Current Protocol

Here is a sample from the Mayo Clinic and other organizations and sites which are fairly representative of the current “standard of care” for concussion.

Treatments and drugs
By Mayo Clinic Staff

Rest is the most appropriate way to allow your brain to recover from a concussion. Your doctor will recommend that you physically and mentally rest to recover from a concussion.

This means avoiding general physical exertion, including sports or any vigorous activities, until you have no symptoms.

This rest also includes limiting activities that require thinking and mental concentration, such as playing video games, watching TV, schoolwork, reading, texting or using a computer.

Your doctor may recommend that you have shortened school day or workdays, take breaks during the day, or have reduced school workloads or work assignments as you recover from a concussion.

As your symptoms improve, you may gradually add more activities that involve thinking, such as doing more schoolwork or work assignments, or increasing your time spent at school or work.

For headaches, try taking a pain reliever such as acetaminophen (Tylenol, others). Avoid other pain relievers such as ibuprofen (Advil, Motrin IB, others) and aspirin, as there’s a possibility these medications may increase the risk of bleeding.

If you or your child sustained a concussion while playing competitive sports, ask your doctor or your child’s doctor when it is safe to return to play. Resuming sports too soon increases the risk of a second concussion and of lasting, potentially fatal brain injury.
Evidence is emerging that some people who have had multiple concussions over the course of their lives are at greater risk of developing lasting, and even progressive, impairment that limits their ability to function.

No one should return to play or vigorous activity while signs or symptoms of a concussion are present.

Experts recommend that adults, children and adolescents not return to play on the same day as the injury.
Defense and Veterans Brain Injury Center (DVBIC)
Concussion/Mild Traumatic Brain Injury
Signs and Symptoms

A traumatic brain injury (TBI) is a blow or jolt to the head that disrupts the normal function of the brain. The severity of the TBI is determined at the time of the injury and may be classified as: mild, moderate or severe.

Common Signs and symptoms:
Did you know? Concussion – another word for a mild TBI – is the most common
form of TBI in the military. Symptoms of concussion often resolve within days or weeks.
Sleep disturbances
Balance problems
Visual disturbances
Light sensitivity
Ringing in ears ?

Slowed thinking
Poor concentration
Memory problems
Difficulty finding words

Mood swings
Coping Tips:
• Write things down.
• Store important items like keys in a designated place to keep from
losing them.
• Pace yourself and take breaks as needed.
• Focus on one thing at a time.
• Allow time for your brain to heal. It’s the most important thing you can do.
Recovery Tips:
• Avoid smoking or drinking.
• Sit out of contact sports.
• Get enough sleep — 7 to 8 hours a night.
• Take medications as instructed.
• Avoid overexerting yourself physically or mentally.
• If you’re concerned about your symptoms or if they’re not improving,
see your provider.
• Stay engaged with your family and provider as your symptoms improve.

Find a DVBIC site near you:

• Camp Lejeune, N.C.
• Camp Pendleton, Calif.
• Fort Bragg, N,C.
• Fort Carson, Colo.
• Fort Hood, Texas
• Landstuhl Regional Medical
Center, Germany
• NMC San Diego
• San Antonio Military
Medical Center, Texas
• Joint Base Elmendorf-Richardson,
• Fort Belvoir, Va.
• Walter Reed National Military
Medical Center, Md.
• VA Boston
• VA Minneapolis
• VA Palo Alto, Calif.
• VA Richmond, Va.
• VA Tampa, Fla.

Recovery is different for every person and depends on the nature of the injury.
How Is a Concussion Treated?
Treatment for a concussion depends on the severity of your symptoms. Surgery or other medical procedures may be required if you have bleeding in the brain, swelling of the brain, or a serious injury to the brain. However, most concussions do not require surgery or any major medical treatment.

During the first 24 hours after the injury, your doctor may suggest that you have someone wake you up every two to three hours. This ensures that you have not gone into a coma and also allows someone to check whether you are experiencing signs of severe confusion or abnormal behavior.

