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William A. Hough High School

Sports MedicinePolicy and Procedures Manual

12420 Bailey RoadCornelius, NC 28031

980.344.0514

Dr. Laura Rosenbach Masanori ToguchiPrincipal Athletic Director

Table of contents

Contact Information 1

Role Descriptions—Members of the Sports Medicine Team 2

Athletic Training Room 3RulesRehabilitation & Return to Play

Visiting Team Services 5

Emergency Action Plan 6Emergency Phone NumbersVenue Locations

AED Plan……………………………………………………………..…………………………….13

Gfeller-Waller Concussion Awareness Act………………………………………………………...15

Concussion Protocol……………………………………………………………………………..…17

Heat Illness………………………………………………………………………………………….21

Severe Weather Safety……………………………………………………………………………...25

Communicable Disease & Skin Infection Procedures…………………………………………...…26

MRSA Protocol

AppendixNCHSAA Sport Pre-Participation Examination Form Post-Concussion Self-Reported Symptom ScaleHome Management Plan/Instructions Post-ConcussionGfeller-Waller Concussion Clearance FormNCHSAA Concussion Return to Play FormCMS Student-Athlete Healthcare ReferralSkin Condition Physician Release FormPrescribed Appliance in Athletic Contest

Contact Information

Erica W Schultz, LAT, ATC, Head Athletic TrainerOffice: 980.344.0514 ext. 4300288Cell: 704.792.6188Athletic Training Room: 980.344.0514 ext 4300286Email: [email protected]

Ray Beltz, LAT, ATC, Athletic TrainerOffice: 704.323.2809Cell: 704.562.5405Email: [email protected]

Masanori Toguchi Jr., CAA, Athletic DirectorOffice: 980.344.0514 ext. 4300282Cell: 704.499.1854Email: [email protected]

Dr. Laura Rosenbach, PrincipalOffice: 980.344.0514Email: [email protected]

Kevin J. Stanley, MD, Team Orthopeadic PhysicianOrthoCarolinaOffice: 704.323.2819

Christina Vorobej, MD, Team Sports Medicine PhysicianCarolinas HealthCare SystemsHuntersville Sports Medicine and Injury CareOffice: 704.863.4878

Certified Athletic Trainer (ATC)

An allied health care professional educated and skilled especially in sports related healthcare. In collaboration with physicians and other allied health care personnel, they serve as the tip of the sword of the athletic health care team at Hough High School. All Certified Athletic Trainers are required by the national certifying body, Board of Certification (BOC) and the State of North Carolina (NCBATE) to maintain our skill through Continuing Education Requirements in health care, while also maintaining current BLS for Healthcare Providers (CPR & AED) certification from the American Heart Association and qualifications in First Aid and Bloodborne Pathogens.

Athletic Trainers are certified by the Board of Certification, after completing a university course of study leading to a bachelors or masters degree in athletic training. This body requires that qualified individuals take extensive written and oral examinations testing their skills in the prevention of injuries/illnesses, the recognition, evaluation, and immediate care of injuries/illnesses, the rehabilitation and reconditioning of injuries/illnesses, administration of this health care plan, and professional development and responsibility.

In addition, as of 1997, all individuals who practice athletic training in the State of North Carolina are required to hold a specific license to practice per General Statute (S.L 1997-387).

Team Physician

The team physician must have an unrestricted medical license and be an MD who is responsible for treating and coordinating the medical care of athletic team members. The principal responsibility of the team physician is to provide for the well being of the individual student-athletes enabling each of them to realize his/her full potential. The team physician should possess special proficiency in the care of musculoskeletal injuries and medical conditions associated with sports. The team physician also must oversee the ATC protocols filed with the North Carolina Board of Athletic Training Examiners.

First Responder

A person designated by the school to provide first aid services at athletic events. A first responder must complete and maintain certification or be in the process of completing courses in the following:

1. Cardio-pulmonary resuscitation as certified by an organization such as the American Red Cross or the American Heart Association;

2. First aid as certified by an organization such as the American Red Cross or the American Heart Association; and

3. Injury prevention and management as certified by an organization such as the National Athletic Trainers’ Association, the North Carolina High School Athletic Association. In addition, each first responder must complete 20 hours in staff development each school year.

Head Coach

All coaching personnel who may be associated with medical coverage for interscholastic sports participation shall be at least minimally qualified as stated in the NCHSA Guidelines. Starting in August 2017 all coaches will be required to be CPR/AED certified.

Athletic Training Room

Location

The Athletic Training Room is located behind the gymnasium between the girls’ and boys’ PE locker rooms.

Hours of Operation

The Athletic Training Room (ATR) will be open Monday through Friday at 12:00pm and will remain open throughout the day as indicated by the Athletic Trainer. The ATR will close at the end of the last practice/game of the day. On weekends and holidays, the ATR will be open one hour prior to practices/games.

In case of inclement weather, the ATR will close ONLY if classes are canceled. If the school has a delayed opening, then the hours of operation would commence at the regular scheduled operating hours.

If there is a conflict with scheduled games and the operation hours, coaches and players will be notified by means of a posted sign on the ATR door stating when the ATR is closing and where the Athletic Trainer will be located.

Rules

1. NO FOOD OR DRINK in the athletic training room. 2. Leave ALL equipment (i.e. balls, bags, etc.) outside the training room or in the lockers provided.3. NO cell phones, IPods, or MP3 players allowed in the athletic training room.4. NO CLEATS OR SPIKES allowed in the athletic training room or in the building.5. NO shoes allowed on the taping/treatment tables.6. Horse play and foul language will not be tolerated.7. Report to the athletic trainer before doing any treatment or rehab. NO SELF TREATMENTS.8. Supplies should only be used when the athletic trainer gives permission.9. All athletes must be clean and properly dressed (athletic shorts and t-shirt) before entering the

athletic training room unless otherwise stated by the athletic trainer.10. Return all equipment issued to you (i.e. crutches, ace wraps, pads, etc.).11. Allow ample time for pre-practice treatments. All treatments take at least 20 minutes.12. Treatment times will be arranged according to the availability of the athletic trainer and the

needs of the athletes.13. Report all injuries to your coach and athletic trainer as soon as possible.14. If an athlete goes to the doctor on their own, they MUST bring a note from that doctor clearing

them to return to sports (not just school). This includes the emergency room.15. In the event that a licensed physician, physician’s assistant or nurse practitioner states that the student-

athlete CAN return to activity, the Hough High School Athletic Training staff reserves the right to still hold the athlete if they feel it is in the best interest of the student-athlete.

16. Rehabilitation is mandatory for all athletes that are receiving daily taping treatments.

The athletic training room will be locked at all times when not in use for athletics events. These facilities are under the direct supervision of the athletic trainer; no one is allowed to use these facilities without the knowledge and approval of the athletic trainer.

ATR rules and policies will be given to every coach and student-athlete. Copies of the operating hours will be posted in the ATR and outside the door. If these rules are broken or if an athlete does not adhere to the rules and policies, the Athletic Trainer has the right to refuse treatment, and it will be the responsibility of the coach.

Rehabilitation & Treatment

All student-athletes will report to rehabilitation (rehab) at 2:15pm. Practice participation for that day will be determined at this time. Athletes that do not show up for rehab will only be allowed to practice at the discretion of the athletic trainer and respective coach.

Return to pLay Criteria

Return to Play criteria is a joint decision made by numerous individuals. In the event that a licensed physician, physician’s assistant or nurse practitioner states that the student-athlete CANNOT return to activity for a specified amount of time or prior to Hough High’s Team Physician reviewing the specific situation, than that decision MUST be adhered to.

In the event that a licensed physician, physician’s assistant or nurse practitioner states that the student-athlete CAN return to activity, the athlete must have a written note indicating so.

If the athlete has not been referred to a medical professional and has no direct recommendations from a healthcare professional, the head athletic trainer or the assistant athletic trainer will then make the decision as to when the athlete can return to play. The decision will be made with consultation of the Team Physician as necessary.

RETURN TO PLAY CRITERIA FOR AN ATHLETE THAT HAS SUSTAINED A HEAD INJURY IS SOLEY THE DECISION OF THE TEAM PHYSICIAN, OTHER PHYSICIAN IN CONSULATION WITH THE TEAM PHYSICIAN, OR HEAD ATHLETIC TRAINER. NO ATHLETE SHALL RETURN TO PLAY, EVEN WHEN CLEARED BY A PHYSICIAN, WITHOUT WRITTEN NOTICE BEING TURNED INTO THE ATHLETIC TRAINING STAFF, AND CLEARANCE BY THE ATHLETIC TRAINING STAFF. THE ATHLETIC TRAINING STAFF RESERVES THE RIGHT, EVEN UPON CLEARANCE BY A PHYSICIAN TO HOLD THE ATHLETE FROM COMPETITION IF IT IS FELT THAT IT IS IN THE BEST INTEREST OF THE ATHLETE. NO EXCEPTIONS WILL BE MADE.

