• Rapid Reviews: Use Your Head! Concussion evaluation and management

    by Dr. Christine Tomkinson. Last modified: 05/03/14

    braininjury

    What is a concussion?

    A concussion is a clinical diagnosis of a biomechanically-induced alteration in brain function. This impairment is usually reversible and often affects memory, orientation, and attention. It may or may not cause a loss of consciousness and does not show evidence of brain damage on CT or MRI scans (Blumenfeld 2010, Bloom & Blount 2013).

    Any new neurological symptom following a head trauma should be considered a concussion until proven otherwise, including headache, dizziness, and nausea. It is important to note that symptoms may arise minutes to hours after the trauma has occurred so a high level of suspicion should be maintained and reassessment performed (Bloom & Blount 2013).

    Assessment after head trauma

    In March 2013, the American Academy of Neurology (AAN) issued an updated guideline on concussion evaluation and management, based on current evidence (Giza et al. 2013). In this review, the authors evaluated multiple studies on various concussion assessment tools and found the following:

    • The Post-concussion symptom scale (graded symptom checklist) had a sensitivity of 64-89% and specificity of 91-100% in identifying a concussion in athletes, following an injury.
    • The Standardized assessment of concussion test (assessment of orientation, memory, concentration and delayed recall) had a sensitivity of 80-94% and a specificity of 76-91% in identifying a concussion.
    • Neuropsychologic testing had a sensitivity of 71-88% in identifying a concussion in adolescents to adults, with insufficient evidence to support use in preadolescent age groups.
    • The Balance error scoring system, used alone, had a sensitivity of 34-64% and a specificity of 91% in identifying a concussion, while the Sensory organization test, used alone, had a sensitivity of 48-61% and specificity of 85-90%.

    Although, in practice, these tools are often used in combination, there was insufficient evidence found to determine which combinations are most effective. The Sport Concussion Assessment Tool, 3rd edition (SCAT3) combines many of these assessment tools, along with the Glasgow Coma Scale, key features of the history, and physical exam findings, and is commonly used in side-line assessment. A copy of the SCAT3 can be found here: http://bjsm.bmj.com/content/47/5/259.full.pdf

    Using the evidence from the reviewed studies, the AAN provided several Level B recommendations:

    1. Standardized assessment tools should be used as an adjunct to evaluation of suspected concussion, in combination with history and physical assessment
    2. Team personnel (eg coaches or trainers) should immediately remove any player suspected of having a concussion from play and should not permit return to play until a full assessment has been made.
    3. The athlete with a concussion diagnosed should be prohibited from returning to play or practice until a physician has judged the concussion to have resolved and the player is asymptomatic, off medications.

    Using the SCAT Tool

    Video courtesy Affiliated Community Medical Centers YouTube channel.

    For a free online education resource on the SCAT Tool and on concussion management in rugby, visit http://www.irbplayerwelfare.com/?documentid=module&module=1

    Management after concussion

    The most important step, reflected in the AAN guidelines, is removing a player with a suspected concussion from activity immediately. A second injury can cause more severe neurological deficits which may result in lasting injury (Blumenfeld 2010, Bloom & Blount 2013). Neurocognitive rest is usually recommended for the first 24-72 hours following injury, to allow the brain’s metabolic processes to return to normal function (although those with only mild symptoms may return to school after 24 hrs). Despite a lack of studies comparing different methods of neurocognitive rest, a conservative approach is generally adopted, advising no school, TV, music, computer, phone, or physical activity (Bloom & Blount 2013).

    When to get them to the Emergency Department

    Red flag symptoms suggesting injury which may be more than a concussion include (Bloom & Blount 2013):

    1. Prolonged loss of consciousness (general defined as more than 1 minute)
    2. Clinical concern of C-spine injury (based on history and/or exam)
    3. High risk for intracranial bleeding (based on history of high velocity injury or fall from height)
    4. Concern for skull fracture
    5. Post-traumatic seizure
    6. Significant worsening of symptoms, with special emphasis on persistent nausea & vomiting, focal neurologic deficits, somnolence, slurred speech, difficulty walking, and worsening mental status

    References (non-PubMed)

    • Blumenfeld H 2010, Neuroanatomy through clinical cases, 2nd ed. Sinauer Associates inc, Sunderland.
    • Bloom J & Blount J 2013, ‘Sideline evaluation of concussion’, In UpToDate, Fields KB (Ed), UpToDate, Waltham, MA. (Accessed March 5, 2014).

    References

     
    1.

    Giza CC1, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, Gronseth GS, Guskiewicz K, Mandel S, Manley G, McKeag DB, Thurman DJ, Zafonte R. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013 Jun 11;80(24):2250-7. PMID: 23508730.

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    Dr. Christine Tomkinson

    Dr. Christine Tomkinson

    BSc BMBS Resident Physician, Neurology
    Christine is a Resident Physician in Neurology based in Ontario, Canada. She studied at the University of Guelph, Ontario and the University of Limerick, Ireland. Her main interests are stroke, dementia care and multiple sclerosis.

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