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Head Injury/Concussion Policy

INTRODUCTION Knowledge and understanding of concussion, its risks and treatment, both in adults and children, has been transformed over the past ten years, particularly over the last three, and current practice at every level has been developed in response to this. The primary mover that drove the new research and interest is the number of cases of epilepsy, brain damage, and worse, as a result of concussion being misunderstood, misdiagnosed and not being treated properly. Highfield and Brookham schools are committed to understanding how to recognise concussion and how to best manage a child’s recovery from concussion in the context of their home life, emotional wellbeing, academic and artistic studies and physical activities.

Pupils may suffer from a range of head injuries while in school. Most head injuries are minor and do not result in trauma to the brain (bleeding or concussion).

Pupils that have a bleed or a concussion will need special attention both at the time of the injury and afterwards. A concussion may result from a blow to the head, face, neck or elsewhere on the body when damaging forces are transmitted to the brain

Rugby causes more head injuries than any other team contact sport. Therefore, this protocol incorporates the International Rugby Board’s Concussion Guidelines which have been developed based on the 2016 Berlin Guidelines published in the 2017 Consensus Statement on Concussion in Sport, and adapted for rugby in England with the assistance of experts in the field. Although the word “player” is used, this policy applies to pupils with head injuries from any cause.

https://www.englandrugby.com/mm/Document/News/General/01/33/13/29/HEADCASEU19ConcussionManagementGuidelines2018_Neutral.pdf

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IMMEDIATE TREATMENT OF A HEAD INJURY

With any head injury, consider the possibility of a spine injury

If a player is unconscious or a neck or spine injury is suspected

the game must be stopped immediately and 999 called

the player must not be moved

If a conscious player shows any signs of a concussion (See Appendix 1) s/he

Must be removed from the field of play.

Must not be left on his/her own o If School Nurse is available, pupil is taken to the Health Centre (HC) by a

staff member who witnessed the event (NOT another pupil) o If not, pupil is observed by a qualified First Aider using the Checklist

(Appendix 1) o Pupil is observed for signs of deterioration & 999 is called if indicated

(Appendix 1) o Parents/carers are notified and the pupil is sent home. The care of

boarders who cannot be collected by their parents will be co-ordinated by the school nurse

Must be examined by a medical practitioner, GP or Highfield School nurse within a day or two.

o No pupil who has had signs or symptoms of a concussion will participate in any sports/games without verbal/written medical clearance and/or before they have met the criteria for graduated return to play. (GRTP)

In addition: The coaching team may use the Pocket SCAT2 (Appendix 2) if they have been trained in its use and the pupil is 10 years of age or older. NB: If a player does not show immediate signs or symptoms of a concussion but the force of the injury is such that a concussion is a possibility, s/he should be observed for at least 30 minutes before s/he is allowed to re-join the match/game/activity/lesson. “When in doubt, sit them out.” Taking a time out is not a sign of weakness: playing with a concussion is dangerous.

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FURTHER CONSIDERATIONS If a pupil has a concussion, his/her brain needs time to heal. While the pupil’s brain is still healing, s/he is much more likely to have another concussion. This is because a child may feel well but is actually still recovering from the physical effects of the concussion. Due to discrete deficiencies in reaction times and co-ordination of gross and fine motor movements they are more vulnerable to a second bump to the head, otherwise known as “Second Impact syndrome”. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in pupils can result in brain swelling or permanent damage to their brain. They can even be fatal. The pupil’s medical practitioner or Highfield school nurse will advise on the return to school and sports but the minimum period a child is recommended to rest from contact sport is 23 days after a confirmed concussion. Return to any sport should be a conservative, graduated process with careful supervision to note any return of concussion signs and symptoms. Thus all staff need to be aware of the possible modifications that may be necessary when a pupil returns to school after a concussion (Appendix 3). The pupil should be completely symptom free at rest and with physical exertion (e.g., sprints, non-contact aerobic activity) and cognitive exertion (e.g., studying, schoolwork) for 23 days prior to return to contact sports or recreational activities. With repeated concussions, however minor, or if there are any post concussion features, a complete ban on contact sports should be considered in consultation with the parents and the pupil’s medical practitioner. Record keeping All significant head injuries must be recorded in an Accident Book and will be reported to the Senior Management Team and/or Health and Safety Executive as appropriate. If the Concussion Checklist is used and a copy is available for retention in the pupil's school medical file all that is needed in the accident book is “see Concussion Checklist”. In addition, a “Head Injury Information” sheet (see Appendix 5) is given to the parent/carer of the child. Both the Checklist and Information sheets are kept with the Accident Book in all First Aid Kits and in the Health Centre office.

