Update information

June 2017: Recommendations 1.2.8 and 1.4.12 were updated with cross-references to related NICE guidelines. An outdated research recommendation was stood down and removed.

This guideline updates and replaces NICE clinical guideline 56 (published September 2007).

Recommendations are marked as [new 2014], [2003], [2003, amended 2007], [2003, amended 2014], [2003, amended 2007 and 2014], [2007] or [2007, amended 2014].

[new 2014] indicates that the evidence has been reviewed and the recommendation has been added or updated.

[2003] indicates that the evidence has not been reviewed since 2003.

[2003, amended 2007] indicates that the evidence has not been reviewed since 2003 but minor changes were made in 2007 for clarification.

[2003, amended 2014] indicates that the evidence has not been reviewed since 2003 but changes have been made to the recommendation wording that change the meaning (see below).

[2003, amended 2007 and 2014] indicates that the evidence has not been reviewed since 2003 but changes have been made that change the meaning (see below).

[2007] indicates that the evidence has not been reviewed since 2007.

[2007, amended 2014] indicates that the evidence has not been reviewed since 2007 but changes have been made that change the meaning (see below).

Recommendations from NICE clinical guideline 56 that have been amended

Recommendations are labelled [2003, amended 2014], [2007, amended 2014] or [2003, amended 2007 and 2014] if the evidence has not been reviewed but changes have been made to the recommendation wording (indicated by highlighted text) that change the meaning.

Recommendation in 2003 or 2007 guideline

Recommendation in current guideline

Reason for change

1.1.4.1 There should be a protocol for all staff to introduce themselves to family members or carers and briefly explain what they are doing. In addition a photographic board with the names and titles of personnel in the hospital departments caring for patients with head injury can be helpful. [2003]

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]

Second sentence detailing photographic board has been removed. The GDG considered this to be a safety/security risk for staff in some departments.

1.2.1.1 Telephone advice services (for example, NHS Direct, emergency department helplines) should refer people 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 risk factors in box 1 (alternative terms to facilitate communication are in parentheses).

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

• Any focal (that is, restricted to a particular part of the body or a particular activity) neurological deficit since the injury (examples include problems understanding, speaking, reading or writing; loss of feeling in part of the body; problems balancing; general weakness; any changes in eyesight; and problems walking).

• Any suspicion of a skull fracture or penetrating head injury (for example, clear fluid running from the ears or nose, black eye with no associated damage around the eye, bleeding from one or both ears, new deafness in one or both ears, bruising behind one or both ears, penetrating injury signs, visible trauma to the scalp or skull).

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

• A high-energy head injury (for example, pedestrian struck by motor vehicle, occupant ejected from motor vehicle, a fall from a height of greater than 1 m or more than five stairs, diving accident, high-speed motor vehicle collision, rollover motor accident, accident involving motorized recreational vehicles, bicycle collision, or any other potentially high-energy mechanism).

• 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).

[2003, amended 2007]

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). [2003, amended 2007 and 2014]

Updated to NHS 111

1.2.1.2 Telephone advice services (for example, NHS Direct, emergency department helplines) should refer people who have sustained a head injury to a hospital emergency department if the history related indicates the presence of any of the risk factors in box 2 (alternative terms to facilitate communication are in parentheses).

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

• Amnesia for events before or after the injury ('problems with memory'). The assessment of amnesia will not be possible in pre-verbal children and is unlikely to be possible in any child aged under 5 years.

• Persistent headache since the injury.

Any vomiting episodes since the injury.

• Any previous cranial neurosurgical interventions ('brain surgery').

• History of bleeding or clotting disorder.

• Current anticoagulant therapy such as warfarin.

• Current drug or alcohol intoxication.

• Age 65 years or older.

• Suspicion of non-accidental injury.

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

• Continuing concern by the helpline personnel about the diagnosis.

[2003]

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').

• 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]

Updated to NHS 111

'Age 65 years or older' as a factor for referring to the emergency department' removed (equality consideration).

1.2.2.1 Community health services (general practice, 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 (see section 1.3.1), if any of the risk factors listed in box 3 are present.

• GCS less than 15 on initial assessment.

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

• Any focal neurological deficit since the injury (examples include problems understanding, speaking, reading or writing; decreased sensation; loss of balance; general weakness; visual changes; abnormal reflexes; and problems walking).

• Any suspicion of a skull fracture or penetrating head injury since the injury (for example, clear fluid running from the ears or nose, black eye with no associated damage around the eyes, bleeding from one or both ears, new deafness in 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).

• Amnesia for events before or after the injury. The assessment of amnesia will not be possible in pre-verbal children and is unlikely to be possible in any child aged under 5 years.

• Persistent headache since the injury.

• Any vomiting episodes since the injury.

• Any seizure since the injury.

• Any previous cranial neurosurgical interventions.

• A high-energy head injury (for example, pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from a height of greater than 1 m or more than five stairs, diving accident, high-speed motor vehicle collision, rollover motor accident, accident involving motorized recreational vehicles, bicycle collision, or any other potentially high-energy mechanism).

• History of bleeding or clotting disorder.

• Current anticoagulant therapy such as warfarin.

• Current drug or alcohol intoxication.

• Age 65 years or older.

