[Audio] National Guidelines for the Management of Traumatic Brain Injury 38
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
Airway In all head injury patients high-flow oxygen should be administered immediately after securing the airway Judging the patency of airway in a nonintubated patient is always clinical Airway assessment in a patient with a secured artificial airway Position Auscultation Chest radiograph Patency Effort of breathing Ease of passing suction catheter Airway pressures if on vetilator Signs of airway compromise Does not talk Noisy breathing Obvious facial injury Indicators of potential airway compromise Use of accessory muscles Neck injury short neck IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
Breathing Spontaneous breathing Patient on a ventilator Clinical sign of indequated ventilation Rapid or very slow respiratory rate Use of accessory muscles Poor chest expansion/ air entry Accessory means of assessing breathing Arterial blood gas Low SpO2 on a pulse oximeter (normal SpO2 while on supplementary oxygen does NOT indicate adequate breathing) Clinical Chest movement Auscultation Intensive care unit (ICU) technology Ventilator parameters Pulse oximetry End-tidal CO2 Arterial blood gas. 

Scene 1

National Guidelines for the Management of Traumatic Brain Injury
38
In all head injury patients high-flow oxygen 
should be administered immediately after 
securing the airway
Airway
Judging the patency of 
airway in a nonintubated 
patient is always clinical
Signs of airway compromise
• Does not talk
• Noisy breathing
• Obvious facial injury
Indicators of potential airway 
compromise
• Use of accessory muscles
• Neck injury
• short neck
Airway assessment in a 
patient with a secured 
artificial airway
Position
• Auscultation
• Chest radiograph
Patency
• Effort of breathing 
• Ease of passing suction catheter
• Airway pressures if on vetilator
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
Breathing
Spontaneous breathing
Clinical sign of indequated ventilation
• Rapid or very slow respiratory rate
• Use of accessory muscles
• Poor chest expansion/ air entry
Accessory means of assessing breathing
• Arterial blood gas
•  Low SpO2 on a pulse oximeter (normal SpO2 
while on supplementary oxygen does NOT 
indicate adequate breathing) 
Patient on a ventilator
Clinical
• Chest movement
• Auscultation 
Intensive care unit (ICU) 
technology
• Ventilator parameters
• Pulse oximetry
• End-tidal CO2
• Arterial blood gas

[Audio] Summary and Conclusions 39
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
Blood pressure Emergency room signs of impaired circulation Pulse—trchycardia, poor valume Blood pressure Capillary refill > 2 seconds, cold extremities Auscultation for pneumothorax or tamponade Monitored area (in emergency room [ER] or high care area) Heart rate Noninvasive blood pressure Invasive blood pressure—if significant Instability present or on vasoactive drugs IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
Intervention Airway Answers Talk to the patient Airway is secure If he does not speak Jaw thrust Remove foreign body (FB) Perform oral suction Noisy breathing/significant blood in oral cavity Insert an oral airway If a definitive airway was not initially necessary frequent reassessment of the airway is mandatory If not available Definitive airway Turn patient semiprone If not possible a cricothyroidotomy Endotracheal intubation/ laryngeal mask airway is the primary option Connect high-flow oxygen after securing airway. 

Scene 2

Summary and Conclusions
39
Emergency room signs of impaired 
circulation
• Pulse—trchycardia, poor valume
• Blood pressure
•  Capillary refill > 2 seconds, cold extremities
•  Auscultation for pneumothorax or 
tamponade
Monitored area (in emergency 
room [ER] or high care area)
• Heart rate
• Noninvasive blood pressure
•  Invasive blood pressure—if 
significant Instability present or on 
vasoactive drugs
Blood pressure
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
Talk to the patient
Airway is secure
Insert an oral airway
Turn patient semiprone
Definitive airway
If not possible a cricothyroidotomy
Connect high-flow oxygen after securing airway
Jaw thrust
Remove foreign body (FB) 
Perform oral suction
Noisy breathing/significant 
blood in oral cavity
Endotracheal intubation/
laryngeal mask airway is the 
primary option
Intervention Airway
If he does not speak
Answers
If not available
If a definitive airway was not initially 
necessary frequent reassessment of 
the airway is mandatory
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)

