JHG - Management of Concussions and Head Injuries
1. PURPOSE AND PHILOSOPHY
1.1Medical management of head injuries and sports-related concussions continues to evolve. Recently, there has been a significant amount of new research regarding sports-related concussions in students and athletes, the treatment, protocol, and long-term effects. This policy is established to provide education about concussions for coaches, school personnel, parents, and students. The protocol herein outlines procedures for District personnel to follow in managing concussions as well as “return to play” and “return to learn” procedures following a concussion.
1.2The Board of Education seeks to provide a safe return to activity for all students following any injury, but particularly after a concussion. To effectively and consistently manage these head injuries, the following procedures have been developed to ensure that concussed students are identified, treated and referred appropriately, receive appropriate follow-up medical care during the school day, and are fully recovered prior to returning to activity.
2. DEFINITIONS
2.1“Agent” is defined in Utah Admin. Code R277-614 and Utah Code Ann. § 26B-4-401 and means a coach, teacher, employee, representative, or volunteer of the District.
2.2“Health Care Provider” means the same as a “qualified health care provider” as defined in Utah Code Ann. § 26B-4-401 and means an individual who may evaluate and manage a concussion within the health care provider’s scope of practice and who is licensed under the Utah Code as:
2.2.1A physician under Title 58, Chapter 67, Utah Medical Practice Act;
2.2.2A physician under Title 58, Chapter 68, Utah Osteopathic Medical Practice Act;
2.2.3An advanced practice registered nurse under Title 58, Chapter 31b, Section 302; or
2.2.4A physician assistant under Title 58, Chapter 70a, Utah Physician Assistant Act.
2.3“Parent” means a parent or legal guardian of a student.
2.4“Sporting event” means a District-sponsored activity listed under Utah Code Ann. § 26B-4-401, and includes games, practices, tryouts, physical education classes, sports camps, and competitions. A sporting event does not include merely making available a field or other facility, or free play or recess taking place during school hours.
2.5“Traumatic head injury” is defined in Utah Code Ann. § 26B-4-401 and means an injury to the head arising from blunt trauma, an acceleration force, or a deceleration force, with one of the following observed or self-reported conditions attributable to the injury:
2.5.1Transient confusion, disorientation, or impaired consciousness;
2.5.2Dysfunction of memory
2.5.3Loss of consciousness; or
2.5.4Signs of other neurological or neuropsychological dysfunction, including
2.5.4.1seizures;
2.5.4.2irritability;
2.5.4.3lethargy;
2.5.4.4vomiting;
2.5.4.5headache;
2.5.4.6dizziness; or
2.5.4.7fatigue.
3. RECOGNITION OF CONCUSSION
3.1A concussion is a type of Traumatic Head Injury that interferes with the normal function of the brain. It occurs when the brain is rocked back and forth or twisted inside the skull as a result of a blow to the head or body. What may appear to be only a mild jolt or blow to the head or body can result in a concussion. A concussion can occur even if a player or student in an activity is not knocked out or does not lose consciousness. (See NFHS “Suggested Guidelines for Management of Concussion in Sports”).
3.2Signs (Observed by Others)
3.2.1Student appears dazed or stunned
3.2.2Confusion
3.2.3Forgets plays
3.2.4Unsure about game, score, opponent
3.2.5Moves clumsily (altered coordination)
3.2.6Balance problems
3.2.7Personality change
3.2.8Responds slowly to questions
3.2.9Forgets events prior to hit
3.2.10Forgets events after the hit
3.2.11Loss of consciousness (any duration)
3.2.12Vomiting
3.2.13Repeats questions
3.2.14Forgets class schedule or assignments
3.3Symptoms (Reported by Student)
3.3.1Headache or pressure in the head
3.3.2Balance problems or dizziness
3.3.3Fatigue or feeling tired
3.3.4Does not "feel right"
3.3.5More emotional than usual
3.3.6Irritable or sad
3.3.7Nausea or vomiting
3.3.8Double vision, blurry vision
3.3.9Sensitive to light or noise
3.3.10Feels sluggish
3.3.11Feels “foggy”
3.3.12Problems concentrating
3.3.13Problems remembering
3.4These signs and symptoms following a witnessed or suspected blow to the head or body should be considered a probable concussion.
