1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

Within this guideline children are defined as patients aged under 16 years and infants as those aged under 1 year at the time of presentation to hospital with head injury.

Terms used in this guideline

Focal neurological deficit

Problems restricted to a particular part of the body or a particular activity, for example, difficulties with understanding, speaking, reading or writing; decreased sensation; loss of balance; general weakness; visual changes; abnormal reflexes; and problems walking.

High-energy head injury

For example, pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from a height of greater than 1 metre or more than 5 stairs, diving accident, high-speed motor vehicle collision, rollover motor accident, accident involving motorised recreational vehicles, bicycle collision, or any other potentially high-energy mechanism.

Base of open or depressed skull fracture or penetrating head injury

Signs include clear fluid running from the ears or nose, black eye with no associated damage around the eyes, bleeding from one or both ears, bruising behind one or both ears, penetrating injury signs, visible trauma to the scalp or skull of concern to the professional.

The wording used in the recommendations in this guideline (for example words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See About this guideline for details.

1.1 Pre-hospital assessment, advice and referral to hospital

1.1.1 Public health literature and other non-medical sources of advice (for example, St John Ambulance, police officers) should encourage people who have any concerns following a head injury to themselves or to another person, regardless of the injury severity, to seek immediate medical advice. [2003]

Telephone advice services

1.1.2 Telephone advice services (for example, NHS 111, emergency department helplines) should refer patients who have sustained a head injury to the emergency ambulance services (that is, 999) for emergency transport to the emergency department if they have experienced any of the following:

  • Unconsciousness or lack of full consciousness (for example, problems keeping eyes open).

  • Any focal neurological deficit since the injury.

  • Any suspicion of a skull fracture or penetrating head injury.

  • Any seizure ('convulsion' or 'fit') since the injury.

  • A high-energy head injury.

  • The injured person or their carer is incapable of transporting the injured person safely to the hospital emergency department without the use of ambulance services (providing any other risk factor indicating emergency department referral is present; see recommendation 1.1.3). [2003, amended 2007 and 2014]

1.1.3 Telephone advice services (for example, NHS 111 or emergency department helplines) should refer patients who have sustained a head injury to a hospital emergency department if they have any of the following risk factors:

  • Any loss of consciousness ('knocked out') as a result of the injury, from which the person has now recovered.

  • Amnesia for events before or after the injury ('problems with memory')[4].

  • Persistent headache since the injury.

  • Any vomiting episodes since the injury.

  • Any previous brain surgery.

  • Any history of bleeding or clotting disorders.

  • Current anticoagulant therapy such as warfarin.

  • Current drug or alcohol intoxication.

  • There are any safeguarding concerns (for example, possible non-accidental injury or a vulnerable person is affected).

  • Irritability or altered behaviour ('easily distracted', 'not themselves', 'no concentration', 'no interest in things around them'), particularly in infants and children aged under 5 years.

  • Continuing concern by helpline staff about the diagnosis. [2003, amended 2014]

Community health services and NHS minor injury clinics

1.1.4 Community health services (GPs, ambulance crews, NHS walk-in centres, dental practitioners) and NHS minor injury clinics should refer patients who have sustained a head injury to a hospital emergency department, using the ambulance service if deemed necessary, if any of the following are present:

  • Glasgow coma scale (GCS) score of less than 15 on initial assessment.

  • Any loss of consciousness as a result of the injury.

  • Any focal neurological deficit since the injury.

  • Any suspicion of a skull fracture or penetrating head injury since the injury.

  • Amnesia for events before or after the injury[4].

  • Persistent headache since the injury.

  • Any vomiting episodes since the injury (clinical judgement should be used regarding the cause of vomiting in those aged 12 years or younger and the need for referral).

  • Any seizure since the injury.

  • Any previous brain surgery.

  • A high-energy head injury.

  • Any history of bleeding or clotting disorders.

  • Current anticoagulant therapy such as warfarin.

  • Current drug or alcohol intoxication.

  • There are any safeguarding concerns (for example, possible non-accidental injury or a vulnerable person is affected).

  • Continuing concern by the professional about the diagnosis. [2003, amended 2007 and 2014]

1.1.5 In the absence of any risk factors in recommendation 1.1.4, consider referral to an emergency department if any of the following factors are present, depending on judgement of severity:

  • Irritability or altered behaviour, particularly in infants and children aged under 5 years.

  • Visible trauma to the head not covered in recommendation 1.1.4 but still of concern to the professional.

  • No one is able to observe the injured person at home.

