Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

For the purposes of this guideline, a head injury is defined as any trauma to the head other than superficial injuries to the face. The term includes both closed head injuries and penetrating head injuries. Babies are defined as being under 1 year, and children and young people as being 1 year to under 16 years.

1.1 Decision making and mental capacity

1.1.1 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. [2023]

1.1.2 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. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on decision making and mental capacity.

1.2 Pre-hospital assessment, advice and referral to hospital

1.2.1 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. [2003]

Remote advice services

1.2.2 Remote advice services (for example, NHS 111) 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 there are any of these risk factors (see NICE's guidelines on shared decision making and decision making and mental capacity):

1.2.3 Remote advice services (for example, NHS 111) should refer people who have sustained a head injury to a hospital emergency department if there are any of these risk factors (see NICE's guidelines on shared decision making and decision making and mental capacity):

  • any loss of consciousness ('knocked out') because of the injury, from which the person has now recovered

  • amnesia for events before or after the injury ('problems with memory'; 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

  • any previous brain surgery

  • 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)

  • irritability or altered behaviour (easily distracted, not themselves, no concentration, no interest in things around them), particularly in babies and children under 5

  • continuing concern by helpline staff about the diagnosis. [2003, amended 2014 and 2023]

Community health services and inpatient units without an emergency department

1.2.4 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 (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. [2003, amended 2007, 2014 and 2023]

1.2.5 In the absence of any risk factors in recommendation 1.2.4, 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 recommendation 1.2.4 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. [2003, amended 2014 and 2023]

Transport to hospital from community health services and inpatient units without an emergency department

1.2.6 Ensure people referred from community health services are accompanied by a competent adult during transport to the emergency department. [2003]

1.2.7 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. [2003]

1.2.8 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. [2003]

Training in risk assessment

1.2.9 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. [2003, amended 2007]

1.3 Immediate management at the scene and transport to hospital

Glasgow Coma Scale

1.3.1 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). [2003]

1.3.2 When recording or passing on information about total GCS score, give this as a score out of 15 (for example, 13 out of 15). [2003]

1.3.3 Describe the individual components of the GCS in all communications and every patient record and ensure that they always accompany the total score. [2003]

1.3.4 In the paediatric version of the GCS, include a 'grimace' alternative to the verbal score to enable scoring in children who are preverbal. [2003]

1.3.5 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. [2014]

Initial assessment and care

1.3.6 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. [2003, amended 2007]

1.3.7 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. [2003, amended 2007]

1.3.8 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. [2003]

1.3.9 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. [2003, amended 2007]

1.3.10 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. [2003]

1.3.11 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. [2007, amended 2014]

1.3.12 Always follow best practice in paediatric coma observation and recording, as detailed by the National Paediatric Neuroscience Benchmarking Group. [2003]

Transport to hospital

1.3.13 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. [2023]

1.3.14 For guidance on the care of people with major trauma, see NICE's guideline on major trauma: service delivery. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on transport to hospital.

Full details of the evidence and the committee's discussion are in evidence review B: transport to a distant specialist neuroscience centre.

Training for ambulance crews and paramedics

1.3.15 Ambulance crews and paramedics should be fully trained in the use of the adult and paediatric versions of the GCS and its derived score. [2003]

1.3.16 Ambulance crews and paramedics should be trained in the safeguarding of people under 16 and people 16 and over who are vulnerable. They should document and verbally inform emergency department staff of any safeguarding concerns. [2003, amended 2014]

Tranexamic acid

1.3.17 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. [2023]

1.3.18 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. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on tranexamic acid.

Full details of the evidence and the committee's discussion are in evidence review A: tranexamic acid.

Direct access from the community to imaging

1.3.19 Do not refer people who have had a head injury for neuroimaging by direct access from the community. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on direct access from the community to imaging.

Full details of the evidence and the committee's discussion are in evidence review C: direct access from the community to imaging.

1.4 Assessment in the emergency department

1.4.1 Be aware that the priority for all people admitted to an emergency department is to stabilise the airway, breathing and circulation (ABC) before attending to other injuries. See NICE's guideline on major trauma: assessment and initial management. [2003]

1.4.2 Only assume a depressed conscious level is due to intoxication after an important traumatic brain injury has been excluded. [2003]

1.4.3 Ensure all emergency department clinicians involved in assessing people with a head injury are capable of assessing the presence or absence of the risk factors for CT head imaging listed in the recommendations on the criteria for doing a CT head scan and the criteria for doing a cervical spine scan in people 16 and over and people under 16. Make training available as needed to ensure this. [2003]

1.4.4 Ensure people presenting to the emergency department with impaired consciousness (a GCS score of less than 15) are assessed immediately by a trained member of staff. [2003]

