Although paramedics are trained in the recognition and management of traumatic brain injuries, the management of the patient with a concussion is a clinical presentation that may not be addressed in sufficient detail within paramedic education, and paramedics may be unaware of the latest evidence-based concussion treatment guidelines and recommendations. While life-support measures are rarely required in concussion injuries, it would be prudent for paramedics to familiarize themselves with this evolving area of concern in medicine. This brief overview aims to address these potential issues

Batt, Alan M

Tomkinson, Christine

Weston, Emily

English

Fanshawe College: FIRST (Fanshawe Innovation Research Scholarship Teaching)

Fanshawe CollegeFIRST: Fanshawe Innovation, Research, Scholarship, TeachingFaculty & Staff Publications - Public Safety School of Public Safety2017A Review of Concussion Recognition, Assessmentand Management for ParamedicsChristine TomkinsonMcMaster UniversityEmily WestonFanshawe College of Applied Arts and TechnologyAlan M. BattFanshawe College of Applied Arts and TechnologyFollow this and additional works at: https://first.fanshawec.ca/fhcsps_publicsafety_facultystaffpublicationsThis Article is brought to you for free and open access by the School of Public Safety at FIRST: Fanshawe Innovation, Research, Scholarship, Teaching.It has been accepted for inclusion in Faculty & Staff Publications - Public Safety by an authorized administrator of FIRST: Fanshawe Innovation,Research, Scholarship, Teaching. For more information, please contact first@fanshawec.ca.Recommended CitationTomkinson, Christine; Weston, Emily; and Batt, Alan M., "A Review of Concussion Recognition, Assessment and Management forParamedics" (2017). Faculty & Staff Publications - Public Safety. 13.https://first.fanshawec.ca/fhcsps_publicsafety_facultystaffpublications/1325AugustSeptember 2017IntroductionA concussion (orig. Latin: concutere, "to shake violently”) is a clinical diagnosis of a biomechanically-induced alteration in brain function. This impairment is usually revers-ible 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 computed tomography (CT) or magnetic resonance imaging (MRI) scans.(1,2)The internationally accepted consensus definition of concussion incorporates several criteria.(3)1.  Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to the head.2.  Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.3.  Concussion may result in neuro-patho-logical changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury, and as such, no abnormality is seen on standard structural neuroimag-ing studies.4.  Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.Although paramedics are trained in the recognition and management of traumatic brain injuries, the management of the patient with a concussion is a clinical presentation that may not be addressed in sufficient detail within paramedic education, and paramedics may be unaware of the latest evidence-based concussion treatment guidelines and recommendations. While life-support measures are rarely required in concussion injuries, it would be prudent for paramedics to familiarise themselves with this evolving area of concern in medicine. This brief overview aims to address these potential issues.EpidemiologyThe incidence and prevalence of concus-sions is felt to be largely underreported with some estimates in the United States quoting up to 3.8 million per year. Even more difficult to quantify is the number of individuals suffering long-term sequelae of concussion, with up to 36% of patients reporting repeat concussions thereby placing them at higher risk for perma-nent injury.(4)High-risk activitiesConcussions are most often associated with sports and most research has investigated the concussion risk associated with individual sports. Risk differs depending on the sex of the A REVIEW OF CONCUSSION RECOGNITION, ASSESSMENT AND MANAGEMENT FOR PARAMEDICSAuthorsChristine Tomkinson BMBS BSc (Hons.)1, Emily Weston BPHE (Hons.) BEd2, Alan M. Batt MSc2-4 1. McMaster University, Hamilton, Ontario, Canada.  2. Fanshawe College, London, Ontario, Canada.3. Centre for Paramedic Education and Research, Hamilton Health Sciences, Ontario, Canada.4. Institute for Health Professions, Portland Community College, Portland, OR, USA.26athlete, with the highest risk sports for males being football, rugby, ice hockey, and wrestling and the highest risk for females being soccer and basketball. Unfortunately, sports which intuitively run a high risk of concussion such as boxing and mixed martial arts do not have sufficient available data but are generally felt to be within the high risk category.