  • Continuing concern by the injured person or their family or carer about the diagnosis. [2003, amended 2014]

Transport to hospital from community health services and NHS minor injury clinics

1.1.6 Patients referred from community health services and NHS minor injury clinics should be accompanied by a competent adult during transport to the emergency department. [2003]

1.1.7 The referring professional should determine if an ambulance is required, based on the patient's clinical condition. If an ambulance is deemed not required, public transport and car are appropriate means of transport providing the patient is accompanied. [2003]

1.1.8 The referring professional should inform the destination hospital (by phone) of the impending transfer and in non-emergencies a letter summarising signs and symptoms should be sent with the patient. [2003]

Training in risk assessment

1.1.9 GPs, nurse practitioners, dentists and ambulance crews should receive training, as necessary, to ensure that they are capable of assessing the presence or absence of the risk factors listed in recommendations 1.1.4 and 1.1.5. [2003, amended 2007]

1.2 Immediate management at the scene and transport to hospital

Glasgow coma scale

1.2.1 Base monitoring and exchange of information about individual patients on the three separate responses on the GCS (for example, a patient scoring 13 based on scores of 4 on eye-opening, 4 on verbal response and 5 on motor response should be communicated as E4, V4, M5). [2003]

1.2.2 If a total score is recorded or communicated, base it on a sum of 15, and to avoid confusion specify this denominator (for example, 13/15). [2003]

1.2.3 Describe the individual components of the GCS in all communications and every note and ensure that they always accompany the total score. [2003]

1.2.4 In the paediatric version of the GCS, include a 'grimace' alternative to the verbal score to facilitate scoring in preverbal children. [2003]

1.2.5 In some patients (for example, patients with dementia, underlying chronic neurological disorders or learning disabilities) the pre-injury baseline GCS may be less than 15. Establish this where possible, and take it into account during assessment. [new 2014]

Initial assessment and care

1.2.6 Initially assess adults who have sustained a head injury and manage their care according to clear principles and standard practice, as embodied in the:

  • Advanced Trauma Life Support (ATLS) course/European Trauma course.

  • International Trauma Life Support (ITLS) course.

  • Pre-hospital Trauma Life Support (PHTLS) course.

  • Advanced Trauma Nurse Course (ATNC).

  • Trauma Nursing Core Course (TNCC).

  • Joint Royal Colleges Ambulance Service Liaison Committee (JRCALC) Clinical Practice Guidelines for Head Trauma. [2003, amended 2007]

1.2.7 Initially assess children who have sustained a head injury and manage their care according to clear principles outlined in the:

  • Advanced Paediatric Life Support (APLS)/European Paediatric Life Support (EPLS) course.

  • Pre-hospital Paediatric Life Support (PHPLS) course.

  • Paediatric Education for Pre-hospital Professionals (PEPP) course. [2003, amended 2007]

1.2.8 When administering immediate care, treat first the greatest threat to life and avoid further harm. [2003]

1.2.9 Attempt full cervical spine immobilisation for patients who have sustained a head injury and present with any of the following risk factors unless other factors prevent this:

  • GCS less than 15 on initial assessment by the healthcare professional.

  • Neck pain or tenderness.

  • Focal neurological deficit.

  • Paraesthesia in the extremities.

  • Any other clinical suspicion of cervical spine injury. [2003, amended 2007]

1.2.10 Maintain cervical spine immobilisation until full risk assessment including clinical assessment (and imaging if deemed necessary) indicates it is safe to remove the immobilisation device. [2003, amended 2007]

1.2.11 Make standby calls to the destination emergency department for all patients with GCS 8 or less to ensure appropriately experienced professionals are available for their treatment and to prepare for imaging. [2003]

1.2.12 Manage pain effectively because it can lead to a rise in intracranial pressure. Provide reassurance, splintage of limb fractures and catheterisation of a full bladder, where needed. [2007, amended 2014]

1.2.13 Follow at all times best practice in paediatric coma observation and recording as detailed by the National Paediatric Neuroscience Benchmarking Group. [2003]

Transport to hospital

1.2.14 Transport patients who have sustained a head injury directly to a hospital that has the resources to further resuscitate them and to investigate and initially manage multiple injuries. All acute hospitals receiving patients with head injury directly from an incident should have these resources, which should be appropriate for a patient's age[5]. [new 2014]

Training for ambulance crews

1.2.15 Ambulance crews should be fully trained in the use of the adult and paediatric versions of the GCS and its derived score. [2003]

