11.3 Acute Head Trauma & Concussion Sideline Triage

Quick Answer: Suspect a concussion → remove from play → no same-day return. Loss of consciousness is not required. Red flags (worsening headache, repeated vomiting, unequal pupils, seizure, focal deficit, GCS drop, raccoon eyes, Battle sign, CSF leak) = EMS, not a quiet SCAT in the locker room. Protect the cervical spine before you sit the athlete up. After a diagnosed concussion, relative rest is 24–48 hours, then symptom-limited activity (NATA 2024 Bridge Statement; Amsterdam 2022). Strict cocooning is outdated.

This section is acute head-trauma triage — recognition, removal, red flags, sideline tools, and EMS. Return-to-play (RTP) staging is Domain 4 and is covered later. The documents to know: NATA 2014 position statement on sport concussion (Broglio et al., JAT 49(2):245–265), the 2024 NATA Bridge Statement (Broglio, Register-Mihalik, Guskiewicz, Leddy, Merriman, Valovich McLeod, JAT 59(3):225–242), and the 6th International Conference on Concussion in Sport — Amsterdam, October 2022 (Patricios et al., British Journal of Sports Medicine 2023;57:695–711), which released SCAT6, Child SCAT6, CRT6, and SCOAT6.

Remove from play — no same-day return

NATA 2014 recommendation 14 (unchanged in 2024): any athlete suspected of sustaining a concussion is immediately removed and evaluated by a physician or designate (the AT). Recommendation 19: a concussed athlete is not returned to athletic participation on the day of injury. Amsterdam 2022 agrees: no same-day return to the match or training after a diagnosed concussion.

Licensed medical professionals have unchallengeable medical authority over concussion removal (NATA 2024 Bridge, new education recommendation). Coaches, parents, and the athlete do not outvote the AT on this point. State concussion laws typically encode the same remove-and-no-same-day-return rule.

Loss of consciousness (LOC) is neither required nor common. Most sport-related concussions have no LOC. “He didn’t black out, so it’s not a concussion” is false. “Let him finish the quarter” is how a second hit lands on an already injured brain. Delayed reporting is associated with longer recovery; immediate removal is associated with shorter recovery (CARE Consortium data cited in the 2024 Bridge).

Observable signs that force removal even if the athlete says “I’m fine”: lying motionless, slow to get up, balance/incoordination, blank or vacant look, facial injury after a head impact, clutching the head, confusion, or impact seizure. When in doubt, sit them out.

Red flags — this is not a concussion workup

SCAT6 / CRT6 open with red flags that require calling an ambulance. These signs suggest intracranial hemorrhage, skull fracture, cervical injury, or deteriorating brain herniation, not garden-variety concussion:

• Neck pain or tenderness (treat as CSI until cleared)
• Double vision
• Weakness, tingling, or burning in arms or legs
• Severe or increasing headache
• Seizure or convulsion
• Loss of consciousness
• Deteriorating conscious state / GCS drop (Glasgow Coma Scale below 15, or any decline)
• Repeated vomiting
• Increasingly restless, agitated, or combative
• Unequal pupils
• Raccoon eyes (periorbital ecchymosis) without direct orbital trauma — basilar skull fracture pattern
• Battle sign (mastoid/retroauricular ecchymosis) — also a basilar-skull pattern; it may appear hours later, so serial observation matters
• CSF otorrhea or rhinorrhea (clear fluid from ear or nose after head trauma) — do not pack the ear or nose; assume a basilar skull fracture and go to EMS
• Focal neurologic deficit (new weakness, aphasia, cranial-nerve palsy)

Serial observation is part of acute care. An athlete who looked “only concussed” at 3 minutes and is vomiting and sleepy at 20 minutes has a different disease until CT says otherwise. Give oral and written home-care instructions to a responsible adult (NATA 2014 rec. 35, still in force). No alcohol, no driving, no leftover narcotics “for the headache,” and return/EMS criteria for worsening.

Sideline tools: name them, do not photocopy them

The Concussion in Sport Group tools are copyrighted. The AT names them, uses the current official form, and does not reproduce the full item lists from memory on a homemade card that is then treated as SCAT6.

• CRT6 (Concussion Recognition Tool 6): for non-medical personnel (coaches, officials). Recognize and remove. CRT6 does not diagnose concussion.
• SCAT6 (Sport Concussion Assessment Tool 6): for health-care professionals, ages 13 and older, most useful in the acute window (about the first 72 hours).
• Child SCAT6: ages 8–12 in that same acute window.
• SCOAT6 / Child SCOAT6: office tools for the subacute period (about 72 hours to 30 days), not the sideline primary survey.

