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Referral and warning signs
When to refer
IMMEDIATE Referral to Hospital (H/NR) required for: Moderate or Severe TBI (GCS ≤ 13). Any deterioration in GCS. Signs of skull fracture (depressed, base of skull). Focal neurological deficits. Seizures following injury. Persistent vomiting. Penetrating head injury. High Risk Mild TBI (see UCG criteria p.58) usually requires observation and potentially CT - refer if CT needed/unavailable or if clinical worsening. Low Risk Mild TBI may be observed locally or discharged with strict instructions if reliable observer available.
Red flags
- GCS score < 14 or decreasing GCS
- Unequal or fixed dilated pupils
- Focal neurological deficit (e.g., limb weakness)
- Signs of skull base fracture (Battle's sign, raccoon eyes, CSF leak, hemotympanum)
- Palpable depressed skull fracture or penetrating injury
- Post-traumatic seizure
- Persistent vomiting
- Severe or worsening headache
Signs and symptoms
- Scalp Injury: Laceration, hematoma (swelling).
- Skull Fracture signs: Visible/palpable depression or deformity, open fracture (brain matter exposed), Battle's sign (bruising behind ear), Raccoon eyes (periorbital bruising), Hemotympanum (blood behind eardrum), CSF leak from nose (rhinorrhea) or ear (otorrhea).
- Brain Injury signs (depend on severity/location):
- - Mild (Concussion): Transient loss of consciousness (LOC) (<5 min), confusion, disorientation, amnesia (before/after event), headache, dizziness, nausea, vomiting, drowsiness. Symptoms typically improve within hours.
- - Moderate/Severe: Prolonged LOC, deteriorating level of consciousness (GCS score decreasing), agitation, seizures, focal neurological deficits (weakness, numbness, speech problems), pupil abnormalities (unequal size, non-reactive), abnormal posturing (decorticate/decerebrate), signs of increased intracranial pressure (ICP) (headache, vomiting, Cushing's triad: hypertension, bradycardia, irregular respirations - late sign).
Risk factors
- Road traffic accidents (most common severe cause).
- Falls (especially elderly and young children).
- Assaults / Violence.
- Sports injuries.
- Blast injuries.
- Factors increasing risk of complications: Age >65, bleeding disorders or anticoagulant use.
Diagnosis
Clinical assessment
Based on history of trauma mechanism and clinical assessment. Key elements: - Mechanism of Injury: High energy impact suggests higher risk. - Level of Consciousness: Assess using Glasgow Coma Scale (GCS) score (Eye opening, Verbal response, Motor response - total 3-15). Use AVPU scale (Alert, Voice, Pain, Unresponsive) for rapid assessment/children. - Neurological Examination: Pupil size/reactivity, focal deficits, reflexes. - Examination for Skull Fracture Signs. - Assess for Associated Injuries (especially cervical spine, chest, abdomen in polytrauma). Severity Classification (based on GCS): - Mild: GCS 14-15. - Moderate: GCS 9-13. - Severe: GCS 3-8. Risk Stratification for Mild Head Injury (UCG p.58): Differentiate Low Risk vs High Risk based on GCS at 2h, LOC/amnesia duration, vomiting, fracture signs, age, mechanism, comorbidities (determines observation/discharge plan).
Investigations
- CT Scan (Head): Gold standard imaging for detecting intracranial hemorrhage (epidural, subdural, subarachnoid, intracerebral), contusions, edema, skull fractures. Indications: Moderate/Severe TBI (GCS <14), signs of skull fracture, focal neurological deficit, seizures, persistent vomiting, deteriorating GCS, anticoagulant use, dangerous mechanism, prolonged LOC/amnesia, age >65 (lower threshold).
- Skull X-ray: Limited utility, mainly detects linear/depressed fractures but doesn't show brain injury. CT preferred if available.
- Cervical Spine Imaging (X-ray or CT): Essential if neck pain/tenderness, neurological deficit, significant trauma mechanism, or altered mental status preventing reliable neck exam.
- Blood Glucose: Rule out hypoglycemia.
- Consider: Coagulation studies (if on anticoagulants), BAC/Toxicology screen (if suspected).
Diagnostic criteria
Clinical assessment of GCS score and neurological findings following head trauma. CT scan findings confirm nature and extent of intracranial injury.
