USA Hockey Concussion Management Program

Michael Stuart MD

Alan Ashare MD

Kevin Margarucci ATC

The standard of care for current medical practice and the law in most states requires that any athlete with a suspected Sports Related Concussion (SRC) is immediately removed from play.

• A Sports Related Concussion is a traumatic brain injury- there is no such thing as a minor brain injury.
• A player does not have to be “knocked-out” to have a SRC- less than 10% of players actually lose consciousness.
• A SRC can result from a blow to head, neck or body.  
• SRCs often occur to players who don’t have or just released the puck, from open-ice hits, unanticipated hits and illegal collisions.
• The youth hockey player’s brain is more susceptible to SRC.  
•  In addition, the SRC in a young athlete may be harder to diagnosis, takes longer to recover, is more likely to have a recurrence, which can be associated with serious long-term effects. 
• The strongest predictor of slower recovery from a concussion is the severity of a person’s initial symptoms in the first day or 2 after the injury.
• Treatment is individualized and it is impossible to predict when the athlete will be allowed to return to play- there is no standard timetable.
• Baseline or pre-season neuropsychological testing is not mandatory, but may be helpful for return-to-plan decision making when an athlete feels normal.
• The use of helmet-based or other sensor systems to diagnose or assess SRC cannot be supported at this time.

A player with any symptoms/signs or a worrisome mechanism of injury has a SRC until proven otherwise:

“When in doubt, sit them out”

Remember these steps: 

1. Remove immediately from play (training, practice or game)
2. Inform the player’s coach/parents 
3. Refer the athlete to a qualified health-care professional 
4. Initial treatment requires physical and cognitive rest
5. The athlete begins a graded exertion and schoolwork protocol.
6. Medical clearance is required for return to play  

Diagnosis

     Players, coaches, officials, parents and heath care providers should be able to recognize the symptoms and signs of a sport related concussion. (refer to the attached Concussion Recognition Tool 5)

Symptoms

• Headache
• Nausea
• Poor balance
• Dizziness
• Double vision
• Blurred vision
• Poor concentration
• Impaired memory
• Light Sensitivity
• Noise Sensitivity
• Sluggish
• Foggy
• Groggy
• Confusion

Signs

• Appears dazed or stunned
• Confused about assignment
• Moves clumsily
• Answers slowly
• Behavior or personality changes
• Unsure of score or opponent
• Can’t recall events after the injury
• Can’t recall events before the injury

Management Protocol

1.  If the player is unresponsive- call for help & dial 911

2.  If the athlete is not breathing: start CPR

• DO NOT move the athlete
• DO NOT remove the helmet
• DO NOT rush the evaluation

3.  Assume a neck injury until proven otherwise

•  DO NOT have the athlete sit up or skate off until you have determined:
  • no neck pain
  • no pain, numbness or tingling
  • no midline neck tenderness
  • normal muscle strength
  • normal sensation to light touch

4.  If the athlete is conscious & responsive without symptoms or signs of a neck injury…

• help the player off the ice to the locker room
• perform an evaluation
• do not leave them alone

5.  Evaluate the player in the locker room: SCAT5 or other sideline assessment tools

• Ask about concussion symptoms (How do you feel?)
• Examine for signs
• Verify orientation (What day is it?, What is the score?, Who are we playing?)
• Check immediate memory  (Repeat a list of 5 words)
• Test concentration (List the months in reverse order)
• Test balance (have the players stand on both legs, one leg and one foot in front of the other with their eyes closed for 20 seconds)
• Check delayed recall (repeat the previous 5 words after 5-10 minutes)

• If a healthcare provider is not available, the player should be safely removed from practice or play and urgent referral to a physician arranged.

6.  A player with any symptoms or signs, disorientation, impaired memory, concentration, balance or recall has a SRC and should not be allowed to return to play on the day of injury.

7.  The player should not be left alone after the injury, and serial monitoring for deterioration is essential over the initial few hours after injury. If any of the signs or symptoms listed below develop or worsen: go to the hospital emergency department or dial 911.

• Severe throbbing headache
• Dizziness or loss of coordination
• Ringing in the ears (tinnitus)
• Blurred or double vision
• Unequal pupil size
• No pupil reaction to light
• Nausea and/or vomiting
• Slurred speech
• Convulsions or tremors
• Sleepiness or grogginess
• Clear fluid running from the nose and/or ears
• Numbness or paralysis (partial or complete)
• Difficulty in being aroused

8.  An athlete who is symptomatic after a concussion initially requires physical and cognitive rest.

• A concussed athlete should not participate in physical activity, return to school, play video games or text message if he or she is having symptoms at rest.

• Concussion symptoms & signs evolve over time- the severity of the injury and estimated time to return to play are unpredictable.

9.  A qualified health care provider guides the athlete through Graduated Return-to-School and Graduated Return-to-Sport strategies

.

Graduated Return-to-Sport Strategy

• After a brief period of rest (24–48 hours after injury), patients can be encouraged to become gradually and progressively more active as long as these activities do not bring on or worsen their symptoms.
• There should be at least 24 hours (or longer) for each step of the progression. If any symptoms worsen during exercise, the athlete should go back to the previous step.
• Resistance training should be added only in the later stages (stage 3 or 4 at the earliest).

Graduated Return-to-School Strategy

• If symptoms are persistent (more than 10–14 days in adults or more than 1 month in children), the athlete should be referred to a healthcare professional who is an expert in the management of concussion.