FA 7341 Simple Single-Stage Concussion Scoring System(s) in the First Aid Setting (FA):TF ScR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable.

The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable.

Task Force Synthesis Citation

Berry DC, Martinez-Mejias A, Rogers J, Laermans J, Douma MJ, Djärv T, Singletary EM, on behalf of the International Liaison Committee on Resuscitation First Aid Task Force. Simple Single-Stage Concussion Scoring System(s) in the First Aid Setting Task Force Synthesis of a Scoping Review. [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, 2025 October. Available from: http://ilcor.org

Collaborators: Laermans, Jorien; Charlton, Nathan; Douma, Matthew; Djarv, Therese

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of single-stage concussion scoring system(s) in the first aid setting conducted by the ILCOR First Aid Task Force Scoping Review team. Evidence from adult and pediatric literature published since 2000 was sought and considered by the First Aid Task Force.

Scoping Review

Berry DC, Martinez-Mejias A, Rogers J, Laermans J, Douma MJ, Djärv T. Simple single-stage concussion scoring system(s) in the first aid setting: a scoping review. (in preparation)

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children with suspected head injury.

Excluded: Adult and children with suspected head injury with loss of consciousness, moderate or severe brain injury.

Intervention: Use of concussion triage recognition tool.

Excluded: Concussion recognition tool requiring baseline and follow-up testing (two-stage) conducted by trained medical personnel and concussion triage recognition tools which are not feasible for lay responders in the out-of-hospital setting (e.g., Glasgow Coma Scale (GCS), Balance Error Scoring System (BESS, mBESS), Sport Concussion Assessment Tool (SCAT v1-6) for healthcare providers (HCPs), Post Concussion Syndrome (PCS) scores, Standard Assessment Concussion (SAC), Acute Concussion Evaluation (ACE), Neurocognitive computer testing (e.g., Impact), King-Devick (KD).

Comparators: Use of a standard first aid assessment without a scoring system or triage tool.

Excluded: Any intervention not feasible in the out-of-hospital setting (e.g., neurocognitive computer testing).

Outcomes: Any clinical outcomes (detection/recognition outcomes as proxies).

Excluded: Intracranial bleeding, PCS, aneurysm, development of head trauma following trauma, concussion knowledge, and validation studies.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies). All relevant publications in any language are included as long as there is an English abstract.

Excluded: Unpublished studies (e.g., conference abstracts, trial protocols), reviews (all types) not addressing interventions feasible in the out-of-hospital setting by first aid responders, and those without an English abstract; animal studies were excluded.

Timeframe: 2000-2024, all languages, if an English abstract was available.

Excluded: Articles in a language other than English, for which no English abstract was available, or were unable to access or translate.

Literature search updated to 23 August 2024

Updated search 24 July 2025

Search Strategies

A search strategy was developed with assistance from the information specialist at the Centre for Evidence-based Practice, Belgian Red Cross (see Appendix 1: Search Strategies). Records for review were obtained by searching PubMed, EMBASE, and Cochrane CENTRAL, for all entries from database inception to 23 July 2024. Records from the database searches were downloaded and imported into Covidence for duplicate removal and screening.

A total of 7021 studies were retrieved from all databases. After removal of 1732 duplicates, 5289 studies underwent title and abstract screening. After initial screening, 35 full-text studies were assessed for eligibility, and 3 studies were ultimately included (See Figure 1 for PRISMA flow chart). Reasons for exclusion at the full text level included: no outcomes data provided (n=2), wrong population (n=2), wrong intervention (n=9), wrong outcome (n=4), wrong setting (n=2), and wrong study design (n=13).

Inclusion and Exclusion criteria

Population Inclusion Criteria:

• Adults and children with suspected head injury (mild traumatic brain injury, sport concussion) without loss of consciousness in the out-of-hospital setting.
  
  

Population Exclusion Criteria:

• Adult and children with suspected head injury with…
  • loss of consciousness
  • moderate or severe brain injury

Intervention Inclusion Criteria:

• Use of the concussion triage recognition tool as a one-time scoring tool in the out-of-hospital setting by lay responders, requiring little to no training.

Intervention Exclusion Criteria:

• Concussion recognition tool requiring baseline and follow-up testing (i.e., two-stage) conducted by trained medical personnel.
• Concussion recognition triage tools not feasible for lay responders in the out-of-hospital setting (e.g.,)
  • Glasgow Coma Scale (GCS)
  • Balance Error Scoring System (BESS, mBESS)
  • Sport Concussion Assessment Tool (SCAT v1-6)
  • Post-Concussion Syndrome (PCS) scores
  • Standard Assessment Concussion (SAC)
  • Acute Concussion Evaluation (ACE)
  • Sport Concussion Office Assessment Tool (SCOAT v1-6)
  • Neurocognitive computer testing (e.g., Impact)
  • King-Devick (KD) test.
  • Blood biomarkers

Outcome Inclusion Criteria:

• Any clinical outcomes (detection/recognition outcomes as proxies).

