Concussion Management Protocol

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    Concussion - Initial Assessment-Use this assessment tool for student who reports, or has been observed to have, an injury to the head or body, that could expect to result in a concussion.

    Student Name: ▁▁▁▁▁▁ DOB: ▁▁▁▁▁▁ Age: ▁▁▁▁▁▁ 

    Date:  ▁▁▁▁▁▁

    Injury Characteristics

    Date/Time Injury:  ▁▁▁▁▁▁

    Reporter: Student ▁▁▁▁▁▁ Parent  ▁▁▁▁▁▁ Other  ▁▁▁▁▁▁

    Injury Description:  ▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁▁

    Is there evidence of a forcible blow to the head (direct or indirect?)  ▁▁▁▁ Yes   ▁▁▁▁ No   ▁▁▁▁Unknown

    Is there evidence of intracranial injury or skull fracture?  ▁▁▁▁ Yes   ▁▁▁▁ No   ▁▁▁▁Unknown

    Location of impact:  ▁▁▁▁ Front   ▁▁▁▁ Left side   ▁▁▁▁ Right side  ▁▁▁▁ Left top ▁▁▁▁ Right top   ▁▁▁▁ Back  ▁▁▁▁ Indirect

    Cause: ▁▁▁▁ MVA ▁▁▁▁ Fall   ▁▁▁▁ Assault  ▁▁▁▁ Sports (specify)▁▁▁▁▁▁▁▁▁▁▁▁ Other ▁▁▁▁▁▁▁▁▁▁▁▁

    Amnesia Retrograde Are there any events just BEFORE the event that he/she has no memory of? ▁▁▁▁ Yes   ▁▁▁▁ No    Duration ▁▁▁▁

    Amnesia Anterograde: Are there any events just AFTER the event that he/she has no memory of? ▁▁▁▁ Yes   ▁▁▁▁ No    Duration ▁▁▁▁

    Loss of Consciousness: Dis he/she los consiousness? ▁▁▁▁ Yes   ▁▁▁▁ No    Duration ▁▁▁▁

    Seizures: Were seizures observed?


    DANGER SIGNS: (check all that apply)

    Assess and moniotr for symptoms of possible serious cervical or brain injury. Contact EMS immediately and transfer to an emergency room if he/she has:

    • Seizure
    • Slurred Speech
    • Repeated nausea or vomiting
    • Difficulty recognizing people or places
    • Increasing confusion, restlessness, agitation or unusual behavior
    • Loss of consciousness or changing/deteriorating level of consciousness
    • Neck pain
    • Headache that worsens
    • Weakness, numbness, facial drooping
    • Persistent decreased coordination or unsteady gait
    • One pupil larger than the other
    • Obvious sign of skull fracture (blood or clear fluid draining from ear or clear fluid draining from nose)

    EMS Notified ▁▁▁▁ Yes   ▁▁▁▁ No    Time of Call▁▁▁▁  Time of Arrival▁▁▁▁

    Symptom Checklist: (check all that apply)

    Remove student from all school and athletic activities for 24 hours and moniotr for symptoms of consussion including:

    • Confusion
    • Headache
    • Vision problems
    • Nausea, Vomiting
    • Concentration problems
    • Confusion
    • Headache
    • Vision problems
    • Nausea, Vomiting
    • Concentration problems
    • Sleep issues
    • Memory issues
    • Balance problems
    • Irritability, sadness

    Initiate Concussion Protocol:

    Parent/Guardian/Adult Emergency Contact Notified: ▁▁▁▁ Yes   ▁▁▁▁ No    Date/Time ▁▁▁▁  Name of Contact▁▁▁▁

    Transfer to care of Prent/Guardian/Adult Emergency Contact: Name of Contact▁▁▁▁  Time of Arrival▁▁▁▁

    Concussion Team Coordinator Notified:▁▁▁▁ Yes   ▁▁▁▁ No    Date/Time▁▁▁▁  Name of Contact▁▁▁▁

    Evaluator's Name:▁▁▁▁▁▁▁▁▁▁▁▁            Signature: ▁▁▁▁▁▁▁▁▁▁▁▁