SCAT5

SCAT5

Sports Concussion Assessment Tool 5 (SCAT5) is a standardized concussion assessment, available as a pdf or online , used by healthcare providers when a concussion is suspected in athletes ages 12 and older.


The Fifth International Conference on Concussion in Sport was held in Berlin in October 2016. A series of 12 questions and subquestions was developed and the expert panel members were required to perform a systematic review to answer each question. Following presentation at the Berlin meeting of the systematic review, poster abstracts and audience discussion, the summary Consensus Statement was produced. Further, a series of tools for the management of sport-related concussion was developed, including the Sport Concussion Assessment Tool Fifth edition (SCAT5), the Child SCAT5, and the Concussion Recognition Tool Fifth edition 1).


PDF


Online


The SCAT5 cannot be performed correctly in less than 10 minutes.

The revision of the SCAT3 (first published in 2013) culminated in the SCAT5. The revision was based on a systematic review and synthesis of current research, public input and expert panel review as part of the 5th International Consensus Conference on Concussion in Sport held in Berlin in 2016. The SCAT5 is intended for use in those who are 13 years of age or older. The Child SCAT5 is a tool for those aged 5-12 years, which is discussed elsewhere 2).


The Sports Concussion Assessment Tool-5th Edition (SCAT5) and the child version (Child SCAT5) are the current editions of the SCAT and have updated the memory testing component from previous editions.


To achieve consensus, via an international panel of SRC experts, on which athlete/player and parent/caregiver demographic variables should be considered for inclusion in future editions of the SCAT/Child SCAT respectively.

Methods: A two-round modified Delphi technique, overseen by a steering committee, invited 41 panellists to achieve expert consensus (≥80% agreement). The first round utilised open questions to generate demographic variables; the second round used a five-point ordinal item to rank the importance of including each variable in future editions of the SCAT/Child SCAT.

Results: 15 experts participated in at least one Delphi round. 29 athlete/player and eight parent/caregiver variables reached consensus for inclusion in the SCAT, whereas two parent/caregiver variables reached consensus for exclusion. 28 athlete/player and four parent/caregiver variables reached consensus for the Child SCAT, whereas two parent/caregiver variables reached consensus for exclusion. Key categories of variables included the following: concussion/sport details, personal medical conditions and family medical history.

Conclusion: This study provides a list of athlete/player and parent/caregiver demographic variables that should be considered in future revisions of the SCAT/Child SCAT. By considering (and ultimately likely including) a wider and standard set of additional demographic variables, the Concussion in Sport experts will be able to provide clinicians and researchers with data that may enhance interpretation of the individual’s data and the building of larger datasets 3).


In a prospective observational study, the ability of the SCAT5 and ChildSCAT5 to differentiate between children with and without a concussion was examined. Concussed children (n=91) and controls (n=106) were recruited from an emergency department in three equal-sized age bands (5-8/9-12/13-16 years). Analysis of covariance models (adjusting for participant age) were used to analyze group differences on components of the SCAT5. On the SCAT5 and ChildSCAT5, respectively, youth with concussion reported a greater number (d=1.47; d=0.52) and severity (d=1.27; d=0.72) of symptoms than controls (all p<0.001). ChildSCAT5 parent-rated number (d=0.98) and severity (d=1.04) of symptoms were greater for the concussion group (all p<0.001). Acceptable levels of between-group discrimination were identified for SCAT5 symptom number (AUC=0.86) and severity (AUC=0.84) and ChildSCAT5 parent-rated symptom number (AUC=0.76) and severity (AUC=0.78). The findings support the utility of the SCAT5 and ChildSCAT5 to accurately distinguish between children with and without a concussion 4).


A study aimed to validate this new memory component against the Rey Auditory Verbal Learning Test (RAVLT) as the validated standard. This prospective, observational study, carried out within The Royal Children’s Hospital Emergency Department, Melbourne, Australia, recruited 198 participants: 91 with concussion and 107 upper limb injury or healthy sibling controls. Partial Pearson correlations showed that memory acquisition and recall on delay aspects of the SCAT5 were significantly correlated with the RAVLT equivalents when controlling for age (p < 0.001, r = 0.565 and p < 0.001, r = 0.341, respectively). Factor analysis showed that all RAVLT and SCAT5 memory components load on to the same factor, accounting for 59.13% of variance. Logistic regression models for both the RAVLT and SCAT5, however, did not predict group membership (p > 0.05). Receiver operating curve analysis found that the area under the curve for all variables and models was below the recommended 0.7 threshold. This study demonstrated that the SCAT5 and Child SCAT5 memory paradigm is a valid measure of memory in concussed children 5).


