Recognising and Treating Concussion

What is Concussion?

A concussion is a form of mild Traumatic Brain Injury (mTBA), and although usually caused by a sudden impact to the head, concussions can also be caused by other trauma to the brain.

The brain is a mass of soft tissue that is protected by the hard bony skull. If the brain is shaken around during a traumatic incident, the nerve fibres within the brain become damaged. This means that the nerves can no longer effectively communicate, and causes a variety of poor functions.

There are 3 main forms of trauma that can negatively affect the brain:

  1. Direct impact against the skull during a sudden force (such as a head knock),
  2. A shaking where the brain impacts the skull in multiple places (this can happen alongside whiplash type injuries),
  3. Rotational forces (these are common in activities where participants travel at high speed and their head may hit the ground at an oblique angle during a crash),

Each of these three types of trauma can cause concussion and possibly more complex brain injuries as well. Damage to the brain can be localised to one area, or diffuse – affecting a larger area of the brain, and therefore causing a more serious brain injury.

How To Recognise a Concussion

The first rule of recognising concussion is to take your time to thoroughly check the casualty over. Concussion symptoms can be hard to spot immediately, especially in the context of an ongoing game or activity where the casualty wants to continue. If there are any signs, or potential of a head trauma having taken place, everything needs to pause for a few minutes while you carry out a Head Injury Assessment.

The first aider should assess the situation, and consider the history of the incident as always. Ask yourself whether there are any signs of head injury, such as: obvious damage to the face or head, a damaged helmet or even a dirty helmet where it has hit the ground, have any witnesses told you that the casualty hit their head?

Once we are happy that the casualty’s Airway, Breathing and Circulation are OK, the first part of our Head Injury Assessment is to identify any ‘red flag symptoms’. These are:

  • 🚩Neck pain or tenderness
  • 🚩Double vision
  • 🚩Weakness or tingling / burning in arms or legs
  • 🚩Severe or increasing headache
  • 🚩Seizure or convulsions
  • 🚩Loss of consciousness (at any time)
  • 🚩Deteriorating Level of Consciousness
  • 🚩Vomiting
  • 🚩Increasingly restless, agitated or combative

🚩If any of these Red Flag Symptoms are observed or reported initially, or during further assessment, the casualty should be safely and immediately removed from activity. Urgent medical assessment is required as soon as possible. 🚩

If no Red Flags are present, then we need to consider the following symptoms, all of which can indicate a concussion and should be taken seriously.

Some of these concussion symptoms may not become apparent for some time after the incident

Other Head Injury Assessment Tools

There are multiple other ways that we can assess a casualty following a suspected head trauma. We should be performing a physical check for signs of damage as part of our Secondary Survey, and we could also ask them to move their neck, to look in different directions, to look into their eyes ourselves to check for discrepancies. Anything unusual, or suspicious should be treated as suspected concussion.

Below is a suggested list of a further five simple tests we can perform. This should be done within 10 minutes of the incident occurring to have some baseline information from the casualty about how well their brain is working. It would be worth repeating these tests after approximately 1 hour, 3 hours, 6 hours and 24 hours.

Any sign of deterioration, or anything that raises suspicion that the casualty is not 100%, should be taken as evidence that they need to be seen by medical professionals.

1          Maddocks Questions – You can relate these to the activity in progress, but use the same progressive memory requirement.

  • Where are we today?
  • Is it morning or afternoon?
  • Where were we yesterday?
  • What did we do this time last week?

2          Orientation Test

  • What month is it?
  • What is the date today?
  • What day of the week is it?
  • What year is it?

3          Immediate Memory – ‘I am going to give you a list of five items, try and remember it and I will ask you to repeat the list again in a few minutes’. Example lists;

  • Elbow, Apple, Carpet, Saddle, Bubble
  • Candle, Paper, Sugar, Sandwich, Wagon

4          Concentration Test – some examples

  • Can you tell me the 12 months of year in order and then can you tell me in reverse?
  • Can you count down from 22 subtracting 3 each time?
  • I am going to give a list of four numbers, can you repeat the list in reverse order?

5          Balance and Co-ordination – these are examples of thing you can do to test balance and co-ordination;

  • Can you stand on one leg for 20 seconds?
  • Can you stand on the opposite leg for 20 seconds?
  • Can you stand on one leg with your eyes closed for 20 seconds?
  • Can you close your eyes and touch your nose with your first finger on your left hand?

How To Treat Concussion

If you suspect for any reason that the casualty may have suffered even a mild concussion, the first rule is to prevent them from continuing further activity. This is to remove the chance of them suffering a secondary impact.

Secondary Impact Syndrome is where a second impact occurs before the symptoms of the initial concussion are healed. Around 50% of Secondary Impact Syndrome cases are fatal. Put another way, if a casualty has concussion (whether diagnosed or not), a second impact has a 50/50 chance of killing them, usually immediately.

Clearly therefore, we cannot be too careful. The casualty should not drive (or ride a bike for example, even slowly), they should not drink alcohol, they should not be left alone for the first 1-2 hours at least. And they must be monitored continuously for worsening symptoms.

The casualty should have complete rest. This means not doing anything that involves a raised heart rate, or stresses their brain. Often this means that working is impossible, and looking at screens or even reading books is too difficult too.

Casualties suffering from severe concussion symptoms should seek the support of a specialist to help them through their recovery.

Returning to Activity Following Concussion

The casualty should not return to activity until signed off as clear of symptoms by a medical professional, ideally a head trauma specialist. Some concussions will take many days to heal, and in some cases weeks or even months are required. The process should not be rushed, and the casualty should be monitored throughout.

If at any point they are suspected of deteriorating, medical attention should be sought.

Find Out More About Concussion and Head Injuries

Our online course “A Deeper Understanding of Concussion and Head Injury Assessment” is 1hr 20mins of in-depth information on recognising concussions and performing a Head Injury Assessment. It explains in depth how to use a Concussion Recognition Tool to manage a suspected head injury, and is available on our website at any time.

Concussion Resources

World Rugby have produced a set of information cards and leaflets that can be downloaded from their site and use the mantra: “Recognise and Remove”.

Sportscotland’s concussion guidance pages contain a lot of useful resources, under the banner of “If In Doubt, Sit Them Out”

Of interest to Mountain Bikers, (but also relevant to all outdoor activities) the Downtime Podcast’s Concussion Special Episode with Adrian Stokes of Pure Body Balance is well worth a listen. Adrian has lots of first hand experience managing the recovery of elite athletes who’ve suffered serious concussions and gives good insight into the process of recovery from concussion.