Guidelines for the Management of Patients with Recent Head Injury

Head injuries presenting to hospital should be managed according to SIGN guidelines (N.B. SIGN 110 has now been archived however the information provided remains applicable to current practice). Multiply injured patients with a reduced level of consciousness should be managed by experienced staff using principles of Advanced Trauma Life Support. A reduced level of consciousness must not be assumed to be due to drug or alcohol intoxication in a patient with a history or examination findings consistent with a head injury.

Indications for admission to a hospital ward

Patient has:

• Impaired level of consciousness (GCS <15/15).
• Is fully conscious (GCS 15/15) but has any indication for a CT scan (patient can be considered for discharge if CT scan is normal and there are no other reasons for admission).
• Significant existing medical problems e.g. anticoagulant use.
• Social problems or cannot be supervised by a responsible adult.

Indications for discharge

Patient can be discharged from A&E for observation at home if fully conscious (GCS 15/15) with no additional risk factors or other relevant adverse medical and social factors.

Prior to discharge the following criteria must be met:

• A responsible adult is available and willing to observe the patient for at least 24 hours.
• Verbal and written instructions about observations to be made and action to be taken are given to and discussed with that adult.
• There is easy access to a telephone.
• The patient is within reasonable access of medical care.
• Transport home is available.

Referral to Neurosurgical Unit

Refer if:

• Persisting coma (GCS score <8/15) after initial resuscitation.
• Confusion which persists for more than four hours.
• Deterioration in level of consciousness after admission (a sustained drop of one point on the motor or verbal subscales, or two points on the eye opening subscale of the GCS).
• Focal neurological signs.
• A seizure without full recovery.
• Compound depressed skull fracture.
• Definite or suspected penetrating injury.
• A CSF leak or other sign of a basal fracture.

Indications for imaging in head injuries

• Where CT is available, skull x-rays should not be performed.
• In adults with GCS <15/15, with indications for a head scan, CT of the cervical spine should also be performed down to body of T4.

• Flowchart Early Management of Patients with a Head Injury

SIGN 110 (archived). Early management of adult patients with a head injury. Quick Reference Guide (May 2009). Algorithm adapted with permission.

Guideline reviewed: November 2022 

Page updated: December 2022