1.2.16 Ambulance crews should be trained in the safeguarding of children and vulnerable adults and should document and verbally inform emergency department staff of any safeguarding concerns. [2003, amended 2014]

1.3 Assessment in the emergency department

1.3.1 Be aware that the priority for all emergency department patients is the stabilisation of airway, breathing and circulation (ABC) before attention to other injuries. [2003]

1.3.2 Ascribe depressed conscious level to intoxication only after a significant brain injury has been excluded. [2003]

1.3.3 All emergency department clinicians involved in the assessment of patients with a head injury should be capable of assessing the presence or absence of the risk factors for CT head and cervical spine imaging listed in recommendations 1.4.7–1.4.12 and recommendations 1.5.8–1.5.14. Training should be made available as required to ensure that this is the case. [2003]

1.3.4 Patients presenting to the emergency department with impaired consciousness (GCS less than 15) should be assessed immediately by a trained member of staff. [2003]

1.3.5 In patients with GCS 8 or less, ensure there is early involvement of an anaesthetist or critical care physician to provide appropriate airway management, as described in recommendations 1.7.7 and 1.7.8, and to assist with resuscitation. [2003]

1.3.6 A trained member of staff should assess all patients presenting to an emergency department with a head injury within a maximum of 15 minutes of arrival at hospital. Part of this assessment should establish whether they are high risk or low risk for clinically important brain injury and/or cervical spine injury, using recommendations 1.4.7–1.4.12 and recommendations 1.5.8–1.5.14. [2003]

1.3.7 In patients considered to be at high risk for clinically important brain injury and/or cervical spine injury, extend assessment to full clinical examination to establish the need to request CT imaging of the head and/or imaging of the cervical spine and other body areas. Use recommendations 1.4.7–1.4.12 and recommendations 1.5.8–1.5.14 as the basis for the final decision on imaging after discussion with the radiology department. [2003, amended 2007]

1.3.8 Patients who, on initial assessment, are considered to be at low risk for clinically important brain injury and/or cervical spine injury should be re-examined within a further hour by an emergency department clinician. Part of this assessment should fully establish the need to request CT imaging of the head and/or imaging of the cervical spine. Use recommendations 1.4.7–1.4.12 and recommendations 1.5.8–1.5.14 as the basis for the final decision on imaging after discussion with the radiology department. [2003, amended 2007]

1.3.9 Patients who return to an emergency department within 48 hours of transfer to the community with any persistent complaint relating to the initial head injury should be seen by or discussed with a senior clinician experienced in head injuries, and considered for a CT scan. [2003]

1.3.10 Manage pain effectively because it can lead to a rise in intracranial pressure. Provide reassurance, splintage of limb fractures and catheterisation of a full bladder, where needed. Treat significant pain with small doses of intravenous opioids titrated against clinical response and baseline cardiorespiratory measurements[6]. [2007]

1.3.11 A clinician with training in safeguarding should be involved in the initial assessment of any patient with a head injury presenting to the emergency department. If there are any concerns identified, document these and follow local safeguarding procedures appropriate to the patient's age. [2003, amended 2014]

1.3.12 Throughout the hospital episode, use a standard head injury proforma in documentation when assessing and observing patients with head injury. This form should be of a consistent format across all clinical departments and hospitals in which a patient might be treated. Use a separate proforma for those under 16 years. Areas to allow extra documentation should be included (for example, in cases of non-accidental injury). Examples of proforma that should be used in patients with head injury are provided in appendix O of the full guideline. [2003, amended 2007]

Involving the neurosurgical department

1.3.13 Discuss with a neurosurgeon the care of all patients with new, surgically significant abnormalities on imaging. The definition of 'surgically significant' should be developed by local neurosurgical centres and agreed with referring hospitals, along with referral procedures. [2003, amended 2014]

1.3.14 Regardless of imaging, other reasons for discussing a patient's care plan with a neurosurgeon include:

  • Persisting coma (GCS 8 or less) after initial resuscitation.

  • Unexplained confusion which persists for more than 4 hours.

  • Deterioration in GCS score after admission (greater attention should be paid to motor response deterioration).

  • Progressive focal neurological signs.

  • A seizure without full recovery.

  • Definite or suspected penetrating injury.

