Head injury: assessment and early management (NG232)

What this guideline says

GMJ summary

This NICE guideline covers the assessment and early management of head injury from the scene of injury through emergency department care to discharge. It provides detailed clinical decision rules for selecting patients for CT head and cervical spine imaging based on Glasgow Coma Scale scores, mechanism of injury, and specific risk factors including age, anticoagulant use, and neurological signs.

Key innovations in the 2023 update include recommendations for tranexamic acid administration (2 g IV bolus for adults, 15–30 mg/kg for children) within 2 hours of injury for moderate-to-severe traumatic brain injury (GCS ≤12), refined criteria for imaging patients on anticoagulants and antiplatelets, and new guidance on early recognition of hypopituitarism. The guideline emphasises direct transport to major trauma centres, standardised observation protocols, and structured discharge advice including recognition of post-concussion syndrome.

The guideline applies to closed and penetrating head injuries in all age groups, from pre-hospital care through to hospital discharge, with age-specific modifications for assessment and imaging thresholds in children and infants.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. CT head scan within 1 hour for adults (≥16 years) with GCS ≤12, GCS <15 at 2 hours, suspected skull fracture, basal skull fracture signs, post-traumatic seizure, focal neurological deficit, or >1 episode vomiting
2. CT head scan within 8 hours (or 1 hour if presenting >8 hours post-injury) for adults with loss of consciousness or amnesia plus: age ≥65, bleeding/clotting disorders, dangerous mechanism, or >30 minutes retrograde amnesia
3. Tranexamic acid 2 g IV bolus (adults) or 15–30 mg/kg up to 2 g (children) within 2 hours of injury for GCS ≤12 without active extracranial bleeding, before imaging
4. For children <16: CT head within 1 hour if suspected non-accidental injury, post-traumatic seizure, GCS <14 (<15 if <1 year), suspected skull fracture, basal skull fracture signs, focal deficit, or bruise/swelling/laceration >5 cm (if <1 year)
5. Consider (not mandate) CT head scan within 8 hours for patients on anticoagulants (warfarin, DOACs, heparin) or antiplatelets (excluding aspirin monotherapy) with no other CT indications; aspirin monotherapy alone does not require routine imaging
6. Admit to hospital if: new clinically important CT abnormalities, GCS not returned to 15, CT cannot be done in appropriate timeframe, continuing worrying symptoms (persistent vomiting, severe headache, seizures), or concerns about supervision at home
7. CT cervical spine within 1 hour for adults if: GCS ≤12, intubated, urgent diagnosis needed, blunt polytrauma, or clinical suspicion plus age ≥65, dangerous mechanism, focal neurological deficit, or paraesthesia in limbs
8. Consider hypopituitarism investigations in admitted patients with persistent abnormal sodium or hypotension, and in primary care patients with persistent symptoms consistent with hypopituitarism weeks to months after injury

CT head scan indications and timeframes for adults (≥16 years)

Table extracted from the guideline

Source: National Institute for Health and Care Excellence (UK), Head injury: assessment and early management (NG232). Reproduced in summary form.

What changed in this edition

Versus the previous edition

• New recommendation for tranexamic acid 2 g IV bolus (adults) or 15–30 mg/kg (children) within 2 hours of injury for GCS ≤12 without active extracranial bleeding, based on CRASH-3 and other RCT evidence showing mortality reduction
• Changed recommendation for patients on anticoagulants from 'offer' to 'consider' CT scan when no other indications present, and expanded to include antiplatelets other than aspirin monotherapy
• New guidance on early recognition and investigation of hypopituitarism in hospital (persistent hyponatraemia, hypotension) and community (persistent symptoms weeks to months post-injury)
• Recommendation against direct access from community to imaging for head injury; all imaging should be via emergency department assessment
• Clarified that isolated simple linear non-displaced skull fractures are unlikely to be clinically important abnormalities requiring admission unless patient is on anticoagulants/antiplatelets
• Updated cervical spine imaging criteria: CT rather than X-ray as primary investigation for adults ≥16 years; X-ray retained for children <16 in specified circumstances
• Emphasis on safeguarding assessment at every stage, with involvement of clinician trained in safeguarding in initial emergency department assessment

From the guideline

Verbatim

“For people with a head injury and a GCS score of 12 or less who are not thought to have active extracranial bleeding, consider a 2 g intravenous bolus injection of tranexamic acid for people 16 and over.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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