[Audio] National Guidelines for the Management of Traumatic Brain Injury 40
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
Intervention Breathing Inadequate Definitive airway (unless the reason is rapidly correctable such as a tension pneumothorax)
Endotracheal tube*
Continue manual assistance and correct cause of impaired breathing Connect to ventilator and refer to higher center *Requires sedation and often muscle relaxants, following which breathing has to be assisted—manually or (where available) with a ventilator.
Supplementary oxygen Avoid hyperventilation (common with manual ventilation)
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
Intervention Blood pressure Low blood pressure (BP)/patient has tachycardia with borderline BP Continue crystalloids rapidly and monitor pulse and blood pressure After > 1 lt—RL preferred O– blood BP does not respond Large caliber peripheral lines in both antecubital fossae (dextrosefree crystalloids @ maximum)
Not ready Blood cross match Vasoactive drugs— to raise BP Controlled No facilities Refer urgently to a higher center while continuing rapid infusion of crystalloids en route Unstable BP Control hemorrhage External Pressure Abdomen—urgent surgical consultation Pelvis—apply binder Femur—splint Surgical control of hemorrhage. 

Scene 3

National Guidelines for the Management of Traumatic Brain Injury
40
Intervention Breathing
Inadequate
Endotracheal tube*
Connect to ventilator and 
refer to higher center
Continue manual assistance and 
correct cause of impaired breathing
Definitive airway (unless the reason is rapidly
correctable such as a tension pneumothorax)
*Requires sedation and often muscle relaxants, following which breathing has to 
be assisted—manually or (where available) with a ventilator.
Supplementary oxygen
Avoid hyperventilation (common with manual ventilation)
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI)
Intervention Blood pressure
Blood cross match
BP does not respond
Surgical control of hemorrhage
Low blood pressure (BP)/patient 
has tachycardia with borderline BP
Continue crystalloids rapidly and 
monitor pulse and blood pressure
Large caliber peripheral lines in 
both antecubital fossae (dextrose-
free crystalloids @ maximum)
Refer urgently to a higher
center while continuing
rapid infusion of
crystalloids en route
Vasoactive drugs—
to raise BP
Control hemorrhage
• External Pressure
•  Abdomen—urgent 
surgical consultation
• Pelvis—apply binder
• Femur—splint
O– blood
No facilities
After > 1 lt—RL preferred
Not ready
Controlled
Unstable BP

[Audio] Summary and Conclusions 41
Head Injury—Gasgow Coma Scale (GCS) Score in normal adults is 15
A. Eye opening Spontaneously 4 To speech 3 To pain 2 None 1
C. Best motor response Obeys commands 6 Localization to pain 5 Withdrawal to pain 4 Spastic flexion to pain 3 Extension to pain 2 None 1
B. Best verbal response Orientated 5 Confused 4 Inappropr words 3 Incompr sounds 2 None 1
Algorithm for Mx of mild head injury History G/E Neurological examination Skull X-Ray Cervical spine X-Ray Blood Alcohol levels Computed tomography (CT) head—ideally in all but completely asymptomatic patients Admit Discharge Does not meet criterion for admission Discuss need to return if problem Amnesia H/o loss of consciousness (LOC) Deteriorating conciousness Moderate-to-severe headache Alcohol/drug intoxication Skull fracture Cerebrospinal fluid (CSF) leak Significant ass injuries Abnormal CT scan. 

Scene 4

Summary and Conclusions
41
Head Injury—Gasgow Coma Scale (GCS) 
Score in normal adults is 15
A. Eye opening
• Spontaneously 
4
• To speech 
3
• To pain 
2
• None 
1
B. Best verbal response
• Orientated 
5
• Confused 
4
• Inappropr words 
3
• Incompr sounds 
2
• None 
1
C. Best motor response
• Obeys commands 
6
• Localization to pain 
5
• Withdrawal to pain 
4
• Spastic flexion to pain 
3
• Extension to pain 
2
• None 
1
• History
• G/E
• Neurological examination
• Skull X-Ray
• Cervical spine X-Ray
• Blood Alcohol levels
• Does not meet criterion for admission
• Discuss need to return if problem
• Amnesia
• H/o loss of consciousness (LOC)
• Deteriorating conciousness
• Moderate-to-severe headache
• Alcohol/drug intoxication
• Skull fracture
• Cerebrospinal fluid (CSF) leak
• Significant ass injuries
• Abnormal CT scan
Algorithm for Mx of mild head injury
Admit
Discharge
Computed tomography (CT) 
head—ideally in all but completely 
asymptomatic patients

[Audio] National Guidelines for the Management of Traumatic Brain Injury 42
Algorithm for Mx of moderate head injury Initial w/u Computed tomography (CT) scan in all cases ADMIT even if CT is normal Frequent neurological examinations Follow up (FU) CT Scan if deteriorates/before discharge If pt improves (90%)
If pt deteriorates (10%)
Discharge when stable Repeat CT Scan Manage as per severe HI Algorithm for Mx of severe head injury History Rescuscitaion—airway, breathing, and circulation (ABC) Catheters X-Rays—Cx/Chest/Skull/Abdomen/
Pelvis/Extremities G/E Emergency measures for ass injuries: Tracheostomy Chest tubes Neck stabilization Abdominal paracentesis Neurological examination. 