Outcome Exclusion Criteria:

• Intracranial bleeding, PCS, aneurysm, development of head trauma following trauma, concussion knowledge, and validation studies.

Data tables

No data was extracted; narrative review provided below.

See Figure 1 (PRISMA Diagram).

Task Force Insights

1. Why this topic was reviewed.

In the past twenty years, there has been a global resurgence related to early recognition, management (including removal from activity), and prevention of concussions, led mainly through the sports world. International summary, agreement, and consensus statements related to sport-related concussion have dramatically evolved over the past twenty years and now assist in guiding current clinical practice (Broglio 2024 225; Davis 2024 1; Harmon 2013 15; Patricios 2023 695; Schneider 2022 1059) for healthcare providers, but not necessarily for non-trained, non-healthcare providers (i.e., lay first aid responders).

A concussion, known as mild traumatic brain injury (mTBI), is a head injury that temporarily affects brain functioning caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth (CDC 2024). A sport-related concussion (SRC) is a traumatic brain injury caused by a direct blow to the head, neck, or body, resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities. The force transmitted to the brain initiates a neurotransmitter and metabolic cascade, potentially causing axonal injury, changes in blood flow, and inflammation affecting the brain. However, no single definition of concussion, minor head injury, or MTBI is universally accepted (Hon 2019 117).

Common causes include motor vehicle collisions, falls, sports injuries, and bicycle accidents. Risk factors include drinking alcohol. The mechanism may involve either a direct blow to the head or forces elsewhere on the body that are transmitted to the head. Either mechanism may result in neuron dysfunction, as there are increased glucose requirements but insufficient blood supply.

Concussions are estimated to affect more than 6 out of every 1,000 people each year (Cassidy 2004, 28) and are the most common type of TBI (Cassidy 2004 28; Voss 2015, 32). Annually, there are over 300,000 sports-related TBIs in the United States, with most being concussions and representing between 9%-13% of all high school athletic injuries (Gardner 2019 768).

Concussions are a common term for acute mild TBIs (Gessel 2007, 495; Centers for Disease Control and Prevention 2024). These numbers likely underestimate the true incidence of concussions, as nearly one-third of athletes have suffered undiagnosed or silent concussions (Gessel 2007, 495; Meehan 2013, 339). Undiagnosed concussions are particularly dangerous because of the elevated risk of a second, often more severe concussion for some time after the first injury. Repeated concussions may also increase the risk in later life of chronic traumatic encephalopathy, Parkinson's disease, depression, and behavior issues in children (Fujiwara 2014 79).

Signs and symptoms may present immediately or evolve over minutes or hours. They commonly resolve within days but may be prolonged. No abnormality is seen in standard structural neuroimaging studies (computed tomography or magnetic resonance imaging T1- and T2- T2-weighted images), but in the research setting, abnormalities may be present in functional, blood flow, or metabolic imaging studies. Sport-related concussions result in a range of clinical symptoms and signs that may or may not involve loss of consciousness. The clinical symptoms and signs of concussion cannot be explained solely by (but may occur concomitantly with) drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction), or other comorbidities (such as psychological factors or coexisting medical conditions) (Patricios 2023 697).

There are numerous observable signs and symptoms of a concussion. The four primary categories include (1) physical, (2) cognitive, (3) emotional, and (4) sleep. Symptoms may include loss of consciousness (LOC), memory loss, headaches, difficulty with thinking, concentration, balance, nausea, blurred vision, sleep disturbances, and mood changes. Any of these symptoms may begin immediately or appear days after the injury (National Institute of Health 2020), and it is not unusual for symptoms to last four weeks. Headache is the most reported symptom, with dizziness the second most common (Marar 2012 747; Meehan 2013 339). Fewer than 10-11% of sports-related concussions among children are associated with loss of consciousness (Collins 2003, Langlois 2006, Meehan 2010). In 2021, a clinical expert group developed the Brain Injury Screening Tool (BIST) to guide healthcare pathways based on clinical indicators of poor recovery. The tool aimed to facilitate access to specialist services (if required) to improve longer-term prognosis (Theadom 2021).

In June 2023, the British Journal of Sports Medicine published The Amsterdam 2022 International Consensus Statement on Concussion in Sport (Patricios 2023 695) (and its associated works), which summarizes published evidence at the conference on concussions in sport. The Concussion in Sport Group revised several concussion assessment tools for healthcare providers (non-lay providers), including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6).

