Remote advice services

1.2.2.

Remote advice services (for example, NHS 111) should refer people who have sustained a head injury to the emergency ambulance services (that is, 999) for emergency transport to the emergency department if there are any of these risk factors (see NICE’s guidelines on shared decision making and decision making and mental capacity):

• unconsciousness or lack of full consciousness (for example, problems keeping eyes open)
• any focal neurological deficit since the injury
• any suspicion of a complex skull fracture or penetrating head injury
• any seizure (‘convulsion’ or ‘fit’) since the injury
• a high-energy head injury
• there is no other way of safely transporting the person to the hospital emergency department (see recommendation 1.2.3). [2003, amended 2007, 2014 and 2023]

1.2.3.

Remote advice services (for example, NHS 111) should refer people who have sustained a head injury to a hospital emergency department if there are any of these risk factors (see NICE’s guidelines on shared decision making and decision making and mental capacity):

• any loss of consciousness (‘knocked out’) because of the injury, from which the person has now recovered
• amnesia for events before or after the injury (‘problems with memory’; it will not be possible to assess amnesia in children who are preverbal and is unlikely to be possible in children under 5)
• a persistent headache since the injury
• any vomiting episodes since the injury
• any previous brain surgery
• any history of bleeding or clotting disorders
• current anticoagulant and antiplatelet (except aspirin monotherapy) treatment
• current drug or alcohol intoxication
• any safeguarding concerns (for example, possible non-accidental injury or a vulnerable person is affected)
• irritability or altered behaviour (easily distracted, not themselves, no concentration, no interest in things around them), particularly in babies and children under 5
• continuing concern by helpline staff about the diagnosis. [2003, amended 2014 and 2023]

Community health services and inpatient units without an emergency department

1.2.4.

Community health services (GPs, ambulance crews, NHS walk-in or minor injury centres, dental practitioners) and inpatient units without an emergency department should refer people who have sustained a head injury to a hospital emergency department, using the ambulance service if necessary, if there are any of these risk factors (see NICE’s guidelines on shared decision making and decision making and mental capacity):

• a Glasgow Coma Scale (GCS) score of less than 15 on initial assessment
• any loss of consciousness because of the injury
• any focal neurological deficit since the injury
• any suspicion of a complex skull fracture or penetrating head injury since the injury
• amnesia for events before or after the injury (it will not be possible to assess amnesia in children who are preverbal and is unlikely to be possible in children under 5)
• a persistent headache since the injury
• any vomiting episodes since the injury (use clinical judgement about the cause of vomiting in children 12 years or under 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 and antiplatelet (except aspirin monotherapy) treatment
• current drug or alcohol intoxication
• any safeguarding concerns (for example, possible non-accidental injury or a vulnerable person is affected)
• continuing concern by the professional about the diagnosis. [2003, amended 2007, 2014 and 2023]

1.2.5.

In the absence of any risk factors in recommendation 1.2.4, consider referral to an emergency department if any of these factors are present, depending on judgement of severity (see NICE’s guidelines on shared decision making and decision making and mental capacity):

• irritability or altered behaviour, particularly in babies and children under 5
• visible trauma to the head not covered in recommendation 1.2.4 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. [2003, amended 2014 and 2023]

Transport to hospital from community health services and inpatient units without an emergency department

1.2.6.

Ensure people referred from community health services are accompanied by a competent adult during transport to the emergency department. [2003]

1.2.7.

The referring professional should determine if an ambulance is needed, based on the person’s clinical condition. If an ambulance is not needed, provided the person is accompanied, public transport or being driven in a car are appropriate means of transport. [2003]

1.2.8.

The referring professional should inform the destination hospital (by phone) of the impending transfer. In non-emergencies, a letter summarising signs and symptoms should be sent with the person. [2003]

Training in risk assessment

1.2.9.

Train GPs, nurse practitioners, dentists and ambulance crews, as necessary, to ensure that they are capable of assessing the presence or absence of the risk factors listed in the section on community health services and inpatient units without an emergency department. [2003, amended 2007]

Glasgow Coma Scale

1.3.1.

Base monitoring and exchange of information about people with a head injury on the 3 separate responses on the GCS (for example, describe a person with a GCS score of 13 based on scores of 4 on eye opening, 4 on verbal response and 5 on motor response as E4, V4, M5). [2003]

1.3.2.

When recording or passing on information about total GCS score, give this as a score out of 15 (for example, 13 out of 15). [2003]

1.3.3.

Describe the individual components of the GCS in all communications and every patient record and ensure that they always accompany the total score. [2003]

1.3.4.

In the paediatric version of the GCS, include a ‘grimace’ alternative to the verbal score to enable scoring in children who are preverbal. [2003]

1.3.5.

