Head injury
Learn to think through head injury, step by step. Who needs a scan, who needs admission, and who can safely go home. Built for revision, not live patient decisions.
Settle them, and check the basics
airway & C-spine firstRed flags — what each should make you think
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
Understand the injury & the person
mechanism & riskThe 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
Rule out the killers
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Head injury (often temporal), a brief loss of consciousness, a lucid interval, then rapid deterioration. Classically younger patients.
CT head — a lens-shaped (biconvex) haematoma.
Urgent neurosurgery. Time-critical; can be fatal if missed.
Older or anticoagulated patients, sometimes after a minor injury; may be acute or develop over days to weeks with confusion or fluctuating consciousness.
CT head — a crescent-shaped haematoma.
Neurosurgical referral, reverse anticoagulation, manage the pressure.
Deteriorating GCS, repeated vomiting, unequal or fixed pupils, or the Cushing response (hypertension + bradycardia).
CT head; clinical signs of herniation.
Neurosurgery + critical care; maintain oxygenation and blood pressure, head-up positioning, avoid secondary injury.
Neck pain or tenderness, focal neurology, dangerous mechanism, distracting injury, or an unreliable exam (intoxication, low GCS).
CT C-spine per the criteria; keep immobilised until cleared.
Immobilise, image, refer as needed. A head injury and a cervical spine injury travel together.
Who to scan — NICE NG232
the CT decisionCT 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.
How the plan comes together
disposition · handoverdischarge
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.
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.
Clerking template
copy or downloadHead injury — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement. Content is AI-generated and not yet fully reviewed.