In situations where a medically trained and licensed healthcare provider is present, any person suspected of having a concussion should be stopped from activity or play and assessed using a standardized approach. Several concussion assessment tools have been developed, and in some settings, these assessment tools are required to manage a concussed person. These standardized measures acquired from the assessment tools are intended to reduce the subjectivity encountered by healthcare providers responsible for making a rapid and accurate injury assessment and concussion diagnosis decision. The assessment examination date should be compared to a reliable pre-injury baseline.

It is important to note that baseline values for common assessment tools can vary widely from person to person or athlete to athlete. The results depend on factors such as age, sport, sex, and any existing medical conditions, making assessments without baseline results very challenging, especially in untrained individuals. Furthermore, baseline data may change as part of the normal maturation and developmental process and can be influenced by factors like current mood, fatigue, and other variables (Harmon 2012 15). Knowing an individual well is crucial when evaluating a concussion, as there can be significant variability in how symptoms present.

First aid responders, especially lay responders without formal medical or concussion training, face significant challenges when assessing concussions in out-of-hospital settings. Concussions are often subtle, with symptoms that can manifest immediately or develop hours later, making it difficult to recognize without medical expertise (CDC 2024). The variability in symptoms, which range from physical signs like headaches and dizziness to cognitive impairments such as memory loss or difficulty concentrating, adds to the complexity (Marar 2012 747; Meehan 2013 339). Furthermore, most standardized concussion assessment tools like the SCAT6 or the CRT6 are designed for use by healthcare professionals and require a solid understanding of neurocognitive evaluation (Patricios 2023 695). Lay first aid responders often lack access to such tools and the necessary knowledge to interpret symptom variations, especially in the absence of a pre-injury baseline assessment (Harmon 2012 15). The absence of visible physical injury and the fact that concussions typically do not appear on standard imaging further complicates the diagnostic process (Patricios 2023 697).

Moreover, there needs to be more evidence supporting the use of simple concussion recognition tools that require little to no training for lay first aid responders. While the sports world has made substantial advancements in concussion management, especially concerning athlete safety and return-to-play protocols, these guidelines do not necessarily translate well to everyday situations involving non-athletes experiencing non-athletic head trauma (Patricios 2023 695; Schneider 2023 615). The lay first aid responders are often tasked with making a quick decision in dynamic environments, such as after motor vehicle accidents or falls, where the symptoms of concussion may be confused with other conditions like intoxication, dehydration, or emotional distress (Cassidy 2004 28). Current consensus statements and concussion assessment tools are tailored to healthcare providers and not adequately adapted for laypeople, creating a gap in concussion triage outside of clinical settings (Broglio 2024 225). This lack of simple, evidence-based tools places both the responder and the injured person at risk, as timely recognition and removal from the activity are critical to preventing further injury (Patricios 2023 695).

This scoping review sought to identify studies and reports on the recognition and assessment of concussions by lay first aid responders in out-of-hospital settings. It aimed to describe the first aid strategies and tools used for concussion recognition and to document the effectiveness or limitations of simple concussion triage tools used by non-medical responders. A prior scoping review was conducted in 2019 (Berry 2019) but was not published.

2. Narrative summary of evidence identified

After removal of duplicates, the initial database search yielded 5289 unique records. Following title and abstract screening, 35 records underwent full text screening, with 32 being excluded for reasons listed in the PRISMA diagram (Figure 1). The most common reasons for exclusion were the wrong study design and the wrong intervention.

The subsequent updated data (July 2025) search yielded 34 unique records. Following title and abstract screening, two records underwent full text screening, with two being excluded for reasons listed in the PRISMA diagram (Figure 1). The most common reasons for exclusion were the wrong study design and the wrong intervention.

A total of 3 reviews were ultimately included in this scoping review after consultation among task force members, all narrative reviews of sports-related concussion (SRC) (Guskiewicz 2011 603; McCrory, 2012 268, McLeod, 2022 40). The task force members determined the information in the reviews would be useful in the out-of-hospital setting by lay first aid responders. Reviews originated in Australia (n=1) and the United States of America (n=2). Of the three included studies, all originated in high-income countries and focused on SCR. No studies originated in low-income countries.

A narrative summary of the included studies follows and is presented beginning with older studies where definitions and diagnostic techniques were not as advanced as those in the newer studies.

