Symptoms Of A Concussion, Concussion Injury

Preventing Serious Injury

From "Having Your Bell Rung" to "Being Knocked Out"
Why Coaches?

Concussions can occur in any sport, in any age group, and in any situation, from drills to practices to games. Far too often, a coach is the only adult present and must administer first aid. When trained medical personnel are neither nearby nor easily accessible, it is a coach's responsibility to evaluate an injury and decide if an athlete should return to play.

What Is a Concussion?

A common assumption is that an athlete must be "knocked out" to sustain a concussion. That's not true. Any change in mental status or function qualifies as a concussion. Unconsciousness, though clearly a severe injury, does not occur frequently. The classic "having your bell rung" or "ding" occurs fairly often and is often ignored, which can be a serious mistake.

Recognizing a subtle concussion is extremely important in preventing the rare but deadly Second Impact Syndrome (SIS) . SIS occurs when an athlete sustains a second blow to the head while still symptomatic from the first "ding," even if the second blow is relatively gently (a slap can provide enough force) or occurs days or weeks later. Sudden swelling of the brain leads rapidly (within two or three minutes) to unconsciousness or cardiac arrest. Fifty percent of people who sustain SIS die, and the rest have a very high risk of permanent brain damage.

How to Recognize Concussions

Symptoms of a concussion may include dizziness, nausea, vomiting, headache, blurred or double vision, ringing in the ears, a funny taste in the mouth, poor coordination, or emotional instability (anger, crying, and anxiety). Keep in mind that your athlete won't necessarily come up to you and complain of these. Watch out for the athlete who just sits and stares, seems to be a step behind where he or she usually is, blows a routine play, or "just doesn't look right" to you. If you are at all suspicious that an athlete may have a concussion, test him or her.

If any of these symptoms disappear, but recur with the exercise test described on the card, do not let the athlete return to play. Symptoms can recur for days after the initial injury and are a sign that the brain has not healed enough to participate in any athletic activity.

If you notice any of these post-concussion syndrome symptoms in your athlete, report it to the athletic trainer, a parent or guardian, and/or a physician. In their desire to play, many athletes try to hide or minimize injuries. Be aware of changes or concerns reported by teammates or teachers. Post-concussion syndrome often has long-term effects that interfere with functioning at home, school, or work. Anyone you suspect may have it should be evaluated by a physician.

Concussions and Return-to-Play Decisions

After an athlete sustains any blow to the head, remove him or her from play for at least 20 minutes. Ask the athlete about symptoms and run through the confusion/orientation test, memory test, concentration test, and neurological tests described on the card. Do not immediately perform the exercise test. If the athlete passes the mental and neurological tests and appears fully orientated, administer the exercise test and recheck for symptoms.

Grade 1: "Ding" or "Having Your Bell Rung"

The athlete is conscious at all times, but dazed, foggy, or fuzzy. The player may miss one or two items in the concentration test, but shows no confusion or memory loss. Ask the concentration questions again in 10 minutes, and again in another 10 minutes. If the athlete answers all the questions correctly, passes all neurological tests, and has no recurrence of any symptoms with the exercise test, you can consider allowing the athlete to return to play.

A second "ding" in the same game or practice requires a trip to the emergency room. If someone from the sidelines or stands offers to evaluate a player to see if he/she can go into a game, remember that only a physician (MD/DO) or a licensed certified athletic trainer has the education and experience to make that evaluation.

No matter how minor the head injury, notify the family about it and about potential symptoms; do not rely on the athlete. A responsible person needs to watch for delayed problems.

Regardless of others' recommendations, if your gut feeling tells you to bench a player, do not let anyone - not players, parents, coaches, fans, or circumstances - change your mind. You are never wrong to keep a player out of a practice or game. It is the safest option.

Grade 2: Out to Lunch

The athlete remains awake at all times, but is dazed or states blankly. Any amnesia (memory loss) is a critical warning sign. For example, you may notice the athlete repeatedly asking the same questions without remembering that he or she asked them, or without remembering the answers. If an athlete misses any of the confusion/orientation or memory test questions, suspect a grade 2 concussion and immediately remove him or her from all activities. It is strongly recommended that you seek emergency medical attention for this athlete. He or she probably should not return to athletic activity for a minimum of 5-7 days after all symptoms have disappeared, and should first be cleared by a physician.

