsible for monitoring recovery & coordinating the appropriate return to play activity progression.

8 4. The ATC will maintain appropriate documentation regarding assessment and management of the injury. V. Guidelines and procedures for coaches: RECOGNIZE, REMOVE, REFER- each coach will have a coach s concussion card for quick reference. A. Recognize concussion 1. All coaches should become familiar with the signs and symptoms of concussion. 2. Very basic cognitive testing should be performed to determine cognitive deficits. B. Remove from activity 1. If a coach suspects the athlete has sustained a concussion, the athlete should be removed from activity until evaluated medically. a. Any athlete who exhibits signs or symptoms of a concussion should be removed immediately, assessed, and should not be allowed to return to activity that day. C. Refer the athlete for medical evaluation 1. Coaches should report all head injuries to the JP II Certified Athletic Trainer (ATC), as soon as possible, for medical assessment and management, and for coordination of home instructions and follow-up care. a. The ATC can be reached at: b. The ATC will be responsible for contacting the athlete s parents and providing follow-up instructions. 2. Coaches should seek assistance from the host site ATC if at an away contest. 3. If the JP II ATC is unavailable, or the athlete is injured at an away event, the coach is responsible for notifying the athlete s parents of the injury. a. Contact the parents to inform them of the injury and make arrangements for them to pick the athlete up at school. b. Contact the ATC at the above number, with the athlete s name and home phone number, so that follow-up can be initiated. Additional copies are available from the ATC. c. Remind the athlete that the ATC will reassess them the following school day after the injury. 4. In the event that an athlete s parents cannot be reached, and the athlete is able to be sent home (rather than directly to MD): a. The Coach or ATC should insure that the athlete will be with a responsible individual, who is capable of monitoring them self and will understand the home care instructions, before allowing the athlete to go home. b. The Coach or ATC should continue efforts to reach the parent. c. If there is any question about the status of the athlete, or if the athlete is not able to be monitored appropriately, the athlete should be referred to the

9 emergency department for evaluation. A coach or ATC should accompany the athlete and remain with the athlete until the parents arrive. d. Athletes with suspected head injuries should not be permitted to drive home. VI. Return to Play Guidelines The return to play guidelines following a concussion follows a step-by-step process: 1. No activity, complete rest. (Objective: Recovery) 2. Light aerobic exercise such as walking or stationary cycling. No resistance training. (Objective: Increase heart rate) 3. Sport specific exercise (i.e. running in soccer, agility drills for football), progressive addition of resistance training at steps 3 or 4. (Objective: Add movement) 4. Non-contact training drills (Objective: Exercise, coordination, and cognitive load) 5. Full contact after medical clearance. (Objective: Restore confidence and assess functional skills by coaching staff) 6. Game play. Summary: During this step-by-step progression, each level will be handled in 24-hour increments. The athlete should only progress to the next level if they are asymptomatic at the current level. If the athlete shows any post-concussion symptoms, then the athlete should revert back to the previous level and try again after 24 hours. Step 5 is not equivalent to a game-time situation. An athlete must participate in at least one (1) full-contact practice before game participation will be recommended. An additional consideration in these return-to-play guidelines is that the injured athlete should not only be symptom free but also should not be taking any medications that may modify or affect the symptoms of a concussion. Physician referral is recommended in any case regarding medication for symptoms of a concussion. Pope John Paul II Catholic High School is committed to make sure that the health and well being of the student athletes is the first priority. As such, the JP II Athletic Department is very proactive in the assessment and management of concussions. To do so limits the risks of concussions associated with athletics, and the potential catastrophic and long-term complications from said concussions.

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