Stop play and ensure the area is safe, then approach the athlete without rushing movement. Instruct the athlete to stay still and apply manual cervical spine stabilization if the mechanism or symptoms suggest neck injury. Do not remove a helmet or shoulder pads unless trained and necessary to access the airway; instead, remove the face mask if airway access is needed. Perform a primary survey to confirm airway, breathing, and circulation, and manage life threats first as part of standard sideline care.
Make an immediate decision about transport needs. If any red flags are present or the athlete’s level of consciousness is altered, activate emergency services according to your protocol and maintain spinal precautions. If red flags are absent but concussion is suspected, proceed with a focused concussion evaluation on the sideline.
Enforce immediate removal from play for any suspected concussion. Do not allow same-day return to sport. Keep the athlete under supervision, discourage physical exertion, and move them to a quiet area for assessment when safe to do so. Do not allow the athlete to drive.
Obtain a brief history: mechanism of injury, point of impact, acute symptoms (headache, dizziness, confusion, visual changes, nausea), any loss of consciousness, amnesia, seizures, previous concussions, and use of anticoagulants or antiplatelets. Record the time of injury and initial observations, including on-field behavior or balance problems witnessed by coaches or teammates.
Conduct a targeted neurological and cognitive screen. Check Glasgow Coma Scale, orientation, concentration, and immediate and delayed recall. Ask sport-appropriate memory questions (for example, last play, opponent, score). Assess pupils for size and reactivity, extraocular movements, facial symmetry, speech, and limb strength and sensation. Evaluate coordination and balance with tandem gait or heel-to-toe walking, taking care not to provoke symptoms excessively.
Use standardized tools whenever possible to structure the assessment. Athletic trainers and clinicians should use the scat6 for adults or the appropriate child version; non-medical personnel can use the Concussion Recognition Tool 6 to aid identification and prompt referral. Incorporate symptom checklists, cognitive tasks, and balance testing as guided by the tool, and note all scores and observations.
Reassess symptoms and vital signs at regular intervals for deterioration. Limit noise, light, and screen exposure during observation, and provide reassurance. Offer small sips of water if the athlete is alert and not vomiting. Document all findings and the rationale for removal from play to support handoff and follow-up with a qualified healthcare professional.
Red-flag symptoms and when to call emergency services
Activate emergency services immediately for any of the following red-flag features after a head impact: loss of consciousness (even brief), deteriorating level of alertness, repeated vomiting, seizure or convulsion, severe or rapidly worsening headache, unequal or unreactive pupils, weakness, numbness, or tingling in the limbs, slurred speech, increasing confusion, agitation, or unusual behavior, severe neck pain or midline cervical tenderness, obvious skull deformity, blood or clear fluid from the ear or nose, bruising behind the ear (Battle sign) or around the eyes (raccoon eyes), vision loss or double vision, or any decline in breathing or circulation. Treat these as time-sensitive emergencies and follow your emergency action protocol without delay.
If you suspect a cervical spine injury, do not move the athlete unless required for airway, breathing, or circulation. Maintain manual in-line stabilization, keep the helmet on, and remove only the face mask if airway access is needed. Ensure the athlete is not eating or drinking and do not administer medications. Prepare the automated external defibrillator and oxygen (if available) as part of standard sideline care, and continuously monitor airway, breathing, and circulation until EMS arrives.
During or after a seizure, protect the athlete from hazards, cushion the head, and time the event. Do not restrain the athlete and do not place objects in the mouth. Once the seizure stops and if the athlete is breathing normally, place them in a recovery position while maintaining spinal precautions if a neck injury is suspected. Call EMS for any first-time seizure, seizure activity lasting longer than 5 minutes, repeated seizures, or delayed recovery of normal awareness.
High-risk medical backgrounds warrant a lower threshold for EMS activation. Call immediately if the athlete uses anticoagulants or antiplatelets, has a known bleeding disorder, has a history of brain surgery, or if the mechanism was high energy (for example, high-speed collision, significant fall) with concerning symptoms. Any progression of symptoms during observation—such as worsening headache, increasing drowsiness, or new focal deficits—requires urgent transport.