  • A cerebrospinal fluid leak. [2003]

1.4 Investigating clinically important brain injuries

1.4.1 The current primary investigation of choice for the detection of acute clinically important brain injuries is CT imaging of the head. [2003]

1.4.2 For safety, logistic and resource reasons, do not perform magnetic resonance imaging (MRI) scanning as the primary investigation for clinically important brain injury in patients who have sustained a head injury, although it is recognised that additional information of importance to the patient's prognosis can sometimes be detected using MRI. [2003]

1.4.3 Ensure that there is appropriate equipment for maintaining and monitoring the patient within the MRI environment and that all staff involved are aware of the dangers and necessary precautions for working near an MRI scanner. [2003]

1.4.4 Do not use plain X-rays of the skull to diagnose significant brain injury without prior discussion with a neuroscience unit. However, they are useful as part of the skeletal survey in children presenting with suspected non-accidental injury. [2007]

1.4.5 If CT imaging is unavailable because of equipment failure, patients with GCS 15 may be admitted for observation. Arrangements should be in place for urgent transfer to a centre with CT scanning available should there be a clinical deterioration that indicates immediate CT scanning is necessary. [2007]

1.4.6 In line with good radiation exposure practice, make every effort to minimise radiation dose during imaging of the head and cervical spine, while ensuring that image quality and coverage is sufficient to achieve an adequate diagnostic study. [2003]

Criteria for performing a CT head scan

Adults

1.4.7 For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:

  • GCS less than 13 on initial assessment in the emergency department.

  • GCS less than 15 at 2 hours after the injury on assessment in the emergency department.

  • Suspected open or depressed skull fracture.

  • Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).

  • Post-traumatic seizure.

  • Focal neurological deficit.

  • More than 1 episode of vomiting.

    A provisional written radiology report should be made available within 1 hour of the scan being performed. [new 2014]

1.4.8 For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury, perform a CT head scan within 8 hours of the head injury:

  • Age 65 years or older.

  • Any history of bleeding or clotting disorders.

  • Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).

  • More than 30 minutes' retrograde amnesia of events immediately before the head injury.

    A provisional written radiology report should be made available within 1 hour of the scan being performed. [new 2014]

Children

1.4.9 For children who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:

  • Suspicion of non-accidental injury

  • Post-traumatic seizure but no history of epilepsy.

  • On initial emergency department assessment, GCS less than 14, or for children under 1 year GCS (paediatric) less than 15.

  • At 2 hours after the injury, GCS less than 15.

  • Suspected open or depressed skull fracture or tense fontanelle.

  • Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).

  • Focal neurological deficit.

  • For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head.

    A provisional written radiology report should be made available within 1 hour of the scan being performed. [new 2014]

1.4.10 For children who have sustained a head injury and have more than 1 of the following risk factors (and none of those in recommendation 1.4.9), perform a CT head scan within 1 hour of the risk factors being identified:

  • Loss of consciousness lasting more than 5 minutes (witnessed).

  • Abnormal drowsiness.

  • Three or more discrete episodes of vomiting.

  • Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object).

  • Amnesia (antegrade or retrograde) lasting more than 5 minutes[4].

    A provisional written radiology report should be made available within 1 hour of the scan being performed. [new 2014]

1.4.11 Children who have sustained a head injury and have only 1 of the risk factors in recommendation 1.4.10 (and none of those in recommendation 1.4.9) should be observed for a minimum of 4 hours after the head injury. If during observation any of the risk factors below are identified, perform a CT head scan within 1 hour:

  • GCS less than 15.

  • Further vomiting.

  • A further episode of abnormal drowsiness.

    A provisional written radiology report should be made available within 1 hour of the scan being performed. If none of these risk factors occur during observation, use clinical judgement to determine whether a longer period of observation is needed. [new 2014]

Patients having warfarin treatment

1.4.12 For patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having warfarin treatment, perform a CT head scan within 8 hours of the injury. A provisional written radiology report should be made available within 1 hour of the scan being performed. [new 2014]

1.5 Investigating injuries to the cervical spine

1.5.1 Be aware that, as a minimum, CT should cover any areas of concern or uncertainty on X-ray or clinical grounds. [2003]

1.5.2 Ensure that facilities are available for multiplanar reformatting and interactive viewing of CT cervical spine scans. [2003, amended 2014]

1.5.3 MR imaging is indicated if there are neurological signs and symptoms referable to the cervical spine. If there is suspicion of vascular injury (for example, vertebral malalignment, a fracture involving the foramina transversaria or lateral processes, or a posterior circulation syndrome), CT or MRI angiography of the neck vessels may be performed to evaluate for this. [2003, amended 2014]

1.5.4 Be aware that MRI may add important information about soft tissue injuries associated with bony injuries demonstrated by X-ray and/or CT. [2003]

1.5.5 MRI has a role in the assessment of ligamentous and disc injuries suggested by X-ray, CT or clinical findings. [2003]

