concussion evaluation: on the sideline
DESCRIPTION
Concussion Evaluation: On the Sideline. Jennifer E Sanders, MD Pediatric Emergency Medicine Fellow Icahn School of Medicine at Mount Sinai. Department of Emergency Medicine. Financial Disclosures. None. Department of Emergency Medicine. Case. - PowerPoint PPT PresentationTRANSCRIPT
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
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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
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Physicians
Nurses
Athletic trainers
Coaches
Parents
Who is responsible?
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Impact may be obvious or subtle
Play may not stop after the injury
Players may minimize or deny symptoms
Recognizing the injury
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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
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ABCs
C-spine evaluation
Remove child from play
Serial monitoring
Initial response
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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
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SAC- 1 point drop80-94% sensitivity76-91% specificity
BESS- 3 point increase34-64% sensitivity91% specificity
SCATunknown
On-field assessment tools
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On-field assessment tools
15-20 minute battery
Includes: Glascow Coma Score SACModified BESS
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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
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Symptom evaluation• 22 symptoms• Likert scale• Self reported
SCAT-3
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SAC Cognitive assessment
• Orientation• Immediate memory• Concentration• Delayed recall
SCAT-3
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Neck exam• Range of motion• Tenderness over spinous processes• Upper and lower limb sensation and
strength
SCAT-3
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Balance Examination (modified BESS)• Double leg stance• Single leg stance*• Tandem stance• Tandem gait
*Not included in SCAT-3 Child
SCAT-3
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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
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Tandem stance• Heel-to-toe with dominant foot in back• Weight evenly distributed across both feet• Hands on hips• Eyes closed
SCAT-3
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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
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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
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Coordination• Finger-nose-finger (1 point)• 5 repetitions in <4 seconds
SAC Delayed Recall• Recall word list (5 points)
SCAT-3
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Scores can be followed over time
SCAT-3 is not intended to diagnose concussion
SCAT-3
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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?
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No protective equipment has been clinically shown to prevent concussions
• Helmets
• Helmet add-on products
• Mouth guards
Protective equipment
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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?
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• Loss of consciousness
• Focal neurologic deficit
• Unequal pupil size
• Severe symptoms
• Decreasing mental status
• Uncontrolled vomiting
• GCS <15
Questions?
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