Simple Single-Stage Concussion Scoring System(s) in the First Aid Setting (FA): Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. There were no declared conflicts of interest.

Task Force Scoping Review Citation

Berry DC, Zideman D, Oliver E, Singletary E -on behalf of the International Liaison Committee on Resuscitation First Aid Task Force. Simple Single Stage Concussion Scoring System in the First Aid Setting Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, 2019 December 31. Available from: http://ilcor.org

Collaborators: Sakamoto T, Klaassen B

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of simple single-stage concussion scoring system(s) in the first aid setting by non-medical providers (first aid providers, lay responders) conducted by the ILCOR First Aid Task Force Scoping Review team. Evidence from adult and paediatric literature was sought and considered by the reviewers.

The 2015, the International Liaison Committee on Resuscitation (ILCOR) Consensus on First Aid Science with Treatment Recommendations (CoSTR) found no clinical studies supporting the use of a simple concussion scoring system by first aid providers (Singletary 2015 S269; Zideman 2015 e229). This scoping review is designed to identify new evidence since the 2015 review, as well as grey literature that might lead to future systematic reviews related to single stage concussion scoring systems. The question used in this review remained the same as for the 2015 review.

A single-stage concussion scoring system was defined as an assessment process requiring no initial baseline testing when presented with an individual with a potential concussion. Currently, the majority of concussion evaluation instruments/devices require a two-step process, baseline testing and a post-trauma evaluation. Baseline testing establishes normative neuropsychological and neurocognitive (including learning and memory skills, ability to pay attention or concentrate, and how quickly individuals thinks and solves problems), as well as an assessment for the presence of any concussion symptoms. Results from these baseline tests (or pre-injury tests) can be used to compare with results from a repeat assessment conducted by a healthcare professional if the same individual has a suspected concussion.

Scoping Review

[Link to Pubmed to be added]

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs, and Timeframe):

Population: Adults and children with suspected head injury without loss of consciousness

Intervention: does use of a simple single-stage concussion scoring system

Comparators: compared with standard first aid assessment without a scoring system

Outcomes: Likelihood of differentiating between minor head contusion and more serious concussion and time to recognition of the deteriorating patient were ranked as critical outcomes. Survival to 30 days with good neurological outcomes, the likelihood of poor neurological outcomes, and the need for advanced medical care were ranked as important outcomes.

Study Designs: Randomized controlled trials (RCTs), controlled clinical trial, clinical trial, comparative study, non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, case-control, cross-sectional, epidemiologic), case series (n>5), survey and retrospective are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols), editorials, commentary, case reports, and animals were excluded. No study design restrictions were applied for the grey literature search.

Timeframe: The original search for the ILCOR 2015 CoSTR (Singletary 2015 S269; Zideman 2015 e229) was completed in January 2014.

Search one was therefore limited from January 1, 2014 and completed on October 4, 2019.

Search two was conducted on November 19, 2019 and was inclusive for all years.

Search three was conducted on November 24, 2019 and was inclusive for all years.

Search four was conducted on November 26, 2019 and inclusive for all years

All literature searches were updated to December 6, 2019.

Search Strategies

The first search used the search terms identified in the 2015 CoSTR (Singletary 2015 S269; Zideman 2015 e229) for consistency.

PubMed: (((((((((((((((brain injuries) OR (TBI OR traumatic brain injury )) AND (mild OR sport OR athletic OR minor)) NOT "loss of consciousness")) AND (((physical examination) AND (((((((Trauma Severity Indices[MeSH Terms]) OR (index or indices[Title])) OR assessment tool[TIAB]) OR diagnostic tool[ TIAB]))))) OR injury severity score[TIAB] ) OR SCAT[TIAB]) OR Sport concussion assessment tool[TIAB] ) OR Glasgow coma scale[MeSH Terms]))))))))) AND ((((((((outcomes) OR recovery of function[MeSH Terms]) OR return to work) OR activities of daily living[MeSH Terms]) OR length of stay[MeSH Terms]) AND ((((((((((("randomized controlled trial"[PT] OR "controlled clinical trial"[PT] OR "clinical trial"[PT] OR "comparative study"[PT] OR random*[TIAB] OR controll*[TIAB] OR "intervention study"[TIAB] OR "experimental study"[TIAB] OR "comparative study"[TIAB] OR trial[TIAB] OR evaluat*[TIAB] OR "Before and after"[TIAB] OR "interrupted time series"[TIAB]))) OR (("Epidemiologic Studies"[Mesh] OR "case control"[TIAB] OR "case-control"[TIAB]

