Mimics and contributors to depressed consciousness
Nontraumatic or mixed etiologies
Toxicologic
Alcohol intoxication (F10.129)
Opioid intoxication (T40.2)
Sedative hypnotic intoxication (T42)
Metabolic
Hypoglycemia (E16.2)
Hyperglycemic crisis (E10.10, E11.10)
Hyponatremia (E87.1)
Hypercapnia
Neurologic emergencies
Status epilepticus (G40.901)
Ischemic stroke (I63)
Intracerebral hemorrhage (I61)
Meningitis or encephalitis (G00, G04)
Shock states
Hemorrhagic shock (R57.1)
Sepsis (A41.9)
Cardiogenic shock (R57.0)
Laboratory Tests
Core trauma and neurocritical labs
Immediate lab panel
Hematology
Complete blood count for anemia and platelet count
Platelet count threshold considerations
Chemistry
Sodium for osmotherapy planning
Potassium for arrhythmia risk
Creatinine for contrast and medication dosing
Serum osmolality when using hyperosmolar therapy
Glucose
Point-of-care glucose
Target range 6 to 10 mmol/L
Coagulation
INR for warfarin effect
aPTT for heparin effect
Fibrinogen for trauma-associated coagulopathy
Blood bank
Type and screen
Crossmatch when hemorrhage suspected
Blood gas and ventilation monitoring
Oxygenation and ventilation assessment
Arterial blood gas when ventilated or unstable
PaO2 confirmation for hypoxemia
PaCO2 confirmation for ventilation targeting
Lactate and perfusion
Lactate for shock screening and resuscitation tracking
Focused adjunct labs
Targeted labs by context
Toxicology
Blood alcohol concentration
Urine drug screen when it changes management
Pregnancy testing
Beta hCG for pregnancy-capable patients
Anticoagulant assessment
Anti-Xa level when available for factor Xa inhibitor exposure
Thrombin time when available for dabigatran exposure
Viscoelastic testing
Thromboelastography or rotational thromboelastometry for trauma coagulopathy when available
Diagnostic Tests
Scoring Systems
Clinical and imaging scores
Glasgow Coma Scale
Moderate traumatic brain injury range 9 to 12
Severe traumatic brain injury range 3 to 8
Pupillary reactivity
Bilateral nonreactive pupils as poor prognostic sign
Unilateral nonreactive pupil as herniation risk marker
CT classification frameworks
Marshall CT classification for diffuse injury versus mass lesion patterns
Rotterdam CT score for outcome prediction
Physiologic risk framing
Hypotension and hypoxemia as major secondary injury modifiers
MRI
MRI brain applications
Indications after CT
Suspected diffuse axonal injury with disproportionate exam
Persistent coma without clear CT explanation
Brainstem injury concern
Sequences and targets
Susceptibility weighted imaging for microhemorrhage
Diffusion weighted imaging for axonal injury patterns
Limitations
Time and transport risk in unstable patients
Implanted device contraindications
CT
CT-based diagnosis and triage
Noncontrast CT head
First-line imaging for suspected intracranial hemorrhage
Mass effect assessment
Midline shift assessment
Basal cistern effacement assessment
Repeat CT head strategy
Neurologic deterioration trigger
Post-procedure trigger
High-risk hemorrhage expansion context
CT cervical spine
High-risk mechanism
Altered mental status preventing reliable exam
CTA head and neck
Cervical vascular injury risk pattern
Basilar skull fracture involving carotid canal
High-risk cervical spine fracture patterns
Ultrasound
Ultrasound adjuncts
Extended FAST
Hemorrhagic shock screening in multi-trauma
Pneumothorax screening
Optic nerve sheath diameter
Screening adjunct for elevated ICP physiology
Not a replacement for CT and invasive monitoring
Cardiac ultrasound
Shock differential support
Pericardial effusion screening in trauma context
Disposition
Level of care and admission criteria
Destination planning
ICU admission indications
Moderate or severe traumatic brain injury with CT abnormality
Need for mechanical ventilation
Need for vasoactive support
Need for frequent neurologic checks
Need for hyperosmolar therapy
Neurosurgical admission indications
Epidural hematoma
Acute subdural hematoma
Depressed skull fracture
Intracranial hemorrhage with mass effect
Penetrating head injury
ICP monitoring pathway
Severe traumatic brain injury with abnormal CT
Severe traumatic brain injury with normal CT plus risk features
Age over 40 years
Unilateral or bilateral motor posturing
SBP under 90 mmHg at admission
Transfer criteria and timing
Transfer to higher level care
Immediate transfer triggers
Need for neurosurgical intervention unavailable locally
Need for ICP monitor or EVD unavailable locally
Refractory intracranial hypertension
Polytrauma requiring trauma center resources
Transport stabilization targets
Secure airway and ventilation targets
Hemodynamic targets met
Hyperosmolar therapy available during transport when indicated
Sedation plan to prevent coughing and agitation
Treatment
Airway, ventilation, and oxygenation
Airway and ventilation strategy
Induction and paralysis considerations
