Excerpt

The guideline covers best practice advice on the care of adults, children (aged 1–15 years) and infants (under one year) who present with a suspected or confirmed traumatic head injury with or without other major trauma. In certain circumstances, the age group ‘infants and young children’ (that is, those aged under 5 years) is used. Cut-off points of 10 years and 12 years are also used. The guideline will offer advice on the management of patients with a suspected or confirmed head injury who may be unaware that they have sustained a head injury because of intoxication or other causes. The primary patient outcome of concern throughout the guideline is ‘clinically important brain or cervical spine injury’. For the purposes of this guideline, clinically important brain or cervical spine injury is defined as any acute condition that has been identified by imaging or by assessment of risk factors.

This update covers the following: the benefits of transporting patients with head injuries to a neurosciences unit compared to an emergency department; the benefits of secondary transfer of patients; the best imaging tool for identifying patients with head and cervical spine injuries; the best clinical prediction rule for selecting patients with head and cervical spine injuries for the imaging tool selected; evidence on harm associated with radiation to the head and/or spine; identification of patients who should be referred to rehabilitation services following the initial management of a head injury.

Contents

• Foreword
• Guideline Development Group membership and acknowledgements
• Stakeholder involvement
• Abbreviations
• Glossary
• 1. Background and scope
  • 1.1 Introduction
  • 1.2 UK Guidelines
  • 1.3 Role of CT imaging
  • 1.4 North American guidelines
  • 1.5 The skull radiograph
  • 1.6 Admission
  • 1.7 Morbidity
  • 1.8 Cause of injury
  • 1.9 Summary of current care in the UK
  • 1.10 Scope
  • 1.11 Population
  • 1.12 Healthcare setting
  • 1.13 The need for this update guideline
  • 1.14 What are clinical practice guidelines?
  • 1.15 The National Collaborating Centre for Acute Care
  • 1.16 Remit of the Guideline
  • 1.17 What the update guideline covers
  • 1.18 What the guideline does not cover
  • 1.19 Who developed this guideline?
• 2. Methods
  • 2.1 Guideline development group
  • 2.2 Working principles
  • 2.3 Systematic reviews
  • 2.4 Resources
  • 2.5 Consensus methods
  • 2.6 Systematic review of indications for CT of the head
  • 2.7 Systematic review of indications for imaging of the cervical spine
  • 2.8 Systematic review of means of identifying patients at high risk of late sequelae following head injury
  • 2.9 Systematic review of medical radiation risks
  • 2.10 Guideline update methodology
  • 2.11 Developing the clinical questions
  • 2.12 Clinical literature search
  • 2.13 Hierarchy of clinical evidence
  • 2.14 The literature reviewing process
  • 2.15 Health economics methods
  • 2.16 Grading of recommendations
  • 2.17 Research recommendations
  • 2.18 Prioritisation of recommendations for implementation
  • 2.19 Validation of the guideline
• 3. Summary of recommendations
  • 3.1 Key Priorities for Implementation
  • 3.2 The complete list of clinical practice recommendations
  • 3.3 Presentation and referral
  • 3.4 Transport from community health services and NHS minor injury clinics and pre-hospital management
  • 3.5 Assessment and investigation in the emergency department
  • 3.6 Transfer from secondary settings to a neuroscience unit
  • 3.7 Observation of admitted patients
  • 3.8 Discharge
  • 3.9 New Recommendations
  • 3.10 Recommendations for research
• 4. Pre-hospital assessment, advice and referral to hospital
  • 4.1 Predictor variables
  • 4.2 Loss of consciousness
  • 4.3 Amnesia
  • 4.4 Neurological signs
  • 4.5 Bleeding disorders and use of anticoagulants
  • 4.6 Skull fracture
  • 4.7 Age
  • 4.8 Mechanism of injury
  • 4.9 Drug or alcohol intoxication
  • 4.10 Headache
  • 4.11 Vomiting
  • 4.12 Irritability and altered behaviour
  • 4.13 History of cranial neurosurgical interventions
  • 4.14 Public health literature
  • 4.15 Telephone advice lines
  • 4.16 Community health services and NHS minor injury clinics
  • 4.17 Transport from community health services and NHS minor injury clinics and pre-hospital management
  • 4.18 Training in risk assessment
• 5. Immediate management at the scene and transport to hospital
  • 5.1 Pre-hospital management
  • 5.2 Glasgow Coma Score
  • 5.3 Glasgow Coma Scale score
  • 5.4 Immediate management of patients with severe head injuries
  • 5.5 The benefits of direct transport from the scene to a specialist neurosciences centre compared to transport to the nearest district general hospital
  • 5.6 Advanced life support training for ambulance crews
