Traumatic brain injury

Rationale

While head trauma/traumatic brain injury is mild and not associated with long-term sequelae, it is imperative to recognize those patients who, having sustained a traumatic brain injury require additional interventions including resuscitation and diagnostic imaging.

Causal Conditions

(list not exhaustive)

1. Skull fracture, penetrating injury
2. Hemorrhage, hematoma (subdural, epidural, subarachnoid, pediatric abusive head trauma)
3. Cerebral contusion
4. Edema (midline shift)
5. Diffuse axonal injury

Key Objectives

Given a patient with a traumatic brain injury, the candidate will diagnose the cause, severity, and complications. In particular, the candidate will determine the appropriate management plan including resuscitation, appropriate imaging, and ongoing surveillance.

Enabling Objectives

Given a patient with a traumatic brain injury, the candidate will

1. list and interpret critical clinical findings, including those derived from
   1. a history aimed at determining if the head injury was severe or associated with complication (e.g., mechanism of injury, loss of consciousness);
   2. perform a physical examination aimed at determining if the head injury was severe or associated with complication (e.g., ecchymosis behind ear, Glasgow Coma Scale);
   3. repeat history and/or physical examination aimed at detecting evolving pathology;
   4. identify clinical signs concerning for death by neurologic criteria;
2. list critical investigations and interpret their results, including
   1. urgent brain imaging if required;
   2. confirmation of brain death with appropriate investigations;
3. conduct an effective initial management plan, including
   1. initiation of resuscitation measures aimed at reducing increased intracranial pressure
   2. initial management of increased intracranial pressure
   3. management of concussion
4. determine if the patient requires specialized or urgent care (e.g., craniotomy, ICP probe)
5. counsel the patient and/or substitute decision-makers on the natural history of traumatic brain injury and concussion.

Second objective: Death by Neurologic Criteria

Rationale

Death by neurologic criteria may occur as a result of traumatic brain injury or other causes. It is imperative to recognize the clinical signs of death by neurologic criteria and to understand the processes for consideration of organ donation in a patient who has sustained death by neurologic criteria.

Enabling Objectives

Given a patient who has sustained neurologic deterioration whose heart is still beating, the candidate will

1. Identify signs on physical examination concerning for death by neurologic criteria
2. List ancillary investigations (brain perfusion scan)

Given a patient in whom death by neurologic criteria has been confirmed, the candidate will

1. Communicate the information to the organ donation coordinator (or equivalent)
2. Confirm the presence or absence of patient and/or substitute decision-maker’s consent for organ donation