Symptoms and signs of acute concussion
The diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, cognitive impairment, neurobehavioural features and sleep disturbance. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a preparticipation examination. The detailed clinical assessment of concussion is outlined in the SCAT3 and Child SCAT3 forms, which are given in the appendix to this document.
The suspected diagnosis of concussion can include one or more of the following clinical domains:
1. Symptoms—somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability);
2. Physical signs (eg, loss of consciousness (LOC), amnesia);
3. Behavioural changes (eg, irritability);
4. Cognitive impairment (eg, slowed reaction times);
5. Sleep disturbance (eg, insomnia).
If any one or more of these components are present, a concussion should be suspected and the appropriate management strategy instituted.
On-field or sideline evaluation of acute concussion
When a player shows ANY features of a concussion:
A. The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury.
B. The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged.
C. Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools.
D. The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury.
E. A player with diagnosed concussion should not be allowed to RTP on the day of injury.
Sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes. In some sports, this may require rule change to allow an appropriate off-field medical assessment to occur without affecting the flow of the game or unduly penalising the injured player’s team. The final determination regarding concussion diagnosis and/or fitness to play is a medical decision based on clinical judgement.
Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the SCAT3, which incorporates the Maddocks’ questions and the Standardized Assessment of Concussion (SAC). It is worth noting that standard orientation questions (eg, time, place and person) have been shown to be unreliable in the sporting situation when compared with memory assessment. It is recognised, however, that abbreviated testing paradigms are designed for rapid concussion screening on the sidelines and are not meant to replace comprehensive neuropsychological testing which should ideally be performed by trained neuropsychologists who are sensitive to subtle deficits that may exist beyond the acute episode; nor should they be used as a stand-alone tool for the ongoing management of sports concussions.
It should also be recognised that the appearance of symptoms or cognitive deficit might be delayed several hours following a concussive episode and that concussion should be seen as an evolving injury in the acute stage.