Management
Non-pharmacological management
- Initial Stabilization (ABCDE): Airway management with C-spine protection is paramount. Assume C-spine injury until cleared. Maintain patent airway (jaw thrust, adjuncts), provide high-flow oxygen. Intubation may be needed for GCS ≤ 8, inability to protect airway, or respiratory insufficiency.
- Breathing: Ensure adequate ventilation and oxygenation (target SpO2 >90-94%). Avoid hyper/hypoventilation unless managing acute herniation.
- Circulation: Treat hypotension aggressively with IV fluids (isotonic crystalloids) to maintain Systolic BP >90-100 mmHg (avoid hypotension, which worsens outcome). Control external hemorrhage.
- Disability: Assess GCS, pupils frequently. Treat hypoglycemia.
- Exposure: Prevent hypothermia.
- Positioning: Elevate head of bed to 30 degrees (if no shock/hypotension) to help reduce ICP.
- Neurological Monitoring: Frequent assessment of GCS, pupil size/reactivity, focal deficits. Report any deterioration immediately.
- Seizure Precautions/Management: Treat seizures promptly with benzodiazepines (Diazepam/Lorazepam). Prophylactic anticonvulsants may be considered in severe TBI (Hospital decision).
- Scalp Laceration Management: Clean, explore for underlying fracture, suture if appropriate (unless over suspected open/depressed fracture).
Pharmacological treatment
- Analgesia: Paracetamol for mild pain. Opioids (use cautiously, avoid if respiratory compromise or obscuring neuro assessment) for severe pain.
- Sedation: Use cautiously ONLY if necessary (e.g., agitation interfering with care/ventilation). Short-acting agents preferred. DO NOT SEDATE routinely as it masks neurological changes.
- Avoid NSAIDs initially due to potential bleeding risk.
- Management of Increased ICP (Hospital/Specialist level): Mannitol or Hypertonic Saline IV, controlled hyperventilation (temporary measure), barbiturate coma, surgical decompression (craniotomy, hematoma evacuation).
- Antibiotics: For open skull fractures or penetrating injuries (e.g., Ceftriaxone 2g IV - Adult; 100mg/kg - Child).
- Tetanus Prophylaxis: If open wound.
Monitoring
Continuous or frequent monitoring of: GCS, Pupil size and reactivity, Vital signs (HR, BP, RR, SpO2, Temp). Monitor for signs of neurological deterioration (decreased GCS, new focal deficit, pupil changes). Monitor for seizures. Monitor ICP if available (ICU setting).
Complications
- Intracranial hemorrhage (epidural, subdural, subarachnoid, intracerebral)
- Cerebral edema / Increased Intracranial Pressure (ICP)
- Brain herniation
- Seizures (early or late onset)
- Hydrocephalus
- Meningitis (esp. with skull base fracture/CSF leak, open fracture)
- CSF leak
- Cranial nerve injuries
- Long-term cognitive, behavioral, physical deficits
- Post-concussion syndrome (headache, dizziness, fatigue, irritability, concentration difficulty)
- Death
Prevention
- Road safety: Seat belts, helmets (motorcycles, bicycles), speed limits, avoid drink-driving.
- Fall prevention: Especially in elderly.
- Use of protective headgear in sports and hazardous occupations.
- Violence prevention.
Patient education
- For Mild TBI discharged home: Provide clear head injury advice sheet. Instruct caregiver to monitor closely for 24-48h. List specific warning signs (Red Flags) requiring immediate return (worsening headache, vomiting, confusion, drowsiness, seizure, weakness, visual changes). Advise rest, avoid alcohol/sedatives, gradual return to activity.
- For Moderate/Severe TBI: Explain seriousness of injury, need for admission/monitoring/investigations (CT). Discuss potential complications and management plan.
- Explain importance of C-spine precautions if relevant.
Uganda-specific notes
Road traffic accidents are a leading cause. CT scanners are limited to referral hospitals. GCS assessment is paramount for triage and monitoring. Early recognition of deterioration and prompt referral are crucial. Management of severe TBI often relies on basic supportive care (airway, oxygenation, maintain BP) due to limited ICU/neurosurgical capacity. Avoid routine sedation. Always consider C-spine injury.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Section 1.2.5 (including GCS and Mild TBI risk criteria)