Excerpt

For the purposes of this guideline, head injury is defined as any trauma to the head other than superficial injuries to the face. Head injury is the commonest cause of death and disability in people aged 1–40 years in the UK. Data for head injury are recorded in the Hospital Episode Statistics (http://www.hscic.gov.uk/hes). Each year, 1.4 million people attend emergency departments in England and Wales with a recent head injury. Between 33% and 50% of these are children aged under 15 years. Annually, about 200,000 people are admitted to hospital with head injury. Of these, one-fifth have features suggesting skull fracture or have evidence of brain damage. Most patients recover without specific or specialist intervention, but others experience long-term disability or even die from the effects of complications that could potentially be minimised or avoided with early detection and appropriate treatment.

The incidence of death from head injury is low, with as few as 0.2% of all patients attending emergency departments with a head injury dying as a result of this injury. Ninety five per cent of people who have sustained a head injury present with a normal or minimally impaired conscious level (Glasgow Coma Scale [GCS] greater than 12) but the majority of fatal outcomes are in the moderate (GCS 9–12) or severe (GCS 8 or less) head injury groups, which account for only 5% of attenders. Therefore, emergency departments see a large number of patients with minor or mild head injuries and need to identify the very small number who will go on to have serious acute intracranial complications. It is estimated that 25–30% of children aged under 2 years who are hospitalised with head injury have an abusive head injury. This guideline has updated some of the terminology used in relation to safeguarding children and vulnerable adults.

The previous head injury guideline produced by NICE in 2003 (NICE clinical guideline 4) and updated in 2007 (NICE clinical guideline 56) resulted in CT scanning replacing skull radiography as the primary imaging modality for assessing head injury. It also led to an increase in the proportion of people with severe head injury having their care managed in specialist centres. This has been associated with a decline in fatality among patients with severe head injury. This update is needed because of the continuing importance of up-to-date evidence-based guidance on the initial assessment and early management of head injury. Appropriate guidance can enable early detection and treatment of life-threatening brain injury, where present, but also early discharge of patients with negligible risk of brain injury. It can therefore save lives while at the same time preventing needless crowding in emergency departments and observation wards.

Further key NHS changes have driven the scope of this update. These include the introduction in 2012 of regional trauma networks with major trauma triage tools within NHS England; the extension of indications for anticoagulation therapy; the expanding use of biomarkers to guide emergent clinical management in other conditions, such as chest pain; and the establishment of local safeguarding boards. The last of these addresses the requirement for front-line clinical staff to assess not only the severity of the head injury but also why it occurred.

