Preventing
Serious Injury
From "Having Your Bell Rung" to "Being Knocked
Out"
Why Coaches?
Concussions can occur in any sport, in
any age group, and in any situation, from drills to practices
to games. Far too often, a coach is the only adult present
and must administer first aid. When trained medical personnel
are neither nearby nor easily accessible, it is a coach's responsibility
to evaluate an injury and decide if an athlete should return
to play.
What Is a Concussion?
A common assumption is that an athlete
must be "knocked out" to sustain a concussion. That's
not true. Any change in mental status or
function qualifies as a concussion. Unconsciousness,
though clearly a severe injury, does not occur frequently. The
classic "having your bell rung" or "ding" occurs
fairly often and is often ignored, which can be a serious mistake.
Recognizing a subtle concussion is extremely
important in preventing the rare but deadly Second Impact
Syndrome (SIS). SIS occurs when an athlete sustains
a second blow to the head while still symptomatic from
the first "ding," even if the second blow is relatively
gently (a slap can provide enough force) or occurs days or
weeks later. Sudden swelling of the brain leads rapidly
(within two or three minutes) to unconsciousness or cardiac
arrest. Fifty percent of people who sustain SIS die,
and the rest have a very high risk of permanent brain
damage.
How to Recognize Concussions
Symptoms of a concussion may include dizziness,
nausea, vomiting, headache, blurred or double vision, ringing
in the ears, a funny taste in the mouth, poor coordination,
or emotional instability (anger, crying, and anxiety). Keep
in mind that your athlete won't necessarily come up to you
and complain of these. Watch out for the athlete who
just sits and stares, seems to be a step behind where he or
she usually is, blows a routine play, or "just doesn't
look right" to you. If you are at all suspicious
that an athlete may have a concussion, test him or her.
If any of these symptoms disappear,
but recur with the exercise test described on the card, do
not let the athlete return to play. Symptoms can
recur for days after the initial injury and are a sign that
the brain has not healed enough to participate in any
athletic activity.
If you notice any of these post-concussion
syndrome symptoms in your athlete, report it to the athletic
trainer, a parent or guardian, and/or a physician. In
their desire to play, many athletes try to hide or minimize
injuries. Be aware of changes or concerns reported by
teammates or teachers. Post-concussion syndrome often
has long-term effects that interfere with functioning at home,
school, or work. Anyone you suspect may have it should
be evaluated by a physician.
Concussions and Return-to-Play
Decisions
After an athlete sustains any blow
to the head, remove him or her from play for at least 20 minutes. Ask
the athlete about symptoms and run through the confusion/orientation
test, memory test, concentration test, and neurologic tests
described on the card. Do not immediately
perform the exercise test. If the athlete passes the
mental and neurologic tests and appears fully orientated, administer
the exercise test and recheck for symptoms.
Grade 1: "Ding" or "Having
Your Bell Rung"
The athlete is conscious at all times,
but dazed, foggy, or fuzzy. The player may miss one or
two items in the concentration test, but shows no confusion
or memory loss. Ask the concentration questions again
in 10 minutes, and again in another 10 minutes. If the
athlete answers all the questions correctly, passes all neurological
tests, and has no recurrence of any symptoms with the exercise
test, you can consider allowing the athlete to return to play.
A second "ding" in the same game
or practice requires a trip to the emergency room. If
someone from the sidelines or stands offers to evaluate a player
to see if he/she can go into a game, remember that only a physician
(MD/DO) or a licensed certified athletic trainer has the education
and experience to make that evaluation.
No matter how minor the head injury, notify
the family about it and about potential symptoms; do not rely
on the athlete. A responsible person needs to watch for
delayed problems.
Regardless of others' recommendations,
if your gut feeling tells you to bench a player, do not let
anyone - not players, parents, coaches, fans, or circumstances
- change your mind. You are never wrong to keep a
player out of a practice or game. It is the safest
option.
