5.1. Pre-hospital management
The following principles should be adhered to in the immediate care of patients who have sustained a head injury.
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[Amended] Adults who have sustained a head injury should initially be assessed and their care managed according to clear principles and standard practice, as embodied in: the Advanced Trauma Life Support (ATLS) course/European Trauma course; the International Trauma Life Support (ITLS) course; the Pre-hospital Trauma Life Support (PHTLS) course; the Advanced Trauma Nurse Course (ATNC); the Trauma Nursing Core Course (TNCC); and the Joint Royal Colleges Ambulance Service Liaison Committee (JRCALC) Clinical Practice Guidelines for Head Trauma. For children, clear principles are outlined in the Advanced Paediatric Life Support (APLS)/European Paediatric Life Support (EPLS) course, the Pre-hospital Paediatric Life Support (PHPLS) course and the Paediatric Education for Pre-hospital Professionals (PEPP) course materials.
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Ambulance crews should be fully trained in the use of the adult and paediatric versions of the GCS.
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Ambulance crews should be trained in the detection of non-accidental injury and should pass information to emergency department personnel when the relevant signs and symptoms arise.
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The priority for those administering immediate care is to treat first the greatest threat to life and avoid further harm.
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[Amended] Patients who have sustained a head injury should be transported directly to a facility that has been identified as having the resources necessary to resuscitate, investigate and initially manage any patient with multiple injuries. It is expected that all acute hospitals and all neuroscience units accepting patients directly from an incident will have these resources, and that these resources will be appropriate for a patient’s age.
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[Amended] Patients who have sustained a head injury and present with any of the following risk factors should have full cervical spine immobilisation attempted unless other factors prevent this:
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GCS less than 15 on initial assessment by the healthcare professional
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neck pain or tenderness
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focal neurological deficit
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paraesthesia in the extremities
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any other clinical suspicion of cervical spine injury.
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[Amended] Cervical spine immobilisation should be maintained until full risk assessment including clinical assessment (and imaging if deemed necessary) indicates it is safe to remove the immobilisation device.
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Standby calls to the destination emergency department should be made for all patients with a GCS less than or equal to 8, to ensure appropriately experienced professionals are available for their treatment and to prepare for imaging.
These recommendations are based on level five evidence and are considered to be grade D recommendations.
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[New] Pain should be managed effectively because it can lead to a rise in intracranial pressure. Reassurance and splintage of limb fractures are helpful; catheterisation of a full bladder will reduce irritability. Analgesia as described in 6.13 should be given only under the direction of a doctor.
5.2. Glasgow Coma Score
The Glasgow Coma Scale and its derivative the Glasgow Coma Score are widely used in the assessment and monitoring of patients who have sustained a head injury59,60.
The assessment and classification of patients who have sustained a head injury should be guided primarily by the adult and paediatric versions of the Glasgow Coma Scale and its derivative the Glasgow Coma Score47,61,62. Recommended versions are shown in Appendix M and Appendix N. Good practice in the use of the Glasgow Coma Scale and Score should be adhered to at all times, following the principles below.
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Monitoring and exchange of information about individual patients should be based 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).
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If a total score is recorded or communicated, it should be based on a sum of 15, and to avoid confusion this denominator should be specified (for example, 13/15).
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The individual components of the GCS should be described in all communications and every note and should always accompany the total score.
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The paediatric version of the GCS should include a ‘grimace’ alternative to the verbal score to facilitate scoring in pre-verbal or intubated patients.
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Best practice in paediatric coma observation and recording as detailed by the National Paediatric Neuroscience Benchmarking Group should be followed at all times. These principles are detailed in Appendix N.
These recommendations are based on level five evidence and are considered to be grade D recommendations.
5.3. Glasgow Coma Scale score
It is well established that the risk of intracranial complications and of subsequent need for surgery increases as GCS score declines.15,25,46 A recent study estimated that the rate of clinically important brain injury in hospital attenders who had experienced some loss of consciousness and/or amnesia since their head injury increased from 5% with an initial GCS equal to 15, to 17% for GCS equal to 14, and to 41% for GCS equal to 13.62 A further study on paediatric head injury found that a GCS less than 13 was a significant predictor of an abnormal CT scan in children with head injury aged 14 years or younger.63
5.4. Immediate management of patients with severe head injuries
There are specific questions regarding the early management of patients with severe head injuries (that is, GCS less than or equal to 8). Exhaustive systematic reviews have examined evidence on the management of severe traumatic brain injury.64,65 These reviews found evidence for only a small number of “standards” (that is, recommendations generally based on class one evidence or strong class two evidence of therapeutic effectiveness) and concluded that there was a paucity of well designed studies examining the efficacy of pre-hospital interventions in severe head injury.
