History

Event and mechanism

Injury context

Symptoms and course

Symptom evolution

OPQRST headache

Onset

Provocation and palliation

Quality

Region and radiation

Severity

Timing

Prior episodes and baseline

Baseline function

Alarm Features

Immediate escalation triggers

Resuscitation triggers

High risk historical features

High risk history

High risk exam findings

High risk exam

Vital sign danger thresholds

Concerning vitals

Medications

Current medications and exposures

Medication list

Bleeding and sedation relevant agents

High risk medication classes

Medication interactions and cautions

ED medication cautions

Diet

Intake and hydration

Intake status

Relevant exposures

Exposures

Review of Systems

Neurologic and cognitive

Neurologic symptoms

GI and systemic

Systemic symptoms

Injury survey symptoms

Other injury symptoms

Collateral History and Family History

Collateral source and reliability

Collateral

Family history and inherited risks

Family history

Safety and maltreatment context

Non accidental trauma concern

Risk Factors

Patient factors increasing ciTBI risk

Pediatric risk modifiers

Bleeding and anticoagulation risks

Hemorrhage risks

Environmental and mechanism risks

Mechanism risks

Differential Diagnosis

Life threatening

Cannot miss diagnoses

Common

Common diagnoses

Less common

Less common and mimics

Past Medical History

Relevant conditions

Chronic conditions

Procedures and devices

Baseline function and supports

Baseline and supports

Physical Exam

Initial impression and vitals

General assessment

Neurologic exam

Head and neck exam

Head and neck findings

Cervical spine and trauma survey

Trauma survey

Lab Studies

Labs when indicated

Targeted labs

Interpretation and limitations

Pitfalls

Imaging

Scoring Systems

Decision instruments for CT avoidance and observation

MRI

MRI options

CT

CT head non contrast

Ultrasound

Point of care ultrasound

Special Tests

Observation and serial exams

ED observation pathway

Concussion focused tools

Concussion assessment tools

Child maltreatment evaluation

Abusive head trauma workup triggers

ECG

Indications when mechanism unclear

ECG indications

High risk patterns

ECG red flags

Assessment

Working diagnosis and risk level

Problem representation

Complications to exclude

Complications

Supporting features and uncertainty

Key data synthesis

Plan

First 5 minutes

Early workflow

Imaging and observation decision pathway

PECARN based pathway

Symptom control

Medications

Reassessment loop

Reassessment timing

Consultation and safeguarding

Consult triggers

Disposition

Admission and higher level care

Admit criteria

Observation pathway

ED or short stay observation

Discharge criteria

Discharge requirements

Discharge Instructions

Copy discharge instructions

Home care summary

Medicines

Return to the emergency department now for

Follow up

References

Guidelines and landmark evidence

Core sources