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Head Injury / Mild TBI

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Head Injury / Mild TBI

  • GCS classification: Mild TBI = GCS 13-15; Moderate = 9-12; Severe = 3-8
  • NICE Head Injury Guidelines — CT indications (adults):
    • GCS <13 anytime; GCS <15 at 2 hours; suspected open/depressed skull fracture; skull base fracture signs (Battle’s sign, raccoon eyes, CSF otorrhoea/rhinorrhoea, haemotympanum); post-traumatic seizure; focal neurological deficit; >1 episode vomiting; amnesia >30 min before impact; age >65 + any LOC/amnesia; coagulopathy + any LOC/amnesia
  • Canadian CT Head Rule (CCHR): Minor head injury + GCS 13-15 — high-risk features = CT needed
  • LOC duration, amnesia duration, mechanism — predict severity
  • Cervical spine injury — ไม่เขย็น C-spine จนกว่าจะ cleared ใน significant MOI
  • Anticoagulation status — warfarin, DOAC → reverse + CT regardless

🕐 One-Day Orders

🔬 Investigation

  • GCS + pupillary reflex q1h (admit) — deterioration = CT urgent
  • CT brain plain — ถ้าครบ criteria ข้างต้น; ดู epidural hematoma (biconvex), subdural (crescent), contusion, SAH
  • C-spine X-ray (AP/lateral/odontoid) หรือ CT C-spine ถ้า high-risk mechanism/neck pain
  • CBC, PT/INR, electrolytes — coagulopathy
  • Blood glucose (DTX) — hypoglycemia masquerade head injury

💊 Medication

  • [Mild TBI / GCS 14-15 with no CT indication:] observe 4-6h, discharge with head injury advice
  • [Admit — GCS 13-15 + CT indication or abnormal CT:]:
    • Neuro obs q1h x 24h (GCS, pupils, BP, HR)
    • ห้าม opioid ถ้าเป็นไปได้ (mask neurological status); Paracetamol แทน
    • Head 30° elevation — reduce ICP
  • [Anticoagulant reversal]: Vitamin K + PCC (warfarin); Idarucizumab (dabigatran); PCC (Xa-inhibitor) — ชัดเจนเสมอใน trauma + anticoagulation
  • Neurosurgery consult: epidural/subdural hematoma, depressed skull fracture, GCS drop
  • [Seizure]: Levetiracetam 500-1000 mg IV/PO BID x 7 วัน (post-traumatic seizure prophylaxis — severe TBI; ไม่ routine ใน mild)

🔁 Continuous Orders

🔬 Investigation

  • Repeat CT brain ถ้า GCS ลดลง หรือ 8-24h หลัง initial (delayed hematoma, contusion expansion)
  • GCS monitoring q1-2h — ถ้าลดลง >2 points = repeat CT + neurosurgery

💊 Medication

  • [Moderate-Severe TBI — ถ้า ICP elevated:]
    • Head 30°, avoid hypotension (SBP >90), avoid hypoxia (SpO₂ >94%), avoid fever
    • Mannitol 0.25-0.5 g/kg IV (20% solution) — ICP spike; หรือ Hypertonic saline 3% 250 mL
    • Intubate GCS ≤8
  • Discharge criteria (mild TBI, CT normal): GCS 15 after 4-6h, ไม่มี focal deficit, ไม่มี seizure, reliable caregiver, head injury discharge card
  • Post-concussion advice: rest 24-48h, หลีกเลี่ยง aspirin/NSAIDs, return precautions

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