1.4.5 For people with a GCS score of 12 or less, see the recommendations on tranexamic acid. [2023]

1.4.6 For people with a GCS score of 8 or less, ensure early involvement of an appropriately trained clinician to provide advanced airway management, as described in recommendations 1.8.7 and 1.8.8 in the section on transfer of people 16 and over, and to assist with resuscitation. [2003]

1.4.7 Ensure a trained member of staff assesses anyone presenting to an emergency department with a head injury within a maximum of 15 minutes of arrival at hospital. Part of this assessment should establish whether they are at high or low risk for clinically important traumatic brain or cervical spine injury, as described in the recommendations on the criteria for doing a CT head scan and the criteria for doing a CT cervical spine scan in people 16 and over and people under 16. [2003]

1.4.8 In people considered to be at high risk for clinically important traumatic brain or cervical spine injury, extend assessment to full clinical examination to establish any need for CT imaging of the head, or imaging of the cervical spine and other body areas. Use the recommendations on the criteria for doing a CT head scan and the criteria for doing a CT cervical spine scan in people 16 and over and people under 16 as the basis for the final decision on imaging after discussion with the radiology department. [2003, amended 2007]

1.4.9 Anyone triaged to be at low risk for clinically important traumatic brain or cervical spine injury at initial assessment should be re-examined by an emergency department clinician. They should establish whether CT imaging of the head or cervical spine will be needed. Use the recommendations on the criteria for doing a CT head scan and the criteria for doing a cervical spine scan in people 16 and over and people under 16 as the basis for the final decision on imaging after discussion with the radiology department. [2003, amended 2007 and 2023]

1.4.10 Review people who return to an emergency department with any persistent complaint relating to the initial head injury and discuss them with a senior clinician experienced in head injuries. Consider whether a CT scan is needed. [2003, amended 2023]

1.4.11 Manage pain effectively to help prevent any rise in intracranial pressure. Provide reassurance, splint limb fractures and catheterise a full bladder when needed. See NICE's guideline on major trauma: assessment and initial management for information on pain management. [2007]

1.4.12 Consider or suspect abuse, neglect or other safeguarding issues as a contributory factor to, or cause of, a head injury. See NICE's guidelines on child maltreatment, child abuse and neglect, domestic violence and abuse and safeguarding adults in care homes for clinical features that may be associated with maltreatment. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on assessment in the emergency department.

Full details of the evidence and the committee's discussion are in evidence review D: clinical decision rules selecting people with head injury for imaging.

1.4.13 Involve a clinician with training in safeguarding in the initial assessment of any person 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 person's age. [2003, amended 2014]

1.4.14 Use a standard head injury proforma for documentation when assessing and observing people with a head injury throughout their time in hospital. This form should be of a consistent format across all clinical departments and hospitals in which a person might be treated. Use a separate proforma for people under 16. Include areas to allow extra documentation (for example, in cases of non-accidental injury). [2003, amended 2007]

Involving the neurosurgical department

1.4.15 Discuss with a neurosurgeon the care of anyone with new and 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]

1.4.16 Regardless of imaging, discuss a person's care plan with a neurosurgeon if they have:

  • persisting coma (a GCS score of 8 or less) after initial resuscitation

  • unexplained confusion that persists for more than 4 hours

  • deterioration in GCS score after admission (pay more attention to motor response deterioration)

  • progressive focal neurological signs

  • a seizure without full recovery

  • a definite or suspected penetrating injury

  • a cerebrospinal fluid leak. [2003]

1.5 Investigating clinically important traumatic brain injuries

1.5.1 The current primary investigation of choice for detecting an acute clinically important traumatic brain injury is CT imaging of the head. [2003]

1.5.2 For safety, logistic and resource reasons, do not do MRI scanning as the primary investigation for clinically important traumatic brain injury in people who have sustained a head injury. But additional information of importance to prognosis can sometimes be detected using MRI. [2003]

1.5.3 Ensure that there is appropriate equipment for monitoring people with a head injury who are having an MRI scan. Also ensure that all staff involved are aware of the dangers and necessary precautions for working near an MRI scanner. [2003]

1.5.4 Do not use plain X‑rays of the skull to diagnose important traumatic brain injury before a discussion with a neuroscience unit. However, people under 16 presenting with suspected non-accidental injury may need a skeletal survey. [2007]

1.5.5 Arrange transfer to a suitable hospital for people with indications for a CT scan who present to a hospital where CT scans are not available (see the recommendations on the criteria for doing a CT head scan and the criteria for doing a CT cervical spine scan in people 16 and over and people under 16). [2007, amended 2023]

1.5.6 Trauma networks should make sure that people can be transferred as indicated in recommendation 1.5.5. [2007, amended 2023]

