Head Injury: Assessment and Early Management

Overview

This Guidelines summary covers assessment and early management of head injury in babies, children, young people, and adults. The summary only includes recommendations on initial assessment and management in primary and community care.

For recommendations specific to secondary and tertiary care, refer to the full guideline. This includes recommendations on assessment in the emergency department, investigating clinically important traumatic brain injuries and injuries to the cervical spine, information and support, transfer to a neuroscience unit, admission and observation, discharge, and follow up. See also NICE’s guideline on major trauma service delivery.

Decision Making and Mental Capacity

• For recommendations on promoting ways for healthcare professionals and people using services to work together to make decisions about treatment and care, see NICE's guideline on shared decision making.
• For recommendations on decision making in people 16 and over who may lack capacity now or in the future, including information on advance care plans, see NICE's guideline on decision making and mental capacity.

Pre-hospital Assessment, Advice and Referral to Hospital

For recommendations for remote advice services, refer to this section in the full guideline.

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

Community Health Services and Inpatient Units Without an Emergency Department

• Community health services (GPs, ambulance crews, NHS walk-in or minor injury centres, dental practitioners) and inpatient units without an emergency department should refer people who have sustained a head injury to a hospital emergency department, using the ambulance service if necessary, if there are any of these risk factors (see NICE's guidelines on shared decision making and decision making and mental capacity):
  • a Glasgow Coma Scale^[A] (GCS) score of less than 15 on initial assessment
  • any loss of consciousness because of the injury
  • any focal neurological deficit since the injury
  • any suspicion of a complex skull fracture or penetrating head injury since the injury
  • amnesia for events before or after the injury (it will not be possible to assess amnesia in children who are preverbal and is unlikely to be possible in children under 5)
  • a persistent headache since the injury
  • any vomiting episodes since the injury (use clinical judgement about the cause of vomiting in children 12 years or under 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 or antiplatelet (except aspirin monotherapy) treatment
  • current drug or alcohol intoxication
  • any safeguarding concerns (for example, possible non-accidental injury or a vulnerable person is affected)
  • continuing concern by the professional about the diagnosis.
• In the absence of any risk factors in the previous recommendation, consider referral to an emergency department if any of these factors are present, depending on judgement of severity (see NICE's guidelines on shared decision making and decision making and mental capacity):
  • irritability or altered behaviour, particularly in babies and children under 5
  • visible trauma to the head not covered in the previous recommendation 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.

Transport to Hospital from Community Health Services and Inpatient Units Without an Emergency Department

• Ensure people referred from community health services are accompanied by a competent adult during transport to the emergency department.
• The referring professional should determine if an ambulance is needed, based on the person's clinical condition. If an ambulance is not needed, provided the person is accompanied, public transport or being driven in a car are appropriate means of transport.
• The referring professional should inform the destination hospital (by phone) of the impending transfer. In non-emergencies, a letter summarising signs and symptoms should be sent with the person.

Training in Risk Assessment

• Train GPs, nurse practitioners, dentists and ambulance crews, as necessary, to ensure that they are capable of assessing the presence or absence of the risk factors listed in the section on community health services and inpatient units without an emergency department.

Immediate Management at the Scene and Transport to Hospital

For recommendations on training for ambulance crews and paramedics, refer to the full guideline.

Glasgow Coma Scale^[A]

• Base monitoring and exchange of information about people with a head injury on the 3 separate responses on the GCS (for example, describe a person with a GCS score of 13 based on scores of 4 on eye opening, 4 on verbal response and 5 on motor response as E4, V4, M5).
• When recording or passing on information about total GCS score, give this as a score out of 15 (for example, 13 out of 15).
• Describe the individual components of the GCS in all communications and every patient record and ensure that they always accompany the total score.
• In the paediatric version of the GCS, include a 'grimace' alternative to the verbal score to enable scoring in children who are preverbal.
• In some people (for example, people with dementia, underlying chronic neurological disorders or learning disabilities), the pre-injury baseline GCS score may be less than 15. Establish this when possible and take it into account during assessment.

