NEUROLOGIC ASSESSMENT

Goal: Rapidly identify the clinical signs and symptoms of TBI and associated traumatic injuries and assess TBI severity.

Track the progression of brain injury over time and be vigilant for the early signs of rising ICP: worsening headache, focal neurologic deficits, and declining neurologic examination.

- Primary survey: Perform a rapid trauma survey to assess all injuries. Determine and record the Glasgow Coma Scale (GCS) score (Table 1 below). Assess pupils and motor function in all four extremities.
- Secondary survey: After stabilizing any immediate life-threatening injuries, assess for TBI red flags that may indicate moderate to severe head injury (Table 2 below), and perform an initial detailed neurologic examination. See Appendix A for further details on performing a neurologic examination. Annotate findings on the PFC flowsheet.
- TBI severity classification using the GCS score4:
  - Mild: 13–15
  - Moderate: 9–12
  - Severe: 3–8

Neurologic Assessment Note

An emerging technology that can be considered as an adjunct to neurologic assessment is ultrasound measurement of optic nerve sheath diameter (ONSD). If the patient is unconscious (i.e. does not follow commands or open eyes spontaneously), measure a baseline ONSD. There is no definite diameter that is diagnostic of increased ICP; however, an ONSD >5.2mm, especially if it increases over time, may indicate elevated ICP.5 In no circumstance should measurement of ONSD take priority over a neurologic examination, and all results must be considered in the context of the neurologic examination and overall patient status. See Appendix B for further details on using ultrasound to obtain and interpret ONSDs.

ONSD should NOT be attempted in any patient who has sustained an open globe injury where any pressure on the globe is contraindicated. As many as 30% of head injuries in combat may also have an eye injury.6