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Concussion

Question Type:
Intervention
Full Question:
Among adults and children with suspected head injury without loss of consciousness (P), does use of a simple single-stage concussion scoring system (I), compared with standard first aid assessment without a scoring system (C), change time to recognition of the deteriorating patient, the likelihood of a poor neurological outcome, survival to 30 days with good neurological outcome, Time to medical transportation, need for advanced medical care, likelihood of differentiating between minor head contusion and more serious concussion (O)?
Consensus on Science:
For the critical outcome of likelihood of differentiating between minor head contusion and more serious concussion (brain injury), we identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 1 observational study(Thompson 2011, 417) with 19 408 patients in a trauma registry using a secondary analysis of rescoring prehospital Glasgow Coma Scale (GCS) scores showing no significant difference between a simple derived motor score versus the GCS score to determine brain injury. For the important outcome of need for advanced medical care (neurosurgical intervention and emergency tracheal intubation), we identified very-low-quality evidence (downgraded for imprecision) from 1 nonrandomized study(Thompson 2011, 417) with 19 408 patients in a trauma registry using a secondary analysis of rescoring the prehospital GCS scores showing no significant difference between a simple derived motor score versus the GCS score for neurosurgical intervention (MD, 0.04; 95% CI, 0.01–0.09) and the need for emergency tracheal intubation (MD, 0.05; 95% CI, 0.01–0.11). For the critical outcome of change in time to recognition of the deteriorating patient, for the important outcomes of survival to 30 days with good neurologic outcome, and for the likelihood of a poor neurologic outcome, we did not identify any evidence.
Treatment Recommendation:
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. Values, Preferences, and Task Force Insights Failure to properly recognize concussion can result in delay or absence of referral for definitive evaluation and care or inappropriate release to activity, which has the potential to worsen outcomes. We did identify concussion assessment tools currently recommended for use in sports medicine, but these require a 2-stage assessment, before competition and after concussion, and were thought to be inappropriate for use in the standard first aid setting. Our extensive search strategy yielded 1837 publications, but subsequent review resulted in the selection of only 1 published manuscript. Despite the finding of 1 prehospital scientific publication supporting a simplified motor score, it was decided that this single article, a retrospective observational study where prehospital GCS scoring extracted from an urban Level 1 trauma registry was rescored by using a 3-point simplified motor score and compared with 4 hospital-based outcomes, did not formally address the PICO question and was in itself a very weak level of scientific evidence. Many of the studies identified in our literature search used the adult and pediatric GCS to grade concussion. The GCS was designed as a tool for use by advanced prehospital and hospital care providers, and it is not commonly used by first aid providers. The task force thought that this was not an appropriate tool to be used by first aid providers to assess concussion. Our search and analysis did not identify any evidence to support or refute the use of a simplified scoring system, such as Sport Concussion Assessment Tool (SCAT); the GCS; or Alert, responds to Voice, responds to Pain, Unresponsive Scale (AVPU), versus standard first aid without a scoring system. It was thought that the serious consequences of not recognizing concussion in the first aid environment warranted an approach whereby any individual with a head injury and any alteration of level of consciousness requires immediate evaluation by an advanced healthcare provider or at a hospital.
CoSTR Attachments:
Concussion 799 Final SOF Table.pdf    

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