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Head injury - Management
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How do I assess someone with a head injury?

  • Take a detailed history, including:
    • Information on how and when the head injury occurred.
    • What symptoms are currently present or have been experienced since the injury, for example any:
      • Loss of consciousness
      • Vomiting
      • Headache
      • Visual disturbance
      • Neck pain
    • Alcohol or drug intake
  • Examination should focus on:
    • The person's level of consciousness (using the Glasgow Coma Scale).
    • Neurological deficits.
    • Signs of physical trauma to the head and neck.
  • Although rare, suspect child maltreatment if a child has a head injury in the absence of major confirmed accidental trauma or know medical cause, in one or more of the following circumstances:
    • The explanation is absent or unsuitable.
    • The child is under 3 years of age.
    • There are also retinal haemorrhages, rib or long bone fractures, or other associated inflicted injuries.
Glasgow Coma Scale

Using the Glasgow Coma Scale

  • The Glasgow Coma Scale is used to assess the level of consciousness in people who have received a head injury. People are scored according to their best eye, verbal, and motor responses, with the lowest possible score being 3 (deep coma or death), and the highest being 15 (fully awake).
    • The person's Glasgow Coma Scale score should be fully documented, with the individual scores for best eye, verbal, and motor responses stated; for example, a person with a best score of 4 for eye response, 5 for verbal response, and 5 for motor response should be recorded as E4, V5, M5 and the total cumulative Glasgow Coma Score given with the denominator (15) always included, for example a score of 14/15.

Glasgow Coma Scale for adults and verbal children (usually 5 years of age and older)

  • Best eye response — does not open eyes, score 1; opens eyes in response to painful stimuli, score 2; opens eyes in response to voice, score 3; opens eyes spontaneously, score 4.
  • Best verbal response — makes no sounds, score 1; incomprehensible sounds, score 2; inappropriate words, score 3; confused and disorientated, score 4; orientated and converses normally, score 5.
  • Best motor response — makes no movement in response to pain, score 1; extension in response to painful stimuli, score 2; abnormal flexion in response to painful stimuli, score 3; flexion or withdrawal in response to painful stimuli, score 4; localizes painful stimuli, score 5; obeys simple commands, score 6.

Glasgow Coma Scale for preverbal children (usually less than 5 years of age)

  • Best eye response — no eye opening, score 1; eyes open in response to pain, score 2; eyes open in response to voice, score 3; eyes open spontaneously, score 4.
  • Best verbal response — no vocal response, score 1; inconsolable or agitated, score 2; inconsistently consolable or moaning, score 3; cries but is consolable or inappropriate interactions, score 4; smiles and orients to sounds, follows objects, and interacts, score 5.
  • Best motor response — no motor response to pain, score 1; extension in response to pain, score 2; flexion in response to pain, score 3; withdrawal from pain, score 4; localizing touch, score 5; spontaneous purposeful movement or obeys simple commands, score 6.
Basis for recommendation
  • The Glasgow Coma Scale (GCS) is used internationally in clinical practice to assess the depth and duration of impaired consciousness and coma.
  • The scale describes the various states of impaired consciousness encountered in clinical practice by assessing three different aspects of behavioural response: motor response, verbal response, and eye opening. Each response is evaluated independently of the other and graded according to a rank order that indicates the degree of dysfunction.
  • GCS has proven practical value in a wide range of settings and does not require special training. It should be applied to all people (including those who appear to be intoxicated), and scores should reflect actual observed activity without attempting to make allowance for intoxication [Teasdale and Jennett, 1974].
  • The recommendations on when to suspect child maltreatment are based on the National Institute for Health and Clinical Excellent guideline [NICE, 2009].

Who should I refer to hospital?

