Dr Simon Kemp Chief Medical Officer - The Rugby Football Union. Acute sideline assessment & the role of the SCAT5

Transcription

1 Dr Simon Kemp Chief Medical Officer - The Rugby Football Union Acute sideline assessment & the role of the SCAT5

2 What do I do? Chief Medical Officer Rugby Football Union, UK Team Physician Sports Physician Parkside Hospital & Royal Ballet Lower School, SW London

3 Learning objectives Participants will be able to use the CRT and SCAT5 tools appropriately in the sideline/pitch side assessment of concussion

4 Concussion Recognition and Diagnosis Recognised to be the most difficult sports injury to consistently recognise and diagnose Why Varied presentations Variation in time scales and presenting features Appearances may overlap with other (brain & non brain) injuries Severe TBi, Neck, peripheral vestibular, face etc No single objective side-line screening or diagnostic tool

5 Head injury events

6 SIDE LINE ASSESSMENT WHERE NO HEALTH CARE PROFESSIONAL IS PRESENT Community and age-group sport Recognise and Remove Head injury event & Any symptom of concussion or Any sign of concussion

7 SIDE LINE ASSESSMENT WHERE A TRAINED HEALTH CARE PROFESSIONAL IS PRESENT Key concept Rapid screening for a suspected SRC rather than a definitive diagnosis of head injury Multi time point assessments Immediately mins post head injury At the end of the game hrs later Positive at any time = concussion

8 Initial triage of head injury in contact and collision sports Minor, moderate and severe head injuries AVPU V or below: Cannot exclude c-spine injury Extrication from the field of play with c-spine immobilised Mild and mild end of minor head injuries AVPU Alert (talking spontaneously) Determine if concussion should be suspected Player removed from the field of play for more detailed assessment

9 The index of suspicion & the screening toolbox Probable Definite On field /observable signs Symptoms Play on and monitor Possible Balance Cognition Remove from field to screen Clinical judgement Video review

10 LOC Tonic posturing Ataxia Clearly dazed Convulsion Threshold for removal Observable signs Head impact where The diagnosis is not apparent With the potential to result in concussive injury

11 Threshold for removal

12 WHAT DOES THE EVIDENCE SAY? Based on a systematic review of the literature an evidenced based recommendation for any individual screening test or protocol is not possible. The best approach therefore is with a multimodal testing approach based on consensus and the SCAT5 (+/- video)

13 Understand That screening sensitivity typically increases as tests of discrete domains are added But specificity falls The limitation of brief on field- assessments with lower specificity Maddocks questions The value of baseline SCAT5 screening That in competition athlete focus may enhance sideline test performance

14 SCAT5 - the model for acute side-line assessment Review Video for Observable signs If seen concussion is confirmed Maddock s questions SAC Balance Assessment Symptom checklist Neurological screen Difference from normal Informing Doctors clinical judgement 1 Maddocks error, SAC < baseline, Reduced balance or 1 symptom no return

15 Understand the range of side-line screening presentations Transient observable signs but all subsequent exams are normal Multiple symptoms or clear deterioration compared with baseline in one or more test domains Subtle deficits that may become clearer as time passes

16 The follow-up post match assessments Full SCAT 5 post match/competition Symptoms are significant Full SCAT hrs later Delayed/late 20% Alternative diagnoses may be considered don t ignore observed signs

17 What do I do if I don t have baseline SCAT5 data and don t know the athlete? Any symptom declared in the symptom list which is not usually experienced by the player following competition or training is strongly in favour of concussion. Sport and population specific normative data Total SAC 26 or below Immediate Memory score 12 or less Concentration score (digits backwards) 2 or below Delayed recall 3 or less words Balance 3 or more errors in any element, single leg stance - 3 or more errors.

18 Sideline screening should be approached with a multi-modal approach using SCAT5 elements Act on observable signs SUMMARY Applying complex side line screening protocols in real-life environment needs skill and resources (real-time video) Subsequent serial assessments using the SCAT5 are needed Act on symptoms not usually experienced Trust your instincts and your clinical judgement