Concussion guidance for outdoor leaders
I have just returned from the annual conference of the British Association of International Mountain Leaders in Chamonix. The gathering is an opportunity to work with a range of industry experts to develop knowledge and skills. We have been working on developing some concussion guidance for outdoor leaders.
At the conference I ran a workshop on head injury management. This was focused on working as a leader in remote settings where recognition of concussion and associated head injuries is important, as location and timescale means access to medical help can be limited. The session focused on; recognition of concussion leading to compression, helmet removal and spinal injury management.
This guidance has come around as I was prompted by James of Marmot Tours who asked ‘How do we know if clients should continue with an activity or be stopped if they have had a heavy bang to the head?’.
Currently there is little guidance for outdoor instructors from any sector (ski-ing, cycling, biking, climbing, paddling) as to how to recognise when a bang to the head is serious enough to stop an activity for a client. Additionally when working with adults they are often motivated to achieve a personal challenge so when you ask them how they are, they often lie and say they are OK, even if they are not!
Two of the main problems are recognition of concussion and when is the head injury getting progressively worse.
How do we know when things are getting worse of when we should stop clients continuing with an activity?
In competitive team sports like rugby and increasingly football there is a strict ‘Concussion Protocol’ which is used at pitchside to decide if players should continue with the game or with training, after a bang to the head. These protocols have been around for a couple of years now and in the outdoors these could be adapted to help instructors and leaders make decisions about clients ability to continue with activities.
SportScotland has issued concussion guidance which has promoted the slogan “If in doubt, sit them out’.
This guidance has been developed from the more detailed Sport Concussion Guidance document – SCAT3 Sport Concussion Assessment Tool.
Recognition of Concussion and worsening situations
What is a concussion?
A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-specific signs and most often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following:
- Change in personality
- Confusion or dizziness
- Nausea or vomit
- Drowsiness or fatigue
- Headache or pressure in head
- Blurred vision, sensitivity to light or noise
A bang to the head can sometimes be associated with a more serious injury; skull fracture, brain compression or neck injury.
Potential signs of concussion?
A casualty who has suffered a head injury and is not alert, needs observation. Urgent evacuation to medical facilities is required if any of the following are seen; deteriorating mental status progressive, worsening symptoms (above) or new neurological signs.
How can we assess if things are stable or things are getting worse? Here is a suggested list of five simple tests for the casualty to check how they are. This should be done within 10 minutes of the incident occurring to have some baseline information from the casualty about how well their brain is working. It would be worth repeating these tests after approximately 1 hour, 3 hours, 6 hours and 24 hours.
Any sign of deterioration should be taken as evidence that the casualty needs to be seen by medical professionals.
1 Maddocks Questions
- Where are we today?
- Is it morning or afternoon?
- Where were we yesterday?
- Where did you stay last night?
2 Orientation Test
- What month is it?
- What is the date today?
- What day of the week is it?
- What year is it?
3 Immediate Memory – ‘I am going to give you a list of five items, try and remember it and I will ask you to repeat the list again in a few minutes’. Example lists;
- Elbow, Apple, Carpet, Saddle, Bubble
- Candle, Paper, Sugar, Sandwich, Wagon
4 Concentration Test – some examples
- Can you tell me the 12 months of year in order and then can you tell me in reverse?
- Can you count down from 22 subtracting 3 each time?
- I am going to give a list of four numbers, can you repeat the list in reverse order
5 Balance and Co-ordination – these are examples of thing you can do to test balance and co-ordination;
- Can you stand on one leg for 20 seconds
- Can you stand on the opposite leg for 20 seconds
- Can you stand on one leg with your eyes closed for 20 second
- Can you close your eyes and touch your nose with your first finger on your left hand
For additional information which will be of interest to Mountain Bikers, (but also relevant to all outdoor activities!) have a listen to the Downtime Podcast’s Concussion Special Episode, with Adrian Stokes of Pure Body Balance who has lots of first hand experience managing the recovery of elite athletes who’ve suffered serious concussions. There’s even a free pdf download to supplement the sportscotland resources, which is specific to managing a suspected concussion whilst out riding.