All right, thanks for having me. I have to mention that the last time Jeff and I shared a stage was in Argentina where they had to translate our talks. And what I found out very quickly is humor doesn't translate very well. So my background is pediatrics. I'm here to give the exchange lecture for ACSM, and I'm going to give a lot of references just like Jeff. You can see from my own personal experience I cover different teams at different levels and I'm trying to give that perspective as well just like Jeff did about what are we going to do with sideline management. As far as disclosures, I receive royalties from up to date but it has nothing to do with concussion. I am going to discuss a book that I wrote a chapter in that I received no money for. My objectives are that you should be able to recognize the signs and symptoms of concussion during play, understand how to perform a SCAT 5 or a child's SCAT 5 just like Jeff alluded to, and then really to realize who should be referred to the emergency department versus who can really stay and just be monitored. So I put my references up early. This textbook that I mentioned really covers this topic in great detail. If you want to know more about this, this textbook came out in January and I wrote the chapter on sideline management which is probably why I got chosen. But great information, a lot more than we can provide today. Jeff mentioned the concussion support group consensus statement. Again, if you're looking for a reference that's practical, this is a great reference. And then all of our organizations, at least everyone I belong to has a position statement on this. So again, all this information has been vetted, much more than we can provide here. If you want to do some training, and we require this of all of our physicians that are covering teams, go to CDC and you can do training and get a certificate, and every year I do this training just like everybody else to prove that I am at least up to date on what is the current information. So it's a good sort of minimum standard to meet for your people that are covering events. If you really want to read a lot, this is a CDC review on concussion in children and what is the kind of data to support what we do. I participated in this. It took about five years, and I have not read this whole document. So it's just a deluge of information. But this kind of summarizes it well, that we have a whole lot of data and things on more severe traumatic brain injury, but we have less on mild traumatic brain injury. And so just like Jeff was talking about, there's new things coming out all the time. You just need more information to be able to say, hey, you can really use this practically. So what about some basic things? So if you're on the sideline, you're watching the game, these are the things you need to be looking for. And most of the time you see that there is some injury, some blow to the body or the head, or they fall to the ground, and then you're looking for these other things. But if you see some of these other things and you don't see a blow to the head, then you should be thinking about other things, like cardiac things or heat illness, right? But if you see an obvious blow, then you should be looking for these other things. And some of them are easy. If you see somebody get up and they're staggering around, if you see posturing or seizure-like activity, if they're lying motionless and not moving, obviously that's much worse than if they're writhing around in agony. Shaking off the cobwebs better get your attention. If you see the player out there shaking their head. That slide that Jeff put up there with the player with the blank stare, obviously hard to see sometimes from the sideline, but once you get up there it becomes more obvious. With soccer, and particularly MLS, this is one of the things that comes up a lot. So you see a blow to the head and then you see the player clutching their head or clutching their face, and then you have to make a determination, is this something that's significant or not? And one of the challenges I think, particularly with soccer, is oftentimes they're clutching their head because they're trying to get a penalty, right, and it has nothing to do with an actual injury. So it just makes it much more challenging to kind of determine, hey, does this person need an evaluation or not? So that's why I put a question mark by that one, but if I see any of those other things, I'm saying we need to do an evaluation on this person. Now there is some evidence that supports the fact of having spotters and video review is actually useful in this context. And I will say, you know, personally that when this first came up, I'm like, oh, I'm standing on the sideline, I can see all these things, why do I need this other person looking too, right? Why can they look better than me? But the reality is there's a lot more TV cameras in most of these events now that they can see that you just can't see. And I've been surprised how many times where I'm watching the game and I didn't actually see anything happen and yet there's a player laying on the ground. And I'm watching the game, like I'm not on my phone, I'm actually watching the game and I missed it. And then they have all these different camera angles where they can slow it down. You can actually say, yeah, he got an elbow to his head, or yeah, he actually got knocked down and hit his head on the ground. It wasn't the actual blow that got him, it was the fall that got him. So there is some pretty good evidence now to support this. Now the reality is, just like Jeff mentioned, that your high school is not going to have video review, probably not going to have a spotter, but you see this more in college now and certainly in professional sports. And so it may be something that we look into, hey, do you have somebody who's the specific concussion spotter for a high school football game, right? That's their job. There's going to be video there, and so why not if we can do it? There's some evidence to support that. And then if you're going to do an evaluation, and I think one of the challenges, depending on what sport you do, is whether you can take them off and do an evaluation when they're allowed back on again, right? So for soccer, it's a challenge because if they come off, most of the time they're not allowed back on again. And so you really don't have a whole lot of time. You can't do an entire SCAT 5, it's just not possible in the amount of time you have. And so asking some of these orientation questions, and I liked looking up what actual Maddox questions were because you can tell it's sport-specific. And so I don't ask all these questions, but I just remember person, place, and time, right? You need to ask something about who are you, what's your name, where are you, what time is it, that kind of stuff. The other thing I have to remind myself is don't ask a question that you don't know the answer to, right? You better have the athletic trainer with you there who knows, like, I don't know what the score was last week. I wasn't there on the road game, right? So you can get yourself in trouble if you don't have somebody there with you. So good to know, though, you know, ask some of these orientation questions. I don't think you need to ask all of them, but it's a good place to start. And then the diagnostic stuff looks very similar to the baseline stuff, not too surprisingly, right? So the