TRAUMATIC BRAIN INJURY TRIAGE, TRANSFER & MANAGEMENT GUIDELINES 2018 SUMMARY OF GUIDELINES I. TRANSFER TO THE TRAUMA CENTER IS INDICATED: A. Severe Head Injury GCS ≤ 8, unless GCS is 3 with fixed and dilated pupils (may be brain death) or B. Moderate or Mild Head Injury GCS 9-13 (moderate) or GCS 14-15 (mild) with one or more clinical risk factors or a significant CT finding (see box below). Clinical Risk Factors: 1. CSF Leak o Bleeding from ears should not be confused with CSF leak. Diagnosis of CSF otorrhea can be made at the bedside by visualizing clear fluid draining from the middle ear into the external auditory meatus. 2. Penetrating intracranial trauma o Except with GCS 3 with injury to both hemispheres or brainstem 3. New focal neurologic deficit o New pupil asymmetry o New dysconjugate gaze o Objective hemiparesis Significant CT Findings: 1. Depressed skull fracture > 1 cm 2. Basilar skull fractures 3. Midline shift ≥ 4 mm 4. Cerebral contusions o Solitary ≥ 10 mm o Multiple ≥ 5mm 5. Subarachnoid hemorrhage ≥ 5 mm 6. Acute subdural hemorrhage o Thickness > 5 mm o Thickness < 5 mm in patients taking anticoagulants or antiplatelet medications 7. Epidural hemorrhage > 5 mm thickness TRAUMATIC BRAIN INJURY TRIAGE, TRANSFER & MANAGEMENT GUIDELINES 2018 SUMMARY OF GUIDELINES II. NO TRANSFER IS REQUIRED: The following findings by themselves do not require neurotrauma evaluation or transfer to the trauma center. For guidelines on admission and management of these types of patients please refer to the Sample Admission Orders for Mild - Moderate Traumatic Brain Injury on pp. 9-10 of this document. A. Isolated non-depressed (< 1 cm) skull fracture (open or closed) Fractures involving the posterior table of the frontal sinus or the base of the skull may be significant and should be discussed with the Trauma Center. B. Isolated pneumocephalus Does not require admission. Requires no specific treatment. Antibiotics are not indicated. C. Solitary cerebral contusion <10 mm diameter Should be admitted for medical observation & repeat CT scan, and transfer if there is significant neurological deterioration. D. Multiple cerebral contusions < 5 mm diameter Should be admitted for medical observation & repeat CT scan, and transfer if there is significant neurological deterioration. E. Subarachnoid hemorrhage < 5 mm in thickness Should be admitted for medical observation & repeat CT scan, and transfer if there is significant neurological deterioration. F. Isolated subdural hemorrhage < 5 mm thickness Should be admitted for medical observation & repeat CT scan, and transfer if there is significant neurological deterioration. G. Isolated epidural hemorrhage < 5 mm thickness Should be admitted for medical observation & repeat CT scan, and transfer if there is significant neurological deterioration. .