What is the immediate management and treatment for a concussion?

Immediate Management and Treatment for Concussion

Remove the person immediately from all activity (sports, play, or physical exertion) the moment concussion is suspected—"When in doubt, sit them out"—and do not allow return until evaluated by a healthcare professional trained in concussion management. 1, 2

Immediate On-Field/On-Site Actions

Remove From Activity

• Stop participation immediately upon suspecting concussion, regardless of symptom severity 1, 2, 3
• Immediate removal is associated with approximately 3 fewer days missed from sport, shorter symptom duration, less severe acute symptoms, and lower risk of prolonged recovery (≥14 days) 4
• Never allow same-day return to play after diagnosed concussion 5, 3

Activate Emergency Medical Services If:

• Loss of consciousness occurs 1, 5
• Severe or worsening headache develops 1, 5
• Repeated vomiting 1, 5
• Altered mental status or confusion 1, 5
• Seizures 1, 5
• Visual changes 1, 5
• Swelling or deformities of the scalp 1
• Focal neurological deficits 5

These signs indicate potential life-threatening complications including epidural hematoma, subdural hematoma, open skull fracture, or brain edema requiring hospital treatment 1

Initial 24-48 Hour Management

Moderate Physical and Cognitive Rest

• Implement moderate (not strict) physical and cognitive rest for the first 24-48 hours to allow initial recovery during the acute neurometabolic cascade 2, 5, 6
• This initial rest period is critical as the concussed brain shows decreased cerebral blood flow and mitochondrial dysfunction with increased local energy demand 5

Cognitive Rest Includes:

• Temporary reduction in school workload 5
• Avoidance of video games 5
• Limited computer use 5
• Reduced television watching 5
• Avoidance of loud music 5

Critical Pitfall to Avoid:

• Do NOT prescribe strict prolonged rest exceeding 3 days, as this can worsen outcomes and be detrimental to recovery 2, 5, 6, 7
• Prolonged activity restriction may contribute to physical deconditioning, psychological consequences from removal from validating life activities, and development of persistent post-concussive symptoms 7

Symptom Monitoring

• Use graded symptom checklists to objectively assess variety and severity of symptoms over serial evaluations 3
• Monitor for deteriorating physical or mental status during the acute phase 3
• Common symptoms include headache, nausea, impaired balance, difficulties concentrating, confusion, emotional lability, and fatigue 1

Medication Management

• Acetaminophen only may be used for symptom management, and only as recommended by a physician 2
• Avoid NSAIDs and aspirin due to theoretical bleeding risk 5
• Do NOT use vestibular suppressants (antihistamines including meclizine, benzodiazepines) as they show no benefit, may interfere with central compensation mechanisms critical for recovery, and can decrease diagnostic sensitivity 5

After Initial 24-48 Hours: Begin Gradual Return to Activity

Supervised Sub-Threshold Exercise

• After the initial 24-48 hour rest period, begin gradual reintroduction of activities that do not worsen symptoms 2, 6
• Introduce supervised, non-contact aerobic exercise that stays below symptom-exacerbation threshold 2, 6
• This approach is supported by strong evidence showing exercise is particularly beneficial for adolescents with acute concussion 6

Progressive Return Protocol

The stepwise progression includes (each step minimum 24 hours): 2, 5

1. Light aerobic exercise (walking, swimming, stationary cycling)
2. Sport-specific exercise (skating drills in hockey, running drills in soccer)
3. Non-contact training drills (passing drills, resistance training)
4. Full-contact practice (following medical clearance)
5. Return to competition

Progression Rules:

• Each step requires minimum 24 hours before advancing 2, 5
• If symptoms recur at any step, return to the previous asymptomatic level and rest 24 hours before attempting progression again 2, 5
• Monitor symptom expression (number and severity) closely throughout 2, 6
• Avoid high-intensity physical activity during recovery as this is detrimental 5, 6

Return to School/Cognitive Activities

• Gradually increase duration and intensity of academic activities as tolerated 2, 6
• Implement temporary accommodations if symptoms interfere with academic performance, including shortened school days, reduced workloads, extended time for assignments and tests 2
• Customize return-to-school protocols based on symptom severity 6

Clearance for Full Return

Allow return to full activity only when the individual: 2, 5, 6

• 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 (as this indicates incomplete recovery) 5

Special Populations

Youth Athletes:

• Manage more conservatively with stricter return-to-play guidelines 2
• Recovery may take longer in younger athletes compared to older ones 2
• Youth are more susceptible to catastrophic injury accompanying concussion 3
• Greater concern for effects on the maturing brain 5

Athletes with Pre-existing Conditions:

• Preinjury mood disorders, learning disorders, ADD/ADHD, and migraine headaches complicate diagnosis and management 3
• History of prior concussion increases risk of sustaining another concussion and may predict prolonged recovery 3

When to Refer for Specialist Care

• Symptoms persisting beyond 10 days require multidisciplinary management 2, 5
• Refer to specialist in traumatic brain injury if symptoms persist beyond 3 weeks 5
• Consider formal neuropsychological assessment for patients with persistent cognitive symptoms 2
• Recognize that 15-20% of concussion patients develop persistent post-concussion syndrome 2, 5