4 Neurologic Injury in Trauma
Learn how to assess traumatic brain and spinal cord injuries, recognize deterioration, and reduce the risk of secondary harm.
Primary and
The is the damage caused by the initial impact. is additional damage that develops afterward, for example from inadequate oxygen delivery, low blood pressure, swelling, impaired perfusion, or other complications.
Early recognition and repeated assessment help identify deterioration and guide urgent care. Assessment principles should be applied alongside local protocols and specialist direction.
Initial assessment and trending
Begin with the trauma primary survey to identify and treat immediate threats. Protect the airway while maintaining when indicated, assess breathing and circulation, control hemorrhage, and evaluate neurologic status. Do not delay urgent resuscitation for a detailed neurologic examination.
Hypoxia and hypotension can worsen brain injury, so identify and correct them promptly. In a patient with possible spinal cord injury, consider bleeding and other causes before attributing shock to the injury.
Obtain a baseline neurologic examination as early as the patient’s condition permits, then repeat it and document changes. Record limitations such as sedation, intoxication, intubation, language barriers, pain, or distracting injuries. Compare later findings with the baseline rather than relying on a single score or examination.
Assessing traumatic brain injury
Assess level of consciousness with the , which measures eye opening, verbal response, and motor response. Record each component, not just the total, because changes in an individual component—especially the motor response—can be clinically important.
GCS scores of , , and or less are commonly grouped as mild, moderate, and severe injury, respectively. These categories are useful descriptions but are not a complete measure of injury severity.
Assess pupil size, symmetry, and reaction to light. Also check limb movement and symmetry, ability to follow commands, speech, and focal weakness. New pupillary asymmetry or a newly unreactive pupil may signal brainstem compression and impending herniation; this calls for urgent reassessment and escalation.
For example, a change from E3 V4 M6 to E2 V3 M5 accompanied by a newly sluggish pupil should be treated as neurologic deterioration. Promptly reassess airway, oxygenation, ventilation, and circulation; alert the trauma or neurosurgical team; and prepare for urgent investigation and management under protocol.
Recognizing brain injury deterioration
Concerning changes include a falling GCS or motor response, increasing confusion or agitation, new weakness, repeated vomiting, seizure, worsening headache, unequal or poorly reactive pupils, and declining responsiveness. These changes may reflect expanding intracranial bleeding, swelling, seizure, hypoxia, hypotension, medication effects, or another problem. Reassess rapidly and escalate rather than assuming the cause.
Head CT is commonly used to identify acute structural injury, but imaging decisions depend on the clinical picture and applicable protocols. In severe traumatic brain injury, the examination and imaging findings inform decisions about monitoring and treatment. When ICP is monitored, the Brain Trauma Foundation recommends treating values above ; interpret the value alongside examination and CT findings.
Preventing secondary brain injury
Reduce avoidable secondary brain injury by maintaining oxygenation and adequate circulation, avoiding hypotension, and preventing fever. Monitor ventilation because carbon dioxide levels that are too high or too low can be harmful.
Routine or prolonged hyperventilation is not a substitute for definitive care. Clinicians may use short-term hyperventilation as a rescue measure when herniation is suspected while other interventions are arranged. In severe traumatic brain injury, positioning, sedation, seizure management, and ICP-directed therapies should be guided by the patient’s condition and local protocol.
Identifying and assessing spinal cord injury
Suspect spinal cord injury after trauma when there is weakness, unequal movement, sensory loss, loss of muscle tone, or new bowel or bladder dysfunction. A high cervical injury may also impair breathing. During the primary survey, rapidly check gross motor function and sensation while addressing life threats.
Spinal column injury can occur with or without cord injury. A normal initial gross examination does not by itself rule out all spinal injury. When the patient can participate, document motor and sensory findings systematically and repeat them to detect progression.
The International Standards for Neurological Classification of Spinal Cord Injury () provide a structured examination and classification. Trained clinicians use to determine neurologic level and injury classification. Interpret findings cautiously when impaired consciousness or other injuries may affect strength or sensation.
Shock and worsening spinal cord function
Spinal cord injury may cause through loss of sympathetic vascular tone; this often involves hypotension and bradycardia, particularly with higher cord injuries. Hemorrhage remains a critical alternative cause of shock in trauma. Look for bleeding and other causes before attributing low blood pressure to spinal cord injury, and allow for the possibility that more than one cause is present.
is a separate term for temporary loss of reflexes and tone below the injury; it is not the same as circulatory shock. Urgently report new or worsening weakness, sensory loss, respiratory difficulty, or changes in bladder or bowel function. These findings may indicate evolving cord compromise or another complication and require immediate reassessment and specialist involvement.
Reducing secondary spinal cord injury
Use when indicated and maintain it during necessary transfers and airway care. Avoid forceful movement or painful positioning. A rigid backboard may help during extrication or transfer, but remove it promptly once the patient is on an appropriate surface because prolonged use can cause discomfort and pressure injury.
Do not delay needed airway management; make a reasonable effort to limit unnecessary neck movement. Prevent avoidable hypoxia and hypotension, promptly evaluate possible spinal instability, and obtain specialist-directed imaging and treatment.
Blood-pressure augmentation may be considered in acute spinal cord injury under specialist guidance and local protocols. The supporting evidence has limitations, so blood-pressure targets should not be treated as universal.