Practice Guidelines

Assessment, investigation, and early management of head injury: summary of NICE guidance

BMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39331.702951.47 (Published 04 October 2007) Cite this as: BMJ 2007;335:719
  1. David Yates, chairman1,
  2. Rifna Aktar, project manager2,
  3. Jennifer Hill, director2
  4. Guideline Development Group
  1. 1Trauma Audit and Research Network (TARN), Manchester M6 8HD
  2. 2National Collaborating Centre for Acute Care (NCC-AC), Royal College of Surgeons of England, London WC2A 3PE
  1. Correspondence to: J Hill NCC-AC{at}rcseng.ac.uk

    Why read this?

    Head injury is a major public health problem both logistically and clinically. Many patients seek healthcare advice for this, although relatively few will need care in a neuroscience centre. Most will make a good recovery, but the incidence of ensuing disability even after apparently “minor” injury is surprisingly high.

    This article summarises the most recent guidance update from the National Institute for Health and Clinical Excellence (NICE) on the appropriate investigation and early care of patients with head injury, where there has been a significant shift from “admit and observe” to “diagnose and decide.”1

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).

    CT imaging of the head in adults

    Request computed tomography (CT) brain scan immediately for adult patients with any of the following risk factors:

    • Glasgow coma score <13 on initial assessment in the emergency department

    • Glasgow coma score <15 two hours after the injury on assessment in the emergency department

    • Suspected open or depressed skull fracture

    • Any sign of basal skull fracture

    • Post-traumatic seizure

    • Focal neurological deficit

    • One or more episodes of vomiting

    • Amnesia for events more than 30 minutes before impact.

    CT imaging of the head in children

    Request computed tomography of the brain immediately for children with any one of the following risk factors:

    • Age over 1 year: Glasgow coma score <14 on assessment in the emergency department

    • Age under 1 year: Glasgow coma score paediatric <15 on assessment in the emergency department

    • Age under 1 year and presence of bruise, swelling, or laceration (>5 cm) on the head

    • Dangerous mechanism of injury

    • Clinical suspicion of non-accidental injury

    • Loss of consciousness lasting more than five minutes (witnessed)

    • Post-traumatic seizure but no history of epilepsy

    • Abnormal drowsiness

    • Suspected open or depressed skull injury, or tense fontanelle

    • Any sign of basal skull fracture

    • Focal neurological deficit

    • Three or more discrete episodes of vomiting

    • Amnesia (antegrade or retrograde) lasting more than five minutes.

    Imaging of the cervical spine

    The initial investigation of choice for the detection of injuries to the cervical spine remains the plain radiograph, but in the following circumstances computed tomography is now preferred.

    In adults and children 10 years or older

    Request computed tomography of the cervical spine immediately for patients with the following risk factors:

    • Glasgow coma score <13 on initial assessment

    • Intubated patients

    • Technically inadequate plain film series

    • Continued clinical suspicion of injury despite a normal x-ray

    • Patient is being scanned for multi-region trauma.

    In children under 10 years

    Because of increased risks associated with irradiation in young children, particularly to the thyroid gland, computed tomography of the cervical spine should only be requested when*:

    • A child has a severe head injury (Glasgow coma score ≤8),

    • A strong clinical suspicion of injury exists despite normal plain films, or

    • Plain films are technically inadequate.

    Transport

    All patients who have sustained a head injury should be transported directly to a facility with the necessary resources to resuscitate, investigate, and initially manage multiple injuries. It is expected that all acute hospitals and all neuroscience units accepting patients directly from the incident will have these resources, and that these resources will be appropriate for the patient's age.*

    Local guidelines on the interhospital transfer of patients with head injuries should be drawn up between the referring hospital trusts, the neuroscience unit, and the local ambulance service. These should recognise the merit of transferring all patients with serious head injuries (GCS ≤8), irrespective of their need for neurosurgery. However, if transfer of those who do not require neurosurgery is not possible, ongoing liaison with the neuroscience unit regarding clinical management is essential.*

    Advice on long term problems and support

    Advise all patients and their carers of the possibility of long term symptoms and disabilities after head injury. Information should be provided on support services that they could contact if they experience long term problems.