Scene 5

National Guidelines for the Management of Traumatic Brain Injury
42
ADMIT even if CT is normal
Frequent neurological examinations
Follow up (FU) CT Scan if deteriorates/before discharge
If pt improves (90%)
Discharge when stable
If pt deteriorates (10%)
Repeat CT Scan
Manage as per severe HI
Algorithm for Mx of moderate head injury
• Initial w/u
• Computed tomography (CT) scan in all cases
Neurological examination
• History
•  Rescuscitaion—airway, breathing, and 
circulation (ABC) 
• Catheters
•  X-Rays—Cx/Chest/Skull/Abdomen/
Pelvis/Extremities
• G/E
Emergency measures for ass injuries:
• Tracheostomy
• Chest tubes
• Neck stabilization
• Abdominal paracentesis
Algorithm for Mx of severe head injury

[Audio] Summary and Conclusions 43
Algorithm for Mx of severe head injury Intubate, Sedate, Resuscitate Computed tomography (CT) Scan Not available Refer to higher level if < 2 hours Diffuse lesion Surgical lesion Operation theater (OT) Intensive care unit (ICU) Monitor intracranial pressure (ICP) Elevate Head end Sedate Maintain Pao2 100 mmHg Maintain PaCo2 30–32 mmHg ICP still high Treat ICP Monitor ICP ICP<20
ICP<20
Check PaO2, PacO2
Head/Neck position Treat pain, Fever Recalibrate ICP system Repeat CT No surgical mass lesion Surgical mass lesion Craniotomy Mannitol/Loo Diuretics Hyperventilate Barbiturate Coma Decompressive craniotomy (DC) Lobectomy. 

Scene 6

Summary and Conclusions
43
Intubate, Sedate, Resuscitate
Diffuse lesion
Intensive care unit (ICU) 
ICP still high
Treat ICP
• Monitor intracranial pressure (ICP)
• Elevate Head end
• Sedate
• Maintain Pao2 100 mmHg
• Maintain PaCo2 30–32 mmHg
Surgical lesion 
 Operation theater (OT) 
Computed tomography 
(CT) Scan
Not available
Refer to higher level 
if < 2 hours
Algorithm for Mx of severe head injury
Monitor ICP
ICP<20
ICP<20
Repeat CT
Check PaO2, PacO2
Head/Neck position
Treat pain, Fever
Recalibrate ICP system
• Mannitol/Loo Diuretics
• Hyperventilate
• Barbiturate Coma
•  Decompressive 
craniotomy (DC)
• Lobectomy
No surgical mass lesion
Surgical mass lesion 
Craniotomy

[Audio] National Guidelines for the Management of Traumatic Brain Injury 44
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI) Criteria for performing a computed tomography (CT) head scan Adults Children Glasgow Coma Scale (GCS) < 13 on initial assessment in emergency department (ED) GCS <15 at 2 hours after the injury in ED Suspected open/depressed skull fracture Any sign of basal skull fracture (hemotympanum, "panda" eyes, cerebrospinal fluid leakage from the ear or nose, Battle sign) Posttraumatic seizure Focal neurological deficit > 1 episode of vomiting Posttraumatic seizure but no history of epilepsy GCS < 14, or for children < 1 year -GCS (pediatric) < 15 At 2 hours after the injury, GCS < 15 Suspected open/depressed skull fracture or tense fontanelle Any sign of basal skull fracture (hemotympanum, "panda" eyes, cerebrospinal fluid leakage from the ear or nose, Battle sign) Focal neurological deficit Loss of consciousness > 5 minutes (witnessed) Abnormal drowsiness or irritability 3/> e/o vomiting Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist, or vehicle occupant, fall from a height of > 3 m, highspeed injury from a projectile or other object) Amnesia (antegrade/retrograde) > 5 minutes. 