OR ((case[TIAB] OR cases[TIAB]) AND (control[TIAB] OR controls[TIAB)) OR "cohort study"[TIAB] OR "cohort analysis"[TIAB] OR "follow up study"[TIAB] OR "follow-up study"[TIAB] OR "observational study"[TIAB] OR "longitudinal"[TIAB] OR "retrospective"[TIAB] OR "cross sectional"[TIAB] OR "cross-sectional"[TIAB] OR questionnaire[TIAB] OR questionnaires[TIAB] OR survey[TIAB])))) NOT (("animals"[MH] NOT (animals[MH] AND "humans"[MH])))) NOT (("letter"[pt] OR

"comment"[pt] OR "editorial"[pt] OR "case reports"[pt]))))))))))))))

Embase: 'brain injuries'/exp OR 'brain injuries':ab,ti OR 'traumatic brain injuries':ab,ti OR 'tbi':ab,ti AND ('physical examination'/exp OR examination:ab,ti OR 'first aid'/exp) AND ('trauma severity indices'/exp OR index:ab,ti OR indices:ab,ti OR 'assessment tool':ab,ti OR 'sport concussion assessment tool':ab,ti OR 'scat':ab,ti OR 'glasgow coma scale'/exp OR 'glasgow coma scale':ab,ti) AND [embase]/lim

Cochrane Central Register of Controlled Trials: ([mh "brain injuries"] or "brain injuries":ti,ab OR "traumatic brain injuries":ti,ab OR tbi:ti) AND ([mh "physical examination"] OR examination:ti,ab OR [mh "first aid"]) AND ([mh "trauma severity indices"] or index: ti,ab OR indices:ti,ab or "assessment tool":ti,ab OR "Sport concussion assessment tool":ti,ab OR "SCAT":ti,ab OR [mh "Glasgow coma scale"] OR "Glasgow coma scale":ti,ab)

A second structured literature search was conducted using Medline to identify relevant studies with no article or date restrictions. Keywords included (1) SCAT 5, (2) CRT 5, (3) concussion recognition tool, (4) sport* concussion assessment tool, and (5) concussion assessment tool. The literature search was updated to December 6, 2019.

A third literature search was conducted on November 24, 2019, using Google Chrome to identify relevant literature not published in the four database searches above. Keywords include “single-stage concussion scoring”, "single-stage concussion assessment" and lay, and "single-stage concussion assessment" and prehospital. One hundred and ten websites were reviewed for relevant literature. The literature search was updated to December 6, 2019.

A fourth search was conducted by hand search for relevant articles in situations that were missed during indexing. This included national advice organisations, medical organisations and societies, and first aid organisations and societies for relevant publications, statements and guidelines where applicable. The literature search was updated to December 6, 2019.

Inclusion and Exclusion Criteria

Inclusion criteria

• Randomized controlled trials (RCTs), controlled clinical trial, clinical trial, comparative study, non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, case-control, cross-sectional, epidemiologic), case series (n>5), survey and retrospective
• Adults and children (> 1-year-old) with suspected head injury without loss of consciousness
• Simple single-stage concussion scoring system
• Assessments in the prehospital (first aid) environment
• Assessments by non-healthcare providers
• Available abstract

Exclusion criteria

• Unpublished studies (e.g., conference abstracts, trial protocols), editorials, commentary, case reports, and animals are excluded in only search strategy one
• Concussion scoring system administered in the emergency department
• Assessments by healthcare providers

First Search - Search Terms and Results Identified in the 2015 CoSTR.

Second Search – Search Terms and Results Identified in Medline.

Third Search – Grey Literature Search of Google Chrome and Hand Search.

Task Force Insights

1. Why this topic was reviewed.

The Center for Disease Control and Prevention (CDC) defines concussion (ie., mild traumatic brain injury [mTBI]) as a "disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury" (CDC 2019a, CDC 2019b 2). A sport-related concussion (SRC) is a "traumatic brain injury that is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces with several common features that help define its nature" (McCrory 2017 877). Symptoms usually fall into four categories, (1) thinking/remembering, (2) physical, (3) emotional/mood, and (4) sleep (CDC 2019c).