1.5.6 In CT, routinely review on 'bone windows' the occipital condyle region for patients who have sustained a head injury. Reconstruction of standard head images onto a high-resolution bony algorithm is readily achieved with modern CT scanners. [2003]

1.5.7 In patients who have sustained high-energy trauma or are showing signs of lower cranial nerve palsy, pay particular attention to the region of the foramen magnum. If necessary, perform additional high-resolution imaging for coronal and sagittal reformatting while the patient is on the scanner table. [2003]

Criteria for performing a CT cervical spine scan in adults

1.5.8 For adults who have sustained a head injury and have any of the following risk factors, perform a CT cervical spine scan within 1 hour of the risk factor being identified:

  • GCS less than 13 on initial assessment.

  • The patient has been intubated.

  • Plain X-rays are technically inadequate (for example, the desired view is unavailable).

  • Plain X-rays are suspicious or definitely abnormal.

  • A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).

  • The patient is having other body areas scanned for head injury or multi-region trauma.

  • The patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply:

    • age 65 years or older

    • dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision)

    • focal peripheral neurological deficit

    • paraesthesia in the upper or lower limbs.

      A provisional written radiology report should be made available within 1 hour of the scan being performed. [new 2014]

1.5.9 For adults who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan (see recommendation 1.5.8), perform 3-view cervical spine X-rays within 1 hour if either of these risk factors are identified:

  • It is not considered safe to assess the range of movement in the neck (see recommendation 1.5.10).

  • Safe assessment of range of neck movement shows that the patient cannot actively rotate their neck to 45 degrees to the left and right.

    The X-rays should be reviewed by a clinician trained in their interpretation within 1 hour of being performed. [new 2014]

Assessing range of movement in the neck

1.5.10 Be aware that in adults and children who have sustained a head injury and in whom there is clinical suspicion of cervical spine injury, range of movement in the neck can be assessed safely before imaging only if no high-risk factors (see recommendations 1.5.8, 1.5.11 and 1.5.12) and at least 1 of the following low-risk features apply. The patient:

  • was involved in a simple rear-end motor vehicle collision

  • is comfortable in a sitting position in the emergency department

  • has been ambulatory at any time since injury

  • has no midline cervical spine tenderness

  • presents with delayed onset of neck pain. [new 2014]

Criteria for performing a CT cervical spine scan in children

1.5.11 For children who have sustained a head injury, perform a CT cervical spine scan only if any of the following apply (because of the increased risk to the thyroid gland from ionising radiation and the generally lower risk of significant spinal injury):

  • GCS less than 13 on initial assessment.

  • The patient has been intubated.

  • Focal peripheral neurological signs.

  • Paraesthesia in the upper or lower limbs.

  • A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).

  • The patient is having other body areas scanned for head injury or multi-region trauma.

  • There is strong clinical suspicion of injury despite normal X-rays.

  • Plain X-rays are technically difficult or inadequate.

  • Plain X-rays identify a significant bony injury.

    The scan should be performed within 1 hour of the risk factor being identified. A provisional written radiology report should be made available within 1 hour of the scan being performed. [new 2014]

1.5.12 For children who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan (see recommendation 1.5.11), perform 3-view cervical spine X-rays before assessing range of movement in the neck if either of these risk factors are identified:

  • Dangerous mechanism of injury (that is, fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision).

  • Safe assessment of range of movement in the neck is not possible (see recommendation 1.5.10).

    The X-rays should be carried out within 1 hour of the risk factor being identified and reviewed by a clinician trained in their interpretation within 1 hour of being performed. [new 2014]

1.5.13 If range of neck movement can be assessed safely (see recommendation 1.5.10) in a child who has sustained a head injury and has neck pain or tenderness but no indications for a CT cervical spine scan, perform 3-view cervical spine X-rays if the child cannot actively rotate their neck 45 degrees to the left and right. The X-rays should be carried out within 1 hour of this being identified and reviewed by a clinician trained in their interpretation within 1 hour of being performed. [new 2014]

1.5.14 In children who can obey commands and open their mouths, attempt an odontoid peg view. [2003, amended 2014]

1.6 Information and support for families and carers

1.6.1 Staff caring for patients with a head injury should introduce themselves to family members or carers and briefly explain what they are doing. [2003, amended 2014]

1.6.2 Ensure that information sheets detailing the nature of head injury and any investigations likely to be used are made available in the emergency department. NICE's information for the public about this guideline may be helpful. [2003]

