What is the appropriate protocol for managing a suspected concussion?

Concussion Management Protocol

Any individual suspected of having a concussion should be immediately removed from activity and undergo prompt medical evaluation by qualified healthcare personnel to reduce morbidity, mortality, and optimize quality of life outcomes. 1

Immediate Management (On-Site)

Recognition and Removal

• Immediately remove from play any athlete/individual with suspected concussion 2
• Look for signs including:
  • Confusion or disorientation
  • Balance disturbance (specific indicator but not very sensitive)
  • Memory problems (inability to recall events before or after injury)
  • Blank or vacant look
  • Visible facial injury or signs of head trauma 3

On-Site Assessment

• Perform initial evaluation using standardized tools:
  • Symptom checklist
  • Cognitive evaluation (orientation, memory, concentration)
  • Balance testing
  • Neurological examination 3
• No same-day return to play is permitted for anyone with diagnosed or suspected concussion 3

Acute Management (24-48 Hours)

Rest Recommendations

• Implement brief relative rest (24-48 hours) 1
• Avoid both strict complete rest and high-intensity physical activity as both can worsen outcomes 2, 1
• Limit activities that significantly worsen symptoms 1

Monitoring

• Monitor for deteriorating physical or mental status 3
• Watch for red flags requiring emergency evaluation:
  • Worsening headache
  • Repeated vomiting
  • Increased confusion
  • Seizures
  • Loss of consciousness
  • Focal neurological signs 4

Early Management (Days 2-7)

Graded Return to Activity

• Begin subsymptom threshold aerobic exercise (activity that doesn't provoke symptoms) 2, 1
• Provide early education and set appropriate expectations for recovery 1
• Implement cognitive rest which may require:
  • Temporary school absence
  • Modified classwork or homework load 4

Symptom Management

• Address specific symptoms with targeted interventions:
  • Headaches: appropriate analgesics
  • Sleep disturbances: sleep hygiene practices
  • Dizziness: vestibular rehabilitation if persistent 1

Return to Activity Protocol

Return to Learn/Work

• Must achieve full return to cognitive activities before progressing to full physical activity 3
• May require academic accommodations:
  • Reduced workload
  • Extended time for tests
  • Frequent breaks 3

Return to Play/Activity Progression

1. Stage 1: Symptom-limited activity (daily activities that don't provoke symptoms)
2. Stage 2: Light aerobic exercise (walking, swimming, stationary cycling at slow-moderate pace)
3. Stage 3: Sport-specific exercise (running drills, no head impact activities)
4. Stage 4: Non-contact training drills (more complex training, may start progressive resistance training)
5. Stage 5: Full-contact practice (following medical clearance)
6. Stage 6: Return to sport/full activity 2, 3

• Progress to next stage only when asymptomatic at current stage
• If symptoms occur during any stage, return to previous asymptomatic stage 3
• Each stage should typically take at least 24 hours (minimum 5-7 days to complete protocol) 3

Special Considerations

High-Risk Populations

• Youth athletes may require more conservative management with longer recovery periods 3
• Athletes with history of multiple concussions require more cautious approach 3
• Consider longer restriction from sports for:
  • Athletes with 3+ concussions in a season
  • Symptoms persisting >3 months 1

Documentation Requirements

• All assessments and management decisions should be thoroughly documented 2
• Document specific details of:
  • Mechanism of injury
  • Initial symptoms
  • Examination findings
  • Recovery progression 2

Common Pitfalls to Avoid

• Premature return to high-risk activities increases risk of second-impact syndrome, especially in youth 1
• Prolonged complete rest can worsen outcomes and delay recovery 2, 1
• Overlooking comorbidities that may complicate recovery (e.g., migraines, ADHD, anxiety) 1
• Failing to provide clear expectations about recovery timeline and process 1
• Delaying initiation of appropriate exercise therapy, which has been shown to improve outcomes, particularly in adolescents 2, 1

Follow-up and Specialist Referral

• Medical clearance from a licensed healthcare provider trained in concussion management is required before full return to play 3
• Consider referral to concussion specialist for:
  • Symptoms persisting beyond 2-4 weeks
  • Complex cases with multiple symptom domains
  • History of multiple concussions
  • Pre-existing conditions that may complicate recovery 1

Remember that most concussions (80-90%) resolve within one month, but approximately 10% of patients experience symptoms beyond 3 months 1. Elective surgery should be delayed at least 4 weeks after concussion 1.