1.5.7 In line with good radiation exposure practice, make every effort to minimise radiation dose during imaging of the head and cervical spine, while ensuring that image quality and coverage is sufficient to achieve an adequate diagnostic study. [2003]

Criteria for doing a CT head scan

People 16 and over

1.5.8 For people 16 and over who have sustained a head injury, do a CT head scan within 1 hour of any of these risk factors being identified:

  • a GCS score of 12 or less on initial assessment in the emergency department

  • a GCS score of 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. [2023]

1.5.9 For people 16 and over who have had some loss of consciousness or amnesia since the injury, do a CT head scan within 8 hours of the head injury, or within the hour in someone presenting more than 8 hours after the injury, if they have any of these risk factors:

  • age 65 or over

  • any current bleeding or clotting disorders

  • dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of more than 1 m or 5 stairs)

  • more than 30 minutes' retrograde amnesia of events immediately before the head injury. [2023]

People under 16

1.5.10 For people under 16 who have sustained a head injury, do a CT head scan within 1 hour of any of these risk factors being identified:

  • suspicion of non-accidental injury

  • post-traumatic seizure

  • on initial emergency department assessment, a GCS score of less than 14 or, for babies under 1 year, a GCS score (paediatric) of less than 15

  • at 2 hours after the injury, a GCS score of 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 babies under 1 year, a bruise, swelling or laceration of more than 5 cm on the head. [2023]

1.5.11 For people under 16 who have sustained a head injury and have more than 1 of these risk factors, do a CT head scan within 1 hour of the risk factors being identified:

  • loss of consciousness lasting more than 5 minutes (witnessed)

  • abnormal drowsiness

  • 3 or more discrete episodes of vomiting

  • dangerous mechanism of injury (high-speed road traffic accident as a pedestrian, cyclist or vehicle occupant, fall from a height of more than 3 m, high-speed injury from a projectile or other object)

  • amnesia (anterograde or retrograde) lasting more than 5 minutes (it will not be possible to assess amnesia in children who are preverbal and is unlikely to be possible in children under 5)

  • any current bleeding or clotting disorder. [2023]

1.5.12 Observe people under 16 who have sustained a head injury but have only 1 of the risk factors in recommendation 1.5.11 for a minimum of 4 hours from the time of injury. If, during observation, any of the following risk factors are identified, do a CT head scan within 1 hour:

  • a GCS score of less than 15

  • further vomiting

  • a further episode of abnormal drowsiness.

    If none of these risk factors occur during observation, use clinical judgement to determine whether a longer period of observation is needed. [2023]

People taking anticoagulant or antiplatelet medication

1.5.13 For people who have sustained a head injury and have no other indications for a CT head scan, but are on anticoagulant treatment (including vitamin K antagonists, direct-acting oral anticoagulants (DOACs), heparin and low molecular weight heparins) or antiplatelet treatment (excluding aspirin monotherapy), consider doing a CT head scan:

Timing of radiology report

1.5.14 Make a provisional written radiology report available within 1 hour of a CT scan. [2014]

For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on criteria for doing a CT head scan.

Full details of the evidence and the committee's discussion are in:

Investigation to predict post-concussion syndrome

1.5.15 For information on referring people with possible post-concussion syndrome, see recommendation 1.10.14 in the section on follow up. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on post-concussion syndrome.

Full details of the evidence and the committee's discussion are in evidence review F: brain injury biomarkers and/or MRI for predicting post-concussion syndrome.

1.6 Investigating injuries to the cervical spine

Assessing range of movement in the neck

1.6.1 Be aware that range of movement in the neck when there is clinical suspicion of a cervical spine injury can only be assessed safely before imaging in people with a head injury if they have no high-risk factors (see recommendation 1.6.2, and recommendations 1.6.4 and 1.6.6). Only do the assessment if they have at least 1 of these low-risk features:

Criteria for doing a CT cervical spine scan in people 16 and over

1.6.2 For people 16 and over who have sustained a head injury (including people with delayed presentation), do a CT cervical spine scan within 1 hour of the risk factor being identified if any of these high-risk factors apply:

  • the GCS score is 12 or less on initial assessment

  • the person has been intubated

  • a definitive diagnosis of a cervical spine injury is urgently needed (for example, if cervical spine manipulation is needed during surgery or anaesthesia)

  • there has been blunt polytrauma involving the head and chest, abdomen or pelvis in someone who is alert and stable

  • there is clinical suspicion of a cervical spine injury and any of these factors:

    • age 65 or over

    • a dangerous mechanism of injury (that is, a fall from a height of more than 1 m or 5 stairs, an axial load to the head such as from diving, a high-speed motor vehicle collision, a rollover motor accident, ejection from a motor vehicle, an accident involving motorised recreational vehicles or a bicycle collision)