In all cases, where a licensed physician, physician’s assistant, nurse practitioner, or other healthcare provider sees an athlete, the athlete must submit a written note indicating permission to return to play to the athletic trainer prior to returning to play.

Visiting team services

The following will be provided for all visiting teams:WaterInjury ice & bagsBiohazard bagsEmergency Equipment—crutches, splints, AED

If a team is traveling without at Athletic Trainer, written permission and directions for the use of modalities (tape, heat, stretch, etc) for each athlete requiring treatment should be provided. Please also provide your team’s Athletic Trainer’s telephone number if he/she needs to be contacted. No athlete from a visiting team will receive treatment without written consent.

Emergency Action PlanThe following emergency action plan is a general outline for William A. Hough High School Sports Medicine Department. Specific emergency plans for each individual sport and/or athletic facility/venue detailing emergency phone numbers, entrances and access routes, emergency phone locations, etc. are available in both sports medicine facilities and can be found in the Appendix of this manual. With athletic association practice and competition, the first responder to an emergency situation is typically a member of the sports medicine staff, most commonly a certified athletic trainer. A team physician will not usually be present at practices or competition. The type and degree of sports medicine coverage for an athletic event may vary widely, based on such factors as the sport or activity, the setting, and the type of training or competition. It is expected that every full-time athletic staff member, volunteer coach, and student-athletic trainers make themselves 100% knowledgeable about all facets of the Emergency Action Plan.

NOTE: In the event that a certified athletic trainer is not on site during an emergency due to coverage guidelines, it is the coach’s responsibility to initiate the Emergency Action Plan.**All members of the emergency response team must make sure a member of the Sports Medicine staff, the Principal, and the Athletic Director are notified of any/all student-athletes taken to the Emergency Room, regardless of the transportation method.

Emergency Phone Numbers

Ambulance/Police/Fire9-911 (on-campus phone)911 (off-campus/pay phone)

Poison Control Center—1-800-222-1222

Cornelius Police Department—(704) 892-1363

North Mecklenburg Rescue Squad—(704) 875-1457

Erica Schultz, Athletic TrainerOffice: 980.344.0514 ext 4300288ATR Main: 980.344.0514 ext 4300286Field House: 980.344.7060 ext 4300273Cell: (704) 972-6188

Ray Beltz, Athletic TrainerCell: (704) 562.5405

Masanori Toguchi, Athletic DirectorOffice: 980.344.0514 ext 4300282Cell: (704) 499-1854

Presbyterian-Huntersville ER—(704) 316-4090

CMC-University ER—(704) 510-4960

CMC-Main ER—(704) 347-2210

Dr. Kevin J. Stanley, Orthopeadic PhysicianOrthoCarolinaAddress: Physicians Plaza, 10030 Gilead Road,

Suite 130, HuntersvillePhone: (704) 323-2819

Northcross Urgent Care (8am-8pm)Address: 16455 Statesville Road, Suite 106,

HuntersvillePhone: (704) 801-1085

Off-Campus PracticeIn an emergency situation that takes place at an off-campus facility, the developed emergency plan for that specific facility will take affect and cooperation with the facility administration is required.

On-Campus Practices

1. Hough High School Sports Medicine personnel and/or other appropriate personnel will go onto the field/court to evaluate the student-athlete, and if necessary, administer basic life support, and stabilize the student-athlete until EMS arrives.

If the injury is a suspected football cervical spine injury, in-line head and shoulder stabilization will be maintained by the certified athletic trainer or the team physician while the facemask is removed as indicated using standard protocols.

If the injury is a suspected non-football cervical spine injury, in-line head and shoulder stabilization will be maintained by the certified athletic trainer or the team physician as per standard protocol.

The student-athlete will be placed on a spine board using standard protocols once EMS arrives. If the injury is a suspected cardio-respiratory emergency, the certified athletic trainer and/or other

appropriate personnel will retrieve, set-up, and use the automated external defibrillator as per State of North Carolina protocols.

2. Hough High School Sports Medicine personnel, a member of the coaching staff, and/or other personnel will immediately use the closest available device to call EMS (911 from a non-campus phone, 9-911 from a campus phone) and direct them to the appropriate location.

3. A member of the athletic staff will proceed to pre-determined locations to wait for EMS, direct them to the proper location, and guide them onto the field/court.

4. Remaining persons will assist with crowd control and securing an unobstructed and safe passageway for EMS personnel.

5. A member of the Hough High School Sports Medicine staff, a member of the coaching staff, and/or a member of the Hough High School athletic department will accompany the injured student-athlete to the medical facility with the injured student-athlete’s emergency medical information.

Once at the medical facility, the designated individual will call back to the certified athletic trainer’s cellular phone with any medical updates.

6. The certified athletic trainer will also call Masanori Toguchi, Athletic Director, and/or his designee to provide any medical updates.

7. The certified athletic trainer, a member of the coaching staff, and/or a member of the Hough High School Athletic Department staff will contact the parent/guardian of the respective student-athlete.

Home Games




The student-athlete will be placed on a spine board using standard protocols once EMS arrives. If the injury is a suspected cardio-respiratory emergency, the certified athletic trainer and/or other

appropriate personnel will retrieve, set-up, and use the automated external defibrillator as per State of North Carolina protocols.


3. After activating EMS, game management personnel should notify all applicable personnel to discontinue all cheerleading and band activities, promotions, commercial announcements, etc.

4. Game management personnel and/or other personnel will proceed to pre-determined locations to wait for EMS, direct them to the proper location, and guide them onto the field/court.

5. Game management personnel and/or other personnel will assist with crowd control and securing an unobstructed and safe passageway for EMS personnel.





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Venue Directions: Football / Soccer / Track & FieldField stadium is located on Bailey Road, directly behind the school. From Bailey Road driving east, turn right on Bailey Glen Drive. Take first left entering the bus parking lot. Football field is on right, just beyond the baseball field. Emergency personnel will enter field at gate between baseball and football venues.




The student-athlete will be placed on a spine board using standard protocols once EMS arrives. If the injury is a suspected cardio-respiratory emergency, the certified athletic trainer and/or other appropriate

personnel will retrieve, set-up, and use the automated external defibrillator as per State of North Carolina protocols.








Bailey Road

Bailey Glen

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Venue Directions: Baseball / Softball The baseball and softball stadiums are located on Bailey Road, directly behind the school and to the right of the football stadium. From Bailey Road driving east, turn right on Bailey Glen Drive. Take first left entering the bus parking lot. Baseball field is located directly on the right; softball field is located behind the baseball field.













Bailey Road

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Venue Directions: Gymnasium / Weight RoomHough High School gymnasium is located on Bailey Road. From Bailey Road driving east, turn right into main school entrance. Take circle to enter through main lobby.













Gym

Bailey Road

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Venue Directions: Tennis CourtsThe tennis courts are located on Bailey Road, directly behind the school (southeast corner). From Bailey Road driving east, turn right into student parking lot (entrance immediately following main school entrance). Drive through parking lot toward back of school. Tennis courts will be on left and right.













Bailey Road Bailey Road

Student Parking Lot

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Automated External Defibrillator (AED)Policies and Procedures

Medical Necessity for Use of AEDDefibrillation is a recognized means of termination of certain potentially fatal arrhythmias during a cardiac arrest. Automated external defibrillators, or AEDs, accurately analyze cardiac rhythms and, if appropriate, advise/deliver an electric counter-shock. AEDs are currently widely used by trained emergency personnel and have become an essential link in the “chain of survival” as defined by the American Heart Association.

Early access Early CPR by first responders or bystanders Early defibrillation Early advanced life support

It is recognized that successful resuscitation is related to the length of time between the onset of a heart rhythm that does not circulate blood (ventricular fibrillation or VF, pulseless ventricular tachycardia) and defibrillation. The AHA states that with every minute it takes to respond, the chance for successful defibrillation decreases 7-10%. The provision of timely emergency attention saves lives. Athletic events (both practice and competition) present a high risk for cardiopulmonary emergencies. Therefore, by training certified athletic trainers and team physicians in the use of AEDs, the emergency response time is shortened.

Explanation of the Use of AEDAutomated external defibrillator, or AED, means a defibrillator which:

is capable of cardiac rhythm analysis will charge and deliver a counter-shock after electrically detecting the presence of cardiac dysrhythmia is capable of continuous recording of the cardiac dysrhythmia at the scene is capable of producing a hard copy of the electrocardiogram

Written Medical Protocol Regarding Use of AEDUse of the AED will follow the American Heart Association AED treatment algorithm. The AED is to be used only on patients in cardiopulmonary arrest. Before the device is utilized to analyze the patient’s ECG rhythm, the patient must be:

unconscious pulseless, and not breathing

The device is, however, not intended for children less than eight years of age and/or victims weighing less than 90 pounds. Hough High School sports medicine staff will shock until “no shock indicated” message is received. VF is not longer present, the patient converts to a perfusing rhythm, or an advanced life support team arrives on scene and assumes control.

Provisions to Coordinate with Local EMSIn the event of a cardiopulmonary emergency, the 911 emergency system should be activated as quickly as possible. The first responders should provide initial care as appropriate to the situation and coordinate with other emergency medical service providers upon their arrival in the provision of CPR, defibrillation, basic life support, and advanced life support.

Operator ConsiderationsThe AED is intended for use by personnel (coaches, certified athletic trainers, and team physicians) who are authorized by a physician/medical director and have, at a minimum, the following skills and training:

CPR training certification AED training certification Training in the use of the AEDs located on site

Location of and Maintenance Required for AEDsHough High School has two (2) AED units. They are housed in the following locations:

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Main Office Main Athletic Training Room

During all outdoor practices, competitions, and scrimmages an AED will be located on the Sports Medicine Gator.

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GENERAL ASSEMBLY OF NORTH CAROLINA SESSION 2011

SESSION LAW 2011-147 HOUSE BILL 792

AN ACT TO ENACT THE GFELLER-WALLER CONCUSSION AWARENESS ACT.

The General Assembly of North Carolina enacts:

TITLE OF ACT SECTION 1. This act may be known and cited as the Gfeller-Waller Concussion Awareness Act.

DEVELOPMENT OF AN ATHLETIC CONCUSSION SAFETY TRAINING PROGRAM SECTION 2.(a) The Matthew A. Gfeller Sport-Related Traumatic Brain Injury Research Center at UNC-Chapel

Hill in consultation with the North Carolina Medical Society, the North Carolina Athletic Trainers Association, the Brain Injury Association of North Carolina, the North Carolina Neuropsychological Society, the North Carolina High School Athletic Association, Inc., and the Department of Public Instruction shall develop an athletic concussion safety training program. The program shall be developed for the use of coaches, school nurses, school athletic directors, volunteers, students who participate in interscholastic athletic activities in the public schools, and the parents of these students.

SECTION 2.(b) The program shall include, but not be limited to, the following: (1) Written information detailing the recognition of the signs and symptoms of concussions and other head injuries. (2) A description of the physiology and the potential short-term and long-term effects of concussions and other head injuries. (3) The medical return-to-play protocol for postconcussion participation in interscholastic athletic activities.

CONCUSSION SAFETY REQUIREMENTS FOR INTERSCHOLASTIC ATHLETIC COMPETITION SECTION 3. G.S. 115C-12(23) reads as rewritten: "(23) Power to Adopt Eligibility Rules for Interscholastic Athletic Competition. – The State Board of

Education may shall adopt rules governing interscholastic athletic activities conducted by local boards of education, including eligibility for student participation. With regard to middle schools and high schools, the rules shall provide for the following: a. All coaches, school nurses, athletic directors, first responders, volunteers, students who

participate in interscholastic athletic activities, and the parents of those students shall receive, on an annual basis, a concussion and head injury information sheet. School employees, first responders, volunteers, and students must sign the sheet and return it to the coach before they can participate in interscholastic athletic activities, including tryouts, practices, or competition. Parents must sign the sheet and return it to the coach before their children can participate in any such interscholastic athletic activities. The signed sheets shall be maintained in accordance with sub-subdivision d. of this subdivision. For the purpose of this subdivision, a concussion is a traumatic brain injury caused by a direct or indirect impact to the head that Page 2 Session Law 2011-147 SL2011-0147 results in disruption of normal brain function, which may or may not result in loss of consciousness.

b. If a student participating in an interscholastic athletic activity exhibits signs or symptoms consistent with concussion, the student shall be removed from the activity at that time and shall not be allowed to return to play or practice that day. The student shall not return to play or practice on a subsequent day until the student is evaluated by and receives written clearance for such participation from (i) a physician licensed under Article 1 of Chapter 90 of the General Statutes with training in concussion management, (ii) a neuropsychologist licensed under Article 18A of Chapter 90 of the General Statutes with training in concussion management and working

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in consultation with a physician licensed under Article 1 of Chapter 90 of the General Statutes, (iii) an athletic trainer licensed under Article 34 of Chapter 90 of the General Statutes, (iv) a physician assistant, consistent with the limitations of G.S. 90-18.1, or (v) a nurse practitioner, consistent with the limitations of G.S. 90-18.2.

c. Each school shall develop a venue specific emergency action plan to deal with serious injuries and acute medical conditions in which the condition of the patient may deteriorate rapidly. The plan shall include a delineation of roles, methods of communication, available emergency equipment, and access to and plan for emergency transport. This plan must be (i) in writing, (ii) reviewed by an athletic trainer licensed in North Carolina, (iii) approved by the principal of the school, (iv) distributed to all appropriate personnel, (v) posted conspicuously at all venues, and (vi) reviewed and rehearsed annually by all licensed athletic trainers, first responders, coaches, school nurses, athletic directors, and volunteers for interscholastic athletic activities.

d. Each school shall maintain complete and accurate records of its compliance with the requirements of this subdivision pertaining to head injuries.

The State Board of Education may authorize a designated organization to apply and enforce the Board's rules governing participation in interscholastic athletic activities at the high school level."

EFFECTIVE DATE SECTION 4. This act is effective when it becomes law and applies beginning with the 2011-2012 school year. In the General Assembly read three times and ratified this the 13th day of June, 2011.

s/ Walter H. Dalton President of the Senate

s/ Dale R. Folwell Speaker Pro Tempore of the House of Representatives

s/ Beverly E. Perdue Governor

Approved 11:55 a.m. this 16th day of June, 2011

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GFELLER-WALLER/NCHSAASTUDENT-ATHLETE

CONCUSSION MANAGEMENT PACKET

Page 1. Gfeller-Waller/NCHSAA Student-Athlete Concussion Evaluation Athlete’s Information Injury History Tenets of Concussion Management NCHSAA specific requirements regarding Gfeller -Waller Law

Page 2. Medical Provider Recommendations

Page 3. Concussion Return-To-Learn Recommendations

Page 4. Concussion Gradual Return-to-Play Protocol FAQs Sheet

Page 5. NCHSAA Concussion Return to Play Protocol Form

La s t Upda ted June 2016

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Gfeller-Waller/NCHSAA Concussion Evaluation

All medical providers are encouraged to review the CDC site if they have questions regarding the latest information on the evaluation and care of the scholas tic athlete following a concus sion injury. Providers s hould refer to NC Session La w 2011-147, House Bill 792 Gfeller-Waller Concuss ion Awa reness Act for requirements for cleara nce, a nd please initia l a ny recommendations you s elect.(Ada pted from the Acute Concussion Evaluation (ACE) ca re plan ( h t t p : // w w w . c d c . g o v / c o n c u s s i o n / i n d e x . h t m l ) a nd the NCHSAA concussion Return to Play Protocol

Form.) Athlete’s Name Date of Birth School Team/Sport INJURY HISTORY Pers on Compl eti ng Inj ury Hi s tory Secti on (ci rcl e one): Li cens ed Athl eti c Tra i ner | Fi rs t Res ponder | Coa ch | Pa rentDa te of Inj ury _ _ Na me of pers on compl eti ng form: _ _ _ _ __ □ Pl ea s e s ee a tta ched i nforma ti on

F o ll o w i n g t h e i n j u r y, d i d t h e a t h l e t e e x p e r i e n c e : C i r c l e on e Du r a t i o n ( wr i t e n u m b e r / c i r c l e a pp r op r i a t e )

C omm e n t s Loss of consciousness or unresponsiveness? YES | NO minutes / hoursSeizure or convulsive activity? YES | NO minutes / hoursBalance problems/unsteadiness? YES | NO hrs / da ys / weeks /continuesDizziness? YES | NO hrs / da ys / weeks /continuesHeadache? YES | NO hrs / da ys / weeks /continuesNausea? YES | NO hrs / da ys / weeks /continuesEmotional Instability (abnormal laughing, crying,anger?)

YES | NO hrs / da ys / weeks/ continues

Confusion? YES | NO hrs / da ys / weeks /continuesDifficulty concentrating? YES | NO hrs / da ys / weeks /continuesVision problems? YES | NO hrs / da ys / weeks /continuesOther YES | NO

Des cri be the i nj ury, or gi ve a ddi ti ona l deta i ls :

Key Tenets of Concussion management:1. No athlete with a suspected concussion is allowed return to practice or play the same day that his or her head

injury occurred.2. Athletes should never return to play or practice if they still have A N Y s y m p t o m s .3. A concus s i on i s a tra uma ti c bra in i njury tha t ca n pres ent i n s evera l wa ys a nd wi th a va ri ety of s i gns , s

ymptoms , a nd neurol ogi c defi ci ts tha t ca n pres ent i mmedi a tel y or evol v e over ti me.4. Provi ders s houl d a ddres s a cademi c a nd cogni ti ve cons i derati ons when ma na gi ng a n a thl ete wi th a concus s i on. The NC

Dept. of Publ i c Ins truction now requi res a “Return to Lea rn” pl a n for s tudents wi th s us pected hea d i nj ury . Al s o, cons i der gui da nce on proper s l eep hygi ene, nutri ti on a nd hydra ti on.

