Reference — Neurology
Traumatic Brain Injury Reference
The numbers and signs that drive TBI monitoring: GCS severity, the early-vs-late ICP signs(a falling LOC first, Cushing’s triad last), and the secondary-injury targets that prevent further damage.
Educational use only. TBI management is time-critical and provider-directed. This reference is an educational aid. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Severity by GCS
| Severity | GCS | Note |
|---|---|---|
| Mild (concussion) | GCS 13–15 | Brief or no LOC; cognitive/physical rest, watch for post-concussive symptoms |
| Moderate | GCS 9–12 | Admission and close neuro monitoring; imaging |
| Severe | GCS ≤ 8 | Coma; intubate to protect the airway; ICU/ICP management |
Rising ICP & Herniation
| Stage | Findings |
|---|---|
| Early ICP signs | Declining LOC (earliest), restlessness, headache, vomiting, pupil changes, focal weakness |
| Late ICP signs | Cushing's triad (HTN with WIDENING pulse pressure, BRADYCARDIA, IRREGULAR respirations), fixed/dilated pupil(s), posturing, coma |
| Herniation | Blown pupil, rapid LOC decline, posturing, Cushing's triad — neurosurgical emergency |
Secondary-Injury Prevention & Fracture Clues
Prevent secondary injury: avoid hypoxia and hypotension, maintain cerebral perfusion, HOB ~30° with head midline, prevent fever/shivering and seizures, avoid Valsalva, and keep normoglycemia. Basilar skull fracture clues: raccoon eyes (periorbital bruising), Battle’s sign (mastoid bruising), and CSF rhinorrhea/otorrhea (the “halo” sign on gauze) — avoid NG tubes/nasal suction with suspected basilar fracture.
NCLEX Pearls
- ✦GCS severity: mild 13–15, moderate 9–12, severe ≤8 (≤8 → intubate).
- ✦A declining LOC is the EARLIEST sign of rising ICP.
- ✦Cushing's triad (↑BP with widening pulse pressure, bradycardia, irregular respirations) is a LATE herniation sign.
- ✦Prevent secondary injury: no hypoxia/hypotension, HOB 30° midline, prevent fever/Valsalva/seizures.
- ✦Basilar skull fracture: raccoon eyes, Battle's sign, CSF oto/rhinorrhea (halo sign) — no nasal tubes.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with American Heart Association / American Stroke Association (AHA/ASA) · American Association of Neuroscience Nurses (AANN). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →