NICE HEAD
INJURY
GUIDELINES
2014
WHAT ARE THE GUIDELINES
FOR THEIR INITIAL
ASSESSMENT IN ED –
All patients with a head injury should be assessed by an experienced
clinician within 15 minutes of arrival
All patients returning to an Emergency Department within 48 hours of
injury with persistent symptoms should be assessed by a senior
clinician
If a patient has any features that would warrant a CT- as described
within this guideline- they should have an immediate full clinical
examination
If there are no high risk features, they should be examined fully within
1 hour by a member of the ED team
CT HEAD WITHIN 1 HOUR
(ADULTS)
GCS <13 on initial assessment
GCS <15 after 2 hours of observation
Open or depressed skull fracture
Signs suggestive of basal skull fracture
Post-traumatic seizure
Focal neurological deficit
>1 episode of vomiting
CT HEAD WITHIN 8
HOURS (ADULTS)
Loss of consciousness or amnesia with one of:
a. >65 years old
b. Bleeding or clotting disorders
c. Dangerous mechanism of injury (fall >1M or >5
stairs; high speed RTC)
Any patient on warfarin with a head injury
MAJOR CHANGE IN CT HEAD
INDICATIONS IN THIS GUIDELINE
?
Warfarin patients now get a CT when the sustain a head
injury without any further factors being required for that
imaging
RISK FACTORS THAT MERIT CT CSPINE (ADULTS)
GCS < 13 on initial assessment
Intubated patient with suspicion of injury
X-Rays technically inadequate
Plain films are suspicious or abnormal
Definitive diagnosis of c-spine injury is needed urgently (e.g. before surgery)
Patient is having other body areas scanned for head injury or multi-region trauma and
there is suspicion of c-spine injury
There is clinical suspicion of injury and any of the following features apply:
a. Age > 65 years
b. Dangerous mechanism (fall >1M or 5 stairs; axial load to head, high speed
RTC)
c. Focal neurological deficit
d. Paraesthesia in upper and lower limbs
ASSESSMENT OF C-SPINE IN
ABSENCE OF HIGH RISK FACTORS
(ADULTS)
1. If there are none of the indications for a CT of your c-spine but an
injury is still suspected, the range of neck movement can be assessed
prior to radiolography if a patient has any 1 of the following features:
a. Involved in simple rear-end vehicular impact
b. Patient is witnessed to be sitting comfortably within the ED
c. Ambulatory at any time since injury
d. No midline C-spine tenderness
e. Delayed onset of neck pain
If they can rotate 45 degrees left and right their c-spine may be cleared,
if not you need to obtain plain films
GUIDELINES FOR CT
HEAD WITHIN 1 HOUR
(CHILDREN)
1.
Any suspicion of non-accidental injury
2.
Post traumatic seizure (and no history of epilepsy)
3.
GCS < 14 or if under 12 months old < 15
4.
GCS < 15 at two hours after injury
5.
Suspected open or depressed skull fracture or tense fontanelle
6.
Signs of basal skull fracture
7.
Focal neurological deficit
8.
Child < 12 months: bruise, swelling or laceration > 5cm on head
9.
More than one of the following risk factors:
a. LOC > 5mins (witnessed)
b. Abnormal drowsiness
c. Three or more discrete episodes of vomiting
d. Dangerous mechanism of injury (high speed RTC as vehicle occupant,
pedestrian or cyclist; fall from >3M; high speed projectile injury)
e. Amnesia (anterograde or retrograde lasting > 5mins)
ARE THEIR ANY CRITERIA FOR
WHICH KIDS WE SHOULD
OBSERVATION
Re. point 9 on previous slide
If 1 risk factor present, observe for 4 hours
If 2 risk factors perform a scan
A CT Head scan should be performed if during the observation
any of the following risk factors are observed:
I.
GCS < 15
II.
Further vomiting
III.
Further episode of abnormal drowsiness
RISK FACTORS THAT MERIT CT CSPINE (CHILDREN)
GCS < 13 on initial assessment
Intubated patient with suspicion of injury
Focal peripheral neurological signs
Paraesthesia in upper / lower limbs
Definitive diagnosis of c-spine injury needed urgently (e.g. before
surgery)
Other body areas being scanned for head injury / multi-system trauma
and clinical suspicion of c-spine injury
Strong suspicion of injury despite normal X-Rays
Technically difficult or inadequate X-Rays
Significant injury on X-Rays
PLAIN FILM RADIOGRAPHY FOR
SUSPECTED NECK INJURY
(CHILDREN)
C-Spine x-rays should be performed before assessing range of motion if:
1. DANGEROUS MECHANISM
- fall >1M or >5 stairs
- axial load to head
- high speed RTC (rollover; ejection; bicycle incident; motorised recreational
vehicle)
2. SAFE ASSESSMENT OF RANGE OF MOTION IS NOT POSSIBLE (i.e. none of the following
features are present):
- simple rear end vehicular impact
- comfortable in a sitting position in the ED
- ambulatory at any time since the injury
- no midline tenderness
-delayed onset of neck pain.
REFERENCES
2014 NICE HEAD INJURY GUIDELINE
http://guidance.nice.org.uk/CG176
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