Head Injury in Adults

NICE Guideline [NG232] Head injury: assessment and early management. Published: May 2023.

Emergency Neurological Life Support Traumatic Brain Injury Protocol Version 6.0. Last updated: Dec 2024.

Article Last Updated:07/06/2026

Head Injury

Head injury is a common emergency presentation and ranges from minor scalp trauma to clinically important traumatic brain injury. This article provides a practical UKMLA-focused overview of head injury assessment based on NICE NG232: CT head indications, CT head timing, when to consider CT cervical spine imaging, and key bedside assessment findings such as Glasgow Coma Score (GCS) score and signs of base of skull fracture.

Glasgow Coma Scale (GCS)

GCS Components

Component	Response	Score
Eye-opening (E)	Spontaneous	4
	To voice	3
	To pain	2
	No response	1
Verbal response (V)	Alert and oriented	5
	Confused	4
	Inappropriate words	3
	Incomprehensible sounds	2
	No response	1
Motor response (M)	Obeys command	6
	Localised to pain	5
	Withdraws from pain	4
	Decorticate posture	3
	Decerebrate posture	2
	Flaccid paralysis	1

To report and communicate a patient’s GCS score, one should report the scoring from each component, but not just the total score:

GCS: E4 V5 M6, 15/15
GCS: E1 V2 M4, 7/15

GCS Interpretation

GCS ranges from 3-15 (3 being the worst and 15 being the best)

TBI severity	Corresponding GCS scores
Mild	13-15
Moderate	9-12
Severe	3-8

Signs of Base of Skull Fracture

Affected cranial fossa	Sign name	Clinical description
Anterior cranial fossa	“Panda eyes” / “Raccoon eyes” / periorbital ecchymosis	Bruising around the eyes, usually bilateral Caused by blood tracking into the periorbital tissue
Anterior cranial fossa	CSF rhinorrhoea	Clear watery fluid leaking from the nose Suggests a CSF leak through the cribriform plate
Middle cranial fossa	Haemotympanum	Blood visible behind the tympanic membrane on otoscopy Temporal bone / middle cranial fossa fracture allows blood to collect in the middle ear
Middle cranial fossa	CSF otorrhoea	Clear watery fluid leaking from the ear Suggests a CSF leak through the temporal bone / middle ear
Posterior cranial fossa	Battle’s sign	Bruising over the mastoid process Due to blood tracking to the mastoid region, often a delayed sign appearing hours after the injury

Guidelines

Assessment and Management in the Emergency Department

A-E primary survey and management (to be started pre-hospitally and continued in the hospital):

Component	Assessment and investigations	Management
A & B – Airway and breathing	Assess airway patency Monitor oxygen saturation	Secure the airway Rapid-sequence intubation if post-resuscitation GCS is 8 or less Maintain oxygenation (≥94%) Target normal ventilation
C – Circulation	Monitor BP FAST exam to check for internal bleeding Clotting studies (PT/aPTT/INR, platelet, fibrinogen)	Obtain IV or IO access Avoid hypotension Maintain systolic BP ≥100-110 mmHg Correct any coagulopathies If on warfarin → IV vitamin K + PCC If on apixaban / rivaroxaban → andexanet alfa If on dabigatran → idarucizumab If on heparin → protamine sulfate If patient on antiplatelets → platelet transfusion +/- desmopressin
D – Disability	Calculate GCS Assess pupil (size, shape and reactivity)	Cervical collar and maintain strict spinal immobilisation until cervical spine stability can be established Important GCS considerations: GCS ≤8 → intubation often required to protect the airway GCS ≤12 + no suspected extracranial bleeding → consider tranexamic acid 2g IV bolus in adults To be given within 2 hours of the injury
E – Exposure	Expose the patient properly to assess for traumatic injuries	Maintain normothermia Avoid prolonged exposure as it can result in hypothermia

Investigation and Diagnosis

Primary investigation of choice: non-contrast CT head and/or CT cervical spine

CT Head Indications

Criteria For CT Within 1 Hour

ANY of the following:

GCS ≤12 on initial assessment
GCS <15 at 2 hours after injury
Suspected open / depressed skull fracture
Signs of basal skull fracture (see above for more details)
Post-traumatic seizure
Focal neurological deficit
>1 vomiting episode

Criteria For CT Within 8 Hours

Presence of loss of consciousness / amnesia after the injury PLUS any of the following:

≥65 y/o
Presence of clotting / bleeding disorders
Dangerous mechanism of injury
>30 min retrograde amnesia

If patients present >8 hours after the injury, perform the head CT within 1 hour.

Patient Taking Anticoagulant / Antiplatelet

This excludes those taking aspirin monotherapy.

Even in the absence of other indications → CT head within 8 hours (or within 1 hour if presented >8 hours).

CT Cervical Spine Indication

Indications to perform a CT cervical spine within 1 hour

Head injury with ANY of the following

Head injury with neck pain OR tenderness with ANY of the following

GCS ≤12 on initial assessment
Blunt polytrauma involving the head and chest, abdomen, or pelvis in someone who is alert and stable
Patient is intubated
Definitive diagnosis of cervical spine injury is urgently needed (e.g. cervical spine manipulation is needed during surgery or anaesthesia)
Clinical suspicion of cervical spine injury and ANY of the following
- ≥65 y/o
- Dangerous mechanism injury
- Focal peripheral neurological deficit
- Paraesthesia in the upper or lower limbs

Not safe to assess the range of movement in the neck
Patient cannot actively rotate their neck 45 degrees to the left and right
Patient has a condition predisposing them to a higher risk of injury to the cervical spine (e.g. axial spondyloarthritis)

Admission and Observation

Admission Criteria

New clinically important abnormalities on imaging (an isolated simple linear non-displaced skull fracture is unlikely to be a clinically important abnormality unless they are taking anticoagulant or antiplatelet medication)
GCS score not returned to baseline / 15 following imaging
CT scanning indicated but cannot be done within the appropriate time period
Continuing worrying symptoms (e.g. persistent vomiting, severe headaches or seizures)
Other sources of concern to the clinician (e.g. drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak, or suspicion of ongoing post-traumatic amnesia).

Inpatient Observation

Documented neurological observations should include;

GCS score
Pupil size and reactivity
Limb movements
Heart rate and blood pressure
Respiratory rate and blood oxygen saturation
Temperature

Observation frequency:

Half-hourly until GCS of 15
Once GCS is 15
- Half-hourly for 2 hours, then
- 1 hourly for 4 hours, then
- 2 hourly

References

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