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Evaluation of Head Injury


Algorithm: Evaluation of head injury

Must-Know Essentials: Evaluation of Head Injury

Glasgow Coma Scale (GCS)

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    Best eye-opening response

Score
■ Spontaneous 4
■ To speech 3
■ To pain 2
■ None 1
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    Best verbal response

■ Oriented 5
■ Confused conversation 4
■ Inappropriate words 3
■ Incomprehensible 2
■ None 1
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    Best motor response

■ Obeys commands 6
■ Localizes pain 5
■ Flexion withdrawal to pain 4
■ Abnormal flexion (decorticate) includes: 3
■ Internal rotation of shoulder
■ Flexion of forearm and wrist with clenched fist
■ Leg extension
■ Planter flexion of foot
■ Extension (decerebrate) includes: 2
■ Adduction of arms
■ Internal rotation of shoulders
■ Pronation of forearms and extension at elbow
■ Flexion of wrist and fingers
■ Leg extension
■ Planter flexion of foot
■ None (flaccid) 1

Grading of Traumatic Brain Injury (Tbi) Based on GCS

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    Mild TBI

GCS Score: 13–15
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    Moderate TBI

GCS Score: 9–12
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    Severe TBI:

GCS Score: 3–8

Full Outline of Unresponsiveness (Four) Score

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    Useful scoring system for assessing consciousness in intubated trauma patients where components of GCS cannot be assessed

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    Has a good correlation with GCS

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    Uses four domains of neurological function:

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      Eye responses

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      Motor responses

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      Brainstem reflexes

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      Breathing pattern

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    Each point increase in FOUR score is associated with decrease in morbidity and mortality.

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    Any decrease in these scores is associated with worsening consciousness as well as ICP.

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    (E) Eye response

Score
■ Eyelids open or opened; tracking or blinking to command 4
■ Eye lids open but not tracking 3
■ Eyelids closed but open to loud voice 2
■ Eyelids closed but open to pain 1
■ Eyelids remain closed to pain 0
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    (M) Motor response

Score
■ Follows commands (thumbs-ups, fist, or peace sign) 4
■ Localizes pain 3
■ Flexion response to pain 2
■ Extension response to pain 1
■ No response to pain or generalized myoclonus status 0
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    (B) Brainstem reflexes

Score
■ Pupillary and corneal reflexes present 4
■ One pupil wide and fixed to light 3
■ Pupillary or corneal reflexes absent 2
■ Pupillary and corneal reflexes absent 1
■ Pupillary, corneal, and cough reflexes absent 0
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    (R) Respiration

Score
■ Not intubated; regular breathing pattern 4
■ Not intubated; Cheyne-Stokes breathing pattern 3
■ Not intubated; irregular breathing pattern 2
■ Intubated (endotracheal or tracheostomy tube); breathing faster than ventilator rate 1
■ Breathing at ventilator rate or is apneic 0

Types of Brain Injury

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    Primary brain injury

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      Injury at the time of impact

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    Secondary brain injury

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      Progression of brain injury due to:

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        hypotension (systolic blood pressure [SBP] <90 mm Hg).

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        hypoxia (PaO 2 <60 mm Hg, and oxygen saturation <90%).

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        cerebral edema.

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        intracranial hypertension.

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    Diffuse axonal injury

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      Associated with rotational head motion, referred to as “shearing” brain injury

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      Commonly causes coma

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      Microscopic examination of the brain reveals swollen and disconnected axons, which is a gold standard for the diagnosis.

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      Computerized tomography (CT) scan has limited value in diagnosis and may show multiple petechial foci of hemorrhage.

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      MRI is more helpful in the diagnosis.

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    Brain contusion

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      Focal injury resulting in damage of capillary or other tissue components (glial cells, nerve cells, etc.)

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      CT reveals a hemorrhagic core surrounded by low-density edema.

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