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Training First Aid training is held within the school during inset days and outside school at recognised training centres. Any staff member needing additional training should contact the school nurse. In addition, staff are encouraged to use the reference websites as sources of information. All sports coaches are asked to complete the online Headcase Concussion Training module at the following link. http://www.englandrugbyfiles.com/concussion/courses/youth-coaches/ Concussion management in school On return to school after a concussion a child is monitored closely for signs of the concussion and possible stressors (see Appendix 3). For a return to normal physical activities and cognitive workload in school including games/PE/swimming sessions and play time activities, a four phase recovery protocol is followed. Any child going through recovery from concussion will be in one of these phases and this is published daily in staff briefings and as part of the off games list. (See Appendix 4). Teachers and sports coaches enforce each stage ensuring the child is able to recover at their own rate. Working with the child and their parents Any child who has suffered with concussion will have an individual rate of recovery from obvious symptoms. However, it has been shown that a child’s brain takes at least 2 weeks to fully heal and recover from the chemical changes in the brain caused by the impact. Management of a child’s recovery both in school and at home needs to be tailored to the individual child and their symptoms. Parents and children can worry about missing school, completing homework or losing a place on a sports team. However, the school is committed to safe and best practice in the management of concussion and this policy has been created in reference to the most recent sports science and medical research. Several documents have been written to help parents learn about concussion and how we aim to support their child’s recovery. The teaching staff, coaches and nurses ask that parents and guardians support the school’s policy and the GRTP protocols so that their child may also respect and understand what is needed to ensure a full recovery from concussion.

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References

1) International Rugby Board Publication. “Concussion guidelines.” 2016 2) The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations

1995 (RIDDOR); Health and Safety Executive 3) http://www.englandrugby.com/my-rugby/players/player-health/concussion-

headcase/coaches/ 4) http://www.englandrugby.com/medical/concussion-

awareness/coaches/pocket%20scat3.ashx.pdf 5) http://bjsm.bmj.com/content/47/5/259.full.pdf 6) https://completeconcussions.com/2017/04/28/consensus-statement-

concussion-sport/ 5th International Consensus Conference on Concussion in Sport (Berlin 2016)

7) https://www.englandrugby.com/mm/Document/News/General/01/33/13/29/HEADCASEU19ConcussionManagementGuidelines2018_Neutral.pdf

Sarah Dove: February 2019 (Due for review February 2020) Appendices Appendix 1: Concussion Signs & Symptoms Checklist Appendix 2: Pocket SCAT 2 Appendix 3: When a Pupil with a Concussion Returns to School Appendix 4: Stages of Academic and Physical involvement after a Concussion Appendix 5: Head Injury Information Sheet Appendix 6: Graduated Return to Play Tracker for Coaches Appendix 7: Heads Up About Concussion. Appendix 8: Highfield and Brookham Schools Parent Guide to Concussion Appendix 9:Responsibilities of non-medical staff when head injury occurs and school nurse is not available. Please scroll down for Appendices

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Appendix 1

Concussion Signs & Symptoms Checklist Pupil’s name: Date & Time of Injury: Where & How Injury Occurred (include cause & force of blow/hit): Description of Injury (include if any loss of consciousness, memory loss or seizures immediately following injury; any previous concussions): Place an X in any boxes that apply. Observe pupil for at least 30 minutes.

