Know Your Concussion ABCs—for School Nurses

What is a concussion?

A concussion is a type of brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head. Concussions can also occur from a fall or blow to the body that causes the head and brain to move rapidly back and forth. Even what seems to be a mild bump to the head can be serious.

How can I recognize a concussion?

To help you recognize a concussion, ask the injured student or witnesses of the incident about:

1. Any kind of forceful blow to the head or to the body that resulted in rapid movement of the head, AND
2. Any change in the student’s behavior, thinking, or physical functioning. (See the signs and symptoms of concussion.)

How can concussions happen in schools?

Children and adolescents are among those at greatest risk for concussion. Concussions can result from a fall, or any time a student’s head comes into contact with a hard object, such as the floor, a desk, or another student’s head or body. The potential for a concussion is greatest during activities where collisions can occur, such as during physical education (PE) class, playground time, or school-based sports activities.

Students may also get a concussion when doing activities outside of school, but then come to school when symptoms of the concussion are presenting. For example, adolescent drivers are at increased risk for concussion from motor vehicle crashes.

Concussions can have a more serious effect on a young, developing brain and need to be addressed correctly. Proper recognition and response to concussion symptoms in the school environment can prevent further injury and can help with recovery.

What are the signs and symptoms of concussion?

Students who experience one or more of the signs and symptoms listed below after a bump, blow, or jolt to the head or body should be referred to a health care professional experienced in evaluating for concussion.

There is no one single indicator for concussion. Rather, recognizing a concussion requires a symptom assessment. The signs and symptoms of concussion can take time to appear and can become more noticeable during concentration and learning activities in the classroom. For this reason, it is important to watch for changes in how the student is acting or feeling, if symptoms become worse, or if the student just “doesn't feel right.”

Signs observed by school nurses

• Appears dazed or stunned
• Is confused about events
• Answers questions slowly
• Repeats questions
• Can’t recall events prior to the hit, bump, or fall
• Can’t recall events after the hit, bump, or fall
• Loses consciousness (even briefly)
• Shows behavior or personality changes

Symptoms reported by the student

Thinking/Remembering

• Difficulty thinking clearly
• Difficulty concentrating or remembering
• Feeling more slowed down
• Feeling sluggish, hazy, foggy, or groggy

Physical

• Headache or “pressure” in head
• Nausea of vomiting
• Balance problems or dizziness
• Fatigue or feeling tired
• Blurry or double vision
• Sensitivity to light or noise
• Numbness or tingling
• Does not “feel right”

Emotional

• Irritable
• Sad
• More emotional than usual
• Nervous

Sleep*

• Drowsy
• Sleeps less than normal
• Sleeps more than normal
• Has trouble falling asleep

*Only ask about sleeping symptoms if the injury occurred on a prior day.

Remember, you can’t see a concussion and some students may not experience or report symptoms until hours or days after the injury. Most young people with a concussion will recover quickly and fully. But for some, concussion signs and symptoms can last for days, weeks, or longer.

What are concussion danger signs?

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. The student should be taken to an emergency department right away if s/he exhibits any of the following danger signs after a bump, blow, or jolt to the head or body:

• One pupil larger than the other
• Is drowsy or cannot be awakened
• A headache that gets worse and does not go away
• Weakness, numbness, or decreased coordination
• Repeated vomiting or nausea
• Slurred speech
• Convulsions or seizures
• Cannot recognize people or places
• Becomes increasingly confused, restless, or agitated
• Has unusual behavior
• Loses consciousness (even a brief loss of consciousness should be taken seriously)

What can school nurses and school professionals do?

Below are steps for you to take when a student comes to your office after a bump, blow, or jolt to the head or body.

• Observe student for signs and symptoms of concussion for a minimum of 30 minutes.
• Complete the Concussion Signs and Symptoms Checklist and monitor students consistently during the observation period. The form includes an easy-to-use checklist of signs and symptoms that you can look for when the student first arrives at your office, fifteen minutes later, and at the end of 30 minutes, to determine whether any concussion symptoms appear or change.
• Notify the student’s parent(s) or guardian(s) that their child had an injury to the head.
  • If signs or symptoms are present: refer the student right away to a health care professional with experience in evaluating for concussion. Send a copy of the Concussion Signs and Symptoms Checklist with the student for the healthcare professional to review. Students should follow their health care professional’s guidance about when they can return to school and to physical activity.
  • If signs or symptoms are not present: the student may return to class, but should not return to sports or recreation activities on the day of the injury. Send a copy of the Concussion Signs and Symptoms Checklist with the student for their parent(s) or guardian(s) to review and ask them to continue to observe the student at home for any changes. Explain that signs and symptoms of concussion can take time to appear. Note that if signs or symptoms appear, the student should be seen right away by a healthcare professional with experience in evaluating for concussion. 

