Which of the following concerns is a priority in a client with an open head injury?
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The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance. Show
Within this guideline children are defined as patients aged under 16 years and infants as those aged under 1 year at the time of presentation to hospital with head injury. 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. Terms used in this guidelineFocal neurological deficitProblems 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; general weakness; visual changes; abnormal reflexes; and problems walking. High-energy head injuryFor example, pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from a height of greater than 1 metre or more than 5 stairs, diving accident, high-speed motor vehicle collision, rollover motor accident, accident involving motorised recreational vehicles, bicycle collision, or any other potentially high-energy mechanism. Base of open or depressed skull fracture or penetrating head injurySigns include clear fluid running from the ears or nose, black eye with no associated damage around the eyes, bleeding from 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. 1.1 Pre-hospital assessment, advice and referral to hospital1.1.1 Public health literature and other non-medical sources of advice (for example, St John Ambulance, police officers) should encourage people who have any concerns following a head injury to themselves or to another person, regardless of the injury severity, to seek immediate medical advice. [2003] Telephone advice services1.1.2 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:
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:
Community health services and NHS minor injury clinics1.1.4 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:
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:
Transport to hospital from community health services and NHS minor injury clinics1.1.6 Patients referred from community health services and NHS minor injury clinics should be accompanied by a competent adult during transport to the emergency department. [2003] 1.1.7 The referring professional should determine if an ambulance is required, based on the patient's clinical condition. If an ambulance is deemed not required, public transport and car are appropriate means of transport providing the patient is accompanied. [2003] 1.1.8 The referring professional should inform the destination hospital (by phone) of the impending transfer and in non-emergencies a letter summarising signs and symptoms should be sent with the patient. [2003] Training in risk assessment1.1.9 GPs, nurse practitioners, dentists and ambulance crews should receive training, as necessary, to ensure that they are capable of assessing the presence or absence of the risk factors listed in recommendations 1.1.4 and 1.1.5. [2003, amended 2007] 1.3 Assessment in the emergency department1.3.1 Be aware that the priority for all emergency department patients is the stabilisation of airway, breathing and circulation (ABC) before attention to other injuries. [2003] 1.3.2 Ascribe depressed conscious level to intoxication only after a significant brain injury has been excluded. [2003] 1.3.3 All emergency department clinicians involved in the assessment of patients with a head injury should be capable of assessing the presence or absence of the risk factors for CT head and cervical spine imaging listed in recommendations 1.4.7 to 1.4.12 and recommendations 1.5.8 to 1.5.14. Training should be made available as required to ensure that this is the case. [2003] 1.3.4 Patients presenting to the emergency department with impaired consciousness (GCS less than 15) should be assessed immediately by a trained member of staff. [2003] 1.3.5 In patients with GCS 8 or less, ensure there is early involvement of an anaesthetist or critical care physician to provide appropriate airway management, as described in recommendations 1.7.7 and 1.7.8, and to assist with resuscitation. [2003] 1.3.6 A trained member of staff should assess all patients 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 high risk or low risk for clinically important brain injury and/or cervical spine injury, using recommendations 1.4.7 to 1.4.12 and 1.5.8 to 1.5.14. [2003] 1.3.7 In patients considered to be at high risk for clinically important brain injury and/or cervical spine injury, extend assessment to full clinical examination to establish the need to request CT imaging of the head and/or imaging of the cervical spine and other body areas. Use recommendations 1.4.7 to 1.4.12 and 1.5.8 to 1.5.14 as the basis for the final decision on imaging after discussion with the radiology department. [2003, amended 2007] 1.3.8 Patients who, on initial assessment, are considered to be at low risk for clinically important brain injury