The recognition of concussion in an individual is important as not recognizing it can lead to serious consequences including further injury and even death. However, recognition is not a simple process and is usually made from a series of simple symptoms and signs in the first aid environment. Some of the symptoms of concussion may present immediately following the event. Others may not be noticed for days or months after the injury, or until the person resumes their everyday life preceding the injury (CDC 2019c). In certain circumstances individuals do not recognize or admit that they are experiencing symptoms of a concussion. Others may not understand the different ways they have been affected and how the symptoms they are experiencing impact on their daily activities.

Concussion incidence and reporting have increased over the last two decades along with emergency department visits over the last decade for recreational and sports related concussions (SRC) (Halstead 2018 3). Over the span of eight years (2006–2014), while age-adjusted rates of TBI-related ED visits increased by 54%, hospitalization rates decreased by 8% and death rates decreased by 6% (CDC 2019b 8). It is widely recognized that an incorrect decision regarding a head injury can have long-term serious sequala (ie., persistent cognitive dysfunction) or even fatal consequences (Tator 2013 975; Williams 2016 43).

First aid providers are often faced with situations where they must decide what advice to offer an individual following head trauma (Singletary 2015 S579; Zideman 2015 278), especially during sport. However, despite the work of clinicians and researchers, relatively little has been established regarding the pathophysiology, risk factors, long-term sequelae, nor a consensus reached on how to evaluate or grade a concussion (Kutcher 2010 197; Singletary 2015 S579; Williams 2016 43), especially in the first aid environment by first aid providers. However, it is widely recognized that an incorrect decision can have severe long-term sequala (ie., persistent cognitive dysfunction) or even fatal consequences (Tator 2013 975; Williams 2016 43).

The 2015 ILCOR CoSTR for this topic made no recommendation for the use of a single-stage concussion scoring system as there were no clinical studies identified specifically addressing a single-stage concussion scoring system to support their usage in the first aid environment (Singletary 2015 S269; Zideman 2015 e229). The CoSTR did acknowledge the role that a simple, validated, single-stage concussion scoring system could play in the first aid provider’s recognition and referral of individuals with suspected concussion.

Therefore, the topic was chosen for review by the First Aid Task Force originally in 2015 and again in this current round of reviews because of the ongoing risk of concussion and the need to identify a simple single-stage concussion scoring system for use by first aid providers in the first aid environment when confronted with an individual with a head injury.

2. Narrative summary of evidence identified

Our extensive search strategy yielded many publications, however, subsequent review resulted in the selection of no published manuscript which identified and examined a single-stage concussion scoring system(s) in the first aid environment undertaken by non-medical providers. We did identify concussion assessment tools currently recommended for use in sport, but these require a 2-stage assessment, baseline testing and evaluation following a head injury; these were thought to be inappropriate for use in the standard first aid setting.

The joint 2015 American Red Cross-American Heart Association first aid guidelines update recommended that “… any person with a head injury that has resulted in a change in level of consciousness, has progressive development of signs or symptoms, … or is otherwise a cause for concern should be evaluated by a healthcare provider or EMS personnel as soon as possible (Class I, LOE C-EO)” (Singletary 2015 S579). Additionally, it was recommended that when “Using any mechanical machinery, driving, cycling, or continuing to participate in sports after a head injury should be deferred by these individuals until they are assessed by a healthcare provider and cleared to participate in those activities (Class I, LOE C-EO)” (Singletary 2015 S579). The European Resuscitation Council published a similar statement in their 2015 first aid guidelines, “Although a concussion scoring system would greatly assist first aid providers in the recognition of concussion, there is no simple validated scoring system in use in current practice. An individual with a suspected concussion should be evaluated by a healthcare professional (Zideman 2015 278).

Sport has also taken the subject of concussion very seriously and now have published the rationale and the fifth version of the Sport Concussion Assessment Tool (SCAT 5) for use by healthcare professionals (Echemendia 2015 848, Sport 2015, 851). The implementation of this tool has resulted in fundamental changes in many sports which has improved both the recognition of concussion and its subsequent management for participants of all ages in sport. However, SCAT 5, is a two-stage concussion scoring system and is not appropriate in the first aid environment by first aid providers.

