People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
For the purposes of this guideline, a head injury is defined as any trauma to the head other than superficial injuries to the face. The term includes both closed head injuries and penetrating head injuries. Babies are defined as being under 1 year, and children and young people as being 1 year to under 16 years.
1.1.1 For recommendations on promoting ways for healthcare professionals and people using services to work together to make decisions about treatment and care, see NICE's guideline on shared decision making. [2023]
1.1.2 For recommendations on decision making in people 16 and over who may lack capacity now or in the future, including information on advance care plans, see NICE's guideline on decision making and mental capacity. [2023]
For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on decision making and mental capacity.
1.2.1 Public health literature and other non-medical sources of advice (for example, St John Ambulance and police officers) should encourage people who have any concerns after a head injury to themselves or to another person, regardless of the injury severity, to seek immediate medical advice. [2003]
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):
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):
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):
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):
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]
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]
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]
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:
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:
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]
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]
For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on transport to hospital.
Full details of the evidence and the committee's discussion are in evidence review B: transport to a distant specialist neuroscience centre.
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]
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:
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]
For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on tranexamic acid.
Full details of the evidence and the committee's discussion are in evidence review A: tranexamic acid.
1.3.19 Do not refer people who have had a head injury for neuroimaging by direct access from the community. [2023]
For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on direct access from the community to imaging.
Full details of the evidence and the committee's discussion are in evidence review C: direct access from the community to imaging.
1.4.1 Be aware that the priority for all people admitted to an emergency department is to stabilise the airway, breathing and circulation (ABC) before attending to other injuries. See NICE's guideline on major trauma: assessment and initial management. [2003]
1.4.2 Only assume a depressed conscious level is due to intoxication after an important traumatic brain injury has been excluded. [2003]
1.4.3 Ensure all emergency department clinicians involved in assessing people with a head injury are capable of assessing the presence or absence of the risk factors for CT head imaging listed in the recommendations on the criteria for doing a CT head scan and the criteria for doing a cervical spine scan in people 16 and over and people under 16. Make training available as needed to ensure this. [2003]
1.4.4 Ensure people presenting to the emergency department with impaired consciousness (a GCS score of less than 15) are assessed immediately by a trained member of staff. [2003]
1.4.5 For people with a GCS score of 12 or less, see the recommendations on tranexamic acid. [2023]
1.4.6 For people with a GCS score of 8 or less, ensure early involvement of an appropriately trained clinician to provide advanced airway management, as described in recommendations 1.8.7 and 1.8.8 in the section on transfer of people 16 and over, and to assist with resuscitation. [2003]
1.4.7 Ensure a trained member of staff assesses anyone presenting to an emergency department with a head injury within a maximum of 15 minutes of arrival at hospital. Part of this assessment should establish whether they are at high or low risk for clinically important traumatic brain or cervical spine injury, as described in the recommendations on the criteria for doing a CT head scan and the criteria for doing a CT cervical spine scan in people 16 and over and people under 16. [2003]
1.4.8 In people considered to be at high risk for clinically important traumatic brain or cervical spine injury, extend assessment to full clinical examination to establish any need for CT imaging of the head, or imaging of the cervical spine and other body areas. Use the recommendations on the criteria for doing a CT head scan and the criteria for doing a CT cervical spine scan in people 16 and over and people under 16 as the basis for the final decision on imaging after discussion with the radiology department. [2003, amended 2007]
1.4.9 Anyone triaged to be at low risk for clinically important traumatic brain or cervical spine injury at initial assessment should be re-examined by an emergency department clinician. They should establish whether CT imaging of the head or cervical spine will be needed. Use the recommendations on the criteria for doing a CT head scan and the criteria for doing a cervical spine scan in people 16 and over and people under 16 as the basis for the final decision on imaging after discussion with the radiology department. [2003, amended 2007 and 2023]
1.4.10 Review people who return to an emergency department with any persistent complaint relating to the initial head injury and discuss them with a senior clinician experienced in head injuries. Consider whether a CT scan is needed. [2003, amended 2023]
1.4.11 Manage pain effectively to help prevent any rise in intracranial pressure. Provide reassurance, splint limb fractures and catheterise a full bladder when needed. See NICE's guideline on major trauma: assessment and initial management for information on pain management. [2007]
1.4.12 Consider or suspect abuse, neglect or other safeguarding issues as a contributory factor to, or cause of, a head injury. See NICE's guidelines on child maltreatment, child abuse and neglect, domestic violence and abuse and safeguarding adults in care homes for clinical features that may be associated with maltreatment. [2023]
For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on assessment in the emergency department.
