injuries poisoning
Traumatic Brain Injury (TBI)
Key Points
TBI can cause a wide variety of neurologic symptoms, sometimes even in the absence of detectable structural brain damage on imaging studies. Follow initial assessment (trauma assessment and stabilization, GCS scoring, rapid and focused neurologic examination) with a more detailed neurologic examination when the patient is stable. Obtain neuroimaging (usually CT) acutely if patients have more than transiently impaired consciousness, GCS score < 15, focal neurologic findings, persistent vomiting, seizures, a history of loss of consciousness, clinically suspected fractures, or possibly other findings. Discharge most patients home if TBI is mild; they can be observed at home if neuroimaging is normal or not indicated and neurologic examination is normal. Admit patients with severe TBI to a critical care unit, and to avoid secondary brain insult, treat them aggressively to maintain adequate ventilation, oxygenation, and brain perfusion. Treat increased ICP usually with rapid sequence intubation, ICP monitoring, sedation, maintenance of euvolemia and normal serum osmolality, and sometimes surgical interventions (eg, CSF drainage, decompressive craniotomy). Treat some lesions surgically (eg, large or arterial epidural hematomas, intracranial hematomas with midline brain shift of > 5 mm, compression of the basal cisterns, worsening neurologic examination findings). 