NATA-BOC Head and Spine Injury Management 2 — Questions and Answers

Question 1: According to the most current concussion consensus guidelines, which symptom most reliably indicates an athlete should be immediately removed from play?

Headache that resolves within 5 minutes
Any observable signs of confusion or disorientation (Correct answer)
Mild sensitivity to light
Difficulty remembering the score of the game

Correct answer: Any observable signs of confusion or disorientation

Observable confusion or disorientation is a red flag that mandates immediate removal from play. The 'when in doubt, sit them out' principle applies, and any signs of altered mental status are the most reliable indicators for removal.

The Berlin Consensus Statement on Concussion in Sport emphasizes that any athlete suspected of having a concussion should be immediately removed from play and not returned on the same day. Observable confusion — such as appearing dazed, being slow to answer questions, being unsure of surroundings, or demonstrating inappropriate behavior — is the most reliable on-field indicator. While headache is the most commonly reported symptom, it can have other causes. Confusion directly indicates brain dysfunction. The athletic trainer should perform a standardized sideline assessment (SCAT6) but should not delay removal while waiting to administer it.

Question 2: An athlete sustains a concussion and is being monitored. Which finding would necessitate emergency transport to a hospital?

Persistent headache that does not worsen
One episode of vomiting immediately after impact
Progressive deterioration of consciousness (Correct answer)
Inability to recall events of the previous day

Correct answer: Progressive deterioration of consciousness

Progressive deterioration of consciousness is a danger sign that may indicate an epidural or subdural hematoma or cerebral edema. This requires immediate emergency transport for neuroimaging.

While all concussion symptoms warrant monitoring, progressive deterioration of consciousness is a red flag for a more serious intracranial injury such as an epidural hematoma (often from middle meningeal artery rupture) or acute subdural hematoma. The classic 'lucid interval' of epidural hematoma involves initial improvement followed by rapid deterioration. Other danger signs requiring emergency transport include: increasingly severe headache, repeated vomiting, seizures, focal neurological deficits, one pupil larger than the other, increasing confusion, unusual behavior, and slurred speech. A single episode of vomiting and persistent (non-worsening) headache are concerning but less emergent.

Question 3: Which grading scale has been recommended for sideline concussion assessment by the Concussion in Sport Group?

Cantu Grading Scale
American Academy of Neurology Grade System
Sport Concussion Assessment Tool (SCAT) (Correct answer)
Glasgow Coma Scale

Correct answer: Sport Concussion Assessment Tool (SCAT)

The SCAT (currently SCAT6) is the standardized tool recommended by the Concussion in Sport Group for sideline concussion evaluation. It includes symptom evaluation, cognitive screening, balance assessment, and neurological screening.

The Sport Concussion Assessment Tool (SCAT) has been the internationally accepted standard for sideline concussion evaluation since its introduction. The current version (SCAT6) includes: immediate assessment (red flags, observable signs, GCS), symptom evaluation (22-item symptom checklist), cognitive screening (orientation, immediate memory, concentration), neurological screen (cervical spine, balance, coordination), and delayed recall. The older grading scales (Cantu, AAN) that classified concussions as Grade 1-3 have been abandoned because research showed concussion severity cannot be determined at the time of injury. The Glasgow Coma Scale is used for traumatic brain injury severity but is not sensitive enough for sport-related concussion.

Question 4: An athletic trainer is managing an athlete with a suspected cervical spine injury in a football helmet and shoulder pads. According to current best practices, what should be done with the equipment?

Remove both the helmet and shoulder pads before transport
Leave both in place; remove the facemask only (Correct answer)
Remove the helmet but leave the shoulder pads
Remove the shoulder pads but leave the helmet

Correct answer: Leave both in place; remove the facemask only

Current guidelines recommend leaving both the helmet and shoulder pads in place to maintain neutral cervical alignment. The facemask should be removed to allow airway access. Removing only one piece of equipment creates cervical hyperflexion or hyperextension.

The Inter-Association Task Force recommendations state that both the helmet and shoulder pads should be left in place during immobilization and transport because they work together to maintain neutral cervical spine alignment. If either must be removed (e.g., the helmet is loose), then BOTH must be removed simultaneously in a controlled manner by trained personnel. The facemask should be removed using appropriate tools (cordless screwdriver, FM Extractor) to gain airway access while the helmet remains in place. Removing only the helmet causes cervical hyperextension because the shoulder pads elevate the torso. Removing only the shoulder pads causes cervical hyperflexion.

Question 5: Which of the following best describes second impact syndrome?

Two concussions occurring in the same season
Diffuse cerebral swelling after a second concussion before the first has resolved (Correct answer)
Post-concussion syndrome lasting more than 3 months
Bilateral subdural hematomas from repeated impacts

Correct answer: Diffuse cerebral swelling after a second concussion before the first has resolved

Second impact syndrome (SIS) occurs when an athlete sustains a second concussion before fully recovering from a first concussion. It results in rapid, often fatal, diffuse cerebral edema due to loss of cerebrovascular autoregulation.

Second impact syndrome is a rare but often fatal condition characterized by rapid diffuse cerebral edema following a second concussion sustained before complete recovery from an initial concussion. The pathophysiology involves loss of cerebrovascular autoregulation, leading to massive cerebral blood flow increase, brain swelling, and herniation — often within minutes. The mortality rate is approximately 50%, and survivors typically have severe permanent disability. This is the primary reason why return-to-play protocols require complete symptom resolution before beginning a graduated return. Young athletes (under 18) appear to be at greatest risk. SIS underscores the critical importance of proper concussion management and the 'when in doubt, sit them out' principle.

Question 6: During the return-to-play protocol after concussion, at which step is resistance training first introduced?

Step 2: Light aerobic exercise
Step 3: Sport-specific exercise
Step 4: Non-contact training drills (Correct answer)
Step 5: Full-contact practice

Correct answer: Step 4: Non-contact training drills

Resistance training is first introduced at Step 4 (non-contact training drills) of the graduated return-to-play protocol. Prior steps focus on light aerobic and sport-specific exercise without resistance or contact.

The Berlin Consensus graduated return-to-play protocol includes six steps, each separated by at least 24 hours: Step 1 — Symptom-limited activity (daily activities that do not provoke symptoms); Step 2 — Light aerobic exercise (walking, swimming, cycling at low intensity); Step 3 — Sport-specific exercise (skating drills, running drills, no head-impact activities); Step 4 — Non-contact training drills (more complex drills, resistance training begins); Step 5 — Full-contact practice (after medical clearance, normal training activities); Step 6 — Return to competition. If symptoms recur at any step, the athlete drops back to the previous asymptomatic step. Each step should take a minimum of 24 hours.

NATA-BOC Head and Spine Injury Management 2

According to the most current concussion consensus guidelines, which symptom most reliably indicates an athlete should be immediately removed from play?