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