The two-week test-retest reliability of the SCAT5 baseline scores varied from moderate to high. However, there was considerable individual variability on the SAC and mBESS scores and most players have notable short-term fluctuation on performance even if uninjured. Recommendations for interpreting change on the SCAT5 are provided 6).


1)

Davis GA, Ellenbogen RG, Bailes J, Cantu RC, Johnston KM, Manley GT, Nagahiro S, Sills A, Tator CH, McCrory P. The Berlin International Consensus Meeting on Concussion in Sport. Neurosurgery. 2018 Feb 1;82(2):232-236. doi: 10.1093/neuros/nyx344. PMID: 29106653.
2)

Echemendia RJ, Meeuwisse W, McCrory P, Davis GA, Putukian M, Leddy J, Makdissi M, Sullivan SJ, Broglio SP, Raftery M, Schneider K, Kissick J, McCrea M, Dvořák J, Sills AK, Aubry M, Engebretsen L, Loosemore M, Fuller G, Kutcher J, Ellenbogen R, Guskiewicz K, Patricios J, Herring S. The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale. Br J Sports Med. 2017 Jun;51(11):848-850. doi: 10.1136/bjsports-2017-097506. Epub 2017 Apr 26. PMID: 28446453.
3)

Shanks MJ, McCrory P, Davis GA, Echemendia RJ, Gray AR, Sullivan SJ. Developing common demographic data elements to include in future editions of the SCAT and Child SCAT: a modified international Delphi study. Br J Sports Med. 2020 Aug;54(15):906-912. doi: 10.1136/bjsports-2018-100482. Epub 2019 Oct 11. PMID: 31604697.
4)

Babl FE, Anderson V, Rausa VC, Anderson N, Pugh R, Chau T, Clarke C, Fabiano F, Fan F, Hearps S, Parkin G, Takagi M, Davis G. Accuracy of Components of the SCAT5 and ChildSCAT5 to Identify Children with Concussion. Int J Sports Med. 2021 Aug 16. doi: 10.1055/a-1533-1700. Epub ahead of print. PMID: 34399426.
5)

Shapiro JS, Hearps S, Rausa VC, Anderson V, Anderson N, Pugh R, Chau T, Clarke C, Davis GA, Fabiano F, Fan F, Parkin GM, Takagi M, Babl FE. Validation of the SCAT5 and Child SCAT5 Word-List Memory Task. J Neurotrauma. 2021 May 10. doi: 10.1089/neu.2020.7414. Epub ahead of print. PMID: 33765839.
6)

Hänninen T, Parkkari J, Howell DR, Palola V, Seppänen A, Tuominen M, Iverson GL, Luoto TM. Reliability of the Sport Concussion Assessment Tool 5 baseline testing: A 2-week test-retest study. J Sci Med Sport. 2021 Feb;24(2):129-134. doi: 10.1016/j.jsams.2020.07.014. Epub 2020 Aug 5. PMID: 32868203.

Helmet

Helmet

Construction helmets are considered essential personal protective equipment for reducing traumatic brain injury risks at work sites. In a study, we proposed a practical finite element modeling approach that would be suitable for engineers to optimize construction helmet design. The finite element model includes all essential anatomical structures of a human head (i.e. skin, scalp, skull, cerebrospinal fluid, brain, medulla, spinal cord, cervical vertebrae, and discs) and all major engineering components of a construction helmet (i.e. shell and suspension system). The head finite element model has been calibrated using the experimental data in the literature. It is technically difficult to precisely account for the effects of the neck and body mass on the dynamic responses, because the finite element model does not include the entire human body. An approximation approach has been developed to account for the effects of the neck and body mass on the dynamic responses of the head-brain. Using the proposed model, we have calculated the responses of the head-brain during a top impact when wearing a construction helmet. The proposed modeling approach would provide a tool to improve the helmet design on a biomechanical basis 1).