  • Refer immediately to the hospital emergency department using the ambulance service if necessary, if there is (or has been):
    • An altered level of consciousness. This can be objectively assessed using the Glasgow Coma Scale; any score of 14 or less (out of a maximum score of 15) indicates emergency referral.
    • Any loss of consciousness after the injury (even if they are fully alert on presentation).
    • A seizure since the injury.
    • Evidence of focal neurological deficit, such as:
      • Problems with sight, speech, understanding speech, reading, or writing.
      • Problems with balance or walking.
      • Loss of muscle power.
      • Paraesthesia of the extremities.
    • Amnesia for events before or after the injury.
    • Any suspicion of a skull fracture, such as:
      • Clear fluid (possible cerebrospinal fluid) running from the ear or nose.
      • A black eye with no damage around the eye.
      • Bleeding from one or both ears; blood behind the ear drum; new deafness in one or both ears; or bruising behind one or both ears.
      • Signs of a penetrating injury.
      • Visible trauma to the scalp or skull that is of concern.
    • Evidence of shock, or other injuries such as chest or abdominal trauma, limb or pelvic trauma, or significant vascular injury.
    • Persistent headache since the injury.
    • Vomiting since the head injury.
      • More than one episode in an adult.
      • Three or more episodes in a child.
    • A high-energy head injury such as: a pedestrian being struck by a motor vehicle; a high-speed motor collision; an axial-loading injury such as diving; a 'rollover' motor accident; or a fall from a height of greater than 1 metre, or more than five stairs.
    • A previous history of brain surgery.
    • A bleeding or clotting disorder, or current anticoagulant treatment (such as warfarin).
    • Suspicion the person has taken drugs or is intoxicated with alcohol.
    • A person 65 years of age or older.
    • Suspicion of a non-accidental injury.
    • Continuing concern about the diagnosis by the healthcare professional.
  • If the criteria listed above are not met, consider referral to a hospital emergency department if there is:
    • Irritability or altered behaviour, particularly in infants and children.
    • Adverse social factors that may affect safety at home.
    • Continuing concern about the diagnosis by the injured person, or their carer.
  • The person may be sent home if:
    • Clinical history and examination indicate a low risk of brain injury and the referral criteria are not met.
    • They have appropriate support structures and competent supervision at home.
    • They have received verbal and written self-care advice.
Basis for recommendation

The recommendations on referral for people with head injury are based on the clinical guidance Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults, produced by the National Collaborating Centre for Acute Care, and commissioned by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Acute Care, 2007]. It can be downloaded from www.nice.org.uk (pdf).

Recognition of high risk factors for brain injury following head injury

  • The risk of intracranial complications is higher in people with a diagnosis of skull fracture. It is estimated, from a meta-analysis of the value of the radiological diagnosis of skull fracture, that the risk of developing an intracranial haematoma is about 12-times higher with a radiographically-detected skull fracture than without this diagnosis [Hofman et al, 2000].
  • Post-traumatic neurological signs, such as focal neurological deficits or seizure, are highly associated with the risk of an intracranial complication [Teasdale et al, 1979].
  • Vomiting is consistently identified as a high risk factor for brain injury. However the predictive power in infants and children is controversial, as 16% of infants and children less than 12 years of age vomit after minor head injury, and this is not related to features specific to the head injury [Brown et al, 2000].
  • High-energy injury has been identified as a high risk factor for clinically important brain injury [Stiell et al, 2001].
  • Altered consciousness after a head injury increases the risk of intracranial complications, although the absolute risk remains low [Teasdale et al, 1990].
  • Amnesia after head injury increases the risk of intracranial complications, although the length and type of amnesia are controversial [Teasdale et al, 1990].
  • Drug and alcohol intoxication have been identified as independent risk factors following head injury. They can also hinder making a correct diagnosis as they may mask symptoms [Cook et al, 1994].
  • Headache is controversial in that there is clear evidence both for and against it being a good indicator for brain injury following head injury. This may in part be due to the difficulties that arise when defining headache, particularly in infants and children.
  • There is limited evidence to indicate that bleeding disorders and anticoagulant use contribute to an increased risk of brain injury following head injury.
  • Increasing age is associated with an increased risk of intercranial complications and a poorer prognosis, following head injury [National Collaborating Centre for Acute Care, 2007]. The NICE guideline development group adopted a standard age threshold of 65 years and older.
  • NICE identified a cohort study which developed a model to predict clinically important brain injury [Stiell et al, 2001]. This model suggested that people who were over 65 years of age had a 4 fold increased risk (odds ratio 4.1, 95% CI 2.8 to 6.1) of developing clinically important brain injury (resulting from a head injury) if loss of consciousness or amnesia were present.