Observed Signs 0 min 15 min 30 min ___min ___min

Appears dazed or stunned

Is confused about events

Repeats questions

Answers questions slowly

Can’t recall events prior to injury

Can’t recall events after injury

Loses consciousness (even briefly)

Shows behaviour or personality changes

Physical Symptoms

Localised headache

Generalised Headache

Presence of any neck pain

“Pressure” in head

Nausea or vomiting

Balance problems or dizziness

Feeling tired

Blurry or double vision

Sensitivity to light or noise

Numbness or tingling

Does not “feel right”

Cognitive Symptoms

Difficulty thinking clearly

Difficulty concentrating

Difficulty remembering

Feeling more slowed down

Felling sluggish, hazy, foggy

Emotional Symptoms

Irritable

Sad

More emotional than usual

Nervous

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Pupils with one or more of the signs or symptoms of concussion after a bump blow or jolt to the head should be referred to the GP, minor injury clinic or A&E depending on the pupil’s condition. When a parent is collecting pupil to take him/her for medical evaluation, observe pupil for any new or worsening symptoms right before the pupil leaves. Send a copy of this checklist with the pupil for the health care professional to review. Red Flags. Pupil should be seen in the A&E immediately if s/he has:

o Loss of consciousness, however brief

o One pupil larger than the other or unusual eye movements

o Drowsiness or cannot be awakened

o Severe or worsening headache

o Weakness, numbness or decreased coordination

o Repeated vomiting

o Slurred speech

o Seizures

o Difficulty recognising people or places

o Increasing confusion, restlessness or agitation

o Unusual behaviour

o Blood or clear fluid leaking from the nose or ear

o Unusual breathing patterns

Resolution of injury ___pupil returned to class ___pupil sent home ___pupil referred to A and E Signature of School Professional Completing this form_____________________________ Title______________________________________________________________________ Comments (include any pertinent examination findings by school nurse):

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Appendix 2

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Appendix 3

When a pupil who has had a concussion returns to school

School staff should monitor pupil for the following signs:

• Increased problems paying attention/concentrating • Increased problems remembering/learning new information • Longer time required to complete tasks • Increased symptoms (e.g., headache, fatigue) during schoolwork • Greater irritability, less tolerance for stressors Until a full recovery is achieved, the pupil may need the following supports:

• Time off from school or a shortened day • Shortened classes (i.e., rest breaks during classes) • Rest breaks during the day • Allowances for extended time to complete coursework/assignments and tests • Reduced homework/classwork load • No significant classroom or standardized testing at this time

A summary of the protocol is:

Red: No school, lots of cognitive rest (no video games; computers; text messaging; mobile

phone use; loud, bright environments; television; and reading)

Amber: Manage symptoms and aim for 2 days’ symptom free. Half-day of school; avoid carrying

textbooks; skip nonessential classes; no tests, homework, or music lessons; lunch or rest in

Health Centre as needed

Yellow: Full day of school; gradual resumption of responsibilities for homework, tests, quizzes,

and make-up work; only one test a day. 2-week recovery phase, no games/ vigorous activity

Green: Full academic load and return to normal physical activity.

A pupil should never return to competitive sporting or recreational activities while experiencing any

lingering or persisting concussion symptoms. This includes PE class, sports practices and games, and

other high-risk/high-exertion activities such as running, swimming bike riding, skateboarding,

climbing trees, jumping from heights, playful wrestling, etc.

References: (Last accessed 11-2-19)

https://www.cdc.gov/headsup/providers/index.html

https://www.youtube.com/watch?v=6gfD-_JFf9s Recommended video

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Appendix 4

Stages of Academic and Physical involvement after a concussion RED: Pupil is at home recovering, symptomatic and avoiding stressors. Off games AMBER: Pupil is in school aiming to achieve/maintain 2 days with no symptoms and managing known stressors as and when they become apparent or occur. Off games YELLOW: Pupil is in school having achieved 2 days free of symptoms. Commencing 2-week recovery period off games. GREEN: Pupil remains symptom free and has been managing a full academic load. Gradually returning to play.

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Appendix 5

Head Injury Information

Dear Parent/Carer,

Today your child had an injury that made it necessary for us to observe him/her for the possible development of signs or symptoms of a concussion and/or bleeding in the brain. We would have contacted you directly if there were any immediate concerns.

