■ Motor exam: To assess for focal neurologic deficits or posturing
■ Decorticate posturing: Abnormal flexion of the upper extremities
(“clutch the cortex”), extension of lower extremities
■ Decerebrate posturing: Extension/adduction and internal rotation of
arms and legs with flexion of wrist, fingers, feet (plantar), and toes
■ Brainstem exam: Via evaluation of respiratory pattern, papillary size, and
eye movements
■ Oculocephalic response(pontine gaze centers): “Doll’s eyes” response
with eyes moving in direction opposite of head turning (once C-spine
is cleared) indicates intact brainstem function in the comatose patient.
■ Oculovestibular response: Instillation of 30 mL ice-cold saline into
the ear; nystagmus with fast component away from indicates intact
brainstem function.DIAGNOSIS
■ CT scan without contrast is the diagnostic test of choice. CT anyone with a
change in mental status. Have a low threshold for head CT in patients who
are elderly or have coagulopathy, vomiting, or have persistent headaches.
■ For children < 2 years old, head CT is appropriate in the presence of:
■ Focal neurologic abnormality
■ Altered mental status
■ Any scalp trauma (laceration/ecchymosis/contusion/abrasion)
■ VomitingTREATMENT
■ Patients with findings or suspicion of head injury warrant aggressive man-
agement to prevent secondary brain injury.
■ Ensure adequate oxygenation and ventilation.
■ Intubate if GCS ≤8 or presence of intracranial injury by CT.
■ Elevate head of bed to 30°.
■ Aggressively treat hypotension with fluids or blood transfusion to maintain
SBP≥90 mmHg.TRAUMA
TABLE 3.3. Categorization of Traumatic Brain Injury (TBI)TBI SEVERITY MILDTBI MODERATETBI SEVERETBIGCS 14–15 9–13 < 9Risk for injury Low Moderate High High HighNo LOC LOC Skull fracture
No/mild HA Amnesia Neuro deficit
Normal exam Vomiting High-risk patient
Diffuse HAHead CT required? No Yes Yes Yes Yes
Incidence of surgical 0.1% 1–3% Up to 10% 8%
interventionMortality 20% 60%Cushing reflex: Hypertension,
bradycardia, and irregular
respirations