What is the most appropriate course of action for a sideline physician to take when a 17-year-old boy regains consciousness after being unconscious for 5 minutes following a tackle in a high school football game and is now confused?

Management of Concussion in a High School Football Player

The most appropriate course of action for the sideline physician is to transport the 17-year-old football player to the local emergency department with cervical spine precautions. 1, 2

Rationale for Emergency Department Transport

When evaluating this case, several critical factors indicate the need for immediate emergency department evaluation:

1. Loss of Consciousness (LOC): The player was unconscious for 5 minutes, which is significant. LOC lasting longer than 30 seconds may indicate more significant intracranial injury 1

2. Confusion Upon Regaining Consciousness: Persistent confusion after regaining consciousness is a concerning neurological sign that requires comprehensive evaluation

3. Mechanism of Injury: The injury occurred during a tackle in football, which involves significant force and potential for both brain and cervical spine injury

Assessment Algorithm for Sideline Concussion Management

Step 1: Immediate Removal from Play

• Any athlete with suspected concussion must be immediately removed from play 2
• No same-day return to play is permitted for an athlete diagnosed with concussion 3

Step 2: Assume Cervical Spine Injury

• When performing an on-field assessment of any athlete with decreased consciousness, head and neck injury must be assumed 4
• Maintain cervical spine stabilization during assessment and transport 4

Step 3: Evaluate for Red Flags Requiring Emergency Transport

Red flags in this case include:

• LOC > 30 seconds (5 minutes in this case)
• Persistent confusion after regaining consciousness
• Potential for structural brain injury

Why Other Options Are Inappropriate

1. Examining at 5-minute intervals for mental status changes: This approach is dangerous as it delays definitive care for a potentially serious injury and fails to address potential cervical spine injury 1, 2

2. Examining immediately and letting him return to play if asymptomatic: This directly contradicts guidelines that prohibit same-day return to play for concussed athletes 1, 3

3. Examining cervical spine for somatic dysfunction and treating as needed: This fails to address the potential intracranial injury and is insufficient given the severity of symptoms 2

4. Monitoring on sideline with physician follow-up the next day: This approach is inadequate given the prolonged LOC and persistent confusion, which warrant immediate medical evaluation 1, 2

Key Considerations for the Sideline Physician

• Preparation is Essential: Sideline physicians should have an emergency action plan and appropriate equipment ready before events 5, 6

• Documentation: Record all findings including duration of LOC, symptoms upon regaining consciousness, and neurological status 2

• Communication: Clearly communicate with coaches, parents, and emergency medical services about the severity of the injury and need for transport 6

• Follow-up Care: After emergency department evaluation, the player will require a graduated return-to-play protocol once asymptomatic, with no return to contact sports until cleared by a physician with experience in concussion management 1, 3

Pitfalls to Avoid

• Underestimating Severity: Prolonged LOC (>30 seconds) should never be treated as a minor injury
• Premature Return to Play: This increases risk of second impact syndrome and prolonged symptoms 2, 3
• Failure to Immobilize: Always assume cervical spine injury with head trauma in contact sports 4
• Inadequate Assessment: Confusion may be the only visible sign of significant brain injury 2

By transporting this player to the emergency department with cervical spine precautions, the sideline physician ensures appropriate medical evaluation for potentially serious injuries and optimizes the player's long-term health outcomes.