1.6.3 Staff should consider how best to share information with children and introduce them to the possibility of long-term complex changes in their parent or sibling. Literature produced by patient support groups may be helpful. [2003]

1.6.4 Encourage family members and carers to talk and make physical contact (for example, holding hands) with the patient. However, it is important that relatives and friends do not feel obliged to spend long periods at the bedside. If they wish to stay with the patient, encourage them to take regular breaks. [2003, amended 2007]

1.6.5 Ensure there is a board or area displaying leaflets or contact details for patient support organisations either locally or nationally to enable family members and carers to gather further information. [2003]

1.7 Transfer from hospital to a neuroscience unit

Transfer of adults

1.7.1 Local guidelines on the transfer of patients with head injuries should be drawn up between the referring hospital trusts, the neuroscience unit and the local ambulance service, and should recognise that:

  • transfer would benefit all patients with serious head injuries (GCS 8 or less) irrespective of the need for neurosurgery

  • if transfer of those who do not require neurosurgery is not possible, ongoing liaison with the neuroscience unit over clinical management is essential. [2003, amended 2007]

1.7.2 The possibility of occult extracranial injuries should be considered for adults with multiple injuries, and they should not be transferred to a service that is unable to deal with other aspects of trauma. [2007]

1.7.3 There should be a designated consultant in the referring hospital with responsibility for establishing arrangements for the transfer of patients with head injuries to a neuroscience unit and another consultant at the neuroscience unit with responsibility for establishing arrangements for communication with referring hospitals and for receipt of patients transferred. [2003]

1.7.4 Patients with head injuries requiring emergency transfer to a neuroscience unit should be accompanied by a doctor with appropriate training and experience in the transfer of patients with acute brain injury. They should be familiar with the pathophysiology of head injury, the drugs and equipment they will use and working in the confines of an ambulance (or helicopter if appropriate). They should have a dedicated and adequately trained assistant. They should be provided with appropriate clothing for the transfer, medical indemnity and personal accident insurance. Patients requiring non-emergency transfer should be accompanied by appropriate clinical staff. [2003, amended 2007]

1.7.5 Provide the transfer team responsible for transferring a patient with a head injury with a means of communicating changes in the patient's status with their base hospital and the neurosurgical unit during the transfer. [2003, amended 2014]

1.7.6 Although it is understood that transfer is often urgent, complete the initial resuscitation and stabilisation of the patient and establish comprehensive monitoring before transfer to avoid complications during the journey. Do not transport a patient with persistent hypotension, despite resuscitation, until the cause of the hypotension has been identified and the patient stabilised. [2003, amended 2007]

1.7.7 Intubate and ventilate all patients with GCS 8 or less requiring transfer to a neuroscience unit, and any patients with the indications detailed in recommendation 1.7.8. [2003]

1.7.8 Intubate and ventilate the patient immediately in the following circumstances:

  • Coma – not obeying commands, not speaking, not eye opening (that is, GCS 8 or less).

  • Loss of protective laryngeal reflexes.

  • Ventilatory insufficiency as judged by blood gases: hypoxaemia (PaO2 < 13 kPa on oxygen) or hypercarbia (PaCO2 > 6 kPa).

  • Spontaneous hyperventilation causing PaCO2 < 4 kPa.

  • Irregular respirations. [2003, amended 2007]

1.7.9 Use intubation and ventilation before the start of the journey in the following circumstances:

  • Significantly deteriorating conscious level (1 or more points on the motor score), even if not coma.

  • Unstable fractures of the facial skeleton.

  • Copious bleeding into mouth (for example, from skull base fracture).

  • Seizures. [2003, amended 2007]

1.7.10 Ventilate an intubated patient with muscle relaxation and appropriate short-acting sedation and analgesia. Aim for a PaO2 greater than 13 kPa, PaCO2 4.5 to 5.0 kPa unless there is clinical or radiological evidence of raised intracranial pressure, in which case more aggressive hyperventilation is justified. If hyperventilation is used, increase the inspired oxygen concentration. Maintain the mean arterial pressure at 80 mm Hg or more by infusion of fluid and vasopressors as indicated. In children, maintain blood pressure at a level appropriate for the child's age. [2003, amended 2007]

1.7.11 Education, training and audit are crucial to improving standards of transfer; appropriate time and funding for these activities should be provided. [2003]

1.7.12 Give family members and carers as much access to the patient as is practical during transfer. If possible, give them an opportunity to discuss the reasons for transfer and how the transfer process works with a member of the healthcare team. [2003, amended 2014]