Additionally, in 2017 the Concussion Recognition Tool, CRT5, was introduced (Echemendia 2017 870, Concussion 2017 872) was introduced to be used by non-healthcare professionals but, to date, there are no published validation data for this tool.

3. Narrative Reporting of the task force discussions

Task force discussions underscored concern for the consequences of failure to recognize a concussion in the first aid setting, and the need for a simple, single stage assessment system for first aid use. Failure to properly recognize concussion can result in a delay or absence of referral for definitive initial and follow-up evaluation and medical care; or in some cases inappropriate release to activity (eg, work, driving, school, sport), which has the potential to exacerbate poor outcomes.

Alternative scoring systems and scales that are used to assess level of consciousness were considered. One such scale, the Glasgow Coma Scale (GCS) (adult and paediatric) or modified Glasgow Coma Scale is commonly used to assess for and grade a minor traumatic brain injury. However, the Glasgow Coma Scale was first designed with 3 scale measures as a way to communicate about the level of consciousness of patients with an acute brain injury (Teasdale 1974 81). The three components of the scale were eventually combined into a single index despite losing some of the detail and discrimination conveyed by the full scale (Teasdale 1979 13) and is now commonly used in the prehospital setting and emergency department by healthcare providers to assess and monitor a person's level of consciousness following a head injury. The task force believes the GCS is not an appropriate tool for use by first aid providers to assess for a possible concussion following a head injury as the majority of concussion events do not result in a loss or alteration in consciousness.

The Alert, Responds to Verbal Stimuli, Responds to Pain, Unresponsive (AVPU) Scale is another commonly used scale in the prehospital setting that was discussed. This simple assessment scale is used to establish a person’s level of responsiveness but should not be used to establish the presence of a concussion (Pabian 2016 126). Using this tool, anyone who does not score ‘A’ (alert) requires immediate evaluation by a healthcare provider. Therefore, the task force believes that this is not an appropriate tool to be used by first aid providers to assess for a possible concussion following a head injury.

The role and value of 2-stage concussion scoring scales was also discussed, including the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), the Standardized Assessment of Concussion (SAC), and the Sport Concussion Assessment Tool (current version, SCAT 5). These scales are designed for use by trained healthcare providers who are able to establish baseline normative data, and are not suitable as a single-stage scoring system for first aid.

One study (Kulnick 2019 1) identified insufficient confidence and knowledge in lay responders to make a decision about how to act in a head injury scenario other than seeking medical assistance, but this varied according to contextual and situational factors.

The 2015 ILCOR Treatment Recommendation for concussion scoring systems states:

No recommendation; we acknowledge the role that a simple, validated, single-stage concussion scoring system could play in the first aid provider’s recognition and referral of victims of suspected head injury. However, review of the available literature shows no evidence regarding the application of such scoring systems by the first aid provider.

In light of the task force discussion points and the limited evidence identified in this scoping review, no change to the existing 2015 ILCOR Treatment Recommendation is indicated.

Knowledge Gaps

Although this scoping review has not identified new evidence to prompt a systematic review or reconsideration of current first aid treatment guidelines, it highlights significant gaps in the research related to recognition of concussion by a first aid provider for both adults and children.

There is an urgent need for a recognizable definition of concussion supported by clinical data that can be used to support assessment made in the first aid environment.

There is an urgent need for the development of a single-stage concussion scoring system for use by non–healthcare professionals in the first aid environment.

There is a need for research to assess the efficacy of the current 2-stage concussion scoring systems in the clinical environment and determine whether they can be applied to non-sports environments as a single-stage scoring system and whether they can be used by non-healthcare providers.

There is a need for research to assess the efficacy of the CRT5 in the clinical environment to determine whether it can be applied to the first aid, non-sport environment as a single-stage concussion scoring system and whether it can be used by first aid providers.

References

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Centers for Disease Control and Prevention. Symptoms of Traumatic Brain Injury (TBI). https://www.cdc.gov/traumaticbraininjury/symptoms.html Reviewed March 11, 2019, Accessed November 17, 2019c

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