What is included in an on-field examination for a concussion?
Sport-related concussion recognition includes being able to recognize the injury on the field. This is where the healthcare providers that are out covering sports are a key member of the healthcare team and a key member in recognizing and diagnosing these particular injuries.
With the on-field evaluation, we want to make sure we implement our emergency action plan (EAP). We want to make sure we're ruling out more serious injuries by recognizing signs and symptoms of intracranial bleeding, such as loss of consciousness, cranial nerve deficits, decreasing mental status and worsening symptoms over time (Dunning et al., 2004). This should be done through a sideline evaluation that serves as the benchmark for serial assessments, with reassessment occurring at five- to ten-minute intervals, until the decision is made to refer the patient or just monitor them through the course of the practice or the game.
Our on-field primary survey should be what we do for all other emergent injuries, including a check of airway, breathing, circulation, and cervical spine. There was a lot of discussion in the Berlin meeting about associated cervicogenic issues. In the immediate care, we do want to make sure we rule out a cervical spine injury. When we get to treatment and rehabilitation, we want to make sure that we are managing those appropriately with different treatment modalities.
As part of our on-field evaluation, we want to assess the level of consciousness (i.e., whether the athlete is alert, lethargic, stuporous, semi-comatose or comatose). However, it is important to note that less than 10% of concussions result in loss of consciousness (Guskiewicz et al., 2000, 2003; McCrea et al., 2003). As such, we certainly don't want to use that as our key symptom or sign that we're looking for, because the majority of concussions are not going to involve loss of consciousness. Interestingly, loss of consciousness has not been related to severity and/or recovery (McCrory et al., 2004). Initial symptom burden tends to be a more consistent predictor of slower recovery in athletes after concussion.
The Berlin recommendations for the on-field screen include that it be a rapid screen (either "go" or "no-go"). We first want to clear the on-field signs, including any loss of consciousness, ataxia, tonic posturing or post-traumatic seizure, which at minimum results in an immediate diagnosis of concussion, but some of these can be indicative of a more severe injury (Patricios, 2017). The SCAT-5 itself includes a first page that has the immediate or on-field assessment information. You'll see several different iterations of the SCAT-5 tool in today's presentation, because it is used in conjunction with various recommendations.
The first piece is the on-field assessment where we're looking for red flags that would warrant immediate referral (Anderson & Schnebel, 2016; Hyden & Petty, 2016). These may include:
- Deteriorating level of consciousness (LOC)
- Loss of or fluctuating LOC
- Increased confusion
- Inability to recognize people and places
- Increased irritability
- Worsening headache
- Repeated vomiting (some indicate three times, although this number is somewhat arbitrary)
- Extremity numbness
- Signs of skull fracture
- Focal findings on neurologic exams (e.g., cranial nerve deficits)
- Glasgow Coma Scale of less than (<) 13
With the Berlin paradigm, after this rapid screen for a suspected sport-related concussion (SRC), you then want to assess and clear those on-field signs. If the suspicion still exists following a significant head impact, or if the patient is reporting symptoms, you would then proceed to the sideline screening using appropriate assessment tools. At this point, a more thorough diagnostic evaluation can be done, ideally in a distraction-free environment.