What is the immediate management and treatment for a patient with a concussion?

Immediate Management and Treatment for Concussion

A 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, with an initial period of relative rest for 24-48 hours followed by a graded return to activity protocol. 1, 2

Initial Assessment and Emergency Management

• Assess for severe head injury 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

• Avoid routine use of:

  • Rigid cervical collars
  • Long spine boards
  • Spinal immobilization (especially for penetrating trauma) 1

Immediate Management (First 24-48 Hours)

1. Remove from activity immediately - No same-day return to play for diagnosed concussions 2

2. Implement relative rest (NOT strict bed rest):

   • Physical rest: Avoid high-intensity physical activity
   • Cognitive rest: Limit activities requiring concentration and attention
   • Duration: 24-48 hours 2

3. Medication management:

   • Use acetaminophen (1000 mg) as first-line treatment for headache
   • Consider ibuprofen (400 mg) as alternative
   • Avoid opioids due to risk of dependency and rebound headaches
   • Monitor for analgesic overuse that can lead to rebound headaches 2

4. Patient/family education:

   • Warning signs requiring immediate medical attention:
     • Worsening headache
     • Repeated vomiting
     • Increasing confusion
     • Signs of increased intracranial pressure 2

Graded Return to Activity Protocol

After the initial 24-48 hours of relative rest, implement a 5-stage graded return to activity protocol:

Stage	Activity	Duration
1	Symptom-limited activity	≥24 hours
2	Light aerobic exercise (walking, swimming, stationary cycling at 70% max heart rate)	≥24 hours
3	Sport-specific exercise (no head impact)	≥24 hours
4	Non-contact training drills (may start light resistance training)	≥24 hours
5	Full-contact practice (after medical clearance)	≥24 hours
6	Return to normal activity/play	-

1, 2

Important Clinical Considerations

• If symptoms return during any stage: Stop activity immediately, rest for at least 24 hours, and resume at the previous asymptomatic level 1

• Minimum recovery time: 5 days to progress through protocol to resume full activity, provided symptoms do not return 1

• Medical clearance requirement: Obtain clearance from a licensed healthcare provider trained in concussion management before full return to play 2

• Early intervention importance: Patients who start cognitive and physical rest immediately after injury are more likely to recover within 30 days compared to those who delay rest (67% vs 35%) 3

Management of Persistent Symptoms

For patients with symptoms persisting beyond 4 weeks, implement targeted interventions:

• Graded physical exercise
• Vestibular rehabilitation
• Manual therapy
• Psychological treatment
• Vision therapy
• Cognitive rehabilitation 2

Caution

The cause of concussion significantly affects recovery time and symptom duration. Sports-related concussions typically have better outcomes than those caused by motor vehicle collisions, which tend to have more symptoms and longer recovery periods 4.

Remember that concussion is a functional rather than structural injury to the brain, but complications can occur, including prolonged symptoms, cognitive deficits, depression, and cumulative deterioration in brain function if not managed properly 5.