Neurotrauma from snow-sports related injuries is infrequently documented in the literature. In Australia no collective data has ever been published. The aim of this study is to document the injury pattern of snow sports related neurotrauma admissions to The Canberra Hospital, the regional trauma centre for the Snowy Mountains. A computerised hospital record search conducted between January 1994 and July 2002 revealed 25 head and 66 spinal injury admissions. The incidence of severe injuries requiring referral to tertiary trauma hospital was estimated to be 7.4 per 100,000 skier-days and for head and spinal injury 1.8 per 1,000,000 skier-days and 5.6 per 1,000,000 skier-days, respectively. Collision with a stationary object was disproportionately associated with head injury and falling forward with spinal injury. Snowboarders tended to sustain cervical fractures more often than skiers. The importance of helmet usage in buffering the impact of head-on collision and the proposition of having both feet fastened to a snowboard in leading to cervical injury were highlighted 2).

Helmets may provide some protection from head injury among skiers and snowboarders involved in falls or collisions 3).

Similar to bicycle helmet promotion programs, ski and snowboard helmet campaigns should focus on delivering a positive image of helmet use and peer acceptance 4).

Parent’s helmet-wearing behavior was strongly associated with the child/adolescent’s helmet-wearing behavior. The results demonstrate the overwhelming influence parental helmet use has on their child/adolescent’s decision to wear a helmet 5).

Skiing

The incidence of possible concussion is high among snowboarding class participants. Emphasis should be given for instituting pre-participation balance training, especially for females to reduce falling in snowboarding. To verify the effects of pre-participation balance training and falling results in a concussion, more research is needed in the future.

Frequently involving occipital impact, could lead to more major head injuries. Measures should be taken to protect the head, especially the occiput, in snowboarding 6).

Not wearing a helmet and riding on icy slopes emerged as a combination of risk factors associated with injury.

Several risk factors and combinations exist, and different risk profiles were identified. Future research should be aimed at more precise identification of groups at risk and developing specific recommendations for each group-for example, a snow-weather conditions index at valley stations 7).

The association between helmet use during alpine skiing and incidence and severity of head injury was analyzed. All patients admitted to a Level I Trauma Center for traumatic brain injurys (TBI) sustained due to skiing accidents during the seasons 2000/01-2010/11 were eligible. Primary outcome was the association between helmet use and severity of TBI measured by Glasgow Coma Scale (GCS), CT-results, and necessity of neurosurgical intervention. Of 1362 patients injured during alpine skiing, 245 (18%) sustained TBI and were included. TBI was fatal in 3%. Head injury was minor (GCS 13-15) in 76%, 6% moderate and 14% severe. Number and percentage of TBI patients showed no significant trend over the investigated seasons. Forty-five percent of the 245 patients had pathological CT-findings and 26% of these required neurosurgical intervention. Helmet use increased from 0% in 2000/2001 to 71% in 2010/2011 (p<0.001). The main analysis, comparing TBI in patients with or without a helmet, showed an adjusted Odds Ratio (OR) of 1.44 (p=0.430) for suffering moderate head injury to severe head injury in helmet users. Analyses comparing off-piste to on-slope skiers revealed a significantly increased OR among off-piste skiers of 7.62 (p=0.004) for sustaining a TBI requiring surgical intervention. Despite increases in helmet use Baschera et al., found no decrease in severe TBI among alpine skiers. Logistic regression analysis showed no significant difference in TBI with regard to helmet use, but increased risk for off-piste skiers. The limited protection of helmets and dangers of skiing off-piste should be targeted by prevention programs 8).

see Helmet for motorcycle.

Electrically Assisted Pedal Cycles (EAPCs) are pedal bikes that are fitted with a motor that travel at higher speeds than conventional bicycles. Recent international data shows that there is an association with increased severity of injury, particularly in paediatric populations. Currently, EAPCs are subject to the same legislation regarding helmet use as pedal bikes in the UK and EU which does not mandate the use of a helmet.

Trichinopoly Krishna et al. examined safety concerns surrounding EAPCs in the context of existing EU and UK legislation to assess whether changes to these should be made by public health bodies to mitigate the increased risk of injury.

retrospective international literature review looking at electric bicycle-related trauma and legislation was conducted using a systematic search of internet databases. Peer-reviewed articles and online resources were reviewed based on relevance to the above objective.

EAPCS can travel at up to 17.5 mph, resulting in higher speeds of travel and collision. The use of EAPCs has been associated with increased severity of head injury. Bicycle helmets have been shown to reduce the severity of head injury in accidents involving both EAPCs and pedal cycles. Healthcare providers should pay extra attention to the possibility of severe injuries when a patient had a bicycle accident with an EAPC, especially in paediatric populations.

