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Sport-related concussion (SRC) is a public health issue of increasing concern. Sports coaches and match officials are important stakeholders in facilitating early recognition, immediate management and appropriate return-to-play following SRC. This systematic review analyses the current evidence on SRC knowledge amongst sports coaches and match officials. The review was conducted in accordance to PRISMA guideline. A qualitative analysis of knowledge on identification, management, prevention and consequences of SRC as well as return-to-play principles was performed. The Appraisal Tool for Cross-sectional Studies was employed to assess the quality and reliability of each study. Searches were conducted on PubMed, Medline Ovid, Web of Science, CINAHL, SPORTDiscus and Psycinfo. Studies included were primary studies in English published in peer-reviewed journals assessing the level of concussion knowledge or education level amongst coaches, officials or both, regardless of sports or competitive level. A total of 20880 studies were identified, from which 27 were included in this review. There were 26 cross-sectional studies and one randomized controlled trial; 20 assessed SRC knowledge amongst coaches, one considered only officials and six studies assessed both groups. Concussion knowledge amongst coaches and match officials was deemed moderate in most studies, although significant knowledge gaps were identified. There is considerable room for further education on SRC amongst coaches and officials, particularly with the less commonly recognized symptoms of SRC and misconceptions about SRC management and prevention. Beyond knowledge assessment, further investigation should explore the translation of concussion knowledge to on-field management of players with SRC.

IMPORTANCE: QT-prolonging medications (QTPMs) are a reported risk factor for sudden cardiac death (SCD) when defined by consensus criteria that presume an arrhythmic cause. The effect of QTPM on autopsy-defined sudden arrhythmic death (SAD) is unknown. OBJECTIVE: To evaluate the association between QTPM and autopsy-defined SAD vs nonarrhythmic cause of sudden death. DESIGN, SETTING, AND PARTICIPANTS: This prospective countywide case-control study included World Health Organization–defined (presumed) SCD cases who underwent autopsy as part of the San Francisco Postmortem Systematic Investigation of Sudden Cardiac Death Study (POST SCD) to determine arrhythmic or nonarrhythmic cause, and control deaths due to trauma (hereinafter referred to as trauma controls) in San Francisco County, California, from February 1, 2011, to March 1, 2014. Multivariate regression was used to evaluate the association of QTPM with the risk of presumed SCD, autopsy-defined SAD, and non-SAD compared with trauma controls. Medication exposure, determined by prescription lists and postmortem toxicologic findings, was used to calculate a summative QTPM exposure score (range, 0-20). Data were analyzed from September 1, 2018, to June 15, 2019. EXPOSURE: QT-prolonging medication exposure, as measured by QTPM score (1 indicated low; 2-4, moderate; and >4, high). MAIN OUTCOMES AND MEASURES: Death due to trauma, presumed SCD, and autopsy-defined non-SAD and SAD with no postmortem findings of extracardiac cause. RESULTS: A total of 629 patients (mean [SD] age, 61.4 [15.7] years; 439 men [69.8%]) were included, 525 with presumed SCDs and 104 traumatic death controls. Individuals with presumed SCDs had higher exposure and were more likely to be taking any QTPM (291 [55.4%] vs 28 [26.9%]; P

Introduction Sports concussion remains challenging to manage despite changes to policy and practice since the 2012 International Consensus Conference on Concussion in Sport. Emergency physicians (EPs) are usually the first line of medical care for athletes in amateur and youth collision sports. This single-centre cross-sectional study aimed to establish EPs' understanding and management of concussion in Singapore. Methods An anonymised, 17-item online questionnaire was sent to EPs requesting for information on their clinical experience, training, exposure to concussion cases in the emergency department (ED) and assessed knowledge of the condition. Results Out of 65 EPs, 52 (80%) responded, 25 (48.1%) of whom were medical officers. Over 90% had not received formal training in concussion management, and 73.1% regularly assessed concussion. 40 (76.9%) EPs recognised that loss of consciousness was not essential for diagnosis and only 24 (46.2%) knew the most common symptom. 26 (50.0%) incorrectly reported that they would perform brain imaging. Among those who indicated onward referral, 29 (55.8%) would refer concussed patients to neurosurgery. There were no significant differences between clinical grade or training in concussion and positive responses for definition, imaging modality or most common symptom of concussion. Conclusion Concussion is a common presentation to EDs in Singapore. However, understanding of the condition, its clinical diagnosis, investigation and onward management is limited. Although EPs reported training in concussion, it is likely to be insufficient. Commencing relevant education programmes for undergraduate and postgraduate medical students may enable progressive acquisition of knowledge and thereby improve patient management in the future.