5. More tha n one eva l ua ti on i s typi ca lly neces s a ry for medi ca l cl ea rance for concus s ion. Due to the need to moni torconcus s i ons for recurrence of s i gns a nd s ymptoms wi th cogni ti ve or phys i ca l s tres s , E m e r g e n c y R oo m a n d U r g e n t C a r e phy s i c i a n s t yp i c a lly d o no t m a k e c l e a r a n c e d e c i s i on s a t t h e t i m e o f fi r s t v i s i t .

6. In order to cl ea r a n a thl ete to return to s port wi thout res tri cti on, a n a thl ete s houl d be compl etel y s ymptom -free both a tres t AND wi th cogni ti ve s tres s , then wi th ful l phys i cal exerti on (i .e. ha s compl eted return to pl a y protocol ).

7. It i s typi ca l ly not fea s i bl e for a provi der to di a gnos i s a n a cute concus s ion a nd provi de cl ea ra nce on the s a me da y .

NCHSAA specific requirements regarding Gfeller-Waller law (as defined by NCHSAA Sports Medicine Advisory Committee)

1. The NCHSAA requi res a l l NC publ i c hi gh s chool a nd mi ddl e s chool a thl etes to ha ve a n MD/DO s i gna ture on the form to return to pl a y.

2. The phys i ci a n s igning thi s form i s l i cens ed under Arti cl e 1 of Cha pter 90 of the Genera l Sta tutes a nd ha s tra i ni ng i n concus s i on ma na gement.

3. A phys i ci an ma y del ega te a s pects of the RTP proces s to a l i cens ed a thl eti c tra i ner, nurs e pra cti ti oner or phys i ci an

http://www.cdc.gov/concussion/index.html

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a s s i sta nt, a nd ma y work i n col l a boration wi th a l i cens ed neurops ychol ogi st i n compl i a nce wi th the Gfel l er -Wa l l erConcus s i on La w for RTP cl ea ra nce.


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Medical Provider Recommendations(to be completed by a medical provider)

Name of Athlete:

Thes e recommenda ti ons a re ba s ed on toda y’s eva l ua ti on.

RETURN TO SCHOOL:PLEASE NOTE

1. Th e North Ca rolina State Board of Ed ucation a pproved “Return -To - Le arn a fter Con cussion” p olicy e ffective 2016-2017 s ch ool year to a dd ress l earning and ed ucational n eeds for stud ents following a concu ssion .

2. A s a mple of s pecific “Re turn to Learn ” accommodations is foun d on p age 3.

SCHOOL (ACADEMICS): □ Out of s chool unti l _.(Check a l l tha t a ppl y) □ Ma y return to s chool on _ _

wi th Return-To-Lea rn Accommoda ti ons (see page 3).

□ Ma y return to s chool now wi th no a ccommoda ti ons needed.

PHYSI CAL EDUCATION: □ Do NOT return to PE cl a s s a t thi s ti me. □ Us e PE cl a s s a s a s tudy ha l l.□ Ma y pa rti ci pa te i n non-conta ct a cti vi ty tha t pos es no ri s k of hea d tra uma. □ Ma y return to PE cl a s s wi thout res tri cti on.

RETURN TO SPORTS:PLEASE NOTE

An e xa mp le of Retu rn-to-Play e xertional p rogression is foun d on p age 5. A s tep wise p rogression of p hysical a nd cogn i tive e xertion is widely a ccepted as the ap prop riate a pproach to e nsure a concussion h as resolved, a nd a na thl ete can re turn to s port s afely to s port.

SPORTS: □ Not cl ea red for s ports pra cti ce or competi ti on a t thi s ti me.(Check a l l tha t a ppl y) □ Ma y s ta rt return to pl a y progres s i on under the s upervi s i on of the hea l th ca re provi der.

□ Ma y be a dva nced ba ck to competi ti on a fter phone convers a ti on wi th a ttendi ng phys i ci an .□ Mus t return to medi ca l provi der for fi na l cl ea rance/repea t eva l ua ti on a nd recommenda ti ons i n da ys .□ Ha s compl eted a gra dua l RTP progres s i on w/o a ny recurrence of s ymptoms & i s cl ea red for ful l pa rti cipati on .

Ad d i tional comments/instructions:

Ph ys i cian Na me (please print) MD or

DO Si gn ature (Required)

Da te

Offi ce Ad dress

Ph on e Nu mb er

All NC public high school and middle school athletes must have an MD/DO signature to return to play.More than one evaluation is typically necessary for medical clearance for concussion as symptoms may not fully present for days. Due to the need to monitor concussions for recurrence of signs & symptoms with cognitive or physical stress, E m e r g e n c y R o o m an d U r g e n t C a r e ph y s i c i a n s t y p i c a l l y d o n o t m a ke c l e a r a n c e d e c i s i o n s a t th e t i m e o f f i r s t v i s i t . Physician signing this form is licensed under Article 1 of Chapter 90 of the GeneralStatutes and has training in concussion management.

A physician may delegate aspects of the RTP process to a licensed athletic trainer, nurse practitioner or physician assistant, and may work in collaboration with a licensed neuropsychologist in compliance with the Gfeller -Waller Concussion Law for RTP clearance.

Me d i cal Provid er Name (please p rint)

NP, PA-C, LAT, Ne u rop sych ologist (please circle on e)

Offi ce Ad dress

Ph on e Nu mb er

Si gn ature

Da te

Name and contact information of supervising/collaborating physician


Concussion Return-To-Learn Recommendations(to be completed by a medical

provider)

Name of Athlete:

Fol l owi ng a concus s ion, mos t i ndi vi dua ls typi ca lly need s ome degree of cogni ti ve a nd phys i ca l res t to fa ci l i ta te a nd expedi te recovery.Acti vi ti es s uch a s rea di ng, wa tchi ng TV or movi es , pl a yi ng vi deo ga mes , worki ng/pl a yi ng on the computer a nd/or texti ng requi re cogni ti ve effort a nd ca n wors en s ymptoms duri ng the a cute peri od a fter concus s i on. Na vi ga ting a ca demi c requi rements a nd a s chool s etti ng pres ent a cha l l enge to a recentl y concus s ed s tudent-a thl ete. A Return-To-Lea rn pol i cy fa ci lita tes a gra dua l progres sion of cogni ti ve dema nd for s tudent - a thl etes i n a l ea rni ng envi ronment. Hea l thca re provi ders s houl d cons i der whether a ca demi c a nd s chool modi fi ca ti ons ma y hel p expedi te recovery a nd l ower s ymptom burden. It i s i mporta nt to the revi ew a ca demi c/s chool s itua ti on for ea ch s tudent a thl ete a nd i denti fyeduca ti ona l a ccommoda ti ons tha t ma y be benefi ci a l .

Educa ti ona l a ccommoda ti ons tha t ma y be hel pful a re l i s ted bel ow.

R et u r n t o s c hool w i t h t he f o ll o w i ng s up p o r t s :

Length of Day Shortened da y. Recommended hours per da y unti l re-eva l ua ted or (da te) _ _ _ _. ≤ 4 hours per da y i n cl a s s (cons ider a l terna ti ng da ys of morni ng/a fternoon cl a s ses to ma xi mi ze cl a s s pa rticipati on) Shortened cl a s ses (i .e. res t brea ks duri ng cl a s ses ). Ma xi mum cl a s s l ength of mi nutes . Us e _ _ _ _ _ _ _ cl a s s a s a s tudy ha l l i n a qui et envi ronment. Check for the return of s ymptoms when doi ng a cti vi ti es tha t requi re a l ot of a t tenti on or concentra ti on.

Extra Time Al l ow extra ti me to compl ete cours ework/a s s i gnments a nd tes ts . Ta ke res t brea ks duri ng the da y a s needed (pa rti cul a rl y i f s ymptoms recur).

Homework Les s en homework by % per cl a s s ; or to a ma xi mum of mi nutes ni ghtl y, no more tha n mi n conti nuous .

Testing

Vision

No s i gni fi ca nt cl as sroom or s ta nda rdi zed tes ti ng a t thi s ti me, a s thi s does not refl ect the pa ti ent's true a bi l i ties . Li mi ted cl a s sroom tes ti ng a l l owed. No more tha n ques ti ons a nd/or tota l ti me.

Student i s a bl e to ta ke qui zzes or tes ts but no bubbl e s heets . Student a bl e to ta ke tes ts but s houl d be a l l owed extra ti me to

compl ete. Li mi t tes t a nd qui z ta ki ng to no more tha n one per da y. Ma y res ume regul a r tes t ta ki ng.

