This guide summarises the essential information clinicians need when providing initial treatments to someone with a traumatic brain injury.
For paediatric patients, refer to the head injury clinical practice guide (Royal Children's Hospital)
On this page:
- Definitions
- Initial assessment
- Critical care priorities
- Signs of acute deterioration
- Managing acute deterioration
- When to consult or transfer to a neurological service
Definitions
A traumatic brain injury (TBI) is graded using the patient's initial Glasgow Coma Scale (GCS) score upon arrival at a healthcare facility following an impact or force applied to the head or body.
| Initial GCS score | TBI | Proportion of patients |
|---|---|---|
| 13–15 | Mild | 80% |
| 9–12 | Moderate | 10% |
| 3–8 | Severe | 10% |
Initial assessment
Start with initial assessment and stabilisation of ABCDEs.
Assessment tools
Critical care priorities
- Prevent secondary brain injury (maintain ABCs)
- Provide early neurosurgical consultation, when indicated
- Provide timely definitive neurosurgical care
- Facilitate early transfer to a neurosurgical centre, when indicated
- Perform early CT scan for moderate to severe TBI and mild TBI with risk factors
- Monitor, with minimum hourly neurological observations until stable
- Maintain physiological targets
- Avoid rises in intracranial pressure (ICP)
Mild head injury (GCS 13–15)
- Perform initial assessment followed by a period of clinical observation to detect risk factors for significant intracranial injury. CT scan not routinely indicated unless one or more risk factors are present.
- Consider hospital admission and consult network neurosurgical service if abnormal CT scan.
- Consider hospital admission for observation if:
- clinically not improving at 4 hours post injury irrespective of CT scan result
- elderly, known coagulopathy or socially isolated.
- Conduct post-traumatic amnesia testing with A-WPTAS.
- Advise patients to see their local doctor if they do not return to normal within 48 hours so they can be reassessed and monitored for post-concussive symptoms.
- Consider domestic abuse risk before discharge.
- Discharge for home observation with brain injury patient fact sheet at 4–6 hours post injury if clinically improving and either no risk factors indicating CT scan or normal CT.
- Re-presentation of patients with persisting post-concussive symptoms may require specialist assessment and management according to the nature of their symptoms.
Moderate head injury (GCS 9–12)
- Provide supportive care of ABCDEs.
- Prevent secondary brain injury by avoiding hypoxaemia and hypotension.
- Perform early CT scan.
- Maintain clinical observation.
- Consider intubation in the event of clinical deterioration or to facilitate management.
- Facilitate early neurosurgical consult if not clinically improving and/or abnormal CT scan.
- Facilitate early retrieval consult if transfer required.
- Admit to hospital for prolonged observation unless rapid clinical improvement to GCS 15, normal CT scan and absence of other risk factors (as per mild head injury).
- Maintain routine post-traumatic amnesia testing (Westmead PTA Scale).
Severe head injury (GCS 3–8)
- Provide supportive care of ABCDEs.
- Prevent secondary brain injury by avoiding hypoxaemia and hypotension.
- Perform early intubation and ventilation.
- Perform early CT scan.
- Facilitate early neurosurgical consult.
- Facilitate early retrieval consult if transfer required.
- Consider analgesia and sedation to avoid spikes in ICP.
- Consider use of anticonvulsants.
- Consider anticoagulant reversal if applicable.
- Consider ICP monitoring within 24 hours.
- Admit to intensive care unit (ICU).
- Maintain routine post-traumatic amnesia testing (Westmead PTA Scale).
Signs of acute deterioration
Early signs
- Confusion
- Agitation
- Drowsiness
- Vomiting
- Severe headache
Late signs
- Decrease in GCS by 2 or more points
- Dilated pupil(s)
- Focal neurological deficit
- Seizure
- Cushing’s response – bradycardia and hypertension
Managing acute deterioration
- Resuscitate ABCDEs and exclude non-head injury cause.
- Intubate early, if indicated.
- Perform CT scan immediately.
- If clinical or CT evidence of raised ICP/mass effect, consult with network neurosurgical and retrieval services about:
- short-term hyperventilation to PaCO2 30–35
- bolus of mannitol or hypertonic saline
- local burr holes/craniotomy > 2 hours from neurosurgical care
- prophylactic anticonvulsants.
- Maintain physiological targets.
More about managing deterioration in a non-neurosurgical facility
When to consult or transfer to a neurosurgical service
Consider discussing ceilings of care with senior medical staff and family, especially for people with advanced age, multiple comorbidities or where the patient is unlikely to survive due to injury profile.
Mild (GCS 13–15)
It is unlikely that patients with mild head injury will need transfer.
Consult and consider transfer to a neurosurgical service if any of the following apply:
- Clinical deterioration, e.g. worsening headache, vomiting, confusion
- Abnormal CT scan, e.g. contusion, haemorrhage
- Normal CT scan but persistent symptoms beyond 4–6 hours post-injury
- CT scan unavailable, especially if any of the following are present:
- Persistent GCS < 15
- Decline in GCS
- Focal neurological deficit
- Clinical suspicion of skull fracture
- Persistent abnormal mental status
- Repeated vomiting
- Severe headache
- Known coagulopathy (especially if age > 65 or INR > 4)
Unsure?
Consult your neurological service early for borderline or uncertain cases, where benefit depends on:
- clinical progression
- CT findings
- overall physiological status
- patient values and goals of care.
Actions
- If neurosurgical transfer is required, engage the retrieval service early and include all relevant parties in a single coordinated phone call whenever possible.
- Facilitate a multidisciplinary discussion with family, treating team and network neurosurgeon.
- Consider goals of care and patient/family wishes.
Moderate (GCS 9–12)
Consult and consider transfer to a neurosurgical service if any of the following apply:
- Not clinically improving
- Clinical deterioration, e.g. drop in GCS, new focal neurological signs
- Abnormal CT scan, e.g. intracranial haemorrhage, midline shift, skull fracture
- Normal CT scan but no clinical improvement within 4–6 hours
- CT scan unavailable
Moderate TBI patients who do not require neurosurgical transfer may still need care in a large centre, such as a regional trauma centre, for ongoing observation, assessment and timely escalation if deterioration occurs
Unsure?
Consult your neurological service early for borderline or uncertain cases, where benefit depends on:
- clinical progression
- CT findings
- overall physiological status
- patient values and goals of care.
Actions
- If neurosurgical transfer is required, engage the retrieval service early and include all relevant parties in a single coordinated phone call whenever possible.
- Facilitate a multidisciplinary discussion with family, treating team and network neurosurgeon.
- Consider goals of care and patient/family wishes.
Severe (GCS 3–8)
Nearly all patients with severe TBI need to be transferred.
Actions
- Immediate neurosurgical referral and intervention planning. This includes early consultation with your neurosurgical network and retrieval service.
- Consider onsite surgical decompression for epidural or subdural haematoma in a regional centre for critically deteriorating patients if transfer time > 2 hours to a neurosurgical service. Consult your neurosurgical service about these options.
When not to transfer
Consider not transferring and discussing ceilings of care with senior medical staff and family, especially:
- for people of advanced age
- for people with multiple comorbidities
- where the patient is unlikely to survive transfer or neurosurgical treatment (discuss with your neurosurgical service):
- catastrophic, non-survivable injuries
- severe or multiple comorbidities with no meaningful expected benefit
- high frailty score (use frailty calculator).
Critical information for the neurosurgical consultant
What to do when a transfer is required