Table 1.

Recommendations of the Clinical/Symptoms Working Group: Clinical Characterization of TBI <24 h Post-Injury^a

(1) Basic clinical descriptors

For all patients, the following must be recorded:

Glasgow Coma Scale (GCS) (full breakdown: motor (M), verbal (V), and eye (E) components).

•Use post-resuscitation GCS for consistency.

•Explicitly note confounds (e.g., intoxication, sedation, intubation).

•Untestable GCS components should be marked with the suffix “U” (untestable) and scored as 1 in sum GCSb

Pupillary responses:

•Report independently from GCS, but assess at the same time as GCS.

•Avoid using an integrated GCS-P score.

•Use automated pupillometry when possible.

(2) Expanded clinical characterization

For a more complete TBI assessment, record:

Injury factors:

•Mechanism, impact velocity, and mitigation (e.g., seat belts, airbags, helmets).

•Extracranial injuries that would warrant hospital admission, even in the absence of a TBI

•Early physiological insults (to include hypoxia and hypotension; based on TQIP consensus thresholds)

•History of loss of consciousness (LoC)

•Presence and duration of post-traumatic amnesia (PTA) duration, ideally determined by prospective serial assessment with a validated tool. Record assessment point (e.g., arrival to trauma ward) and time post-injury

•In patients with GCS verbal score >4 in ED: document acute symptoms, ideally with standardized rating scales

Biopsychosocial-ecological vulnerabilities:

•Physical/psychological comorbidities.

•Relevant therapies (especially those affecting hemostasis).

•Age, frailty, socioeconomic status, education, and employment status.

Dynamic assessment:

•Record neuroworsening (GCS, pupillary reactivity, neurological examination) over the first 7–14 days.

•Monitor symptom severity over first 7–14 days in patients not admitted to the hospital.

(3) Emerging clinical variables

Consider these additional assessments, though further validation is needed of their use and utility:

•Vestibulo-oculomotor dysfunction and balance, particularly for less severe cases.

•Cognitive assessment: standardized objective tests soon after injury (no specific platform recommended).

•Mental health: assess symptoms 7–14 days post-injury using validated scales.

Research recommendations

•Address empirical validation, refinement, implementation, and impact of the recommendations listed above.

•Define optimal approaches for assessment and notation where components of the GCS are not assessable

•Define the objective and widely accepted thresholds to characterize the full range of physiological insults.

•Evaluate data-driven tools that integrate dynamic and imputed data for prognostication and decision support.

^a These recommendations apply to patients presenting to hospital <24 h post-injury, with features recorded as part of a clinical, biomarker, imaging (CBI) framework, as well as recording modifiers (M) that may affect assessment or modify expected outcomes. Items in the clinical (C) pillar of CBI-M are classified into three categories, with a separate listing of research recommendations.

^b Untestable: e.g., M_U V_U E_U = GCS: 3U for a patient who is sedated and intubated.

TBI, traumatic brain injury; TQIP, trauma quality improvement program.