Immediate Management of Sports-Related Concussion
Any athlete with suspected concussion must be immediately removed from play and not allowed to return to activity until evaluated by a healthcare professional. 1
Immediate On-Field Actions
Remove from Play Immediately
- Pull the athlete from competition the moment concussion is suspected—no exceptions. 1, 2
- Never allow same-day return to play, even if symptoms resolve quickly. 2
- Avoid using dismissive terms like "ding" as this minimizes injury severity. 1
Initial Assessment and Monitoring
- Record the exact time of injury for documentation. 1, 3
- Monitor vital signs and level of consciousness every 5 minutes until the athlete's condition stabilizes. 1, 3
- Assess for cervical spine injury, particularly in unconscious athletes—this is a critical step that cannot be overlooked. 1, 2
- Evaluate for both obvious signs (fluctuating consciousness, balance problems, memory deficits) and self-reported symptoms (headache, tinnitus, nausea). 1, 3
Activate Emergency Medical Services If:
Call 911 immediately for any of the following red flags: 1
- Loss of consciousness
- Severe or worsening headache
- Repeated vomiting
- Altered mental status or confusion
- Seizures
- Visual changes
- Swelling or deformities of the scalp
- Focal neurological deficits
These signs indicate potential life-threatening injuries such as epidural hematoma, subdural hematoma, or brain edema requiring hospital treatment. 1
Sideline Evaluation Tools
- Use standardized symptom checklists to document all findings. 1, 3
- Perform Balance Error Scoring System (BESS) testing for postural stability assessment. 3
- Conduct cognitive screening including immediate memory, concentration, and delayed recall tests. 2, 3
- No single test determines recovery—use multiple assessment modalities. 1
Initial Management Instructions
First 24-48 Hours
- Prescribe complete physical and cognitive rest for the first 24-48 hours. 4, 3
- This includes limiting reading, video games, computer use, television, loud music, and bright lights. 4
- Allow only acetaminophen for pain as recommended by a physician. 4
- Avoid alcohol, illicit drugs, NSAIDs, and any substances that interfere with cognitive function. 4
Ongoing Monitoring
- Continue monitoring for delayed signs and symptoms for several days after injury. 1, 3
- Provide written instructions on warning signs requiring immediate return to emergency department: repeated vomiting, worsening headache, increased confusion, focal deficits, abnormal behavior, increased sleepiness, loss of consciousness, or seizures. 4
Common Pitfalls to Avoid
- Returning to activity before symptoms fully resolve—this is the most dangerous error. 4
- Inadequate rest in the initial 24-48 hours. 4
- Ignoring subtle symptoms or proceeding without proper medical evaluation. 4
- Using rigid cervical collars or long spine boards routinely (not recommended unless specific indications warrant movement). 1
- Strict rest beyond 48 hours, which can actually be detrimental to recovery. 4
Return to Activity Protocol
Once asymptomatic, follow this stepwise progression with each step taking minimum 24 hours: 1, 4, 3
- No activity (complete rest)
- Light aerobic exercise (walking, stationary cycling)
- Sport-specific training (skating, running)
- Non-contact training drills
- Full contact practice after medical clearance
- Return to game play
If any symptoms recur at any step, drop back to the previous asymptomatic level and wait 24 hours before attempting progression again. 1, 4, 3
Special Considerations
- Pediatric and adolescent athletes have longer recovery times than adults and require more conservative management. 2
- Students may need academic accommodations including shortened school days, reduced workloads, extended time for assignments, and postponement of standardized testing. 4, 3
- Baseline cognitive and postural stability testing should be obtained for athletes in high-risk sports before the season begins. 1, 4
- Refer to a specialist in traumatic brain injury if symptoms persist beyond 3 weeks. 4, 3