SCAT6 is a multimodal screen, not a blood test. The clinical examination remains the criterion standard (NATA 2014/2024). A “normal” SCAT6 does not grant same-day return.

Pieces the AT must understand (concepts, not a bootleg form)

• Immediate on-field screen: red flags, observable signs, Glasgow Coma Scale, cervical-spine questions, and a brief Maddocks-style orientation to this game (not the president’s name). Failing those items ends the sideline debate: remove, and consider EMS.
• Symptom scale: graded symptoms now versus typical. Athletes lie. Use serial scores and collateral from teammates.
• Cognitive screen (SAC-style): orientation, immediate memory, concentration, delayed recall. Word-list length and digits were updated in SCAT6; administer from the official tool.
• mBESS / BESS: Balance Error Scoring System. Double-leg, single-leg, and tandem stances, eyes closed, hands on hips, typically 20 seconds. mBESS is the firm-surface subset used on the sideline; full BESS adds foam. Count errors (eyes opening, hands off hips, stumbling). A downed athlete with a possible CSI does not stand on one foot.
• VOMS (Vestibular/Ocular Motor Screening): smooth pursuits, saccades, near-point of convergence, vestibulo-ocular reflex, visual motion sensitivity. The 2024 Bridge added visual-vestibular function as a key assessment domain. Symptom provocation (headache, dizziness, fogginess, nausea) is the clinical signal. VOMS is usually done when the athlete can sit or stand safely — again, after the neck is not an emergency.

Baseline testing is not mandatory in the 2024 Bridge if resources are limited; post-injury trajectory and the clinical exam still work. If baselines exist, they must be collected under proper conditions, not as a mass-testing circus.

C-spine before you sit them up

Head injury and cervical injury share mechanisms. NATA 2024: the clinical examination includes a cervical-spine and neurologic evaluation at the time of injury. A full seated SCAT6 with Maddocks, mBESS, and VOMS requires an athlete who can sit and stand. That is contraindicated until CSI is not the working diagnosis.

Practical rule: if the athlete is down after trauma, unresponsive, has bilateral neurologic symptoms, midline neck pain, or deformity, this is Section 11.1 first. MILS, face mask, EMS. You do not sit them up to finish a symptom checklist. Only after the neck is conceptually cleared (no red-flag CSI features, a focused cervical exam that does not light up, and the athlete can move under their own power without neurologic change) do you move to a full sideline concussion battery.

Relative rest — the 2024 update

The 2014-era instinct was strict rest / cocooning: dark room, no phones, no school, no walking until every symptom hit zero. Amsterdam 2022 and the 2024 NATA Bridge Statement retired that as first-line treatment.

• Acute stage (about 24–48 hours): avoid physical or mental exertion that exacerbates symptoms more than mildly (Bridge update to 2014 rec. 39, SOR B). That is relative rest, not solitary confinement.
• After that brief window, symptom-limited activity (walking, light cognitive load, gradual return to school with adjustments) improves outcomes.
• Aerobic exercise that does not exacerbate symptoms more than mildly is treatment, not cheating (new 2024 recommendation). Buffalo-style subsymptom threshold exercise belongs in the management plan with the physician — still not same-day sport.
• Screen time is reduced early if it worsens symptoms; it is not a moral prohibition forever.
• Return to sport remains a graded, medically cleared process with no same-day return. That ladder is Domain 4. The sideline message is only: out now, relative rest tonight, structured activity tomorrow if symptoms allow, never back into the game today.

Second-impact syndrome and why “he’s fine” is not a plan

Second-impact syndrome (SIS) is described as catastrophic, often fatal cerebral edema after a second head impact while an athlete — typically a child or adolescent — is still symptomatic from a first concussion. The entity is rare and the original case series is debated in the literature. The exam still wants the clinical rule: do not return a still-symptomatic athlete, because a second hit in that window is associated with worse injury, delayed recovery, and, in the feared SIS story, death. “Playing through it” is the opposite of CARE Consortium evidence.

Same-day return after a suspected concussion is how that window is created.

Exam traps: “He didn’t lose consciousness so it’s not a concussion.” “Let him finish the quarter.” Sitting a downed, neck-pain athlete up for SCAT6 before CSI is addressed. Sending a vomiting, unilaterally pupillary athlete home with a SCAT packet instead of EMS. Ordering a week of strict dark-room cocooning as if it were 2012.