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Head Injury

NICE Guideline [NG232] Head injury: assessment and early management. Published: May 2023 The author would like to clarify that only recommendations for >16 y/o are included. Recommendations regarding indications of CT cervical spine are not included.

Background Information

Component Response Score
Eye opening (E) Spontaneous 4
To voice 3
To pain 2
No response 1
Verbal response (V) Alert and oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Motor response (M) Obeys command 6
Localised to pain 5
Withdraws from pain 4
Decorticate posture 3
Decerebrate posture 2
Flaccid paralysis 1
 

To report and communicate a patient’s GCS score, report the scoring from each component, but not just the total score:

  • GCS: E4 V5 M6, 15/15
  • GCS: E1 V2 M4, 7/15

GCS ranges from 3-15 (3 being the worst and 15 being the best).
  • Mild TBI: GCS 13-15
  • Moderate TBI: 9-12
  • Severe TBI: 3-8

Guidelines

Important GCS considerations
  • GCS ≤8 → intubation often required to protect the airway
  • GCS ≤12 + no suspected extracranial bleeding → consider tranexamic acid
    • 2g IV bolus in adults
    • To be given within 2 hours of the injury

Primary investigation of choice: non-contrast head CT

ANY of the following:
  • ≤GCS 12 on initial assessment
  • ≤GCS 15 at 2 hours after injury
  • Suspected open / depressed skull fracture
  • Signs of basal skull fracture (haemotympanum, panda eyes, CSF leakage from the nose / ear, Battle’s sign)
  • Post-traumatic seizure
  • Focal neurological deficit
  • >1 vomiting episode

Presence of loss of consciousness / amnesia after the injury + any of the following:
  • ≥65 y/o
  • Presence of clotting / bleeding disorders
  • Dangerous mechanism of injury
  • >30 min retrograde amnesia

If patients present >8 hours after the injury, perform the head CT within 1 hour.

In the absence of other indications → CT head within 8 hours (or within 1 hour if presented >8 hours).

 

  • New clinically important abnormalities on imaging (an isolated simple linear non-displaced skull fracture is unlikely to be a clinically important abnormality unless they are taking anticoagulant or antiplatelet medication)

  • GCS score not returned to baseline / 15 following imaging

  • CT scanning indicated but cannot be done within the appropriate time period

  • Continuing worrying symptoms (e.g. persistent vomiting, severe headaches or seizures) 

  • Other sources of concern to the clinician (e.g. drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak, or suspicion of ongoing post-traumatic amnesia).

Documented neurological observations should include;
  • GCS score
  • Pupil size and reactivity
  • Limb movements
  • Heart rate and blood pressure
  • Respiratory rate and blood oxygen saturation
  • Temperature

Observation frequency:
  • Half-hourly until GCS of 15
  • Once GCS is 15
    • Half-hourly for 2 hours, then
    • 1 hourly for 4 hours, then
    • 2 hourly

References

Author: Adams Lau
Reviewer: Dr. Joseph Graham
Last Edited: 21/01/2025