(4)Outside of the sports arena, most concussions are recognized through motor vehicle collisions (MVC), pedestrian struck, or major trauma due to the direct force mechanism of injury (MOI); however, impulsive forces and coup-contre-coup injuries should also be considered. MVCs, pedestrians struck and many sports carry the potential for individuals to experience injuries that may not present as head trauma but run the risk of causing concussion due to transfer forces throughout the body. A hard hit to the body during a football game, running into a hard screen during basketball practice, taking a tumble over the handlebars of a bike, or landing hard on the floor after slipping in the shower all pose risk for concussion but often go unrecognized due to the lack of direct trauma to the head.Considering the MOI and identifying any potential impulsive forces should be a top prior-ity for paramedics when assessing for potential brain injuries and concussion.PathophysiologyAs noted, the clinical features of a concus-sion syndrome imply a biomechanically-in-duced alteration in brain function. There are multiple ways in which this alteration occurs, involving direct mechanical forces as well as ionic changes and distortions in cerebral blood flow. Ionic changes occur after mechan-ical forces alter cellular membranes, ultimately leading to release of excitatory neurotransmit-ter and depletion of energy stores. At the same time, blood flow in the area decreases, thereby worsening the poor metabolic state of the affected neurons.(4)RecognitionAny new neurological symptom follow-ing a head trauma should be considered a concussion until proven otherwise, including headache, dizziness, confusion, incoordination and nausea.(4) 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 should be regularly performed.(1) Concussion should be seen as an evolving injury in the acute stage. A post-concussion syndrome is also recognized where patients can have similar symptoms lasting for weeks to months.In March 2013, the American Academy of Neurology (AAN) issued an updated guideline on concussion evaluation and management, based on current evidence. Within this guide-line, the AAN provided several Level B recom-mendations. These include using standardized assessment tools as an adjunct to evaluation of suspected concussion, in combination with history and physical assessment. Addition-ally, team personnel (such as coaches or train-ers) 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. Finally, the athlete with a concussion diagnosis should be prohib-ited from returning to play or practice until a physician has judged the concussion to have resolved and the player is asymptomatic and off medications.(5)Further AssessmentThe authors of the AAN Guidelines also evaluated multiple studies on various concus-sion assessment tools. 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.(5)The Standardized Assessment of Concus-sion (SAC) test (which comprises an assess-ment of orientation, memory, concentration and delayed recall) had a sensitivity of 80-94% and a specificity of 76-91% in identifying a concussion. Neuropsychological testing had a sensitivity of 71-88% in identifying a concus-sion in adolescents to adults, with insufficient evidence to support use in pre-adolescent age groups.(5)The Balance Error Scoring System (BESS), which measures postural stability, when used alone, had a sensitivity of 34-64% and a speci-ficity of 91% in identifying a concussion, while the Sensory Organization Test (SOT), used alone, had a sensitivity of 48-61% and speci-ficity 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.(5)The Sport Concussion Assessment Tool, 3rd edition (SCAT-3) combines many aspects of these assessment tools (SAC, BESS), along with the Glasgow Coma Scale, key features of the history, and physical exam findings. The SCAT-3 is commonly used in side-line assessment and is often the first set of baseline information obtained. It is generally accepted that no single tool used alone will be suffi-cient, and combinations of the above screen-ing and assessment tools are commonly used.(5) It is important to note that although these tests provide information post trauma, they should be compared to a pre-trauma baseline to identify any areas of discrepancy especially during recovery.A note on sensitivity and specificitySensitivity, also known as the “true positive rate”, in this case measures the percentage of ‘sick’ people who are correctly identified as having a concussion. Specific-ity, also known as the “true negative rate” measures the percentage of ‘healthy’ people who are correctly identified as not having a concussion. Ideally, a test will be both highly sensi-tive and highly specific to ensure there are minimal false positives (someone without a concussion incorrectly identified as having one) and minimal false negatives (someone with a concussion incorrectly identified as not having one).Emergency ManagementRed flag symptoms listed below suggest injury which may be more than a concussion.