SOAP Note: Traumatic Brain Injury
Subjective
Document the following critical elements:
- Mechanism of injury (fall, motor vehicle collision, assault, blast injury) 1, 2
- Timeline: exact time of injury, any loss of consciousness (duration), presence and duration of lucid interval, subsequent deterioration 2, 3
- Symptoms: headache severity, nausea/vomiting, confusion, amnesia (retrograde vs. anterograde), vision changes, seizure activity 4
- Past medical history: anticoagulation use, bleeding disorders, prior head injuries, alcohol/drug use 5
- Age: critical prognostic factor 1, 4
Objective
Initial Assessment (perform immediately):
Glasgow Coma Scale (GCS): Document all three components (Eye-Verbal-Motor), with particular emphasis on motor response 1, 4
- Severe TBI: GCS ≤8
- Moderate TBI: GCS 9-13
- Mild TBI: GCS 14-15 4
Pupillary examination: size, symmetry, and reactivity to light (key prognostic indicator) 1, 4, 3
Vital signs with specific attention to:
Neurological examination: focal deficits, cranial nerve abnormalities, signs of herniation (Cushing's triad, posturing) 6, 5
Secondary survey: scalp lacerations, Battle's sign, raccoon eyes, hemotympanum, CSF rhinorrhea/otorrhea 5
Assessment
Classify severity based on GCS and clinical findings:
- Severe TBI (GCS ≤8): Requires immediate airway management, ICP monitoring, and neurosurgical consultation 1, 4, 6
- Moderate TBI (GCS 9-13): High risk for deterioration, requires urgent neuroimaging and close monitoring 4, 5
- Mild TBI (GCS 14-15): Risk stratify using clinical decision rules; patients with lucid interval require urgent CT regardless of current stability 2, 4
Critical red flags requiring immediate intervention:
- History of lucid interval (high risk for epidural hematoma) 2, 3
- Deteriorating GCS 2, 6
- Asymmetric or non-reactive pupils 1
- Signs of herniation 2, 6
Plan
Immediate Resuscitation (First Priority)
Airway and Breathing:
- Secure airway if GCS ≤8 or inability to protect airway 4, 6
- Maintain normocapnia (PaCO₂ 35-40 mmHg): avoid prolonged hyperventilation as it causes cerebral ischemia 2, 4, 7
- Ensure adequate oxygenation: hypoxemia significantly increases mortality 4, 6, 5
Circulation:
- Maintain systolic BP ≥100 mmHg: avoid permissive hypotension even in polytrauma 2, 3, 8
- Elevate head of bed to 30 degrees to improve venous drainage 2
- Avoid hypotonic fluids that worsen cerebral edema 2, 4
Neuroimaging
Obtain urgent non-contrast head CT immediately for: 2, 4, 3, 5
- All severe TBI (GCS ≤8)
- All moderate TBI (GCS 9-13)
- Mild TBI with any of: loss of consciousness, amnesia, age >60, anticoagulation, focal deficits, vomiting, severe headache
- Any patient with history of lucid interval, even if currently stable 2, 3
Neurosurgical Consultation
Immediate consultation required for: 2, 3
- Epidural hematoma with mass effect
- Depressed skull fractures
- Open skull fractures with CSF leak or brain tissue exposure
- Any expanding intracranial lesion causing midline shift or significant mass effect
- All patients with history of lucid interval and abnormal CT
Intracranial Pressure Management
ICP Monitoring Indications: 2, 4, 3
- Severe TBI (GCS ≤8) with abnormal CT findings
- Consider in moderate TBI with history of lucid interval
ICP Management Targets:
Tiered ICP Management Approach:
First-tier interventions: 2, 3
- Adequate sedation and analgesia (propofol can decrease ICP but monitor for hypotension) 7
- Maintain normothermia
- Treat seizures if present
- Head of bed elevation to 30 degrees
Second-tier interventions (for refractory elevated ICP): 2, 3
- Osmotic therapy with mannitol (0.25-2 g/kg) for clinical deterioration
- Consider hypertonic saline (3% HTS) 9
Sedation Considerations
If sedation required:
- Propofol can decrease ICP when given by infusion or slow bolus 7
- Caution: Propofol causes 15-20% decrease in blood pressure; monitor cerebral perfusion pressure closely 7
- Avoid propofol infusion >5 mg/kg/h for >48 hours due to risk of Propofol Infusion Syndrome (metabolic acidosis, rhabdomyolysis, cardiac failure, death) 7
- Most patients require opioids (morphine or fentanyl) for analgesia 7
Seizure Prophylaxis
- Address detection and prevention of post-traumatic seizures per institutional protocol 1
Metabolic Management
Maintain biological homeostasis: 1
- Normal osmolarity
- Normoglycemia (avoid both hypo- and hyperglycemia) 5
- Normal coagulation parameters 2
Disposition
Severe TBI (GCS ≤8):
Moderate TBI (GCS 9-13):
- ICU or step-down unit with frequent neurological assessments 5
- Consider ICP monitoring if deterioration or lucid interval 2
Mild TBI (GCS 14-15) with normal CT:
- Observation period with serial neurological exams 4
- Comprehensive discharge instructions including warning signs of deterioration 4
- Gradual return to activity with symptom monitoring 4
Critical Pitfalls to Avoid
- Never delay neuroimaging in patients with lucid interval history, even if currently stable 2, 4, 3
- Never use hypotonic fluids 2, 4
- Never employ prolonged hyperventilation (causes cerebral ischemia) 2, 4, 7
- Never allow hypotension in TBI patients 2, 3, 8
- Never assume stability in patients who appear well after initial injury—deterioration can be sudden 2, 4
- Never use permissive hypotension strategies in TBI, even with hemorrhagic shock elsewhere 2, 3
- Never prescribe complete rest beyond first few days in mild TBI (may delay recovery) 4