Narrative Reviews of Sports-Related Concussion

A review by Guskiewicz and Broglio (2011, 603) found that the systematic management of SRCs is critical for minimizing adverse outcomes and ensuring athlete safety. According to the authors' review of SRC on-field and sideline assessment, effective management begins with proactive preseason planning, including developing emergency action plans, baseline evaluations, and education for athletes, parents, and coaches. The authors emphasized the multifaceted nature of SRCs, noting their highly variable presentations and the absence of a definitive diagnostic tool. Instead, assessments rely on clinical evaluations, symptom checklists, and objective measures like the Standardized Assessment of Concussion (SAC) and the Balance Error Scoring System (BESS), which require advanced training and tools. On-field evaluations prioritize identifying life-threatening conditions during the primary survey, while the secondary survey involves detailed history-taking, neuropsychological testing, balance assessments, and observation of neurological deficits. The hallmark signs of concussion, such as impaired balance, combined with detailed injury histories provided by athletes, teammates, and coaches, are essential for accurate identification and management. Notably, only a tiny percentage (<10%) of SRCs involve a loss of consciousness, meaning most cases lack overt signs, complicating their detection. A standardized sideline protocol featuring seven steps—history, observation, palpation, special tests, range of motion (ROM), strength, and functional tests—is strongly recommended. These protocols and baseline data collected during an athlete's uninjured state enable individualized evaluations and support the detection of post-injury changes. The authors advocate for individualized approaches using baseline data to detect post-injury changes. They also recommend a precautionary approach—stating that no athlete should return to play if symptoms persist, encapsulated in the maxim "When in doubt, sit them out." This comprehensive framework highlights the critical role of structured protocols and education in managing SRCs and underscores the need for continued research and innovation in concussion assessment and management strategies.

McCrory et al. (2012 268) reviewed the challenges of diagnosing SRCs, emphasizing the absence of definitive diagnostic tools and the evolving nature of the injury. Most SRCs occur without loss of consciousness or overt neurological signs, complicating on-field identification and necessitating reliance on clinical evaluations, reported symptoms, and assessments of cognitive, balance, and neurobehavioral functions. Hallmark indicators of SRC include (1) memory impairment, (2) attentional deficits, and (3) balance disturbances. Acute symptoms such as headache, dizziness, nausea, and blurred vision often emerge within the first 24 hours, with additional symptoms like irritability, sleep disturbances, and light sensitivity potentially arising later. However, the presentation of symptoms can vary widely, even within the same athlete across different concussion incidents. Baseline assessments conducted in the absence of injury are critical for personalizing concussion management and providing a reference point for post-injury evaluation. A concussion often becomes the default diagnosis unless alternative conditions are confirmed, as no single test definitively identifies a concussion. This limitation, compounded by the lack of specific biomarkers or imaging capabilities, necessitates a precautionary approach where suspected cases are treated as concussions until proven otherwise. McCrory et al. (2012 268) advocate for a multifaceted diagnostic framework incorporating sideline assessments, extended observation, and exclusion of other conditions. Athletes exhibiting clear physical signs (e.g., loss of consciousness, convulsions, unsteady gait), cognitive or behavioral changes (e.g., confusion, emotional instability), self-reported symptoms (those of the patient), or abnormal neurocognitive or balance findings must be removed from play for a complete evaluation. Recognizing injury, even in subtle or cumulative impact scenarios, is critical. SRC diagnosis and management are further complicated by situational factors such as stress, fatigue, or illness, which can influence symptom reporting. Acute symptoms like headache, dizziness, and confusion are commonly observed in the initial minutes post-injury, with additional symptoms like balance problems and memory loss manifesting within the first 24 hours. Given that the mechanism of injury may involve cumulative impacts rather than a single blow, vigilance is essential. Symptoms are typically most severe during the first 24–48 hours and often resolve over days to weeks.

McLeod and Jhala (2022 40) reviewed the challenges and advancements in diagnosing and managing SRC. An SRC is a transient neurological injury resulting from a direct blow to the head or neck or indirect trauma to the body that transmits force to the head. Its presentation may be rapid (within seconds to minutes) or delayed (over minutes to hours) and typically resolves spontaneously. According to McLeod and Jhala (2022 40), no defined validated biomarker or specific imaging finding exists to diagnose concussion definitively. The clinical approach is based on observed mechanisms of injury, overt signs, and self-reported symptoms and provides a reliable method for diagnosis. Initial examination prioritizes ruling out life-threatening conditions such as bleeding or spinal injuries. Concussion assessment tools are highlighted as essential for standardized screening. However, they are not substitutes for a complete assessment. Symptoms of SRC may emerge immediately or evolve, with headache, dizziness, and cognitive difficulties. Recognizing subtle signs, such as brief motor incoordination or a vacant stare, is especially important in amateur sports, where access to medical professionals may be limited. Overt signs, such as loss of consciousness, ataxia, tonic posturing, or post-traumatic seizures, are uncommon but diagnostic of concussion or brain injury. Athletes presenting with such signs must be immediately removed from play. Management protocols emphasize the "recognize, remove, refer" approach. Recognizing the possibility of a concussion involves determining the mechanisms of injury, overt signs, and self-reported symptoms. Individuals with suspected concussions should be removed from play under the principle "If in doubt, sit them out." McLeod and Jhala (2022 40).