Contents

• Guideline development group and project team
• Acknowledgments
• 1. Background and scope
  • 1.1. Introduction (2014)
  • 1.2. Introduction (2007)
  • 1.3. Introduction (2003)
• 2. Development of the guideline
  • 2.1. What is a NICE clinical guideline? (2014)
  • 2.2. Remit (2003)
  • 2.3. Who developed this guideline? (2014)
  • 2.4. Scope (2003)
  • 2.5. Guideline update (2014)
  • 2.6. Guideline update (2007)
  • 2.7. Structure of the updated guideline (2014)
  • 2.8. Relationships between the guideline and other NICE guidance (2014)
• 3. Methods
  • 3.1. Guideline update methods (2014)
  • 3.2. Developing the review questions and outcomes (2014)
  • 3.3. Searching for evidence (2014)
  • 3.4. Evidence of effectiveness (2014)
  • 3.5. Evidence of cost effectiveness (2014)
  • 3.6. Developing recommendations (2014)
  • 3.7. Guideline update methods (2007)
  • 3.8. Methods (2003)
• 4. Guideline summary
  • 4.1. Algorithms
  • 4.2. Key priorities for implementation
  • 4.3. Full list of recommendations
  • 4.4. Key research recommendations
• 5. Pre-hospital assessment, advice and referral to hospital
  • 5.1. Predictor variables (2003)
  • 5.2. Loss of consciousness (2003)
  • 5.3. Amnesia (2003)
  • 5.4. Neurological signs (2003)
  • 5.5. Bleeding disorders and use of anticoagulants (2003)
  • 5.6. Skull fracture (2003)
  • 5.7. Age (2003)
  • 5.8. Mechanism of injury (2003)
  • 5.9. Mechanism of injury (2007)
  • 5.10. Drug or alcohol intoxication (2003)
  • 5.11. Headache (2003)
  • 5.12. Vomiting (2003)
  • 5.13. Irritability and altered behaviour (2003)
  • 5.14. History of cranial neurosurgical interventions (2003)
  • 5.15. Public health literature (2003)
  • 5.16. Telephone advice lines (2007)
  • 5.17. Community health services and NHS minor injury clinics (2003)
  • 5.18. Community health services and NHS minor injury clinics (2007)
  • 5.19. Transport from community health services and NHS minor injury clinics and pre-hospital management (2003)
  • 5.20. Training in risk assessment (2003)
• 6. Immediate management at the scene and transport to hospital
  • 6.1. Introduction (2014)
  • 6.2. Pre-hospital management (2003)
  • 6.3. Glasgow Coma Score (2003)
  • 6.4. Glasgow Coma Scale score (2003)
  • 6.5. Immediate management of patients with severe head injuries (2003)
  • 6.6. The benefits of direct transport from the scene to a specialist neurosciences centre compared to transport to the nearest district general hospital (2007)
  • 6.7. What is the effectiveness of pre-hospital assessment tools for selecting adults, infants and children with head injury, for transport direct to specialist neuroscience care or a major trauma centre with neuroscience if the nearest hospital does not provide these? (2014)
  • 6.8. Recommendations and link to evidence (2014)
  • 6.9. Advanced life support training for ambulance crews (2003)
  • 6.10. Priority dispatch of emergency ambulances (2003)
• 7. Assessment in the emergency department: imaging of the head
  • 7.1. Introduction (2014)
  • 7.2. Focus of emergency department assessment in patients with a head injury (2003)
  • 7.3. What is the best clinical decision rule for selecting adults, infants and children with head injury for CT head scan? (2014)
  • 7.4. Recommendations and link to evidence (2014)
  • 7.5. Research recommendation (2014)
  • 7.6. What is the best clinical decision rule for selecting adults, infants and children with head injury for CT head scan who have no history of amnesia or loss of consciousness who are on anticoagulant or antiplatelet therapy? (2014)
  • 7.7. Recommendations and link to evidence (2014)
  • 7.8. Research recommendations (2014)
  • 7.9. What is the diagnostic accuracy of biomarkers (S100B, NSE, GFAP) in the emergency department for selecting adults with head injury for CT head scan? (2014)
  • 7.10. Research recommendations (2014)
  • 7.11. Investigation of clinically important brain injuries (2003)
  • 7.12. What is the best initial diagnostic technique to determine which patients have sustained damage to the head and require further assessment of the head? (2007)
  • 7.13. What are the effects on patient outcomes of providing an immediate CT versus observation? (2007)
  • 7.14. Piloting the new rules (2003)
  • 7.15. Non-accidental injury in children (2003)
  • 7.16. Safeguarding and initial investigations
• 8. Assessment in the emergency department: imaging of the cervical spine
  • 8.1. Introduction (2014)
  • 8.2. Investigation of cervical spine injuries (2007)
  • 8.3. What is the best diagnostic imaging technique to determine which patients have sustained damage to the cervical spine and require further assessment of cervical spine? (2007)
  • 8.4. Recommendations (2003)
  • 8.5. Review question: What is the best clinical decision rule for selecting adults, infants and children with head injury for initial imaging with plain X-rays or CT scan for cervical spine injury? (2014)
  • 8.6. Review question: What is the best clinical decision rule for selecting adults, infants and children with head injury, who have received a negative or indeterminate X-ray of the cervical spine, for further imaging with CT or MR imaging for cervical spine injury? (2014)
