When to Go to the ER for Concussion: An ER Referral Checklist for Athletic Trainers

Concussions are a frequent concern in athletic environments—affecting everyone from youth athletes to collegiate competitors. While most concussions can be managed conservatively on the sidelines or in outpatient settings, the ability to identify those rare but serious cases requiring emergency care is a vital skill for athletic trainers. Delays in recognizing severe symptoms can result in serious outcomes, including prolonged disability or death.

For athletic trainers, particularly those working in high-stakes or resource-limited environments, the decision to refer an athlete to the emergency department (ED) is a critical juncture in concussion care. This article provides a structured approach based on established red flags, clinical decision rules, and current research, to help guide ER referrals and enhance athlete safety.

At Sway, we’ve designed our mobile platform to help athletic trainers recognize red flags and make fast, objective decisions when seconds count. With sideline-ready assessments that include on-field assessments, balance, cognitive, and symptom tracking, you can confidently determine when ER referral is necessary—right from your smartphone.

Recognizing the Red Flags: What Demands an Immediate ER Visit?

Accurate identification of red-flag signs is essential for athletic trainers to determine when a concussion may indicate a more serious brain or spinal injury requiring emergency care. Established guidelines from the CDC and major medical centers present a comprehensive set of symptoms and warning signs that should never be ignored.

Recognizing the Red Flags

According to the CDC’s Heads Up initiative, the following “danger signs” warrant immediate medical attention or EMS activation if observed after a bump, blow, or jolt to the head: [source]

  • Convulsions or seizures
  • Difficulty waking up, excessive drowsiness, or inability to stay awake
  • Not recognizing people or places, increasing confusion, restlessness, or agitation
  • Repeated vomiting
  • Slurred speech
  • Weakness, numbness, or difficulty with coordination
  • One pupil larger than the other or sudden changes in vision
  • Headache that worsens or does not improve

Furthermore, a 2022 study comparing SCAT5 with emergency department clinical decision rules such as PECARN and the Canadian CT Head Rule confirmed that loss of consciousness, vomiting, seizure, and severe or worsening headache are reliable red flags. These signs demonstrated comparable or greater sensitivity for detecting serious traumatic brain injuries and should be treated as immediate indicators for ER referral. [source]

Glasgow Coma Scale: A Quantitative Anchor

The Glasgow Coma Scale remains one of the most objective tools for assessing consciousness and guiding ER decisions. A GCS score below 14 (or below 15 in pediatric cases) suggests altered mental status and potential for intracranial injury. According to the NCBI Bookshelf's Head Injury Management Guide (2023), any deviation in GCS from baseline should prompt hospital-level care. [source]

For athletic trainers, even a brief assessment using modified GCS components (eye opening, verbal response, motor response) can support more confident triage and referral decisions.

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Cervical Spine and Structural Red Flags

While much of concussion assessment focuses on cognitive and vestibular signs, structural injuries should not be overlooked. Neck pain, midline spinal tenderness, or any sign of instability should be treated with spinal precautions and immediate ER transport.

A 2020 publication in PM&R Clinics emphasized that motor incoordination, convulsions, and post-injury ataxia are warning signs not just of brain injury but also of possible cervical involvement. [source]

Real-World Scenario: What It Looks Like in Practice

Consider a high school football game. An athlete sustains a helmet-to-helmet collision and lies motionless for five seconds. He regains consciousness but is confused, struggles to walk straight, and reports seeing double. The athletic trainer initiates a SCAT5 but notes unequal pupil size and delayed responses.

Gap in Current Emergency Department Practices

In this scenario, the combination of transient unconsciousness, oculomotor abnormalities, and motor incoordination warrants immediate ER referral. While the athlete may be alert and talking, these red flags outweigh typical symptomatology and indicate the potential for intracranial hemorrhage or structural damage.

The Gap in Current Emergency Department Practices

Alarmingly, a 2019 observational study on concussion care in the ER found that fewer than 50% of patients with high-risk mild TBI received a full neurological exam, and only 15% were given documented discharge instructions about warning signs. [source] This gap underscores the importance of precise communication from athletic trainers when transferring care to the ER.

When initiating an ER referral, athletic trainers should:

  • Document observed red-flag symptoms thoroughly
  • Communicate time of injury, initial symptoms, and any changes over time
  • Share pre- and post-injury baseline comparisons, if available

This documentation can help ensure athletes receive more comprehensive and accurate evaluations upon arrival.

Integrating SCAT6 and CDC Acute Concussion Evaluation

Integrating SCAT6 into sideline assessment alongside validated clinical decision rules—such as the Canadian CT Head Rule (CCHR) in adults and the PECARN rule for pediatric cases—enhances the ability to detect potentially serious brain injury. SCAT6 begins with a neuro-screen that checks red flags, including Glasgow Coma Scale (GCS) < 15, seizure activity, double vision, limb weakness or numbness, vomiting, or worsening headache. These indicators align with CCHR and PECARN criteria, and in both adults and children, their presence should prompt consideration of urgent neuroimaging and emergency department referral.

A Checklist for Emergency Referral

Here is a clinically grounded checklist athletic trainers can use:

Immediate ER Referral If Any of the Following Are Present:

  • GCS < 14 in adults or < 15 in children
  • Seizure activity or convulsions
  • Persistent vomiting (more than once)
  • Unequal pupils or vision disturbances
  • Slurred speech or facial droop
  • Weakness or numbness in limbs
  • Loss of consciousness > 1 minute
  • Rapidly worsening headache
  • Suspicion of cervical spine injury
  • Ataxia or motor incoordination
  • Post-traumatic amnesia > 24 hours

The Athletic Trainer’s Role in Critical Triage

Concussion management begins long before an athlete steps into a physician's office. Athletic trainers not only assess and support injured athletes but also serve as critical decision-makers in moments where minutes matter. By grounding referral decisions in evidence-based criteria and staying vigilant to red-flag signs, athletic trainers ensure that no serious injury goes unnoticed.

In situations where concussion symptoms are ambiguous or evolving, it's safer to over-refer than underreact. Better one precautionary ER visit than a missed diagnosis with lasting consequences.

Reviewed by Kim Wyand, PT, DPT

Director of Customer Experience, Sway Medical

Dr. Kim Wyand is a licensed physical therapist and concussion education specialist with more than a decade of experience in outpatient orthopedic and neurological rehabilitation. On top of leading the customer experience team, Kim works closely with Sway's research team, ensuring the platform remains grounded in research and consistently aligned with evidence-based best practices. She leads the development of tools and resources that support over 13,000 clinicians and athletic programs in delivering high-quality concussion care.