Hemodynamic stability prioritization
Cervical spine protection technique
Ventilator targets
PaCO2 35 to 40 mmHg
PaO2 adequate for SpO2 94% to 98%
Rescue hyperventilation pathway
If herniation physiology, temporary PaCO2 30 to 35 mmHg
Stop rescue hyperventilation after definitive ICP therapy and stabilization
Hemodynamics and perfusion
Blood pressure and perfusion support
SBP thresholds
Age 15 to 49 years SBP 110 mmHg or higher
Age 50 to 69 years SBP 100 mmHg or higher
Age 70 years or older SBP 110 mmHg or higher
Vasopressor strategy when fluids insufficient
Norepinephrine infusion
Start 0.05 microg/kg/min
Titrate every 2 to 5 minutes to SBP target
Typical range 0.05 to 1 microg/kg/min
Avoidances
Hypotension
Excess crystalloid causing pulmonary edema
Hypotonic fluid
Intracranial pressure control and herniation treatment
Stepwise ICP control
Nonpharmacologic measures
Head elevation 30 degrees
Neutral neck alignment
Analgesia and sedation optimization
Normothermia
PaCO2 35 to 40 mmHg
Hyperosmolar therapy
Hypertonic saline bolus options
Sodium chloride 3% IV 2 to 3 mL/kg bolus
Repeat bolus by clinical response and sodium trend
Sodium monitoring every 2 to 4 hours when actively dosing
Sodium chloride 23.4% IV 0.5 mL/kg
Maximum 30 mL dose
Central access preferred
Continuous ECG monitoring
Mannitol option
Mannitol IV 0.25 g/kg to 1 g/kg
Avoid if hypotension or hypovolemia
Serum osmolality monitoring and renal function monitoring
Pre-ICP monitor use limited to herniation physiology or progressive deterioration without extracranial cause
CSF diversion
External ventricular drain
Continuous drainage strategy when used
Level III recommendation language for continuous drainage in severe TBI
Sedation escalation
Propofol infusion
Start 5 to 10 microg/kg/min
Titrate by 5 to 10 microg/kg/min every 5 to 10 minutes
Typical upper range 50 to 80 microg/kg/min
Hypotension risk and propofol infusion syndrome awareness
Midazolam infusion
Start 0.02 to 0.1 mg/kg/hour
Titrate to ventilator synchrony and ICP control
Analgesia adjunct
Fentanyl infusion
Start 1 microg/kg/hour
Titrate to comfort and ventilator synchrony
Refractory ICP rescue
Neuromuscular blockade as short-term adjunct
Rocuronium bolus 1 mg/kg
Continuous infusion if required with deep sedation
Barbiturate coma consideration with neurosurgical and ICU coordination
Continuous EEG monitoring requirement
Decompressive craniectomy pathway
Neurosurgery-led decision for refractory intracranial hypertension
Cerebral perfusion targets
ICP and CPP targets
ICP threshold treatment target
Treat ICP above 22 mmHg
Level II B recommendation language for ICP threshold 22 mmHg
CPP target range
60 to 70 mmHg target
Avoid aggressive CPP over 70 mmHg with fluids and pressors
Monitoring alignment
Arterial line for vasoactive titration
End-tidal CO2 monitoring for ventilation targets
Seizure management and prophylaxis
Seizure pathway
Acute seizure treatment
Lorazepam IV 0.1 mg/kg
Maximum 4 mg per dose
Repeat once after 5 minutes if ongoing seizure
If refractory, antiseizure loading
Levetiracetam IV 60 mg/kg
Maximum 4500 mg
Fosphenytoin IV 20 mg PE/kg
Maximum 1500 mg PE
Early post-traumatic seizure prophylaxis
Indication framing
Severe traumatic brain injury
Intracranial hemorrhage on CT
Depressed skull fracture
Penetrating head injury
Levetiracetam regimen
Levetiracetam IV 1000 mg load
Then 1000 mg every 12 hours
Duration 7 days
Renal dosing adjustment when needed
Phenytoin regimen alternative
Phenytoin IV 15 to 20 mg/kg load
Then 100 mg every 8 hours
Level monitoring as locally available
Duration 7 days
Coagulopathy and anticoagulant reversal
Hemorrhage expansion risk reduction
Warfarin-associated intracranial hemorrhage
4-factor PCC dosing by INR and weight per local protocol
Typical 25 to 50 units/kg based on INR category
Vitamin K IV 10 mg
Slow infusion to reduce reaction risk
Factor Xa inhibitor associated intracranial hemorrhage
Andexanet alfa when available and indicated by agent and timing
Dosing per specific agent and last dose timing
If andexanet not available, 4-factor PCC per local protocol
Dabigatran associated intracranial hemorrhage
Idarucizumab IV 5 g
Two 2.5 g doses
Antiplatelet exposure considerations
Desmopressin IV 0.3 microg/kg for life-threatening bleeding consideration
Platelet transfusion individualized for neurosurgical procedure planning
Thrombocytopenia
Platelet transfusion threshold individualized for bleeding and procedure needs
DVT prophylaxis and supportive ICU care
ICU supportive care bundle
Venous thromboembolism prevention
Mechanical prophylaxis when bleeding risk present
Pharmacologic prophylaxis timing after stable head CT with neurosurgery input
Stress ulcer prevention
ICU indication-based prophylaxis
Nutrition
Early enteral nutrition when feasible
Skin and eye care
Corneal protection in ventilated patients
Pressure injury prevention