Les s en s creen ti me (computer, vi deos , etc.) to a ma xi mum mi nutes per cl a s s AND no more tha n conti nuous mi nutes (wi th 5-10 mi nute brea k i n between).

Pri nt cl a s s notes a nd onl i ne a s s ignments (14 font or l a rger recommended). Al l ow s tudent to wea r s ungl a s s es or ha t wi th bi l l worn forwa rd to reduce l i ght expos ure.

Environment Provi de a l terna ti ve s etti ng duri ng ba nd o r mus i c cl a s s (outs i de of tha t room). Provi de a l terna ti ve s etti ng duri ng PE a nd/or reces s to a voi d noi s e expos ure a nd ri s k of i nj ury (out of gym). Al l ow ea rl y cl a s s rel ea s e for cl a s s tra ns itions to reduce expos ure to ha l l wa y noi s e/a ctivity. Provi de a l terna ti ve l oca ti on to ea t l unch outs i de of ca feteri a . Al l ow the us e of ea rpl ugs when i n noi s y envi ronment. Pa ti ent s houl d not a ttend a thl eti c pra cti ce Pa ti ent i s a l l owed to be pres ent but not pa rti ci pa te i n pra cti ce, l i mi ted to hours

Additional Recommendations

Concussion Gradual Return-to-Play Protocol FAQs

Once a student-athlete is completely symptom-free at rest and has no symptoms with cognitive st imulation (e.g. reading, computer work, and schoolwork), a gradual Return-to-Play (RTP) progression can be initiated.

W h o c a n su p e r v i se t h e R T P?

The school’s athletic trainer, first responder can supervise the RTP.

W h o m u st g o t h r ou g h t h e R T P?

All student-athletes diagnosed with a concussion are required to complete a Return-to-Play Protocol that proceeds in a step- wise fashion with gradual, progressive stages.

W h a t a c t i v i t i e s a r e i n c l ud e d i n t h e R T P s t a g e s?

The RTP begins with light aerobic exercise designed only to increase your heart rate (e.g. stati onary bicycle), then progresses to increasing heart rate with movement (e.g. running), then adds increased intensity and sport -specific movements requiring more levels of neuromuscular coordination and balance including non -contact drills and finally, full practice with controlled contact prior to final clearance to competition. An athlete should only be progressed to the n e x t s t a g e i f t h e y d o no t e x p e r i e n c e a n y s i g n s / s y m p t o m s .

W h a t sh ou l d b e don e i f t h e s t ud e n t - a t h l e t e i s un a b l e t o c o m p l e t e a s t a g e su c c e ss f u ll y a f t e r tw o a tt e m p t s?

If a student-athlete is unable to complete a stage twice without return of signs/symptoms consultation with the healthcare provider is advised.

H o w d o e s t h e s t ud e n t - a t h l e t e k no w i f h e / she i s r e a d y t o a dv a n c e t o t h e n e x t s t a g e ?

After supervised completion of each stage w i t hou t p r o v o c a t i on / r e c u rr e n c e o f s i g n s / s y m p t o m s , an athlete is allowed to advance to the next stage of activity.

W h a t sh ou l d t h e s t ud e n t - a t h l e t e d o i f s i g n s / s y m p t o m s r e t u r n ?

If signs/symptoms occur with exercise, the student-athlete should stop and rest. Once free of sign/symptom for 24 hours, the student-athlete returns to the previously completed stage of the protocol that was completed without recurrence of signs/symptoms and progresses forward in the protocol. During this process, it is important that student-athletes pay careful attention to note any re turn of concussion signs/symptoms (headache, dizziness, vision problems, lack of coordination, etc.) both during and/or in the minutes to hours after each stage. In the event that signs/symptoms are experienced, they should be reported to the health care provider overseeing the RTP Protocol.


NCHSAA Concussion Return to Play Protocol FormName of Athlete: Sport: Male/Female

Date of Injury: Date Concussion Diagnosed: Date Symptom Free:

STAGE EXERCISE GOAL DATE STAGESUCESSFULLY COMPLETED

COMMENTS SUPERVISED BY

1 20-30 mi n of ca rdio a ctivity: walkin g,s ta tionary b ike.

Pe rce i ve di n te nsity/exertion : Li gh t Acti vity

2 30 mi n of ca rdio a ctivity: jogging a tme d i um pace. Bod y weight re sistance e xe rci se (e.g. p ush-ups, l unge walks)wi th mi nimal h ead rotation x 25 e a ch .

Pe rce i ve di n te nsity/exertion : Mod e ra te Activi ty

3 30 mi n u tes of ca rdio a ctivity: ru n ning a tfa s t p ace, in corp orate in tervals. I ncrease re p e titions of b od y weight re sistancee xe rci se (eg. sit-ups, p ush-ups, l unge wa l ks) x 50 e a ch . Sp ort-

Pe rce i ve di n te nsity/exertion :Ha rd Acti vity, ch anges of d i re ction withi n cre ased h ead a nde ye move ment4 Pa rti ci pate in n on-con tact p ractice

drills.Wa rm-u p a nd stretch x 10 mi n utes. I n te nse, n o n - c on t a c t , s port-specific a gi lity d rills x 30-60 mi n u tes.Cons ul t wi th phy s i cia n reg a rdi ng the

Pe rce i ve di n te nsity/exertion :Hi gh /Maximu m EffortActi vi ty

5 Pa rti ci pate in full p ractice. If i n a con tacts p ort, con trolled con tact p ra ctice a l lowed.6 Re s ume fu ll p articipation i ncomp e tition.

* * O n l y a ph y s i c i a n ca n p r o v i d e f i n a l c l ea r a n c e t o r e t u r n t o s po r t w i t hou t r e s t r i c t i on . P r i o r t o b e i n g c l ea r e d , t h e a t h l e t e m u s t b e c o m p l e t e l y s y m p t o m -f r e e bo t h a t r e s t A N D w i t h f u l l c ogn i t i v e s t r es s A N D w i t h f u l l ph y s i ca l

exe r t i o n a l s t r e s s (i. e. co m p l eted th e Retu rn - to - Pl ay Pro to co l ). **

By signing below, I attest that the above named student-athlete has completed, without return of symptoms, the GradualReturn-to-Play Protocol.

Signature of Athletic Trainer/Firs t Res ponder (Pleas e Circle) Date

Pleas e Print Nam e

By signing below, I am aware that my child has completed, without return of symptoms, the Gradual Return-to-Play Protocol.

Signature of Parent/Legal Cus todian Date

Please Print Name Last Updated June 2016

W. A. Hough High school Concussion Protocol

The following policy outlines the procedures to be followed in the management of mild traumatic brain injury (mTBI), or concussion. This policy describes baseline neurocognitive testing, initial management, serial monitoring, and return to play guidelines developed in order to provide for the safety and well being of those student-athletes participating Hough High School Athletics.

A concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. This includes a direct blow to the head, face, neck or elsewhere on the body, which creates an impulsive force transmitted to the head, resolves spontaneously and follows a sequential course although some post concussive symptoms may be prolonged.

Signs and Symptoms

SYMPTOMSPhysicalHeadacheDizzinessNauseaBalance DifficultiesLight SensitivityDouble VisionFatigueFeeling dazed, stunned, dingedRinging in the ears

CognitiveConfusionAmnesiaDisorientationPoor ConcentrationMemory DisturbanceReasoning Difficulties

EmotionalIrritabilitySadnessNervousnessDepressionMoodinessSleep Disturbances

PHYSICAL SIGNSLoss of/Impaired ConsciousnessPoor Coordination or BalanceInappropriate EmotionsVacant Stare/Glassy EyedInappropriate Behavior

Poor Coordination or BalanceSlow to Answer QuestionsVomitingSlurred speech

Concussive Convulsion/Impact SeizureSlow to Follow DirectionsEasily Distracted, Poor ConcentrationPersonality ChangesSignificantly Decreased Performance

Baseline Assessment

All incoming freshmen or those first entering Hough High School who are participating in those sports which have been identified as a high-risk contact or collision sport and/or those who have had a previous history of concussion or mTBI as identified by their health history will have a baseline neurocognitive test (ImPACT) performed as part of their athletic medical screening. The sports which currently undergo ImPACT testing are football, soccer, wrestling, basketball, baseball, softball, volleyball, cheerleading, lacrosse, rugby, diving, and pole vaulting.

Time of Injury

If concussion is suspected, a cervical spine injury should be excluded. Vital signs such as blood pressure and heart rate should be monitored.

If symptoms have cleared within 15 minutes, then the student-athlete will complete a set of sports-specific exertional drills to stimulate a return of symptoms. If symptoms do not return, then the athlete can be considered for return to play. According to state policy, any athlete that is suspected of having sustained a possible concussion cannot return to play that day and cannot return without a doctor’s note.

