Traumatic Head Injury

1 · Primary survey (ATLS)

• Airway with c-spine control
• Breathing
• Circulation
• Disability — GCS, pupils
• Exposure
• Assume c-spine injury until cleared

2 · GCS assessment

• Eye, Verbal, Motor
• GCS ≤13: seek neurosurgical advice
• GCS ≤8: severe TBI — consider intubation

3 · CT head — within 1 hour

• GCS <13 on initial assessment
• GCS <15 at 2 hours
• Suspected open or depressed skull fracture
• Any basal skull fracture sign — haemotympanum, panda eyes, CSF leak, Battle's sign
• Post-traumatic seizure
• Focal neurological deficit
• More than one episode of vomiting

4 · CT head — within 8 hours

LOC or amnesia plus any one of:

• Age ≥65
• Bleeding or clotting disorder
• Dangerous mechanism — pedestrian or cyclist vs vehicle, ejection, fall >1m or 5 stairs
• >30 min retrograde amnesia

Do not refer for imaging by direct access from the community.

5 · On an anticoagulant or antiplatelet?

• Applies to warfarin, DOACs, heparin, LMWH and antiplatelets — not aspirin alone
• CG176 said scan everyone. NG232 says CONSIDER, and widened the group
• Within 8 hours of injury, or within 1 hour if presenting >8 hours after
• GCS 15, no LOC, no amnesia, nothing else: can be risk assessed instead — a shared decision
• LOC and amnesia are the features that matter (AHEAD). Scan if you cannot risk assess reliably, or if they may not come back

6 · Pupils

• Unequal pupils — blown pupil suggests uncal herniation, a neurosurgical emergency
• Fixed dilated pupils suggest brainstem compression

7 · Prevent secondary injury

• SpO₂ >95%
• SBP >90, or MAP >70 in severe TBI
• Avoid hyperthermia
• Treat seizures
• BM 5–10 mmol/L
• Head of bed 30°

8 · Neurosurgical referral

• Extradural: lens-shaped, often a lucid interval — emergency
• Subdural: crescent-shaped, often elderly on anticoagulants
• Depressed skull fracture

An isolated simple linear closed non-depressed skull fracture, in someone not anticoagulated, does not by itself require admission.

9 · C-spine clearance

• NEXUS or Canadian C-Spine Rule
• CT c-spine for high risk — and also for medium risk in adults
• No role for plain X-rays in adults
• Rigid collar until cleared

10 · Before they go home

• Written and verbal head injury advice, with someone to supervise
• Pre-injury cognitive impairment or custodial setting: check supervision is actually arranged
• Any severity can cause pituitary dysfunction — immediately, or months later. Persistent hyponatraemia or hypotension: consider hypopituitarism
• Consider a falls assessment or safeguarding referral