See “Concussion Signs & Symptoms Checklist" for details of the injury & treatment received.

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move rapidly back and forth. Sometimes even what seems to be a mild bump or blow to the head can be serious. Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

Most concussions occur without loss of consciousness. Young children and teens are more likely to get a concussion and take longer to recover than adults. If a person has had a concussion they are at increased risk for another concussion.

Therefore, if your child develops any of the signs or symptoms on the “Concussion Signs & Symptoms Checklist”, s/he needs to be seen by a health care provider who is experienced in evaluating and treating children for concussions.

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. Be alert for the following for 24-48 hours after the injury:

The following are emergency symptoms. Seek immediate medical care or call 999 if:

o Loss of consciousness, however brief

o One pupil larger than the other or unusual eye movements

o Drowsiness or cannot be awaken *

o Severe or worsening headache **

o Weakness, numbness or decreased coordination

o Repeated vomiting

o Slurred speech

o Seizures

o Difficulty recognising people or places

o Increasing confusion, restlessness or agitation

o Unusual behaviour

o Blood or clear fluid leaking from the nose or ear

o Unusual breathing patterns

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Even if emergency care is not needed, it is suggested that all children who have had more than a minor bump should be seen by their GP or Highfield school nurse within 1-2 days for advice.

*Drowsiness. It is OK to let a child go to sleep at his/her normal nap or bedtime. Experts vary in their advice about waking the child. Most do suggest observing the child every 2 hours through the night. If the child is sleeping in a normal position, breathing normally and has a good colour, you may decide to let the child sleep. Any unusual appearance/breathing pattern/colour, or if you are concerned, wake the child for a complete evaluation.

**Headache Although “headache” is listed on the “Concussion Signs & Symptoms Checklist”, a mild headache of short duration may not be considered a sign of a concussion by your health care provider. However, a severe headache that becomes worse is extremely concerning. Many health care providers and /or websites suggest paracetamol or ibuprofen for a mild headache, BUT the NHS Choices article on Concussion says to NOT use NSAIDs such as ibuprofen because of the possible increased risk of bleeding. If your child is diagnosed with a concussion, you will need to follow the medical advice given to you about restricting participation in school and sport, and Highfield school nurses will need to be satisfied the pupil has completely recovered before they can return to full activity (Highfield and Brookham Schools Head Injury/Concussion Policy, April 2020) Call NHS Advice on 111 for further advice and support if at all concerned. References & Information (last accessed 11-2-19) http://www.patient.co.uk/health/Head-Injury-Instructions.htm; http://www.nhs.uk/Conditions/Concussion/Pages/Introduction.aspx https://www.cdc.gov/headsup/index.html

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Appendix 6:

Graduated Return to Play Tracker for Coaches

How can I keep my child from getting a concussion? There are a few things you can do to decrease your child’s chances of getting a concussion. • Ensure your child’s equipment fits properly and is checked and maintained regularly. • Encourage your child to follow the rules of your sport and practice good sportsmanship. • Encourage your child to listen to their coaches and practice good technique. If recognized and treated properly, most children will recover fully from a single concussion. However, children who sustain multiple concussions during an early sports career tend to take longer to recover after each concussion and are more likely to experience prolonged post-concussion symptoms or cognitive impairment. Therefore, make sure your child is getting the best care and management possible for his or her concussion.

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Resource https://www.nationwidechildrens.org/specialties/concussion-clinic/concussion-toolkit/a-parents-guide-to-concussions The Concussion Clinic at Nationwide Children’s Hospital utilizes the expertise of Paediatric Sports Medicine specialists and Physical Medicine and Rehabilitation specialists, along with neurologists, neurosurgeons, radiologists, neuropsychologists, physical therapists, and athletic trainers to best manage paediatric concussions. © 2019

When a pupil who has had a concussion returns to school: School staff should monitor pupil for the following signs: • Increased problems paying attention/concentrating

