Emergency Department Evaluation and Management of Severe Traumatic Brain Injury (Trauma CME)

Publication Date: March 2026 (Volume 28, Number 3)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 03/01/2029.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma credits, subject to your state and institutional approval.

Authors

Dana Klavansky, MD

Assistant Professor of Neurology and Neurosurgery, Associate Director of Neurocritical Care Advanced Practice Provider and Nursing Education, Icahn School of Medicine at Mount Sinai, New York, NY

Anirudha Rathnam, MD, MPH

Assistant Professor of Clinical Neurology, University of California Irvine School of Medicine, Irvine, CA

Abstract

Traumatic brain injury is a significant cause of long-term disability and death worldwide. Recent advances in the acute management of traumatic brain injury have improved outcomes across the full spectrum of disease, including severe injury. Early recognition, optimization of oxygenation and perfusion, and appropriate disposition are essential components of care for patients with severe traumatic brain injury. A systematic history and physical examination are critical to identifying life-threatening injuries and guiding timely interventions, including management of elevated intracranial pressure. This review summarizes current evidence-based recommendations for the emergency department evaluation and management of severe traumatic brain injury, highlights ongoing controversies, and identifies key areas for future research.

Case Presentations

CASE 1

A 70-year-old man with a history of coronary artery disease presents to the ED for headache...

He reports that the headache began after he sustained a head injury in an assault, but is unable to provide any additional details.
He says he takes aspirin at home.
A noncontrast CT of the head shows an acute 0.5-cm right temporal subdural hemorrhage.
Should you consult neurosurgery for emergent surgical intervention? What medical interventions are indicated? Should repeat imaging be obtained, and if so, when?

CASE 2

A 20-year-old woman with no past medical history presents via EMS after being involved in a motor vehicle crash on a motorcycle…

EMS reports that she was not wearing a helmet when the crash occurred.
Her GCS score on arrival at the ED is 6. You immediately place a cervical collar and intubate the patient to stabilize her for imaging.
A noncontrast CT of the head shows a 0.6-cm right subdural hematoma with 0.7-cm leftward midline shift, subarachnoid hemorrhage in the suprasellar cistern, a 0.2-cm epidural hematoma, and a nondisplaced skull fracture.
Is additional imaging indicated? What initial interventions should you consider?

CASE 3

A 41-year-old man is brought in by EMS after being hit in the head by a falling metal beam while he was working in a scrap yard…

EMS reports that the patient was mumbling incoherently and had a GCS score of 12 at the scene.
On arrival at the ED, his GCS score is 10. He is no longer verbal but does appear to be protecting his airway.
A noncontrast CT of the head shows a left temporal depressed skull fracture, additional frontal and parietal fractures, left lateral and medial orbital wall fracture, a 0.7-cm subdural hemorrhage, a 0.2-cm epidural hemorrhage, and a 3-mm rightward midline shift of the brain, with a small left parietal intraparenchymal hemorrhage.
What are your immediate treatment options, and what neurosurgical interventions are indicated?

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