In some people (for example, people with dementia, underlying chronic neurological disorders or learning disabilities), the pre-injury baseline GCS score may be less than 15. Establish this when possible and take it into account during assessment. [2014]

Initial assessment and care

1.3.6.

Initially assess people 16 and over who have sustained a head injury and manage their care according to clear principles and standard practice, as embodied in the:

• Advanced Trauma Life Support course or European Trauma course
• International Trauma Life Support course
• Pre-hospital Trauma Life Support course
• Advanced Trauma Nurse Course
• Trauma Nursing Core Course
• Joint Royal Colleges Ambulance Service Liaison Committee Clinical Practice Guidelines for Head Trauma. [2003, amended 2007]

1.3.7.

Initially assess people under 16 who have sustained a head injury and manage their care according to clear principles outlined in the:

• Advanced Paediatric Life Support course or European Paediatric Life Support course
• Pre-hospital Paediatric Life Support course
• Paediatric Education for Pre-hospital Professionals course. [2003, amended 2007]

1.3.8.

When administering immediate care, first treat the greatest threat to life and avoid further harm. For advice on volume resuscitation for people with a traumatic brain injury and haemorrhagic shock, see NICE’s guideline on major trauma: assessment and initial management. [2003]

1.3.9.

For recommendations on when to carry out full in-line spine immobilisation and how long immobilisation is needed if indicated, see NICE’s guideline on spinal injury. [2003, amended 2007]

1.3.10.

Make pre-alert calls to the destination emergency department for anyone with a GCS score of 8 or less to ensure appropriately experienced professionals are available for their treatment and to prepare for imaging. [2003]

1.3.11.

Manage pain effectively because it can lead to a rise in intracranial pressure. Provide reassurance, splint limb fractures and catheterise a full bladder when needed. Also see NICE’s guideline on major trauma: assessment and initial management. [2007, amended 2014]

1.3.12.

Always follow best practice in paediatric coma observation and recording, as detailed by the National Paediatric Neuroscience Benchmarking Group. [2003]

Transport to hospital

1.3.13.

Transport people who have sustained a head injury directly to a major trauma centre or trauma unit that has the age-appropriate resources to further resuscitate them, and to investigate and initially manage multiple injuries. [2023]

1.3.14.

For guidance on the care of people with major trauma, see NICE’s guideline on major trauma: service delivery. [2023]

Training for ambulance crews and paramedics

1.3.15.

Ambulance crews and paramedics should be fully trained in the use of the adult and paediatric versions of the GCS and its derived score. [2003]

1.3.16.

Ambulance crews and paramedics should be trained in the safeguarding of people under 16 and people 16 and over who are vulnerable. They should document and verbally inform emergency department staff of any safeguarding concerns. [2003, amended 2014]

Tranexamic acid

1.3.17.

For people with a head injury and a GCS score of 12 or less who are not thought to have active extracranial bleeding, consider:

• a 2 g intravenous bolus injection of tranexamic acid for people 16 and over
• a 15 mg/kg to 30 mg/kg (up to a maximum of 2 g) intravenous bolus injection of tranexamic acid for people under 16.
  Give the tranexamic acid as soon as possible within 2 hours of the injury, in the pre-hospital or hospital setting and before imaging. In March 2023, these were off-label uses of tranexamic acid. See NICE’s information on prescribing medicines. [2023]

1.3.18.

For people with a head injury, and suspected or confirmed extracranial bleeding, see the recommendations in the section on haemostatic agents in pre-hospital and hospital settings in NICE’s guideline on major trauma: assessment and initial management. [2023]

Direct access from the community to imaging

1.3.19.

Do not refer people who have had a head injury for neuroimaging by direct access from the community. [2023]

Involving the neurosurgical department

1.4.15.

Discuss with a neurosurgeon the care of anyone with new and surgically significant abnormalities on imaging. The definition of ‘surgically significant’ should be developed by local neurosurgical centres and agreed with referring hospitals, along with referral procedures. [2003, amended 2014]

1.4.16.

Regardless of imaging, discuss a person’s care plan with a neurosurgeon if they have:

• persisting coma (a GCS score of 8 or less) after initial resuscitation
• unexplained confusion that persists for more than 4 hours
• deterioration in GCS score after admission (pay more attention to motor response deterioration)
• progressive focal neurological signs
• a seizure without full recovery
• a definite or suspected penetrating injury
• a cerebrospinal fluid leak. [2003]

Criteria for doing a CT head scan

Assessing range of movement in the neck

1.6.1.