• Increased problems remembering/learning new information

• Longer time required to complete tasks

• Increased symptoms (e.g., headache, fatigue) during schoolwork

• Greater irritability, less tolerance for stressors

Until a full recovery is achieved, the pupil may need the following supports: • Time off from school

• Shortened day

• Shortened classes (i.e., rest breaks during classes)

• Rest breaks during the day

• Allowances for extended time to complete coursework/assignments and tests

• Reduced homework/classwork load

• No significant classroom or standardized testing at this time

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In summary the protocol is:

Red: No school, lots of cognitive rest (no video games; computers; text messaging; mobile phone use; loud, bright environments; television; and reading)

Orange: Manage symptoms and aim for 2 days free of symptoms. Half-day of school; avoid carrying textbooks; skip nonessential classes; no tests, homework, or music lessons; rest in Health Centre as needed

Yellow: Full day of school; gradual resumption of responsibilities for homework, tests, quizzes, and make-up work; only one test a day. 2-week recovery phase, no games/vigorous activity

Green: Full academic load and return to normal physical activity

A pupil should never return to competitive sporting or recreational activities while experiencing any lingering or persisting concussion symptoms. This includes PE class, sports practices and games, and other high-risk/high-exertion activities such as running, bike riding, skateboarding, climbing trees, jumping from heights, playful wrestling, etc. Reference https://www.cdc.gov/headsup/providers/index.html Accessed 11-2-19 Sarah Dove – reviewed 11-2-19

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Appendix 7:

The Heads Up about Concussion Dear Parents, Please may we ask you to take a moment or two to read the following information, as we need all parents to understand how concussion is managed at Highfield and Brookham. The following points need to be understood: The management of concussion and return to sport afterwards. The 4th International Consensus Conference on Concussion in Sport was held in Berlin in 2016 and published guidelines for the management of concussion. All schools and sports institutions and clubs have since been working to ensure that concussion is now managed according to these guidelines. Highfield and Brookham Schools are no exception. Our Head Injury policy and Graduated Return to Play (GRTP) protocol have been written with reference to these guidelines and can be found on the school website. N.B. Concussion often happens when not playing sports but the management is the same. How is a child who has had a bump to the head treated and assessed at school? Any child who has had a significant bump or jolt to the head is assessed, ideally in the Health Centre. If the nurse is concerned and suspects that concussion may develop, she will check the child’s signs and symptoms against a checklist every 15 minutes from the time of injury for 30 minutes. (N.B. Any child with a head injury showing signs of serious internal bleeding will be immediately treated via emergency services and parents informed as soon as possible. This is a very rare occurrence with concussion being far more common.) If, after 30 minutes, the child is clear of any signs of concussion the nurse will send them back to class and alert staff to the incident asking them to be watchful for signs of delayed concussion. They may be put off games for the day just to be sure. A phone call and follow up email will be sent to parents to let them know and to ask them to watch out for signs of delayed concussion which can develop up to 48 hours afterwards (and sometimes later). If concussion is evident we will call parents and ask them to collect their child from school. Concussion watch – The 48-hour window during which delayed concussion may occur. Signs of concussion may develop during this time and we often find that a child may have been feeling well when resting at home but finds returning to the busy, noisy environment of school causes concussion to become more evident. For example, focusing on computer or iPad screens, reading text, looking up and down at the whiteboard or just running about with friends during break times. This may cause a generalised headache or just difficulty concentrating on lessons and these are both signs of concussion.