If you experience headaches, your doctor may tell you to take over-the-counter pain relievers such as ibuprofen (Advil) or acetaminophen (Tylenol). Your doctor may also tell you to get plenty of rest, avoid sports and other strenuous activities, and avoid driving a vehicle or riding a bike for 24 hours or a few months, depending on the severity of your injury. Alcohol might slow your recovery, so discuss with your doctor whether you should stop drinking alcoholic beverages and for how long.
Concussion Treatment
Call 911 if the person:
Is vomiting repeatedly
Has unequal pupils
Is confused or agitated
Has weakness on one side of the body
Passes out or is unconscious
Is very drowsy or unable to wake up
Has neck pain after a fall
Has slurred speech
Has a seizure
1. Prevent Swelling and Further Injury
Have the person stop activity and rest.
Apply ice wrapped in a washcloth.
2. Treat Symptoms
For pain, take over-the-counter acetaminophen (Tylenol). Aspirin or ibuprofen (Advil, Motrin) may make bruising worse.
3. Monitor Symptoms
If possible, stay with the person for 24 hours.

4. When to Call a Doctor
Anyone with a suspected concussion should be seen by a doctor. Once discharged, seek immediate medical care again if any of these symptoms develop:
A headache that seems to be getting worse
Continued vomiting
Increased drowsiness or dizziness
Increased confusion
Young children may not have the same symptoms as adults. Seek immediate medical help if your child will not nurse or eat after a head injury or if you cannot get them to stop crying.
5. Follow-Up
Symptoms will likely improve in 7 to 10 days. Call your doctor if symptoms persist or worsen.
Treat a Concussion Step 1.jpg
1Assess the victim. Examine the wound and look carefully at the victim. Visible external injuries are not always a good gauge, as some very minor scalp wounds bleed profusely, while some less visible impact injuries can cause major brain impairment. If the victim displays two or more of the following symptoms, assume that this is a case of concussion and treat the victim appropriately:[4]
Physical symptoms include Traumatic Brain Injury, loss of consciousness, severe headache, light sensitivity, double or blurred vision, seeing “stars”, spots or other visual anomalies, loss of coordination and balance, vertigo, numbness, tingling, or weakness in legs and arms, stumbling or poor hand-eye coordination, nausea and vomiting.
Cognitive symptoms include unusual irritability or excitability, disinterest, difficulties with concentration, logic, and memory, mood swings or outbursts of inappropriate emotions, tearfulness, and sleepiness or lethargy

2Contact a doctor. Any suspected head injury or concussion needs to be evaluated by a medical professional. What may seem like a minor head injury could be a fatal one. If the victim is not regaining consciousness, call for an ambulance. Otherwise, drive to the nearest emergency room or your doctor’s office.[5]
If the patient is unconscious or if you are not sure what is wrong, call an ambulance. Driving a head trauma patient indicates your moving them which you should never do until their head is stabilized with a hard collar device and then they should be on a backboard with straps. Moving a head trauma patient could lead to death.

3Stay still and avoid movement. Avoid moving the victim as doing so may cause further injury. Have the victim lay down and remain still, giving them a pillow for head support if desired.
Treat a Concussion Step 4.jpg

4Assess consciousness. It is important to know whether or not the victim is conscious and their level of cognitive function. To check the consciousness of the victim, try the AVPU code:[6]
A – is the victim alert? – are your questions being answered? (see step below for question samples)
V – does the victim respond to voice? – give spoken commands or ask questions (see step below for question samples)
P – does the victim respond to pain or touch? – pinch skin to see if there is movement or eyes opening
U – is the victim unresponsive to anything attempted?

5Keep focused. If the victim is conscious, ask questions continually. This serves two purposes: to assess the degree of the victim’s impairment, and to keep the victim awake. Good questions include:
“What is today’s date?”
“Where are you?”
“What happened to you?”
“What is your name?”
“Are you feeling alright?”

6Reduce the temperature. Keep the conscious or unconscious victim’s head cool with an ice pack or damp cloths. This can prevent brain swelling. Monitor the body temperature, however, as the victim should be protected from any extremes of temperature.[7]
Do not however apply pressure to any head trauma wound as this could push bone splinters into the brain.

7Allow the victim to rest. If the victim wishes to sleep, wake the victim every quarter hour for the first 2 hours, then every half hour for the following 2 hours, then hourly.[8]
Every time you wake them, do the AVPU consciousness test as outlined above. It may be irritating for the victim and tiring for you, but their safety is your number one priority.
If the victim does not respond to being woken up, treat as for an unconscious patient.

8Continue treatment. There is very little known about the effects of concussion on the brain and on cognitive function.
Post-Concussion Syndrome is a well-documented condition known to persist in concussion sufferers for months or even years; these symptoms may gradually improve but never fully heal.
Rest often and avoid any extreme exercise or movement of the head. No reading, watching TV, or playing video games, your brain has been injured and needs time to heal the same as a wound on your arm, it will take time. Unconsciousness = a brain injury of some degree.