Be aware that range of movement in the neck when there is clinical suspicion of a cervical spine injury can only be assessed safely before imaging in people with a head injury if they have no high-risk factors (see recommendation 1.6.2, and recommendations 1.6.4 and 1.6.6). Only do the assessment if they have at least 1 of these low-risk features:

• they were in a simple rear-end motor vehicle collision
• they are comfortable in a sitting position
• they have been ambulatory at any time since injury
• there is no midline cervical spine tenderness
• they present with delayed onset of neck pain.
  See also NICE’s guideline on spinal injury: assessment and initial management. [2014]

Criteria for doing a CT cervical spine scan in people 16 and over

1.6.2.

For people 16 and over who have sustained a head injury (including people with delayed presentation), do a CT cervical spine scan within 1 hour of the risk factor being identified if any of these high-risk factors apply:

• the GCS score is 12 or less on initial assessment
• the person has been intubated
• a definitive diagnosis of a cervical spine injury is urgently needed (for example, if cervical spine manipulation is needed during surgery or anaesthesia)
• there has been blunt polytrauma involving the head and chest, abdomen or pelvis in someone who is alert and stable
• there is clinical suspicion of a cervical spine injury and any of these factors:

  —

  age 65 or over

  —

  a dangerous mechanism of injury (that is, a fall from a height of more than 1 m or 5 stairs, an axial load to the head such as from diving, a high-speed motor vehicle collision, a rollover motor accident, ejection from a motor vehicle, an accident involving motorised recreational vehicles or a bicycle collision)

  —

  focal peripheral neurological deficit

  —

  paraesthesia in the upper or lower limbs. [2023]

1.6.3.

For people 16 and over who have sustained a head injury, and have neck pain or tenderness but no high-risk indications for a CT cervical spine scan (see recommendation 1.6.2), do a CT cervical spine scan within 1 hour for any of these risk factors:

• it is not thought to be safe to assess the range of movement in the neck (see recommendation 1.6.1)
• safe assessment of range of neck movement shows that the person cannot actively rotate their neck 45 degrees to the left and right
• the person has a condition predisposing them to a higher risk of injury to the cervical spine (for example, axial spondyloarthritis). [2023]

Criteria for doing a CT cervical spine scan in people under 16

1.6.4.

For people under 16 who have sustained a head injury (including those with delayed presentation), only do a CT cervical spine scan if any of these risk factors apply:

• the GCS score is 12 or less on initial assessment
• the person has been intubated
• there are focal peripheral neurological signs
• there is paraesthesia in the upper or lower limbs
• a definitive diagnosis of a cervical spine injury is needed urgently (for example, if manipulation of the cervical spine is needed during surgery or anaesthesia)
• the person is having other body areas scanned for head injury or multisystem trauma, and there is clinical suspicion of a cervical spine injury
• there is strong clinical suspicion of injury despite normal X-rays
• plain X-rays are technically difficult or inadequate
• plain X-rays identify a significant bony injury.
  Do the scan within 1 hour of the risk factor being identified. [2023]

1.6.5.

For people under 16 who have sustained a head injury, and have neck pain or tenderness but no indications for a CT cervical spine scan (see recommendation 1.6.4), do 3-view cervical spine X-rays before assessing range of movement in the neck if any of these risk factors are identified:

• there was a dangerous mechanism of injury (that is, a fall from a height of more than 1 m or 5 stairs, an axial load to the head such as from diving, a high-speed motor vehicle collision, a rollover motor accident, ejection from a motor vehicle, an accident involving motorised recreational vehicles or a bicycle collision)
• safe assessment of range of movement in the neck is not possible (see recommendation 1.6.1)
• the person has a condition that predisposes them to a higher risk of injury to the cervical spine (for example, collagen vascular disease, osteogenesis imperfecta, axial spondyloarthritis).
  The X-rays should be done within 1 hour of the risk factor being identified and reviewed by a clinician trained in their interpretation. [2023]

1.6.6.

If range of neck movement can be assessed safely (see recommendation 1.6.1) in a person under 16 who has sustained a head injury, and has neck pain or tenderness but no indications for a CT cervical spine scan, do 3-view cervical spine X-rays if they cannot actively rotate their neck 45 degrees to the left and right. When the person is unable to understand commands or open their mouth, a peg view may be omitted. The X-rays should be done within 1 hour of this risk factor being identified, and reviewed by a clinician trained in their interpretation. [2014]

Timing of radiology report

1.6.7.

Make a provisional written radiology report available within 1 hour of a CT scan. [2014]

Imaging investigations

1.6.8.

Ensure that imaging reports are based on high-resolution source data and multiplanar reformatting of the entire cervical spine. [2003, amended 2014 and 2023]

1.6.9.

Do MRI in addition to CT if there are neurological signs and symptoms suggesting injury to the cervical spine. [2003, amended 2014 and 2023]

1.6.10.

