What is the recommended protocol for managing concussion and head trauma in patients?

Concussion and Head Trauma Management Protocol

For acute concussion management, implement 24-48 hours of moderate physical and cognitive rest followed immediately by supervised, sub-threshold aerobic exercise—particularly in adolescents where this approach has the strongest evidence—while strictly avoiding prolonged rest beyond 3 days which worsens outcomes. 1, 2, 3

Immediate On-Field/Emergency Assessment

Remove from activity immediately when concussion is suspected—"When in doubt, sit them out"—and never allow same-day return to play even if symptoms resolve. 2, 4, 3

Red Flags Requiring Emergency CT and Hospital Evaluation:

• Loss of consciousness or altered mental status 2, 4, 3
• Glasgow Coma Scale <15 at any point 3
• Repeated vomiting or severe/worsening headache 2, 4, 3
• Seizure activity or focal neurological deficits 2, 4, 3
• Signs of basilar skull fracture 3
• Dangerous mechanism of injury or any coagulopathy/anticoagulant use 3

Critical distinction: Concussion shows no abnormality on standard neuroimaging by definition, while contusion requires CT/MRI for diagnosis and represents structural brain injury requiring hospitalization and neurosurgical consultation. 4

Acute Phase Management (First 24-48 Hours)

Physical Rest:

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

Cognitive Rest:

• Limit screen time (television, computers, video games) 2, 3
• Reduce academic workload temporarily 2, 3
• Avoid activities requiring intense concentration 3
• Minimize loud music and overstimulating environments 2

Avoid the common pitfall: Do NOT prescribe strict rest beyond 48-72 hours, as prolonged rest exceeding 3 days actually worsens outcomes and delays recovery. 1, 2, 3

Progressive Return to Activity Protocol (After Initial 24-48 Hours)

Begin supervised, sub-threshold aerobic exercise after the initial rest period—this is the only intervention with strong evidence as appropriate therapy, particularly in adolescents. 1, 2, 3

Stepwise Progression (Minimum 24 Hours Per Step):

1. Light aerobic exercise: Walking, swimming, or stationary cycling at <70% maximum heart rate, staying below symptom threshold 2, 4, 3

2. Sport-specific exercise: Skating drills in hockey, running drills in soccer—no head impact activities 2, 4

3. Non-contact training drills: Passing drills, resistance training, more complex movements 2, 4

4. Full-contact practice: Following medical clearance only 2, 4

5. Return to competition: Full unrestricted play 2, 4

If symptoms recur at any step: Return to the previous asymptomatic level and rest 24 hours before attempting progression again. 2, 4, 3

Return to School/Academic Activities

Gradually increase academic activities as tolerated, implementing temporary accommodations: 2, 3

• Shortened school days 2, 3
• Extended time for assignments and tests 2, 3
• Reduced workload 2, 3
• Scheduled breaks during the day 3

Most teenagers recover within 7-10 days, though some require weeks to months. 3

Criteria for Full Return to Activity

Allow return to full activity ONLY when ALL of the following are met: 2, 4, 3

• Returned to premorbid performance level 2, 4, 3
• Completely symptom-free at rest 2, 4, 3
• No symptom recurrence with increasing physical exertion 2, 4, 3
• NOT taking any medications for concussion symptoms 2, 4, 3
• Medical clearance from physician experienced in concussion management 3

Management of Persistent Symptoms (Beyond 10 Days)

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

Evidence-Based Interventions for Persistent Symptoms:

• Graded physical exercise programs (primary intervention) 2
• Vestibular rehabilitation for vestibular dysfunction 2, 4
• Manual therapy for cervical spine/neck pain 2, 4
• Cognitive behavioral therapy for psychological symptoms 2
• Formal neuropsychological assessment for persistent cognitive symptoms 2, 3
• Oculomotor vision therapy when indicated 4

Do NOT use vestibular suppressants (antihistamines like meclizine or benzodiazepines) as they show no benefit, may interfere with central compensation mechanisms, and can decrease diagnostic sensitivity. 4

Medication Guidelines

• Acetaminophen only for symptom management, and only as recommended by a physician 2, 3
• Avoid NSAIDs/aspirin due to theoretical bleeding risk 4
• Never clear for return to play while taking any medications for concussion symptoms 2, 4, 3

Special Population Considerations

Pediatric and Adolescent Athletes:

• Manage more conservatively with stricter return-to-play guidelines 2, 3
• Recovery may take longer due to the developing brain 2
• Exercise therapy has the strongest evidence specifically in adolescents 1, 2, 3
• Higher risk of catastrophic injury with premature return 3

Older Adults:

• Often experience concussions from low-velocity mechanisms such as falls from standing height 1

Assessment Tools for Monitoring Recovery

Use objective assessment tools in combination with symptom checklists rather than relying solely on patient self-report: 3

• Graded symptom checklists 3
• Cognitive screening 3
• Balance testing 3
• Neuropsychological testing when available for baseline comparison 3

Common pitfall: Patient self-report alone increases risk of recall bias and under/overreporting—underreporting leads to premature return and increased risk of persisting symptoms, while overreporting leads to prolonged unnecessary rest. 1

Critical Pitfalls to Avoid

• Never allow same-day return to play after diagnosed concussion, even if asymptomatic 2, 4, 3
• Avoid high-intensity physical activity during recovery as this is detrimental 1, 2, 4
• Do not prescribe strict rest beyond 48-72 hours—prolonged rest worsens outcomes 1, 2, 3
• Never return to play while on concussion medications—this indicates incomplete recovery 2, 4, 3
• Do not rely solely on patient-reported symptoms without objective assessment 1, 3
• Assess for preexisting comorbidities (mood disorders, ADHD, learning disabilities, migraines) as these are the most consistent predictors of persistent symptoms in youth 1

Contusion Management (Structural Brain Injury)

Fundamentally different from concussion management: 4

• Requires hospitalization for neurological monitoring 4
• Serial neurological examinations to detect deterioration 4
• Repeat imaging as clinically indicated to assess for expansion 4
• Requires neurosurgical clearance before any return to physical activity 4
• May require months of complete rest from contact activities 4
• Many patients with significant contusions permanently disqualified from contact sports 4
• Long-term follow-up to monitor for late complications (post-traumatic epilepsy, hydrocephalus) 4