3.4.1A student with a concussion may have one or many of the signs or symptoms listed above.
3.4.2Any student who exhibits signs, symptoms, or behaviors consistent with a concussion shall be immediately removed from the Sporting Event and shall not return to play until cleared by an appropriate Health Care Provider.
3.4.3Parent notification must be made for any and all suspected or witnessed head injuries.
3.5Many symptoms may progress or change in the days and weeks following an injury, including:
3.5.1Trouble sleeping,
3.5.2Emotional distress, and
3.5.3Academic difficulty.
3.6If symptoms persist, a student is advised to seek care from a qualified healthcare provider specializing in the evaluation and management of head injuries and concussions.
4. MANAGEMENT AND REFERRAL GUIDELINES
4.1The following situations indicate a medical emergency and require activation of the Emergency Medical System (EMS):
4.1.1Any student with a witnessed loss of consciousness (LOC) of any duration should be transported immediately to the nearest emergency department via emergency vehicle.
4.1.1.1A District agent shall remain in contact with 911 and stabilize the student while waiting for EMS to arrive.
4.1.2Any student who has symptoms of a concussion, and who is not stable (i.e., condition is worsening), should be transported immediately to the nearest emergency department via emergency vehicle.
4.1.3A student who exhibits any of the following symptoms should be transported immediately to the nearest emergency department via emergency vehicle.
4.1.3.1Deterioration of neurological function (such as pupil changes and responses, muscle weakness, or increased difficulty responding to questions)
4.1.3.2Decreasing level of consciousness
4.1.3.3Decrease or irregularity in respirations
4.1.3.4Any signs or symptoms of associated injuries, spine or skull fracture, or bleeding
4.1.3.5Mental status changes: lethargy, difficulty maintaining arousal, confusion, or agitation
4.1.3.6Seizure activity
4.2A student who is symptomatic but stable may be transported by his or her Parents. The Parents should be advised to contact the student’s physician or other competent medical professional, or seek care at the nearest emergency department, on the day of the injury.
5. GUIDELINES AND PROCEDURES FOR COACHES AND TEACHERS SUPERVISING CONTESTS AND GAMES: RECOGNIZE, REMOVE, REFER
5.1Recognize Concussion
5.1.1All District Agents should become familiar with the signs and symptoms of concussion that are described above.
5.1.2District Agents shall have appropriate training about recognizing and responding to traumatic head injuries, consistent with the employees’ responsibilities for supervising students and athletes. Such Agents shall be given annual in-service training on concussions and head injuries as provided or directed by the District.
5.2Remove from Activity
5.2.1Any student suspected of suffering a concussion or Traumatic Head Injury during a Sporting Event shall be immediately removed from the Sporting Event and shall not return to play until cleared by an appropriate Health Care Provider.
5.3Refer the Athlete/Student for Medical Evaluation
5.3.1The Agent of the District is responsible for notifying the student’s Parent(s) of the injury.
5.3.1.1Contact the Parent(s) to inform them of the injury. Depending on the injury, either an emergency vehicle will transport or Parent(s) will pick the student up at the event for transport.
5.3.1.2A medical evaluation is required before returning to play.
5.3.2In the event that a student’s Parent(s) cannot be reached, and the student is able to be sent home (rather than directly to a medical doctor):
5.3.2.1The District Agent should ensure that the student will be with a responsible individual, who is capable of monitoring the student and understanding the home care instructions, before allowing the student to go home.
5.3.2.2The District Agent should continue efforts to reach a Parent.
5.3.2.3If there is any question about the status of the student, or if the student cannot be monitored appropriately, the student should be referred to an emergency department for evaluation. The District Agent should accompany the student and remain with the student until a Parent arrives.
5.3.2.4The District Agent shall provide for supervision of other students for whom he or she is responsible when accompanying the injured student.
5.3.2.5Students with suspected head injuries should not be permitted to drive home.
5.3.3It is recommended that District Agents should seek assistance from the host site Certified Athletic Trainer (ATC) or team physician, if available.
6. RETURN TO LEARN (RTL) PROCEDURES AFTER A CONCUSSION
6.1Medical and school-based teams should counsel the student and family about the process of gradually increasing the duration and intensity of academic activities as tolerated, with the goal of increasing participation without significantly exacerbating symptoms.