Do CT or MRI angiography of the neck vessels if there is a suspicion of vascular injury, for example, because of:

• vertebral malalignment
• a high-risk fracture (that is, a high-grade or complex facial fracture or a base of skull fracture likely to involve the internal carotid artery or vertebral artery)
• posterior circulation syndrome. [2003, amended 2014 and 2023]

1.6.11.

Consider MRI for assessing ligamentous and disc injuries suggested by CT or clinical findings. [2003]

Transfer of people 16 and over

1.8.1.

Ensure local guidelines on the transfer of people with a severe traumatic brain injury are drawn up between the referring hospital trusts, the neuroscience unit and the local ambulance service, and recognise that:

• transfer would benefit anyone with serious head injuries (a GCS score of 8 or less), irrespective of the need for neurosurgery
• if transfer of people who do not need neurosurgery is not possible, ongoing liaison with the neuroscience unit over clinical management is essential. Also see the recommendations on transfer between emergency departments in NICE’s guideline on major trauma: service delivery. [2003, amended 2007]

1.8.2.

Think about the possibility of occult extracranial injuries in people 16 and over with multiple injuries, and do not transfer them to a service that is unable to deal with other aspects of trauma. [2007]

1.8.3.

Ensure there is a designated consultant in the referring hospital with responsibility for establishing arrangements for the transfer of people with head injuries to a neuroscience unit. Also ensure there is another consultant at the neuroscience unit with responsibility for establishing arrangements for communication with referring hospitals, and for receiving people transferred. [2003]

1.8.4.

Ensure that people with traumatic brain injuries needing emergency transfer to a neuroscience unit are accompanied by healthcare staff with appropriate training and experience in the transfer of people with an acute traumatic brain injury. They should:

• be familiar with the pathophysiology of traumatic brain injuries, the medicines and equipment they will use, and working in the confines of an ambulance (or helicopter if appropriate)
• have a dedicated and adequately trained assistant
• be provided with appropriate clothing for the transfer, medical indemnity and personal accident insurance.
  Ensure that people needing non-emergency transfer are accompanied by appropriate clinical staff. [2003, amended 2007]

1.8.5.

Provide the transfer team responsible for transferring a person with a head injury with a means of communicating changes in the person’s status with their base hospital and the neurosurgical unit during the transfer. [2003, amended 2014]

1.8.6.

Although it is understood that transfer is often urgent, complete the initial resuscitation and stabilisation of the person, and establish comprehensive monitoring before transfer, to avoid complications during the journey. Do not transport someone with persistent hypotension, despite resuscitation, until the cause has been identified and they are stabilised. [2003, amended 2007]

1.8.7.

Intubate and ventilate anyone with a GCS score of 8 or less needing transfer to a neuroscience unit, and anyone with the indications detailed in recommendation 1.8.8. [2003]

1.8.8.

Intubate and ventilate the person immediately when there is:

• coma, that is, they are not obeying commands, not speaking and not eye opening (a GCS score of 8 or less)
• loss of protective laryngeal reflexes
• ventilatory insufficiency, as judged by blood gases: hypoxaemia (PaO₂ less than 13 kPa on oxygen) or hypercarbia (PaCO₂ more than 6 kPa)
• irregular respirations. [2003, amended 2007]

1.8.9.

Use intubation and ventilation before the start of the journey when the person has:

• significantly deteriorating conscious level (1 or more points on the motor score), even if not coma
• unstable fractures of the facial skeleton
• copious bleeding into the mouth (for example, from a skull base fracture)
• seizures. [2003, amended 2007]

1.8.10.

Anyone whose trachea is intubated should have appropriate sedation and analgesia along with a neuromuscular blocking drug. Aim for a PaO₂ of more than 13 kPa, and a PaCO₂ of 4.5 kPa to 5.0 kPa, unless there is clinical or radiological evidence of raised intracranial pressure, in which case more aggressive hyperventilation is justified. If hyperventilation is used, increase the inspired oxygen concentration. Maintain the mean arterial pressure at 80 mmHg or more by infusion of fluid and vasopressors, as indicated. [2003, amended 2007]

1.8.11.

Give family members and carers as much access to the person with a head injury as is practical during transfer. If possible, give them an opportunity to discuss the reasons for transfer and how the transfer process works with a member of the healthcare team. [2003, amended 2014]

Transfer of people under 16

1.8.12.

Recommendations 1.8.1 to 1.8.9 and 1.8.11 were written for people 16 and over, but apply these principles to people under 16, providing that the paediatric modification of the GCS is used for preverbal and non-verbal children. Ventilate people under 16 according to the age-appropriate level of oxygen saturation and maintain blood pressure at a level appropriate for their age. [2003, amended 2023]

1.8.13.

