Trauma
A 70 year old woman is brought to the Emergency Department by her family after falling at home. She describes tripping on a rug and falling forwards, hitting her head on the corner of a wall. Her husband describes a "few minutes" of loss of consciousness. She has vomited once since the injury. She has no significant past medical history or regular medications. On examination her observations are recorded as:
- Heart rate: 87 beats per minute
- Blood pressure: 145/89 mmHg
- Respiratory rate: 16 breaths per minute
- GCS: 15/15
What is the recommended management for this patient?
Answer:
For adults 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 years or older.
- 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 greater than 1 metre or 5 stairs).
- More than 30 minutes' retrograde amnesia of events immediately before the head injury.
Head Injury: Assessment
Trauma
Last Updated: 7th November 2023
Assessment in the ED
- Be aware that the priority for all emergency department patients is the stabilisation of airway, breathing and circulation (ABC) before attention to other injuries.
- Only assume a depressed conscious level is due to intoxication after an important traumatic brain injury has been excluded.
- Patients presenting to the emergency department with impaired consciousness (GCS less than 15) should be assessed immediately by a trained member of staff.
- 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 patients with GCS 8 or less, ensure there is early involvement of an anaesthetist or critical care physician to provide appropriate airway management.
- 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:
- 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.
- 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.
- 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.
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Manage pain effectively because it can lead to a rise in intracranial pressure. Provide reassurance, splinting 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.
- Consider or suspect abuse, neglect or other safeguarding issues as a contributory factor to, or cause of, a head injury. 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.
- 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)
Criteria for performing a CT head scan in adults (16 years and over) with head injury
For adults who have sustained a head injury, do a CT head scan within 1 hour of any of these risk factors being identified:
- GCS of 12 or less on initial assessment in the emergency department.
- GCS 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.
For adults 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 years or older.
- 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 greater than 1 metre or 5 stairs).
- More than 30 minutes' retrograde amnesia of events immediately before the head injury.
CT findings of significance include scalp swelling and subgaleal hematomas at the region of impact. Skull fractures can be seen better with bone windows but are often apparent even on the soft-tissue windows. Crucial CT findings are intracranial blood, contusions, shift of midline structures (mass effect), and obliteration of the basal cisterns. A shift of 5 mm or greater often indicates the need for surgery to evacuate the blood clot or contusion causing the shift.
Criteria for performing a CT head scan in children (< 16 years) with head injury
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, GCS less than 14, or for children under 1 year GCS (paediatric) less than 15
- At 2 hours after the injury, GCS 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 children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
For people under 16 who have sustained a head injury and have more than one 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
- Three or more discrete episodes of vomiting
- 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 (antegrade or retrograde) lasting more than 5 minutes
- Any current bleeding or clotting disorder
Observe people under 16 who have sustained a head injury but have only one of the risk factors listed above 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 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.
People taking anticoagulant or antiplatelet medication
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:
- within 8 hours of the injury (for example, if it is difficult to do a risk assessment or if the person might not return to the emergency department if they have signs of deterioration) or
- within the hour if they present more than 8 hours after the injury.
Criteria for performing a CT cervical spine in adults with head injury
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:
- 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.
For adults who have sustained a head injury and have neck pain or tenderness but no high-risk indications for a CT cervical spine scan, do a CT cervical spine scan within 1 hour for any of these risk factors:
- It is not considered safe to assess the range of movement in the neck.
- Safe assessment of range of neck movement shows that the patient cannot actively rotate their neck to 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).
Be aware that in adults 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 and at least 1 of the following low-risk features apply. The patient:
- was involved in a simple rear-end motor vehicle collision.
- is comfortable in a sitting position in the emergency department.
- has been ambulatory at any time since injury.
- has no midline cervical spine tenderness.
- presents with delayed onset of neck pain.
Criteria for performing a CT cervical spine scan in children with a head injury
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). The scan should be performed within 1 hour of the risk factor being identified:
- GCS score 12 or less on initial assessment
- The patient has been intubated
- Focal peripheral neurological signs
- Paraesthesia in the upper or lower limbs
- A definitive diagnosis of cervical spine injury is needed urgently (for example, if manipulation of the cervical spine is needed during surgery or anaesthesia)
- The patient is having other body areas scanned for head injury or multi-region 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
For children who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan, perform 3-view cervical spine X-rays before assessing range of movement in the neck if any of these risk factors are identified:
- 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.
- 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.
If range of neck movement can be assessed safely 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. In children who can obey commands and open their mouths, attempt an odontoid peg view.
Involving the neurosurgical department
Discuss with a neurosurgeon the care of all patients with new, surgically significant abnormalities on imaging. Regardless of imaging, other reasons for discussing a patient's care plan with a neurosurgeon include:
- Persisting coma (GCS 8 or less) after initial resuscitation.
- Unexplained confusion which persists for more than 4 hours.
- Deterioration in GCS score after admission (greater attention should be paid to motor response deterioration).
- Progressive focal neurological signs.
- A seizure without full recovery.
- Definite or suspected penetrating injury.
- A cerebrospinal fluid leak.
Indications for intubation and ventilation
Intubate and ventilate the patient immediately in the following circumstances:
- Coma – not obeying commands, not speaking, not eye opening (that is, GCS 8 or less).
- Loss of protective laryngeal reflexes.
- Ventilatory insufficiency as judged by blood gases: hypoxaemia (PaO2 < 13 kPa on oxygen) or hypercarbia (PaCO2 > 6 kPa).
- Irregular respirations.
Use intubation and ventilation before transfer in the following circumstances:
- 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 mouth (for example, from skull base fracture).
- Seizures.
Anyone whose trachea is intubated should have appropriate sedation and analgesia along with a neuromuscular blocking drug. 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, increase the inspired oxygen concentration. Maintain the mean arterial pressure at 80 mmHg or more by infusion of fluid and vasopressors as indicated.
Admission
Use the criteria below for admitting patients to hospital following a head injury:
- Patients with new, clinically significant abnormalities on imaging.
- Patients whose GCS has not returned to 15 after imaging, regardless of the imaging results.
- When a patient has indications for CT scanning but this cannot be done within the appropriate period, either because CT is not available or because the patient is not sufficiently cooperative to allow scanning.
- Continuing worrying signs (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).
Observation
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.
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:
- half-hourly for 2 hours
- then 1-hourly for 4 hours
- then 2-hourly thereafter
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.
Any of the following examples of neurological deterioration should prompt urgent reappraisal by the supervising doctor:
- Development of agitation or abnormal behaviour.
- A sustained (that is, for at least 30 minutes) drop of 1 point in GCS score (greater weight should be given to a drop of 1 point in the motor response score of the GCS).
- Any drop of 3 or more points in the eye-opening or verbal response scores of the GCS, or 2 or more points in the motor response score.
- Development of 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.
If any of the changes noted above are confirmed, an immediate CT scan should be considered, and the patient's clinical condition re‑assessed and managed appropriately. 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 scan should be considered and discussed with the radiology department.
Discharge and follow-up
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).
After normal imaging of the head or cervical spine, 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.
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.
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. Advice should include:
- Details of the nature and severity of the injury
- Risk factors that mean patients need to return to the emergency department
- A specification that a responsible adult should stay with the patient for the first 24 hours after their injury
- Details about the recovery process, including the fact that some patients may appear to make a quick recovery but later experience 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
Refer people with a head injury to investigate its causes and manage contributing factors, if appropriate. This could include, for example, referral for a falls assessment or to safeguarding services.
Consider referring people who have persisting problems to a clinician trained in assessing and managing the consequences of traumatic brain injury (for example, a neurologist, neuropsychologist, clinical psychologist, neurosurgeon or endocrinologist, or a multidisciplinary neurorehabilitation team).
Suspecting non-accidental injury in children with head injury
- The child is not yet independently mobile (crawling, cruising, walking).
- The injury or bruise is:
- On any non-bony part of the face (including the eyes or ears).
- On both sides of the face or head.
- Any bruises are:
- Disproportionate to the explanation of injury sustained.
- Present in multiple sites or in clusters.
- Of a similar shape and size.
- The child has retinal haemorrhages or injury to the eye (in the absence of major confirmed accidental trauma or a known medical explanation).
- The explanation for the injury is implausible, inadequate, or inconsistent:
- With the child's presentation, normal activities, existing medical conditions, age or developmental stage, or account — compared with that given by parents or carers.
- Between parents or carers.
- Between accounts over time.
- There is a delay in presentation.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
