NICE guidelines on Head Injury

Question 1

Pre-hospital assessment, advice and referral to hospital

Answer 1

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:

• Unconsciousness or lack of full consciousness (for example, problems keeping eyes open).
• Any focal neurological deficit since the injury.
• Any suspicion of a skull fracture or penetrating head injury.
• Any seizure (‘convulsion’ or ‘fit’) since the injury.
• A high-energy head injury.
• The injured person or their carer is incapable of transporting the injured person safely to the hospital emergency department without the use of ambulance services (providing any other risk factor indicating emergency department referral is present; see recommendation 1.1.3).

Question 2

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:

Answer 2

• Any loss of consciousness (‘knocked out’) as a result of the injury, from which the person has now recovered.
• Amnesia for events before or after the injury (‘problems with memory’)[4].
• Persistent headache since the injury.
• Any vomiting episodes since the injury.
• Any previous brain surgery.
• Any history of bleeding or clotting disorders.
• Current anticoagulant therapy such as warfarin.
• Current drug or alcohol intoxication.
• There are 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 infants and children aged under 5 years.
• Continuing concern by helpline staff about the diagnosis. [2003, amended 2014]

Question 3

Immediate management at the scene and transport to hospital

Answer 3

• *Glasgow coma scale:**
• *1.2.1** Base monitoring and exchange of information about individual patients on the three separate responses on the GCS (for example, a patient scoring 13 based on scores of 4 on eye-opening, 4 on verbal response and 5 on motor response should be communicated as E4, V4, M5). [2003]

1.2.2 If a total score is recorded or communicated, base it on a sum of 15, and to avoid confusion specify this denominator (for example, 13/15). [2003]

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

1.2.4 In the paediatric version of the GCS, include a ‘grimace’ alternative to the verbal score to facilitate scoring in preverbal children. [2003]

1.2.5 In some patients (for example, patients with dementia, underlying chronic neurological disorders or learning disabilities) the pre-injury baseline GCS may be less than 15. Establish this where possible, and take it into account during assessment. [new 2014]