Head injury: assessment and early management

Resource impact statement

The guideline covers the assessment and early management of head injury in babies, children, young people and adults. It aims to promote effective clinical assessment so that people have the right care for the severity of their head injury, including direct referral to specialist care if needed. It updates the previous version published in January 2014.

Each year, around 1 million people attend emergency departments in England with a recent head injury. About 200,000 people are admitted to hospital with a head injury every year. Of these, about 40,000 have evidence of traumatic brain injury. Most people with a head injury recover without specific or specialist intervention, others have long-term disability or even die from associated traumatic brain or other injuries.

Of people who have sustained a head injury, 95% present with a normal or minimally impaired conscious level, that is, a Glasgow Coma Scale (GCS) score of 13 or more. Most fatal outcomes are in the groups with a moderate (GCS score of 9 to 12) or severe (GCS score of 8 or less) head injury, and account for only 5% of attenders. This means emergency departments need to identify the small number who will go on to have serious acute intracranial complications.

Most of the recommendations in the updated guideline reinforce best practice and should not need any additional resources to implement. However, some of the guideline areas and recommendations may represent a change to current local practice. Where a change is required to current practice, this may require additional resources to implement, which may be significant at a local level. Benefits derived from the change in practice may help mitigate any additional costs.

Depending on current local practice, recommendations/areas which may require additional resources and result in additional costs include:

• Using tranexamic acid for isolated head injuries (recommendation 1.3.17). This is expected to increase tranexamic acid use by paramedics. The cost of using tranexamic acid as a result of this recommendation is not expected to be significant at a national level, but more resources might be needed for treatment, rehabilitation and care for the people who would not have survived without tranexamic acid. The committee identified there was a benefit with tranexamic acid in terms of reducing all-cause mortality and mortality from traumatic brain injury.
• CT head scan for people who have sustained a head injury and are on anticoagulant or antiplatelet treatment but have no other indications for a CT head scan (recommendation 1.5.13). Clinical opinion indicates there may be an overall increase in the number of scans. The recommendation wording has changed in this update from ‘offer’ to ‘consider’ for people with a head injury who are on anticoagulants and have no other indication for imaging but has been expanded to include people with a head injury who are on antiplatelet treatment.

Implementing the guideline may lead to the following benefits:

• A reduction in the number of people with an isolated skull fracture who are admitted for observation. It is expected that many of these people could be discharged from the emergency department without admission to hospital unless there are other indications for admission (recommendation 1.9.1).
• Better health outcomes and care experience.

These benefits may also provide some savings to offset some of the potential costs identified above.

Head injury services are commissioned by integrated care boards and NHS England. Providers are NHS hospital trusts, community providers, primary care providers and tertiary care providers.