Scene 7

National Guidelines for the Management of Traumatic Brain Injury
44
Adults
Children
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (TBI) 
Criteria for performing a computed tomography (CT) head scan
•  Glasgow Coma Scale (GCS) 
< 13 on initial assessment in 
emergency department (ED)
•  GCS <15 at 2 hours after the 
injury in ED
•  Suspected open/depressed 
skull fracture
•  Any sign of basal skull 
fracture (hemotympanum, 
“panda” eyes, cerebrospinal 
fluid leakage from the ear or 
nose, Battle sign)
• Posttraumatic seizure
• Focal neurological deficit
• > 1 episode of vomiting
•  Posttraumatic seizure but no history of epilepsy
•  GCS < 14, or for children < 1 year -GCS (pediatric) 
< 15
• At 2 hours after the injury, GCS < 15
•  Suspected open/depressed skull fracture or tense 
fontanelle
•  Any sign of basal skull fracture (hemotympanum, 
“panda” eyes, cerebrospinal fluid leakage from 
the ear or nose, Battle sign)
• Focal neurological deficit
•  Loss of consciousness > 5 minutes (witnessed)
• Abnormal drowsiness or irritability
• 3/> e/o vomiting
•  Dangerous mechanism of injury (high-speed road 
traffic accident either as pedestrian, cyclist, or 
vehicle occupant, fall from a height of > 3 m, high-
speed injury from a projectile or other object)
•  Amnesia (antegrade/retrograde) > 5 minutes

[Audio] The need for the development of guidelines for the management of traumatic brain injury (TBI) has long been a matter of concern to the treating medical personnel, and its importance has been recognized ever since improvements in TBI outcomes have been reported after the adoption of similar guidelines by the more developed nations across the globe. The Neurotrauma Society of India (NTSI) in collaboration with the Neurological Society of India (NSI) took up the mammoth responsibility of bringing forth these India-centric guide- lines in a concise and comprehensive manner. A logical effort has been made to make these guidelines as practical as possible, depending upon the resources available at the treating hospital, rather than keeping them "ideal" but impractical to follow. These guidelines are expected to bring about an enormous change in the management of TBI across the country, especially if followed by the treating doctors, thereby improving the outcomes of TBI.
—Neurotrauma Society of India (NTSI)
An award-winning international medical and scientific publisher, Thieme has demonstrated its commitment to the highest standard of quality in the state-of-the-art content and presentation of all its products. Founded in 1886, the Thieme name has become synonymous with high quality and excellence in online and print publishing.
ISBN 978-93-90553-98-3
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Scene 8

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An award-winning international medical and scientific publisher, Thieme has demonstrated its
commitment to the highest standard of quality in the state-of-the-art content and presentation
of all its products. Founded in 1886, the Thieme name has become synonymous with high 
quality and excellence in online and print publishing.
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The need for the development of guidelines for the management of traumatic 
brain injury (TBI) has long been a matter of concern to the treating medical 
personnel, and its importance has been recognized ever since improvements 
in TBI outcomes have been reported after the adoption of similar guidelines 
by the more developed nations across the globe. The Neurotrauma Society of 
India (NTSI) in collaboration with the Neurological Society of India (NSI) took 
up the mammoth responsibility of bringing forth these India-centric guide- 
lines in a concise and comprehensive manner. A logical effort has been made 
to make these guidelines as practical as possible, depending upon the  
resources available at the treating hospital, rather than keeping them “ideal” 
but impractical to follow. These guidelines are expected to bring about an 
enormous change in the management of TBI across the country, especially if 
followed by the treating doctors, thereby improving the outcomes of TBI.
—Neurotrauma Society of India (NTSI)
MedCom_TraumaticBrainInjury_1E_9789390553983_15,2x22,9_(6x9')SC_3Seiten_k5.indd   1,3
MedCom_TraumaticBrainInjury_1E_9789390553983_15,2x22,9_(6x9')SC_3Seiten_k5.indd   1,3

MedCom_TraumaticBrainInjury_1E_9789390553983_15,2x22,9_(6x9')SC_3Seiten_k8.indd part 3