Commonwealth of Virginia Protocol for Concussions

§ 22.1-271.5. Guidelines and policies and procedures on concussions in student-athletes.

A. The Board of Education shall develop and distribute to each local school division guidelines on policies to inform and educate coaches, student-athletes, and their parents or guardians of the nature and risk of concussions, criteria for removal from and return to play, risks of not reporting the injury and continuing to play, and the effects of concussions on student-athletes’ academic performance.

B. Each local school division shall develop policies and procedures regarding the identification and handling of suspected concussions in student-athletes. Such policies shall require:

1. In order to participate in any extracurricular physical activity, each student-athlete and the student-athlete’s parent or guardian shall review, on an annual basis, information on concussions provided by the local school division. After having reviewed materials describing the short- and long-term health effects of concussions, each student-athlete and the student-athlete’s parent or guardian shall sign a statement acknowledging receipt of such information, in a manner approved by the Board of Education; and

2. A student-athlete suspected by that student-athlete’s coach, athletic trainer, or team physician of sustaining a concussion or brain injury in a practice or game shall be removed from the activity at that time. A student-athlete who has been removed from play, evaluated, and suspected to have a concussion or brain injury shall not return to play that same day nor until (i) evaluated by an appropriate licensed health care provider as determined by the Board of Education and (ii) in receipt of written clearance to return to play from such licensed health care provider.

The licensed health care provider evaluating student-athletes suspected of having a concussion or brain injury may be a volunteer.

C. Each non-interscholastic youth sports program utilizing public school property shall either (i) establish policies and procedures regarding the identification and handling of suspected concussions in student-athletes, consistent with either the local school division’s policies and procedures developed in compliance with this section or the Board’s Guidelines for Policies on Concussions in Student-Athletes, or (ii) follow the local school division’s policies and procedures as set forth in subsection B. In addition, local school divisions may provide the guidelines to organizations sponsoring athletic activity for student-athletes on school property. Local school divisions shall not be required to enforce compliance with such policies.

D. As used in this section, “non-interscholastic youth sports program” means a program organized for recreational athletic competition or recreational athletic instruction for youth.



What is a concussion?

A concussion is a type of traumatic brain injury. Concussions are caused by a bump or blow to the head. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

You can’t see a concussion. Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If your child reports any symptoms of concussion, or if you notice the symptoms yourself, seek medical attention right away.

What are the signs and symptoms of a concussion?

If your child has experienced a bump or blow to the head during a game or practice, look for any of the following signs of a concussion:


Headache or “pressure” in head

Nausea or vomiting

Balance problems or dizziness

Double or blurry


Sensitivity to light

Sensitivity to noise

Feeling sluggish, hazy, foggy, or groggy

Concentration or memory problems


Just “not feeling right” or “feeling down”

Forgets and instruction

Shows mood, behavior, or personality changes

Appears dazed or stunned

Is confused about assignment or position

Is unsure of game, score, or opponent

Moves clumsily

Answers questions slowly

Loses consciousness (even briefly)

How can you help your child prevent a concussion or other serious brain injury?

Ensure that they follow their coach’s rules for safety and the rules of the sport.

Encourage them to practice good sportsmanship at all times.

Make sure they wear the right protective equipment for their activity. Protective equipment should fit properly and be well maintained.

Wearing a helmet is a must to reduce the risk of a serious brain injury or skull fracture.

However, helmets are not designed to prevent concussions. There is no “concussion-proof” helmet. So, even with a helmet, it is important for kids and teens to avoid hits to the head.

What should you do if you think your child has a concussion?

SEEK MEDICAL ATTENTION RIGHT AWAY. A health care professional will be able to decide how serious the concussion is and when it is safe for your child to return to regular activities, including sports.

KEEP YOUR CHILD OUT OF PLAY. Concussions take time to heal. Don’t let your child return to play the day of the injury and until a health care professional says it’s OK. Children who return to play too soon—while the brain is still healing—risk a greater chance of having a repeat concussion. Repeat or later concussions can be very serious. They can cause permanent brain damage, affecting your child for a lifetime.

TELL YOUR CHILD’S COACH ABOUT ANY PREVIOUS CONCUSSION. Coaches should know if your child had a previous concussion. Your child’s coach may not know about a concussion your child received in another sport or activity unless you tell the coach.