Do not rely on a brief improvement to delay transport when red flags are present. Once red flags are identified, stop all sideline evaluation and prioritize stabilization and handoff. This is not the time to complete the scat6 or similar tools. Document times, observed signs, witnessed events, and care provided to support EMS and subsequent hospital assessment.
Maintain close observation while awaiting EMS. Keep the environment calm and quiet, limit light and noise exposure, and reassess airway, breathing, circulation, vital signs, pupils, and level of consciousness at regular intervals. If the athlete becomes drowsier, vomits again, develops new neurological signs, or complains of increasing neck pain, treat it as deterioration and communicate this to EMS on arrival.
Ensure absolute removal from play and do not allow the athlete to drive. Athletic trainers and coaches should notify parents/guardians for minors and arrange supervised transport if EMS is not activated but medical evaluation is still needed. Provide a concise handoff including mechanism, initial symptoms, changes over time, medications, allergies, past concussions, use of blood thinners, and the exact rationale for EMS activation according to your protocol.
Removal from play and safety precautions
Once concussion is suspected, enforce immediate and absolute removal from play with no same-day return under any circumstances, even if symptoms appear to improve. Clearly communicate the decision to the athlete, coaches, and, when relevant, parents/guardians. Emphasize the risk of further brain injury with continued participation and that return is not allowed until medical clearance and a stepwise return-to-play progression are completed.
Designate a qualified professional—ideally a team physician or athletic trainers—to lead decision-making and documentation. Follow your organization’s concussion protocol to ensure consistent actions across practices and competitions. Record the time of injury, on-field signs, symptom evolution, mechanism, and key findings from the sideline evaluation (for example, scat6/CRT6 elements, balance tests, and memory questions) to support continuity of care.
Move the athlete to a quiet, low-stimulation area away from the field once it is safe to do so. Minimize noise, bright light, and screen exposure. Have the athlete sit or lie comfortably without forcing neck movement, and avoid repeated position changes that provoke symptoms. Provide sips of water if not vomiting and keep a receptacle nearby in case nausea worsens. Do not administer alcohol, cannabis, or sedating substances. Avoid nonsteroidal anti-inflammatory drugs in the acute window because of bleeding risk; if pain control is necessary, defer to a clinician’s direction.
Assign a responsible adult to stay with the athlete at all times. Check level of alertness, pupils, speech, and symptoms at regular intervals and watch for red flags such as worsening headache, repeated vomiting, increasing confusion, or new weakness or numbness. Any deterioration should prompt escalation to emergency services per protocol. Maintain ready access to the AED and basic sideline care supplies while monitoring.
Address equipment and re-entry risks. If cervical spine injury is not suspected, remove the helmet to reduce the temptation to return and separate the athlete from teammates who are still competing. If a neck injury is possible, keep the helmet on, maintain inline stabilization, and await EMS. Regardless, ensure the athlete does not participate in drills, warm-ups, or celebrations and is supervised during movement to the locker room or medical area.
Prohibit driving, cycling, or operating machinery for the rest of the day. Arrange safe transport with a trusted adult; do not allow the athlete to go home alone or on public transit without supervision. For minors, notify parents/guardians promptly and provide clear, written take-home instructions outlining red-flag symptoms, activity restrictions, and the need for medical follow-up.
Provide immediate post-removal guidance focused on safety. Avoid strenuous physical activity, risk-heavy tasks, and environments with intense light or noise for the remainder of the day. Keep hydration and nutrition simple and avoid large meals if nauseated. It is acceptable to sleep; ensure a competent adult can observe for red flags and wake the athlete if concerning changes occur.
Complete thorough documentation before handoff, including observed signs, symptom lists, scat6 or CRT6 scores if obtained, vital checks, communications made, and the rationale for removal from play. Share this information with the receiving clinician to streamline formal assessment and later return-to-play decisions. Consistent application of removal from play procedures protects the athlete’s short- and long-term health and underpins high-quality concussion management on the sideline.
Cognitive and physical rest guidelines
Prioritize relative rest for the first 24–48 hours after injury, avoiding both complete “cocooning” and strenuous exertion. Permit activities of daily living and short, calm social interaction while minimizing loud environments, bright light, and extended screen use. Keep sessions of reading, gaming, texting, or studying brief and spread out through the day, and avoid driving, alcohol, and recreational drugs. Align these instructions with the removal from play decision made during initial evaluation and document them as part of routine sideline care.
