concussion evaluation: on the sideline

Concussion Evaluation: On the Sideline

Jennifer E Sanders, MDPediatric Emergency

Medicine FellowIcahn School of Medicine at

Mount SinaiDepartment of Emergency Medicine

None

Financial Disclosures

Department of Emergency Medicine

12 year old soccer player collides with another player, striking their heads together. There is no loss of consciousness. He is pulled over to this sideline where he reports he has no headache or dizziness. He is put back into the game, but has trouble finding his position on the field and runs in the direction opposite his team.

• Does this player have a concussion?• Should he be allowed to continue play?• How should he be evaluated?

Case


Know how to recognize concussion symptoms

Understand the role of concussion assessment tools

Recognize that no child with concussion or suspected of having concussion should return to play on the same day

Objectives/Goals


Physicians

Nurses

Athletic trainers

Coaches

Parents

Who is responsible?


Impact may be obvious or subtle

Play may not stop after the injury

Players may minimize or deny symptoms

Recognizing the injury


McCrea M, Barr WB, Guskiewicz KM, et al. Standard regression-based methods for measuring recovery after sport-related concussion.J Int Neuropsychol Soc. 2005;11:58-69.

Somatic symptoms

Physical signs

Behavioral / emotional changes

Cognitive impairment

Sleep disturbance

Signs and symptoms


ABCs

C-spine evaluation

Remove child from play

Serial monitoring

Initial response


Standardized Assessment of Concussion (SAC)

Balance Error Scoring System (BESS)

Sport Concussion Assessment Tool (SCAT)

• SCAT-3 (age >13 years)

• SCAT-3 Child (age 5-12 years)

On-field assessment tools


SAC- 1 point drop80-94% sensitivity76-91% specificity

BESS- 3 point increase34-64% sensitivity91% specificity

SCATunknown




15-20 minute battery

Includes: Glascow Coma Score SACModified BESS


Maddock’s Score• What venue are we at today?• Which half is it now?• Who scored last in this match?• What team did you play last week?• Did your team win the last game?

SCAT-3


Symptom evaluation• 22 symptoms• Likert scale• Self reported

SCAT-3


SAC Cognitive assessment

• Orientation• Immediate memory• Concentration• Delayed recall

SCAT-3


Neck exam• Range of motion• Tenderness over spinous processes• Upper and lower limb sensation and

strength

SCAT-3


Balance Examination (modified BESS)• Double leg stance• Single leg stance*• Tandem stance• Tandem gait

*Not included in SCAT-3 Child

SCAT-3


Double leg stance• Feet together• Hands on hips• Eyes closed

Single leg stance• Stand on non-dominant foot• Dominant leg: 30° hip flexion / 45° knee flexion• Hands on hips• Eyes closed

SCAT-3


Tandem stance• Heel-to-toe with dominant foot in back• Weight evenly distributed across both feet• Hands on hips• Eyes closed

SCAT-3


Balance testing errors• Hands lifted off iliac crest• Opening eyes• Step, stumble or fall• Moving hip into > 30° abduction• Lifting forefoot or heel• Remaining out of test position > 5 sec

SCAT-3


Tandem gait• Feet together behind starting line• Walk forward with alternate heel-to-toe gait for 3

meters• Return to starting point with same gait• 4 trials performed• Should be completed within 14 seconds

SCAT-3


Coordination• Finger-nose-finger (1 point)• 5 repetitions in <4 seconds

SAC Delayed Recall• Recall word list (5 points)

SCAT-3


Scores can be followed over time

SCAT-3 is not intended to diagnose concussion

SCAT-3


When in doubt, sit them out!

No child athlete with a concussion should return to play on the same day

Sequester essential playing equipment to avoid inadvertent return to the game

Return to play?


No protective equipment has been clinically shown to prevent concussions

• Helmets

• Helmet add-on products

• Mouth guards

Protective equipment


McGuine TA, Hetzel S, Rasmussen J, et al. The Association of the Type of Football Helmet and Mouth Guard With the Incidence of Sport Related Concussion in High School Football Players. Unpublished paper presented at 2013.AOSSM Annual Meeting. Paper 27.

When to refer to ED?


• Loss of consciousness

• Focal neurologic deficit

• Unequal pupil size

• Severe symptoms

• Decreasing mental status

• Uncontrolled vomiting

• GCS <15

Questions?


concussion evaluation: on the sideline

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