Head Injury — Approach & Revision

1

Settle them, and check the basics

airway & C-spine first

Red flags — what each should make you think

GCS falling, or ≤8severe injury — airway at risk Focal neurological deficitintracranial bleed Panda eyes, CSF leak, haemotympanumbasal skull fracture Post-traumatic seizureintracranial injury Repeated vomitingraised intracranial pressure On anticoagulants / antiplateletshigher bleeding risk

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Pearl

A lucid interval — a patient who was knocked out, woke up and seemed fine, then deteriorates — is the classic story of an extradural haematoma. "Talk and die" is real. Never be reassured by a well patient in front of you if the story or risk factors are worrying.

Your first moves

A–EA–E with C-spine controlimmobilise if any spinal concern
GCSGCS + pupils, and re-check oftena trend matters more than one number
gluBlood glucosea reversible cause of reduced consciousness
℞Analgesia + antiemeticand check for other injuries
coagAsk about anticoagulationand send clotting; plan reversal if a bleed
CTDecide on CT using NICE criteriasee step 4

2

Understand the injury & the person

mechanism & risk

The history that changes your threshold

Mechanism — dangerous (high-speed, fall >1 m or 5 stairs, ejection)?
Loss of consciousness & amnesia — was there any, and for how long?
Anticoagulation / antiplatelets — the biggest single risk modifier
Age, frailty, alcohol — all raise the risk and complicate assessment
Trajectory — improving, static, or getting worse?

Work A–E — assess and act as you go

AAirway + C-spine. A GCS of 8 or less means the airway is at risk.immobilise C-spine; call anaesthetics if GCS ≤8

BBreathing. Hypoxia worsens brain injury.oxygen, maintain saturations

CCirculation. Maintain the blood pressure — hypotension harms the injured brain.look for other bleeding sources

DDisability. GCS, pupils (a fixed dilated pupil is a surgical emergency), focal signs, glucose.re-check GCS regularly; image on the criteria

EExposure. Scalp wounds, signs of basal skull fracture, other injuries.full secondary survey

3

Rule out the killers

tap to open each

What points toward it, what would rule it in, and how to manage it.

points toward it

Head injury (often temporal), a brief loss of consciousness, a lucid interval, then rapid deterioration. Classically younger patients.

rule in

CT head — a lens-shaped (biconvex) haematoma.

manage it

Urgent neurosurgery. Time-critical; can be fatal if missed.

Source: NICE NG232 — head injury · neurosurgery

points toward it

Older or anticoagulated patients, sometimes after a minor injury; may be acute or develop over days to weeks with confusion or fluctuating consciousness.

rule in

CT head — a crescent-shaped haematoma.

manage it

Neurosurgical referral, reverse anticoagulation, manage the pressure.

Source: NICE NG232 · neurosurgery

points toward it

Deteriorating GCS, repeated vomiting, unequal or fixed pupils, or the Cushing response (hypertension + bradycardia).

rule in

CT head; clinical signs of herniation.

manage it

Neurosurgery + critical care; maintain oxygenation and blood pressure, head-up positioning, avoid secondary injury.

Source: NICE NG232 · critical care

points toward it

Neck pain or tenderness, focal neurology, dangerous mechanism, distracting injury, or an unreliable exam (intoxication, low GCS).

rule in

CT C-spine per the criteria; keep immobilised until cleared.

manage it

Immobilise, image, refer as needed. A head injury and a cervical spine injury travel together.

Source: NICE NG232

4

Who to scan — NICE NG232

the CT decision

CT head within 1 hour if any of these

GCS below 13 on initial assessment, or below 15 at 2 hours after the injury
Suspected open or depressed skull fracture, or any sign of a basal skull fracture
Post-traumatic seizure
Focal neurological deficit
More than one episode of vomiting

CT head within 8 hours for some risk factors — for example age 65 or over, any current anticoagulation, a dangerous mechanism, or more than 30 minutes of retrograde amnesia — when there was loss of consciousness or amnesia. Anticoagulated patients without other indications should still be considered for imaging. Always check the current NICE criteria and your local pathway for the exact wording.

Alongside the CT

Clotting if anticoagulated (and plan reversal for any bleed), glucose, and CT C-spine where the neck criteria are met.

5

How the plan comes together

disposition · handover

discharge

Low risk, GCS 15, normal exam (and normal CT if done), a responsible adult at home.

Safety-net: written head-injury advice and clear return criteria.

admit / refer

Any bleed → neurosurgery. Persisting symptoms, abnormal GCS, significant mechanism or anticoagulation → admit and observe.

Hand over: mechanism, GCS trend, CT result, anticoagulation and reversal.

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Pearl

Give every discharged head injury clear written advice and someone to watch them overnight. The deterioration you're guarding against often happens after they leave. Nicely done getting here.