Characteristics for equity according to the checklist for Progress Plus (O'Neill 2014 56; Karran, 2023 70) in all reviews identified the place (country) of residence for review, occupation, and age of population. Other characteristics for equity, such as ethnicity, sex, education, and socioeconomic status, were lacking.

Gray Literature

The gray literature search focused on the identification of current first aid guidelines from ILCOR member organizations and known prehospital trauma organizations and first aid training programs that specifically address the recognition or assessment of concussions and single citation sources where indicated.

Organizational Guidelines and Training Programs

The European Resuscitation Council (Zideman 2021 270) first aid guidelines, based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendation (Singletary 2020 A24), which included the topic of ‘recognition of concussions.’ The recommendations included (1) although a simple single-stage concussion scoring system would greatly assist first aid providers’ recognition and referral of victims of suspected head injury, there is currently no such validated system in current practice, and (2) an individual with a suspected concussion must be evaluated by a healthcare professional.

The International Federation of Red Cross and Red Crescent Societies, International First Aid, Resuscitation, And Education Guidelines (Red Cross Red Crescent Networks 2020 223) defines a concussion as a forceful bump, blow, or jolt to the head or body that results in the rapid movement of the head and brain and includes incidents such as a fall, a road traffic accident or an explosion. Mild head injury may present with a (1) bump on the head, (2) a mild headache, and (3) feeling nauseous. If the person has a mild headache or feels nauseous following a blow to the head, they may rest and continue to be observed for any change to their symptoms or behaviour requiring medical care. A patient with a "severe" head injury (or concussion) becomes unresponsive, even for just a few seconds, (2) present with altered mental status (e.g., they become aggressive, have slurred speech, have a seizure; children may have an abnormal attitude or be very quiet and stop playing), (3) may present with a motor or sensory deficit of one or more limbs (e.g., tingling in a limb, or balance or coordination problems), (4) has a severe headache for more than two hours despite taking pain relief, (5) has impaired vision (e.g., sensitivity to light, blurred or double vision), (6) has blood or clear fluid coming out of their nose, ear or mouth, (7) vomits more than once, (8) is unresponsive with abnormal breathing. Other signs could also indicate a head injury, and the signs may present differently in people. The main thing to look for is a change in the person. The signs of a severe head injury can happen immediately or can develop over several hours or days.

The ANZCOR Guideline 9.1.4– First Aid for Management of Head Injury (ANZCOR Guidelines 2024) states that a head injury may be caused by several mechanisms, including falls, assaults, motor vehicle crashes, sporting injuries, and, less commonly, penetrating injuries. A victim may sustain a significant head injury without loss of consciousness or loss of memory (amnesia). Therefore, loss of consciousness or memory loss should not be used to define the severity of a head injury or to guide management. The initial first aid for a victim with a head injury includes assessing and managing the airway and breathing whilst caring for the neck until expert help arrives. There is insufficient evidence to support or refute the use by first aiders of simplified concussion scoring systems such as the Sport Concussion Assessment Tool (SCAT), the Glasgow Coma Scale (GCS), or Alert, Voice, Pain, Unresponsive (AVPU) versus standard first aid without a scoring system (Zideman 2015 e225). The serious consequences of not recognizing a concussion in the first aid environment warrant advising all victims who have sustained a head injury, regardless of severity, to seek assessment by a healthcare professional or at a hospital. A brain injury should be suspected if the victim has a reported or witnessed injury, has signs of injury to the head or face, such as bruises or bleeding, or is found in a confused or unconscious state. A victim may have a brain injury without external signs of injury to the head or face. Serious problems may not be evident for several hours after the initial injury.

The UK Concussion Guidelines for Non-Elite (Grassroots) Sport (UK Government 2024 1) provides a structured approach to recognizing, managing, and recovering from concussions in non-elite sports settings, emphasizing safety and long-term health outcomes. Concussions are defined as traumatic brain injuries resulting from direct or indirect impacts, causing temporary disturbances in brain function. These injuries often occur without loss of consciousness, making early recognition critical. Concussion symptoms can present immediately, within minutes, or over the first 24–48 hours. Symptoms are categorized as (1) Physical: headache, dizziness, vision changes, (2) Mood: irritability, sadness, emotional instability, (3) Cognitive: mental clouding, confusion, slow thinking, and (4) Sleep: Insomnia or excessive sleep. "Red flags" requiring urgent medical assessment include loss of consciousness, amnesia, seizures, severe headaches, and neurological deficits. The guidelines promote the principle, “If in doubt, sit them out,” as the cornerstone of concussion management.

