Covering Assessment (hospital, pre-hospital and community), management at the scene, transport to hospital, the requirement for CT scan, recommendations on the use of TXA, safeguarding and suspected abuse issues.

NICE, (National Institute for Health and Care Excellence) has issued updated guidance, relevant from 18 May 2023 and relating to babies, children and adults, for clinical and medical professionals involved in the treatment and care of patients with head injury. This is the 4^th substantial revision of the guidelines.

The guidelines cover all aspects of pre-hospital and Emergency Department triage, advice and referral to hospital and discharge and follow-up.

Pre-Hospital Assessment – What’s Changed?

Pre-hospital assessment, including by professionals, laypersons or injured parties, should include encouragement for anyone with a suspected head injury, regardless of severity, to seek immediate medical advice either through self-transport to the emergency department or the use of remote advice services such as NHS 111 or 999 emergency transport (ambulance services). Risk factors for emergency admission would include:

·      Unconsciousness or lack of full consciousness

·      Reduced focal deficit

·      Suspected skull fracture or penetrating skull injury

·      High energy head injury

·      Any seizure

·      Any amnesia or memory problems (not relevant in preverbal children or under-5s)

·      Headache or vomiting

*This list is not exhaustive, and NICE guideline Remote Advice Services 1.2.3 should be referred to.

When To Refer

Community health services and inpatient units without an emergency department (ED) should refer head injury patients to the nearest emergency department where certain criteria are met or suspected (Community Health Services 1.2.4). Also, see NICE’s guidelines on shared decision-making and mental capacity in cases of multiple risk factors.

It is incumbent upon the persons referring from community health services or inpatient units without an ED to ensure the person they refer to an ED is accompanied by a competent adult during transport to the ED.

Injury Management

Immediate management at the scene of a head injury and during transport to the hospital should include assessment using the Glasgow Coma Scale (1-15) to assess the level of consciousness, and verbal and motor responses. Very young children and those with dementia where cognitive and verbal deficits are present may be assessed slightly differently on the GCS.

In terms of new transport to hospital guidelines, 1.3.13 states that people who have sustained a head injury should be transported directly to a major trauma centre or trauma unit with age-appropriate resources for resuscitation, investigation and management of multiple injuries. Where CT scan facilities are not available, clinicians should arrange transportation to a suitable hospital as recommended in 1.5.5 and 1.5.6.

ED Assessment

During assessment in the ED, the new guidance for people with a GCS score of 12 or less covering the administration of tranexamic acid (2023) should be followed. This sets out how much should be used where there is possible extracranial bleeding, with the amounts differing for under 16s and over 16s. The guidance states that the tranexamic acid should be given within 2 hours of the injury, either pre-hospital or in the ED. 

The new guidance also covers haemostatic agents in pre-hospital and hospital settings in those with suspected or confirmed extracranial bleeding.

New guidelines have also been issued in reference to the required criteria for doing a CT head scan, and these can be found in 1.5.8 – 1.5.12. 

See guideline 1.5.13 with reference to people needing a CT head scan who are taking anticoagulants or antiplatelets.

The Need For Re-Assessment – Even If Low Risk

The amendments for 2023 state that anyone deemed to be at low risk for clinically important traumatic brain or cervical spine injury at initial assessment should be re-examined by an ED clinician, in particular with reference to CT scans.

Anyone returning to the ED with a persistent complaint relating to a head injury should be reviewed by a senior head injury clinician, who should decide whether a CT scan is needed.

Finally, Guideline 1.4.12 concerns suspected abuse, neglect or safeguarding issues as a contributory in, or cause of head injury.