    Overcoming barriers

    Although implementation of these guidelines is clearly intended to improve patient care, the sheer number of patients with head injury means that any change in policy may have important effects on the ambulance service, neuroscience centres, and the other work of emergency, intensive care, and radiology departments. Reassuringly, though, the major change advocated in the first NICE head injury guideline—from a policy of admission (with plain skull radiographs being used as a triage tool), to diagnosis through computed tomography—was not as disruptive as many had anticipated and led to improvements with safe early discharge, evidence of a reduction in the numbers of admitted patients and cost savings in some centres.2 The modest increase in the use of computed tomography for imaging of the cervical spine recommended in this update should be even less disruptive.

    Further information about the guidance

    Background

    The guideline offers best practice for the care of all patients who present with a suspected or confirmed traumatic head injury with or without other major trauma, and includes separate advice for adults and children (including infants) as indicated. It offers advice on the management of patients with such head injury who may be unaware of having sustained a head injury, due to intoxication or other causes. The guideline does not provide advice on the management of patients with other traumatic injury to the head (for example, to the eye or face). It does not address the rehabilitation or long term care of patients with a head injury but does give possible criteria for the early identification of patients who require rehabilitation.

    This latest guideline presents an up to date systematic review and analysis of the evidence on the assessment, investigation, and early management of head injury. It updates NICE clinical guideline 4, published in June 2003, amending a few of the recommendations in the original guideline and adding some new recommendations.

    The update was prompted by the publication of new research, particularly:

    • New studies validating previous advice on computed tomography of the head

    • New evidence on the management of paediatric head injuries

    • Concern about the value of plain radiographs of the cervical spine

    • Emerging evidence on the merit of care in a neuroscience for those who do not require operative treatment.

    The previous guidance was based on the Canadian CT head rules3 and represented a major shift away from the use of plain radiographs with 24 hour observation to computed tomography of the head. Now, with the publication of reassuring validation studies,3 we have been able to refine and clarify the previous guidance. Although the initial investigation of choice for detecting injuries to the cervical spine remains the plain radiograph, in certain circumstances computed tomography is now preferred. This change has been prompted as plain films may not reveal clinically important lesions, and emerging evidence shows its value, particularly in patients with impaired consciousness.

    More evidence is now available on the value of specialist care for non-operative cases than when the first guideline was published four years ago, so we are able to extend our guidance to cover transfers to another hospital.

    Methodology

    The guideline was developed according to NICE guideline methodology (see www.nice.org.uk/page.aspx?o=114219) by the National Collaborating Centre for Acute Care. The collaborating centre convened a development group of clinicians and patient representatives to oversee the work and help to develop the recommendations.

    The group conducted an extensive systematic review of the literature and assessed the quality of the literature. Economic evidence was reviewed, and models were developed to ascertain the most cost effective strategies.

    The guideline underwent an external consultation with stakeholders. The development group then assessed the comments, reanalysed the data where necessary, and modified the guideline.

    NICE and the National Collaborating Centre for Acute Care have produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG056) or the website of the National Collaborating Centre for Acute Care (www.rcseng.ac.uk/surgical_research_units/nccac/).

    Future updates of the guideline will be produced as part of the NICE guideline development programme.4 Information about the progress of any update will be posted on the NICE website (www.nice.org.uk/CG056). NICE hopes to audit the uptake of the guideline and provide the data in any future update.

    Future research

    Future research should be carried out in the following priority areas:

    • Comparison of outcomes when patients are transported directly from the scene to a specialist neurosciences centre versus when they are transported to the nearest district general hospital

    • The validity of published clinical decision rules for selecting infants and children with head injury for computed tomography to exclude significant brain injury

    • Determining criteria for surgery for intracerebral lesions

    • Identifying features of non-operative care uniquely available in a neuroscience centre which are associated with improved survival

    • Identifying the optimal prognostic indicators for long term sequelae after mild traumatic brain injury

    Guideline development group

    The guideline development group comprised Rifna Aktar, John Browne, Nicola Chater, Paul Cooper, Hilary Dent, Joel Dunning, Roger Evans, Elisabetta Fenu, Jennifer Hill, Clare Jones, Peter B Katz, David Lloyd, Gabrielle Lomas, Ian Maconochie, David Mendelow, David Menon, Archie Morson, Edward Moss, David Murfin, Susan Murray, Kathryn Oliver, Christopher Rowland-Hill, Carlos Sharpin, Paul Sidi, David Wonderling, David Yates (chair).

    Footnotes

    • Contributors: All authors contributed to reviewing the evidence and writing and correcting the article.

    • Funding: The National Collaborating Centre for Acute Care was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References