This guideline updates and replaces the NICE guideline on head injury (CG56). The recommendations are labelled according to when they were originally published (see update information for details).
For the purposes of this guideline, head injury is defined as any trauma to the head other than superficial injuries to the face. Head injury is the commonest cause of death and disability in people aged 1 to 40 years in the UK. Each year, 1.4 million people attend emergency departments in England and Wales with a recent head injury. Between 33% and 50% of these are children aged under 15 years. Annually, about 200,000 people are admitted to hospital with head injury. Of these, one-fifth have features suggesting skull fracture or have evidence of brain damage. Most patients recover without specific or specialist intervention, but others experience long-term disability or even die from the effects of complications that could potentially be minimised or avoided with early detection and appropriate treatment.
The incidence of death from head injury is low, with as few as 0.2% of all patients attending emergency departments with a head injury dying as a result of this injury. Ninety five per cent of people who have sustained a head injury present with a normal or minimally impaired conscious level (Glasgow Coma Scale [GCS] greater than 12) but the majority of fatal outcomes are in the moderate (GCS 9–12) or severe (GCS 8 or less) head injury groups, which account for only 5% of attenders. Therefore, emergency departments see a large number of patients with minor or mild head injuries and need to identify the very small number who will go on to have serious acute intracranial complications. It is estimated that 25% to 30% of children aged under 2 years who are hospitalised with head injury have an abusive head injury. This guideline has updated some of the terminology used in relation to safeguarding of children and also of vulnerable adults.
The previous head injury guideline produced by NICE in 2003 (NICE guideline CG4) and updated in 2007 (NICE guideline CG56) resulted in CT scanning replacing skull radiography as the primary imaging modality for assessing head injury. It also led to an increase in the proportion of people with severe head injury having their care managed in specialist centres. This has been associated with a decline in fatality among patients with severe head injury. This update is needed because of the continuing importance of up-to-date evidence-based guidance on the initial assessment and early management of head injury. Appropriate guidance can enable early detection and treatment of life-threatening brain injury, where present, but also early discharge of patients with negligible risk of brain injury. It can therefore save lives while at the same time preventing needless crowding in emergency departments and observation wards.
Further key NHS changes have driven the scope of this update. These include the introduction in 2012 of regional trauma networks with major trauma triage tools within NHS England; the extension of indications for anticoagulation therapy; the expanding use of biomarkers to guide emergent clinical management in other conditions, such as chest pain; and the establishment of local safeguarding boards. The last of these addresses the requirement for front-line clinical staff to assess not only the severity of the head injury but also why it occurred.
This update addresses these areas, including in particular:
indications for transporting patients with a head injury from the scene of injury directly to the nearest neuroscience centre, bypassing the nearest emergency department
indications for and timing of CT head scans in the emergency department, with particular reference to anticoagulant therapy and levels of circulating brain injury biomarkers
the relative cost effectiveness of different strategies for initial imaging of the cervical spine
information that should be provided to patients, family members and carers on discharge from the emergency department or observation ward.
Remember that child maltreatment:
can present anywhere – including emergency departments and primary care.
Consider or suspect abuse as a contributory factor to or cause of head injury in children. Abuse may also coexist with a head injury. See the NICE guideline on child maltreatment for clinical features that may be associated with maltreatment. (This section has been agreed with the Royal College of Paediatrics and Child Health.)
The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.
This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or those with authority to give consent on their behalf) should provide informed consent, which should be documented. See the General Medical Council's good practice in prescribing and managing medicines and devices for further information. Where recommendations have been made for the use of drugs outside their licensed indications ('off-label use'), these drugs are marked with a footnote in the recommendations.