Delirium mitigation framework
Sedation minimization when safe
Day-night cycling in ICU
Special Populations
Pregnancy
Pregnancy-specific considerations
Maternal stabilization priority
Oxygenation and SBP targets to protect uteroplacental perfusion
Left uterine displacement in late pregnancy when supine
Imaging considerations
CT head when clinically indicated
Radiation counseling and shielding practices per local protocol
Medication considerations
Hyperosmolar therapy risk-benefit framing with multidisciplinary input
Antiseizure medication selection balancing maternal stability and fetal considerations
Obstetric coordination
Fetal monitoring when viable gestational age
Rh immunoglobulin for Rh-negative trauma patients per obstetric guidance
Geriatric
Older adult considerations
Anticoagulant and antiplatelet prevalence
Low threshold for reversal pathway activation with intracranial hemorrhage
Brain atrophy effect
Delayed symptom progression risk
Subdural hematoma risk pattern
Comorbidity burden
Blood pressure support balancing cardiac disease
Polypharmacy interactions
Goals of care
Early discussion when severe injury and poor prognosis markers present
Pediatrics
Pediatric considerations
Age-specific physiology
Weight-based dosing for hyperosmolar therapy and antiseizure therapy
Higher risk of abusive head trauma in infants and toddlers
Imaging thresholds and sedation needs
Transport and monitoring planning for CT and MRI
Hypertonic saline dosing
Sodium chloride 3% IV 2 to 5 mL/kg bolus
Sodium monitoring frequency aligned with active therapy
Child protection pathway
Safeguarding consultation when mechanism inconsistent or concerning findings present
Background
Epidemiology
Epidemiology and burden
Common mechanisms
Falls
Motor vehicle collision
Assault
Sports and recreation
Severity categories
Moderate traumatic brain injury as Glasgow Coma Scale 9 to 12
Severe traumatic brain injury as Glasgow Coma Scale 3 to 8
Outcome drivers
Secondary brain injury from hypotension and hypoxemia
Intracranial hypertension and herniation
Coagulopathy and hemorrhage expansion
Pathophysiology
Injury mechanisms
Primary injury
Contusion and laceration
Diffuse axonal injury
Vascular disruption and hemorrhage
Secondary injury cascade
Excitotoxicity
Mitochondrial dysfunction
Neuroinflammation
Cerebral edema
Monro-Kellie doctrine implications
Compensatory reserve exhaustion
Rapid ICP rise after reserve exhaustion
Herniation syndromes
Uncal herniation with ipsilateral pupil dilation
Central herniation with progressive coma
Therapeutic Considerations
Therapeutic rationale and evidence framing
ICP threshold management
ICP above 22 mmHg associated with increased mortality
Treating ICP above 22 mmHg recommended at Level II B
CPP optimization
CPP target 60 to 70 mmHg as Level II B
Autoregulation status influence on optimal CPP target
Blood pressure thresholds
Age-stratified SBP thresholds as Level III recommendation
Hyperosmolar therapy role
Rapid reduction in ICP as bridge to definitive management
Agent selection influenced by hemodynamics and renal function
Ventilation strategy
Normocapnia as default
Hyperventilation as time-limited bridge for herniation physiology
Patient Discharge Instructions
Copy discharge instructions
Discharge instructions for hospitalized moderate to severe TBI survivors
Safety and supervision
Adult supervision until cleared by treating team
No driving until cleared
No alcohol or recreational drugs
Activity restrictions
No contact sports until cleared
Gradual return to activity under clinician guidance
Medication guidance
Take prescribed antiseizure medication exactly as directed
Avoid sedatives unless prescribed
Return immediately for
Worsening headache
Repeated vomiting
New weakness or numbness
New confusion or agitation
Seizure
Difficulty waking up
New vision changes
Clear fluid from nose or ear
Fever with worsening mental status
Follow-up planning
Neurosurgery or trauma clinic appointment as scheduled
Rehabilitation assessment when recommended
Cognitive and mood symptom screening follow-up
References
Clinical guidelines and protocols
Evidence-based guidelines and protocols
Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury
ICP threshold treatment recommendation 22 mmHg
CPP target recommendation 60 to 70 mmHg
SBP threshold recommendations by age category
Emergency Neurological Life Support protocols
Traumatic Brain Injury protocol
Intracranial Hypertension and Herniation protocol
Pharmacotherapy protocol for hyperosmolar dosing
Key studies and evidence summaries
Supporting evidence base
Comparative studies of levetiracetam versus phenytoin for early post-traumatic seizure prevention
Hyperosmolar therapy systematic reviews for ICP reduction
Trauma registry analyses linking hypotension thresholds to mortality in TBI
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.