Always attempt to identify the exact mechanism of injury, as this may predict the severity of damage to the central nervous system (CNS). For example, clarify the height of a fall, the speed of a motor vehicle collision (MVC), or the use of seatbelt restraints or airbag deployment. Emergency medical service personal can be invaluable in this setting. Inquire about any loss of consciousness, as this may portend more significant injury. The antecedent use of alcohol or illicit drugs may complicate the neurologic assessment, and their influence should be documented. Ask about the use of any prescription or over-the-counter medications, as anticoagulants can induce life-threatening bleeding despite only minor injury. Finally, look for any signs and symptoms suggestive of increased ICP (altered mental status, vomiting, headache), as this will require emergent neurosurgical intervention.
As with all trauma patients, begin with a rapid primary survey, and aggressively address any emergent life threats. Carefully note vital signs, as they can predict the likelihood of secondary brain injury. Cushing reflex, defined as progressive hypertension, bradycardia, and a decreased respiratory rate, is frequently indicative of a potentially life-threatening increase in ICP.
A gross inspection of the scalp may reveal gaping lacerations or obvious cranial deformities. Carefully inspect all deep lacerations for violation of the galea, as disruption of this tough layer of connective tissue mandates careful primary closure. Palpate the skull to detect step-off deformities indicative of underlying fracture. Examine the eyes and the ears for any signs of injury. Battle sign (retroauricular ecchymosis), raccoon eyes (periorbital ecchymosis), hemotympanum, and CSF rhinorrhea or otorrhea are all signs of an underlying basilar skull fracture (Figure 85-2). Carefully palpate the cervical spine and always assume an occult C-spine injury until proven otherwise.
“Raccoon eyes” suggestive of a basilar skull fracture.
Perform a comprehensive neurologic exam to identify any findings suggestive of significant injury. Examine the pupils, taking care to note size, symmetry, and reactivity. A dilated unresponsive pupil in the setting of cranial trauma indicates transtentorial herniation until proven otherwise. Document an initial GCS and repeat frequently to detect any signs of decompensation. The uncoordinated flexion (decorticate) or extension (decerebrate) of one's upper extremities on painful stimulation indicates severe intracranial injury with possible brainstem compromise.