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Requirement for Concussion clearance or confirmation Highfield school nurses are able to recognise and diagnose concussion and will also refer a child with a serious head injury to be assessed in an emergency department if they are concerned that a medical assessment is also needed. In the past a GP assessment was required by the school but we have been told by the Highfield school doctor that they are happy with our concussion assessment skills. If the nurses diagnose concussion at any point, this is not a decision that can later be reversed and the child will need to follow the GRTP protocol. Please understand that the nurses and sports staff are acting in the best interest of your child. If the child is cleared of concussion they will be able to return to sports but we will still be watchful for delayed concussion. Parental responsibility if possible concussion occurs outside of school hours. 1) Requirement for Concussion clearance or confirmation (as above) by medical personnel. This could be at MIU or own GP. The Highfield school nurses could assess your child, however, a parent will need to attend to give first hand history of the head injury, the circumstances surrounding the event and any signs and symptoms the child has had. The child is not to be expected or allowed to do this on their own. Please note: It has unfortunately been our experience that medical personnel such as GPs, A and E and Minor Injuries staff although skilled in diagnosis of concussion, are not all up to date with GRTP and we have had children with obvious and confirmed concussion being told they can return to sport in a couple of days, a week or 6 weeks. This lack of consistency is troubling so we do ask parents to abide by the school policy if concussion is confirmed. Also, we have had parents told they can give Ibuprofen for headache when this is NOT advised. NHS guidelines are that only Paracetamol is advised for headache in the case of concussion/head injury. 2) Please plan ahead to include an appointment with your surgery if you have not had your child assessed by the Highfield school nurses. 3) Please be aware that on requesting an appointment your GP surgery may offer an appointment with their nurse, this should be fine. Please stress that we need your child to be cleared of or confirmed with concussion and ask them to use this word in their diagnosis. 4) Please read all information given to you by the nurses, either by hard copy or later by email. This includes: On Concussion watch:

o A letter detailing how to observe for signs of a serious head injury and concussion. o Document: A Parents’ Guide to Concussion

Signs of concussion: The above documents plus: o This document: The Heads Up About Concussion

Concussion confirmed: The above documents plus: o Document: When a child returns to school after concussion o Document: The GRTP Protocol.

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After concussion has been confirmed, how soon does the GRTP protocol allow my child to return to sport at school (including PE, swim school and tennis)? After two days clear of any residual signs or symptoms of concussion your child will need 14 days of rest from all sports and vigorous playtime games. Once this is completed there are 4 stages, each lasting 2 days during which games staff will gradually introduce activities and sports that increasingly challenge the child’s activity. If all stages are completed with no return of symptoms they will be ready for match play in 9 days. This is a total of 23 days across the whole GRTP protocol. What will my child be doing during games sessions? Your child will be allowed home early on match days. Otherwise they may join other children who are off games in the supervised classroom. They will be able to make the most of their time by having extra time to get their prep done (unless this causes concussion symptoms to return), do some quiet reading or, with permission and weather permitting, they may go out to watch a games session. How is return to school after concussion managed in the classroom? Please see the document “When a pupil returns to school after a concussion”. Teachers will be aware that concussion may affect any tests undertaken by the child at this time and should modify how much prep they are set. Please liaise with your child’s form teacher and the nurses on a daily basis with an email update until all symptoms resolve.

https://www.youtube.com/watch?v=6gfD-_JFf9s Recommended video

Thank you for taking the time to read this information. We are hoping that parents will appreciate the opportunity to educate themselves about concussion whilst, of course, hoping they will not need to refer to it in the future. Kind regards Sarah Dove and Alison Udall SD: October 2016. Reviewed February 2019