Background: Conventional definitions of sudden cardiac death (SCD) presume cardiac cause. We studied the World Health Organization–defined SCDs autopsied in the POST SCD study (Postmortem Systematic Investigation of SCD) to determine whether premortem characteristics could identify autopsy-defined sudden arrhythmic death (SAD) among presumed SCDs. Methods: Between January 2, 2011, and January 4, 2016, we prospectively identified all 615 World Health Organization–defined SCDs (144 witnessed) 18 to 90 years in San Francisco County for medical record review and autopsy via medical examiner surveillance. Autopsy-defined SADs had no extracardiac or acute heart failure cause of death. We used 2 nested sets of premortem predictors—an emergency medical system set and a comprehensive set adding medical record data—to develop Least Absolute Selection and Shrinkage Operator models of SAD among witnessed and unwitnessed cohorts. Results: Of 615 presumed SCDs, 348 (57%) were autopsy-defined SAD. For witnessed cases, the emergency medical system model (area under the receiver operator curve 0.75 [0.67–0.82]) included presenting rhythm of ventricular tachycardia/fibrillation and pulseless electrical activity, while the comprehensive (area under the receiver operator curve 0.78 [0.70–0.84]) added depression. If only ventricular tachycardia/fibrillation witnessed cases (n=48) were classified as SAD, sensitivity was 0.46 (0.36–0.57), and specificity was 0.90 (0.79–0.97). For unwitnessed cases, the emergency medical system model (area under the receiver operator curve 0.68 [0.64–0.73]) included black race, male sex, age, and time since last seen normal, while the comprehensive (area under the receiver operator curve 0.75 [0.71–0.79]) added use of β-blockers, antidepressants, QT-prolonging drugs, opiates, illicit drugs, and dyslipidemia. If only unwitnessed cases Conclusions: Our models identify premortem characteristics that can better specify autopsy-defined SAD among presumed SCDs and suggest the World Health Organization definition can be improved by restricting witnessed SCDs to ventricular tachycardia/fibrillation or nonpulseless electrical activity rhythms and unwitnessed cases to

With the upcoming fifth International Conference on Concussion in Sport taking place in October 2016, the management of concussion in athletes will again be under increased scrutiny. However, it has rarely left the spotlight with 58 articles published in BJSM alone between 2012 and 2016! An off-field event fuelling this continued interest has been the American NFL players’ lawsuit; a group of retired NFL athletes won a US$900 million out-of-court settlement from the organisation, stating they were not warned about brain injury risk and that cases were hidden from them. Upheld by the court of appeals, there are calls to include players with chronic traumatic encephalopathy in this decision. This may set a new legal precedent, and already another lawsuit has been filed by American footballers against the National Collegiate Athletic Association on similar grounds. Media attention on the concussion lawsuit in America highlights the potential medico-legal sequelae if concussion is (or is perceived to be) inadequately detected or managed. Commentary by …

Objective 1. To gain an understanding of Singapore Emergency Physicians (EPs) knowledge and practice habits when assessing concussions in the Emergency Department (ED). 2. To determine what knowledge exists regarding current international concussion management and return-to-play guidelines Design A 21 item anonymous internet survey was developed and disseminated to EPs in Singapore. A limited time period for completion was given. Because of anonymity, non-responders could not be specifically targeted. Participation was voluntary and no incentives were offered. Results 26 responses which included 9 Associate Consultants or above, 4 Registrars, 14 junior doctors. 63% were Singapore trained. 88.9% were aware of the concussion diagnosis but only 50% could document the salient points required to diagnose concussion. The highest percentage (33.3%) reported seeing cases of concussion monthly, 18.5% fortnightly, 29.6% weekly and 14.8% daily. 33.3% of EPs were aware of Internationally Recognised guidelines but only 11% use them. 70.4% refer concussions for follow up (47.4% to Neurosurgery and 21.1% to Sports Medicine). Only 14.8% of EPs have had specific training in sports concussion management. Conclusions 1. It is likely that concussion is under diagnosed; many EPs only report seeing cases monthly and are unaware of the salient features to diagnose concussion. 2. International guidelines regarding return-to-play and standardised assessment have not reached the majority of EPs. 3. A small proportion of concussion cases are referred to Sports Clinics for follow up. 4. Further training in sports concussion management in Singapore EDs is needed. 5. Further studies in this area are required. Competing interests Joanne Probert – Trainer for World Rugby.

Objective To compare the clinical effectiveness of intravenous paracetamol with intravenous morphine in patients with moderate to severe traumatic limb pain. Methods This randomised, double-blind pilot study was conducted in an urban UK emergency department. Patients between 16 and 65 years old with isolated limb trauma and in moderate to severe pain (pain score of 7 or more) received either 1 g intravenous paracetamol or 10 mg intravenous morphine sulphate over 15 min. The primary outcome measure was pain score measured on a visual analogue scale at 0, 5, 15, 30 and 60 min after commencing drug administration. The requirement for rescue analgesia and the frequency of adverse reactions were also recorded. Results 55 patients were recruited over 10 months. There was no significant difference in analgesic effect between the paracetamol and morphine groups at any time interval. There was no significant difference in the rescue analgesia administered, but there were significantly more adverse reactions in the morphine group. Conclusion Intravenous paracetamol appears to provide a level of analgesia comparable to intravenous morphine in isolated limb trauma. Further larger studies are required.

Report by Dr Joanne Probert , Clinical Fellow Emergency Medicine Search checked by Dr Jacqui Macnair , Clinical Fellow Emergency Medicine Institution: Bristol Royal Infirmary, Bristol, UK ### CLINICAL SCENARIO A 26-year-old man attends the emergency department having recently used cocaine. He is hyperthermic. You have heard that dantrolene may have a place in the management of …