From NSW ITIM
Despite head injuries being a frequent presentation at hospital emergency departments, the management of head injuries remains controversial and is subject to variation.
 Mild head injury (GCS 14-15)
Approximately 80% of head injury presentations to emergency departments are classified as mild.
 Standard care
- All head injury patients should have their ABCDE's rapdily assessed and stabilised.
- Commence at least hourly clinical observations of vital signs, GCS, pupils, PTA and clinical symptoms.
- The initial assessment should be followed by a period clinical observation to detect risk factors for significant intracranial injury. The patient should be risk stratified into “low” or “high” risk groups based on the presence or absence of identified clinical risk factors. See the assessement of head injuries article for more information on risk stratification.
- CT scan not routinely indicated unless one or more high risk factors are present.
- Discharge for home observation with head injury advice sheet at 4 hours post injury if clinically improving with either no risk factors indicating need for CT scan or normal CT scan if performed.
- Consider hospital admission and consult regional neurosurgical service if abnormal CT scan.
- Consider hospital admission for observation if clinically not improving at 4 hours post injury irrespective of CT scan result.
- Consider hospital admission for observation if elderly, known coagulopathy or socially isolated.
- Advise patients to see their local doctor if they do not return to normal within 48 hours so they can be reassessed and monitored for post concussion symptoms.
For more information see the Algorithm 1: Initial management of adult mild head injury from the NSW ITIM head injury guidelines.
 Low risk mild head injury
The absence of clinical risk factors on initial assessment combined with a period of observation during which the patients clinically improves makes the probability of a significant intracranial injury extremely unlikely. These low risk mild head injury patients can be discharged for home observation without CT scanning.
 High risk mild head injury
Among the patients with identified risk factors, there are those who clearly require CT scanning and those in whom clinical judgement may be required. In the high risk group, which includes initially low risk patients who fail to clinically improve, both CT scanning and prolonged clinical observation are indicated. In the patients where clinical judgement is required this should be based on the clinician’s experience, the number of identified risk factors and clinical observation of the patient.
 Discharge for home observation
Mild head injury patients can be safely discharged for home observation after an initial period of in-hospital observation if they meet the following clinical, social and discharge advice criteria:
| Safe for discharge criteria
- GCS 15/15
- No persistent post traumatic amnesia (nb. A-WPTAS 18/18)
- Alertness / behaviour / cognition returning to normal
- Clinically improving after observation.
- Normal CT scan or no indication for CT scan.
- Clinical judgment required regarding discharge and follow up of elderly patients or patients with known coagulopathy or bleeding disorder due to increased risk of delayed subdural haematoma.
- Responsible person available to take home and observe.
- Able to return if deteriorates.
- Discharge advice is understood.
If the above clinical and socical criteria are met, all patients should be:
- Provided with a written patient advice sheet such as the 2 page discharge advice card from the NSW ITIM head injury guidelines.
- Provided with a discharge summary for GP
- Advised to see their GP for follow up if they are not feeling back to normal within 2 days
- Any patients who have minor CT abnormalities, who suffered significant clinical symptoms or who had prolonged post traumatic amnesia should be routinely referred to their GP for follow up of post concussion symptoms.
 Moderate head injury (GCS 9-13)
Approximately 10% of head injury presentations to emergency departments are classified as moderate.
Patients with moderate head injuries tend to either deteriorate (10-20%) and should then be managed as severe head injuries or improve (80-90%) and can be managed as “complicated” mild head injuries. Patients who present initially with moderate head injuries should all have an early CT scan and close clinical observation.
Patients with moderate head injury have higher rates of intracranial lesions and cognitive behavioural social sequelae. They should be admitted to hospital for at least 24 hours observation unless they rapidly return to normal, have a normal CT scan and absence of other clinical risk factors. All moderate head injury patients should be routinely followed up for evidence of cognitive behavioural social sequelae.
 Standard care
- Initial systematic assessment and resuscitation of ABCDEs
- Supportive care of ABCDEs
- Prevention of secondary brain injury by avoiding hypoxaemia (O2 saturation <90%) and hypotension (systolic BP <90)
- Early CT scan to identify acute neurosurgical lesions
- Period of clinical observation (at least hourly clinical observations of vital signs, GCS, pupils and clinical symptoms).
- Consider intubation in the event of clinical deterioration to facilitate resuscitation of ABCDEs or to facilitate management of agitated patients
- Early neurosurgical consult if not clinically improving and/or abnormal CT scan
- Early retrieval consult if transfer required
- Admit to hospital unless rapid clinical improvement to GCS 15, normal CT scan and absence of other risk factors (as per mild head injury)
- Repeat CT scan at 24 hours if not clinically improving or abnormal initial CT scan
- Routine post traumatic amnesia testing and consider referral to a brain injury rehabilitation service (see the Brain Injury Rehabilitation Program for services in NSW).
 Severe head injury (GCS 3-8)
Approximately 10% of head injury presentations to emergency departments are classified as severe.
For the majority of severe head injury patients the most important aspect of care is systematic resuscitation of the ABCDEs with prevention of secondary brain injury as per current ATLS guidelines. Resuscitation of the ABCDEs with adequate oxygenation and fluid resuscitation and the treatment of other immediately life threatening injuries should be the priority for patients with severe head injury followed by the CT identification of focal intracranial lesions requiring acute neurosurgical intervention.
 Standard care
- Initial systematic assessment and resuscitation of ABCDEs.
- Early intubation.
- Supportive care of ABCDEs with appropriate attention to positioning (30° head up), basic nursing care and avoidance of hyperventilation.
- Prevention of secondary brain injury by avoiding hypoxaemia (O2 saturation <90%) and hypotension (systolic BP<90).
- Early CT scan to identify acute neurosurgical lesions.
- Early neurosurgical consult
- Early retrieval consult if transfer required
- Consider use of anticonvulsants to prevent early post traumatic seizures
- Consider ICP monitoring to guide management of cerebral perfusion pressure.
- Low threshold to repeat CT scan if patient condition changes
- ICU admission
- Routine repeat CT scan at 24 hours
- Brain injury rehabilitation consult
Minimum supportive care aims:
- PaO2 > 60
- SaO2 > 90
- PaCO2 35 – 40
- Systolic BP > 90
- Head up 30°
 See also