An athlete who has lost consciousness or has amnesia lasting longer than 15 minutes will be referred to a physician on the same day.

If the student-athlete is suffering from the following symptoms, he/she will be immediately transported to the hospital for imaging:

Prolonged loss of consciousness (>1 minute) and/or Focal neurologic deficit and/or Significant alteration or deterioration in mental status Increase in symptoms or concern that there might be a bleed

Written instructions will be given to the athlete and to another responsible adult who will observe and supervise the athlete during the acute stages of a concussion.

A checklist will be administered by the Athletic Trainer to determine the number of symptoms after the event; the student-athlete will complete the Self-Reported Symptom Scale every 24 hours until symptom free and after each graded exertional test completed by the student-athlete thereafter. This information will be shared with the referring physician during each post-concussive evaluation.

Recommendations

Student-athletes should cease doing any activity that causes the symptoms of a concussion to increase. If recommended by the Attending Physician, Tylenol or Acetaminophen may be used to help headache

symptoms. School modifications may be necessary, and should be initiated based on student-athlete’s symptoms. Student-athletes should not return to physical activity until they are symptom free and their ImPACT

testing in within normal limits.

Return to Play Decisions

If symptoms have cleared within 15 minutes, then the student-athlete will complete a set of sports-specific exertional drills to stimulate a return of symptoms. If symptoms do not return, then the athlete can be considered for return to play.

An athlete may not return to full participation in sports after a concussion for a minimum 5 days after asymptomatic assessment with physician clearance, neurocognitive testing (ImPACT) is within normal limits AND completion of the Functional Exertional Testing Protocol. Return to play should occur in gradual steps beginning with light aerobic exercise only to increase your heart rate (e.g. stationary cycle); moving to increasing your heart rate with movement (e.g. running); then adding controlled contact if appropriate; and finally return to sports competition.Pay careful attention to your symptoms and your thinking and concentration skills at each stage or activity. After completion of each step without recurrence of symptoms, you can move to the next level of activity the next day. Move to the next level of activity only if you do not experience any symptoms at the present level. If your symptoms return, let your health care provider know, return to the first level and restart the program gradually.

o Day 1: Light aerobic exercise; no resistance training Stationary bike: 10-20 minutes

o Day 2: Moderate aerobic exercise: no resistance training Continuous jogging: 10-20 minutes, target HR>140-170bpm

o Day 3: Weigh-training Session Warm-up with light, aerobic exercise Do not allow any 1-rep max or sub-maximal lifting Monitor breathing & technique throughout session

o Day 4: Sprinting (anaerobic exertion) Minimum of 5 sprints of 30 yards

o Day 5: Non-contact agility drills, Non-contact practice Sport specific activities

o Day 6: Full contact practice

This protocol should not be initiated until the student-athlete is asymptomatic and their neurocognitive testing (ImPACT) is within normal limits. If at any point during the progression post-concussive symptoms return, the student-athlete will revert back to the previous asymptomatic step after he/she returns to an asymptomatic state. If symptoms do not resolve, the Attending Physician should be consulted and appropriate medical attention should be provided.

RETURN TO PLAY CRITERIA FOR AN ATHLETE THAT HAS SUSTAINED A HEAD INJURY IS SOLEY THE DECISION OF THE TEAM PHYSICIAN, OTHER PHYSICIAN IN CONSULATION WITH THE TEAM PHYSICIAN, OR HEAD ATHLETIC TRAINER. NO ATHLETE SHALL RETURN TO PLAY, EVEN WHEN CLEARED BY A PHYSICIAN, WITHOUT WRITTEN NOTICE BEING TURNED INTO THE ATHLETIC TRAINING STAFF, AND CLEARANCE BY THE ATHLETIC TRAINING STAFF. THE ATHLETIC TRAINING STAFF RESERVES THE RIGHT, EVEN UPON CLEARANCE BY A PHYSICIAN TO HOLD THE ATHLETE FROM COMPETITION IF IT IS FELT THAT IT IS IN THE BEST INTEREST OF THE ATHLETE. NO EXCEPTIONS WILL BE MADE.

Multiple concussions

Athletes who sustain a second concussion within the same competitive season or an adjacent season will be referred to a physician and will not be allowed to return to play without the physician’s clearance. These student-athletes should not begin the Functional Exertional Protocol for a minimum of 9 days following asymptomatic self-report and normalization of all testing measures, and cannot return to full contact participation until 15 days following normalization of all testing measures.

Heat Illness Prevention and ManagementHeat illness is inherent in athletic participation and can produce many different types of medical problems. Heat illness primarily will affect those athletes involved in high-intensity or long-duration exercise. The incidence of heat illness increases as ambient temperature and relative humidity increase, but can occur in the absence of hot and humid conditions.

Risk Factors for Heat Illness Dehydration Barriers to evaporation (i.e. athletic

equipment, rubber suits) Current or recent illness History of heat illness Increased body mass index Wet bulb globe temperature previous

night/day Poor physical condition Excessive or dark-colored clothing or

equipment

Overzealous athletes Lack of acclimatization Certain medications & drugs Electrolyte imbalance Predisposing medical conditions Poor diet Heavy/salty sweaters Certain supplements and/or ergogenic aides Low percent body fat

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Prevention & Recommendations

The National Athletic Trainers’ Association recommends educating student-athletes on the effects of dehydration and over-hydration on physical performance. Identify student-athletes susceptible to heat illness and dehydration prior to participation and developing a subsequent hydration protocol can optimize hydration status throughout participation. In addition, acclimatization to the weather or climate can help prevent heat loss. The process of acclimatization can take up to 12 or more days in adolescents and should begin prior to the start of the season.

Recognition & Management

Exercise-Associated Muscle (Heat) CrampsSigns & Symptoms TreatmentDehydrationThirstSweatingTransient muscle crampsFatigue

Stop activity; move to shaded, cool areaProvide sodium-containing fluidMild stretching with massage of muscle spasmPlace student-athlete in recumbent positionGive athlete Heat Illness Warning sheetD/C participation that day; RTP next day if weight loss

is <3% and athlete’s hydration status is WNL

Heat SyncopeSigns & Symptoms TreatmentBrief episode of faintingDizzinessTunnel visionPale or sweaty skinDecreased pulseNormal body temp

Stop activity; move to shaded, cool areaProvide sodium-containing fluidMonitor vital signsElevate legs above headGive athlete Heat Illness Warning sheetD/C participation that day; RTP next day if weight loss

is <3% and athlete’s hydration status is WNL

Heat ExhaustionSigns & Symptoms TreatmentRaised body temperature (<104°F)Headache, dizziness, faintnessNormal blood pressureTachycardia (rapid heart rate)Weak pulseDehydrationCold, damp, ashen skinNausea and/or vomitingProfuse sweating

Stop activity; move to shaded, cool areaRemove equipment/constrictive clothingMonitor vital signsElevate legs above head Provide sodium-containing fluidPlace ice towels on athletePlace ice bags on athlete’s neck, wrists, ankles, groin, behind knees, under armsGive athlete Heat Illness Warning sheetD/C participation that day; Consult with physician;

RTP 48 hours if weight loss is <3% and athlete’s hydration status is WNL

Exertional Heat Stroke Signs & Symptoms TreatmentSudden onsetRaised body temperature (<104°F)Pulse rate > 160 bpmRapid respirations (20-30 rpm)Hot, dry, flushed skinNausea/vomitingLack of perspirationDry mouth and/or intense thirst

LIFE-THREATENING EMERGENCY. SEEK IMMEDIATE MEDICAL ATTENTION.Stop activity; activate EMS immediatelyRemove from environmentRemove equipment/constrictive clothingMaintain ABCsMonitor vital signsUtilize ice tub/cold whirlpool

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Headache, dizziness, confusion, lethargyStaggering body control, poor judgmentDecreasing consciousnessConvulsion/muscle spasms

Provide sodium-containing fluidNo RTP until written clearance by MD 3-5 day

progressive RTP

Exertional HyponatremiaSigns & Symptoms TreatmentRaised body temperature (<104°F)Nausea/vomitingExtremity (hands/feet) swellingLow blood-sodium levelsProgressive headacheConfusionSignificant mental compromiseLethargyAltered consciousnessPulmonary edemaCerebral edemaSeizuresComa

LIFE-THREATENING EMERGENCY. SEEK IMMEDIATE MEDICAL ATTENTION.Stop activity; activate EMS immediatelyRemove from environmentRemove equipment/constrictive clothingMaintain ABCsMonitor vital signsUtilize ice tub/cold whirlpoolDo NOT administer fluids without MD consentNo RTP until written clearance by MD 3-5 day

progressive RTP

Sickle Cell TraitSigns & Symptoms TreatmentRBC can sickle during exertion in heat MIMICS

CRAMPINGTriggered by heat stress, dehydration, and/or lactic

acidosisCOLLAPSE EARLY IN EXERCISEHYPERVENTILATIONMEDICAL EMERGENCY

LIFE-THREATENING EMERGENCY. SEEK IMMEDIATE MEDICAL ATTENTION.Stop activity; activate EMS immediatelyRemove from environmentRemove equipment/constrictive clothingMaintain ABCsMonitor vital signsProvide fluidsNo Day 1 fitness testsStop at first cramp

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2.3 HEALTH AND SAFETY

2.3.1 Fundamentals of Heat Illness Prevention and Management:(a) A Certified Athletic Trainer or First Responder MUST be in attendance at all football practices and

games.(b) The vast majority of serious heat illness occurs during the first week of practice/training. The key to

appropriate acclimatization should consist of gradually increasing the amount of time ofenvironmental exposure (heat and humidity) while progressively increasing physical exertion andtraining activities is the key to appropriate acclimatization.(1) Begin with shorter, less intense practices and training activities, with longer recovery

intervals between bouts of activity.(2) Minimize protective gear during first several practices, and introduce additional uniform and

protective gear progressively over successive days. (e.g. in football, helmets only, no shoulderpads).

