Background Information

Glasgow Coma Scale (GCS)

GCS Components

GCS Interpretation

GCS ranges from 3-15 (3 being the worst and 15 being the best).

• Mild TBI: GCS 13-15
• Moderate TBI: 9-12
• Severe TBI: 3-8

Guidelines

Assessment and Management in the Emergency Department

Important GCS considerations

• GCS ≤8 → intubation often required to protect the airway
• GCS ≤12 + no suspected extracranial bleeding → consider tranexamic acid
  • 2g IV bolus in adults
  • To be given within 2 hours of the injury

Investigation and Diagnosis

Primary investigation of choice: non-contrast head CT

Criteria for CT within 1 hour

ANY of the following:

• GCS ≤12 on initial assessment
• GCS <15 at 2 hours after injury
• Suspected open / depressed skull fracture
• Signs of basal skull fracture (haemotympanum, panda eyes, CSF leakage from the nose / ear, Battle’s sign)
• Post-traumatic seizure
• Focal neurological deficit
• >1 vomiting episode

Criteria for CT within 8 hours

Presence of loss of consciousness / amnesia after the injury + any of the following:

• ≥65 y/o
• Presence of clotting / bleeding disorders
• Dangerous mechanism of injury
• >30 min retrograde amnesia

If patients present >8 hours after the injury, perform the head CT within 1 hour.

Patient Taking Anticoagulant / Antiplatelet – excluding aspirin monotherapy

In the absence of other indications → CT head within 8 hours (or within 1 hour if presented >8 hours).

Admission and Observation

Admission Criteria

• New clinically important abnormalities on imaging (an isolated simple linear non-displaced skull fracture is unlikely to be a clinically important abnormality unless they are taking anticoagulant or antiplatelet medication)
• GCS score not returned to baseline / 15 following imaging
• CT scanning indicated but cannot be done within the appropriate time period
• Continuing worrying symptoms (e.g. persistent vomiting, severe headaches or seizures)
• Other sources of concern to the clinician (e.g. drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak, or suspicion of ongoing post-traumatic amnesia).

Inpatient Observation

Documented neurological observations should include;

• GCS score
• Pupil size and reactivity
• Limb movements
• Heart rate and blood pressure
• Respiratory rate and blood oxygen saturation
• Temperature

Observation frequency:

• Half-hourly until GCS of 15
• Once GCS is 15
  • Half-hourly for 2 hours, then
  • 1 hourly for 4 hours, then
  • 2 hourly

References

Original Guidelines