This updated guideline on head injury from NICE doesn't change much in practice for us. The previous guideline came out quite a long time ago, so I don't think I'd ever read it. It does have a useful list of when we 'should' refer after head injury. Most of it is pretty obvious, but I've included the list below. There was also a good section on c-spine injuries, which is mainly based at AE departments, but it is quite relevant to us too, so I've included that.
The following criteria should prompt referral from us to AE for assessment.
- Glasgow coma scale (GCS) score of less than 15 on initial assessment.
- Any loss of consciousness as a result of the injury.
- Any focal neurological deficit since the injury.
- Any suspicion of a skull fracture or penetrating head injury since the injury.
- Amnesia for events before or after the injury
- Persistent headache since the injury.
- Any vomiting episodes since the injury (clinical judgement should be used regarding the cause of vomiting in those aged 12 years or younger and the need for referral).
- Any seizure since the injury.
- Any previous brain surgery.
- A high-energy head injury.
- Any history of bleeding or clotting disorders.
- Current anticoagulant therapy such as warfarin.
- Current drug or alcohol intoxication.
- There are any safeguarding concerns
- Continuing concern by the professional about the diagnosis.
If none of the above is present, but there is still concern, then referral to AE could be considered if:
- Irritability or altered behaviour, particularly in infants and children aged under 5 years.
- Visible trauma to the head not suggestive of #, but still 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
All of the following is only relevant if there is clinical suspicion of c-spine #
C-spine CT scan – if there is any of the following:
- 65 or over
- Dangerous mechanism of injury
- Focal peripheral neurological deficit
- Paraesthesia in upper or lower limbs
C-spine xrays would be indicated if none of the above were present, but:
- The patient can’t actively rotate their neck to 45 degrees each way
When is it safe to assess movement?
If no high risk factors as above are present and at least one of:
- 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.