1.4.13 Involve a clinician with training in safeguarding in the initial assessment of any person with a head injury presenting to the emergency department. If there are any concerns identified, document these and follow local safeguarding procedures appropriate to the person's age. [2003, amended 2014]
1.4.14 Use a standard head injury proforma for documentation when assessing and observing people with a head injury throughout their time in hospital. This form should be of a consistent format across all clinical departments and hospitals in which a person might be treated. Use a separate proforma for people under 16. Include areas to allow extra documentation (for example, in cases of non-accidental injury). [2003, amended 2007]
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:
1.5.1 The current primary investigation of choice for detecting an acute clinically important traumatic brain injury is CT imaging of the head. [2003]
1.5.2 For safety, logistic and resource reasons, do not do MRI scanning as the primary investigation for clinically important traumatic brain injury in people who have sustained a head injury. But additional information of importance to prognosis can sometimes be detected using MRI. [2003]
1.5.3 Ensure that there is appropriate equipment for monitoring people with a head injury who are having an MRI scan. Also ensure that all staff involved are aware of the dangers and necessary precautions for working near an MRI scanner. [2003]
1.5.4 Do not use plain X‑rays of the skull to diagnose important traumatic brain injury before a discussion with a neuroscience unit. However, people under 16 presenting with suspected non-accidental injury may need a skeletal survey. [2007]
1.5.5 Arrange transfer to a suitable hospital for people with indications for a CT scan who present to a hospital where CT scans are not available (see the recommendations on the criteria for doing a CT head scan and the criteria for doing a CT cervical spine scan in people 16 and over and people under 16). [2007, amended 2023]
1.5.6 Trauma networks should make sure that people can be transferred as indicated in recommendation 1.5.5. [2007, amended 2023]
1.5.7 In line with good radiation exposure practice, make every effort to minimise radiation dose during imaging of the head and cervical spine, while ensuring that image quality and coverage is sufficient to achieve an adequate diagnostic study. [2003]
1.5.8 For people 16 and over who have sustained a head injury, do a CT head scan within 1 hour of any of these risk factors being identified:
1.5.9 For people 16 and over who have had some loss of consciousness or amnesia since the injury, do a CT head scan within 8 hours of the head injury, or within the hour in someone presenting more than 8 hours after the injury, if they have any of these risk factors:
1.5.10 For people under 16 who have sustained a head injury, do a CT head scan within 1 hour of any of these risk factors being identified:
1.5.11 For people under 16 who have sustained a head injury and have more than 1 of these risk factors, do a CT head scan within 1 hour of the risk factors being identified:
1.5.12 Observe people under 16 who have sustained a head injury but have only 1 of the risk factors in recommendation 1.5.11 for a minimum of 4 hours from the time of injury. If, during observation, any of the following risk factors are identified, do a CT head scan within 1 hour:
1.5.13 For people who have sustained a head injury and have no other indications for a CT head scan, but are on anticoagulant treatment (including vitamin K antagonists, direct-acting oral anticoagulants (DOACs), heparin and low molecular weight heparins) or antiplatelet treatment (excluding aspirin monotherapy), consider doing a CT head scan:
1.5.14 Make a provisional written radiology report available within 1 hour of a CT scan. [2014]
For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on criteria for doing a CT head scan.
Full details of the evidence and the committee's discussion are in:
1.5.15 For information on referring people with possible post-concussion syndrome, see recommendation 1.10.14 in the section on follow up. [2023]
For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on post-concussion syndrome.
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:
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:
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:
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:
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:
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]
1.6.7 Make a provisional written radiology report available within 1 hour of a CT scan. [2014]
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:
1.6.11 Consider MRI for assessing ligamentous and disc injuries suggested by CT or clinical findings. [2003]
For a short explanation of why the committee made these recommendations and how they might affect practices or services, see the rationale and impact section on investigating injuries to the cervical spine.
1.7.1 Staff caring for people with a head injury should introduce themselves to family members or carers, and briefly explain what they are doing. [2003, amended 2014]
1.7.2 Ensure that information for families and carers explains the nature of the head injury and the likely care pathway. [2003]
1.7.3 Staff should think about how best to share information with people under 16, and introduce them to the possibility of long-term complex changes in their parent or sibling who has had a head injury. Literature produced by patient support groups may be helpful. [2003]
1.7.4 Encourage family members and carers to talk to and make physical contact (for example, holding hands) with the person with a head injury. But ensure that relatives and friends do not feel obliged to spend long periods at the bedside. If they wish to stay with the person with a head injury, encourage them to take regular breaks. [2003, amended 2007]
1.7.5 Ensure there is a board or area displaying leaflets or contact details for local and national patient support organisations to help family members and carers gather further information. [2003]
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:
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:
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:
1.8.9 Use intubation and ventilation before the start of the journey when the person has:
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]
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]
1.8.14 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]
1.9.1 Use these criteria for admitting people to hospital after a head injury:
1.9.2 Be aware that some people may need an extended period in a recovery setting because of having general anaesthesia during CT imaging. [2003, amended 2007]
1.9.3 Admit people with multiple injuries under the care of the team that is trained to deal with their most severe and urgent problem. [2003]
1.9.4 When someone with a head injury needs hospital admission, admit them under the care of a team led by a consultant who has been trained in managing this condition. The consultant and their team should have competence (defined by local agreement with the neuroscience unit) in:
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]
For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on admission and observation.