Initial Assessment and Care

• Initially assess people 16 and over 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 course or European Trauma course
  • International Trauma Life Support course
  • Pre-hospital Trauma Life Support course
  • Advanced Trauma Nurse Course
  • Trauma Nursing Core Course
  • Joint Royal Colleges Ambulance Service Liaison Committee Clinical Practice Guidelines for Head Trauma.
• Initially assess people under 16 who have sustained a head injury and manage their care according to clear principles outlined in the:
  • Advanced Paediatric Life Support course or European Paediatric Life Support course
  • Pre-hospital Paediatric Life Support course
  • Paediatric Education for Pre-hospital Professionals course.
• When administering immediate care, first treat the greatest threat to life and avoid further harm. For advice on volume resuscitation for people with a traumatic brain injury and haemorrhagic shock, see NICE's guideline on major trauma: assessment and initial management.
• For recommendations on when to carry out full in-line spine immobilisation and how long immobilisation is needed if indicated, see NICE's guideline on spinal injury.
• Make pre-alert calls to the destination emergency department for anyone with a GCS score of 8 or less to ensure appropriately experienced professionals are available for their treatment and to prepare for imaging.
• Manage pain effectively because it can lead to a rise in intracranial pressure. Provide reassurance, splint limb fractures and catheterise a full bladder when needed. Also see NICE's guideline on major trauma: assessment and initial management.
• Always follow best practice in paediatric coma observation and recording, as detailed by the National Paediatric Neuroscience Benchmarking Group.

Transport to Hospital

• Transport people who have sustained a head injury directly to a major trauma centre or trauma unit that has the age-appropriate resources to further resuscitate them, and to investigate and initially manage multiple injuries
• For guidance on the care of people with major trauma, see NICE's guideline on major trauma: service delivery.

Tranexamic Acid

• For people with a head injury and a GCS score of 12 or less who are not thought to have active extracranial bleeding, consider:
  • a 2 g intravenous bolus injection of tranexamic acid for people 16 and over
  • a 15 mg/kg to 30 mg/kg (up to a maximum of 2 g) intravenous bolus injection of tranexamic acid for people under 16. 
    
    Give the tranexamic acid as soon as possible within 2 hours of the injury, in the pre-hospital or hospital setting and before imaging. In March 2023, these were off-label uses of tranexamic acid. See NICE's information on prescribing medicines.
• For people with a head injury, and suspected or confirmed extracranial bleeding, see the recommendations in the section on haemostatic agents in pre-hospital and hospital settings in NICE's guideline on major trauma: assessment and initial management.

Direct Access from the Community to Imaging

• Do not refer people who have had a head injury for neuroimaging by direct access from the community.

Discharge and Follow Up

For recommendations on discharge from emergency and hospital services, refer to the full guideline.

Follow Up 

• Refer people with a head injury to investigate its causes and manage contributing factors, if appropriate. This could include, for example, referral for a falls assessment or to safeguarding services.
• Consider referring people who have persisting problems to a clinician trained in assessing and managing the consequences of traumatic brain injury (for example, a neurologist, neuropsychologist, clinical psychologist, neurosurgeon or endocrinologist, or a multidisciplinary neurorehabilitation team).

Footnote

[A] In people with a head injury, the Glasgow Coma Scale (GCS) is an early assessment of the severity of any associated traumatic brain injury. It is a standardised system used to assess the degree of brain impairment and to identify the seriousness of injury in relation to outcome. The scale has 3 domains: eye opening, verbal and motor responses. These are all evaluated independently in the scale according to a numerical value that indicates the level of consciousness and degree of dysfunction. The scores in each element of the GCS are summed to give the overall GCS score, which ranges from 3 (unresponsive in all domains) to 15 (no deficits in responsiveness):

• Mild traumatic brain injury is a GCS score of 13 to 15.
• Moderate traumatic brain injury is a GCS score of 9 to 12.
• Severe traumatic brain injury is a GCS score of 8 or less.