and/or cervical spine injury should be re-examined within a further hour by an emergency department clinician. Part of this assessment should fully establish the need to request CT imaging of the head and/or imaging of the cervical spine. Use recommendations 1.4. to 1.4.12 and 1.5.8 to 1.5.14 as the basis for the final decision on imaging after discussion with the radiology department. [2003, amended 2007] 1.3.9 Patients who return to an emergency department within 48 hours of transfer to the community with any persistent complaint relating to the initial head injury should be seen by or discussed with a senior clinician experienced in head injuries, and considered for a CT scan. [2003] 1.3.10 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. Treat significant pain with small doses of intravenous opioids titrated against clinical response and baseline cardiorespiratory measurements. [2007]At the time of publication (January 2014), intravenous opioids did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's General Medical Council's good practice in prescribing and managing medicines and devices for further information. 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] 1.3.12 Throughout the hospital episode, use a standard head injury proforma in documentation when assessing and observing patients with head injury. This form should be of a consistent format across all clinical departments and hospitals in which a patient might be treated. Use a separate proforma for those under 16 years. Areas to allow extra documentation should be included (for example, in cases of non-accidental injury). Examples of proforma that should be used in patients with head injury are provided in appendix O of the full guideline. [2003, amended 2007] Involving the neurosurgical department1.3.13 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] 1.3.14 Regardless of imaging, other reasons for discussing a patient's care plan with a neurosurgeon include:
1.4 Investigating clinically important brain injuries1.4.1 The current primary investigation of choice for the detection of acute clinically important brain injuries is CT imaging of the head. [2003] 1.4.2 For safety, logistic and resource reasons, do not perform magnetic resonance imaging (MRI) scanning as the primary investigation for clinically important brain injury in patients who have sustained a head injury, although it is recognised that additional information of importance to the patient's prognosis can sometimes be detected using MRI. [2003] 1.4.3 Ensure that there is appropriate equipment for maintaining and monitoring the patient within the MRI environment and that all staff involved are aware of the dangers and necessary precautions for working near an MRI scanner. [2003] 1.4.4 Do not use plain X-rays of the skull to diagnose significant brain injury without prior discussion with a neuroscience unit. However, they are useful as part of the skeletal survey in children presenting with suspected non-accidental injury. [2007] 1.4.5 If CT imaging is unavailable because of equipment failure, patients with GCS 15 may be admitted for observation. Arrangements should be in place for urgent transfer to a centre with CT scanning available should there be a clinical deterioration that indicates immediate CT scanning is necessary. [2007] 1.4.6 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 performing a CT head scanAdults1.4.7 For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
1.4.8 For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury, perform a CT head scan within 8 hours of the head injury:
Children1.4.9 For children who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
1.4.10 For children who have sustained a head injury and have more than 1 of the following risk factors (and none of those in recommendation 1.4.9), perform a CT head scan within 1 hour of the risk factors being identified:
1.4.11 Children who have sustained a head injury and have only 1 of the risk factors in recommendation 1.4.10 (and none of those in recommendation 1.4.9) should be observed for a minimum of 4 hours after the head injury. If during observation any of the risk factors below are identified, perform a CT head scan within 1 hour:
1.5 Investigating injuries to the cervical spine1.5.1 Be aware that, as a minimum, CT should cover any areas of concern or uncertainty on X-ray or clinical grounds. [2003] 1.5.2 Ensure that facilities are available for multiplanar reformatting and interactive viewing of CT cervical spine scans. [2003, amended 2014] 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] 1.5.4 Be aware that MRI may add important information about soft tissue injuries associated with bony injuries demonstrated by X-ray and/or CT. [2003] 1.5.5 MRI has a role in the assessment of ligamentous and disc injuries suggested by X-ray, CT or clinical findings. [2003] 1.5.6 In CT, routinely review on 'bone windows' the occipital condyle region for patients who have sustained a head injury. Reconstruction of standard head images onto a high-resolution bony algorithm is readily achieved with modern CT scanners. [2003] 1.5.7 In patients who have sustained high-energy trauma or are showing signs of lower cranial nerve palsy, pay particular attention to the region of the foramen magnum. If necessary, perform additional high-resolution imaging for coronal and sagittal reformatting while the patient is on the scanner table. [2003] Criteria for performing a CT cervical spine scan in adults1.5.8 For adults who have sustained a head injury and have any of the following risk factors, perform a CT cervical spine scan within 1 hour of the risk factor being identified:
1.5.9 For adults who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan (see recommendation 1.5.8), perform 3-view cervical spine X-rays within 1 hour if either of these risk factors are identified:
Assessing range of movement in the neck1.5.10 Be aware that in adults and children who have sustained a head injury and in whom there is clinical suspicion of cervical spine injury, range of movement in the neck can be assessed safely before imaging only if no high-risk factors (see recommendations 1.5.8, 1.5.11 and 1.5.12) and at least 1 of the following low-risk features apply. The patient:
Criteria for performing a CT cervical spine scan in children1.5.11 For children who have sustained a head injury, perform a CT cervical spine scan only if any of the following apply (because of the increased risk to the thyroid gland from ionising radiation and the generally lower risk of significant spinal injury):
1.5.12 For children who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan (see recommendation 1.5.11), perform 3-view cervical spine X-rays before assessing range of movement in the neck if either of these risk factors are identified:
1.5.13 If range of neck movement can be assessed safely (see recommendation 1.5.10) in a child who has sustained a head injury and has neck pain or tenderness but no indications for a CT cervical spine scan, perform 3-view cervical spine X-rays if the child cannot actively rotate their neck 45 degrees to the left and right. The X-rays should be carried out within 1 hour of this being identified and reviewed by a clinician trained in their interpretation within 1 hour of being performed. [new 2014] 1.5.14 In children who can obey commands and open their mouths, attempt an odontoid peg view. [2003, amended 2014] 1.6 Information and support for families and carers1.6.1 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] 1.6.2 Ensure that information sheets detailing the nature of head injury and any investigations likely to be used are made available in the emergency department. NICE's information for the public about this guideline may be helpful. [2003] 1.6.3 Staff should consider how best to share information with children and introduce them to the possibility of long-term complex changes in their parent or sibling. Literature produced by patient support groups may be helpful. [2003] 1.6.4 Encourage family members and carers to talk and make physical contact (for example, holding hands) with the patient. However, it is important that relatives and friends do not feel obliged to spend long periods at the bedside. If they wish to stay with the patient, encourage them to take regular breaks. [2003, amended 2007] 1.6.5 Ensure there is a board or area displaying leaflets or contact details for patient support organisations either locally or nationally to enable family members and carers to gather further information. [2003] 1.7 Transfer from hospital to a neuroscience unitTransfer of adults1.7.1 Local guidelines on the transfer of patients with head injuries should be drawn up between the referring hospital trusts, the neuroscience unit and the local ambulance service, and should recognise that:
1.7.2 The possibility of occult extracranial injuries should be considered for adults with multiple injuries, and they should not be transferred to a service that is unable to deal with other aspects of trauma. [2007] 1.7.3 There should be a designated consultant in the referring hospital with responsibility for establishing arrangements for the transfer of patients with head injuries to a neuroscience unit and another consultant at the neuroscience unit with responsibility for establishing arrangements for communication with referring hospitals and for receipt of patients transferred. [2003] 1.7.4 Patients with head injuries requiring emergency transfer to a neuroscience unit should be accompanied by a doctor with appropriate training and experience in the transfer of patients with acute brain injury. They should be familiar with the pathophysiology of head injury, the