Transfer of children

1.7.13 Recommendations 1.7.1–1.7.12 were written for adults, but apply these principles equally to children and infants, providing that the paediatric modification of the GCS is used. [2003]

1.7.14 Service provision in the area of paediatric transfer to tertiary care should also follow the principles outlined in the National Service Framework for Paediatric Intensive Care. These do not conflict with the principles outlined in this section. [2003]

1.7.15 The possibility of occult extracranial injuries should be considered for children with multiple injuries. Do not transfer them to a service that is unable to deal with other aspects of trauma. [2007]

1.7.16 Transfer of a child or infant to a specialist neurosurgical unit should be undertaken by staff experienced in the transfer of critically ill children. [2003]

1.7.17 Give family members and carers as much access to their child as is practical during transfer. If possible, give them an opportunity to discuss the reasons for transfer and how the transfer process works with a member of the healthcare team. [2003, amended 2014]

1.8 Admission and observation

1.8.1 Use the criteria below for admitting patients to hospital following a head injury:

  • Patients with new, clinically significant abnormalities on imaging.

  • Patients whose GCS has not returned to 15 after imaging, regardless of the imaging results.

  • When a patient has indications for CT scanning but this cannot be done within the appropriate period, either because CT is not available or because the patient is not sufficiently cooperative to allow scanning.

  • Continuing worrying signs (for example, persistent vomiting, severe headaches) of concern to the clinician.

  • Other sources of concern to the clinician (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak). [2003]

1.8.2 Be aware that some patients may require an extended period in a recovery setting because of the use of general anaesthesia during CT imaging. [2003, amended 2007]

1.8.3 Admit patients with multiple injuries under the care of the team that is trained to deal with their most severe and urgent problem. [2003]

1.8.4 In circumstances where a patient with a head injury requires hospital admission, admit the patient only under the care of a team led by a consultant who has been trained in the management of this condition during their higher specialist training. The consultant and their team should have competence (defined by local agreement with the neuroscience unit) in assessment, observation and indications for imaging (see recommendations 1.4.7–1.4.12 and 1.5.8–1.5.14); inpatient management; indications for transfer to a neuroscience unit (see section 1.7); and hospital discharge and follow-up (see section 1.9). [2003, amended 2007]

Observation of admitted patients

1.8.5 In-hospital observation of patients with a head injury should only be conducted by professionals competent in the assessment of head injury. [2003]

1.8.6 For patients admitted for head injury observation the minimum acceptable documented neurological observations are: GCS; pupil size and reactivity; limb movements; respiratory rate; heart rate; blood pressure; temperature; blood oxygen saturation. [2003]

1.8.7 Perform and record observations on a half-hourly basis until GCS equal to 15 has been achieved. The minimum frequency of observations for patients with GCS equal to 15 should be as follows, starting after the initial assessment in the emergency department:

  • Half-hourly for 2 hours.

  • Then 1-hourly for 4 hours.

  • Then 2-hourly thereafter. [2003]

1.8.8 Should the patient with GCS equal to 15 deteriorate at any time after the initial 2-hour period, observations should revert to half-hourly and follow the original frequency schedule. [2003]

1.8.9 Any of the following examples of neurological deterioration should prompt urgent reappraisal by the supervising doctor.

  • Development of agitation or abnormal behaviour.

  • A sustained (that is, for at least 30 minutes) drop of 1 point in GCS score (greater weight should be given to a drop of 1 point in the motor response score of the GCS).

  • Any drop of 3 or more points in the eye-opening or verbal response scores of the GCS, or 2 or more points in the motor response score.

  • Development of severe or increasing headache or persisting vomiting.

  • New or evolving neurological symptoms or signs such as pupil inequality or asymmetry of limb or facial movement. [2003, amended 2007]

1.8.10 To reduce inter-observer variability and unnecessary referrals, a second member of staff competent to perform observation should confirm deterioration before involving the supervising doctor. This confirmation should be carried out immediately. Where a confirmation cannot be performed immediately (for example, no staff member available to perform the second observation) the supervising doctor should be contacted without the confirmation being performed. [2003]

1.8.11 If any of the changes noted in recommendation 1.8.9 are confirmed, an immediate CT scan should be considered, and the patient's clinical condition re‑assessed and managed appropriately. [2003, amended 2007]

1.8.12 In the case of a patient who has had a normal CT scan but who has not achieved GCS equal to 15 after 24 hours' observation, a further CT scan or MRI scanning should be considered and discussed with the radiology department. [2003]

