Traumatic Brain Injury Management By GCS


Eyes Open Best Verbal Response Best Motor Response
Spontaneously 4 Answers questions appropriately 5 Obeys commands 6
To voice 3 Confused, disoriented 4 Localizes to pain 5
To pain 2 Inappropriate words 3 Withdraws from pain 4
No response 1 Incomprehensible sounds 2 Decorticate (flexion) 3

 

 
No verbal response 1 Decerebrate (extension) 2
 
 

 

 
No response 1

Background

  1. Noncongenital, nondegenerative insult to the brain
  2. Comes from external mechanical force
  3. Results in permanent or temporary impairment
  4. Has associated diminished or altered state of consciousness
  5. Can be caused by many mechanisms
  6. Most common causes:
  7. Multiple manifestations

Crucial Points

  1. Brain is housed in inelastic skull
  2. Intracranial pressure
  3. Brain Swelling
  4. Cerebral perfusion pressure (CPP) 

Primary injury

  1. Occurs at the moment of trauma
  2. Physical mechanisms of injury
  3. Types of tissue malformation
  4. Pathophysiology

Secondary injury

  1. Occurs immediately after trauma
  2. Major secondary insults:

Injury Severity

  1. Mild Head Injury
  2. Moderate Head Injury
  3. Severe Head Injury

 


GCS 13-15

GCS Score 9- 12

GCS Score 3-8

All PATIENTS: PERFORM ABCDEs WITH SPECIAL ATTENTION TO HYPOXIA AND HYPOTENSION
GCS Classific. 13-15
Mild TBI
9-12
Moderate TBI
3-8
Severe TBI
  May discharge if admission criteria not met Admit for indications below: Neurosurg. eval required Urgen neurosurgery consult required
Initial Mgmt AMPLE History and neurologic exam: -Prim. survey & resuscitation

- Arrange for transfer to definitive neurosurgical eval & mgmt.

- Focused neuro exam.

- Secondary survey & AMPLE Hx
-Prim. Survey & resuscitation

-Intubation & ventilation for airway protection

-Tx hypotension, hypovolemia & hypoxia

- Focused Neuro exam

-Secondary survey & AMPLE Hx
Determine mechanism, times of injury, initial GCS, confusion, amnestic interval, seizure, headache severity etc.
Secondary Survey including focused neurologic exam
No CT available, CT abnormal, Skull Fx, CSF leak


Focal neurologic deficit.
GCS does not return to 15 within 2hr.
Dx -CT scanning

-Blood/Urine EtOH & tox screens
-CT not available, CT abnormal, Skull Fx.
-Significant intoxication (admit or observe)
-CT scan in all cases

-Evaluate carefully for other injuries

-Full preop labs & XRAYs
CT scan in all cases
-Evaluate carefully for other injuries

- Full preop labs & XRAYs
Second. MGMT -Serial Examinations until GCS 15 & pt. has no perseveration of memory deficit.

-Rule out indication for CT
-Perform serial exams

-Perform F/U CT if 1st is abnormal or GCS remains <15

-Repeat CT if neuro exam deteriorates.
-Serial exams

-Consider F/U CT in 12-18 hr
-Frequent serial neuro examinations w/GCS

-Moderate hyperventilation (Pco2 35 +/- 3)

-Anticonvulsants

-Manniotol, Pco2 28-32 for deterioration.

-Avoid Pco2 < 28

-Address intracranial lesion appropriately
Disposition -Home if pt. does not meet criteria for admission.

-D/C w/ head injury warning sheet & F/U arranged
-Obtain Neurosurg. eval if CT or neuro. exam abnormal or pt. deteriorates.

-Arrange for medical F/U & neuropsych eval as required (may be done as outpt.)
-Repeat CT immediately for deterioration & manage as in severe brain inj (10%)

-D/C w/ medical & neuropsych F/U arranged when stable GCS 15 (90%)
- Transfer ASAP to definitive neurosurgical care.

TBI = Traumatic Brain Injury


SOURCE: ATLS 9th edition