    • focal peripheral neurological deficit

    • paraesthesia in the upper or lower limbs. [2023]

1.6.3 For people 16 and over who have sustained a head injury, and have neck pain or tenderness but no high-risk indications for a CT cervical spine scan (see recommendation 1.6.2), do a CT cervical spine scan within 1 hour for any of these risk factors:

  • it is not thought to be safe to assess the range of movement in the neck (see recommendation 1.6.1)

  • safe assessment of range of neck movement shows that the person cannot actively rotate their neck 45 degrees to the left and right

  • the person has a condition predisposing them to a higher risk of injury to the cervical spine (for example, axial spondyloarthritis). [2023]

Criteria for doing a CT cervical spine scan in people under 16

1.6.4 For people under 16 who have sustained a head injury (including those with delayed presentation), only do a CT cervical spine scan if any of these risk factors apply:

  • the GCS score is 12 or less on initial assessment

  • the person has been intubated

  • there are focal peripheral neurological signs

  • there is paraesthesia in the upper or lower limbs

  • a definitive diagnosis of a cervical spine injury is needed urgently (for example, if manipulation of the cervical spine is needed during surgery or anaesthesia)

  • the person is having other body areas scanned for head injury or multisystem trauma, and there is clinical suspicion of a cervical spine injury

  • there is strong clinical suspicion of injury despite normal X‑rays

  • plain X‑rays are technically difficult or inadequate

  • plain X‑rays identify a significant bony injury.

    Do the scan within 1 hour of the risk factor being identified. [2023]

1.6.5 For people under 16 who have sustained a head injury, and have neck pain or tenderness but no indications for a CT cervical spine scan (see recommendation 1.6.4), do 3‑view cervical spine X‑rays before assessing range of movement in the neck if any of these risk factors are identified:

  • there was a dangerous mechanism of injury (that is, a fall from a height of more than 1 m or 5 stairs, an axial load to the head such as from diving, a high-speed motor vehicle collision, a rollover motor accident, ejection from a motor vehicle, an accident involving motorised recreational vehicles or a bicycle collision)

  • safe assessment of range of movement in the neck is not possible (see recommendation 1.6.1)

  • the person has a condition that predisposes them to a higher risk of injury to the cervical spine (for example, collagen vascular disease, osteogenesis imperfecta, axial spondyloarthritis).

    The X‑rays should be done within 1 hour of the risk factor being identified and reviewed by a clinician trained in their interpretation. [2023]

1.6.6 If range of neck movement can be assessed safely (see recommendation 1.6.1) in a person under 16 who has sustained a head injury, and has neck pain or tenderness but no indications for a CT cervical spine scan, do 3‑view cervical spine X‑rays if they cannot actively rotate their neck 45 degrees to the left and right. When the person is unable to understand commands or open their mouth, a peg view may be omitted. The X‑rays should be done within 1 hour of this risk factor being identified, and reviewed by a clinician trained in their interpretation. [2014]

Timing of radiology report

1.6.7 Make a provisional written radiology report available within 1 hour of a CT scan. [2014]

Imaging investigations

1.6.8 Ensure that imaging reports are based on high-resolution source data and multiplanar reformatting of the entire cervical spine. [2003, amended 2014 and 2023]

1.6.9 Do MRI in addition to CT if there are neurological signs and symptoms suggesting injury to the cervical spine. [2003, amended 2014 and 2023]

1.6.10 Do CT or MRI angiography of the neck vessels if there is a suspicion of vascular injury, for example, because of:

  • vertebral malalignment

  • a high-risk fracture (that is, a high-grade or complex facial fracture or a base of skull fracture likely to involve the internal carotid artery or vertebral artery)

  • posterior circulation syndrome. [2003, amended 2014 and 2023]

1.6.11 Consider MRI for assessing ligamentous and disc injuries suggested by CT or clinical findings. [2003]

For a short explanation of why the committee made these recommendations and how they might affect practices or services, see the rationale and impact section on investigating injuries to the cervical spine.

Full details of the evidence and the committee's discussion are in evidence review H: CT, MRI and X-ray of the cervical spine in people with head injury – diagnostic.