6.2The student, family, health care provider, and school teams should monitor symptoms and academic progress to decide together the modifications that are needed to maintain an academic workload without making symptoms worse.
6.3School teams should monitor and adjust educational supports until the student’s academic performance has returned to pre-injury levels.
7. RETURN TO PLAY (RTP) PROCEDURES AFTER CONCUSSION
7.1Return to activity and play in a Sporting Event is a medical decision. The student must meet all of the following criteria in order to progress to activity:
7.1.1Be asymptomatic at rest and with exertion (including mental exertion in school);
7.1.2Have successfully returned to regular academic activities, and
7.1.3Have written clearance from the student’s Health Care Provider consistent with Utah Code Ann. § 26B-4-404. The written clearance must state that:
7.1.3.1the Health Care Provider has, within three (3) years before the day on which the written clearance is made, successfully completed a continuing education course in the evaluation and management of a concussion; and
7.1.3.2the student is cleared to resume participation in the Sporting Event.
7.2Once the above criteria are met, the student will be progressed back to full activity following the step-wise process detailed below. (This progression must be closely supervised by a District Agent. If the school does not have an athletic trainer, then the coach must have a very specific plan to follow as directed by the athlete’s physician).
7.3Progression is individualized and will be determined on a case-by-case basis. Factors that may affect the rate of progression include: previous history of concussion, duration and type of symptoms, age of the student, and sport/activity in which the student participates. An athlete/student with a prior history of concussion, one who has had an extended duration of symptoms, or one who is participating in a collision or contact sport may be progressed more slowly.
7.4Step-wise progression for return to play in a Sporting Event is provided below. The student should spend one (1) to two (2) days at each step before advancing to the next. If post-concussion symptoms occur at any step, the student must stop the activity and the treating Health Care Provider must be contacted. Depending upon the specific type and severity of the symptoms, the student may be told to rest for twenty-four (24) hours and then resume activity at one step below where he or she was at when the symptoms occurred.
7.4.1Step 1. Complete cognitive rest. This may include staying home from school or limiting school hours (and studying) for several days. Activities requiring concentration and attention may worsen symptoms and delay recovery. Light activity including walks may be encouraged at this level, provided that the activity is tolerated by the student without significant exacerbation of symptoms.
7.4.2Step 2. Return to school, during which time staff and agents will follow the health care provider's protocol on return to learn (RTL).
7.4.3Step 3. Light exercise. This step cannot begin until the student is no longer having concussion symptoms and is cleared by an appropriate Health Care Provider for further activity. At this point the athlete may begin walking or riding an exercise bike. No weight lifting.
7.4.4Step 4. Running in the gym or on the field. No helmet or other equipment.
7.4.5Step 5. Non-contact training drills in full equipment. Weight training can begin.
7.4.6Step 6. Full contact practice or training.
7.4.7Step 7. Play in game. Must be cleared by an appropriate Health Care Provider before returning to play.
8. FREE-PLAY CONCUSSION AND HEAD INJURY MANAGEMENT
8.1While many head injuries that happen at school are minor, when a student has a bump, blow, or jolt to the head or body, the following steps are necessary when a student has a bump, blow, or jolt to the head or body:
8.1.1Observe the student for signs and symptoms of a concussion for a minimum of 30 minutes.
8.1.2Ask people who saw the injury occur about how the injury happened and any concussion signs they observed.
8.2If the student has concussion signs or symptoms:
8.2.1Notify the parent that the student needs to see a health care provider experienced in concussion management.
8.2.2Give the parent a copy of the completed Concussion: Signs and Symptoms Checklist for the health care provider to review.
8.2.3Obtain guidance from the student’s health care provider about when the student can return to school and physical activity.
9. ANNUAL NOTIFICATION AND ACKNOWLEDGMENT
9.1Each school year and prior to a student’s participation in a Sporting Event, as defined herein, a copy of this policy shall be made available to the Parent of a student, and the Parent shall sign and return to the school the Parent Consent and Acknowledgment of Management of Concussions and Head Injuries Policy form.
10. DISSEMINATION OF POLICY
10.1This policy shall be posted on the District’s website. This policy, or a summary thereof, may also be published in parent information guides, student handbooks, student registration materials, and/or other appropriate school publications as directed by the District.