These guidelines are intended for implementation by Athletic Trainers, Athletic Directors and Coaches. Diagnosis of concussion and return to play decisions should be made by licensed physicians only. First aid should only be administered by trained individuals.
All children with head injuries should be referred to hospital.
Important points
Everyone should be aware of the following important points when evaluating athletes in the immediate post-concussion period:
- If a patient reports any symptoms, assume they have been concussed until proven otherwise.
- Diagnosis of concussion must include a formal evaluation such as the Maddocks questions or the Standardized Assessment of Concussion (SAC). Both of these are described below.
- All patients suspected of concussion should undergo formal medical evaluation by a qualified physician.
- All patients suspected of concussion must be serially monitored until they fully recover.
- Never return a patient suspected of concussion to the field of play on the day of the injury.
- When in doubt, refer the patient to the nearest hospital emergency department.
Sideline evaluation
Once the patient has been removed from the field and been stabilized, a full medical and neurological assessment exam should be undertaken. This assessment should include:
- Evaluation of potential signs and symptoms of concussion;
- Evaluation/diagnosis of concussion using a sideline mental status examination;
- Consideration for urgent hospital referral.
Signs & Symptoms of Concussion
If any one of the symptoms or signs described in the box below is present, a head injury should be suspected. A player does not need to have lost consciousness to suffer a concussion. In order to make a specific diagnosis the clinician should test the player's cognitive function formally using a sideline mental status exam.
| Typical Symptoms | |
| Headache | Dizziness |
| Nausea | Unsteadiness/loss of balance |
| Confusion | Unaware of period, opposition, score of game |
| Feeling "dinged", stunned or "dazed" | Seeing stars or flashing lights |
| Ringing in the ears | Double vision |
| Physical signs | |
| Loss of consciousness/impaired conscious state | |
| Concussive convulsion/impact seizure | Gait unsteadiness/loss of balance |
| Slow to answer questions or follow directions | Easily distracted, poor concentration |
| Displaying unusual or inappropriate emotions | Nausea/vomiting |
| Vacant stare/glassy eyed | Slurred speech |
| Personality changes | Inappropriate playing behavior |
| Significantly decreased playing ability | Poor coordination or balance |
Mental Status Examination
There are two validated systems by which a physician can make a rapid diagnosis of concussion. These are known as the Maddocks questions and the Standardized Assessment of Concussion (both described below). Such abbreviated testing paradigms are designed for rapid concussion diagnosis on the sidelines, and are not meant to replace comprehensive neurological and neuropsychological testing, which may detect subtle deficits that can persist beyond the acute episode. Further, although such tools may be used by non-medically trained individuals to suspect a diagnosis of concussion, it is recommended that a mandatory medical examination follow this provisional diagnosis as soon as possible.
Maddocks questions
The Maddocks questions combine scientific validity with a quick simple and practical tool which can be administered either on-field or on the sidelines. Any incorrect response indicates concussion and requires removal from the playing field for further medical evaluation.
| Maddocks questions |
| Which field are we at? |
| Which team are we playing today? |
| Who is your opponent at present? |
| Which half/period is it? |
| How far into the half is it? |
| Which side scored the last touchdown/goal/point? |
| Which team did we play last week? |
| Did we win last week? |
Standardized Assessment of Concussion (SAC)
The Standardized Assessment Of Concussion (SAC) takes 5-10 minutes to administer and includes measures of orientation, immediate memory, concentration and delayed recall. The SAC also includes a brief neurological screen including questions about Loss of Consciousness (LOC) and Post-Traumatic Amnesia (PTA), and some co-ordination and movement tests. The outcome of the SAC is a ‘summary score' out of 30. A manual for the administration, scoring and interpretation of the SAC can be purchased from CNS Inc, Wakeusha, WI, USA.
Further evaluation and referral to hospital
Further post-injury assessment is best performed in a quiet medical room rather than in the middle of a sports field. The major priorities at this stage are to establish an accurate diagnosis and exclude a catastrophic intracranial injury. Thus a full neurological examination should be conducted. Having determined the presence of a concussive injury, the patient needs to be serially monitored until they recover fully.
The treating physician must also determine who should be referred on to a hospital emergency department or neurosurgical center. There are a number of urgent indications for hospital referral. These are listed in the box below. The overall approach should be ‘when in doubt, refer to hospital'. All children with head injuries should be referred to hospital.
| Indications for urgent hospital referral | |
| Fractured skull | Penetrating skull trauma |
| Deterioration in conscious state following injury | Focal neurological signs |
| Confusion or impairment of consciousness > 30 minutes | Loss of consciousness > 5 minutes |
| Persistent vomiting or increasing headache post injury | Any convulsive movements |
| More than one episode of concussive injury in a match or training session | Where there is assessment difficulty (e.g. an intoxicated patient) |
| All children with head injuries | High risk patients (e.g. hemophilia, anticoagulant use) |
| Inadequate post injury supervision | High risk injury mechanism (e.g. high velocity impact, missile injury) |
Never return a patient with a confirmed or suspected concussion to the field of play on the day of the injury. For concussed adult patients, referral to an Emergency Department depends on the experience, ability and competency of the individual physician. Some patients may be discharged home under the care of a responsible adult. The patient and this responsible adult should both be given a ‘head injury' card upon discharge. There is a suggested card in the box below.
| Head Injury |
| This patient has received an injury to the head. A careful medical examination has been carried out and no sign of any serious complications has been found. It is expected that recovery will be rapid, but in such cases it is not possible to be quite certain. If you notice any change in behavior, vomiting, dizziness, headache, double vision or excessive drowsiness, please telephone the medical clinic or the nearest hospital emergency department immediately. No alcohol Patient's name _________________________ Date & time of injury ____________________ Date of medical review __________________ Treating physician ______________________ CLINIC PHONE # ________________________ |
Neuroimaging
The Vienna conference recognized that conventional structural neuroimaging is usually normal in concussive injury. Given that caveat, the following suggestions are made. Brain CT (or where available MR brain scan) contributes little to concussion evaluation but should be employed whenever suspicion of a structural lesion exists. Examples of such situations may include prolonged disturbance of conscious state, focal neurological deficit, seizure activity or persistent clinical or cognitive symptoms. Although neuroimaging may play a part in post-concussive return to play decisions or for the assessment of moderate to severe brain injury, it is not essential for otherwise uncomplicated concussive injury.