(1) In these circumstances, paramedics should ensure immediate management of airway, breathing and circulation, and expedite trans-port to the nearest neurosurgical capable facility if possible.• Prolonged loss of consciousness (generally defined as > 1 minute)• Clinical concern of c-spine injury (based on history and/or physical exam)• High risk for intracranial bleeding (based on history of high velocity injury or fall from height)• Concern for skull fracture• Post-trauma seizure• Significant worsening of symptoms, with special emphasis on persistent nausea & vomiting, focal neurologic deficits, somno-lence, slurred speech, difficulty walking, and worsening mental status.Post-concussion managementThe single most important management step, as 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.(1,2) Neurocogni-tive 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 potentially return to school after 24 hours).Despite a lack of studies comparing differ-ent methods of neurocognitive rest, a conser-vative approach is generally adopted, advising no school or work, television, music, computer, phone, or physical activity.(1) The majority (80% 27AugustSeptember 2017to 90%) of concussions resolve in a short (7–10 day) period, although the recovery timeframe may be longer in children and adolescents.(6)Long-term consequencesThe concern surrounding repeated concus-sions has been elevated in recent years with increasing recognition of the long-term sequelae of concussion, from chronic post-concussive symptoms to a neurodegenerative dementia, referred to as chronic traumatic encephalopathy (CTE). Although the majority of patients find their symptoms resolve within weeks to months, it is concerning to note that up to 15% of the general population (i.e. non-athletes) may continue to have symptoms longer than one year after a single concussion.After repeated concussions, CTE can occur, with the insidious onset of behavioural and cognitive dysfunction as well as various effects on motor function and coordination. Similar to other types of dementia, CTE is not reversible and there are no effective treatments.(7) As a result, prevention of CTE is of primary concern when managing a concussion patient - preven-tion of return to play, and appropriate rest as described above are key in the prevention of long-term sequelae.  Resources• For a free online education resource on concussion management in rugby, visit http://www.irbplayerwelfare.com/concus-sion • A copy of the SCAT-3 can be found here: http://bjsm.bmj.com/content/47/5/259.full.pdfReferences1.  Bloom J, Blount J. Sideline evaluation of concussion. In: Fields K, editor. UpToDate. Waltham, MA.: UpToDate; 2013. 2.  Blumenfeld H. Neuroanatomy through Clinical Cases. Copyright © 2010 by Sinauer Associates, Inc. 2010. 1033 p. 3.  McCrory P, Meeuwisse WH, Aubry M, Cantu RC, Dvorák J, Echemendia RJ, et al. Consensus statement on concussion in sport: The 4th international conference on concussion in sport, Zurich, November 2012. In: Journal of Athletic Training. 2013. p. 554–75. 4.  Giza CC, Kutcher JS. An introduction to sports concussions. Continuum (Minneap Minn). 2014;20(6 Sports Neurol-ogy):1545–51. 5.  Giza CC, Kutcher JS, Ashwal S, Barth J, Getchius TSD, Gioia GA, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Neurology. 2013;80(24):2250–7. 6.  McCrory P. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. 2005;39(Supplement 1):i78–86. 7.  Jordan BD. Chronic Traumatic Encephalopathy and Other Long-term Sequelae. Contin Lifelong Learn Neurol. 2014;20:1588–604. AUTHORSDr. Christine Tomkinson is a Resident Physician in Adult Neurology at McMaster University, Hamilton, Ont., Canada.Email: christine.tomkinson@medportal.caEmily Weston is a student paramedic in the Primary Care Paramedic program at Fanshawe College, London, Ont., Canada.Email:e_weston@fanshaweonline.caTwitter: @_emwestonAlan Batt is a faculty member in the Paramedic Programs at Fanshawe College, London, Ont., Canada.Email: abatt@fanshawec.caTwitter: @alan_batt

A Review of Concussion Recognition, Assessment and Management for Paramedics

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A Review of Concussion Recognition, Assessment and Management for Paramedics

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