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Recognizing a Concussion: Does a person need to be “knocked out” to get a concussion?

Recognizing a concussion

Noticing a person is knocked out is the easiest way to know he or she has suffered a concussion.

But being knocked out is NOT a requirement. In fact, 90% of concussions do not involve a loss of consciousness (being knocked out).

As an example, you may have watched a boxing or MMA match being broadcast and the fight is stopped by the referee. The fight has been won by TKO or Technical Knock Out. If you watch the replay, you will likely notice a heavy blow to the head then you will notice the fighter's reactions are off or slow, he may seem dazed or confused, he may appear off balance or stumbling, or he’s not fighting back. These signs are very likely the result of a concussion.


How do You Recognize a Concussion?

Recognizing a concussion is an important skill because unfortunately, there currently isn’t a perfect way to test and diagnose a concussion. Many researchers are looking for clear biomarkers using quick blood tests or brain scanning equipment used on site, but such tests have yet to be cleared for standard practice.

But it's important to identify the person that may have suffered a concussion.

This allows you to pull them from play to prevent further injury.

It also allows the person to be observed:

  • Observed for developing symptoms (what the person describes feeling)

  • Observed for developing signs (behavior you can observe)

  • Observed for progression of symptoms

  • Or maybe in the future, a sideline biomarker test to define whether a concussion has occurred.


Immediate recognition of a concussion from the sidelines other than being knocked out:

  • Slow to get up from being knocked down or after falling.

  • The head hits the ground.

  • Looking dazed or confused.

  • Behaving confused (examples: forgetting the play, where to go next, or what part of the routine is next).

  • Appears wobbly or off balance or somewhat clumsy.

  • Grabs and holds her head or helmet quickly with both hands as if struck by a sudden headache.

  • Vomiting.

If you observe any of these, the person should be pulled from play immediately.

Of course, other conditions can cause the same things, but diagnosing this from the side line is probably not the best decision.

It’s better to use the adage of “When in doubt, sit them out.” when dealing with possible concussion.


What questions do you ask a person that you suspect might have a concussion?

Your first question to the injured person:

  • Wrong: “Are you okay?”

If you’re dealing with athletes, the first response will likely be “Yes.” Then “Can I go back and play?”

  • Better question: “Tell me what happened.”

- This tests for the person’s recall of events leading up to the possible concussion. A person without a concussion should have a clear recall of what he was planning and what he was doing before the incident.

- Ask this question as soon as possible after the incident.

- Is the answer consistent with what you observed?

- You can also ask this question later on to compare the consistency / recall of the story.

Next questions: (These are more helpful in people aged 12 and older).

Ask about important aspects of the game / team / environment such as

- What’s the score?

- Which half of the game is it?

- Who are we playing against?

- Who’s your coach?

- Who’s the team captain?

- What venue are we at now?

- Did your team win the last game?

Wrong answers can give you a clue that the person may have a concussion.

Once the person is pulled from play, you can begin asking specifically about symptoms of concussion (what the person feels):

  • Headache or pressure in the head?

  • Ringing in the ears?

  • Sensitive to noise?

  • Dizziness?

  • Vision changes: Blurred? Sensitive to light?


What you might observe after the person has been pulled from play at a sporting event if a person has a concussion:

  • Imbalance or incoordination. Does the person seem off balance or somewhat in-coordinated?

  • Speaking problems. Is the voice clear and the words appropriate?

  • Story telling is not consistent. Does the person seem confused?

  • Memory is not accurate. For example, does the person forget who brought her off the field?

  • Slow to respond to questions or appears dazed.

  • Emotionally irritable or easily agitated.

  • Confused.

  • Does the person “just not seem right?” This is an important clue as well. If you haven’t been trained to specifically assess a person for concussion, your instinct for normal human behavior and conversation will give you important clues about signs of concussion.

Thinking and remembering:

Does the person seem forgetful or confused? If so, then the person may have a concussion.

Some quick tests of thinking and remembering during the initial period of observation:

One thing you can do is give the person three words to remember early on and then retest the accuracy at a later time, maybe 5 or 10 minutes later.

Try picking an object, a colour, and a food, and have the person repeat it back to you to ensure immediate recall.

Example: “I want you to remember 3 things and I’m going to ask you about them later: First, a bus (they repeat), the colour green (they repeat), “and a carrot” (they repeat). “Now say the three words to me again” (to ensure immediate recall and understanding).

Other tests:

Ask the person to repeat a series of 3 - 5 numbers but backwards.

(eg. 3, 5, 9, 1, 7. The person repeats backwards 7, 1, 9, 5, 3)


Ask the person to say the months of the year backward (but for children ask to say the days of the week backward).


If you're interested...

The British Medical Journal has a free download for you:

The Concussion Recognition Tool 5

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