What is the standard protocol for managing a suspected concussion?

Standard Concussion Management Protocol

Immediately remove any individual from activity if concussion is suspected and never allow same-day return to play—this is non-negotiable, even if symptoms resolve. 1, 2, 3

Immediate Sideline Management

Remove from play immediately when ANY of the following are present:

• Loss of consciousness (any duration) 1, 3
• Amnesia (retrograde or anterograde) 1
• Any concussion symptoms whatsoever 1
• Altered mental status or confusion 3
• Balance disturbance or coordination problems 4

The "when in doubt, sit them out" principle is mandatory. 2 Do not leave the individual alone and implement continuous monitoring for deterioration. 5

Emergency Red Flags Requiring Immediate CT and Hospital Evaluation

Transport immediately to emergency department if any of these develop:

• Loss of consciousness 1, 3
• Repeated vomiting 1, 2, 3
• Severe or progressively worsening headache 1, 2, 3
• Seizure activity 1, 3
• Focal neurological deficits 3
• Altered mental status or increasing confusion 2, 3
• Visual changes 1, 2
• Signs of skull fracture or scalp swelling/deformities 1, 3

Acute Phase: First 24-48 Hours

Implement complete physical and cognitive rest for exactly 24-48 hours after injury—no more, no less. 1, 2, 3 Strict rest beyond 48-72 hours is counterproductive and can worsen outcomes. 2, 6

Physical rest includes:

• No sports, exercise, or strenuous physical activity 3
• Avoid activities that significantly increase heart rate 3
• No contact or collision activities 3

Cognitive rest includes:

• Limit all screen time (television, video games, computers, smartphones) 1
• Reduce reading and activities requiring concentration 1
• Avoid loud music and bright lights 1
• Reduce academic workload 3

Medication restrictions:

• Use only acetaminophen for pain, and only as recommended by a physician 1, 2
• Avoid all other medications, alcohol, and illicit drugs 1
• Never allow return to play while taking any medications for concussion symptoms 1, 3

Gradual Return-to-Activity Protocol (After 48 Hours)

Begin supervised, sub-threshold aerobic exercise after the initial 24-48 hour rest period—this has the strongest evidence, particularly in adolescents. 5, 3 Each step requires a minimum of 24 hours; if ANY symptoms recur at any stage, immediately drop back to the previous asymptomatic level and rest for 24 hours before attempting to progress again. 5, 1, 2

The six-step protocol:

1. No activity: Complete rest until asymptomatic at rest for 24 hours 5, 1

2. Light aerobic exercise: Walking, swimming, or stationary cycling at <70% maximum heart rate; no resistance training 5, 2, 3

3. Sport-specific exercise: Skating drills in hockey, running drills in soccer; still no head impact activities 5, 2, 3

4. Non-contact training drills: Progression to more complex training drills (passing drills); may start progressive resistance training 5, 2, 3

5. Full-contact practice: Following medical clearance only; normal training activities including body contact 5, 2, 3

6. Return to competition: Normal game play 5, 2, 3

Critical rule: The individual must be completely symptom-free at rest AND show no symptom recurrence with increasing physical exertion before advancing to the next step. 1, 3

Return to School/Academic Activities

Implement gradual return to cognitive activities in parallel with physical activity progression. 2, 3

Temporary academic accommodations include:

• Shortened school days 1, 3
• Reduced workload and extended time for assignments 1, 3
• Extended time for tests 3
• Breaks during the day as needed 3
• Postponement of standardized testing 1

These accommodations should continue until the student returns to premorbid academic performance. 3

Management of Persistent Symptoms (Beyond 10 Days)

Implement multidisciplinary management for symptoms persisting beyond 10 days, as 15-20% of patients develop persistent post-concussion syndrome. 1, 2, 3

Multidisciplinary approach includes:

• Formal neuropsychological assessment for persistent cognitive symptoms 1, 3
• Graded physical exercise programs under professional guidance 1, 3
• Vestibular rehabilitation for balance/dizziness symptoms 1
• Manual therapy of the neck and spine 1
• Psychological treatment for mood symptoms 3
• Oculomotor vision treatment 2

Special Population Considerations

Younger athletes (pediatric/adolescent) require more conservative management with stricter return-to-play guidelines because damage to the maturing brain can be catastrophic. 1, 4 Recovery typically takes longer in younger athletes compared to older ones. 2, 3

Athletes with three or more prior concussions who experience slowed recovery may require temporary or permanent disqualification from contact sports. 1 Each case requires individualized deliberation, but err on the side of caution. 4

Pre-existing conditions that complicate management:

• Mood disorders 3, 4
• Learning disabilities 3, 4
• ADHD 3, 4
• Migraine headaches 3, 4

Final Medical Clearance Criteria

Allow return to full activity only when ALL of the following are met:

• Complete symptom resolution at rest 1, 3
• No symptom recurrence with increasing physical exertion 1, 3
• Return to premorbid performance level 1, 3
• Medical clearance from a physician experienced in concussion management 1, 3
• Not taking any medications for concussion symptoms 1, 3

Return-to-play decisions should involve a team approach including the athletic trainer, physician, athlete, and any referral sources. 1

Critical Pitfalls to Avoid

The most dangerous mistake is allowing return to play too soon, which can worsen outcomes, prolong recovery, or risk second-impact syndrome. 1, 7, 4 A significant proportion of pediatric concussions involve delayed symptom onset (16.7% in one study), and these patients are less likely to be immediately removed from play, increasing their risk. 8

Other critical errors:

• Skipping steps in the return-to-play protocol 1
• Prescribing excessive prolonged rest beyond 48-72 hours 2, 6
• Relying solely on patient-reported symptoms without objective assessment 2
• Underestimating recovery time in younger athletes 1, 2
• Failing to identify and manage persistent symptoms beyond 10 days 1
• Allowing return to play while symptomatic or on medications 1, 3

Prolonged activity restriction itself may contribute to protracted recovery through physical deconditioning and psychological consequences of removal from validating life activities. 6 This is why the initial rest period should be limited to 24-48 hours, followed by gradual reintroduction of activities. 2, 6