drugs and equipment they will use and working in the confines of an ambulance (or helicopter if appropriate). They should have a dedicated and adequately trained assistant. They should be provided with appropriate clothing for the transfer, medical indemnity and personal accident insurance. Patients requiring non-emergency transfer should be accompanied by appropriate clinical staff. [2003, amended 2007] 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] 1.7.6 Although it is understood that transfer is often urgent, complete the initial resuscitation and stabilisation of the patient and establish comprehensive monitoring before transfer to avoid complications during the journey. Do not transport a patient with persistent hypotension, despite resuscitation, until the cause of the hypotension has been identified and the patient stabilised. [2003, amended 2007] 1.7.7 Intubate and ventilate all patients with GCS 8 or less requiring transfer to a neuroscience unit, and any patients with the indications detailed in recommendation 1.7.8. [2003] 1.7.8 Intubate and ventilate the patient immediately in the following circumstances:
1.7.9 Use intubation and ventilation before the start of the journey in the following circumstances:
1.7.10 Ventilate an intubated patient with muscle relaxation and appropriate short-acting sedation and analgesia. Aim for a PaO2 greater than 13 kPa, PaCO2 4.5 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 mm Hg or more by infusion of fluid and vasopressors as indicated. In children, maintain blood pressure at a level appropriate for the child's age. [2003, amended 2007] 1.7.11 Education, training and audit are crucial to improving standards of transfer; appropriate time and funding for these activities should be provided. [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] Transfer of children1.7.13 Recommendations 1.7.1–1.7.12 were written for adults, but apply these principles equally to children and infants, providing that the paediatric modification of the GCS is used. [2003] 1.7.14 Service provision in the area of paediatric transfer to tertiary care should also follow the principles outlined in the National Service Framework for Paediatric Intensive Care. These do not conflict with the principles outlined in this section. [2003] 1.7.15 The possibility of occult extracranial injuries should be considered for children with multiple injuries. Do not transfer them to a service that is unable to deal with other aspects of trauma. [2007] 1.7.16 Transfer of a child or infant to a specialist neurosurgical unit should be undertaken by staff experienced in the transfer of critically ill children. [2003] 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] 1.8 Admission and observation1.8.1 Use the criteria below for admitting patients to hospital following a head injury:
1.8.2 Be aware that some patients may require an extended period in a recovery setting because of the use of general anaesthesia during CT imaging. [2003, amended 2007] 1.8.3 Admit patients with multiple injuries under the care of the team that is trained to deal with their most severe and urgent problem. [2003] 1.8.4 In circumstances where a patient with a head injury requires hospital admission, admit the patient only under the care of a team led by a consultant who has been trained in the management of this condition during their higher specialist training. The consultant and their team should have competence (defined by local agreement with the neuroscience unit) in assessment, observation and indications for imaging (see recommendations 1.4.7 to 1.4.12 and 1.5.8 to 1.5.14); inpatient management; indications for transfer to a neuroscience unit (see section on transfer from hospital to a neuroscience unit); and hospital discharge and follow-up (see section 1.9). [2003, amended 2007] Observation of admitted patients1.8.5 In-hospital observation of patients with a head injury should only be conducted by professionals competent in the assessment of head injury. [2003] 1.8.6 For patients admitted for head injury observation the minimum acceptable documented neurological observations are: GCS; pupil size and reactivity; limb movements; respiratory rate; heart rate; blood pressure; temperature; blood oxygen saturation. [2003] 1.8.7 Perform and record observations on a half-hourly basis until GCS equal to 15 has been achieved. The minimum frequency of observations for patients with GCS equal to 15 should be as follows, starting after the initial assessment in the emergency department:
1.8.8 Should the patient with GCS equal to 15 deteriorate at any time after the initial 2-hour period, observations should revert to half-hourly and follow the original frequency schedule. [2003] 1.8.9 Any of the following examples of neurological deterioration should prompt urgent reappraisal by the supervising doctor.
