What are the initial steps to manage a suspected concussion?

Initial Management of Suspected Concussion

Immediately remove any athlete or patient from activity when concussion is suspected—there is no same-day return to play regardless of how quickly symptoms resolve. 1, 2, 3

Immediate On-Field/Sideline Assessment

Remove from play and begin serial monitoring:

• Document the exact time of injury and monitor the patient every 5 minutes until their condition stabilizes or they require emergency referral 1, 2
• Look for obvious signs: loss of consciousness (even brief), confusion, disorientation, balance problems, visible memory difficulties, or fluctuating level of consciousness 2, 3
• Ask about symptoms: headache, dizziness, nausea, visual disturbances (blurred or double vision), tinnitus, feeling "in a fog," or sensitivity to light/noise 2, 4

Perform structured sideline evaluation:

• Use a standardized symptom checklist to document all symptoms and their severity 1, 2, 3
• Conduct brief cognitive screening including orientation (person, place, time, situation), immediate and delayed memory recall, and concentration testing 1, 2
• Perform Balance Error Scoring System (BESS) testing—ideally more than 15 minutes after cessation of exercise and in a quiet setting rather than on the sideline 1
• Complete a focused neurological examination including gait assessment 1, 2

Critical Red Flags Requiring Emergency Referral

Transfer immediately to emergency department if any of the following are present:

• Loss of consciousness of any duration 1
• Amnesia lasting longer than 15 minutes 1
• Repeated vomiting 1
• Worsening or severe headache 1
• Seizure activity 1
• Focal neurological deficits 1
• Glasgow Coma Scale score less than 15 at 2 hours post-injury 1
• Suspected skull fracture (visible deformity, clear fluid from nose/ears) 1
• Deteriorating mental status or increasing confusion 1, 2

Initial Management for Non-Emergency Cases

First 24-48 hours:

• Prescribe complete physical and cognitive rest—this means no sports, no exercise, limited screen time, and reduced cognitive demands 2, 3
• Avoid all medications except acetaminophen (avoid NSAIDs and aspirin initially due to bleeding risk) 2
• Provide written instructions to the patient and family about warning signs that require immediate emergency evaluation 1
• Monitor for delayed symptom onset—symptoms may worsen or new symptoms may appear over the first 24-48 hours 2, 4

Academic accommodations for students:

• Implement cognitive rest with reduced workload, extended time for tests, frequent breaks, and possible temporary school absence 2, 3
• Coordinate with school personnel to adjust demands based on symptom severity 2

Disqualification Criteria from Same-Day Return

An athlete must be disqualified from returning to activity on the day of injury if ANY of the following apply:

• Any loss of consciousness occurred 1, 2
• Any amnesia was present 1, 2
• Symptoms persist at rest OR after 20 minutes of exertional testing (jogging, sprinting, sit-ups, push-ups, sport-specific movements) 1, 2
• Any concussion symptoms are still present 2, 5

Follow-Up and Ongoing Assessment

Schedule structured follow-up:

• All patients discharged after mild traumatic brain injury should have scheduled follow-up, as more than 50% do not recover to pre-injury levels by 6 months 1
• Reassess at 24 hours, 48 hours, and then as clinically indicated using the same standardized tools 1, 2
• Evaluate for five concussion subtypes within the first 3 days: cognitive, vestibular, ocular, headache/migraine, and anxiety/mood disturbances, plus sleep dysfunction 2

When to Refer to Specialists

Refer to a physician on the day of injury if:

• Loss of consciousness occurred 1
• Amnesia lasted longer than 15 minutes 1
• Any red flag criteria are met 1

Refer to specialists for persistent symptoms:

• If symptoms persist beyond 3 weeks, refer to appropriate specialists (neurologist for persistent headaches/sleep disturbances, neuropsychologist for cognitive issues, vestibular therapist for balance problems) 1, 2
• Implement targeted interventions based on the specific subtype of symptoms 2

Common Pitfalls to Avoid

• Never use minimizing language like "ding" or "bell rung" when documenting, though these terms may help elicit history from athletes who might otherwise underreport 1
• Do not rely solely on loss of consciousness—it occurs in less than 10% of sport-related concussions 1, 4
• Avoid routine neuroimaging—CT or MRI is only indicated when structural brain injury is suspected based on red flag criteria 1, 3
• Do not allow premature return to activity—the concussed brain shows metabolic vulnerability and decreased responsiveness to neural activation, making it susceptible to prolonged dysfunction with premature cognitive or physical activity 3
• Recognize high-risk populations requiring more conservative management: athletes with prior concussion history, young athletes under 18 years (who have longer recovery times and risk of catastrophic second-impact syndrome), and those with pre-existing mood disorders, learning disabilities, ADHD, or migraines 2, 3

Team Approach

Involve multiple disciplines in decision-making:

• Use a multidisciplinary team including athletic trainers, primary care physicians, neurologists, and neuropsychologists for return-to-play decisions 1, 2
• Integrate findings from physical examination, objective testing, exertional testing, and when indicated, neuroimaging or neuropsychological testing 1, 2