  • 8.7. Review question: What is the best clinical decision rule for selecting adults, infants and children with head injury, who have received a negative or indeterminate CT cervical spine scan, for further imaging with MR scan for cervical spine injury? (2014)
  • 8.8. Recommendations and link to evidence (2014)
  • 8.9. Research recommendation
  • 8.10. Using adult rules with infants and children (2007)
  • 8.11. Good practice in emergency department assessment (2003)
• 9. Imaging practice and involvement of the neurosurgical department
  • 9.1. Good practice in imaging of patients with a head injury (2003)
  • 9.2. Involving neurosurgical care (2003)
  • 9.3. Other reasons for discussing a patient's care with a neurosurgeon (2003)
  • 9.4. Criteria for neurosurgical interventions (2003)
  • 9.5. Transfer from secondary to tertiary care settings (2003)
  • 9.6. What are the benefits for patients of receiving treatment at a neurosciences centre who have suffered a clinically important brain injury that does not require surgical intervention? (2007)
  • 9.7. Transfer of children (2003)
• 10. Discharge and follow-up
  • 10.1. Introduction (2014)
  • 10.2. Introduction (2003)
  • 10.3. Discharge of low risk patients with GCS equal to 15 (2003)
  • 10.4. Discharge of patients with normal imaging of the head (2003)
  • 10.5. Discharge of patients with normal imaging of the cervical spine (2003)
  • 10.6. Discharge of patients admitted for observation (2003)
  • 10.7. Discharge and GCS status (2003)
  • 10.8. Review question: What information and support do patients with head injury say they want? What discharge information should be given to patients with head injury? (2014)
  • 10.9. Economic evidence
  • 10.10. Recommendations and link to evidence
  • 10.11. Discharge of patients with no carer at home (2003)
  • 10.12. The best tool for identifying the patients who should be referred to rehabilitation services following the initial management of a head injury (2003)
  • 10.13. Outpatient appointments (2003)
  • 10.14. Prognosis in severe head injury (2003)
  • 10.15. Re-attendees (2003)
• 11. Admission and observation
  • 11.1. Introduction (2003)
  • 11.2. Admission (2003)
  • 11.3. Good practice in observation of patients with head injury (2003)
  • 11.4. Minimum documented observations (2003)
  • 11.5. Frequency of observations (2003)
  • 11.6. Patient changes requiring review while under observation (2003)
  • 11.7. Imaging following confirmed patient deterioration during observation (2003)
  • 11.8. Further imaging if GCS equal to 15 not achieved at 24 hours (2003)
  • 11.9. Observation of children and infants (2003)
  • 11.10. Training in observation (2003)
  • 11.11. Support for families and carers (2003)
• 12. Medical radiation
  • 12.1. Introduction (2007)
  • 12.2. Patient doses from head CT (2007)
  • 12.3. Patient doses from cervical spine CT (2007)
  • 12.4. Summary of effective doses from CT and conventional X-ray examinations of the head and cervical spine (2007)
  • 12.5. Cancer risks (2007)
  • 12.6. Radiation exposure management (2003)
• 13. Economic evaluation
  • 13.1. Introduction (2003)
  • 13.2. Methods (2003)
  • 13.3. Diagnosis of intracranial haematoma in patients with a minor/mild head injury (2003)
  • 13.4. Identifying cervical spine damage in patients with head injury (2003)
  • 13.5. Discussion (2007)
  • 13.6. Addendum 2007 – Direct transport from injury scene to a specialist neurosciences centre (2007)
• 14. Acronyms and abbreviations
• 15. Glossary
• 16. Reference list
• Appendices
  • Appendix A. List of stakeholders
  • Appendix B. Declarations of interest
  • Appendix C. Scope
  • Appendix D. Review protocols
  • Appendix E. Clinical article selection
  • Appendix F. Economic article selection
  • Appendix G. Literature search strategies
  • Appendix H. Clinical evidence tables
  • Appendix I. Economic evidence tables
  • Appendix J. Forest plots
  • Appendix K. Excluded clinical studies
  • Appendix L. Excluded economic studies
  • Appendix M. Cost-effectiveness analysis: Cervical spinal injury clearance strategies
  • Appendix N. Research recommendations
  • Appendix O. 2003 and 2007 guideline appendices
  • Appendix P. Reference list

This guidance partially updates and replaces NICE clinical guideline CG56, Head Injury; Triage, assessment, investigation and early management of head injury in infants, children and adults (published September 2007).

Recommendations are marked to indicate the year of the last evidence review: [2003] or [2007] if the evidence has not been updated since the original guideline, [2003, amended 2014] or [2007, amended 2014] if the evidence has not been updated since the original guideline, but changes have been made that alter the meaning of the recommendation, [2014] if the evidence has been reviewed but no change has been made to the recommendation and [new 2014] if the evidence has been reviewed and the recommendation has been added or updated.

New and updated evidence reviews and recommendations are shaded pink with ‘Update 2014’ in the right hand margin.

Appendix O contains recommendations from the 2007 guideline that have been consulted on for deletion from this 2014 update. Details of any replacement recommendations are included. The original NICE guideline and supporting documents are available from www.nice.org.uk/guidance/CG56

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.