What is the protocol to rule out a suspected concussion injury on a cricket pitch?

On-Field Concussion Assessment Protocol for Cricket

Any player with suspected concussion must be immediately removed from play and not allowed to return to the match that day, regardless of symptom resolution. 1, 2

Immediate Recognition: Signs and Symptoms to Assess

When a head impact occurs on the cricket pitch, assess for ANY of the following indicators:

Observable Physical Signs

• Loss of consciousness or altered mental state (even brief) 1
• Balance problems, unsteady gait, or poor coordination 1
• Vacant stare, glassy eyes, or confused facial expression 1
• Slow to respond to questions or follow directions 1
• Vomiting or repeated nausea 1
• Seizure activity or convulsive movements 1
• Inappropriate behavior (running wrong direction, unusual emotions) 1
• Slurred speech or personality changes 1

Player-Reported Symptoms

• Headache or pressure in head 1
• Dizziness or feeling "dinged," stunned, or dazed 1
• Seeing stars, flashing lights, or double vision 1
• Ringing in ears (tinnitus) 1
• Nausea or balance problems 1
• Feeling slowed down or "in a fog" 1

Critical Point: Loss of consciousness occurs in less than 10% of concussions—its absence does NOT rule out concussion. 1 The presence of ANY single symptom or sign warrants removal from play. 1

Structured Sideline Assessment

Step 1: Immediate Monitoring (First 5 Minutes)

• Monitor every 5 minutes from time of injury 2
• Document time of injury and serial vital signs 2
• Watch for deterioration in consciousness level 1

Step 2: Symptom Checklist Evaluation

• Use a standardized graded symptom checklist to assess severity 2, 3
• Document all symptoms present, even if mild 2

Step 3: Cognitive Assessment (if trained)

• Orientation questions (person, place, time, situation) 1
• Immediate and delayed memory testing 1
• Concentration assessment (digits backward, months in reverse) 1
• The Standardized Assessment of Concussion (SAC) is 95% sensitive when any decrease from baseline occurs 1

Step 4: Balance Testing (if trained and >15 minutes post-exercise)

• Balance Error Scoring System (BESS) on firm surface 1, 2
• Test should occur >15 minutes after exercise cessation for reliability 1
• Note: Balance testing has limited sensitivity but high specificity 3

Important Caveat: Standardized tools like SCAT2 require specific training and have not been fully validated in all settings. 1 When in doubt about assessment findings, err on the side of caution. 1

Immediate Management Decisions

Mandatory Removal Criteria (Any ONE Present)

• ANY loss of consciousness or amnesia 2
• ANY symptoms persisting at rest or after 20 minutes 2
• ANY positive findings on cognitive or balance testing 2

Emergency Medical Services Activation Required For:

• Loss of consciousness (any duration) 1
• Worsening or severe headache 1
• Repeated vomiting 1
• Seizure activity 1
• Altered mental status or confusion that worsens 1
• Visual changes or neurological deficits 1
• Neck pain or suspected cervical spine injury 1

Post-Removal Monitoring

• Player must NOT be left alone after suspected concussion 1
• Continue monitoring for several hours for deterioration 1
• Provide written instructions to player and family about warning signs requiring emergency department evaluation 1
• Arrange follow-up with healthcare professional trained in concussion management within 24-48 hours 1

Common Pitfalls to Avoid

Never allow same-day return to play: Even if symptoms resolve quickly, the concussed brain remains vulnerable to prolonged dysfunction with premature activity. 4, 3 In elite Australian cricket, 83% of concussions resulted in missing no more than one game, but none returned same-day. 5

Don't minimize terminology: While athletes may respond better to terms like "getting your bell rung" or "ding" during history-taking, these terms should not minimize the seriousness of the injury. 1

Avoid relying solely on loss of consciousness: This occurs in fewer than 10% of sport-related concussions and is NOT required for diagnosis. 1, 3

Don't trust athlete self-reporting alone: Up to 50% of concussions go unreported, and athletes may downplay symptoms to continue playing. 3

Cricket-Specific Context

Concussion rates in elite cricket are higher than previously recognized, with match incidence of 2.3 concussions per 1000 player-days in males and 2.0 in females—approximately one concussion every 9,000 balls bowled in domestic male cricket. 5 Fielding and wicket-keeping account for 28.6% of cricket injuries, while bowling accounts for 41.3%. 6 The implementation of head impact protocols has increased concussion diagnosis rates by improving symptom reporting. 5