Ensure that service provision for transfer to tertiary care follows the principles outlined in the NHS England service specification for paediatric intensive care retrieval (transport) and the Paediatric Critical Care Society quality standards for the care of critically ill or injured children. [2003]

1.8.14.

Think about the possibility of occult extracranial injuries for people under 16 with multiple injuries. Do not transfer them to a service that is unable to deal with other aspects of trauma. [2007]

1.8.15.

Ensure that transfer of people under 16 to a specialist neurosurgical unit is done either by staff experienced in the transfer of people under 16 who are critically ill or according to local guidelines with specialist paediatric retrieval teams. [2003, amended 2023]

1.8.16.

Give family members and carers as much access to their child as is practical during transfer. If possible, give them an opportunity to discuss the reasons for transfer and how the transfer process works with a member of the healthcare team. [2003, amended 2014]

Admission and observation of people with concussion symptoms

1.9.5.

For people with concussion symptoms after normal brain imaging or no indication for early imaging, follow the indications for admission in recommendation 1.9.1. Also see the section on discharge advice. [2023]

Early diagnosis of hypopituitarism

1.9.6.

Be aware that any severity of head injury can cause pituitary dysfunction. This may present immediately, hours, weeks or months after the injury. A variety of symptoms could indicate hypopituitarism. [2023]

1.9.7.

In people admitted to hospital with a head injury who have persistently abnormal low sodium levels or low blood pressure, consider investigations for hypopituitarism. [2023]

1.9.8.

In people presenting to primary or community care with persistent symptoms consistent with hypopituitarism in the weeks or months after a head injury, consider investigations or referral for hypopituitarism. [2023]

Observation of people who are admitted

1.9.9.

Ensure that in-hospital observation of people with a head injury is only done by professionals competent in assessing head injuries. [2003]

1.9.10.

For people admitted for head injury observation, the minimum acceptable documented neurological observations are: GCS score, pupil size and reactivity, limb movements, respiratory rate, heart rate, blood pressure, temperature and blood oxygen saturation. [2003]

1.9.11.

Carry out and record observations on a half-hourly basis until there is a GCS score of 15. Observations for people with a GCS score of 15 should start after the initial assessment in the emergency department and the minimum frequency should be:

• half-hourly for 2 hours, then
• 1 hourly for 4 hours, then
• 2 hourly. [2003]

1.9.12.

Revert to half-hourly observations and follow the original frequency schedule for people with a GCS score of 15 who deteriorate at any time after the initial 2-hour period. [2003]

1.9.13.

Urgently reassess a person with a head injury if they have any of these signs of neurological deterioration:

• agitation or abnormal behaviour
• a sustained (that is, for at least 30 minutes) drop of 1 point in GCS score (give more weight to a drop of 1 point in the motor response score of the GCS score)
• any drop of 3 or more points in the eye opening or verbal response scores of the GCS score, or 2 or more points in the motor response score
• severe or increasing headache, or persistent vomiting
• new or evolving neurological symptoms or signs such as pupil inequality or asymmetry of limb or facial movement.
  A supervising doctor should do the appraisal. [2003, amended 2007]

1.9.14.

To reduce interobserver variability and unnecessary referrals, get a second member of staff competent in observations to confirm deterioration before involving the supervising doctor. Do this immediately if possible. If not possible (for example, because no staff member is available to do the second observation), contact the supervising doctor without the confirmation being done. [2003]

1.9.15.

If any of the changes noted in recommendation 1.9.13 are confirmed, consider doing an immediate CT scan, and reassess the person’s clinical condition and manage appropriately. [2003, amended 2007]

1.9.16.

If a person has had a normal CT scan but does not have a GCS score of 15 after 24 hours of observation, consider a further CT or MRI scan and discuss with the radiology department. [2003]

Observation of babies and children under 5

1.9.17.

Be aware that observation of babies and children under 5 is difficult, so should only be done by units with staff experienced in the observation of under 5s with a head injury. Babies and children under 5 may be observed in normal paediatric observation settings, as long as staff have the appropriate experience. [2003]

Training in observation

1.9.18.

All staff caring for people with a head injury admitted for observation should be trained in doing the observations listed in recommendations 1.9.10 to 1.9.14 in the section on observation of people who are admitted, and the recommendation on observation of babies and children under 5. [2003]

1.9.19.

Make dedicated training available to all relevant staff to enable them to acquire and maintain observation and recording skills. Specific training is needed for the observation of people under 16. [2003]

People with pre-injury cognitive impairment

1.10.6.

Ensure that people with pre-injury cognitive impairment (for example, dementia or a learning disability) and people returning to a custodial setting are supervised and monitored. Also, make sure that arrangements are in place should there be any signs of deterioration. [2023]

Discharge after observation

1.10.7.

