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Concussion Evaluation: On the Sideline

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.

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Concussion Evaluation: On the Sideline

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  1. Concussion Evaluation: On the Sideline Jennifer E Sanders, MD Pediatric Emergency Medicine Fellow Icahn School of Medicine at Mount Sinai Department of Emergency Medicine

  2. Financial Disclosures • None Department of Emergency Medicine

  3. Case 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? Department of Emergency Medicine

  4. Objectives/Goals • 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 Department of Emergency Medicine

  5. Who is responsible? • Physicians • Nurses • Athletic trainers • Coaches • Parents Department of Emergency Medicine

  6. Recognizing the injury • Impact may be obvious or subtle • Play may not stop after the injury • Players may minimize or deny symptoms 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.  Department of Emergency Medicine

  7. Signs and symptoms • Somatic symptoms • Physical signs • Behavioral / emotional changes • Cognitive impairment • Sleep disturbance Department of Emergency Medicine

  8. Initial response • ABCs • C-spine evaluation • Remove child from play • Serial monitoring Department of Emergency Medicine

  9. On-field assessment tools • 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) Department of Emergency Medicine

  10. On-field assessment tools • SAC- 1 point drop • 80-94% sensitivity • 76-91% specificity • BESS- 3 point increase • 34-64% sensitivity • 91% specificity • SCAT • unknown Department of Emergency Medicine

  11. On-field assessment tools • 15-20 minute battery • Includes: • Glascow Coma Score • SAC • Modified BESS Department of Emergency Medicine

  12. Department of Emergency Medicine

  13. SCAT-3 • 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? Department of Emergency Medicine

  14. SCAT-3 • Symptom evaluation • 22 symptoms • Likert scale • Self reported Department of Emergency Medicine

  15. SCAT-3 • SAC Cognitive assessment • Orientation • Immediate memory • Concentration • Delayed recall Department of Emergency Medicine

  16. Department of Emergency Medicine

  17. SCAT-3 • Neck exam • Range of motion • Tenderness over spinous processes • Upper and lower limb sensation and strength Department of Emergency Medicine

  18. SCAT-3 • Balance Examination (modified BESS) • Double leg stance • Single leg stance* • Tandem stance • Tandem gait *Not included in SCAT-3 Child Department of Emergency Medicine

  19. 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 Department of Emergency Medicine

  20. SCAT-3 • Tandem stance • Heel-to-toe with dominant foot in back • Weight evenly distributed across both feet • Hands on hips • Eyes closed Department of Emergency Medicine

  21. 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 Department of Emergency Medicine

  22. 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 Department of Emergency Medicine

  23. SCAT-3 • Coordination • Finger-nose-finger (1 point) • 5 repetitions in <4 seconds • SAC Delayed Recall • Recall word list (5 points) Department of Emergency Medicine

  24. SCAT-3 • Scores can be followed over time • SCAT-3 is not intended to diagnose concussion Department of Emergency Medicine

  25. Return to play? • 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 Department of Emergency Medicine

  26. Protective equipment • No protective equipment has been clinically shown to prevent concussions • Helmets • Helmet add-on products • Mouth guards 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. Department of Emergency Medicine

  27. When to refer to ED? • Loss of consciousness • Focal neurologic deficit • Unequal pupil size • Severe symptoms • Decreasing mental status • Uncontrolled vomiting • GCS <15 Department of Emergency Medicine

  28. Questions? Department of Emergency Medicine

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