STEP # 4

Focused Physical Exam

• Signs of basal skull fracture: retroauricular bruising, periorbital bruising, hemotympanum, CSF leak
  
  

• Balance & gait: Romberg, tandem gait
  
  

• VOMS (Vestibular/Ocular-Motor Screening)
  
  

• Full neurologic exam

STEP # 5

Prognosticators :Risk of Prolonged Recovery

• High symptom burden at presentation
  
  

• Older age, female sex
  
  

• Pre-existing psychiatric illness
  
  

• Previous TBI with prolonged symptoms
  
  

• Fewer years of education
  
  

• Migraine or seizure history
  
  

• Lower GCS
  
  

• Photophobia/phonophobia or slow responses at presentation
  
  

• Traumatic intracranial lesion on CT
  
  

• Balance/oculomotor abnormalities
  
  

• Significant extracranial injury
  
  

• Children: Use 5P’s Rule

STEP # 6

Symptom Management

• Headache: NSAIDs or paracetamol (avoid opioids)
  
  

• Nausea: Ondansetron

STEP # 7

Discharge Instructions

• Explain: diagnosis, expected symptoms, warning signs
  
  

• When to return: worsening headache, vomiting, confusion, seizures, focal deficits
  
  

• Rest: 2–3 days of relative physical & mental rest
  
  

  • Avoid prolonged inactivity
    
    

  • Limit screen time for 48 hrs
    
    

• Gradual return to activity as tolerated; pause briefly if symptoms worsen, then resume
  
  

• Avoid high-risk activities until cleared
  
  

• Provide written handouts:
  
  

  • CDC Adult TBI Instructions (PDF)
    
    

  • CDC Pediatric Discharge Materials
    
    

• Offer documentation for school/work accommodations
  
  

• Use as a teachable moment: discuss safety & risk reduction
  
  

• Referral:
  
  

  • Outpatient TBI specialty clinic for high-risk patients
    
    

  • Sports clearance cannot be given in ED if diagnosed with TBI