What is the immediate treatment and management for a concussion?

Immediate Concussion Management

Remove the person from activity immediately and implement 24-48 hours of moderate physical and cognitive rest, followed by gradual reintroduction of supervised sub-threshold aerobic exercise—strict prolonged rest beyond 3 days is harmful and worsens outcomes. 1, 2, 3

Immediate Actions at Time of Injury

• Stop all activity immediately when concussion is suspected—"When in doubt, sit them out!" 1, 2, 3
• Activate EMS immediately if any of these red flags are present: loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes, swelling or deformities of the scalp 1, 2, 3
• Monitor continuously for neurological deterioration during the first 24-48 hours, as life-threatening complications like epidural hematoma or subdural hematoma can develop 1
• Do not allow return to play the same day under any circumstances—this is a critical safety principle 4

Initial 24-48 Hour Rest Period

• Implement moderate cognitive rest: temporarily reduce school workload, avoid video games, computer use, television, and loud music 2, 3, 5
• Implement moderate physical rest: avoid all sports, physical education, and strenuous activities 2, 3, 5
• Avoid strict prolonged rest beyond 48-72 hours—this is detrimental and can worsen outcomes, prolong recovery, cause physical deconditioning, and contribute to depression 1, 2, 6
• Use acetaminophen only for headache management if recommended by a physician—avoid NSAIDs and aspirin due to theoretical bleeding risk 2, 3

Gradual Return to Activity (After Initial 24-48 Hours)

• Begin supervised, sub-threshold aerobic exercise that stays below the level that provokes symptoms—this has the strongest evidence, particularly for adolescents 1, 2, 3, 5
• Follow a stepwise progression with each step requiring minimum 24 hours before advancement 2, 3:
  1. Light aerobic exercise (walking, swimming, stationary cycling) 2, 3
  2. Sport-specific exercise (skating drills, running drills) 2, 3
  3. Non-contact training drills (passing drills, resistance training) 2, 3
  4. Full-contact practice (only after medical clearance) 2, 3
  5. Return to competition 2, 3
• If symptoms recur at any step, return to the previous asymptomatic level and rest 24 hours before attempting progression again 2, 3, 5
• Avoid high-intensity physical activity during recovery—this is detrimental and can worsen outcomes 1, 2, 5

Return to School/Cognitive Activities

• Gradually increase academic activities as tolerated after the initial 24-48 hour rest period 2, 5
• Implement temporary accommodations if symptoms interfere with performance: shortened school days, reduced workloads, extended time for assignments and tests 2, 5
• Monitor symptom expression closely (both number and severity) during cognitive activities 2, 5

Criteria for Full Return to Activity

• All three criteria must be met 2, 3, 5:
  1. Returned to premorbid performance level
  2. Remains symptom-free at rest
  3. Shows no symptom recurrence with increasing physical exertion
• Do not return to play while taking any medications for concussion symptoms—this indicates incomplete recovery 2, 3
• Obtain medical clearance from a healthcare provider trained in concussion management before returning to contact sports 1, 2, 4

Management of Persistent Symptoms (Beyond 10 Days)

• Implement multidisciplinary management including graded physical exercise, vestibular rehabilitation, manual therapy for neck pain, oculomotor vision therapy, and psychological treatment 2, 3
• Recognize that 15-20% develop persistent symptoms beyond 2 weeks, requiring specialist referral 1, 2, 3
• Consider formal neuropsychological assessment for persistent cognitive symptoms 2, 4

Critical Pitfalls to Avoid

• Never allow same-day return to play—this increases risk of repeat concussion, prolonged symptoms, and catastrophic injury 2, 3, 4
• Never prescribe strict rest beyond 3 days—this causes physical deconditioning, psychological consequences from removal from validating activities, and worsens outcomes 1, 2, 6
• Never return to activity while symptomatic or taking symptom-management medications—this indicates incomplete recovery and increases vulnerability to reinjury 2, 3, 4
• Never use vestibular suppressants like meclizine routinely—these provide no benefit for concussion, may interfere with central compensation mechanisms, and can mask important clinical findings 3
• Be more conservative with younger athletes (<18 years)—they have more prolonged recovery and are more susceptible to catastrophic injury 1, 2, 4