1.7 Information and support for families and carers

1.7.1 Staff caring for people with a head injury should introduce themselves to family members or carers, and briefly explain what they are doing. [2003, amended 2014]

1.7.2 Ensure that information for families and carers explains the nature of the head injury and the likely care pathway. [2003]

1.7.3 Staff should think about how best to share information with people under 16, and introduce them to the possibility of long-term complex changes in their parent or sibling who has had a head injury. Literature produced by patient support groups may be helpful. [2003]

1.7.4 Encourage family members and carers to talk to and make physical contact (for example, holding hands) with the person with a head injury. But ensure that relatives and friends do not feel obliged to spend long periods at the bedside. If they wish to stay with the person with a head injury, encourage them to take regular breaks. [2003, amended 2007]

1.7.5 Ensure there is a board or area displaying leaflets or contact details for local and national patient support organisations to help family members and carers gather further information. [2003]

1.8 Transfer from hospital to a neuroscience unit

Transfer of people 16 and over

1.8.1 Ensure local guidelines on the transfer of people with a severe traumatic brain injury are drawn up between the referring hospital trusts, the neuroscience unit and the local ambulance service, and recognise that:

1.8.2 Think about the possibility of occult extracranial injuries in people 16 and over with multiple injuries, and do not transfer them to a service that is unable to deal with other aspects of trauma. [2007]

1.8.3 Ensure there is a designated consultant in the referring hospital with responsibility for establishing arrangements for the transfer of people with head injuries to a neuroscience unit. Also ensure there is another consultant at the neuroscience unit with responsibility for establishing arrangements for communication with referring hospitals, and for receiving people transferred. [2003]

1.8.4 Ensure that people with traumatic brain injuries needing emergency transfer to a neuroscience unit are accompanied by healthcare staff with appropriate training and experience in the transfer of people with an acute traumatic brain injury. They should:

  • be familiar with the pathophysiology of traumatic brain injuries, the medicines and equipment they will use, and working in the confines of an ambulance (or helicopter if appropriate)

  • have a dedicated and adequately trained assistant

  • be provided with appropriate clothing for the transfer, medical indemnity and personal accident insurance.

    Ensure that people needing non-emergency transfer are accompanied by appropriate clinical staff. [2003, amended 2007]

1.8.5 Provide the transfer team responsible for transferring a person with a head injury with a means of communicating changes in the person's status with their base hospital and the neurosurgical unit during the transfer. [2003, amended 2014]

1.8.6 Although it is understood that transfer is often urgent, complete the initial resuscitation and stabilisation of the person, and establish comprehensive monitoring before transfer, to avoid complications during the journey. Do not transport someone with persistent hypotension, despite resuscitation, until the cause has been identified and they are stabilised. [2003, amended 2007]

1.8.7 Intubate and ventilate anyone with a GCS score of 8 or less needing transfer to a neuroscience unit, and anyone with the indications detailed in recommendation 1.8.8. [2003]

1.8.8 Intubate and ventilate the person immediately when there is:

  • coma, that is, they are not obeying commands, not speaking and not eye opening (a GCS score of 8 or less)

  • loss of protective laryngeal reflexes

  • ventilatory insufficiency, as judged by blood gases: hypoxaemia (PaO2 less than 13 kPa on oxygen) or hypercarbia (PaCO2 more than 6 kPa)

  • irregular respirations. [2003, amended 2007]

1.8.9 Use intubation and ventilation before the start of the journey when the person has:

  • significantly deteriorating conscious level (1 or more points on the motor score), even if not coma

  • unstable fractures of the facial skeleton

  • copious bleeding into the mouth (for example, from a skull base fracture)

  • seizures. [2003, amended 2007]

1.8.10 Anyone whose trachea is intubated should have appropriate sedation and analgesia along with a neuromuscular blocking drug. Aim for a PaO2 of more than 13 kPa, and a PaCO2 of 4.5 kPa to 5.0 kPa, unless there is clinical or radiological evidence of raised intracranial pressure, in which case more aggressive hyperventilation is justified. If hyperventilation is used, increase the inspired oxygen concentration. Maintain the mean arterial pressure at 80 mmHg or more by infusion of fluid and vasopressors, as indicated. [2003, amended 2007]

1.8.11 Give family members and carers as much access to the person with a head injury 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]

Transfer of people under 16

1.8.12 Recommendations 1.8.1 to 1.8.9 and 1.8.11 were written for people 16 and over, but apply these principles to people under 16, providing that the paediatric modification of the GCS is used for preverbal and non-verbal children. Ventilate people under 16 according to the age-appropriate level of oxygen saturation and maintain blood pressure at a level appropriate for their age. [2003, amended 2023]

1.8.13 Ensure that service provision for transfer to tertiary care follows the principles outlined in the NHS England service specification for paediatric intensive care retrieval (transport) and the Paediatric Critical Care Society quality standards for the care of critically ill or injured children. [2003]

1.8.14 Think about the possibility of occult extracranial injuries for people under 16 with multiple injuries. Do not transfer them to a service that is unable to deal with other aspects of trauma. [2007]