Use cognitive pacing to control symptom load. Start with short, simple thinking tasks at home (for example, 15–30 minutes of light reading or homework) followed by a 10-minute break in a quiet area. Increase duration and complexity only if symptoms do not worsen more than 2 points on a 0–10 scale and settle within an hour. If symptoms escalate beyond these thresholds or new symptoms appear, stop the task, rest, and resume later at a lower intensity or shorter duration.
Begin return-to-learn before return-to-play. Transition from home-based cognitive work to partial school or work days with accommodations, then to full days as tolerated. Common supports include reduced workload, extra time for assignments and tests, scheduled breaks in a quiet space, preferential seating, sunglasses or hats for light sensitivity, larger font, blue-light filters, and printed materials to limit screen exposure. Delay major exams, high-stakes testing, and multitasking until symptoms are consistently mild and stable.
Promote sleep and routines that support brain recovery. Set a consistent bedtime and wake time, limit naps to 20–30 minutes before mid-afternoon, avoid heavy meals late at night, and reduce evening screen exposure. Encourage hydration and regular, balanced meals. For headache or pain, avoid nonsteroidal anti-inflammatory drugs during the first 24–48 hours; use acetaminophen only if directed by a clinician and never exceed labeled dosing. Do not self-medicate with sedatives or stimulants.
Introduce light, symptom-limited physical activity after 24–48 hours, provided no red flags are present and symptoms are stable at rest. Start with 10–20 minutes of walking or easy stationary cycling at a comfortable pace (for example, a conversational pace or low rating of perceived exertion). Stop or reduce intensity if symptoms increase by more than 2 points or do not return to baseline within an hour. If tolerated, increase duration or intensity in small steps (for example, 5–10 minutes or modest heart rate increments) on subsequent days.
Avoid activities that pose a risk of head impact, falls, or high physiological stress until medically cleared. This includes contact drills, scrimmages, heavy lifting, sprint intervals, gymnastics, skating tricks, and any sport-specific skills that could precipitate collision. Refrain from biking on roads, climbing, or operating machinery. Driving should be deferred until attention, reaction time, and symptom control are normal in routine environments.
Coordinate adjustments with school, coaches, and family so expectations are consistent across settings. Athletic trainers should provide written instructions and check-ins, reinforce pacing strategies, and liaise with teachers or employers to align workload with symptom tolerance. Use your team’s concussion protocol to structure communication, escalation, and documentation.
Track progress daily to guide decisions. Simple symptom scales and brief performance checks can be incorporated into routine follow-up; the scat6 symptom checklist is useful for monitoring trends from rest through light exercise. Note any triggers (for example, screens, noise, reading, or balance activities) and the level at which symptoms emerge, and adjust activity plans accordingly. Stable or improving symptoms at rest, tolerating a full school or work day with accommodations, and successful completion of light aerobic activity without delayed worsening are typical criteria before starting a formal return-to-play progression.
Address common symptom domains with targeted, low-risk strategies. For headache, maintain hydration, regular meals, and consistent sleep; manage light sensitivity with screen filters and sunglasses; for vestibular or visual strain, use brief, spaced reading with larger fonts and good lighting. If dizziness, visual disturbances, or neck pain persist beyond 10–14 days, arrange referral for cervicovestibular or vision therapy per local resources and protocol.
Adopt a more conservative pace for children and adolescents, those with a history of migraines, mood disorders, ADHD, or multiple concussions, and for athletes returning to safety-sensitive roles. Re-evaluate promptly if symptoms worsen with minimal activity, plateau without improvement over several days, or interfere substantially with daily functioning. Any emergence of red-flag symptoms at rest or during activity requires immediate reassessment and escalation according to your emergency and concussion protocols.
Return-to-play progression and follow-up
Use a structured, stepwise progression under the direction of a qualified healthcare professional, with oversight from athletic trainers and clear documentation at each step. Return begins only after symptom stability at rest, successful return-to-learn as appropriate, and formal evaluation confirming readiness to exercise. Carry forward objective notes from sideline care and removal from play to guide decisions and maintain continuity.