The American Red Cross First Aid/CPR/AED training guidelines (American Red Cross 2021) define a concussion as a traumatic brain injury that alters the way the brain functions and that often occurs as a sports-related injury. However, a concussion can occur whenever a person experiences a bump, blow, or jolt to the head or body that results in rapid movement of the brain within the head. A concussion can result from a seemingly minor bump, blow, or jolt and may be tricky to recognize. Many people who experience a concussion do not lose consciousness, or they may only lose consciousness very briefly. The best clues that a person may have a concussion are often changes in the person’s behavior or other signs noted after the person has experienced a bump, blow, or jolt. Signs and symptoms of a concussion usually are apparent soon after the injury, although some can appear hours or days later (Table 1). For example, the person may sleep more or less than usual. Children may show changes in playing or eating habits. The effects of the concussion can last for several days, weeks, or longer.

Table 1. Signs and Self-Reported Symptoms of a Concussion Taught in a First Aid Course to Lay First Aid Responders.

The Canadian Red Cross (Canadian Red Cross 2017 112) defines a concussion as a subset of traumatic brain injuries (TBI) that involve a temporary alteration in brain function and can result from even a seemingly minor bump, blow, or jolt, and may be difficult to recognize because the signs and symptoms may not be immediately apparent. Concussions are evolving injuries, with the effects intensifying, dissipating, or changing unexpectedly in the days and weeks following the event of the injury. Depending on the severity of the concussion, signs and symptoms can last for days, weeks, or even months. The majority of concussions, however, resolve in a short period. A person with a concussion should seek medical attention following a blow to the head, neck, or upper body with any concussion symptoms. Cessation of physical activity and the promotion of cognitive rest (reducing "screen time" and other activities that require concentration) are critical to the resolution of concussion injuries. The signs and self-reported symptoms of a concussion taught in a Canadian Red Cross first Aid course for lay first aid responders are consistent with those taught by the American Red Cross (Table 1).

St. John Ambulance's First Aid Reference Guide, Canada (St. John Ambulance 2019) defines a concussion as a temporary disturbance of brain function usually caused by a blow to the head or neck. The casualty may become unconscious, but usually for only a few moments. They recommend using both the mechanism of injury and the signs and symptoms below to assess for concussion, including:

1. Partial or complete loss of consciousness, usually of short duration.
2. Shallow breathing.
3. Nausea and vomiting when regaining consciousness.
4. Casualty says they are (or were) "seeing stars".
5. Loss of memory of events immediately preceding and following the injury.
6. Severe overall headache (not local scalp pain).

The Sri Lanka Internationally Accredited First Aid Manual (St. John Ambulance Association and Brigade in Sri Lanka 2018 116) does not define a concussion but states it may be caused by shaking of the brain within the skull following an impact on the head. Signs of a serious head injury may include (1) a history of a severe blow to the head, (2) vomiting since the injury, (3) loss of balance, (4) seizure, and (5) unequal pupils.

The Indian Red Cross Society's Indian First Aid Manual (7th ed) (Indian Red Cross Society 2016) does not address the concussion issue in their training manual.

In summary, international organizations agree that concussions are a type of traumatic brain injury caused by a direct blow to the head, neck, or body, resulting in rapid movement of the brain within the skull. Concussions often present with symptoms that may develop immediately or evolve over hours or days. Common signs include difficulty thinking clearly, memory problems, headache, dizziness, sensitivity to light or noise, irritability, and changes in sleep patterns. Although concussions may result from minor impacts and often occur without loss of consciousness, they can still have significant effects on brain function.

Guidelines from various organizations underscore the crucial role of healthcare professionals in promptly recognizing and managing concussions. The European Resuscitation Council (Zideman 2021 270) and ANZCOR guidelines (ANZCOR Guidelines 2024) stress the absence of a validated single-stage concussion scoring system and recommend immediate evaluation for any suspected concussion. Tools such as the SCAT5 and CRT5 can aid in initial screening, but they should not replace comprehensive clinical assessments. The "recognize," "remove," and "refer" approach underscores the need for immediate removal from activity and referral to medical care when a concussion is suspected, placing the responsibility on healthcare professionals to act swiftly and decisively.

Various organizations, including the American Red Cross (American Red Cross 2021) and Canadian Red Cross (Canadian Red Cross 2017 112), stress that concussions are evolving injuries with symptoms that can intensify or change over time. This underscores the need for continuous vigilance and monitoring during the recovery process. Cognitive rest, cessation of physical activity, and medical evaluation are critical for recovery. The Canadian Red Cross (Canadian Red Cross 2017 112) notes that while most concussions resolve quickly, some may persist for weeks or months. Meanwhile, the Sri Lanka (St. John Ambulance Association and Brigade in Sri Lanka 2018 116) and St. John Ambulance (St. John Ambulance 2019) manuals focus on identifying serious head injuries through signs such as vomiting, loss of balance, seizures, or unequal pupils. Across all guidelines, the emphasis remains on prompt recognition and referral to reduce the risk of delayed diagnosis and treatment.

