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
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None
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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.
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Does this player have a concussion?
Should he be allowed to continue play?
How should he be evaluated?
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Objectives/Goals
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Know how to recognize concussion symptoms
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Understand the role of concussion assessment
tools
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Recognize that no child with concussion or
suspected of having concussion should return to
play on the same day
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Who is responsible?
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Physicians
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Nurses
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Athletic trainers
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Coaches
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Parents
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Recognizing the injury
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Impact may be obvious or
subtle
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Play may not stop after the
injury
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Players may minimize or deny
symptoms
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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.
Signs and symptoms
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Somatic symptoms
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Physical signs
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Behavioral / emotional changes
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Cognitive impairment
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Sleep disturbance
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Initial response
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ABCs
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C-spine evaluation
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Remove child from play
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Serial monitoring
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On-field assessment tools
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Standardized Assessment of Concussion (SAC)
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Balance Error Scoring System (BESS)
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Sport Concussion Assessment Tool (SCAT)
• SCAT-3 (age >13 years)
• SCAT-3 Child (age 5-12 years)
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On-field assessment tools
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SAC- 1 point drop
 80-94% sensitivity
 76-91% specificity
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BESS- 3 point increase
 34-64% sensitivity
 91% specificity
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SCAT
 unknown
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On-field assessment tools
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15-20 minute battery
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Includes:
 Glascow Coma Score
 SAC
 Modified BESS
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SCAT-3
Maddock’s Score
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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?
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SCAT-3
Symptom evaluation
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22 symptoms
Likert scale
Self reported
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SCAT-3
SAC Cognitive assessment
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Orientation
Immediate memory
Concentration
Delayed recall
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SCAT-3
Neck exam
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Range of motion
Tenderness over spinous processes
Upper and lower limb sensation and
strength
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SCAT-3
Balance Examination (modified BESS)
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Double leg stance
Single leg stance*
Tandem stance
Tandem gait
*Not included in SCAT-3 Child
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SCAT-3
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Double leg stance
• Feet together
• Hands on hips
• Eyes closed
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Single leg stance
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Stand on non-dominant foot
Dominant leg: 30° hip flexion / 45° knee flexion
Hands on hips
Eyes closed
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SCAT-3
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Tandem stance
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Heel-to-toe with dominant foot in back
Weight evenly distributed across both feet
Hands on hips
Eyes closed
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SCAT-3
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Balance testing errors
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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
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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
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SCAT-3
Coordination
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Finger-nose-finger (1 point)
5 repetitions in <4 seconds
SAC Delayed Recall
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Recall word list (5 points)
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SCAT-3
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Scores can be followed over time
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SCAT-3 is not intended to diagnose concussion
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Return to play?
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When in doubt, sit them out!
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No child athlete with a concussion should
return to play on the same day
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Sequester essential playing equipment to
avoid inadvertent return to the game
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Protective equipment
No protective equipment has been clinically
shown to prevent concussions
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Helmets
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Helmet add-on products
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Mouth guards
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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?
• Loss of consciousness
• Focal neurologic deficit
• Unequal pupil size
• Severe symptoms
• Decreasing mental status
• Uncontrolled vomiting
• GCS <15
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Questions?
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