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Head Injury: NICE Guidelines

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Overview

The most common causes of head injury are falls, being struck by or against an object, and motor vehicle-related injuries. Traumatic brain injury (TBI) occurs when a head injury results in a disturbance of normal brain function.

TBI can broadly be classified based on the Glasgow coma scale (GCS):

  • Mild TBI (concussion): GCS 13-15
  • Moderate TBI: GCS 9-12
  • Severe TBI: GCS <9

Initial Assessment

ABCDE approach

Any patient with TBI should be assessed with an ABCDE approach (airway, breathing, circulation, disability, and exposure if relevant). The priority is ABC (airway, breathing,  and circulation) along with cervical spine injuries first.

People with a GCS of 8 or less may need intubation. Therefore, seek advice from anaesthetics or critical care to provide appropriate airway management.

Cervical spine injuries

An assessment of the cervical spine must be made, as TBI and cervical spine injuries often co-exist.

Full cervical spine immobilisation (e.g. using a cervical spine collar) should be performed in the following patients if possible:

  • GCS <15 on initial assessment
  • Neck pain or tenderness
  • Focal neurological deficits
  • Paraesthesia in the extremities
  • Any other clinical suspicion of a cervical spine injury

Cervical spine immobilisation should be kept in place until a full risk assessment including imaging deems it is safe to remove the immobilisation device.

Analgesia

Appropriate analgesia should be given as pain can increase intracranial pressure (ICP). Analgesia and anxiolytics should be given after a neurological examination, as these may cause sedation and affect the GCS.

Elevated intracranial pressure

Patients with an elevated ICP should be managed as mentioned in Elevated Intracranial Pressure: Management

Investigations

CT head

Perform a CT head within 1 hour if any of the following apply:

  • GCS <13 on initial assessment
  • GCS <15 at 2 hours post-injury
  • Suspected open or depressed skull fracture
  • Any sign of a basal skull fracture:
    • Haemotympanum, ‘panda eyes’, cerebrospinal fluid (CSF) leakage from the ear or nose, Battle’s sign
  • Post-traumatic seizure
  • Focal neurological deficits
  • More than 1 episode of vomiting

Perform a CT head within 8 hours if:

  • Patients have had some loss of consciousness or amnesia since the injury and any of the following apply:
    • ≥65 years old
    • A history of bleeding, coagulopathy, or anticoagulant use
    • A dangerous mechanism of injury which may be:
      • A pedestrian/cyclist hit by a motor vehicle
      • An occupant ejected from a motor vehicle
      • A fall from a height greater than 1 metre or 5 stairs
    • >30 minutes retrograde amnesia of the events immediately before the head injury
  • Or if the patient takes warfarin and has no indications for a CT scan

CT cervical spine

Perform a CT cervical spine within 1 hour if:

  • GCS <13 on initial assessment
  • The patient requires intubation
  • A definitive diagnosis of cervical spine injury is required urgently (e.g. before surgery)
  • Other body areas are being scanned for head injury or multi-region trauma
  • The patient is alert and stable but there is suspicion of a cervical spine injury and any of the following are present:
    • >65 years old
    • Dangerous mechanism of injury (described above)
    • Focal neurological deficits
    • Paraesthesia in the lower limbs

Assess the patient’s need for an X-ray of the cervical spine:

  • The following low risk factors are present which indicate it is safe to assess the range of movement of the neck:
    • A simple rear-end motor vehicle collision
    • The patient is comfortable in a sitting position in the emergency department
    • The patient has been ambulatory at any time since the injury
    • There is no midline cervical tenderness
    • Presents with a delayed onset of neck pain
  • If these low risk factors are not present perform a three-view cervical spine x-ray within 1 hour
    • If this x-ray is abnormal, suspicious, or inadequate, perform CT cervical spine within 1 hour
  • If these low risk factors are present, assess if the patient can actively rotate the neck to 45 degrees to the left and right:
    • If they can, no further imaging is required
    • If they cannot, perform a three-view cervical spine x-ray within 1 hour:
    •  If this x-ray is abnormal, suspicious, or inadequate, perform CT cervical spine within 1 hour

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