National Guidelines for the Management of Traumatic Brain Injury 38
In hospital Care In Traumatic Brain Injury (tbi)
Airway In all head injury patients high flow oxygen  should be administered immediately after  securing the airway Judging the patency of  airway in a nonintubated  patient is always clinical Airway assessment in a  patient with a secured  artificial airway Position 
 Auscultation 
 Chest radiograph Patency 
 Effort of breathing  
 Ease of passing suction catheter 
 Airway pressures if on vetilator Signs of airway compromise 
 Does not talk 
 Noisy breathing 
 Obvious facial injury Indicators of potential airway  compromise 
 Use of accessory muscles 
 Neck injury 
 Short Neck In hospital Care In Traumatic Brain Injury (tbi)
Breathing Spontaneous breathing Patient on a ventilator Clinical sign of indequated ventilation 
 Rapid or very slow respiratory rate 
 Use of accessory muscles 
 Poor chest expansion/ air entry Accessory means of assessing breathing 
 Arterial blood gas 
  Low SpO2 on a pulse oximeter (normal SpO2  while on supplementary oxygen does Not  indicate adequate breathing)  Clinical 
 Chest movement 
 Auscultation  Intensive care unit (I-C-U--)  technology 
 Ventilator parameters 
 Pulse oximetry 
 End tidal C-O-2

 Arterial blood gas

avatar

Summary and Conclusions 39
In hospital Care In Traumatic Brain Injury (tbi)
Blood pressure Emergency room signs of impaired  circulation 
 Pulse—trchycardia, poor valume 
 Blood pressure 
  Capillary refill > 2 seconds, cold extremities 
  Auscultation for pneumothorax or  tamponade Monitored area (in emergency  room [ER] or high care area)

 Heart rate 
 Noninvasive blood pressure 
  Invasive blood pressure—if  significant Instability present or on  vasoactive drugs IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (T-B-I--)
Intervention Airway Answers Talk to the patient Airway is secure If he does not speak Jaw thrust Remove foreign body (F-B---)  Perform oral suction Noisy breathing/significant  blood in oral cavity Insert an oral airway If a definitive airway was not initially  necessary frequent reassessment of  the airway is mandatory If not available Definitive airway Turn patient semiprone If not possible a cricothyroidotomy Endotracheal intubation/ laryngeal mask airway is the  primary option Connect high flow oxygen after securing airway

National Guidelines for the Management of Traumatic Brain Injury 40
In hospital Care In Traumatic Brain Injury (tbi)
Intervention Breathing Inadequate Definitive airway (unless the reason is rapidly correctable such as a tension pneumothorax)
Endotracheal tube*
Continue manual assistance and  correct cause of impaired breathing Connect to ventilator and  refer to higher center *Requires sedation and often muscle relaxants, following which breathing has to  be assisted—manually or (where available) with a ventilator.
Supplementary oxygen Avoid hyperventilation (common with manual ventilation)
In hospital Care In Traumatic Brain Injury (tbi)
Intervention Blood pressure Low blood pressure (B-P---)/patient  has tachycardia with borderline BP Continue crystalloids rapidly and  monitor pulse and blood pressure After > 1 lt—RL preferred O– blood BP does not respond Large caliber peripheral lines in  both antecubital fossae (dextrosefree crystalloids @ maximum)
Not ready Blood cross match Vasoactive drugs— to raise BP Controlled No facilities Refer urgently to a higher center while continuing rapid infusion of crystalloids en route Unstable BP Control hemorrhage 
 External Pressure 
  Abdomen—urgent  surgical consultation 
 Pelvis—apply binder 
 Femur—splint Surgical control of hemorrhage

Summary and Conclusions 41
Head Injury—Gasgow Coma Scale (G-C-S--)  Score in normal adults is 15
A Eye opening 
 Spontaneously  4

 To speech  3

 To pain  2

 None  1
C Best motor response 
 Obeys commands  6

 Localization to pain  5

 Withdrawal to pain  4

 Spastic flexion to pain  3

 Extension to pain  2

 None  1
B Best verbal response 
 Orientated  5

 Confused  4

 Inappropr words  3

 Incompr sounds  2

 None  1
Algorithm for Mx of mild head injury 
 History 
 G/E

 Neurological examination 
 Skull X-Ray 
 Cervical spine X-Ray 
 Blood Alcohol levels Computed tomography (C-T---)  head—ideally in all but completely  asymptomatic patients Admit Discharge 
 Does not meet criterion for admission 
 Discuss need to return if problem 
 Amnesia 
 H/o loss of consciousness (L-O-C--)

 Deteriorating conciousness 
 Moderate to severe headache 
 Alcohol/drug intoxication 
 Skull fracture 
 Cerebrospinal fluid (C-S-F--) leak 
 Significant ass injuries 
 Abnormal CT scan

