Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

Transport to hospital

  • 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[2]. [new 2014]

Assessment in the emergency department

  • 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]

Criteria for performing a CT head scan

  • 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]

  • 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]

  • For children who have sustained a head injury and have more than one of the following risk factors (and none of those in recommendation 1.4.9 above), 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.[3]

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

  • 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]

  • 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. (For advice on reversal of warfarin anticoagulation in people with suspected traumatic intracranial haemorrhage, see the NICE guideline on blood transfusion.) [new 2014]

Investigating injuries to the cervical spine

  • 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]

Discharge and follow-up

  • 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]

  • Printed advice for patients, family members 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]



[2] 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.

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

  • National Institute for Health and Care Excellence (NICE)