Single Citation Search

One observational study collected data during the development of the HeadCheck app (Clarke 2020 595). The HeadCheck app assists parents, coaches, and first aid providers in recognizing the signs and symptoms of concussion and managing a child's safe return to recovery. Clarke et al. (2020 595) found parents either agreed or strongly agreed that the app increased awareness and importance of concussion recovery, increased knowledge of safely managing recovery from a concussion, and helped decide when to send the child back to school, practice, or normal activities. Clarke et al. (2020 595) concluded that HeadCheck provides an accessible platform for disseminating best practice evidence to help recognize a concussion and symptoms of more severe injuries, and assist parents in guiding their child's recovery.

Hall et al.'s (2021 A89) observational study evaluated the feasibility and performance of a triage screen for mTBI in children. As a part of a larger project, the TBI Evaluation and Management (TEaM) study at a tertiary-care pediatric ED and trauma center and three pediatric urgent care centers implemented a novel triage screening tool within the electronic medical record. Triage nurses asked three serial questions: 1) Did an injury occur? 2) Was the mechanism consistent with a head injury? 3) Was there any altered mental status? There were 91,916 (95.7%) patients screened and subsequently discharged. 1,010 (1.1%) were positive for all three screening questions. Median age was 12.2 years (IQR: 9.1-14.9); 60.1% were male. Among screen-positive patients, 713 (70.6% [95% CI: 59.8-79.5]) were diagnosed with mTBI, and 297 (29.4% [95% CI:20.5-40.2]) were not. McDonald et al. (2021 104) concluded that screening for pediatric mTBI by nurses at triage was feasible and demonstrated concurrence with a final ED diagnosis of concussion in the majority of patients.

McDonald et al.'s (2021, 104) retrospective cohort study estimated the proportion of people who followed up with urgent care recommendations to see a provider and determined the prevalence of concussion diagnoses after being screened with the Barton Schmitt Pediatric Head Injury Telephone Triage Protocol. Five of the initial assessment questions include:

• Mechanism: "How did the injury happen?" For falls, ask: "What height did he fall from?" and "What surface did he fall against?" (Suspect child abuse if the history is inconsistent with the child's age or the type of injury.)
• When: "When did the injury happen?" (Minutes or hours ago)
• Neurological symptoms: "Was there any loss of consciousness?" "Are there any other neurological symptoms?"
• Mental status: "Does your child know who he is, who you are, and where he is? What is he doing right now?"
• Location: "What part of the head was hit?"

Out of 2,454 calls with recommendations to be seen urgently, the estimated proportion of being seen at a healthcare facility was 84.1%. The estimated overall diagnosis of concussion among those who were seen was 39.5%. McDonald et al. (2021, 104) concluded that these data could be used to improve patient education and follow-up and the utility of the telephone triage system.

In summary, the three studies (Clarke 2020 595; Hall 2021 A89, McDonald 2021 104) highlight innovative tools and approaches for recognizing and managing pediatric concussion. Clarke et al. (2020 595) found that the HeadCheck app effectively increased parental awareness and knowledge of concussion recovery, offering a practical platform for guiding safe return to activities and recognizing severe symptoms. Hall et al. (Hall 2021 A89) demonstrated the feasibility of a triage screening tool for pediatric mTBI implemented by nurses in a clinical setting, showing high concurrence with ED diagnoses of concussion, asking three simple serial questions: 1) Did an injury occur? 2) Was the mechanism consistent with a head injury? 3) Was there any altered mental status?

McDonald et al. (2021 104) evaluated follow-up adherence and outcomes after using a telephone triage protocol, finding that 84.1% of patients followed urgent care recommendations and 39.5% were diagnosed with a concussion. Together, these studies emphasize the importance of accessible, structured tools to improve recognition, management, and follow-up for pediatric concussions in diverse care settings.

3. Narrative Reporting of the task force discussions

• This scoping review identified no direct evidence regarding a concussion triage recognition tool that can be used as a one-time scoring tool by lay first aid responders requiring little to no training in the out-of-hospital setting. The task force scoping review team notes that no randomized controlled studies were found during the initial search that directly addressed this topic.
• Three reviews focused on SRC emphasize the absence of definitive diagnostic tools, underscoring the reliance on clinical evaluations and symptom checklists and highlighting the critical need for systematic management of head trauma.

• The scoping review team and task force note the multifaceted nature of concussion symptoms, ranging from memory impairment and attentional deficits to balance disturbances and headaches.

