Patient Care, Trauma

Watch for Concussions Presenting Subtly

Issue 4 and Volume 39.

You didn’t see the hit, but you heard the gasp of the crowd. You look to the field and see the coaching and officiating staff running toward a downed player.

You quickly grab your kit and approach the injured player—a healthy, teenage male sitting with his head down. Several players describe the hit as you begin your assessment. Your patient, Daniel, was hit and knocked off his feet. As he was falling to the ground he was hit again by a player moving in the opposite direction of the first hit.

Daniel is awake, responsive and says he feels “fine.” His pulse is strong and regular at 110. His breathing is uncompromised at a rate of 20. His skin is hot and sweaty, which is consistent with participating in an exertional activity such as football. He’s oriented to his name and can tell you he’s playing football, but as you ask further assessment questions he restates he’s fine and needs to get back in the game.

The coach tells him to sit and talk with you, so he agrees to your evaluation but is clearly frustrated. He’s unsure if he lost consciousness after being hit but doesn’t think so. He denies any pain as you palpate his head and neck and, again, states he feels fine.

Upon further questioning, he can’t recall what team he played last week or who won. He’s also unable to recall which quarter the current game is in or who’s winning.

You advise Daniel’s parents he may have experienced a head injury and should be seen by a physician. Daniel, upset he can’t return to the game, begins to cry as they walk to their car.

They transport Daniel to the ED without incident where he’s diagnosed with a concussion. He’s released with instructions to avoid all contact sports and to rest. His parents are given aftercare instructions that include the signs of postconcussion syndrome, which may occur after a traumatic brain injury (TBI).

A concussion, sometimes referred to as a mild TBI, is defined by the Quality Standards Subcommittee of the American Academy of Neurology as a trauma-induced alteration in mental status that may involve loss of consciousness.1 A more recent definition comes from a multidisciplinary conference in 2012, which describes a concussion as a “complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”2

Further description by this consensus group states concussions may be caused by either a direct blow to the head or impact elsewhere on the body that transmits an “impulsive” force to the head. Concussions typically result in a rapid onset of short-lived neurologic impairment with functional rather than structural findings—this means there are no findings on imaging studies such as a CT scan.

Evaluating patients who may have sustained a concussion can be challenging. Significant damage to the brain can result in unconsciousness, seizures and posturing, but some concussions may present more subtly. Patients with a concussion may present with delayed responses to questions, disorientation, difficulty focusing and emotional instability.

Crashes, falls, and any blow to the head can result in a concussion, and you should consider possibility of a TBI. Concussions can also occur without a direct blow to the head. Forces causing the head and neck to move back and forth can cause coupe/contra-coupe and shearing forces, which can result in a concussion.

Patients with concussions may experience a loss of consciousness and may appear to have appropriate mentation upon initial assessment. Preliminary orientation questions such as person, place and time haven’t been shown to be helpful in early recognition of concussions.3 More in-depth assessment is required.

Daniel initially presented awake, alert and ready to get back into the game. Further evaluation revealed his inability to recall recent events, including the status of the current game. The fact he began to cry as he left the field may be attributed to a brain injury and should be recognized by EMS providers as a possible sign of concussion.

When EMS providers have any concern that a patient may have a concussion or other brain injury, the recommendation for evaluation by a physician is imperative. And if placed in a position to determine the ability to return to play, providers should err on the side of caution if signs and symptoms are unclear. Additional trauma to an injured brain can cause substantial damage.

1. Practice parameter: The management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology. 1997;48(3):581–585.

2. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: The 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47(5):250–258.

3. McCrea M, Kelly JP, Randolph C, et al. Standardized assessment of concussion (SAC): On-site mental status evaluation of the athlete. J Head Trauma Rehabil. 1998;13(2):27–35.

There are several assessment tools available to assist in the evaluation of a patient with a possible concussion. The standardized assessment of concussion (SAC) and the Sport Concussion Assessment Tool 2 (SCAT2) both offer in-depth evaluation of cognitive function by having patients recall recent events, words or images, and perform simple cognitive exercises. Each also includes instructions for a physical examination.

To access examination worksheets for each test, visit: