What does NICE say about head injuries?
This post is based on the NICE Clinical Guidelines, 2014. One part of their guidelines was in turn updated in 2019.
This post shows the key points and quotes as they relate to frontline ambulance staff; anything not relevant has not been included, but you may read more by following the link to the guidelines here.
Remember to read our disclaimer before putting into practice anything you see, hear, or read here. Also remember to check your local guidelines and the scope of practice for your role before putting any of this into practice.
Article 999: Simplifying the Long Stuff; Presenting the Relevant Stuff; Refreshing you on the Important Stuff.www.article999.co.uk
Definition of Head Injuries
‘any trauma to the head other than superficial injuries to the face.’ p6National Institute for Health and Care Excellence [NICE], 2014: 6
‘Head injury is the commonest cause of death and disability in people aged 1-40 years in the UK.’NICE, 2014: 6
‘The incidence of death from head injury is low, with as few as 0.2% of all patients attending emergency departments with a head injury dying as a result of this injury.’NICE, 2014: 6
‘the majority of fatal outcomes are in the moderate (GCS 9-12) or severe (GCS 8 or less) head injury groups’NICE, 2014: 6
When might adults need to attend A&E for a CT head scan following a head injury?
‘For adults who have sustained a head injury and have any of the following risk factors’
- Reduced GCS, ‘less than 13’ initially, or ‘less than 15 at 2 hours after the injury on assessment in the emergency department’*
- suspected skull fracture of any type
- ‘post-traumatic seizure’
- Neurological deficit
- ‘More than 1 episode of vomiting’
–> This should happen within one hour of identifying the situation.
(NICE, 2014: 10)
*Consider ‘the pre-injury baseline GCS may be less than 15. Establish this where possible’ (NICE, 2014: 19).
If the patient is on anticoagulants and has none of the above, they should have a CT head ‘within 8 hours of the injury’. (NICE, 2014: 12)
When might adults need to attend A&E for a CT cervical spine following a head injury?
- ‘The patient has been intubated’
- ‘The patient is having other body areas scanned for head injury
- ‘…there is clinical suspicion of cervical spine injury and any of the following apply:
- => 65
- ‘dangerous mechanism of injury’
- neuro deficit
- ‘paraesthesia in the upper or lower limbs’
(NICE, 2014: 13)
When might children need to attend hospital for a CT head scan following a head injury?
- ‘Suspicion of non-accidental injury’
- ‘Post-traumatic seizure but no history of epilepsy’
- Reduced GCS <14 initially, <15 2 hours later
- For under 1 year olds, Reduced GCS <15 on the paediatric scale
- Suspected skull fracture of any type
- Neuro deficit
- For under 1 year olds, ‘presence of bruise, swelling or laceration of more than 5 cm on the head’
(NICE, 2014: 11)
If a child has ‘more than one’ of these, he/she should have a CT scan within an hour:
- ‘Loss of consciousness lasting more than 5 minutes (witnessed)’
- ‘Abnormal drowsiness’
- Vomiting x3 or more episodes
- ‘Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object)’
- ‘Amnesia […] lasting more than 5 minutes’
(NICE, 2014: 11)
Note: If the child has just one of these, he/she ‘should be observed for a minimum of 4 hours after the head injury’ and if he/she then develops more of the above, a CT is warranted. (NICE, 2014: 12)
The rules regarding CT cervical spine scans are different in children, compared to adults, due to the risk of radiation to their thyroid.
For what other reasons should an adult or child with a head injury attend A&E?
- loss of consciousness
- ‘Amnesia for events before or after the injury’
- ‘Persistent headache since the injury’
- ‘Any vomiting episodes since the injury’ – but NICE advise considering the causes of single vomiting episodes in those under 12
- ‘Any seizure since the injury’
- ‘Any previous brain surgery’
- ‘A high-energy head injury’
- ‘Any history of bleeding and clotting disorders’
- ‘Current drug or alcohol intoxication’
- Safeguarding issues
- ‘Continuing concern by the professional about the diagnosis’
(NICE, 2014: 17-18)
- Patients who, 48 hours later, have ‘any persistent complaint relating to the initial head injury’
(NICE, 2014: 23)
Also, ‘depending on judgement of severity:’
- ‘irritability or altered behaviour’
- Other ‘Visible trauma to the head […] 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’
(NICE, 2014: 18)
What else should I consider in my assessment and treatment of a patient with a head injury?
- For adults, NICE recommends ‘managing their care according to clear principles and standard practice’ as in the ATLS and PHTLS courses, and the JRCALC for adults, and the APLS and PHPLS courses for children. There are others referenced, but Article 999 has included the most relevant here.
(NICE, 2014: 19-20)
- ‘Manage pain effectively because it can lead to a rise in intracranial pressure’
(NICE, 2014: 21)
- ‘Ascribe depressed conscious level to intoxication only after a significant brain injury has been excluded’
(NICE, 2014: 21-22)
- Pre-alert patients with a reduced GCS, especially of <8. They will most likely need anesthetist or critical care involvement
(NICE, 2014: 21-22)
What’s worth bearing in mind during hospital-neuroscience unit transfers of patients with head injuries?
- Patients who have a GCS of less than 8 should be intubated
- Before transporting, make sure to stabilise the patient and ensure monitoring is attached
- A patient ‘with persistent hypotension’ should not be transported until they are ‘stabilised’
(NICE, 2014: 32-33)
During these transfers, patients ‘should be accompanied by a doctor with appropriate training and experience in the transfer of patients with acute brain injury. […] Patients requiring non-emergency transfer should be accompanied by appropriate clinical staff.’NICE, 2014: 32-33
National Institute for Health and Care Excellence. (2014). Head injury: assessment and early management (NICE Clinical Guideline 176). Retrieved from https://www.nice.org.uk/guidance/cg176
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