1.8.15 Ensure that transfer of people under 16 to a specialist neurosurgical unit is done either by staff experienced in the transfer of people under 16 who are critically ill or according to local guidelines with specialist paediatric retrieval teams. [2003, amended 2023]

1.8.16 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]

1.9 Admission and observation

1.9.1 Use these criteria for admitting people to hospital after a head injury:

  • new, clinically important abnormalities on imaging (an isolated simple linear non-displaced skull fracture is unlikely to be a clinically important abnormality unless they are taking anticoagulant or antiplatelet medication)

  • after imaging, a GCS score that has not returned to 15 or their pre-injury baseline, regardless of the imaging results

  • when there are indications for CT scanning but this cannot be done within the appropriate time period, either because CT is not available or because the person is not sufficiently cooperative to allow scanning

  • continuing worrying symptoms (for example, persistent vomiting, severe headaches or seizures) of concern to the clinician

  • other sources of concern to the clinician (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak, or suspicion of ongoing post-traumatic amnesia).

    See the section on discharge and follow up for recommendations about other factors to consider, such as whether supervision at home is available. [2003, amended 2023]

1.9.2 Be aware that some people may need an extended period in a recovery setting because of having general anaesthesia during CT imaging. [2003, amended 2007]

1.9.3 Admit people with multiple injuries under the care of the team that is trained to deal with their most severe and urgent problem. [2003]

1.9.4 When someone with a head injury needs hospital admission, admit them under the care of a team led by a consultant who has been trained in managing this condition. The consultant and their team should have competence (defined by local agreement with the neuroscience unit) in:

Admission and observation of people with concussion symptoms

1.9.5 For people with concussion symptoms after normal brain imaging or no indication for early imaging, follow the indications for admission in recommendation 1.9.1. Also see the section on discharge advice. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on admission and observation.

Full details of the evidence and the committee's discussion are in:

Early diagnosis of hypopituitarism

1.9.6 Be aware that any severity of head injury can cause pituitary dysfunction. This may present immediately, hours, weeks or months after the injury. A variety of symptoms could indicate hypopituitarism. [2023]

1.9.7 In people admitted to hospital with a head injury who have persistently abnormal low sodium levels or low blood pressure, consider investigations for hypopituitarism. [2023]

1.9.8 In people presenting to primary or community care with persistent symptoms consistent with hypopituitarism in the weeks or months after a head injury, consider investigations or referral for hypopituitarism. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on early diagnosis of hypopituitarism.

Full details of the evidence and the committee's discussion are in:

Observation of people who are admitted

1.9.9 Ensure that in-hospital observation of people with a head injury is only done by professionals competent in assessing head injuries. [2003]

1.9.10 For people admitted for head injury observation, the minimum acceptable documented neurological observations are: GCS score, pupil size and reactivity, limb movements, respiratory rate, heart rate, blood pressure, temperature and blood oxygen saturation. [2003]

1.9.11 Carry out and record observations on a half-hourly basis until there is a GCS score of 15. Observations for people with a GCS score of 15 should start after the initial assessment in the emergency department and the minimum frequency should be:

  • half-hourly for 2 hours, then

  • 1 hourly for 4 hours, then

  • 2 hourly. [2003]

1.9.12 Revert to half-hourly observations and follow the original frequency schedule for people with a GCS score of 15 who deteriorate at any time after the initial 2‑hour period. [2003]

1.9.13 Urgently reassess a person with a head injury if they have any of these signs of neurological deterioration:

  • agitation or abnormal behaviour

  • a sustained (that is, for at least 30 minutes) drop of 1 point in GCS score (give more weight to a drop of 1 point in the motor response score of the GCS score)

  • any drop of 3 or more points in the eye opening or verbal response scores of the GCS score, or 2 or more points in the motor response score

  • severe or increasing headache, or persistent vomiting

  • new or evolving neurological symptoms or signs such as pupil inequality or asymmetry of limb or facial movement.

    A supervising doctor should do the appraisal. [2003, amended 2007]

1.9.14 To reduce interobserver variability and unnecessary referrals, get a second member of staff competent in observations to confirm deterioration before involving the supervising doctor. Do this immediately if possible. If not possible (for example, because no staff member is available to do the second observation), contact the supervising doctor without the confirmation being done. [2003]

1.9.15 If any of the changes noted in recommendation 1.9.13 are confirmed, consider doing an immediate CT scan, and reassess the person's clinical condition and manage appropriately. [2003, amended 2007]

1.9.16 If a person has had a normal CT scan but does not have a GCS score of 15 after 24 hours of observation, consider a further CT or MRI scan and discuss with the radiology department. [2003]