What should I do while waiting for transfer to hospital?

  • People who have sustained a head injury should have cervical spine stabilization if they have:
    • An altered level of consciousness (Glasgow Coma Scale score of 14/15 or less).
    • A focal neurological deficit.
    • Neck pain or tenderness.
    • Clinical suspicion of cervical spine injury.
  • Provide analgesia as appropriate:
    • Paracetamol is recommended first-line.
    • Avoid aspirin and nonsteroidal anti-inflammatory drugs in the first 72 hours.
    • Avoid sedative analgesics (such as morphine).
Basis for recommendation

These recommendations are based on the clinical guidance Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults, produced by the National Collaborating Centre for Acute Care, and commissioned by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Acute Care, 2007]. It can be downloaded from www.nice.org.uk (pdf).

Neck stabilization

  • The recommendation for neck stabilization for people with head injury prior to hospital transfer includes the Canadian Cervical Spine Rule for selecting people with cervical spine damage for imaging. Whilst the Canadian rules were derived and validated on people older than 16 years of age, they have a sensitivity of 100% (95% CI 98 to 100) and a specificity of 42% (95% CI 40 to 44) for identifying clinically significant injuries [Bandiera et al, 2003].

What self-care advice should I give?

  • Advise adults to:
    • Stay within easy reach of help and near to a telephone for the first 48 hours.
    • Have plenty of rest and avoid stressful situations.
    • Avoid:
      • Taking any alcohol or drugs, sedatives, or tranquillizers (unless they are given by a doctor).
      • Contact sports (including rugby and football) for at least 3 weeks; the person should talk to their doctor first.
      • Returning to normal activity until they are completely recovered.
      • Driving or operating machinery, unless they are completely recovered.
    • Attend an emergency department if:
      • They have a change in consciousness, or experience confusion.
      • Fluid leaks from their ear or nose.
      • They are drowsy when they would normally be awake.
      • They have problems with understanding or speaking, loss of balance or problems walking, or weakness in one or both arms or legs.
      • They develop new problems with their eyesight.
      • They have a worsening headache.
      • There is vomiting or seizures.
  • Advise parents or carers that a child should:
    • Take simple painkillers if required for mild headache, such as paracetamol.
    • Eat only light meals for 1 or 2 days.
    • Avoid too much excitement, and not have too many visitors when they return home.
    • Avoid contact sports (and the parent should also discourage too much 'rough and tumble' play for the next few days).
    • Attend an emergency department urgently if they:
      • Become unusually or increasingly sleepy.
      • Complain of headaches which become more severe or, in the case of a young baby, if they cry persistently.
      • Appear unsteady when walking.
      • Vomit repeatedly.
      • Has a fit.
      • Develop a squint or blurred vision or starts seeing double.
      • Become unconscious.
Basis for recommendation
  • These recommendations are based on the clinical guidance Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults, produced by the National Collaborating Centre for Acute Care, and commissioned by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Acute Care, 2007]. It can be downloaded from www.nice.org.uk (pdf).
  • Some of the recommendations for parents or carers of a child with head injury are pragmatic and based on expert opinion from reviewers.

What advice should telephone advice services give a person with a head injury?

