What is the recommended assessment and treatment approach for a young adult athlete with a suspected concussion, presenting with symptoms such as headache, dizziness, and confusion, and a history of traumatic head injury?

Concussion Assessment in Young Adult Athletes

Remove the athlete immediately from play and do not allow return the same day—this is non-negotiable even if symptoms resolve, as cognitive and metabolic recovery lags behind symptom resolution. 1, 2

Immediate Sideline Assessment

Perform a structured evaluation using the following components:

Symptom Evaluation

• Use a standardized symptom checklist (SCAT6 or similar) where the athlete self-reports symptoms on a 0-6 severity scale 2
• Headache is the most common symptom (present in majority of cases), followed by dizziness and confusion 1
• Document all symptoms across four domains: physical (headache, dizziness, nausea, balance problems), cognitive (confusion, difficulty concentrating, feeling "foggy"), emotional (irritability, sadness), and sleep disturbances 1, 2
• Ask about feeling "dinged" or having "bell rung"—athletes may be more forthcoming with these colloquial terms 1

Cognitive Assessment

• Avoid standard orientation questions (time, place, person) as they are unreliable in sports settings 1
• Instead, assess memory function using tools like the Standardized Assessment of Concussion (SAC) or Maddock's questions 1
• Test immediate memory (word list recall), concentration (digits backward), and delayed recall 2
• Evaluate for both retrograde amnesia (events before injury) and anterograde amnesia (events after injury)—these are important indicators of more serious injury 1

Neurological Examination

• First rule out cervical spine injury—assume spine injury in any unconscious athlete until proven otherwise 1
• Assess gait and balance using Modified Balance Error Scoring System (mBESS) or Romberg test 1, 2
• Note that balance testing is specific but not sensitive for concussion 3
• Check for physical signs: loss of consciousness (occurs in <10% but indicates potentially more severe injury), poor coordination, slurred speech, vacant stare, inappropriate emotions, vomiting 1

When to Obtain Neuroimaging

CT imaging is indicated when suspicion exists for structural brain injury, not for routine concussion diagnosis 1

Obtain immediate CT if:

• Glasgow Coma Scale score <15 at 2 hours post-injury 1
• Suspected open or depressed skull fracture 1
• Prolonged loss of consciousness (>30 seconds) 2
• Focal neurological deficits 1
• Seizure activity 1
• Persistent worsening headache 1
• Repeated vomiting 1
• Deteriorating mental status 1

Conventional CT/MRI is typically normal in uncomplicated concussion—neuroimaging contributes little to concussion evaluation itself but is critical for excluding structural lesions 1

Neuropsychological Testing

Neuropsychological testing is a cornerstone of concussion evaluation but should never be used in isolation 1, 3

• Baseline testing maximizes clinical utility but is not mandatory 1
• Testing should assess information processing, planning, memory, and mental set-switching 1
• Cognitive recovery may precede OR follow symptom resolution—this is why both symptom assessment and cognitive testing are essential 1
• Computerized tests (ImPACT, CogSport, ANAM) or comprehensive paper-and-pencil batteries administered by neuropsychologists are both valid options 1
• Most concussions can be managed appropriately without neuropsychological testing 3

Acute Management Protocol

Immediate Actions:

• Do not leave the athlete alone; monitor regularly for deterioration 1
• Provide written instructions to athlete and family about warning signs requiring emergency evaluation 1
• Mandate complete physical AND cognitive rest for first 24-48 hours 4

Medication Considerations:

• Avoid NSAIDs and aspirin in the immediate post-injury period due to theoretical bleeding risk 4
• Acetaminophen may be used cautiously for headache management 4

Red Flags Requiring Emergency Evaluation:

• Worsening or severe headache 1
• Repeated vomiting 1
• Seizures 1
• Increasing confusion or deteriorating consciousness 1
• Focal neurological signs 1
• Unequal pupils 4

Return-to-Play Protocol

The athlete must be completely asymptomatic at rest AND with exertion before beginning graduated return-to-play 1, 2

Stepwise Progression (minimum 24 hours per step):

1. Complete rest until asymptomatic at rest 1
2. Light aerobic exercise (walking, stationary bike) at <70% max heart rate 1
3. Sport-specific exercise without contact 1
4. Non-contact training drills with progressive resistance 1
5. Full-contact practice after medical clearance 1
6. Return to competition 1

If ANY symptoms recur at any step, stop immediately and return to the previous asymptomatic level 1, 2

Critical Pitfalls to Avoid

• Never use rigid grading systems—these have been abandoned in favor of individualized assessment based on symptom duration and recovery trajectory 1, 3
• Never allow same-day return to play even if the athlete becomes asymptomatic 2, 3
• Consider pre-existing conditions (ADHD, depression, learning disabilities, migraines) that may complicate diagnosis and prolong recovery 1, 3
• Young adult athletes may require longer recovery than professional athletes 2, 4
• Most concussions resolve in 7-10 days, but some take weeks to months—do not rush recovery 2, 4

Academic Accommodations

• Require cognitive rest including reduced screen time, limited reading, and no testing 3
• Provide academic accommodations: reduced workload, extended test time, excused absences 3
• Gradual return to full academic load as symptoms permit 3