Full details of the evidence and the committee's discussion are in:
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]
For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on early diagnosis of hypopituitarism.
Full details of the evidence and the committee's discussion are in:
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:
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:
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]
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]
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]
1.10.1 If CT is not indicated based on history and examination and there is no suspicion of clinically important traumatic brain injury, discharge the person from hospital if there are:
1.10.2 If imaging of the head is normal and the risk of clinically important traumatic brain injury is low, transfer the person to the community if:
1.10.3 After normal imaging of the cervical spine, risk of injury to the cervical spine is low enough to warrant transfer to the community if:
1.10.4 Do not discharge people presenting with a head injury until their GCS score is 15 or, in preverbal and non-verbal children, consciousness is normal as assessed by the paediatric version of the GCS. In people with pre-injury cognitive impairment, their GCS score should be back to that documented before the injury. [2003]
1.10.5 Only transfer people with any degree of head injury to their home if there is somebody suitable at home to supervise them. Discharge people with no carer at home only if suitable supervision arrangements have been organised, or when the risk of late complications is thought to be negligible. [2003]
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]
For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on discharge and follow up.
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]
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:
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]
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]
For a short explanation of why the committee made these recommendations and how they might affect practice or services, see the rationale and impact section on follow up.
Full details of the evidence and the committee's discussion are in:
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]
For a short explanation of why the committee made this recommendation and how it might affect practice or services, see the rationale and impact section on investigations for hypopituitarism.
Full details of the evidence and the committee's discussion are in:
This section defines terms that have been used in a particular way for this guideline.
A closed head injury occurs when there is either a direct injury (for example, blow to the head) or an indirect injury (for example, shaking or deceleration) without penetration of the skull or brain tissue by an object. The injury causes tearing, shearing or stretching of the nerves at the base of the brain, blood clots in or around the brain or oedema (swelling) of the brain. The skull may be fractured but this does not result in a direct connection between the brain and the outside.
Neurological problems restricted to a particular part of the body or a particular activity, for example:
In people with a head injury, the Glasgow Coma Scale (GCS) is an early assessment of the severity of any associated traumatic brain injury. It is a standardised system used to assess the degree of brain impairment and to identify the seriousness of injury in relation to outcome. The scale has 3 domains: eye opening, verbal and motor responses. These are all evaluated independently in the scale according to a numerical value that indicates the level of consciousness and degree of dysfunction. The scores in each element of the GCS are summed to give the overall GCS score, which ranges from 3 (unresponsive in all domains) to 15 (no deficits in responsiveness):
An injury arising from, for example, a pedestrian being struck by a motor vehicle, an occupant being ejected from a motor vehicle, a fall from a height of more than 1 m or more than 5 stairs, a diving accident, a high-speed motor vehicle collision, a rollover motor accident, an accident involving motorised recreational vehicles, a bicycle collision or any other potentially high-energy mechanism.
Underactivity of the pituitary gland that can lead to:
A single or solitary linear fracture that does not exhibit any inward or outward displacement, does not consist of multiple fracture lines and does not involve or cross the normal sutures of the skull.
Pins and needles, or a prickling sensation, tingling or itching in any part of the body.
A penetrating head injury occurs when an object penetrates the scalp and skull, and enters the brain or its lining.
Post-concussion syndrome (or post-concussion symptoms) is seen in all severities of head injury and is under-recognised in mild head injuries. It is the term used in evidence review F: brain injury biomarkers and/or MRI for predicting post-concussion syndrome. The term 'concussion' is used in evidence review J: admission and observation of people with concussion symptoms.
Examples of symptoms in these reviews include, but are not limited to:
Sensory and motor:
Cognition:
Emotional:
Additional symptoms that may present in children under 5:
Signs of a basal, open or depressed skull fracture or penetrating head injury include:
An alteration in brain function, or other evidence of brain pathology, caused by an external force.