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Traumatic brain injury (TBI) is the impairment in brain function after direct or indirect forces to the brain. The force of an object striking the head or a penetrating injury causes direct injury. Indirect injuries occur from acceleration/deceleration forces that result in the movement of the brain within the skull.
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TBI can be classified as mild, moderate, and severe. Mild TBI includes patients with a Glasgow Coma Scale (GCS, see Table 160-1) score ≥14. Patients may be asymptomatic with only a history of head trauma, or may be confused and amnestic of the event. They may have experienced a brief loss of consciousness and complain of a diffuse headache, nausea, and vomiting. Patients at high risk in this subgroup include those with a skull fracture, large subgaleal swelling, focal neurologic findings, coagulopathy, age >60 years, or drug/alcohol intoxication.
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Moderate TBI include patients with a GCS score of 9 to 13. Overall, 40% of these patients have a positive CT scan and 8% require neurosurgical intervention.
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The mortality of severe TBI (GCS score <9) approaches 40%. The immediate clinical priority in these patients is to prevent secondary brain injury, identify other life-threatening injuries, and identify treatable neurosurgical conditions.
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Prehospital medical personnel often may provide critical parts of the history, including mechanism and time of injury, presence and length of unconsciousness, initial mental status, seizure activity, vomiting, verbalization, and movement of extremities. For an unresponsive patient, contact family and friends to gather key information including past medical history; medications (especially anticoagulants); and recent use of alcohol or drugs.
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Clinically important features of the neurologic examination that should be addressed include assessing the mental status and GCS; pupils for size, ...