Appendix C1: Tool to Identify a Suspected Concussion

Identification of Suspected Concussion

Following a significant impact to the head, face, neck, or body that is either observed or reported, a concussion must be suspected in the presence of any one or more of the signs or symptoms outlined below and/or the failure of the Quick Memory Function Assessment.

 

First, assess the danger to the victim and the rescuer, and then check airway, breathing and circulation.

 

COMPLETE APPROPRIATE STEPS BELOW.

 

The student was observed for signs and symptoms of a concussion.

 

No signs or symptoms described below were noted at the time of assessing the student/athlete.

 

 

Note: Continued monitoring of the student/athlete is important as signs and symptoms of a concussion may appear hours or days later (refer to Step D).

The following signs were observed or symptoms reported (refer to Step A or Step B).

 

 

STEP A

If any one or more of the following Red Flag sign(s) or symptom(s) are present, call 911. Then call parents/guardians/emergency contact.

 

Red Flag(s) sign(s) and/or symptoms.

·   Neck pain or tenderness

·   Severe or increasing headache

·   Deteriorating conscious state Double vision

·   Seizure or convulsion

·   Vomiting

·   Weakness or tingling/burning in arms or legs Loss of consciousness

·   Increasingly restless, agitated or combative

 

If Red Flag(s) are identified, complete only Step D – Action to be taken.

 

 

If Red Flag(s) have not   been identified, please complete the following steps.  

 

STEP B

Other Sign(s) and Symptoms(s)

If red flag(s) are not identified continue and complete the following steps (as applicable) and Step D

·   Action to be taken.

STEP B1

Other Concussion Signs

Check for visual cues (what you see).

·   Lying motionless on the playing surface (no loss of consciousness)

·   Disorientation or confusion, or an inability to respond appropriately questions

·   Balance, gait difficulties, motor incoordination, stumbling, slow laboured movements

·   Slow to get up after a direct or indirect hit to the head

·   Blank or vacant look

·   Facial injury after head trauma

 

STEP B2

 

Other Concussion Symptoms reported (what the student is saying)

Check for what the student feels:

·   Headache

·   Blurred Vision

·   More emotional  

·   Difficulty concentrating

·   “Pressure in head”

·   Sensitivity to light

·   More irritable

·   Difficulty remembering

·   Balance problems

·   Sensitivity to noise

·   Sadness

·   Feeling slowed down

·   Nausea

·   Fatigue or low energy

·   Nervous or anxious

·   Feeling like “in a fog"

·   Drowsiness

·   “Don’t feel right”

·   Dizziness

IF ANY SIGN(S) OR SYMPTOM(S) WORSEN, CALL 911

STEP C: Perform Quick Memory Function Assessment

Ask the student the following questions and record the answers below. Failure to answer any one of these questions correctly may indicate a concussion.

Note : It may be difficult for younger students (under the age of 10), students with special needs or students for whom English is not their first language to communicate how they are feeling. Select the most appropriate questions for the student based on their ability to respond.

 

Primary/Junior Student Questions

 

 

·   What is your name?   Answer:___________________________________________

·   How old are you?   Answer:___________________________________________

·   What grade are you in?   Answer:__________________________________________

·   What is your teacher’s name?   Answer:___________________________________________

·   What room are we in right now?

 

Answer: ____________________________________________

 

·   What activity/sport/game are we playing now?

 

Answer: ____________________________________________

 

·   What field are we playing on today?

 

Answer: ___________________________________________

 

·   What part of the day is it?

 

Answer: ___________________________________________

 

·   What is the name of your teacher/coach?

 

Answer: __________________________________________

 

What school do you go to?

 

·   Answer: __________________________________________

 

 

Comments:

 

 

 

 

STEP D: Action to be taken

Red Flag(s) sign(s) observed and/or symptom(s) reported and EMS called. Parent/guardian (or emergency contact) contacted.

 

 

Signs observed or Symptoms reported:

 

 

 

If there are any signs observed or symptoms reported, or if the student/athlete fails to answer any of the above questions correctly:

·   a concussion should be suspected;

·   the student/athlete must be immediately removed from play and must not be allowed to return to play that day even if the student/athlete states that they are feeling better; and

·   the student/athlete must not:

o   leave the premises without parent/guardian (or emergency contact) supervision;

o   drive a motor vehicle until cleared to do so by a medical doctor or a nurse practitioner; and

o   take medications except for life threatening medical conditions (for example, diabetes, asthma).

In all cases of a suspected concussion, the student/athlete must be examined by a medical doctor or nurse practitioner for diagnosis and must follow the Concussion Policy.

No signs observed or symptoms reported:

 

 

·   Student to be monitored for 24 hours and removed from physical activity (where sign(s) and/or symptom(s) were not identified but a possible concussion event was recognized by supervising school staff/volunteers).

·   Monitoring of the student/athlete to take place at home by parents and at school by school staff.

·   To monitor for signs and symptoms parents/guardians can refer to Step A and B on the front of this information form.

·   If any signs or symptoms emerge, the student/athlete needs to be examined by a medical doctor or nurse practitioner as soon as possible that day.

Comments:

 

 

 

 

 

 

 

 

School Contact/Teacher/Coach Name:____________________________	Date _________________

 

Following the completion of this form (Appendix C1, and OSBIE Incident Report Form must be completed, indicating that the tool has been completed and the parent/guardian has received copies.

  *The original copy is filed with the principal   *Duplicate copy provided to parent/guardian Reproduced and adapted with permission form Ophea, (Ontario Physical Education Safety Guidelines, 2018).

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