What are the concussion precautions for a teenage boy with a hockey injury presenting with nausea and headache?

Concussion Management for a Teenage Hockey Player with Headache and Nausea

This teenage boy must be immediately removed from all hockey activities and not allowed to return to play until evaluated and cleared by a healthcare professional trained in concussion management, with follow-up arranged within 24-48 hours. 1, 2

Immediate Actions Required

Remove from Activity Immediately

• Any athlete with a single concussion symptom must be removed from play immediately and cannot return to activity that same day, regardless of whether symptoms improve. 1, 2
• The presence of both headache (the most common concussion symptom) and nausea confirms this patient has sustained a concussion requiring immediate removal from the ice. 1, 3

Assess for Emergency Red Flags

You must immediately evaluate this patient for critical warning signs that would require emergency medical services activation: 1, 2

• Loss of consciousness (even brief)
• Worsening or severe headache (not just mild persistent headache)
• Repeated vomiting (not just nausea)
• Altered mental status (confusion, disorientation, difficulty staying awake)
• Seizure activity
• Visual changes (blurred vision, double vision, visual field defects)
• Signs of skull fracture (scalp swelling/deformities, Battle's sign, raccoon eyes, blood behind eardrum, clear fluid from nose/ears)

If any of these red flags are present, activate EMS immediately. 1, 2

Initial Assessment on the Sideline

Cervical Spine Evaluation

• If the player was unconscious at any point or you did not witness the injury, assume cervical spine injury until proven otherwise. 1
• Maintain cervical spine stabilization and evaluate neurologic function in all four limbs, check for neck pain, and palpate for cervical spine tenderness. 1
• If you cannot complete this evaluation or lack qualified personnel, transport to the emergency department. 1

Symptom Documentation

Document all symptoms across the four concussion domains using a graded scale (0-6 severity): 1, 3

Physical symptoms: Headache, nausea, vomiting, dizziness, balance problems, fatigue, light sensitivity, noise sensitivity, visual problems 1, 3

Cognitive symptoms: Difficulty concentrating, difficulty remembering, feeling "slow" or "foggy," confusion 1, 3

Emotional symptoms: Irritability, sadness, nervousness, feeling more emotional 1, 3

Sleep symptoms: Trouble falling asleep, excessive sleep, drowsiness 1, 3

Amnesia Assessment

• Evaluate for both retrograde amnesia (events before injury) and anterograde amnesia (events after injury), as amnesia indicates more serious injury. 1, 3
• Ask specific questions about game details before and after the hit (e.g., "What period was it?" "What was the score?" "What happened after you got hit?"). 1

Follow-Up Management

Medical Evaluation Timeline

• Arrange follow-up with a healthcare professional trained in concussion management within 24-48 hours, even if symptoms appear mild. 2
• This evaluation should occur before any consideration of return to activity. 1, 2

Activity Restrictions During Recovery

• Complete cognitive and physical rest initially until asymptomatic. 1
• Limit moderate and vigorous physical activity during the first 3 days post-injury, as higher activity levels during this period are associated with prolonged recovery time. 4
• Avoid activities that worsen symptoms, including screen time, schoolwork, and physical exertion. 1

Return to Play Protocol

Once completely asymptomatic, follow this stepwise progression (minimum 24 hours per step): 1

1. Complete rest until symptom-free
2. Light aerobic exercise (walking, stationary cycling)
3. Sport-specific training (skating drills without contact)
4. Non-contact training drills
5. Full contact practice after medical clearance
6. Game play

If any symptoms recur at any step, drop back to the previous level and wait 24 hours before attempting to progress again. 1

Critical Pitfalls to Avoid

• Do not allow return to play the same day even if symptoms resolve—this is dangerous and violates current guidelines. 1, 2
• Loss of consciousness occurs in less than 10% of concussions—its absence does not rule out concussion or reduce its seriousness. 1, 2
• Do not rely on the player's self-report alone—athletes often minimize symptoms to return to play, particularly male athletes. 1
• Nausea can progress to repeated vomiting—monitor closely as repeated vomiting is a red flag requiring emergency evaluation. 1, 2