25th June 2023

Assessment of head injury

Overview

Head injury is the commonest cause of death and disability in people aged 1-40 years old in the UK. Each year, over 1 million people present to emergency departments in England and Wales with a recent head injury. The spectrum of complications secondary to head injury ranges from concussion and headache, through to significant intracerebral haemorrhage and death. Certain populations, such as the elderly or those taking anticoagulant medications, are particularly at risk.

Glasgow Coma Scale

The Glasgow coma scale (GCS) is a key part in head injury assessment. Low GCS at the time of injury and on initial assessment are concerning features for significant injury. In addition, monitoring consciousness level in head injury is important to identify patients at risk of deterioration. The combined scores of eye, verbal and motor responses are used to assess the consciousness level, with a minimum score of 3 and a maximum score of 15.

Investigations

Plain (non-contrast) CT scanning is a key investigation in patients presenting with a head injury. CT has a number of advantages, including being quick and easy to perform, widespread availability, and high sensitivity for picking up intracerebral bleeding.

Intracerebral haemorrhage is one of the most significant complications of head injury. Prompt assessment and investigation are required to identify those with intracerebral bleeding in order to facilitate neuromonitoring, reversal of anticoagulation and surgical treatment where required.

NICE have specific criteria to identify which patients require CT imaging:

For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:

• GCS less than 13 on initial assessment in the emergency department
• GCS less than 15 at 2 hours after the injury on assessment in the emergency department
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture (haemotympanum, “panda” eyes, CSF fluid leakage from the ear or nose, Battle’s sign)
• Post-traumatic seizure
• Focal neurological deficit
• More than one episode of vomiting

For adults who have sustained a head injury with no other indications for a CT head scan and who are having anticoagulant treatment, perform a CT head scan within 8 hours of the injury.