Traumatic Brain Injury (TBI) Assessment
OVERVIEW
TBI assessment involves:
- determining nature and severity of TBI
- diagnosing underlying causes, complications and associated injuries
- identify indications for monitoring and therapies
- determining prognosis
HISTORY
General (AMPLE)
- Allergies and ADT
- Medications
- Past history and pregnancy status
- last meal
- Events leading up to injury
Specifically:
- Age
- Mechanism of injury
- Significant co-morbidities
- Pre-existing neurological deficits
- GCS at the scene
- GCS during transport to hospital
- Oxygen saturation
- Blood pressure
- Coagulation status
- Treatments already given and response to treatment
EXAMINATION
- Primary and secondary survey as per ATLS algorithms
- Vital signs (obtain SpO2 and BP as soon as possible)
Specifically in TBI assess:
- Glasgow coma scale (E1-4 V1-5 M1-6; assess after resuscitation)
- Pupils (assess after resuscitation and note evidence of orbital trauma)
— reactivity to light (a fixed pupil is <1mm response to bright light)
— asymmetry
— dilation (‘blown pupil’) - Focal neurological deficit
- Lateralising weakness
- Evidence of:
– penetrating head injury
— blunt trauma
Evidence of base of skull fracture:
- Peri-orbital ecchymosis
- Retroauricular ecchymosis
- CSF otorrhoea
- CSF rhinorrhoea
- Cranial nerve palsies (especially CN VIII)
- Haemotympanum
Look for evidence of trans-tentorial herniation:
- Dilated and non-reactive pupils
- Asymmetric pupils
- Deterioration in neurological condition
- Cushing reflex:
— Hypertension
— Bradycardia
— Irregular respirations
Look for evidence of underlying causes and complications
- e.g. medic alert bracelets, evidence of seizures (tongue biting, incontinence, etc)
INVESTIGATIONS
Bedside
- glucose
- ECG
- blood gas
- FAST scan
Laboratory
- Trauma series bloods (e.g. FBC, UEC, LFTs, lipase, coags, cross-match)
Imaging
- Urgent CT head and cervical spine (Ensure airway adequately protected and haemodynamically stable prior to transfer to CT)
- Trauma series radiographs as indicated
- MRI may be required sub-acutely (e.g. DAI, spinal cord injury)
References and Links
- CCC – Traumatic Brain Injury: Assessment
- CCC – Traumatic Brain Injury: Management
- CCC – Traumatic Brain Injury: Monitoring
- CCC – Traumatic Brain Injury: Prognosis
- CCC – Traumatic brain injury: Overview
- CCC – Increased ICP in TBI
- CCC – Cerebral Perfusion Pressure (CPP) in TBI
- CCC – Limitations of CT in Traumatic Brain Injury
- CCC – Traumatic brain injury: Literature Summaries
- Brain Trauma Foundation Guidelines – Guidelines for the Management of Severe TBI
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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