What is the standard protocol for managing a suspected concussion?

Standard Protocol for Managing a Suspected Concussion

The standard protocol for managing a suspected concussion requires immediate removal from activity, followed by a structured assessment, initial rest for 24-48 hours, and then a gradual, stepwise return to activity only when the patient is asymptomatic at rest. 1

Immediate Management

• Any person showing signs or symptoms of concussion should be immediately removed from activity and not allowed to return until evaluated by a healthcare professional 1
• For severe head injury symptoms, emergency medical services should be activated immediately 1
• The phrase "When in doubt, sit them out!" is paramount in concussion management 1
• Under no circumstances should athletes with concussion return to play the same day of their concussion 1

Initial Assessment

• Recognition and assessment should include:
  • Symptom checklist (headache, dizziness, visual disturbances, etc.)
  • Cognitive evaluation (orientation, memory, concentration)
  • Balance testing
  • Neurological examination 1, 2
• Warning signs requiring immediate medical attention include:
  • Loss of consciousness
  • Severe or worsening headache
  • Repeated vomiting
  • Altered mental status
  • Seizures
  • Visual changes
  • Swelling or deformities of the scalp 1

Rest and Recovery Phase (First 24-48 Hours)

• Complete physical rest for the first 24-48 hours after concussion 1
• Cognitive rest is essential, especially in the first 24-48 hours 1
• Limit activities requiring concentration and attention, including:
  • Reading
  • Playing video games
  • Using computers
  • Viewing television
  • Exposure to loud music or bright lights 1
• Avoid strict prolonged rest (exceeding 3 days) as this may be detrimental to recovery 3
• Avoid medications except acetaminophen after injury, and only as recommended by a physician 1
• Avoid alcohol, illicit drugs, or other substances that might interfere with cognitive function 1

Gradual Return to Activity Protocol

• Begin gradual reintroduction of activities that do not worsen symptoms after the initial rest period 3
• Follow a stepwise return to activity protocol:
  1. No activity, complete rest until asymptomatic
  2. Light aerobic exercise (walking, swimming, stationary cycling)
  3. Sport-specific training (non-contact)
  4. Non-contact training drills
  5. Full contact training after medical clearance
  6. Return to normal play/activity 1
• Each step should take a minimum of 24 hours 1
• If any symptoms recur, the patient should drop back to the previous asymptomatic level and try to progress again after 24 hours of rest 1
• For adolescents specifically, supervised, non-contact aerobic exercise that stays below symptom-exacerbation threshold is beneficial 3

Return to School/Work Considerations

• Gradually increase duration and intensity of academic/cognitive activities as tolerated 3
• Consider temporary accommodations:
  • Shortened school/work days
  • Reduced workloads
  • Extended time for assignments and tests
  • Postponement of standardized testing 1
• Customize return protocols based on symptom severity 3

Criteria for Return to Full Activity

• Return to full activity should only occur when:
  • The patient has returned to premorbid performance
  • Remains symptom-free at rest
  • Shows no symptom recurrence with increasing physical exertion
  • Is not taking any medications for concussion symptoms 3, 1
• Medical clearance from a licensed healthcare provider trained in concussion management is required 2

Common Pitfalls to Avoid

• Returning to play too soon (primary concern is decreased reaction time leading to repeat concussion) 1, 2
• Inadequate rest in the initial phase 1
• High-intensity physical activity during recovery (can be detrimental) 3
• Ignoring symptoms that develop with delayed onset (16.7% of concussions may have delayed symptom onset) 4
• Lack of standardized assessment tools for proper evaluation 2
• Underestimating recovery time (recovery varies between individuals and may take longer in younger athletes) 1

Special Considerations for Children and Adolescents

• Recovery may take longer in younger athletes compared to older ones 1
• Younger athletes should be managed more conservatively with stricter return-to-play guidelines 1
• Exercise is particularly beneficial for adolescents with acute concussion 3
• Parents, coaches, and school staff should be educated about the symptoms and management of concussion 1