Given these findings, no changes to current practice were recommended in the pre-hospital management of patients who have sustained a severe head injury.
5.5. The benefits of direct transport from the scene to a specialist neurosciences centre compared to transport to the nearest district general hospital
5.5.1. Introduction and rationale for the clinical question
This question has been included in this update because many healthcare professionals, especially ambulance staff, may be uncertain when deciding on the most appropriate destination for a patient with severe head injury. This is pertinent as the severity of head injury may not be known at the scene and the nearest neuroscience unit may be further away than the emergency department. There is also some confusion amongst hospital staff with regards to interhospital transfer of head injured patients. This is because patients who do not require surgery but do require neurosurgical care may remain in the district general hospital (DGH) and receive treatment there, when they actually require specialist treatment at a neuroscience unit. For interhospital transfers please see Chapter 7.
An emergency department is described as a local, regional DGH with no neurosciences unit or a non specialist centre whereas a neurosciences unit is described as a specialist centre or a unit that has neurosurgical and neurointensive care facilities.
The outcome measures for including studies for this review were mortality, neurological outcome, disability and hospital duration. Studies were excluded where;
data on head injury patients was not provided,
the patient group was less than 50% head injured patients,
intervention was pre hospital care rather than transfer and
the outcomes reported only duration of transfer and no other outcomes.
5.5.2. Clinical evidence
The first study66 was a retrospective observational cohort study (evidence level 2+), that obtained data from the New York State Trauma Registry from 1996–1998. This study examined patients who were transported to a regional/area trauma centre compared with patients transferred to non trauma centre. The patients in the latter group were assessed via the American Triage system (pre hospital care) and referred directly to a non trauma centre. The population were adults (over 13 years) with a GCS less than 14. Sub group data of 2763 head injured patients from a data set of 5419 trauma patients were analysed. Group 1 (n=2272 (82.2%)) patients were transported to regional/area trauma centre. These patients were assessed via American Triage system (pre hospital care) and referred directly to the emergency department of either a regional or area trauma centre. Group 2 (n=491 (17.8%)) patients were assessed via American Triage system (pre hospital care) and referred directly to a non trauma centre. The limitations of this study were that patients were categorised as head injured from data reported in trauma registry however the extent of head injury was unknown, because the GCS was classified as less than 14. The results of this study66 showed that the mortality rate of immediate transfer to a neurosciences centre versus transfer to a non trauma centre were in favour of transfer to neuroscience centre with an odds ratio 0.88, CI (0.64–1.22) which did not reach statistical significance.
The second study67 (evidence level 2+) described a cohort of paediatric patients aged under 20 years old using a large national US paediatric trauma registry, admitted to one of ninety paediatric hospitals or trauma centres. The cohort compared 3 sub groups defined by the site of intubation; in the field, in the trauma centre (n=1874) or in a non-trauma centre (n=1647). Taking the data from the latter two branches, risk stratification was performed in patients whose degree of head injury was measured using the New Injury Severity Score (NISS), and the Relative Head Injury Severity Scale (RHISS). The main outcomes were unadjusted mortality rates and functional outcomes. Patients who were assessed using the different scales had no significant differences in outcome or the place of intubation. Mortality (observed vs expected) rate in group 1 was 16.5% and in group 2 was 13.3%. Stratification of injury by NISS or degree of head injury showed that higher mortality rates were not only observed in the severely head injured patients who were intubated in a non trauma but also the mild and moderate head injured patients. Some doubt remains over the definition of head injured patients as it is unclear if these were isolated injury or part of a multiple trauma. This affects the conclusions one can draw from this study.
5.5.3. Economics Evidence from 2007 update
See economics chapter 11.6
5.5.4. Summary of evidence from 2007 update
With one study67 it is difficult to draw rational conclusions as to the benefits of direct transport of patients from the scene to either a neurosciences unit or a DGH as there is doubt over the definition of head injured patients. The other study66 showed that the mortality rate of immediate transfer to a neurosciences centre versus DGH were in favour of transport to a neuroscience centre. From this evidence review there is limited evidence for direct transport of head injured patients from the scene to a neurosciences unit being beneficial.
A simulation model68 showed improved survival from directly transporting patients to a neurosciences hospital. However, a number of parameters were based on expert judgement rather than strong evidence. A cost-effectiveness analysis based on this model showed that direct transport is likely to be cost-effective.