1.8.10 To reduce inter-observer variability and unnecessary referrals, a second member of staff competent to perform observation should confirm deterioration before involving the supervising doctor. This confirmation should be carried out immediately. Where a confirmation cannot be performed immediately (for example, no staff member available to perform the second observation) the supervising doctor should be contacted without the confirmation being performed. [2003] 1.8.11 If any of the changes noted in recommendation 1.8.9 are confirmed, an immediate CT scan should be considered, and the patient's clinical condition re‑assessed and managed appropriately. [2003, amended 2007] 1.8.12 In the case of a patient who has had a normal CT scan but who has not achieved GCS equal to 15 after 24 hours' observation, a further CT scan or MRI scanning should be considered and discussed with the radiology department. [2003] Observation of infants and young children1.8.13 Observation of infants and young children (that is, aged under 5 years) is a difficult exercise and therefore should only be performed by units with staff experienced in the observation of infants and young children with a head injury. Infants and young children may be observed in normal paediatric observation settings, as long as staff have the appropriate experience. [2003] Training in observation1.8.14 Medical, nursing and other staff caring for patients with head injury admitted for observation should all be capable of performing the observations listed in recommendations 1.8.6, 1.8.9 and 1.8.10. [2003] 1.8.15 The acquisition and maintenance of observation and recording skills require dedicated training and this should be made available to all relevant staff. [2003] 1.8.16 Specific training is required for the observation of infants and young children. [2003] 1.9 Discharge and follow-up1.9.1 If CT is not indicated on the basis of history and examination the clinician may conclude that the risk of clinically important brain injury to the patient is low enough to warrant transfer to the community, as long as no other factors that would warrant a hospital admission are present (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak) and there are appropriate support structures for safe transfer to the community and for subsequent care (for example, competent supervision at home). [2003] 1.9.2 After normal imaging of the head, the clinician may conclude that the risk of clinically important brain injury requiring hospital care is low enough to warrant transfer to the community, as long as the patient has returned to GCS equal to 15, and no other factors that would warrant a hospital admission are present (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak) and there are appropriate support structures for safe transfer to the community and for subsequent care (for example, competent supervision at home). [2003] 1.9.3 After normal imaging of the cervical spine the clinician may conclude that the risk of injury to the cervical spine is low enough to warrant transfer to the community, as long as the patient has returned to GCS equal to 15 and their clinical examination is normal, and no other factors that would warrant a hospital admission are present (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak) and there are appropriate support structures for safe transfer to the community and for subsequent care (for example, competent supervision at home). [2003] 1.9.4 Do not discharge patients presenting with head injury until they have achieved GCS equal to 15, or normal consciousness in infants and young children as assessed by the paediatric version of the GCS. [2003] 1.9.5 All patients with any degree of head injury should only be transferred to their home if it is certain that there is somebody suitable at home to supervise the patient. Discharge patients with no carer at home only if suitable supervision arrangements have been organised, or when the risk of late complications is deemed negligible. [2003] Discharge after observation1.9.6 Patients admitted after a head injury may be discharged after resolution of all significant symptoms and signs providing they have suitable supervision arrangements at home. [2003] Discharge advice1.9.7 Give verbal and printed discharge advice to patients with any degree of head injury who are discharged from an emergency department or observation ward, and their families and carers. Follow recommendations in the NICE guideline on patient experience in adult NHS services about providing information in an accessible format. [new 2014] 1.9.8 Printed advice for patients, families and carers should be age-appropriate and include:
1.9.9 Offer information and advice on alcohol or drug misuse to patients who presented to the emergency department with drug or alcohol intoxication when they are fit for discharge. [2003] 1.9.10 Inform patients and their families and carers about the possibility of persistent or delayed symptoms following head injury and whom to contact if they experience ongoing problems. [new 2014] 1.9.11 For all patients who have attended the emergency department with a head injury, write to their GP within 48 hours of discharge, giving details of clinical history and examination. This letter should also be shared with health visitors (for pre-school children) and school nurses (for school-age children). If appropriate, provide a copy of the letter for the patient and their family or carer. [new 2014] Follow-up1.9.12 When a patient who has undergone imaging of the head and/or been admitted to hospital experiences persisting problems, ensure that there is an opportunity available for referral from primary care to an outpatient appointment with a professional trained in assessment and management of sequelae of brain injury (for example, clinical psychologist, neurologist, neurosurgeon, specialist in rehabilitation medicine). [2003] What is your top priority in managing a patient with a head injury?The first priority in any emergency is always an adequate airway. The nurse is involved in clearing the mouth, inserting an oral airway, assisting with intubation, oxygen therapy and assessing continually the patient's respiratory system.
What is the first and most important signal of a serious head injury?Symptoms of serious head injury can include clear fluid leaking from the nose or ears, altered consciousness or a period of unconsciousness, skull deformities, vision changes, bruised eyes and ears, nausea and vomiting. A person who has sustained a head injury may also have injured their spine.
What are the priorities for initial management of a head injury?In the setting of acute head injury, give priority to the immediate assessment and stabilization of the airway and circulation.
What is the major concern with the patient who has sustained a head injury?Complications. A severe head injury can result in pressure being placed on the brain because of bleeding, blood clots or a build-up of fluid. This can sometimes lead to brain damage, which can be temporary or permanent.
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