Grade 2: Out to Lunch
The athlete remains awake at all times,
but is dazed or states blankly. Any amnesia (memory loss)
is a critical warning sign. For example, you may notice
the athlete repeatedly asking the same questions without remembering
that he or she asked them, or without remembering the answers. If
an athlete misses any of the confusion/orientation or memory
test questions, suspect a grade 2 concussion and immediately
remove him or her from all activities. It is strongly
recommended that you seek emergency medical attention for this
athlete. He or she probably should not return to athletic
activity for a minimum of 5-7 days after all symptoms have
disappeared, and should first be cleared by a physician.
Grade 3: Knocked Out - Blacked
Out
Any loss of consciousness, no matter how
brief, even if the athlete successfully completes all of the
exams after he or she returns to consciousness, is a grade
3 concussions requiring medical attention:
Immobilize the athlete's head and call
an ambulance.
-
If the athlete wakes up within one
minute and does not have any neck pain, call an ambulance
or ask a responsible adult to take the player to an emergency
room.
-
If the athlete is unconscious longer
than one minute, or complains of neck pain after returning
from consciousness, assume that a spine injury exists. Call
an ambulance. While waiting for it to arrive, keep
the athlete's head from being moved. Expect the
athlete to be prohibited from taking part in activity
for a minimum of two weeks to one month.
Symptoms of Concussion
Headache, any vision change, ringing in
one or both ears, nausea or vomiting, confusion, unsteadiness,
altered emotional state for that athlete, e.g., anxiety,
crying, being excessively angry.
Grade 1, Ding - Bell Ring
(Conscious at all times but dazed, foggy, or fuzzy)
-
Administer confusion/orientation,
memory, and concentration tests.
He or she may miss one to two items. If more than
that, no return to play, even if normal later on in the
contest/practice.
-
Administer the neurological tests.
Athlete must pas al components of the neurological tests. If
not, there is no return to play, even if normal later
in the contest/practice. If pupils are unequal
in size, send to emergency room immediately.
-
Administer the tests again, 10
minutes later.
If the athlete again passes these tests, go to (4). If
not, there is no return to play, even if tests normal
later.
-
Administer the tests again, 20
minutes from the time of the first test.
If the athlete passes all tests with no mistakes, can
administer exercise test.
-
Administer the exercise test.
If the athlete denies any of the symptoms (including
headache), and has no symptoms from the exercise testing,
you may consider allowing him or her to return to play. Remember,
though, if the athlete receives a second "ding," no
matter how slight, immediate medical attention is required.
Grade 2, Out to Lunch
(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 on your first time of testing, immediately remove
him or her from play and get emergency medical attention. Never
administer exercise test. The athletes should not return
to play for at least five to seven days and should be cleared
by his/her doctor first.
Grade 3, Knocked Out - Blacked
Out
(Any loss of consciousness, no matter how brief.)
Immediately immobilize head while unconscious. No
return to play even if the athlete passes all of the exams
after returning to consciousness. The athlete should
not participate in practice or games for at least two to four
weeks. Never administer exercise test.
Unconscious for less than 1 minute:
Check for neck pain
-
If yes, immediately immobilize head
and call an ambulance. Don't move the athlete.
-
If no, call an ambulance or ask a
responsible adult to take the athlete to the emergency
room immediately.
Unconscious for more than 1 minute:
Keep head immobilized.
Call and ambulance.
Tests
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 the 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.
Concentration
Repeat these numbers backward (4-3-6, 8-2-7-1,
9-4-5-2-0). 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.
-
Have the athlete touch a finger to
nose with eyes closed. Fails test if misses nose.
-
Have the athlete stand on 2 feet
with arms out, first with eyes open and then with eyes
closed - fails test if sways (for hockey, skate blue
line forward on 1 foot).
-
Have the athlete walk heel-toe in
straight line, forward and backward. Fails test
if wavers or line is not straight (for hockey, skate
backwards without looking).
Exercise Tests
(Only for suspected Grade 1 concussion, to see if symptoms
return. Alter it depending on the sport, e.g., hockey)
5 each: deep knee bends/sit-ups/push-ups/gut
busters
Sprint full speed 40 yards, cut on command
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