Observation of babies and children under 5

1.9.17 Be aware that observation of babies and children under 5 is difficult, so should only be done by units with staff experienced in the observation of under 5s with a head injury. Babies and children under 5 may be observed in normal paediatric observation settings, as long as staff have the appropriate experience. [2003]

Training in observation

1.9.18 All staff caring for people with a head injury admitted for observation should be trained in doing the observations listed in recommendations 1.9.10 to 1.9.14 in the section on observation of people who are admitted, and the recommendation on observation of babies and children under 5. [2003]

1.9.19 Make dedicated training available to all relevant staff to enable them to acquire and maintain observation and recording skills. Specific training is needed for the observation of people under 16. [2003]

1.10 Discharge and follow up

1.10.1 If CT is not indicated based on history and examination and there is no suspicion of clinically important traumatic brain injury, discharge the person from hospital if there are:

  • no other factors that would warrant a hospital admission (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, or cerebrospinal fluid leak)

  • appropriate support structures for safe discharge to the community and for subsequent care (for example, competent supervision at home). [2003]

1.10.2 If imaging of the head is normal and the risk of clinically important traumatic brain injury is low, transfer the person to the community if:

  • the GCS score has returned to 15 or the pre-injury baseline GCS score

  • there are no other factors that would warrant a hospital admission (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, or cerebrospinal fluid leak)

  • there are appropriate support structures for safe transfer to the community and for subsequent care (for example, competent supervision at home). [2003]

1.10.3 After normal imaging of the cervical spine, risk of injury to the cervical spine is low enough to warrant transfer to the community if:

  • the GCS score is 15

  • clinical examination is normal

  • there are no other factors that would warrant a hospital admission present (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, or cerebrospinal fluid leak)

  • there are appropriate support structures for safe transfer to the community and for subsequent care (for example, competent supervision at home). [2003]

1.10.4 Do not discharge people presenting with a head injury until their GCS score is 15 or, in preverbal and non-verbal children, consciousness is normal as assessed by the paediatric version of the GCS. In people with pre-injury cognitive impairment, their GCS score should be back to that documented before the injury. [2003]

1.10.5 Only transfer people with any degree of head injury to their home if there is somebody suitable at home to supervise them. Discharge people with no carer at home only if suitable supervision arrangements have been organised, or when the risk of late complications is thought to be negligible. [2003]

People with pre-injury cognitive impairment

1.10.6 Ensure that people with pre-injury cognitive impairment (for example, dementia or a learning disability) and people returning to a custodial setting are supervised and monitored. Also, make sure that arrangements are in place should there be any signs of deterioration. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on discharge and follow up.

Full details of the evidence and the committee's discussion are in evidence review E: selecting adults, children and infants with head injury for CT or MRI head scan in sub-groups.

Discharge after observation

1.10.7 People admitted after a head injury may be discharged after resolution of all significant symptoms and signs, provided they have suitable supervision arrangements at home, in custody or in continued care. [2003, amended 2023]

Discharge advice

1.10.8 Give verbal and printed discharge advice to people with any degree of head injury who are discharged from an emergency department or observation ward. This should also be provided to the person responsible for their care after discharge. This may include their families, carers, social workers or custodial staff. Follow the recommendations in NICE's guidelines on patient experience in adult NHS services and babies, children and young people's experience of healthcare, including on providing information in an accessible format. [2014, amended 2023]

1.10.9 Ensure that printed advice for people with a head injury, and their families and carers, is age appropriate and includes:

  • details of the nature and severity of the injury

  • risk factors that mean people need to return to the emergency department (see the recommendations on community health services and inpatient units without an emergency department)

  • a specification that a responsible adult should stay with the person for the first 24 hours after their injury

  • details about the recovery process, including the fact that some people may appear to make a quick recovery but later have 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. [2014]

1.10.10 Offer information and advice on alcohol or drug misuse to people who presented to the emergency department with drug or alcohol intoxication when they are fit for discharge. [2003]

1.10.11 Inform people with a head injury, and their families and carers, about the possibility of persistent or delayed symptoms after a head injury and who to contact if they have ongoing problems. [2014]

1.10.12 For anyone who has attended the emergency department with a head injury, write to their GP within 48 hours of discharge, giving details of clinical history and examination. Also share this letter with health visitors (for preschool children) and school nurses (for school-age children and young people). If appropriate, provide a copy of the letter for the person with a head injury, and their family or carers, custodial staff or social worker. [2014]

Follow up

1.10.13 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. [2023]

1.10.14 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). [2003, amended 2023]

For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on follow up.

Full details of the evidence and the committee's discussion are in:

Investigations for hypopituitarism

1.10.15 Consider further endocrinology investigations for people who have been discharged after a head injury if they have persistent symptoms consistent with hypopituitarism or are not recovering as expected. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on investigations for hypopituitarism.