  • 5.7 Priority dispatch of emergency ambulances
• 6. Assessment in the emergency department
  • 6.1 Focus of emergency department assessment in patients with a head injury
  • 6.2 Investigation of clinically important brain injuries
  • 6.3 What is the best initial diagnostic technique to determine which patients have sustained damage to the brain and require further assessment of the head?
  • 6.4 What are the effects on patient outcomes of providing an immediate CT versus observation?
  • 6.5 The best clinical prediction rule for selecting adults, infants and children with head injury for CT imaging of the head
  • 6.6 Investigation of cervical spine injuries
  • 6.7 What is the best diagnostic imaging technique to determine which patients have sustained damage to the cervical spine and require further assessment of cervical spine
  • 6.8 Cervical spine imaging of Infants and children
  • 6.9 The best clinical prediction rule for selecting patients that have sustained damage to the cervical spine for the imaging technique selected in ?
  • 6.10 Using adult rules with infants and children
  • 6.11 Piloting the new rules
  • 6.12 Non-accidental injury in children
  • 6.13 Good practice in emergency department assessment
• 7. Imaging practice and involvement of the neurosurgical department
  • 7.1 Good practice in imaging of patients with a head injury
  • 7.2 Urgency in performing CT of the head
  • 7.3 Cervical spine imaging urgency
  • 7.4 Involving neurosurgical care
  • 7.5 Other reasons for discussing a patient’s care with a neurosurgeon
  • 7.6 Criteria for neurosurgical interventions
  • 7.7 Transfer from secondary to tertiary care settings
  • 7.8 What are the benefits for patients of receiving treatment at a neurosciences centre who have suffered a clinically important brain injury that does not require surgical intervention?
  • 7.9 Transfer of children
• 8. Discharge and follow-up
  • 8.1 Introduction
  • 8.2 Discharge of low risk patients with GCS equal to 15
  • 8.3 Discharge of patients with normal imaging of the head
  • 8.4 Discharge of patients with normal imaging of the cervical spine
  • 8.5 Discharge of patients admitted for observation
  • 8.6 Discharge of patients at risk of non-accidental injury
  • 8.7 Discharge and Glasgow Coma Scale status
  • 8.8 Discharge advice
  • 8.9 Discharge of patients with no carer at home
  • 8.10 The best tool for identifying the patients who should be referred to rehabilitation services following the initial management of a head injury
  • 8.11 Outpatient appointments
  • 8.12 Prognosis in severe head injury
  • 8.13 Advice about long term problems and support services
  • 8.14 Communication with community services
  • 8.15 Re-attendees
• 9. Admission and observation
  • 9.1 Introduction
  • 9.2 Admission
  • 9.3 Good practice in observation of patients with head injury
  • 9.4 Minimum documented observations
  • 9.5 Frequency of observations
  • 9.6 Patient changes requiring review while under observation
  • 9.7 Imaging following confirmed patient deterioration during observation
  • 9.8 Further imaging if GCS equal to 15 not achieved at 24 hours
  • 9.9 Observation of children and infants
  • 9.10 Training in observation
  • 9.11 Support for families and carers
• 10. Medical radiation
  • 10.1 Introduction
  • 10.2 Patient doses from head CT
  • 10.3 Patient doses from cervical spine CT
  • 10.4 Summary of effective doses from CT and conventional X-ray examinations of the head and cervical spine
  • 10.5 Cancer risks
  • 10.6 Radiation exposure management
• 11. Economic evaluation
  • 11.1 Introduction
  • 11.2 Methods
  • 11.3 Diagnosis of intracranial haematoma in patients with a minor/mild head injury
  • 11.4 Identifying cervical spine damage in patients with head injury
  • 11.5 Discussion
  • 11.6 Addendum 2007 – Direct transport from injury scene to a specialist neurosciences centre
• Appendices
  • Appendix A Remit and Scope
  • Appendix B Declarations of Interest
  • Appendix C Key Clinical Questions included in the update
  • Appendix D Search strategies
  • Appendix E Suggested written discharge advice card for patients aged over 12 years who have sustained a head injury
  • Appendix F Suggested written discharge advice card for carers of children who have sustained a head injury
  • Appendix G Suggested written discharge advice card for carers of adults
  • Appendix H Abbreviations used in these evidence tables
  • Appendix I Evidence Tables
  • Appendix J Adult observation proforma
  • Appendix K Paediatric observation proformas
  • Appendix L Letter of referral to neurosurgical department
  • Appendix M The Glasgow Coma Scale for adults
  • Appendix N Paediatric version of the Glasgow Coma Scale
• Bibliography

First published June 2003