Given that EAPCS have been associated internationally with increased severity of head injuries they propose that existing EU and UK legislation may not be fit for purpose with respects to increased EAPC usage and criteria for impact protection of existing helmets. Further research and audit with more accurate recording of data associated with EAPCs use and associated injuries would inform enhanced regulation regarding EAPC usage in the future 9).


1) 
Wu JZ, Pan CS, Wimer BM, Rosen CL. Finite element simulations of the head-brain responses to the top impacts of a construction helmet: Effects of the neck and body mass. Proc Inst Mech Eng H. 2017 Jan;231(1):58-68. doi: 10.1177/0954411916678017. PubMed PMID: 28097935.
2) 
Siu TL, Chandran KN, Newcombe RL, Fuller JW, Pik JH. Snow sports related head and spinal injuries: an eight-year survey from the neurotrauma centre for the Snowy Mountains, Australia. J Clin Neurosci. 2004 Apr;11(3):236-42. PubMed PMID: 14975409.
3) 
Mueller BA, Cummings P, Rivara FP, Brooks MA, Terasaki RD. Injuries of the head, face, and neck in relation to ski helmet use. Epidemiology. 2008 Mar;19(2):270-6. doi: 10.1097/EDE.0b013e318163567c. PubMed PMID: 18277163.
4) 
Peterson AR, Brooks MA. Pilot study of adolescent attitudes regarding ski or snowboard helmet use. WMJ. 2010 Feb;109(1):28-30. PubMed PMID: 20942297; PubMed Central PMCID: PMC2957671.
5) 
Provance AJ, Engelman GH, Carry PM. Implications of parental influence on child/adolescent helmet use in snow sports. Clin J Sport Med. 2012 May;22(3):240-3. doi: 10.1097/JSM.0b013e3182410335. PubMed PMID: 22270869
6) 
Nakaguchi H, Fujimaki T, Ueki K, Takahashi M, Yoshida H, Kirino T. Snowboard head injury: prospective study in Chino, Nagano, for two seasons from 1995 to 1997. J Trauma. 1999 Jun;46(6):1066-9. PubMed PMID: 10372627.
7) 
Hasler RM, Berov S, Benneker L, Dubler S, Spycher J, Heim D, Zimmermann H, Exadaktylos AK. Are there risk factors for snowboard injuries? A case-control multicentre study of 559 snowboarders. Br J Sports Med. 2010 Sep;44(11):816-21. doi: 10.1136/bjsm.2010.071357. PubMed PMID: 20820060.
8) 
Baschera D, Hasler RM, Taugwalder D, Exadaktylos A, Raabe A. Association between head injury and helmet use in alpine skiers: Cohort study from a Swiss level I trauma center. J Neurotrauma. 2014 Sep 22. [Epub ahead of print] PubMed PMID: 25244343.
9) 
Trichinopoly Krishna S, Roberts S, Dardis R. Electrically assisted pedal cycles: is new legislation required to mitigate increased head injury risk? Br J Neurosurg. 2021 Jun 26:1-4. doi: 10.1080/02688697.2021.1940846. Epub ahead of print. PMID: 34180330.

Brain death

Brain death

The published World Brain Death Project aims in alleviating inconsistencies in clinical guidelines and practice in the determination of death by neurologic criteria. However, critics have taken issue with a number of epistemic and metaphysical assertions that critics argue are either false, ad hoc, or confused.

Lazaridis disscussed the nature of a definition of death; the plausibility of neurologic criteria as a sensible social, medical, and legal policy; and within a Rawlsian liberal framework, reasons for personal choice or accommodation among neurologic and circulatory definitions. Declaration of human death cannot rest on contested metaphysics or unmeasurable standards, instead it should be regarded as a plausible and widely accepted social construct that conforms to best available and pragmatic medical science and practice. The definition(s) and criteria should be transparent, publicly justifiable, and potentially allow for the accommodation of reasonable choice. This is an approach that situates the definition of death as a political matter. The approach anticipates that no conceptualization of death can claim universal validity, since this is a question that cannot be settled solely on biologic or scientific grounds, rather it is a matter of normative preference, socially constructed and historically contingent 1).

The concept of brain death has periodically come under criticism 2).

Confirmatory tests for the diagnosis of brain death in addition to clinical findings may shorten observation time required in some countries and may add certainty to the diagnosis under specific circumstances.