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Appendix 8

Parents’ Guide to Concussion

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Concussion Identification What is a concussion? A concussion may be caused by a blow, bump, or jolt to the head or by any fall or hit that jars the brain. This “invisible” injury disrupts the brain’s normal physiology which can affect mental stamina and function, causing the brain to work longer and harder to complete even simple tasks. A concussion may involve loss of consciousness (being “knocked out”), but the majority do not. Ultimately, ALL concussions are serious because they are brain injuries! How do I tell if my child has sustained a concussion? A concussion can affect a child in many different ways: physically, cognitively, emotionally, and by disturbing sleep. The table below indicates common symptoms for each category. Common Concussion Symptoms Physical Cognitive Emotional Sleep Headache Feeling mentally foggy Irritability Trouble falling asleep Dizziness Feeling slowed down Sadness Sleeping more than usual Balance problems Difficulty concentrating Nervousness Sleeping less than usual Nausea/vomiting Difficulty remembering More emotional than usual Fatigue Difficulty focusing Sensitivity to light Sensitivity to noise While a blow to the head may not seem serious immediately, concussion symptoms can develop upon impact or up to 48 hours after the incident. Ignoring any signs or symptoms of a concussion is putting the child’s long- and short-term health at risk. Underreporting of concussions: The importance of honesty Even though concussions are very serious and potentially life threatening to the young athlete, studies show that less than 50% of school athletes will report their concussions. Even after being diagnosed, many athletes feel pressured to say they do not have symptoms when they still do. This is dangerous and should always be avoided. Almost all athletes who have died or suffered serious complications from repeated concussions did not report their continued concussion symptoms to their parents, coach or doctor. Therefore, it is vitally important that parents, coaches, and athletes recognize the signs and symptoms of concussions and encourage honesty in reporting them. Is it dangerous for my child to play sports with a concussion? Yes, without question. Second impact syndrome is a catastrophic event that can occur when a second blow to the head happens before an athlete has completely recovered from a concussion. This second impact, which may be even a minor blow, causes brain swelling, resulting in severe consequences such as brain damage, paralysis, and even death. This condition occurs only in youth and adolescents up to age 21. Therefore, no child should be allowed to participate in any physical activity if he or she has sustained a possible concussion. In addition, no child should return to participation after sustaining a concussion before he or she is cleared by a medical professional trained in concussion evaluation and management.

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Concussion Management If my child sustains a concussion, what should I do? First, the child should be monitored for worsening signs and symptoms in the 24 to 48 hours following the injury. If any of the following danger signs present themselves, the child should be evaluated by a physician immediately. • Severe or increased headache • Double vision • Unequal pupils • Convulsions • Unusual/increased drowsiness • Bleeding/clear fluid from the ear/nose • Projectile or repeated vomiting • Unusual stiffness in the neck area • Severe personality changes • Weakness in either arm(s) or leg(s) • Numbness in the face/extremities Second, follow these recommendations: • Do not let the child perform any strenuous activity or go back to playing in sports. • Do not use aspirin or ibuprofen for headaches. Use Paracetamol only. • Encourage your child to rest and eat normally. • Allow them to use ice packs on the head and/or neck to ease pain. • Let them sleep in a cool, dark, quiet room. Third, arrange for your child to be evaluated by a medical professional qualified and educated in concussion evaluation and management. Knowledge about concussions is rapidly evolving. The previous severity scales such as mild, moderate or severe concussion should no longer be used. Preventing your child from going to sleep or waking him or her every hour after a concussion is also an outdated practice. Don’t be afraid to ask the healthcare provider if he or she is aware of the up-to-date concussion protocols.

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Concussion Recovery Concussion recovery should be a collaborative approach A concussion can affect school, work, and sports. Along with the school nurse, the child’s coaches and teachers should be aware of the child’s injury and their roles in helping the child recover. Varying or mixed messages from parents and any of these parties may cause the child unnecessary distress and confusion, so clear communication among the group is vital. Once cleared of current symptoms of the concussion a Graduated Return to Play (GRTP) protocol may be commenced. Why is mental rest important to recovery? A concussion affects how the brain works, so resting the brain as much as possible is necessary for recovery. In this context, mental activities are defined as those in which the brain must work hard to process information. This includes critical thinking and problem solving activities such as schoolwork, homework, and technology use. What can I do to help my child achieve mental rest? Restrictions from the following should be considered, because these activities increase brain function, and therefore may worsen symptoms and delay recovery: • Computer work/Internet use • Video games • Television • Excessive text messaging/ mobile phone use • Bright lights, such as strobe lights. • Listening to loud music or music through headphones. • Loud noises. • Parties, concerts. • Work

