What is the assessment and management protocol for a suspected concussion?

Assessment and Management Protocol for Suspected Concussion

Any person with signs and symptoms of a concussion should be immediately removed from activity and not allowed to return until evaluated by a healthcare professional. 1

Initial Assessment

Signs and Symptoms to Evaluate

• Common Immediate Symptoms:

  • Headache
  • Nausea
  • Dizziness and balance problems
  • Blurred vision or visual disturbance
  • Confusion
  • Memory loss
  • Fatigue
  • Emotional lability 1

• Red Flag Signs (requiring immediate EMS activation):

  • Loss of consciousness
  • Worsening headache
  • Repeated vomiting
  • Altered mental status
  • Seizures
  • Visual changes
  • Swelling or deformities of the scalp 1

On-Field/Immediate Assessment

1. Remove from activity: Immediately remove the person from play/sports/activity 1
2. Assess for severe injury: Check for red flag signs that require EMS activation 1
3. Monitor: Do not leave the person alone; regular monitoring for deterioration is essential 1
4. Avoid movement: Have the person remain as still as possible unless safety considerations warrant movement 1
5. Avoid spinal immobilization: Routine use of rigid cervical collars and spine boards is not recommended 1

Medical Evaluation

Clinical Assessment Tools

1. Symptom Evaluation:

   • Use a graded symptom checklist to document type and severity of symptoms 2

2. Cognitive Assessment:

   • Orientation testing
   • Memory evaluation (immediate and delayed recall)
   • Concentration testing (e.g., digits backward, months in reverse order) 1

3. Balance Testing:

   • While balance disturbance is specific for concussion (but not very sensitive), assess using standardized tests 2
   • Note that balance testing may be affected by footwear, surface, or lower extremity injuries 2

4. Neurological Examination:

   • Assess cranial nerves, coordination, and strength 2

Imaging Considerations

• Routine imaging is NOT recommended for uncomplicated concussion 1
• Consider imaging (CT or MRI) only when there is suspicion of:
  • Prolonged disturbance of conscious state
  • Focal neurological deficit
  • Seizure activity
  • Persistent clinical or cognitive symptoms 1

Management Protocol

Immediate Management (First 24-48 Hours)

1. Physical and cognitive rest until symptoms begin to improve 1, 2
2. No return to play on the same day of concussion, even if symptoms resolve 1
3. Monitor for worsening symptoms that may indicate more serious injury 1

Recovery Phase

1. Cognitive Rest:

   • May require temporary school absence
   • Modified class work or homework load
   • Gradual return to full academic activities 3

2. Physical Rest:

   • Avoid activities that exacerbate symptoms
   • Concussion symptoms should be resolved before returning to exercise 2

Return to Play Protocol

Only begin after complete symptom resolution at rest and full return to school/cognitive activities 1

Follow this stepwise progression (minimum 24 hours per step) 1:

1. No activity: Complete physical and cognitive rest
2. Light aerobic exercise: Walking, swimming, stationary cycling at 70% maximum heart rate; no resistance exercises
3. Sport-specific exercise: Sport-related drills without head impact
4. Non-contact training drills: More complex drills, may start light resistance training
5. Full-contact practice: After medical clearance
6. Return to play: Normal game play

Important: If symptoms recur at any step, the person should return to the previous asymptomatic level for at least 24 hours before attempting to progress again 1

Special Considerations

Factors Affecting Recovery

• Amnesia: Athletes who experience amnesia may have greater deficits and slower recovery trajectories 4
• Continuing play after concussion: Associated with higher symptom severity 5
• Multiple concussions: May affect recovery and should be considered in management 2

Prevention

• Education: Ensure athletes, parents, coaches, and officials understand concussion recognition and management 2
• Rule enforcement: Proper enforcement of rules and fair play can help prevent concussions 2
• Equipment: While helmets can prevent impact injuries, they have not been conclusively shown to reduce concussion incidence or severity 2

Follow-up Care

• Schedule follow-up evaluation for all patients with concussion 1
• Monitor for persistent symptoms that may require additional intervention
• Medical clearance should be required before full return to play 2

Remember: "When in doubt, sit them out!" 1