Observation of infants and young children

1.8.13 Observation of infants and young children (that is, aged under 5 years) is a difficult exercise and therefore should only be performed by units with staff experienced in the observation of infants and young children with a head injury. Infants and young children may be observed in normal paediatric observation settings, as long as staff have the appropriate experience. [2003]

Training in observation

1.8.14 Medical, nursing and other staff caring for patients with head injury admitted for observation should all be capable of performing the observations listed in recommendations 1.8.6, 1.8.9 and 1.8.10. [2003]

1.8.15 The acquisition and maintenance of observation and recording skills require dedicated training and this should be made available to all relevant staff. [2003]

1.8.16 Specific training is required for the observation of infants and young children. [2003]

1.9 Discharge and follow-up

1.9.1 If CT is not indicated on the basis of history and examination the clinician may conclude that the risk of clinically important brain injury to the patient is low enough to warrant transfer to the community, as long as no other factors that would warrant a hospital admission are present (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak) and there are appropriate support structures for safe transfer to the community and for subsequent care (for example, competent supervision at home). [2003]

1.9.2 After normal imaging of the head, the clinician may conclude that the risk of clinically important brain injury requiring hospital care is low enough to warrant transfer to the community, as long as the patient has returned to GCS equal to 15, and no other factors that would warrant a hospital admission are present (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak) and there are appropriate support structures for safe transfer to the community and for subsequent care (for example, competent supervision at home). [2003]

1.9.3 After normal imaging of the cervical spine the clinician may conclude that the risk of injury to the cervical spine is low enough to warrant transfer to the community, as long as the patient has returned to GCS equal to 15 and their clinical examination is normal, and no other factors that would warrant a hospital admission are present (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak) and there are appropriate support structures for safe transfer to the community and for subsequent care (for example, competent supervision at home). [2003]

1.9.4 Do not discharge patients presenting with head injury until they have achieved GCS equal to 15, or normal consciousness in infants and young children as assessed by the paediatric version of the GCS. [2003]

1.9.5 All patients with any degree of head injury should only be transferred to their home if it is certain that there is somebody suitable at home to supervise the patient. Discharge patients with no carer at home only if suitable supervision arrangements have been organised, or when the risk of late complications is deemed negligible. [2003]

Discharge after observation

1.9.6 Patients admitted after a head injury may be discharged after resolution of all significant symptoms and signs providing they have suitable supervision arrangements at home. [2003]

Discharge advice

1.9.7 Give verbal and printed discharge advice to patients with any degree of head injury who are discharged from an emergency department or observation ward, and their families and carers. Follow recommendations in Patient experience in adult NHS services [NICE clinical guideline 138] about providing information in an accessible format. [new 2014]

1.9.8 Printed advice for patients, families and carers should be age-appropriate and include:

  • Details of the nature and severity of the injury.

  • Risk factors that mean patients need to return to the emergency department (see recommendations 1.1.4 and 1.1.5).

  • A specification that a responsible adult should stay with the patient for the first 24 hours after their injury.

  • Details about the recovery process, including the fact that some patients may appear to make a quick recovery but later experience difficulties or complications.

  • Contact details of community and hospital services in case of delayed complications.

  • Information about return to everyday activities, including school, work, sports and driving.

  • Details of support organisations. [new 2014]

1.9.9 Offer information and advice on alcohol or drug misuse to patients who presented to the emergency department with drug or alcohol intoxication when they are fit for discharge. [2003]

1.9.10 Inform patients and their families and carers about the possibility of persistent or delayed symptoms following head injury and whom to contact if they experience ongoing problems. [new 2014]

1.9.11 For all patients who have attended the emergency department with a head injury, write to their GP within 48 hours of discharge, giving details of clinical history and examination. This letter should also be shared with health visitors (for pre-school children) and school nurses (for school-age children). If appropriate, provide a copy of the letter for the patient and their family or carer. [new 2014]

Follow-up

1.9.12 When a patient who has undergone imaging of the head and/or been admitted to hospital experiences persisting problems, ensure that there is an opportunity available for referral from primary care to an outpatient appointment with a professional trained in assessment and management of sequelae of brain injury (for example, clinical psychologist, neurologist, neurosurgeon, specialist in rehabilitation medicine). [2003]



[4] Assessment of amnesia will not be possible in preverbal children and is unlikely to be possible in children aged under 5 years.

[5] In the NHS in England these hospitals would be trauma units or major trauma centres. In the NHS in Wales this should be a hospital with equivalent capabilities.

[6] At the time of publication (January 2014), intravenous opioids did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

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