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How do I know when my child is using his or her brain too much? Continued activity when symptoms are moderate to severe can prevent the brain from healing. Therefore, the key to concussion recovery is to reduce mental activities until symptoms improve and then gradually begin increasing the length and difficulty of those activities as symptoms allow. On days where the symptoms are severe (which often occur in the first few days after injury), it may be better to suspend any scheduled mental activities (i.e. school, homework, etc.) and have the child rest at home. As symptoms improve, the child may begin to gradually resume simple school-related mental activities. As difficulty is increased, continue monitoring symptoms. Ask, “Do you have any symptoms? Are your symptoms getting worse since you started this activity?” If the child states symptoms are worsening, have him or her stop what they are doing and rest. If the symptoms resolve with rest in a short period of time (20 minutes or less), the child may be allowed to resume the mental activity. If symptoms remain elevated, the child should discontinue the activity and rest and re-attempt when symptoms have improved (such as the next day). Note that there may be good days when symptoms are very mild and bad days when symptoms may be a little worse. This is a normal part of recovery. Sometimes there is a fine line between how much mental activity is okay and how much is too much. The key is to try to figure out where that line is to minimize symptoms as much as possible.

How is school affected by a concussion? Schoolwork demands focus, memory, and concentration – all brain processes that are affected by a concussion. Academic accommodations, ranging from medically necessary absences to tutoring or extra time for test taking, may be necessary in some cases to decrease symptoms and begin the healing process. Notify your child’s teachers that he or she has sustained a concussion and provide them with any written recommendations you were given during your visit to your healthcare professional. Please see Appendix 4 When a child returns to school after a concussion.

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Why is physical rest important to recovery? In the context of concussions, physical activity is any situation in which a child has an elevated heart rate. Such activities include, but are not limited to, sports, gym class, weight lifting, and active play. Due to the risk of Second Impact Syndrome and other complications, a child who has been diagnosed with a concussion should not return to any physical activity and/or athletics until cleared by a healthcare provider experienced in concussion evaluation and management. Physical rest is essential to keep the child safe and to enable the brain to heal. N.B. Activities such as playing wind instruments can increase intracranial pressure and cause the concussion headache to return so resting from this and drumming is also be advised. When can a child who has sustained a concussion safely go back to participating in games or PE? A child who has sustained a concussion should not return to physical activity until cleared by an appropriate healthcare provider. The child should be completely symptom free and participating in school fully. Once cleared, the child should participate in a gradual progression back to activity. Ideally, a certified athletic trainer should supervise the child during this timeframe. This gradual progression is critical because a return of any signs or symptoms of concussion during mild physical activity signals that the brain has not healed and the child is not ready to return to activity. Highfield and Brookham Schools policy has been formulated with reference to the most up to date recommendations for return to play. Please see the following for more information: https://www.englandrugby.com/mm/Document/News/General/01/33/13/29/HEADCASEU19ConcussionManagementGuidelines2018_Neutral.pdf

Appendix 9

Responsibilities of non-medical staff when head injury occurs and school nurse not available.

When pitch-side: Follow the Concussion Recognition Tool 2 (SCAT2) that is in all the first aid bags and respond

accordingly. Note exactly what happened, when, how and the mechanism/force of the injury. If

you did not witness the incident then ask by standers, including other players what actually

happened & record. If any red flags are apparent ensure the pupil is taken to A and E for assessment, calling 999/112

as needed as per policy Inform the parents if they are not present. If concussion is suspected and the child is in your care on the journey home:

o Complete the Concussion Signs and Symptoms checklist and observe the pupil over 30

minutes. This can be done while on the coach. Call or text school nurse on your way home. o Handover your findings to the school nurse/boarding staff/parent on arrival at the school,

ideally giving them a photocopy of the concussion checklist.

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o If handing over to a parent, give them a copy of the Head Injury Information letter and

request an update to be given to the nurses the next morning.

When in school/boarding houses: Complete the Concussion Signs and Symptoms checklist and observe the pupil over 30 minutes.

If any red flags are apparent (See SCAT 2) ensure the pupil is taken to A and E for assessment,

calling 999/112 as needed as per policy. Inform the parents. Inform the school nurses by email or in person when they are next on duty. Handover exactly

what happened, when, how and the mechanism/force of the injury. If caring for a pupil with signs of concussion over the weekend, inform the parents, ensure

reduced activities, monitor closely, give pain relief as needed (Paracetamol only) and encourage

rest from screens etc. Keep a record of symptoms and handover to the school nurses when they

are next on duty. SD and AU: February 2019