(3) Emphasize instruction over conditioning during the first several practices.(c) Keep each athlete’s individual level of conditioning and medical status in mind and adjust activity

accordingly. These factors directly affect exertional heat illness risk. For example, there is an increasedrisk of heat injury if the athlete is obese, unfit, has been recently ill (particularly gastrointestinalillness), has a previous history of exertional heat illness, has Sickle Cell Trait, or is using certainmedications. Players at risk should be identified from their pre-participation examination.

(d) High temperatures and high humidity are potentially dangerous for athletes. In these conditions,lower the intensity of practices and increase the frequency and duration of rest breaks, and considerreducing uniform and protective equipment. Also, be sure to monitor all players more closely asconditions are increasingly warm/humid, especially if there is a change in weather from the previousfew days.

(e) Athletes should begin practices and training activities adequately hydrated.(f ) Recognize early signs of distress and developing exertional heat illness (weakness, nausea/vomiting,

paleness, headache, lightheadedness). Promptly remove from activity, and treat appropriately. Firstaid should not be delayed.

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(g) Recognize more serious signs of exertional heat illness (clumsiness, confusion, stumbling, collapse, obvious behavioral changes and/or other central nervous system problems), immediately stop activity, begin rapid cooling, and activate the Emergency Medical System.

(h) All schools should have a heat illness prevention and management policy for all sanctioned activities and this policy must be followed.

(i) A venue-specific Emergency Action Plan (EAP) with clearly defined written and practiced procedures should be developed and in place ahead of time.

(j) Prior to the season all coaches, athletic training personnel and first responders working with the team should review the signs and symptoms of heat illness and the emergency action plan for their school.

(k) A Wet Bulb Globe Temperature (WBGT) chart should be available at practices and contests. IF an in strument to assess WBGT is unavailable, the heat and humidity guidelines chart should be used.

(l) Supplies to assess WBGT (or alternatively, heat and humidity on site), to assess core temperature, and to provide for rapid cooling should be on-site for all practices and games as environmental conditions require.

2.3.2 Acclimatization:(a) Days 1–5 are the first formal practices. No more than 1 practice occurs per day.(b) Total practice time should not exceed 3 hours in any 1 day.(c) 1-hour maximum walk-through is permitted on days 1–5, however there must be a minimum 3 hour

break in a cool environment between practice and walk-through (or vice versa).(d) During days 1–2 of first formal practices, a helmet should be the only protective equipment permitted

(if applicable). During days 3–5, only helmets and shoulder pads should be worn (if applicable).Beginning on day 6, all protective equipment may be worn and full contact may begin.(1) Football only: on days 3–5, contact with blocking sleds and tackling dummies may be

initiated.(2) Full-contact sports: 100% live action drills should begin no earlier than day 6.

(e) Day 6–14, double-practice days must be followed by a single-practice day. On single-practice days,1 walk-through is permitted, separated from the practice by at least 3 hours of continuous rest. Whena double-practice day is followed by a rest day, another double practice day is permitted after the restday.

(f ) On a double-practice day, neither practice day should exceed 3 hours in duration, and no more than5 total hours of practice in the day. During the 2 hour practice, there can be NO live action. Warm-up,stretching, cool-down, walk-through, conditioning and weight-room activities are included as part ofthe practice time. The 2 practices should be separated by at least 3 continuous hours in a coolenvironment.

(g) Because the risk of exertional heat illnesses during the preseason heat-acclimatization period is high,we strongly recommend that an athletic trainer be on site before, during and after all practices.(Adapted from Korey Stringer Institute, 2015)

2.3.3 Prevention of Heat Illness:(a) The wet bulb globe temperature (WBGT) reading using a scientifically approved device for

measuring WBGT should be used in all instances regarding heat and humidity issues and illnesses.Use of the WBGT reading is recommended for the 2016-17 academic year. WBGT readings will bemandatory for the 2017-2018 academic year. Readings should be taken every hour beginning 30minutes before the beginning of practice. Refer to the WBGT chart. If unable to obtain WBGT reading,obtain onsite heat and humidity levels and refer to the heat index chart. Reliable heat and humiditylevels should be taken on site. Avoid using readings from locations more than 5 miles away.

(b) As WBGT (or heat index) increases, minimize clothing and equipment.(c) Provide unlimited drinking opportunities during hotter practices. NEVER withhold water from

athletes.(d) Pre and post-practice weigh-ins SHOULD be conducted. NOTE: an athlete who is not within 3% of the

previous pre-practice weight should be withheld from practice. These athletes should be counseledon the importance of re-hydrating. Pre and post-practice weigh-ins are recommended for all sportsparticipating during periods of high heat and humidity.

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WBGT Index and Athletic Activity ChartWBGT Index (F) Heat Index Athletic Activity Guidelines

Less than 80 Less than 80 Unlimited activity with primary cautions for new or unconditioned athletes or extreme exertion; schedule mandatory rest/water breaks (5 min water/rest break every 30 min)

80 - 84.9 80 - 90 Normal practice for athletes; closely monitor new or unconditioned athletes and all athletes during extreme exertion. Schedule mandatory rest/water breaks. (5 min water/rest break every 25 min)

85 - 87.9 91 - 103 New or unconditioned athletes should have reduced intensity practice and modifications in clothing. Well-conditioned athletes should have more frequent rest breaks and hydration as well as cautious monitoring for symptoms of heat illness. Schedule frequent mandatory rest/water breaks. (5 min water/rest break every 20 min) Have cold or ice immersion pool on site for practice.

88 - 89.9 104 - 124 All athletes must be under constant observation and supervision. Remove pads and equipment. Schedule frequent mandatory rest/ water breaks. (5 min water/rest break every 15 min) Have cold or ice immersion pool on site for practice.

90 or Above 125 and up SUSPEND PRACTICE

Temperature

NOAAA’s National Weather Service

Heat Index ChartHumidity 80 82 84 86 88 90 92 94 96 98 100 102 104 106 108 110

40 80 81 83 85 88 91 94 97 101 105 109 114 119 124 130 136

45 80 82 84 87 89 93 96 100 104 109 114 119 124 130 137

50 81 83 85 88 91 95 99 103 108 113 118 124 131 137

55 81 84 86 89 93 97 101 106 112 117 124 130 137

60 82 84 88 91 95 100 105 110 116 123 129 137

65 82 85 89 93 98 103 108 114 121 128 136

70 83 86 90 95 100 105 112 119 126 134

75 84 88 92 97 103 109 116 124 132

80 84 89 94 100 106 113 121 129

85 85 90 96 102 110 117 126 135

90 86 91 98 105 113 122 131

95 86 93 100 108 117 127

100 87 95 103 112 121 132Likelihood of Heat Disorders with Prolonged Exposure or Strenuous Activity

Caution Extreme Caution Danger Extreme Danger

2.3.4 Recognition of Heat Illness:(a) Heat Exhaustion

(1) The clinical criteria for heat exhaustion generally include the following:(i) Athlete has obvious difficulty continuing with exercise(ii) Body temperature is usually 101 to 104°F (38.3 to 40.0°C) at the time of collapse or

need to drop out of activity.(iii) No significant dysfunction of the central nervous system is present (e.g., seizure,

altered consciousness, persistent delirium)(2) If any central nervous system dysfunction develops, such as mild confusion, it resolves

quickly with rest and cooling.(3) Patients with heat exhaustion may also manifest:

(i) Tachycardia (very fast heart rate) and hypotension (low blood pressure)(ii) Extreme weakness(iii) Dehydration and electrolyte losses(iv) Ataxia (loss of muscle control) and coordination problems, syncope (passing out),

light-headedness(v) Profuse sweating, pallor (paleness), “prickly heat” sensations(vi) Headache(vi) Abdominal cramps, nausea, vomiting, diarrhea(vii) Persistent muscle cramps

(b) Heat Stroke(1) The two main criteria for diagnosing exertional heat stroke:

(i) Rectal temperature above 104°F (40°C), measured immediately following collapseduring strenuous activity.

