On the pitch: Initial assessment
The initial assessment of a player with suspected concussion follows the standard SABCDE approach.
Having run through the ABC component of the primary survey as described throughout this manual, D or neurological assessment is performed on the pitch initially using ACVPU.
All participants following a head injury who have an ACVPU of C or less, should be extricated with spinal immobilisation from the pitch as soon as it is safe to do so and transferred as soon as possible to the nearest appropriate emergency department if there are no signs of recovery.
If the player scores A on ACVPU and no other problems have been identified in the initial assessment, then the on-field assessment issues are focussed on determining if concussion should be suspected and the player removed from the field of play for a more detailed assessment and follow-up.
There has been ongoing debate on the minimum threshold needed for concussion to be suspected on the pitch. The present consensus view is that any sign or symptom of concussion (See symptoms and signs in Appendix 1 - Concussion Recognition Tool) in the context of a head impact event, should lead to concussion being suspected and the player being removed from play.
A particular challenge faced by the healthcare practitioner working in rugby union, and other sports where there is no temporary interchange for the assessment of injured players (other than those with bleeding wounds), is the difficulty in creating an appropriate environment for the field of play initial clinical assessment. As a consequence, there has been a tendency for concussed players to remain on the field of play.
A solution to the difficulty of creating an appropriate environment for the initial assessment of the player who may have sustained a concussion has been explored through a recent law change in the adult professional rugby union game, endorsed by World Rugby. The law permits a 12 minute temporary substitution to assess the player who has sustained a head injury event and where the diagnosis is not clear, using a standard off-field screening tool, the Head Injury Assessment tool (HIA) . Full details of the HIA process can be found in the Concussion Management for Match Day Medical Staff using the HIA Protocol module at: www.worldrugby.org/playerwelfare This approach has been evaluated in a number of competitions world-wide and differentiates between:
- Situations where the player shows signs or symptoms of concussion and should be definitively removed from the game
- Situations where the diagnosis is not apparent but meet the HIA criteria for temporary removal from play for further assessment.
In matches or tournaments where World Rugby have not granted the use of the HIA tool then “recognise and remove” is the key to safely managing players with suspected concussion.
On field indications for permanent removal from the field of play
Any player who demonstrates any of the following signs or symptoms on field following a head impact should definitively be removed from the field of play:
- Convulsion
- Tonic posturing
- Ataxia
- Suspected LOC
- Clearly dazed
- Confirmed LOC
- Oculomotor signs
- Player not orientated in time, place or person (TPP)
- Definite confusion
- Definite behaviour change
- On-field identification of sign or symptom of concussion
Indications for HIA tool and side-line neurological assessment
For a World Rugby approved match or tournament a player may be temporarily replaced for 12minutes for further assessment using the HIA tool in the following circumstances.
- Head injury where the diagnosis is not apparent
- Possible behaviour change
- Possible confusion
- Injury event witnessed with the potential to result in concussive injury