• This scoping review identified two observational studies and one retrospective cohort study during the gray literature search. These studies highlight innovative tools (apps) and approaches for recognizing pediatric concussion by identifying when the injury occurred, the mechanism of injury, and symptoms, including any altered mental status.
• The scoping review team notes that Hall et al.'s (2021 A89) focuses on nurses in the emergency department (indirect evidence); however, the team believes the three simple serial questions in the study are as follows: 1) Did an injury occur? 2) Was the mechanism consistent with a head injury? 3) Was there any altered mental status?

• The scoping review team and task force believe lay first aid responders can use the three simple serial questions in the out-of-hospital setting to recognize a potential concussion. Additionally, these questions are similar to those used in McDonald et al.'s (2021 10) retrospective cohort study, which estimated the proportion of people who followed up with urgent care recommendations to see a provider and determined the prevalence of concussion diagnoses after being screened with the Barton Schmitt Pediatric Head Injury Telephone Triage Protocol.
• The grey literature search identified international organizations' guidelines and treatment recommendations that agree concussions are a type of traumatic brain injury caused by a direct blow to the head, neck, or body, resulting in rapid movement of the brain within the skull. Concussions often present with symptoms that may develop immediately or evolve over hours or days. Common signs include difficulty thinking clearly, memory problems, headache, dizziness, sensitivity to light or noise, irritability, and changes in sleep patterns. Although concussions may result from minor impacts and often occur without loss of consciousness, they can still have significant effects on brain function.
• The gray literature search also found guidelines from international organizations (ANZCOR Guidelines 2024; Zideman 2021 270) that stress the absence of a validated single-stage concussion scoring system and recommend immediate evaluation for any suspected concussion.
• The first aid task force agreed that recognition of a concussion is complicated by its variable symptomatology and the lack of a validated concussion triage recognition tool that can be used as a one-time scoring tool by lay first aid responders. Rather, signs and self-reported symptoms will fall into THINKING AND REMEMBERING, PHYSICAL, EMOTIONAL, and BEHAVIORAL (See Appendix). Symptoms may evolve rapidly (within seconds to minutes) or develop over hours, with acute symptoms such as dizziness and nausea presenting early, while irritability and sleep disturbances emerge later.
• The task force agrees that altered mental status (AMS) refers to a significant change in a person's level of consciousness, cognition, or behavior. It can manifest as a range of symptoms, including confusion, disorientation, lethargy, agitation, delirium, difficulty concentrating, slurred speech, and altered sleep patterns.
• The task force scoping review team noted the "recognize," "remove," and "refer" approach underscores the need for immediate removal from activity and referral to appropriate medical care when a concussion is suspected.
• The task force scoping review team agrees that educational efforts must address the importance of initial assessment based on observed mechanisms of injury (or self-reported), overt signs, and self-reported symptoms. Initial examination prioritizes ruling out life-threatening conditions such as severe bleeding or spinal injuries.

Considering these findings, a systematic review is not recommended.

Good Practice Statement

Considering the evidence reviewed and based on the first aid task force consensus of expert opinion, the following good practice statements are made:

When attempting to determine if a concussion has occurred, non-medically trained, non-healthcare providers (i.e., lay first aid responders) may consider utilizing a three-question screening process.

1. Did a potential injury occur?

2. Was the mechanism associated with a potential head injury?

3. Was there any altered mental status?

If the answer to all three questions is “yes,” the existing literature suggests that these individuals be removed from the activity and EMS be activated, or the patient be referred to a qualified healthcare professional.

Since concussion symptoms vary, first aid responders who are unsure if a concussion occurred may consider removing the individual from the activity until a qualified healthcare professional can evaluate them.

Knowledge Gaps

• No randomized controlled studies were identified that directly evaluated this question.

• The majority of studies or reports evaluating concussion triage recognition are with medical personnel with specific training in multi-stage concussion triage tools.
• Research with lay responders in the prehospital setting seems to focus on knowledge acquisition rather than its application.
• While guidelines emphasize the "recognize, remove, refer" approach, their application varies widely across regions, sports, and care settings. There is insufficient research on how well these guidelines are implemented in real-world scenarios and their impact on outcomes.
• Characteristics like socioeconomic status, ethnicity, and education level are rarely addressed in studies, leaving gaps in understanding how these factors influence concussion recognition, triage, and outcomes.
• While tools like the HeadCheck app and triage protocols for children exist, more research is needed to validate their effectiveness in diverse pediatric populations and to understand how age-related differences affect concussion symptom presentation and recovery.
• While apps like the HeadCheck app show promise, the potential of digital tools, AI, and wearable technology for concussion triage and recognition still needs to be explored.

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