People admitted after a head injury may be discharged after resolution of all significant symptoms and signs, provided they have suitable supervision arrangements at home, in custody or in continued care. [2003, amended 2023]

Discharge advice

1.10.8.

Give verbal and printed discharge advice to people with any degree of head injury who are discharged from an emergency department or observation ward. This should also be provided to the person responsible for their care after discharge. This may include their families, carers, social workers or custodial staff. Follow the recommendations in NICE’S guidelines on patient experience in adult NHS services and babies, children and young people’s experience of healthcare, including on providing information in an accessible format. [2014, amended 2023]

1.10.9.

Ensure that printed advice for people with a head injury, and their families and carers, is age appropriate and includes:

• details of the nature and severity of the injury
• risk factors that mean people need to return to the emergency department (see the recommendations on community health services and inpatient units without an emergency department)
• a specification that a responsible adult should stay with the person for the first 24 hours after their injury
• details about the recovery process, including the fact that some people may appear to make a quick recovery but later have difficulties or complications
• contact details of community and hospital services in case of delayed complications
• information about return to everyday activities, including school, work, sports and driving
• details of support organisations. [2014]

1.10.10.

Offer information and advice on alcohol or drug misuse to people who presented to the emergency department with drug or alcohol intoxication when they are fit for discharge. [2003]

1.10.11.

Inform people with a head injury, and their families and carers, about the possibility of persistent or delayed symptoms after a head injury and who to contact if they have ongoing problems. [2014]

1.10.12.

For anyone who has attended the emergency department with a head injury, write to their GP within 48 hours of discharge, giving details of clinical history and examination. Also share this letter with health visitors (for preschool children) and school nurses (for school-age children and young people). If appropriate, provide a copy of the letter for the person with a head injury, and their family or carers, custodial staff or social worker. [2014]

Follow up

1.10.13.

Refer people with a head injury to investigate its causes and manage contributing factors, if appropriate. This could include, for example, referral for a falls assessment or to safeguarding services. [2023]

1.10.14.

Consider referring people who have persisting problems to a clinician trained in assessing and managing the consequences of traumatic brain injury (for example, a neurologist, neuropsychologist, clinical psychologist, neurosurgeon or endocrinologist, or a multidisciplinary neurorehabilitation team). [2003, amended 2023]

Investigations for hypopituitarism

1.10.15.

Consider further endocrinology investigations for people who have been discharged after a head injury if they have persistent symptoms consistent with hypopituitarism or are not recovering as expected. [2023]

1. Indications for admission in people with a mild head injury and a confirmed abnormality on a CT scan

What are the indications for admission using clinical decision rules in people with a Glasgow Coma Scale (GCS) score of 13 to 15 (a mild head injury) and a confirmed abnormality on a CT scan? [2023]

2. Using biomarkers for predicting acute post-traumatic brain injury complications

What is the diagnostic accuracy of brain injury biomarkers for predicting acute complications after a traumatic brain injury? [2023]

3. Indications for imaging for people with a history of recurrent head injuries

What is the risk of intracranial injuries in people with a history of recurrent head injuries, including from sports and falls, and no other indications for a CT scan? [2023]

4. Risk of bleeding for people with a pre-injury coagulopathy

What is the risk of any intracranial bleeding or intracranial bleeding associated with clinical deterioration after head injury in people with a pre-injury coagulopathy? This includes medical conditions such as liver failure or haemophilia, or taking anticoagulants or antiplatelets in people who:

• have a GCS score of 15 at 2 hours after the head injury and medium risk factors for intracranial bleeding or
• loss of consciousness or amnesia with no additional risk factors (that is, they are under 65, had a low-energy transfer injury and any retrograde amnesia has lasted for less than 30 minutes) or
• there is no loss of consciousness or amnesia [2023]

5. Indications for imaging for people with a pre-injury cognitive impairment

What are the indications for selecting imaging in adults, young people, children and babies with a head injury sustained through a low-energy fall and with suspected pre-injury cognitive impairment when loss of consciousness or amnesia is difficult to assess or the pre-injury GCS score is not 15? [2023]

6. Transport to a neuroscience centre

What is the clinical and cost effectiveness of pre-hospital strategies to take people with a head injury to a distant specialist neuroscience centre instead of a closer non-specialist unit? [2023]

7. Tranexamic acid

What is the clinical and cost effectiveness of tranexamic acid before imaging in people presenting within 2 hours of a head injury with a GCS score of 13 to 15 and high-risk indications for intracranial bleeding? [2023]

8. Indications for selecting people for imaging when they present more than 24 hours after a head injury

What are the indications for selecting people of any age who present more than 24 hours after a head injury for a CT or MRI head scan? [2023]

9. Using biomarkers and MRI for predicting post-concussion syndrome

What is the prognostic accuracy of brain injury biomarkers or MRI for predicting post-concussion syndrome? [2023]

10. Timing of testing for hypopituitarism

When should people with a head injury be investigated for hypopituitarism? [2023]

Why the committee made the recommendations

The committee recognised the need to involve people with a head injury, and their family and carers, in decisions about their care, including referral to the emergency department. They also highlighted the importance of making decisions for people who may lack capacity now or in the future, and to follow any advance care plans.