The current U.S. approach to determining death was developed in response to the emergence of technologies that made the traditional standard of cardiopulmonary death problematic. In 1968, an ad hoc committee at Harvard Medical School published an influential article arguing for extending the concept of death to patients in an “irreversible coma.“ 3). The emerging neurologic criteria for death defined it in terms of loss of the functional activity of the brain stem and cerebral cortex. Although clinical criteria were developed in the 1960s, it took more than a decade for consensus over a rationale for the definition to emerge. In 1981, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research provided a philosophical definition of brain death in terms of the loss of the critical functions of the organism as a whole 4).

Shortly thereafter, the National Conference of Commissioners on Uniform State Laws produced the Uniform Determination of Death Act, which has been adopted in 45 states and recognized in the rest through judicial opinion 5).

see Computed tomography angiography for brain death.

Changes in S100B protein, especially the levels of this dimer 48 hours after trauma can be used as marker to predict brain death. Alongside other known prognostic factors such as age, GCS and diameters of the pupils, however, this factor individually can not conclusive predict the patient’s clinical course and incidence of brain death. However, it is suitable to use GCS, CT scan, clinical symptoms and biomarkers together for a perfect prediction of brain death 6).

Near-Infrared Spectroscopy for Brain death

The practicability of Gadolinium-enhanced magnetic resonance angiography to confirm cerebral circulatory arrest was assessed after the diagnosis of brain death in 15 patients using a 1.5 Tesla MRI scanner. In all 15 patients extracranial blood flow distal to the external carotid arteries was undisturbed. In 14 patients no contrast medium was noted within intracerebral vessels above the proximal level of the intracerebral arteries. In one patient more distal segments of the anterior and middle cerebral arteries (A3 and M3) were filled with contrast medium. Gadolinium-enhanced MRA may be considered conclusive evidence of cerebral circulatory arrest, when major intracranial vessels fail to fill with contrast medium while extracranial vessels show normal blood flow 7).

The level of knowledge of medical students at Centro Universitário Lusíada – UNILUS- Santos (SP), Brazil, regarding brain death and transplantation is limited, which could be the result of inadequate education during medical school 8).

Brain death criteria.

In a editorial, Hibi et al., aimed to provide an outline of the world history of liver transplantation (LT), with a special focus on the innovation, development, and current controversies of living donor (LD) LT from East Asian and Western perspectives. In 1963, Starzl et al. (University of Colorado, U.S.) performed the world’s first human LT for a 3-year-old child with biliary atresia. The donor was a 3-year-old patient who had suffered from brain death following neurosurgery9).


1)

Lazaridis C. Defining Death: Reasonableness and Legitimacy. J Clin Ethics. 2021 Summer;32(2):109-113. PMID: 34129526.
2)

Truog RD, Miller FG, Halpern SD. The dead-donor rule and the future of organ donation. N Engl J Med 2013;369:1287-1289
3)

A definition of irreversible coma: report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA 1968;205:337-340
4)

President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Defining death: a report on the medical, legal and ethical issues in the determination of death. Washington, DC: Government Printing Office, 1981.
5)

National Conference of Commissioners on Uniform State Laws. Uniform Determination of Death Act, 1981 (http://www.uniformlaws.org/shared/docs/determination%20of%20death/udda80.pdf).
6)

Shakeri M, Mahdkhah A, Panahi F. S100B Protein as a Post-traumatic Biomarker for Prediction of Brain Death in Association With Patient Outcomes. Arch Trauma Res. 2013 Aug;2(2):76-80. doi: 10.5812/atr.8549. Epub 2013 Aug 1. PubMed PMID:24396798.
7)

Luchtmann M, Beuing O, Skalej M, Kohl J, Serowy S, Bernarding J, Firsching R. Gadolinium-enhanced magnetic resonance angiography in brain death. Sci Rep. 2014 Jan 13;4:3659. doi: 10.1038/srep03659. PubMed PMID: 24413880.
8)

Reis FP, Gomes BH, Pimenta LL, Etzel A. Brain death and tissue and organ transplantation: the understanding of medical students. Rev Bras Ter Intensiva. 2013 Oct-Dec;25(4):279-283. Portuguese, English. PubMed PMID: 24553508.
9)

Hibi T, Eguchi S, Egawa H. Evolution of living donor liver transplantation: A global perspective. J Hepatobiliary Pancreat Sci. 2018 Jun 28. doi: 10.1002/jhbp.571. [Epub ahead of print] PubMed PMID: 29953731.
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