Grade 3: Knocked Out - Blacked Out

Any loss of consciousness, no matter how brief, even if the athlete successfully completes all of the exams after he or she returns to consciousness, is a grade 3 concussions requiring medical attention:

Immobilize the athlete's head and call an ambulance.

  • If the athlete wakes up within one minute and does not have any neck pain, call an ambulance or ask a responsible adult to take the player to an emergency room.
  • If the athlete is unconscious longer than one minute, or complains of neck pain after returning from consciousness, assume that a spine injury exists. Call an ambulance. While waiting for it to arrive, keep the athlete's head from being moved. Expect the athlete to be prohibited from taking part in activity for a minimum of two weeks to one month.

Symptoms of Concussion

Headache, any vision change, ringing in one or both ears, nausea or vomiting, confusion, unsteadiness, altered emotional state for that athlete, e.g., anxiety, crying, being excessively angry.

Grade 1: Ding - Bell Ring
(Conscious at all times but dazed, foggy, or fuzzy)
  • Administer confusion/orientation, memory, and concentration tests - He or she may miss one to two items. If more than that, no return to play, even if normal later on in the contest/practice.
  • Administer the neurological tests - Athlete must pass all components of the neurological tests. If not, there is no return to play, even if normal later in the contest/practice. If pupils are unequal in size, send to emergency room immediately.
  • Administer the tests again, 10 minutes later - If the athlete again passes these tests, go to (4). If not, there is no return to play, even if tests normal later.
  • Administer the tests again, 20 minutes from the time of the first test - If the athlete passes all tests with no mistakes, can administer exercise test.
  • Administer the exercise test - If the athlete denies any of the symptoms (including headache), and has no symptoms from the exercise testing, you may consider allowing him or her to return to play. Remember, though, if the athlete receives a second "ding," no matter how slight, immediate medical attention is required.
Grade 2: Out to Lunch
(Conscious at all times but dazed, blank stares, "clueless," or amnesia of any kind.)

If the athlete gives wrong answers to more than two questions on the confusion/orientation or memory tests on your first time of testing, immediately remove him or her from play and get emergency medical attention. Never administer exercise test. The athletes should not return to play for at least five to seven days and should be cleared by his/her doctor first.

Grade 3: Knocked Out - Blacked Out
(Any loss of consciousness, no matter how brief.)

Immediately immobilize head while unconscious. No return to play even if the athlete passes all of the exams after returning to consciousness. The athlete should not participate in practice or games for at least two to four weeks. Never administer exercise test.

Unconscious for less than 1 minute:
  • Check for neck pain:
    • - If yes, immediately immobilize head and call an ambulance. Don't move the athlete.
    • - If no, call an ambulance or ask a responsible adult to take the athlete to the emergency room immediately.
Unconscious for more than 1 minute:
  • Keep head immobilized.
  • Call an ambulance.


  • What's your name?
  • Where are you?
  • What month or year is it?
  • Who are we playing?
  • What sport are we playing?
  • Who's winning?
  • Who was our last opponent?
  • Who won that game?
  • When was the last major holiday?
  • What is the next one?
  • What has happened so far in the game?
  • Who is the President of the United States?
  • Give the athlete three objects (cat, book, tree) to remember, then ask him or her to tell you what they are after three minutes.
  • Repeat these numbers backward ( 4-3-6 , 8-2-7-1, 9-4-5-2-0).
  • Beginning with December, say the months of the year backwards.
  • Tell me a multiplication table forwards.
Neurological Tests
  • Pupils should be of equal size. If not, call an ambulance.
  • Have the athlete touch a finger to nose with eyes closed. Fails test if misses nose.
  • Have the athlete stand on 2 feet with arms out, first with eyes open and then with eyes closed - fails test if sways (for hockey, skate blue line forward on 1 foot).
  • Have the athlete walk heel-toe in straight line, forward and backward. Fails test if wavers or line is not straight (for hockey, skate backwards without looking).
Exercise Tests
(Only for suspected Grade 1 concussion, to see if symptoms return. Alter it depending on the sport, e.g., hockey).
  • 5 each: deep knee bends/sit-ups/push-ups/gut busters.
  • Sprint full speed 40 yards, cut on command.