20) Anesthetics, analgesics, and sedatives: Timing: < 1.5 Hrs after surgery / 1.5-2.

ery / 1.5-2.5 Hrs CSF leak: N/Y

Barbiturates prophylaxis against ICP: N / Y after surgery / > 2.5 Hrs after surgery Subdural hygroma: N/Y
Barbiturates to control elevated ICP refractory Duration: < 48 Hrs / > 48 Hrs Nutritional deficit: N/Y
to all treatments: N/Y Coverage: Head only / Systemic cooling
Propofol to control elevated ICP refractory to all
24) Hyperosmolar Therapy: 28) Glasgow Outcome Scale:
treatments: N/Y
Type: HS / Mannitol / RL / Sodium Lactate First 24 Hrs:
Morphine Sulphate: N/Y
Percentage (%): Dose: 30 days post-trauma:
Midazolam: N/Y
Method: Bolus / Continuous 90 days post-trauma:
Others:
29) Mortality:
21) ICP intervention & Management: 25) Nutrition: First 24 Hrs:
ICP management: Medical / Surgical / Both Route of feeding: Oral / Enteral / Intravenous 30 days post-trauma:
Surgery: None / Decompressive craniotomy / Method: Oral / NGT / TPN / G-tube or J-tube 90 days post-trauma:
Decompressive craniectomy Elements / Vitamins deficiency: N/Y
Time from ICP decompression (HH:MM): Complication of feeding:
30) Discharge:
22) Surgical intervention: Fate: Death / Alive
Surgery: N/Y 26) CSF Drainage: Date (DD/MM/YY):
Knife to skin date (DD/MM/YYY): Drainage: N/Y Discharge Destination: Home / Rehabilitation
Knife to skin time (HH:MM): Indication: Hydrocephalus / Infection / Leak unit / Morgue / Another ICC / Another
Timing of decompression: Late / Early Duration (Days): Intermittent / Continuous intermediate-low care somatic hospital ward /
Main operator: Resident / Staff surgeon Type of Drainage: EVD / LP / VP / VA / VSG other or unknown
Main anesthesiologist: Resident / Staff
Type of surgery: Evacuation only /
Decompression only / Both (craniotomy) / Both 27) Complications:
(craniectomy) Fever: N/Y
Site of surgery: F / FP / FPT / PT / OP / T / P / O / Infection: N/Y
Interhemispheric / Posterior Fossa Infection source: Unknown / URTI / UTI / GIT /
Intraoperative complications (IOC): N / Y LRTI / Eye / Skin abscess / Perinephric abscess
Type of IOC: Spasticity: N/Y
Reoperation: N/Y Bleeding diathesis: N/Y
Indication: Increased ICP / Re-bleed / Infection Type of bleeding diathesis: Platelet dysfunction
(empyema or abscess) / Surgical site infection / Factor IIX or IX / DIC
Wound complications: N / Y
23) Temperature management: Type of wound complication: Mal-alignment /
Prophylactic hypothermia: N / Y Stitch sinus / Collection underneath / surgical
When: site infection
B. Pneumocephalus: N/Y 15) Vascular Injuries: Timing of seizure: Immediate / Early post-
Type: Extradural / Subdural / Ventricular / Presence of vascular injuries: No / Arterial trauma / late post-trauma
Cisternal dissection / Traumatic Pseudoaneurysm / Therapy: None / Monotherapy / Dual drug
Tension Pneumocephalus: N / Y Carotid venous fistula / Dural AV fistula / therapy / IV BDZ / IV Phenytoin / General
C. Subdural Hematoma: N / Y Cerebral fat embolism Anesthesia
Location: F / FP / FPT / PT / OT / T / P / O / Side: Right / Left / Bilateral Maintenance: Carbamazepine / Lamotrigine /
Interhemispheric / Posterior Fossa Levetiracetam / Gabapentin / Oxcarbazepine /
Side: Right / Left / Bilateral Phenobarbital / Phenytoin / Fosphenytoin /
15) CSF leak:
Size (cm3): Diameter (cm): Pregabalin / Topiramate / Valproate /
Presence of leak: N/Y
D. Subarachnoid Hemorrhage (SAH): Zonisamide / Others
Site of leak: Rhinorrhea/Otorrhea/ Strange taste
Location: No / Cortical / Cisternal Hypo/Hyper-natremia: N/Y
Treatment: Medical / Surgical
Fisher Classification: Not estimated / No SAH /
Surgical treatment: Endoscopic Endonasal 18) Neuromonitoring:
Grade 1 / Grade 2 / Grade 3 / Grade 4
repair / Open (craniotomy) ICP Monitoring: Not available / available but not
E. Contusion(s): N/Y
used / used
Number of contusion(s): 17) Secondary injuries:
Types: Intraventricular / Intraparenchymal /
Side: Right / Left / Bilateral Presence of secondary injuries: N/Y
Subarachnoid / Epidural / Subdural
Location: F / FP / FPT / PT / OT / T / P / O / PF Hypotension: N/Y
Technique: EVD / Micro-transducer
Diameter (cm): Hypertension: N/Y
Inc-ICP: N/Y
F. Intracerebral Hemorrhage: Ischemia: N/Y
Hi-ICP: N/Y
Location: F / FP / FPT / PT / OT / T / P / O / Anemia: N/Y
Cerebral Oxygenation Monitoring: Not available
Posterior fossa Blood transfusion: N/Y