What do I need to know about students returning to school after a concussion?

Supporting a student recovering from a concussion requires a collaborative approach among school professionals, health care professionals, parents, and students. All school staff, such as teachers, school nurses, counselors, administrators, speech-language pathologists, coaches, and others should be informed about a returning student’s injury and symptoms, as they can assist with the transition process and making accommodations for a student. If symptoms persist, a 504 meeting may be called. Section 504 Plans are implemented when students have a disability (temporary or permanent) that affects their performance in any manner. Services and accommodations for students may include speech-language therapy, environmental adaptations, curriculum modifications, and behavioral strategies.

Encourage teachers and coaches to monitor students who return to school after a concussion. Students may need to limit activities while they are recovering from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms (such as headache or tiredness)to reappear or get worse. After a concussion, physical and cognitive activities — such as concentration and learning — should be carefully monitored and managed by health and school professionals.

If a student already had a medical condition at the time of the concussion (such as chronic headaches), it may take longer to recover from the concussion. Anxiety and depression may also make it harder to adjust to the symptoms of a concussion.

School professionals should watch for students who show increased problems paying attention, problems remembering or learning new information, inappropriate or impulsive behavior during class, greater irritability, less ability to cope with stress, or difficulty organizing tasks. Students who return to school after a concussion may need to:

• Take rest breaks as needed,
• Spend fewer hours at school,
• Be given more time to take tests or complete assignments,
• Receive help with schoolwork, and/or
• Reduce time spent on the computer, reading, or writing.

It is normal for a student to feel frustrated, sad, and even angry because s/he cannot return to recreation or sports right away, or cannot keep up with schoolwork. A student may also feel isolated from peers and social networks. Talk with the student about these issues and offer support and encouragement. As the student’s symptoms decrease, the extra help or support can be gradually removed.

What can I do to prevent and prepare for a concussion?

Here are some steps you can take to prevent concussions in school and ensure the best outcome for your students:

Prepare a concussion action plan. To ensure that concussions are identified early and managed correctly, have an action plan in place before the start of the school year. This plan can be included in your school or district’s concussion policy. You can use the online action plan for sports and recreation activities at: www.cdc.gov/concussion/response/html. Be sure that other appropriate school and athletic staff know about the plan and have been trained to use it.

Educate parents, teachers, coaches, and students about concussion. Parents, teachers, and coaches know their students well and may be the first to notice when a student is not acting normally. Encourage teachers, coaches, and students to:

• Learn about the potential long-term effects of concussion and the dangers of returning to activity too soon.
• Look out for the signs and symptoms of concussion and send students to see you if they observe any or even suspect that a concussion has occurred.
• View videos about concussion online at: www.cdc.gov/Concussion.

Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous concussion — usually within a short period of time (hours, days, or weeks) — can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death. Keep students with a known or suspected concussion out of physical activity, sports, or playground activity on the day of the injury and until a health care professional with experience in evaluating for concussion says they are symptom-free and it is OK for the student to return to play.

Create safe school environments. The best way to protect students from concussions is to prevent concussions from happening. Make sure your school has policies and procedures to ensure that the environment is a safe, healthy place for students. Talk to all school staff and administrators and encourage them to keep the physical space safe, keep stairs and hallways clear of clutter, secure rugs to the floor, and check the surfaces of all areas where students are physically active, such as playing fields and playgrounds. Playground surfaces should be made of shock-absorbing material, such as hardwood mulch or sand, and maintained to an appropriate depth. Proper supervision of students is also important.

Monitor the health of your student athletes. Make sure to ask whether an athlete has ever had a concussion and insist that your athletes are medically evaluated and are in good condition to participate in sports. Keep track of athletes who sustain concussions during the school year. This will help in monitoring injured athletes who participate in multiple sports throughout the school year.

Some schools conduct preseason baseline testing (also known as neurocognitive tests)to assess brain function — learning and memory skills, ability to pay attention or concentrate, and how quickly someone can think and solve problems. If an athlete has a concussion, these tests can be used again during the season to help identify the effects of the injury. Before the first practice, determine whether your school would consider baseline testing.

For more information and toolkits for youth sports coaches and high school coaches, visit www.cdc.gov/Concussion.