Goal: Prevent secondary brain injury by maintaining adequate oxygenation and ventilation, avoiding hypotension, observing for signs and symptoms of elevated ICP, and trending the response to resuscitation. Detect changes in vital signs and neurologic examination as early as possible.

- Minimum: Blood pressure cuff, stethoscope, pulse oximeter, method to monitor urine output. If an advanced airway is in place, monitor EtCO2 with capnometer. Check pupillary response and GCS as often as possible. Document vital signs, GCS score, and urine output on the PFC Casualty Card available at https://prolongedfieldcare.org.
- Best: Portable monitor providing continuous vital signs display, Foley catheter to monitor urine output. If an advanced airway is in place, monitor end-tidal carbon dioxide (EtCO2) with capnography. Check pupillary response and GCS score every hour. Document vital signs, GCS, and urine output on the PFC Casualty Card available at https://prolongedfieldcare.org.

Assessment and Monitoring Notes

- Perform an initial assessment according to TCCC/MARCH (Massive hemorrhage, Airway, Respirations, Circulation, Head injury/Hypothermia) algorithms.
- Severe head injury is associated with additional trauma in 60% of patients.7
- If ONSD is used to evaluate for increased ICP and response of ICP to interventions, repeated ultrasound examinations should be performed if there is any change in neurologic examination and at regular intervals (30 minutes) after performing ICP-lowering interventions.
- When possible, a pocket ophthalmoscope can be used to assess for the presence or absence of spontaneous venous pulsations (SVPs). SVPs are only present when ICP is normal. Visualization of SVPs can reassure the provider that ICP is not critically elevated.8 See Appendix C for additional information on the rapid assessment of SVPs.
- Consider early C-spine immobilization. The incidence of concomitant brain and spinal cord injury in trauma ranges from 25% to 60%, with motor vehicle crashes and falls having the highest incidence of co-occurence.9 Ensure the cervical collar does not compress the jugular veins in the neck, because that could worsen ICP.
- The neurologic examination is essential to identify deterioration in a TBI patient. Treat for elevated ICP for any deterioration in neurologic examination findings.
- Pain medication and sedation are usually required for TBI patients; however, these medications also make it difficult to follow the neurologic examination.
- Obtain a telemedicine consultation if possible. If in doubt, treat for elevated ICP according to ICP management outlined in the next section.
- Close control of EtCO2 is critical for severe TBI patients. Plan and ensure the capability to monitor EtCO2 is available whenever advanced airway is placed. Goal EtCO2 is 35-45mmHg.

Cushing’s triad (i.e., increased SBP and/or widening pulse pressure, bradycardia, and irregular respirations) is a physiologic response that can occur with elevated ICPs, resulting in medullary compression. It is a late finding of severe brain injury with brainstem herniation. Cushing’s triad should be viewed as a sign of cerebral herniation and addressed immediately when recognized (see ICP Management).