National Guidelines for the Management of Traumatic Brain Injury 42
Algorithm for Mx of moderate head injury 
 Initial w/u 
 Computed tomography (C-T---) scan in all cases A-D-M-I-T even if CT is normal Frequent neurological examinations Follow up (F-U---) CT Scan if deteriorates/before discharge If pt improves (90%)
If pt deteriorates (10%)
Discharge when stable Repeat CT Scan Manage as per severe HI Algorithm for Mx of severe head injury 
 History 
  Rescuscitaion—airway, breathing, and  circulation (A-B-C--)  
 Catheters 
  X-Rays—Cx/Chest/Skull/Abdomen/
Pelvis/Extremities 
 G/E Emergency measures for ass injuries:

 Tracheostomy 
 Chest tubes 
 Neck stabilization 
 Abdominal paracentesis Neurological examination

Summary and Conclusions 43
Algorithm for Mx of severe head injury Intubate, Sedate, Resuscitate Computed tomography  (C-T---) Scan Not available Refer to higher level  if < 2 hours Diffuse lesion Surgical lesion  Operation theater (O-T---)  Intensive care unit (I-C-U--)  
 Monitor intracranial pressure (I-C-P--)

 Elevate Head end 
 Sedate 
 Maintain Pao2100  millimetersHg 
 Maintain PaCo2 30–32  millimetersHg I-C-P still high Treat I-C-P Monitor ICP ICP<20
ICP<20
Check PaO2, PacO2
Head/Neck position Treat pain, Fever Recalibrate I-C-P system Repeat CT No surgical mass lesion Surgical mass lesion  Craniotomy 
 Mannitol/Loo Diuretics 
 Hyperventilate 
 Barbiturate Coma 
  Decompressive  craniotomy (D-C---)

 Lobectomy

National Guidelines for the Management of Traumatic Brain Injury 44
IN-HOSPITAL CARE IN TRAUMATIC BRAIN INJURY (T-B-I--)  Criteria for performing a computed tomography (C-T---) head scan Adults Children 
  Glasgow Coma Scale (G-C-S--)  < 13 on initial assessment in  emergency department (E-D---)

  GCS <15 at 2 hours after the  injury in ED

  Suspected open/depressed  skull fracture 
  Any sign of basal skull  fracture (hemotympanum,  "panda" eyes, cerebrospinal  fluid leakage from the ear or  nose, Battle sign)

 Posttraumatic seizure 
 Focal neurological deficit 
 > 1 episode of vomiting 
  Posttraumatic seizure but no history of epilepsy 
  GCS < 14, or for children < 1 year -GCS (pediatric)  < 15

 At 2 hours after the injury, GCS < 15

  Suspected open/depressed skull fracture or tense  fontanelle 
  Any sign of basal skull fracture (hemotympanum,  "panda" eyes, cerebrospinal fluid leakage from  the ear or nose, Battle sign)

 Focal neurological deficit 
  Loss of consciousness > 5 minutes (witnessed)

 Abnormal drowsiness or irritability 
 3/> e/o vomiting 
  Dangerous mechanism of injury (high speed road  traffic accident either as pedestrian, cyclist, or  vehicle occupant, fall from a height of > 3  meters, highspeed injury from a projectile or other object)

  Amnesia (antegrade/retrograde) > 5 minutes

The need for the development of guidelines for the management of traumatic  brain injury (T-B-I--) has long been a matter of concern to the treating medical  personnel, and its importance has been recognized ever since improvements  in T-B-I outcomes have been reported after the adoption of similar guidelines  by the more developed nations across the globe. The Neurotrauma Society of  India (N-T-S-I-) in collaboration with the Neurological Society of India (N-S-I--) took  up the mammoth responsibility of bringing forth these India centric guide  lines in a concise and comprehensive manner. A logical effort has been made  to make these guidelines as practical as possible, depending upon the   resources available at the treating hospital, rather than keeping them "ideal"  but impractical to follow. These guidelines are expected to bring about an  enormous change in the management of T-B-I across the country, especially if  followed by the treating doctors, thereby improving the outcomes of T-B-I-.
—Neurotrauma Society of India (N-T-S-I-)
An award winning international medical and scientific publisher, Thieme has demonstrated its commitment to the highest standard of quality in the state of the art content and presentation of all its products. Founded in 1886, the Thieme name has become synonymous with high  quality and excellence in online and print publishing.
ISBN 978-93-9-0-5-5-3-98-3
9 7 8 9 3 9 0
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