In a primary care setting, the severity of a traumatic brain injury (TBI) should be assessed initially using the Glasgow Coma Scale (GCS), which evaluates eye opening, verbal response, and motor response, with a total score out of 15. Document each component separately (e.g., E4, V4, M5) alongside the total score to provide a detailed assessment.
Assess for any loss of consciousness, amnesia, persistent headache, vomiting, seizures, focal neurological deficits, or altered behaviour, especially in children under 5 years old. These symptoms indicate a higher risk and may necessitate urgent referral.
Consider any history of bleeding or clotting disorders, current anticoagulant or antiplatelet therapy (except aspirin monotherapy), drug or alcohol intoxication, previous brain surgery, or safeguarding concerns as factors increasing severity.
If the GCS score is less than 15, or if any of the above risk factors are present, refer the patient promptly to an emergency department for further assessment and imaging, typically a CT head scan.
Ensure that the patient is accompanied by a competent adult during transport and inform the receiving hospital of the referral and clinical findings.