Head injury in Adults

General principles

Assessment of conscious level is standardised using GCS
Check short term memory in all "minor" head injury patients

Indications for skull x-ray

Suspected penetrating injury
Suspected isolated depressed skull fracture (image) (no neurological concerns or risk factors)

Glasgow Coma Score

Score	Eye Opening	Verbal	Motor
6	Obeys commands
5	Speech orientated , localises to pain
4	Spontaneous eye opening	Confused speech	Withdrawal to pain
3	Eye open to speech	Incoherent words	Abnormal flexion to pain
2	Eyes open to pain	Only sounds	Extends to pain
1	No eye opening	No sounds	No movements

Indication for admission

Loss of consciousness for more than 5 minutes
Confusion / impairment of consciousness at examination
Skull fractures, Any neurological signs or symptoms
Worsening headache, nausea, vomiting
Difficulty in assessing the patient - e.g., alcohol
Lack of responsible adult or relative or phone at home
CUH neurosurgical admission policy

CT scanning in MUH

The agreed hospital policy is that out of hours requests for CT scanning must be as consultant to consultant referrals.

Please ensure you refer patients requiring scanning or admission for observation to the surgical team as early as possible.

Notes

Clinical judgment is necessary
There should be a lower threshold for admission of children in pre-school age
Post-traumatic amnesia with full recovery and no skull fracture is not an indication for admission
Patients sent home receive advice to return immediately if there is deterioration.
They should be given the Head Injury Instruction for adults or children (carers)

Indication for IMMEDIATE CT

Patients with fractured skull
- with confusion or impairment of consciousness or
- with focal neurological signs or
- with seizures or with any other neurological signs or symptoms
Persistent GSC<13 even if no skull #
Any deterioration in conscious level or neurological signs (a fall of two points on the GCS)
Any impaired consciousness or any symptoms in high risk patients (coagulopathy/warfarin etc.)
Impaired consciousness or any neurological signs for more than 8 hours (even if there is no skull #)
Compound (open) depressed fracture of the skull
Any penetrating skull injury (e.g. a stabbing when the skull x-ray may appear normal)
Suspected skull base fracture (CSF leakage, bilateral orbital bruising, mastoid bruising)
Focal neurological deficit
Post traumatic seizure

Please discuss any cases of doubt with the ED Duty Doctor.

In MUH, please refer early to the on-call surgical team. Please see letter above.

Glasgow Coma Score

Score	Eye Opening	Verbal	Motor
6	Obeys commands
5	Speech orientated , localises to pain
4	Spontaneous eye opening	Confused speech	Withdrawal to pain
3	Eye open to speech	Incoherent words	Abnormal flexion to pain
2	Eyes open to pain	Only sounds	Extends to pain
1	No eye opening	No sounds	No movements

These guidelines are for ADULT patients. Please see Paediatric Head Injury guidelines for agreed guidelines for the management of children with head injury.

Please note that Nimodipine (Nimotop) is not indicated in traumatic subarachnoid haemorrhage

Please consider CT scan of upper cervical spine in all patients needing CT head for altered level consciousness [BestBets].

Base of skull #

Antibiotics are not indicated [BestBets] with or without CSF leak

Head injury in Adults

General principles

Indications for skull x-ray

Glasgow Coma Score

Indication for admission

CT scanning in MUH

Notes

Indication for IMMEDIATE CT

Glasgow Coma Score

Base of skull #

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