  • Refer the person to the hospital emergency department using the emergency ambulance service (that is, 999) if they:
    • Are unconscious or are not fully conscious.
    • Have had a seizure since the injury.
    • Have any focal neurological deficit, such as:
      • Problems with sight, speech, understanding speech, reading, or writing.
      • Problems with balance or walking.
      • Loss of muscle power.
      • Paraesthesia of the extremities.
    • Have any suspicion of a skull fracture or penetrating head injury, such as:
      • Clear fluid (possible cerebrospinal fluid) running from the ear or nose.
      • A black eye with no damage around the eye.
      • Bleeding from one or both ears; blood behind the ear drum; new deafness in one or both ears; or bruising behind one or both ears.
      • Signs of a penetrating injury.
      • Visible trauma to the scalp or skull that is of concern.
    • Have had a high-energy head injury such as: a pedestrian being struck by a motor vehicle; a high-speed motor collision; an axial-loading injury such as diving; a 'rollover' motor accident; or a fall from a height of greater than 1 metre, or more than five stairs.
  • Refer the person to the hospital emergency department (using the emergency ambulance service if it is not otherwise possible to transport the injured person safely) if there is (or has been):
    • Amnesia for events before or after the injury.
    • Persistent headache since the injury.
    • Vomiting since the head injury.
      • More than one episode in an adult.
      • Three or more episodes in a child.
    • A previous history of brain surgery.
    • A bleeding or clotting disorder, or current anticoagulant treatment (such as warfarin).
    • Suspicion the person has taken drugs or is intoxicated with alcohol.
    • A person 65 years of age or older.
    • Suspicion of a non-accidental injury.
    • Irritability or altered behaviour, particularly in infants and children.
    • Continuing concern about the diagnosis by the healthcare professional.
  • If the criteria for referral to an emergency department are not met, advise the person to seek medical advice from community settings (such as general practice) if there is:
    • Adverse social factors that may affect safety at home.
    • Continuing concern about the diagnosis by the injured person or their carer.
Basis for recommendation
  • These recommendations are based on the clinical guidance Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults, produced by the National Collaborating Centre for Acute Care, and commissioned by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Acute Care, 2007]. It can be downloaded from www.nice.org.uk (pdf).

How do I manage a person with persistent symptoms following a head injury?

  • If the person returns complaining of ongoing symptoms after a minor head injury, take a detailed history and perform a thorough examination.
    • If the person has 'red flag' symptoms or signs (such as altered consciousness), refer to an emergency department.
    • If the person does not have 'red flag' symptoms and signs (for example, they present with: persistent [but not worsening] headache; dizziness; generalized weakness; tinnitus; nausea; problems with mental activity [such as comprehension and memory]; sleep deprivation and fatigue):
      • Reassure that symptoms do not usually have a serious underlying cause, and normally resolve within 3 months of the injury.
      • Advise early return to activity, but also advise reducing daily demands and gradually returning to usual activities (if possible).
      • Advise a regular schedule of activity and sleep if fatigue and sleep deprivation are issues.
      • Provide appropriate treatment for specific symptoms (such as analgesia or depression).
    • Refer for appropriate specialist assessment (such as neurology, neuropsychology or psychiatry) if:
      • The person is distressed by their symptoms despite treatment and a period of watchful waiting for 3 months.
      • There are clinical concerns regarding type or severity of individual symptoms.
  • Consider if the person's on-going symptoms could be due to hypopituitarism, particularly if the brain injury was severe. Refer to a neurologist or endocrinologist for further assessment if appropriate.
    • Symptoms of hypopituitarism include tiredness, thirst, polydipsia, polyuria, amenorrhoea, erectile dysfunction, loss of libido, impaired cognitive function, and/or depression.
    • The symptoms of hypopituitarism following traumatic brain injury are often non-specific and similar to symptoms commonly experienced by people following a head injury. As a result, hypopituitarism following traumatic brain injury often remains unrecognized.
Basis for recommendation

Cause and prognosis of persistent symptoms

  • The cause of longer-term symptoms in people with minor head injury is not yet known, but there is little evidence to suggest a neurological basis. The minor symptoms described are consistent with expert opinion from a review article [Alves et al, 1993].
  • Most people who have persistent symptoms recover within 3 months, but about 8% have symptoms for at least a year, and sometimes symptoms are permanent. Up to 14% of people are disabled and can not work due to persistent symptoms [Binder, 1997].
  • Hypopituitarism can result from a traumatic brain injury (particularly a severe injury) and is estimated to occur in 15–25% of survivors [Ghigo et al, 2005; Agha and Thompson, 2006; Klose et al, 2007].

Psychological intervention

  • The recommendation for provision of psychological interventions (including reassurance, information provision, and advice) is based on expert opinion in a review article [King, 2003].
  • This is supported by evidence from a placebo-controlled trial (n = 218) that showed that intervention in the form of reassurance and education given within the first few weeks of minor head injury significantly improves post-concussion symptoms. In the study there was significantly less social disability (p = 0.01) and less severe post-concussion symptoms (p = 0.02) at follow up 6 months after injury in the active intervention group [Wade et al, 1998].

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