Traumatic Brain Injury: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps. Assessment after traumatic brain injury (TBI) is performed using the Glasgow Coma Scale. According to this, TBI can be classified as follows:

Craniocerebral Trauma (TBI) Glasgow Coma Scala Unconsciousness
Mild TBI 13-15 points up to 15 minutes
Moderately severe TBI 9-12 points up to one hour
Severe TBI 3-8 points > 1 hour

Glasgow Coma Scale, GCS). This contains the following criteria:

Criterion Score
Eye opening spontaneous 4
on request 3
on pain stimulus 2
no reaction 1
Verbal communication conversational, oriented 5
conversational, disoriented (confused) 4
incoherent words 3
unintelligible sounds 2
no verbal reaction 1
Motor response Follows prompts 6
Targeted pain defense 5
untargeted pain defense 4
on pain stimulus flexion synergisms 3
on pain stimulus stretching synergisms 2
No response to pain stimulus 1

Assessment

  • Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
  • If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
  • If GCS ≤ 8, intubation (“insertion of a hollow tube into the trachea”) and adequate ventilation must be provided. Note: In brain-injured patients, respiratory deterioration can be expected at any time. Ensuring the oxygen supply to the brain thus has the highest urgency.

TBI includes:

  • Scalp injuries,
  • Bony fractures (broken bones).
  • Dura injuries (dura: hard meninges; outermost meninges).
  • Intracranial lesions (injuries within the brain).

This is followed by a comprehensive physical and neurological examination:

  • General physical examination – including blood pressure, pulse, body weight, height; furthermore:
    • Inspection (viewing).
      • Head/skull [due topossible symptoms (grade 1): swelling, bleeding on skull].
      • Skin and mucous membranes [differential diagnostic signs: tongue bite/urination?]
      • Abdomen (abdomen)
        • Shape of the abdomen?
        • Skin color? Skin texture?
        • Efflorescences (skin changes)?
        • Pulsations? Bowel movements?
        • Visible vessels?
        • Scars? Hernias (fractures)?
    • Auscultation (listening) of the heart [due topossible symptom (grade 1): disturbances of heart rate].
    • Auscultation of the lungs [due topossible symptom (grade 1): disorders of respiration]
    • Palpation (palpation) of the abdomen (abdomen) (pressure pain?, knock pain?, cough pain?, defensive tension?, hernial orifices?, kidney bearing knock pain?) [due topossible symptoms (grade 1): nausea (nausea), vomiting].
  • If necessary, ENT medical examination [due topossible symptom (grade 1): hearing loss (hypacusis)].
  • Neurological examination – including checking reflexes, pupillary response and cranial nerve function [due topossible symptom (grade 1):
    • Amnesia (memory lapse).
    • Cephalgia (headache)
    • Seizure
    • Unconsciousness lasting a short time
    • Subsequent drowsiness and deceleration
    • Visual disturbances such as diplopia (double vision, double images).
    • Vertigo (dizziness)
    • Confusion (also instead of unconsciousness).

    due topossible symptoms (grade 2): neurological disorders such as reflex changes, pupil changes, paresis (paralysis)] [wg.Differential diagnoses (if no definite evidence of an accident exists):

    • Apoplexy (stroke)
    • Basilar artery thrombosis – occlusion of a basilar artery of the brainstem associated with severe neurologic damage.
    • Chronic subdural hematoma – hemorrhage between layers of the meninges that can lead to various neurological symptoms.
    • Coma vigile (akinetic mutism) – muteness with general inhibition of motor functions, which is mainly conditioned by psychiatric diseases or injuries/tumors of the brain
    • Epilepsy
    • Increased intracranial pressure
    • Brain abscess – encapsulated collection of pus in the brain.
    • Brain contusion (brain contusion)
    • Brain mass hemorrhage
    • Cerebral sinus thrombosis – occlusion of a venous cerebral blood duct.
    • Brainstem hemorrhage
    • Brainstem infarction
    • Meningoencephalitis – combined inflammation of the brain (encephalitis) and meninges (meningitis).
    • Subarachnoid hemorrhage – bleeding between the cobweb and the surface of the brain; in 75-80% of cases, the cause is an aneurysm (bulging of an artery)]
  • If necessary, urological examination [due todifferential diagnosis (if there is no definite evidence of an accidental event): coma uremicum (coma caused by uremia (occurrence of urinary substances in the blood above the normal values))]

Square brackets [ ] indicate possible pathological (pathological) physical findings.