idea here is we're doing this evaluation and get some result or number, and then we want to compare it back to what was their baseline. And so if you have a baseline, that's great. Just as Jeff mentioned, a lot of times you don't. Or same thing happens at our school where we go back to look at the baseline, and we're like, nope, can't use that one, right, because that one's no good. So but just think about these things. What are you going to use? Step five was mentioned multiple times, but there are other tools, a sideline assessment tool is another one. Symptom checklist is probably the most important thing from a practical standpoint that you have some way of doing that. I like the CDC stuff because they put it on a coach's clipboard. They have an app you can put on your phone, so you have a list of questions that you can ask if you don't have a specific app that you use. Getting a quick neuro and cervical exam, VOMS and BALANCE, just like Jeff already kind of went into, and then just realizing that these other things for diagnosis are not there yet. Imaging, there's good evidence on functional MRI and diffuse and tensor imaging that they can do it, but you better be at a major medical center like ours where you can get this, but we can't get it quickly, and so we're not going to use it for diagnosis because it's just not practical. And then I'm going to mention a little bit about biomarkers that Jeff alluded to. So just to delve into the SCAT 5 a little bit, Jeff mentioned this, and I appreciate his family medicine background bringing up pediatrics, that there's a child version of this, and I'm going to talk a little bit about that, but I highlighted these sections that are what you're supposed to do on the sideline, right? So you need to be looking for the red flags and the observable signs that I talked about, the Maddox questions, doing a glass glaucoma scale and a quick cervical exam. To me, like, if you're really worried, this is what you need to be doing. The other stuff is if you don't think it's something bad and you have time to do the rest of this assessment, right, and that includes the things that Jeff already alluded to. At the end of that, you've got to make a decision, do you think that's what this is or not? And I would always defer to the side of caution that if you are suspicious, then you should probably hold them out, right, because oftentimes these symptoms get worse and it becomes more clear later. So what are the red flags? Again, this is who do I send to the emergency room, right? So if you're going to take something away from my talk, this is probably what you want to take away. Somebody who's got cervical pain or tenderness, complaining of double vision, complaining of some sort of paresthesia or weakness on testing in the limbs, severe or worsening headache, I like how I put sever, that's my pediatric background again, seizures, loss of consciousness, deteriorating condition, vomiting, and then this kind of restlessness, agitation, combativeness. These are things that should trigger you to say, okay, this might be more severe than just a simple concussion, right? This is what we don't want to miss. We can manage concussion. It's the other stuff you don't want to miss. I mentioned this, but what's different about the child SCAT-5 and the regular SCAT-5? The red flags are the same, the signs are the same, the Glasgow Coma Scale is the same, the cervical spine is the same, but then when they go into some of the symptom checklists, the words are changed, they're simplified. There's a checklist for both the parent and the child to fill out. You can see the number of words that they ask is less, the number of digits they ask is less. I'm curious about that 5-10 word thing in kids versus adults, because I suspect that kids would have a harder time with it in general, but again, when you get to the end of it, you're making a decision. Is this something to be concerned about or not? But kids can do all these things pretty well. We do this routinely in youth sports and they can do this assessment just like adults can. So there you are on the sideline. You've pulled them off. You're doing your assessment. This is something you want to make sure that you continue to monitor them, because whatever your initial assessment is might change over time. They do not need to be sent to the showers alone. Somebody needs to be with them at all times. If you are in a youth sports or high school sports situation, you want to make sure they're going home with somebody that can continue to monitor them. So oftentimes with our public high schools that we cover, we know that there is nobody at home to monitor them because the parents aren't there because they're working. And so maybe that's somebody we want to observe in the emergency room, even if they aren't going to get a CT scan, so they can have continued observation. But a couple of things to look for, again, if they're throwing up, I mentioned that loss of consciousness I mentioned, we can have a discussion about what do you consider prolonged loss of consciousness? I can tell you if you're there for a minute, that seems like a long time, some of these out that long. But I don't know the right answer. It's not like we can say we have data saying one minute is more significant than five or five is more significant than one. I mentioned the other things, but I think looking for sign of skull fracture. So I think this is where looking for raccoon eyes, battle sign, a bruise behind the ear, looking in the ear to see if there's blood behind the eardrum. Those are all simple things you can do that if you find those things, those have significant implications. And here's the data on that. So looking at CTs that were positive for bleed, and then going backwards, which ones could you predict potentially causes vomiting, correlates very well and skull fracture correlates very well. Interestingly, other things don't. So loss of consciousness, amnesia, seizure, headache, none of those things really correlate very well. So that's why I say if you get vomiting or any of those signs of skull fracture, you should be sending them. A little bit about these biomarkers, and I bring up Copeptin because it has the most kind of information that I can share with you, and this is a systematic review again from this year. And what they took from this is that it has significant value in diagnosing concussion. And so the next question is how do you use this practically, and that's what we don't have data on. So you have, you know, something that's showing some promise, now we need to actually try to use this in the real world and see what happens. The systematic reviews on this is that they are currently saying there's insufficient evidence to support its use. But I do think it's coming. I do think we will be using it. It's probably salivary is going to be the easiest way to do it. So stay tuned on that one. So as far as summary for my sideline assessment talk, if signs are observed during play, then an evaluation should be performed. Again, those main ones that I mentioned. Use a symptom checklist at minimum. If you have other things, I think it's great, but some of it is what do you actually have time to do in a timely fashion. And then referring those people with red flags to the emergency room. Thank you very much. Look forward to your questions.

sideline management

concussions in sports

SCAT 5

red flags

biomarkers