If you think your teen has a concussion:

Don’t assess it yourself. Take him/her out of play. Seek the advice of a health care professional.

It’s better to miss one game than the whole season.

April 2013  For more information, visit

* * * * * * *

Here’s the NFL’s 2013 Protocol, not dissimilar from the Army’s protocol for front-line concussions, which is to say “watchful waiting” while “the tincture of time” works its magic.’s-2013-protocol-for-players-with-concussions?ref=0ap2000000253716

NFL’s 2013 protocol for players with concussions

  • Published: Oct. 1, 2013 at 05:51 p.m.
  • Updated: Aug. 22, 2014 at 12:26 p.m.

What is the NFL’s protocol for managing concussions?

It starts long before a player sustains a concussive hit. It begins prior to training camp and continues after the player returns to the field.

Every head injury is different and there is no definitive timetable for each. However, this is the basic template for assessing and managing player concussions based on the latest recommendations from the NFL’s Head, Neck and Spine Committee.


The process begins before the season with team doctors performing examinations to clinically assess functions such as memory, concentration and balance that can be affected by a concussion. Also the doctors evaluate the player regarding how many concussions they have experienced and how long the player needed to recover as well as other medical factors that can affect concussion recovery. Players also fill in a list of current symptoms, including headache, neck pain, fatigue and others as it is important to know what they are experiencing before any concussion standardized baseline concussion tool is utilized.

This history and physical examination information is supplemented with baseline neuropsychological testing, comprehensive tests that assess memory, reaction time, attention span, problem-solving abilities and other cognitive skills. Some neuropsychological tests are computer based such as the ImPACT test — Immediate Post-Concussion Assessment and Cognitive Testing. and the Automated Neuropsychological Assessment Metrics (ANAM) test developed by the Army. Other neuropsychological tests are standard paper and pencil tests typically administered by a neuropsychologist. Each team has a neuropsychologist to interpret the neuropsychological tests and serve as a consultant to help with this aspect of concussion care.

This preseason assessment process has many benefits. “It’s a forum for dialogue to build rapport,” Dr. Stan Herring, one of the team physicians with the Seahawks and Seattle Mariners and a member of the NFL’s Head, Neck and Spine Committee, told “The most important thing is knowing what he was like before a concussion.”


To assist the medical teams on game day, there is now an “eye in the sky” – a certified athletic trainer sitting in a stadium box who watches the game and television replays to scan the field and look for players with a potential head injury who may require assessment by the medical staff.

Players who are suspected of suffering a concussion are assessed by their team’s medical staff. The team physician first reviews a six-item checklist outlining findings that necessitate a player’s immediate removal from the game. This checklist includes the more obvious symptoms of concussion: loss of consciousness, unresponsiveness, confusion, amnesia and other concerning symptoms. The team doctor then administers the rest of the sideline concussion assessment tool in order to further assess for concussion. This sideline test includes the same tests performed as part of the pre-season baseline concussion assessment, as well as some additional questions. Like the preseason evaluation, the test measures, memory, concentration and balance. as well as measuring how quickly and thoroughly the player recalls words given to them at least five minutes earlier. As in the preseason examination, the team doctor asks players to name the month, date, day of week, year and time. The additional questions include specific sideline orientation questions that ask players to identify the venue, quarter of game, who scored most recently, the team’s previous opponent and whether the team won or lost its most recent game. This process takes about 8-12 minutes.

Beginning this year, a neuro-trauma expert physician unaffiliated with an NFL team will be available on the sideline as an extra set of eyes. He can be consulted by the NFL medical team or NFL player.

NFL regulations require a player diagnosed with a possible concussion to leave the field for the locker room. Medical personnel remain with the player for the remainder of the game. Team physicians determine whether the player’s condition is stable enough to send him home — with instructions that include physical and cognitive rest, avoiding certain medications and alcohol, and a plan for follow up care including phone numbers to call if there are any questions or concerns.


The initial treatment is rest, and the team doctors and athletic trainers begin monitoring to see when a player appears to have returned to baseline functioning. Do symptoms return when a player watches practice or when he watches film? Is there return of symptoms with physical activity?

Once symptoms have completely subsided, the player again performs more comprehensive neuropsychological tests interpreted by the team neuropsychologist. There are no pass-fail grades, only additional data for physicians to consider.