/ Available but not used / JV oximetry / Brain
Side: Right / Left / Bilateral Hypo/Hyper-carbia:
Tissue pO2 / Near infrared spectroscopy
Size (cm3): No / Hypocarbia / Hypercarbia
CBF monitoring: Not available / available but
G. Diffuse Axonal Injury: N/Y Hypo/Hyper-glycemia:
not used / Transcranial doppler / Thermal
H. Brainstem injury: N/Y No / Hypoglycemia / Hyperglycemia
diffusion flowmetry
I. Midline shift: No / Yes, < 1 cm / Yes > 1cm Hydrocephalus: N/Y
EEG: Not available / Available but not used /
Treatment of Hydrocephalus: EVD / LP / VP / VA
13) Herniation Syndrome: Non-invasive scalp / Invasive scalp / Invasive
/ VSG
Presence of herniation: N/Y depth
Infection: N/Y
Type of herniation: Uncal / Central / Cingulate /
Type of infection: Brain abscess / Meningitis / 19) ICU admission:
Subfalcine / Upward / Tonsillar / None
Ventriculitis Admitted to ICU: N/Y
14) Infarction: Edema: N/Y Frequency:
Presence of infarction: N/Y Grade: None / Grade 1 / Grade 2 / Grade 3 Total duration (days):
Offending vessels: None / ACA / MCA / PCA / Seizure: N/Y Mechanical Ventilator: N / Y
ICA / Vertebral artery / Venous infarction Type of seizure: SP / CP / GTC / GT / GC / EPC / Total Ventilation duration: ________days
Side: Right / Left / Bilateral SE
1) PATIENT DEMOGRAPHIC CHARACTERISTICS: 5) OTHER INJURIES: 8) TBI CLASSFICIATION & SEVERITY:
Patient ID #: Cervical spine injuries: None / C1 / C2 / C3 / C4 GCS on admission:
Sex: M / F DOB: / C5 / C6 / C7 Injury severity score (ISS):
Time & Date of Injury: Thoracolumbar spine injuries: D 1-4 / D 5-9 / D Category of head injury severity: Minimal / Mild
Time & Date of Admission: 10-12 / L1 / L2 / L3 / L4 / L5 / S1 / Other sacral / Moderate / Severe / Critical
Previous History of TBI: N / Y injuries Abbreviated Injury Scale (AIS):
Spinal cord injuries: None / Radiculopathy /
2) INJURY TYPE & MECHANISM:-
Complete injury / Brown-Sequard / Anterior 9) CONCUSSION:
Mechanism of Injury:
cervical cord syndrome / Posterior cervical cord Presence of concussion: N / Y
Traffic: MVC / Motorcycle / Bicycle / Pedestrian
syndrome / Central cord syndrome Grade: 1 / 2 / 3 / 4 / No concussion
/ Other
Treatment of spinal cord injuries: None /
Gunshot: Handgun / Shotgun / Rifle / Other
Conservative / Decompression only / Fixation 10) CT & MRI:
Stab: Knife / Sword / Dagger / Other
only / Decompression & Fixation CT: Not available / No, but available / Yes
Hit: Tree / Tree branch / Bar / Stone / Human
Polytrauma 1: Facial injury / PTX / HTX / Blunt MRI: Not available / No, but available / Yes
Body / Metal / Other
abdominal injury / Intrabdominal bleeding /
Fall: Low-energy fall / High-energy fall
Visceral injury / Pelvic # / Femur # / Leg # 11) SCALP INJURIES:
Other: Unknown
Polytrauma 2: Facial Injury Facial injury / PTX / Scalp Injuries: N / Y
Intention of Injury: Accident / Self-inflected /
HTX / Blunt abdominal injury / Intrabdominal Location: Frontal / Parietal / Temporal /
Assault / Unknown
bleeding / Visceral injury / Pelvic # / Femur # / Occipital / Zygomatic / Eyebrow
Multi-Trauma: N / Y
Leg # Length (cm):
Polytrauma 3: Facial injury / PTX / HTX / Blunt Skull fracture (bone plate): N / Y
3) PRE-HOSPITAL:
abdominal injury / Intrabdominal bleeding / Simple vs. Compound: Simple / Compound
Pre-injury ASA-PS: 1 / 2 / 3 / 4 / 5 / 6 / 7
Visceral injury / Pelvic # / Femur # / Leg # Number:
Post-injury ASA Score: 1 / 2 / 3 / 4 / 5 / 6 / 7
Location: F / P / T / O / Z
Method of Transport: Ground ambulance /
6) OTHER EVALUATIONS: Side: Right / Left / Bilateral
Helicopter ambulance / Fixed-wing ambulance /
Arterial Base Excess: INR: Skull fracture (diastatic fracture): N / Y
Private or public vehicle / Walk-in / Police /
RR on admission: HR on admission: Location: FP / FT / ZT / PT / OP / Sagittal / Other
Unknown
Side: Right / Left / Bilateral
Prehospital arrest: No / Yes / Unknown
7) B.P. & C.P.P.
Prehospital intubation: No / Yes / Unknown
SBP on admission: 12) Imaging Findings:
Prehospital prophylactic hyperventilation:
CPP on admission: A. Epidural Hematoma : Y/ N
No / Yes / Unknown
Lowest SBP in 1st 24 Hrs: Location: F / FP / FPT / PT / OP / T / P / O /
Highest CPP in 1st 24 Hrs: Posterior Fossa
4) NEUROLOGICAL ASSESSMENT (within first
Side: Right / Left / Bilateral
24 Hrs):
Size (cm3): Diameter (cm):
GCS:
Pupils: Responsive / Unresponsive