Chapter 3.

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THE DIAGNOSTIC ALGORITHM AT HOSPITAL

Note:
Procedures during admission of a TBI casualty to hospital and in ICU are described. All from the standpoint of a treating physician co-ordinating diagnostical and therapeutical measures.

Contents:
3.1.: Assessment of vital functions
3.2.: Extracranial injuries
3.3.: Neuroradiological diagnosis
3.4.: Cerebral concussion
3.5.: Cerebral contusion with GCS 8 or less as single trauma

STANDARD 3.1: ASSESSMENT OF VITAL FUNCTIONS Hvezdicka.GIF (147 bytes)

On admission, verify whether the vital functions of the casualty have been ensured. Together with the emergency care physician identify trends in consciousness, breathing, and blood circulation. Also, assess the effect of therapy given prior to admission to hospital.

STANDARD 3.2: EXTRACRANIAL INJURIES Hvezdicka.GIF (147 bytes)

Examine the casualty for all possible extracranial injuries inferred from the mechanism of injury. Use the Champion Trauma Scale and the Glasgow Coma Scale. If the victim is in hypovolemic shock, injury to the abdomen and/or thorax should be taken into consideration. Determine whether you are dealing with single, associated or multiple trauma.

STANDARD 3.3: NEURORADIOLOGICAL DIAGNOSIS Hvezdicka.GIF (147 bytes)

X-rays of the head, cervical spine, chest, pelvis or other organs are indicated depending on the mechanism of injury and clinical assessment. Scanning is performed if the vital functions are fully stabilized. The basic method for the diagnosis of TBI is computed tomography (CT). Urgent surgical treatment of life-threatening injuries to the chest, abdomen, or vessels is a priority to scanning.

For open head injuries associated with skull fractures head CT scan should always be performed on admission. For closed head injuries, head CT scan is indicated depending on the level of consciousness:
1. For TBI casualties with GCS between 3 and 8, head CT scanning should be performed as early as possible (after stabilization of the vital functions and transport). The patient shold be accompanied by the physician during transport and the actual scanning.
2. For TBI casualties with GCS between 9 and 12, we indicate head CT scanning if compression of the brain by hematoma is suspected.
3. For TBI casualties with GCS between 13 and 15 admitted to hospital for observation, we do not perform head CT scanning. However, if a change in level of consciousness is monitored, we indicate head CT to rule out post-traumatic intracranial lesions.

STANDARD 3.4: CEREBRAL CONCUSSION Hvezdicka.GIF (147 bytes)

The diagnosis of cerebral concussion is established from history (head injury, transient loss of consciousness, retrograde amnesia). Neurological assessment is normal. Vegetative symptoms may be present. Close observation for at least 24 hours is recommended.

STANDARD 3.5.: CEREBRAL CONTUSION WITH GCS 8 OR LESS AS SINGLE TRAUMA Hvezdicka.GIF (147 bytes)

After ensuring the vital functions of the patient and determining TBI as single trauma, we perform a complete neurological assessment in ICU.

For casualties with severe brain injuries, we recommend that algosedation and skeletal muscle relaxation which has been established during pre-hospital care should not be discontinued immediately on admission because of possible intracranial hypertension.

Commentaries:
3.5.1. Neurological examination timing
3.5.2. The role of neurologist during emergency admission of a patient in hospital  

Coordinated by Vit MARECEK, M.D.

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Last updated: 2000-08-04