Full details of the evidence and the committee's discussion are in:

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

Closed head injury

A closed head injury occurs when there is either a direct injury (for example, blow to the head) or an indirect injury (for example, shaking or deceleration) without penetration of the skull or brain tissue by an object. The injury causes tearing, shearing or stretching of the nerves at the base of the brain, blood clots in or around the brain or oedema (swelling) of the brain. The skull may be fractured but this does not result in a direct connection between the brain and the outside.

Focal neurological deficit

Neurological problems restricted to a particular part of the body or a particular activity, for example:

  • difficulties with understanding, speaking, reading or writing

  • decreased sensation

  • loss of balance

  • weakness

  • visual changes

  • nystagmus

  • abnormal reflexes

  • problems walking

  • amnesia since the injury.

Glasgow Coma Scale

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.

High-energy head injury

An injury arising from, for example, a pedestrian being struck by a motor vehicle, an occupant being ejected from a motor vehicle, a fall from a height of more than 1 m or more than 5 stairs, a diving accident, a high-speed motor vehicle collision, a rollover motor accident, an accident involving motorised recreational vehicles, a bicycle collision or any other potentially high-energy mechanism.

Hypopituitarism

Underactivity of the pituitary gland that can lead to:

  • adrenocorticotropic hormone deficiency causing weakness, fatigue, weight loss, hypotension, hyponatraemia, hypoglycaemia, hypercalcaemia, anaemia and fatigue

  • growth hormone deficiency causing decreased energy, low mood, neuropsychiatric and cognitive symptoms, decreased lean body mass, increased fat mass, altered metabolic profile and decreased exercise capacity

  • lack of sex hormones that can cause later puberty, hot flushes, fatigue, tiredness, loss of body hair, reduced sex drive, irregular periods, erectile dysfunction and reduced fertility

  • thyroid-stimulating hormone deficiency presenting with slow growth, fatigue, lethargy, cold intolerance and weight gain

  • vasopressin deficiency causing polyuria, polydipsia, nocturia and incontinence.

Isolated simple linear non-displaced skull fracture

A single or solitary linear fracture that does not exhibit any inward or outward displacement, does not consist of multiple fracture lines and does not involve or cross the normal sutures of the skull.

Paraesthesia

Pins and needles, or a prickling sensation, tingling or itching in any part of the body.

Penetrating head injury

A penetrating head injury occurs when an object penetrates the scalp and skull, and enters the brain or its lining.

Post-concussion syndrome

Post-concussion syndrome (or post-concussion symptoms) is seen in all severities of head injury and is under-recognised in mild head injuries. It is the term used in evidence review F: brain injury biomarkers and/or MRI for predicting post-concussion syndrome. The term 'concussion' is used in evidence review J: admission and observation of people with concussion symptoms.

Examples of symptoms in these reviews include, but are not limited to:

Sensory and motor:

  • headache

  • dizziness

  • nausea

  • changes in vision, such as blurred vision, double vision, 'seeing stars' and 'looking through a haze'

  • visual processing problems, such as not taking in what you are seeing

  • difficulties staying awake, sleeping for many more hours than usual and chronic fatigue when awake

  • unusual sensitivity to noise (hyperacusis)

  • unusual sensitivity to bright lights (photophobia)

  • difficulties with balance, coordination and mobility, often resulting in falls, banging into objects and, at times, further traumatic brain injuries

  • speech problems.

Cognition:

  • cognitive difficulties (as long as the GCS score is 15), sometimes described as 'brain fog', which may include problems finding words or numbers, difficulty speaking, slowed responsiveness, short-term memory problems, difficulty concentrating and problems with information processing, such as following conversations, digesting text and finding words

  • difficulties with executive functions, such as organising, planning and multitasking

  • amnesia

  • problems with spatial awareness and proprioception, including the sensation of touching something as if through a layer of numbness.

Emotional:

  • lability, such as unusual laughing or crying (because of being overwhelmed by sense impressions) or irritability

  • depression

  • anxiety.

Additional symptoms that may present in children under 5:

  • changes in normal behaviour after a head injury, such as crying a lot or irritability

  • changes in feeding or sleeping habits

  • loss of interest in people or objects

  • listlessness.

Signs of a complex skull fracture or penetrating head injury

Signs of a basal, open or depressed skull fracture or penetrating head injury include:

  • clear fluid running from the ears or nose

  • a black eye with no associated damage around the eyes

  • bleeding from 1 or both ears

  • bruising behind 1 or both ears

  • penetrating injury signs

  • visible trauma to the scalp or skull of concern to the professional.

Traumatic brain injury

An alteration in brain function, or other evidence of brain pathology, caused by an external force.