What is the standard assessment for a patient with Traumatic Brain Injury (TBI)?

Standard Assessment for Traumatic Brain Injury

The standard TBI assessment centers on the Glasgow Coma Scale (GCS) with detailed documentation of all three components (eye, verbal, motor), pupillary size and reactivity, and serial neurological examinations to detect deterioration. 1, 2

Initial Clinical Assessment Components

Glasgow Coma Scale Evaluation

• Document each GCS component separately (Eye-Verbal-Motor) rather than just the sum score, as patients with identical sum scores but different component profiles have different outcomes 1, 3
• The motor component has the highest predictive value in severe TBI and remains robust even in sedated patients 1, 4
• Identify and clearly document confounding factors (sedation, intubation, facial trauma, intoxication) that affect assessment 2
• Mark non-assessable components explicitly rather than assigning arbitrary scores 2

Pupillary Assessment

• Assess pupillary size and reactivity at every neurological examination 1, 4
• Document pupillary findings separately from GCS, not as an integrated GCS-Pupils score 2
• Pupillary reactivity is a key prognostic indicator for 6-month neurological outcome 1

Additional Clinical Variables

• For patients with GCS 14-15: document presence and duration of loss of consciousness using validated tools 2
• For patients with GCS 14-15: assess and document duration of post-traumatic amnesia (must be <24 hours for mild TBI classification) 5, 2
• For patients with verbal score 4-5: document acute symptoms using standardized rating scales 2
• Record injury mechanism and presence of extracranial injuries 2

Serial Neurological Monitoring

Frequency of Reassessment

• Repeat neurological examination at regular intervals to detect secondary deterioration 1
• For moderate TBI (GCS 9-12): examine every 15 minutes for first 2 hours, then hourly for 12 hours 1, 6
• For mild TBI with abnormalities: examine every 30 minutes for first 2 hours, then hourly for 4-12 hours 1
• Continue serial assessments for 14 days for complete characterization of disease progression 2

Critical Thresholds for Action

• A decrease of 2 or more points in GCS score mandates immediate repeat CT scanning 1, 6
• Development of focal neurological deficits requires urgent neurosurgical consultation 6
• Any secondary neurological deterioration warrants repeat imaging 1

Severity Classification

Mild TBI (GCS 13-15)

• Loss of consciousness <30 minutes 5
• Post-traumatic amnesia <24 hours 5
• Up to 15% have acute lesions on CT despite GCS 15, with <1% requiring neurosurgical intervention 5

Moderate TBI (GCS 9-12)

• Significant risk of secondary neurological degradation requiring intensive monitoring 1, 5

Severe TBI (GCS 3-8)

• Requires immediate neurosurgical capability and intensive care 4, 5

Imaging Strategy

CT Scan Indications

• Obligatory for moderate to severe TBI (GCS ≤12) 5
• For mild TBI (GCS 13-15): obtain CT if skull fracture, neurological deficit, or other high-risk criteria present 1, 5
• Immediate non-contrast head CT for all severe TBI to identify surgical lesions 4

Physiological Monitoring Priorities

Prevention of Secondary Brain Injury

• Maintain oxygen saturation >95% 4, 6
• Maintain systolic blood pressure >110 mmHg (or mean arterial pressure ≥80 mmHg) 4, 6
• Detect and correct systemic factors causing secondary cerebral insults 4

Critical Assessment Pitfalls to Avoid

• Never rely on a single GCS determination—serial assessments are essential 4, 6
• Approximately 13% of patients who become comatose had initial GCS 15, demonstrating inadequacy of single assessment 6
• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks deterioration 6
• Avoid using only the GCS sum score without component documentation 1, 2, 3
• Do not delay correction of hypotension or hypoxia while waiting to prognosticate 6

Prognostic Assessment

• Age, initial GCS, and pupillary reactivity are key determinants of 6-month neurological outcome 1
• Marshall and Rotterdam CT-based scales predict 6-month mortality in moderate-severe TBI 5
• Extended Glasgow Outcome Scale provides granular assessment of functional recovery over time 4
• Neurological status at 72 hours is a good prognostic factor for in-hospital death but does not reliably predict long-term outcomes for survivors 6