Guidelines for the Management of Patients with Recent Head Injury
(Also see SIGN 110)
Head injuries presenting to hospital should be managed according to SIGN guidelines. 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
- 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
- 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.
SIGN 110. Early management of adult patients with a head injury. Quick Reference Guide (May 2009). Algorithm adapted with permission.