What diagnostic steps are recommended for an adult with suspected moderate‑to‑severe traumatic brain injury in a primary‑care (district) hospital?

Diagnostic Approach for Moderate-to-Severe TBI in Primary Care Hospitals

Perform immediate brain and cervical spine CT scan without delay, maintain systolic blood pressure >110 mmHg during evaluation, and arrange urgent transfer to a specialized neurosurgical center while conducting these essential diagnostics. 1

Immediate Clinical Assessment

Neurological Status Documentation

• Document complete Glasgow Coma Scale (GCS) with all three components separately (eye, verbal, motor responses), noting any confounding factors that prevent accurate assessment 2
• Assess and record pupillary size and reactivity bilaterally as a separate finding, not integrated into GCS scoring 2
• Perform systematic ABCDE assessment (airway, breathing, circulation, disability, exposure) to identify time-critical abnormalities 3

Critical Physiological Parameters

• Maintain systolic blood pressure >110 mmHg throughout the diagnostic period, as mortality increases markedly below this threshold 1, 4
• Monitor and maintain oxygen saturation >90% continuously 5
• Target PaCO2 between 35-40 mmHg if mechanical ventilation is required 4
• Avoid any episodes of hypotension (SBP <90 mmHg), which definitively worsen neurological outcomes 1

Essential Imaging Studies

Primary Imaging (Perform Immediately)

• Brain CT scan using inframillimetric sections reconstructed with thickness >1mm, visualized with double fenestration showing both central nervous system and bone windows 1, 4
• Cervical spine CT scan performed simultaneously with brain imaging 1
• This imaging must occur without delay in any patient with coma or abnormal neurological examination to identify primary brain lesions, guide neurosurgical decisions, and determine monitoring needs 1

CT Angiography Indications

Add CT-angiography of supra-aortic and intracranial vessels if any of these risk factors are present: 1, 4

• Cervical spine fracture
• Focal neurological deficit unexplained by brain imaging
• Claude Bernard-Horner syndrome
• LeFort II or III facial fractures
• Basal skull fractures
• Soft tissue neck lesions

Consider extending CT-angiography indications to the most severe patients even without these specific risk factors, particularly when neurological examination is limited 1

Follow-up Imaging Considerations

• If CT-angiography is normal but strong suspicion of arterial dissection persists, complete evaluation with MR-angiography or digital subtraction angiography 1
• MRI should be obtained when patient safety conditions allow for superior characterization of injuries, though CT remains the first-line modality due to availability 4

Critical Management During Diagnostic Phase

Airway and Ventilation Control

• Control ventilation through tracheal intubation and mechanical ventilation if GCS indicates severe TBI 1
• Monitor end-tidal CO2 continuously, targeting 30-35 mmHg initially before arterial blood gas confirmation 1

Hemodynamic Support

• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment, which have delayed effects 1
• Avoid hypotensive sedation agents and use continuous sedation rather than boluses 1

Transfer Planning

The primary care hospital must arrange immediate transfer to a specialized neurosurgical center after completing initial CT imaging and stabilization, as mortality is lower in neurosurgical centers even for patients not requiring surgery 1, 6

District Hospital Capabilities

While carefully selected severe TBI patients can be managed in district hospitals with intracranial pressure monitoring capability and neurosurgical consultation, this should only occur when transfer is not possible 6

Common Pitfalls to Avoid

• Never use permissive hypotension in patients with ongoing neurological impairment 4
• Do not delay CT imaging for any reason in patients with coma or abnormal neurological examination 1
• Avoid corticosteroids, as they provide no mortality or neurological outcome benefit in TBI 4
• Do not rely on GCS alone for complete characterization; document pupillary reactivity, loss of consciousness history, and post-traumatic amnesia duration separately 2