How the recommendations might affect practice or services

There is not expected to be any change to practice or services.

Return to recommendations

Why the committee made the recommendations

Evidence from 1 randomised controlled trial (RCT) and 1 retrospective cohort study was identified. This compared transport for a head injury to a specialist neuroscience centre with transport to the nearest non-specialist acute hospital or general hospital emergency department. All the evidence was in people 16 and over. No evidence was available for people under 16.

The evidence from the RCT suggested some benefit for transfer to a non-specialist general hospital for the outcome of mortality, but this was uncertain. The evidence from the retrospective cohort study suggested that there was no difference between the 2 groups for the outcome of survival benefit. The committee agreed that there was limited evidence of a possible benefit for transfer to a specialist neuroscience centre for some outcomes but that this was uncertain. They agreed that there was no compelling evidence to change practice, and to cross refer to NICE’s guideline on major trauma: service delivery.

The committee noted that the data collection for the RCT was in 2012. This was when trauma care was reorganised in the UK to enable rapid and safe transfer of people to major trauma centres. So, the evidence does not reflect the recent trauma care system, which includes more consultants, quicker CT scans and rehabilitation. So, the committee agreed that further research should be done in this area to determine the effectiveness of transport to specialist neuroscience centres in people with a head injury. They developed a recommendation for research on transport to a neuroscience centre.

How the recommendations might affect practice or services

There is not expected to be any change.

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Why the committee made the recommendations

How the recommendations might affect practice or services

Tranexamic acid is already used for people who have a head injury and other major trauma. NICE has not previously recommended it for people with an isolated head injury. It is expected that doing so will increase tranexamic acid use by paramedics. This should lead to improved survival for people with a head injury. More resources might be needed for treatment, rehabilitation and care for the people who would not have survived without tranexamic acid.

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Why the committee made the recommendation

No evidence was identified for direct access from the community for CT scans or MRI of the head compared with usual care for a suspected or confirmed head injury (including people with delayed presentation, and people in residential and care homes). The committee discussed that imaging ordered in the community setting is mainly used to exclude intracranial bleeding or provide reassurance. They noted that the timing of imaging depends on whether there is an acute injury or the person has post-concussion syndrome. Based on their experience, the committee agreed that people should go to hospital if:

• there has been important traumatic brain injury within 24 hours or
• there is a reduced Glasgow Coma Scale (GCS) score.

The committee were aware that some trusts have referral pathways that allow for imaging to be requested directly from the community setting or primary care. But they noted the logistical challenges in the acute phase of a head injury in getting access to, and timely reporting of, imaging. They also noted the challenges faced in primary care and general practice in interpreting complex neuroradiology reports. The committee therefore agreed that people should not be referred to imaging directly from the community.

How the recommendation might affect practice or services

This is expected to be a change in practice for a few centres that will now have to send people for imaging by the emergency department route.

Return to recommendation

Why the committee made the recommendation

The committee highlighted the need to follow relevant guidance if abuse or other safeguarding issues may be factors in a head injury.

How the recommendation might affect practice or services

There is not expected to be any change to practice or services.

Return to recommendation

Why the committee made the recommendations

How the recommendations might affect practice or services

Weakening the recommendation for people with a head injury who are on anticoagulants but have no other indication for imaging from ‘offer’ to ‘consider’ is expected to result in fewer scans. But expanding the recommendation to include people with a head injury who are on clopidogrel, prasugrel or ticagrelor is expected to result in more scans. It is uncertain whether this will lead to an overall increase or decrease in scanning.

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Why the committee made the recommendation

How the recommendation might affect practice or services

Biomarkers are not routinely used in people with acute head injury and the recommendation for MRI has not changed. So, there is not expected to be a change in practice.

Return to recommendation

Why the committee made the recommendations

The committee considered sensitivity to be the most important measure for types of investigation for cervical spine injuries in people with head injuries. This is to ensure the investigation does not miss important cervical spine injuries, which could result in subsequent negative consequences such as disability. The evidence was limited because the proportion of people with a confirmed head injury was not reported in the diagnostic accuracy studies, but it suggested that X-rays have poor sensitivity compared with CT scans in people 16 and over.