5.5.5. Rationale behind recommendation
There is no strong evidence to suggest a change in the previous recommendation (see bullet 5 within section 5.1). The GDG recognises that the transported patients with head injury directly to a neuroscience unit rather than a DGH would require a major shift of resources of between an additional 84,000 and 105,000 bed days to neurosurgery from the existing general surgical, orthopaedic, emergency department, paediatric and geriatric services that currently care for these patients. The GDG recognize that further research is needed in this area in order to identify benefits in transporting patients with head injury to a neuroscience unit or a district general hospital. Therefore the GDG propose a research recommendation for this question (see section 5.5.7).
5.5.6. Recommendation
[Amended] Patients who have sustained a head injury should be transported directly to a facility that has been identified as having the resources necessary to resuscitate, investigate and initially manage any patient with multiple injuries. It is expected that all acute hospitals and all neuroscience units accepting patients directly from an incident will have these resources, and that these resources will be appropriate for a patient’s age. (Same as the recommendation in section 5.1)
5.5.7. Recommendations for research
The GDG identified the following priority area for research.
5.5.7.1. Research Question
Is the clinical outcome of head injury patients with a reduced level of consciousness improved by direct transport from the scene of injury to a tertiary centre with neurosciences facilities compared with the outcome of those who are transported initially to the nearest hospital without neurosurgical facilities?
The aim of this study is to conduct a comparison of patient outcomes (mortality/morbidity) for those head injured patients that are transported directly to a centre with neurosciences facilities with the outcomes of those who are transported to the nearest hospital without neurosciences facilities, possibly necessitating a secondary transfer. Patients suffering from serious head injuries with a reduced level of consciousness are currently transported to the nearest hospital by land ambulance or helicopter. The nearest hospital may not have the resources or expertise to provide definitive care for these patients. Patients should be followed as they pass through the care system with mortality and morbidity outcomes collected. These should be compared to allow, using sub-group analysis, the identification of patients for whom direct transfer is most beneficial.
5.5.7.2. Why this research is important
Limited evidence in this area has shown that patients do better in terms of outcome if they are transported directly to a neurosciences centre when compared to those who are taken to the nearest DGH. This evidence however does not appear to have influenced current practice. For people working in the prehospital arena, it is important to define which patients who have sustained a head injury would do better by being transported directly to a neurosciences centre.
Currently patients are either always transported to the nearest DGH as is the case in most land vehicle deployment or in some organisations especially those involving helicopter emergency medical services the decision is left to the judgement of the clinicians at the scene. Those patients transported to the nearest DGH may suffer a significant delay in receiving definitive treatment for their head injury. Information from such research can help to define which patients should be transported direct to a neurosciences centre bypassing the nearest hospital.
Guidance will be required to define the patient population for example, researchers may focus on isolated injuries or head injuries associated with multi trauma. Further specification about what level of consciousness would be suitable for primary transfer to a neurosciences unit would be required. Researchers should look at the impact of the duration of transport on study outcome. So for a journey time to the neurosciences unit of less than 20 minutes, direct transport might improve outcomes, (as concluded by the London Severe Injury Working Group) but beyond this time, direct transport might worsen outcomes.
5.6. Advanced life support training for ambulance crews
The value of advanced life support (ALS) training for ambulance crews over basic life support training (BLS) is controversial. ALS trained ambulance crews receive extra training in endotracheal intubation, intravenous cannulation, the administration of intravenous fluids and the use of selected drugs. A recent Cochrane systematic review concluded that insufficient evidence existed on the effectiveness of ALS training for ambulance crews.69
Given this finding no change to current practice in ALS training for ambulance crews is recommended in these guidelines. This stance will be reviewed in forthcoming versions of these guidelines depending on advances in the literature.
5.7. Priority dispatch of emergency ambulances
The use of an emergency medical dispatch (EMD) system is controversial. The EMD system requires a form of telephone assessment carried out by ambulance dispatchers to determine the urgency of the emergency. A recent systematic review found little evidence on the effectiveness of EMD in terms of improved clinical outcomes.70 However, a recent study on the acceptability of EMD in a UK context found increased satisfaction among callers to the 999 service. The amount of first aid advice and general information received by the service users increased while satisfaction with response times was maintained.71
Given these findings no change to current practice in EMD is recommended in these guidelines. This stance will be reviewed in forthcoming versions of these guidelines depending on advances in the literature.