If the player is progressing, he would be become eligible for increased physical activity. The workouts would ramp up over a few days if no symptoms occur.

A player feeling normal one day after the game might pass cognitive testing Tuesday and begin a light exercise program, intensify their exercise routine Wednesday, participate in non-contact aspects of practice on Thursday and return to full practice Friday. But if a player has a history of concussions or isn’t progressing as quickly as planned, the process moves accordingly.

The medical team increases the exercise regimen to full speed as the player proves he can handle the escalation without incident. Some teams stage controlled contact drills featuring, for example, one lineman blocking another the way they would in an unpadded practice.

“The thing that I think is important here is you don’t manage concussions by a calendar,” Dr. Herring said. “Some guys may come back in a week. Some guys may come back in six weeks. These steps don’t have an expiration date on them. The player’s history of injury and other issues come into play.”

Once a team doctor signs off on a player’s return, the player is evaluated in person by an unaffiliated concussion expert physician approved by both the NFL and NFL Players Association. This unaffiliated expert also must sign off on the player’s health before he is allowed to return to play.

“The thinking is that we have done our best work, but an automatic second opinion is built in,” Herring said. “We’ve never had a disagreement, but I would welcome it if we did because we could learn from it. This is a trust issue. We need assurances there is no rush to return to play for any reason.”

— NFL Head, Neck and Spine Committee and Bill Bradley, contributing editor

ARMY Protocol

Army Refines Medical Management of Concussion

By Cheryl Pellerin
American Forces Press Service

WASHINGTON, April 18, 2012 – Over the past 20 months, the Army has been working to refine the way it tracks and treats the most common form of battlefield brain injuries — concussion, also called mild traumatic brain injury, or mTBI.

The job isn’t easy, because even in the United States, where civilians experience traumatic brain injuries at the rate of 2.5 million a year, according to the Centers for Disease Control and Prevention, no single diagnostic standard exists for TBI.

In the words of experts at the 2nd Annual Traumatic Brain Injury Conference last month in Washington, treatment of TBI and especially acute, or rapid-onset, TBI is still “a major unmet medical need” worldwide.

“This is why we have our program,” Army Col. (Dr.) Dallas Hack, director of the Army’s Combat Casualty Care Research Program, told American Forces Press Service.

“This is why Congress in 2007 issued a special appropriation of $300 million to start funding traumatic brain injury and psychological health research for our troops,” he added, “and has continued to [add] significant amounts of funding,” up to $633 million today.

In the research program, scientists try to find ways to look into the brain noninvasively to measure the effects of brain trauma, using brain scans, electroencephalograms for measuring brain electrical activity, eye-tracking systems that offer a window into the brain, and more.

Objective measurements are critical for mild brain trauma, which is called an invisible injury because effects on the brain of falls or explosions or vehicle accidents aren’t always obvious.

Today, while processes and devices sensitive enough to measure mild brain trauma are in development, on the battlefield and at home mild TBI tends to be assessed in large part using the best tools available — questionnaire-type assessments.

During a recent briefing at the Pentagon, Army specialists in behavioral health and in rehabilitation discussed the evolving behavioral health system of care for TBI.

A hallmark of the Army’s standard of behavioral health care is a screening process administered to soldiers before they deploy, while they are in theater, as they prepare to return home, and while they are in garrison, said the behavioral health specialist.

The assessment process includes the following questionnaires:

— Predeployment: All incoming service members are screened with the neurocognitive assessment tool, called NCAT, which is used as a baseline for future concussion or mTBI injuries.

— In theater: Immediately after injury, the Military Acute Concussion Evaluation, called MACE, is used to quickly measure orientation, immediate memory, concentration, and memory recall. Combined with clinical information, a MACE score can guide recommendations, including evacuation to a higher care level.

— Postdeployment: Because mTBI is not always recognized in the combat setting, active duty service members receive postdeployment health assessments. Four questions adapted from the Brief Traumatic Brain Injury Survey are asked during the assessments. Positive responses on all four prompt an interview with a doctor for an mTBI evaluation.

— Veterans: Vets are screened for mTBI when they enter the Veterans Health Administration system. A TBI clinical reminder tracking system identifies all who were deployed to Iraq or Afghanistan. Those who report such deployment and don’t have a prior mTBI diagnosis are screened using four sets of questions based on the Brief Traumatic Brain Injury Survey. Those who screen positive for mTBI are offered further evaluation.