• Suspicion of non-accidental injury.

• Continuing concern by the professional about the diagnosis.

[2003, amended 2007]

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 (assessment of amnesia will not be possible in preverbal children and is unlikely to be possible in children aged under 5 years).

• 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]

'Age 65 years or older' as a factor for referring to the emergency department' removed (equality consideration) and risk covered by loss of consciousness rec.

Extra bullet point added in to highlight safeguarding concerns (widely used terminology).

Clinical judgement re vomiting reflects high incidence of single vomit in younger children in head injury which alone is not of concern.

1.2.2.2 In the absence of any the factors listed in box 3, the professional should consider referral to an emergency department if any of the following factors are present depending on their own judgement of severity.

• Irritability or altered behaviour, particularly in infants and young children (that is, aged under 5 years).

• Visible trauma to the head not covered above but still of concern to the professional.

• Adverse social factors (for example, no one able to supervise the injured person at home).

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

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 healthcare 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]

Adverse social factors removed from penultimate bullet point, as the GDG considered this was inappropriate terminology.

1.3.2.3 Ambulance crews should be trained in the detection of non-accidental injury and should pass information to emergency department personnel when the relevant signs and symptoms arise. [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]

The term 'non-accidental injury' has been replaced with safeguarding as non-accidental injury is a child specific term and therefore appears to exclude adults. Text has been added to indicate that information should be documented

1.3.2.9 Pain should be managed effectively because it can lead to a rise in intracranial pressure. Reassurance and splintage of limb fractures are helpful; catheterisation of a full bladder will reduce irritability. Analgesia as described in 1.4.1.9 should be given only under the direction of a doctor. [2007]

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]

Second sentence about analgesia removed (analgesia as described in 1.4.1.9 should be given only under the direction of a doctor), as this is covered in the first sentence. The GDG felt that this needs to be managed under local protocols. It covers additional complexities which have not been reviewed and may be confusing to readers.

1.4.3.3 With modern multislice scanners the whole cervical spine can be scanned at high resolution with ease and multiplanar reformatted images generated rapidly. Facilities for multiplanar reformatting and interactive viewing should be available. [2003]

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

First sentence removed as this is now unnecessary. Imaging practice has moved on: with modern multislice scanners the whole cervical spine can be scanned at high resolution with ease and multiplanar reformatted images generated rapidly.

1.4.3.4 MRI is indicated in the presence of neurological signs and symptoms referable to the cervical spine and if there is suspicion of vascular injury (for example, subluxation or displacement of the spinal column, fracture through foramen transversarium or lateral processes, posterior circulation syndromes). [2003]

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]

Changes based on updated terminology and current practice.

1.4.3.12 Children under 10 years should receive anterior/posterior and lateral plain films without an anterior/posterior peg view. [2003]

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

Amended based on GDG consensus as satisfactory peg views can often be obtained in those younger than 10 (essentially down to the age where they can obey the command to open their mouth nice and wide – usually about 5).

1.4.4.1 A clinician with expertise in non-accidental injuries in children should be involved in any suspected case of non-accidental injury in a child. Examinations/investigations that should be considered include: skull X-ray as part of a skeletal survey, ophthalmoscopic examination for retinal haemorrhage, and examination for pallor, anaemia, and tense fontanelle or other suggestive features. Other imaging such as CT and MRI may be required to define injuries. [2003, amended 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]

Updated to reflect current terminology.

Updated for equality consideration, guideline did not previously include a recommendation for safeguarding concerns in adults ('A clinician with expertise in non-accidental injuries in children should be involved in any suspected case of non-accidental injury in a child').

Text removed: 'Examinations/investigations that should be considered include: skull X-ray as part of a skeletal survey, ophthalmoscopic examination for retinal haemorrhage, and examination for pallor, anaemia, and tense fontanelle or other suggestive features. Other imaging such as CT and MRI may be required to define injuries'.

Text has been added to indicate that information should be documented.

1.4.6.1 The care of all patients with new, surgically significant abnormalities on imaging should be discussed with a neurosurgeon. The definition of 'surgically significant' should be developed by local neurosurgical centres and agreed with referring hospitals. An example of a neurosurgical referral letter is provided on the NICE website. [2003]

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]

Reference to neurosurgical letter removed to reflect current practice.

1.6.1.5 The transfer team should be provided with a means of communication with their base hospital and the neurosurgical unit during the transfer. A portable phone may be suitable providing it is not used in close proximity (that is, within 1 m) of medical equipment prone to electrical interference (for example, infusion pumps). [2003]

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]

Reference to portable phone deleted, as this is outdated terminology.

Additional text added for clarity: 'changes in the patient's status'.

1.6.1.12 Carers and relatives should have as much access to the patient as is practical during transfer and be fully informed on the reasons for transfer and the transfer process. [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]

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]

Updated based on equality consideration to allow patient discussion.

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of 'The guidelines manual' (January 2009). This does not apply to any recommendations ending [2003] or [2007] (see update information for details about how recommendations are labelled). In particular, for recommendations labelled [2003] and [2007], the word 'consider' may not necessarily be used to denote the strength of the recommendation.

ISBN: 978-1-4731-0405-1

  • National Institute for Health and Care Excellence (NICE)