Based on the evidence, and the committee’s experience and knowledge of current practice, the committee agreed that X-rays of the cervical spine should not be done initially in people 16 and over with a head injury. They also agreed that CT scans of the cervical spine should be used in people 16 and over in a way consistent with current clinical practice. There was limited evidence for MRI (less accurate at showing bony injuries, takes longer to do and younger people might need sedation). Also, MRI is rarely used as an initial imaging strategy. So, MRI is recommended as an additional form of imaging in certain circumstances (as in previous versions of the guideline). For people under 16, limitations in the evidence, and radiation exposure and risk of cancer, contributed to the committee’s decision not to make any major changes to the recommendations.

How the recommendations might affect practice or services

CT scanning of the neck in people 16 and over with a head injury has already replaced X-rays when there is at least a medium risk of serious spinal injury. So, there is not expected to be a change in practice.

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Why the committee made the recommendations

How the recommendations might affect practice or services

Currently, most people with an isolated skull fracture are admitted for observation. It is expected that many of these people could be discharged from the emergency department without admission to hospital unless there are other indications for admission. For people on anticoagulants or antiplatelets, and people with concussion symptoms, there are no significant changes in practice recommended, and the recommendations are thought to reflect current practice.

Return to recommendations

Why the committee made the recommendations

The committee highlighted that there is a higher risk of hypopituitarism with more severe head injuries, but noted that it can be caused by a mild head injury. Also, the condition can occur immediately after a head injury or in the weeks to months afterwards. This, and the wide variety of symptoms of hypopituitarism, can make the condition difficult to diagnose.

The committee supplemented the small amount of observational evidence (cohort studies) with their expertise. They discussed that why head injury causes hypopituitarism is not fully understood, and that there could be various reasons. Current practice for screening for hypopituitarism is variable, but it is not commonly identified on CT scanning in the emergency department. The clinician’s familiarity and suspicion of hypopituitarism may affect diagnosis rates. Also, testing in the emergency department may not be useful because the acute injury phase stimulates cortisol secretion. This makes it difficult to tell if there is hypoadrenalism. So, the committee agreed that it would be better to investigate for hypopituitarism in people admitted to hospital with a head injury if they have clinical symptoms or biochemical findings such as hypotension or hyponatraemia. The committee suggested this would provide an opportunity for referral to a specialist.

In the absence of evidence on the timing of investigations, the committee also made a recommendation for research on timing of testing for hypopituitarism.

How the recommendations might affect practice or services

Hospital staff are advised to look out for symptoms of hypopituitarism in people admitted to hospital after a head injury. So, there might be an increase in testing for hypopituitarism in hospital. It is also intended that people will get referred for specialist care sooner.

Return to recommendations

Why the committee made the recommendation

How the recommendation might affect practice or services

There might be a small increase in overnight admissions for people with a pre-existing cognitive impairment when no supervision is available at home. This should lead to better outcomes for people who do deteriorate and reduced longer-term care costs.

Return to recommendation

Why the committee made the recommendations

People with a head injury may need investigation for the causes of the injury or to manage contributing factors. People with a head injury may have persisting problems, including physical, sensory, motor, cognitive, emotional and hormonal (hypopituitarism). These can occur even in people who are not admitted to hospital or have normal imaging at the time of their injury. It is important that people know how to seek help and ongoing support for these symptoms. It is also important for healthcare professionals to make appropriate outpatient referrals to other healthcare professionals trained in managing these symptoms.

Some people who have had a head injury will be at increased risk of further injury. It is important that these people can access relevant services.

How the recommendation might affect practice or services

There might be an increase in referrals from primary care to hospital outpatient clinics for people who were not admitted to hospital, or had a normal scan or no scan at the time of their head injury. This should mean that people get earlier access to effective treatment for persisting symptoms resulting from their head injury and prevention services.

Return to recommendation

Why the committee made the recommendation

The committee discussed further endocrinology investigations for suspected hypopituitarism in people who have been discharged after a head injury if symptoms persist or they are not recovering as expected. They noted that some of the symptoms of hypopituitarism may be non-specific and caused by other conditions, making diagnosis difficult. They agreed that investigation in endocrinology may be needed.

In people under 16, delayed symptoms may include slow growth, tiredness and late puberty. The committee emphasised that, if hypopituitarism is suspected, it is important to urgently refer the person under 16 to a paediatric endocrinologist.

How the recommendation might affect practice or services

The guideline raises awareness of the symptoms of hypopituitarism for people with a head injury, and their carers and clinicians. So, there might be an increase in testing for hypopituitarism in primary care. It is also intended that people will get referred for appropriate care sooner.

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