Confirm prerequisites before starting: symptoms are mild to none at rest; the athlete tolerates typical daily activities and a full or near-full school/work day with accommodations; sleep is regular; no red-flag features are present; and the athlete is not relying on medication to mask symptoms. Establish a baseline using a symptom scale such as the scat6 and record neurocognitive, balance, and vestibular findings where available. Align the plan with your team’s protocol and communicate it to the athlete, family, and coaching staff.
Stage 1 focuses on symptom-limited activity. Permit light activities of daily living and brief, low-stimulation tasks. Short, easy walks can be introduced while monitoring for increases in headache, dizziness, or cognitive fatigue. Keep exposures brief, insert rest breaks, and stop if symptoms worsen by more than 2 points on a 0–10 scale or do not settle within about an hour.
Stage 2A introduces light aerobic exercise such as 10–20 minutes of walking or stationary cycling at a conversational pace or roughly 55% of age-predicted maximum heart rate. If tolerated, Stage 2B advances to moderate aerobic work for 20–30 minutes at about 70% of maximum heart rate. No resistance training or activities with risk of head impact are permitted. Progress only if there is no more than a mild, transient symptom uptick that resolves quickly after exercise.
Stage 3 adds sport-specific exercise without contact, such as running or skating drills, change-of-direction patterns, and simple footwork. Emphasize control, technique, and hydration while avoiding scrimmage, heading the ball, checking, or drills that could cause collision or falls. Maintain close symptom surveillance during and for at least an hour after sessions.
Stage 4 advances to non-contact training with increased complexity. Introduce position-specific patterns, reaction and decision-making elements, and gradually add resistance training. Increase cognitive load (for example, dual-task drills) only if tolerated at prior levels. If symptoms return or worsen, stop the session, document specifics, and resume at the previous asymptomatic stage after at least 24 hours.
Stage 5 is full-contact practice, permitted only after medical clearance. Begin with controlled contact and limited duration, then expand toward usual practice load if there is no delayed symptom worsening. Reassess within 24 hours of the first contact exposure and before moving forward.
Stage 6 is unrestricted return to competition. Continue to monitor for delayed symptoms after games or high-intensity practices, and enforce prompt removal from play and re-evaluation if symptoms recur.
Follow a minimum of 24 hours between stages; most athletes require several days or longer to progress. Youth and those with risk modifiers (for example, prior concussions, migraine, mood disorders, ADHD) often benefit from a more conservative pace, such as 48 hours or more per stage. If symptoms increase by more than 2/10 during activity or persist longer than about an hour afterward, stop, rest 24 hours, and restart at the last tolerated stage.
When available, use an exercise tolerance assessment such as a sub-symptom threshold treadmill or bike test to set a safe heart rate ceiling for aerobic stages. These tests should be performed by trained clinicians and incorporated into the protocol to personalize intensity and progressions.
Schedule timely follow-up: an initial clinical visit within 24–72 hours, then regular check-ins (for example, every few days during early progression and weekly until clearance). Athletic trainers should track daily symptoms and exertion using tools like the scat6, record stage completion, and share updates with the supervising clinician, school, and family to maintain a unified plan.
Use consistent clearance criteria before advancing and at final return: symptom-free at rest and with typical physical and cognitive exertion; normal neurological and vestibular/ocular screening; stable balance and coordination; full school or work participation without accommodations (or with minimal supports trending to none); and no reliance on analgesics or sedatives to suppress symptoms. When neurocognitive testing is part of your protocol, ensure results are at baseline or within expected norms and interpreted by a qualified provider.
Address persistent or domain-specific problems with targeted referral. Consider vestibular/ocular therapy for dizziness or visual strain, cervical management for neck-related symptoms, headache specialists for migrainous features, and sleep or mental health support when insomnia, anxiety, or mood changes interfere with recovery. Re-evaluate the plan if symptoms plateau beyond 10–14 days in adults or 4 weeks in youth, or if new concerns arise.
Adhere to league, school, and state regulations that mandate licensed healthcare professional clearance before return to contact or competition. Provide written documentation of each stage, objective findings, and the final clearance decision. Consistent application of the progression, meticulous documentation, and coordinated communication across the care team ensure safe return and reinforce the standards established during sideline care and initial evaluation.
