Guidelines from NICE for Head Injuries and their assessment:
Overview | Head injury: assessment and early management | Guidance | NICE
CT guidelines for head injuries:
For people 16 and over who have sustained a head injury, do a CT head scan within 1 hour of any of these risk factors being identified:
- A GCS score of 12 or less on initial assessment in the emergency department
- A GCS score of 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 people 16 and over 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 or over
- 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 more than 1 m or 5 stairs)
- More than 30 minutes’ retrograde amnesia of events immediately before the 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, a GCS score of less than 14 or, for babies under 1 year, a GCS score (paediatric) of less than 15
- At 2 hours after the injury, a GCS score of 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 babies under 1 year, a 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 1 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
- 3 or more discrete episodes of vomiting
- Dangerous mechanism of injury (high-speed road traffic accident as a pedestrian, cyclist or vehicle occupant, fall from a height of more than 3 m, high-speed injury from a projectile or other object)
- Amnesia (anterograde or retrograde) lasting more than 5 minutes (it will not be possible to assess amnesia in children who are preverbal and is unlikely to be possible in children under 5)
- Any current bleeding or clotting disorder.
Observe people under 16 who have sustained a head injury but have only 1 of the risk factors from 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 of 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.
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.
For advice on reversing vitamin K antagonists for people with traumatic intracranial haemorrhage, see the section on prothrombin complex concentrate in NICE’s guidelines on blood transfusion. For advice on reversing DOAC’S, see the MGRA safety advice on DOAC’s for a lost of reversal agents and NICE’s technology appraisal guidance on andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban. On call haematologist will also be happy to provide advice.