Box 2 Indications for urgent referral 1. Fractured skull 2. Penetrating skull trauma 3. Deterioration in consciousness following injury 4. Focal neurological signs 5. Confusion or impairment of con- sciousness >30 minutes 6. Loss of consciousness >5 min- utes 7. Persistent vomiting or increasing headaches post-injury 8. Any convulsive movements 9. More than one episode of con- cussive injury in a match or train- ing session 10. Any assessment difficulty (eg.intoxicated patient) 11. Head injuries in children 12. High risk condition (eg.haemophilia, anticoagulant use)
13. Inadequate post-injury supervi- sion
14. Injury that results from a high- risk mechanism (eg. high-velocity impact, missile injury)
Players need to be removed from contact training as well as competition if they have any post-concussion symptoms.
Whatever the grade of concussion and however long the interval since the injury no athlete should return to play if they remain symptomatic.
Concussive/impact convulsions Convulsions at the time of injury are rare but well recognised events. They occur within two seconds of impact and last for less than three minutes. Providing there is no structural injury the concussion should be managed in the usual way. It does not affect the grading of the concussion or herald post-traumatic epilepsy, exclusion from sport and anti-convulsant therapy are not indicated.
Recurrent concussion Some athletes who sustain recurrent con- cussions are labelled as being prone to concussion. It has been suggested, incor- rectly, that these athletes are unsuited to
that particular sport and they should either give it up or accept that they will get concussed regularly.
Research has shown that these athletes are prone not because of some inherent weakness of their skull or brain but
because they repeat activities that would result in concussion in anyone (4).
Once the athlete and coach are made aware that poor technique or reckless behaviour is the problem, steps can be taken to reduce the incidence of concussion.
Table 3 Questions to test recent memory - good discriminators
ITEM What ground are you at? When was your last goal?