(ii) Central Nervous System dysfunction with possible symptoms and signs:disorientation, headache, irrational behavior, irritability, emotional instability,confusion, altered consciousness, coma, or seizure.

(2) Most patients are tachycardic and hypotensive.(3) Patients with heat stroke may also exhibit:

(i) Hyperventilation(ii) Dizziness(iii) Nausea(iv) Vomiting(v) Diarrhea(vi) Weakness(vii) Profuse sweating(viii) Dehydration(ix) Dry mouth(x) Thirst(xi) Muscle cramps(xii) Loss of muscle function(xiii) Ataxia

(4) Absence of sweating with heat stroke is not typical and usually indicates additionalmedical issues.

2.3.5 Management of Heat Illness:(a) A primary goal of management of heat illness is to reduce core body temperature as quickly as

possible. When exertional heat stroke is suspected, immediately initiate cooling, and then activate emergency medical system. Remember “Cool First, Transport Second”.

(b) Remove all equipment and excess clothing(c) If appropriate medical staff is present, assess athlete’s rectal temperature(d) Immerse the athlete in a tub of cold water (the colder the better). Water temperature should be

between 35 to 60°F (2 to 15˚C); ice water is ideal but even tepid water is helpful. Maintain anappropriately cool water temperature. Stir the water vigorously during cooling.

(e) Monitor vital signs (rectal temperature, heart rate, respiratory rate, blood pressure) and mentalstatus continually. Maintain patient safety.

(f ) Cease cooling when rectal temperature reaches 101 to 102°F (38.3 to 38.9°C)(g) If an immersion pool is unavailable or in cases of heat exhaustion, use these cooling methods:

(i) Place icepacks at head, neck, axillae and groin.(ii) Bathe face and trunk with iced or tepid water.(iii) Fan athlete to help the cooling process.

(iv) Move athlete to a shaded or air conditioned area if available near the practice site.

The heat index is defined by the National Weather Service as the combination of air temperature (Fahrenheit degrees) and relative humidity (percent). This produces a reading of how the air feels to human skin. This “apparent temperature” or “heat index” for a particular day will dictate any cancellations or restricted game and practice conditions. The chart below converts temperature and humidity into heat index.

National Weather Service Heat Index Chart

The weather will be monitored by the athletic training staff and any accommodations to games and practices will be determined from there. Accommodations may also need to be made due to air quality. Asthmatic athletes may also have a more difficult time due to air quality.Heat Index Reading….. Restrictions105 or greater…… Danger! Discontinue regular practice. All outside athletic events are to be

canceled. Very short restricted practice is permitted. Practice indoors if possible.95-104……. Extreme Caution! Modify practice with frequent (required) water breaks.

Games/events may continue with mandatory official time outs midway through quarters. Observe athletes carefully for signs of heat injuries. Make sure athletes drink water.

84-93……. Warning. Provide plenty of water, and ensure that they are taking a break every half hour.

Below 82….. No restrictions. Water is to be available at all times. Monitor the heat index for increases.

SEVERE WEATHER SAFETY POLICY

The certified athletic trainer and/or the athletic director will determine whether or not a practice will continue due to severe weather. During games, these individuals will be in contact with the referees to coordinate efforts to suspend, delay or postpone a game.

If any of these individuals recommends that the fields be cleared, please do so immediately. If the above individuals are not present, and lightening is spotted, please use common sense and clear the fields.The National Athletic Trainers’ Association recommends the following guidelines for lightening, which we will be following:

If severe weather is showing imminent signs, consider delaying the start of an event in order to allow the storm to pass.

If lightening is present, use a flash to bang count to determine the distance of the storm. To use the flash to bang count, begin counting when the lightening flash is seen and stop counting when thunder is heard. By the time your flash to bang count is 30 or less, all individuals should be seeking shelter in a safe area.

Once the storm has passed you must wait at least 30 minutes after the last sound of thunder or lightening flash before resuming activity. By not waiting the indicated time, you run the risk of a lightning strike by the back end of the storm.

LIGHTENING SAFE LOCATIONS Any substantial frequently inhabited building. Buildings are grounded by their plumbing and electrical

systems, so they are naturally safe. However, you should not be connected to these systems, i.e. being on the phone, taking a shower. DUG OUTS ARE NOT CONSIDERED ACCEPTABLE SHELTER. Also, the press box is not considered a safe zone. The concession stand is only considered one, if all doors and windows are completely closed.

The secondary choice for a safer location is in an enclosed vehicle with a metal roof and closed windows. Convertible cars do not provide protection from lightening danger. It is important not to touch any part of the car’s metal frame while inside it during a lightning storm.

SPECTATORS MUST ALSO CLEAR THE AREA DURING A LIGHTENING DELAY. THEY MAY NOT REMAIN IN THE STANDS.

CARE FOR THE LIGHTENING STRUCK ATHLETE:If anyone is struck by lightning, EMS should be activated immediately. Next, the condition of the athlete should be evaluated and appropriate care provided. CPR should be administered if needed. Those still conscious should be treated for shock until EMS arrives.In event of a tornado, all fields must be cleared and athletes and spectators should report to the main building.

Communicable Disease & Skin Infection Procedures

The North Carolina High School Athletic Association (NCHSAA) has adopted the National Federation Guidelines (NFG) in an effort to minimize the possibility of transmission of any infectious disease during a high school athletic practice or contest. Each school is strongly encouraged to develop its own action plan for the prevention of the transmission of infectious diseases.

Communicable Disease and Skin Infection ProceduresWhile the risk for blood-borne infectious diseases, such as HIV/Hepatitis B, remains low in sports, proper precautions are needed to reduce the risk of spreading diseases. Along with these issues are skin infections that occur due to skin contact with competitors and equipment.

Universal Hygiene Protocol for All Sports Shower immediately after all competition and practice Wash all workout clothing after practice Wash personal gear, such as knee pads, periodically Don’t share towels or personal hygiene products with others Refrain from (full body) cosmetic shaving

Infectious Skin DiseasesMeans of reducing the potential exposure to these agents include:

Notify guardian, athletic trainer and coach of any lesion before competition or practice. Athlete must have a health-care provider evaluate lesion before returning to competition.

If an outbreak occurs on a team, especially in a contact sport, consider evaluating other team members for potential spread of the infectious agent.

Follow NFHS or NCHSAA guidelines on “time until return to competition.” Allowance of participation with a covered lesion can occur if approved by health-care provider and in

accordance with NFHS or NCHSAA guidelines.

Blood-Borne Infectious DiseasesMeans of reducing the potential exposure to these agents include:

Bleeding must be stopped immediately and all wounds covered. All blood-soaked clothing must be removed before continuing competition or practice.

Contaminated clothing must be cleaned before using again. Athletic trainers or caregivers need to wear gloves and take other precautions to prevent blood-splash from

contaminating themselves or others. Immediately wash contaminated skin or mucous membranes with soap and water. Clean all contaminated surfaces and equipment with disinfectant before returning to competition. Be sure to

use gloves with cleaning. Any blood exposure or bites to the skin that break the surface must be reported and evaluated by a medical

provider immediately.

These procedures were obtained and revised by the NFHS (August 2005)

Authorization to Use a Prescribed Appliance in an Athletic Contest

Must meet NFHS rule requirements. Officials have the final authority to approve the appliance at the time of the contest.

N OT E: Fo r m is s til l r eq u i r e d, b u t d oe s N O T re q ui r e N CH S AA a ppr o v a l .

Student’s Name Grade Age

School Class

Sport Uniform #

Injury

Appliance

The above student is permitted to participate in athletics while wearing the prescribed appliance, assuming all other stipulations as decreed by the National Federation of High School Associations are met. This appliance is being used for the sole purpose of protecting an existing injury and is, under no circumstance, to be used as a weapon, to gain an unfair advantage, or abuse an opponent.

Licensed Medical Physician Signature

AddressAddress including city/state/zip

Telephone _ Date

Parent/Guardian Signature

AddressAddress including city/state/zip

Telephone Date

Head Coach’s SignatureHead coach is responsible for NFHS uniform & appliance rule compliance and MUST sign this form.

UPDATED 8/23/07

The parties below have read and approved this policy and procedure manual and Emergency Action Plan

W.A. Hough Principal, __________________________________________ Date: _____________Dr. Laura Rosenbach

W.A. Hough Athletic Director, _____________________________________ Date: _____________Masanori Toguchi

W.A. Hough, Carolinas Healthcare Athletic Trainer,______________________________ Date: _____________ Erica Schultz

This Policy and Procedure Manual has been updated on July 18, 2016.

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