Head Injury Clinical Tool

Step 1 of 5 — Initial Severity

What is the patient's current GCS?

Establish baseline. Check blood glucose as part of initial assessment — altered consciousness may be metabolic. → Use GCS Calculator

🔴 Severe TBI — Time Critical

GCS ≤8. High risk of death or long-term disability. Immediate management and transport required.

Airway & Breathing

Manage airway with C-spine protection. Basic manoeuvres first
Consider loosening/removing collar once secured — tight collars raise ICP
O₂ 10–15 L/min via NRB mask, target SpO₂ 94–98%
Avoid hyperventilation (↓CO₂ → cerebral vasoconstriction → worse hypoxia)
Avoid hypercapnia (↑ICP via vasodilation)
Consider pre-hospital emergency anaesthesia if skilled clinician available
Head should remain above or level with feet throughout

Circulation

Haemorrhage control early — scalp wounds bleed heavily
Isolated head injury: titrate fluids to SBP ≥110 mmHg
Head injury + blunt trauma: titrate to radial pulse or SBP ≥90 mmHg
Head injury + penetrating torso: titrate to central pulse or SBP ≥60 mmHg
GCS ≤12: administer TXA as soon as possible (pre-hospital preferred)
Signs of cerebral herniation: consider hypertonic saline per local protocol

Herniation Signs — Neurosurgical Emergency

Hypertension + Bradycardia + Unilateral/bilateral fixed dilated pupils
= Cushing's triad → time-critical transfer to neurosurgical centre
Seek clinical advice / consider HEMS rendezvous

Transport

Pre-alert receiving unit — ATMIST handover
Consider major trauma centre vs trauma unit (only divert for unmanageable airway)
Minimise on-scene time — keep warm, normothermic

🟡 Moderate TBI — Transport to Hospital

GCS 9–12. High risk of deterioration. Immediate transport and pre-alert.

A–E assessment, C-spine control as indicated
O₂ to maintain SpO₂ 94–98%
Monitor GCS trend — any deterioration = severe TBI management
Check and correct blood glucose
TXA if GCS ≤12 — administer pre-hospital
IV access en route, titrate fluids to SBP ≥110 if isolated head injury
Pre-alert with ATMIST — document time of GCS assessment
Pupils: size, reactivity, equality
Consider HEMS if prolonged transport time

🚨 Transport to ED — Red Criteria Met

One or more red criteria are present. Transport to emergency department. Do not discharge at scene.

Standard A–E assessment and management en route
Monitor GCS — document baseline and trend
Check pupils and glucose
If anticoagulated or on antiplatelets (non-aspirin) — flag at handover
Consider pre-alert if GCS declining or signs of herniation
Provide written and verbal head injury advice if any delay or patient request
Document all findings, clinical reasoning and mechanism

💊 Transport to ED — Anticoagulant / Antiplatelet

Patients on anticoagulants or non-aspirin antiplatelets require ED assessment regardless of other symptoms. CT consideration will be made in hospital.

Risk of intracranial bleeding is low but clinically important — do not dismiss
Transport to ED for clinical assessment and CT consideration
Document medication name, dose and last taken
Flag to ED team — decision re: pausing anticoagulation may be needed
If dual antiplatelet therapy (e.g. aspirin + clopidogrel) — transport to ED
Involve patient in decision and communicate risks clearly
If uncertainty remains, seek clinical advice per local procedures

👴 Transport to ED — Older / Frail Patient

Patients ≥65 or CFS >4 have increased risk of intracranial haemorrhage from apparently minor injury. GCS may not drop until significant bleeding has already occurred.

Consider transport to ED for assessment
Symptoms can mimic stroke, delirium, spinal injury — be vigilant
If cognitive impairment: use carer/family baseline for comparison
Assess Clinical Frailty Score — CFS >4 = transport to ED
Check for advanced care plans / ReSPECT documents if very frail or end of life
Document decision-making rationale and any safety-netting advice given
Seek clinical advice if uncertain about ED referral

✅ Safe Discharge at Scene

All green criteria met. No red criteria. Patient may be discharged with appropriate safety-netting.

Before Leaving

Provide verbal and written head injury advice (age-appropriate, NICE NG232)
Minimum 24 hours of supervision by a suitable adult
Advise what symptoms require 999/111 — see safety netting below
Confirm supervision arrangements are in place before leaving
Document discharge decision and rationale fully

Safety Netting — Return to ED / Call 999 if:

Worsening headache not relieved by paracetamol
Any vomiting
Confusion, unusual drowsiness or difficulty waking
Seizure of any kind
Any weakness, numbness or speech difficulty
Visual disturbance
Any deterioration in condition
Patient or carer has any concerns

🚨 Transport to ED — Cannot Meet Discharge Criteria

Green criteria cannot be fully satisfied. Do not discharge. Transport to ED for assessment.

If patient lives alone and no supervision can be arranged — transport to ED
If patient or carer has ongoing concerns — transport to ED
If clinician has ongoing concerns — transport to ED
Document clearly why discharge was not appropriate

Clinical Disclaimer: Based on JRCALC Head Injury Guideline (G0570, updated July 2024) and NICE NG232 (2023). This tool is a clinical aid only — it does not replace clinical judgement, local protocols or NWAS guidelines. Always consider the individual patient. When in doubt, convey.

🧠 GCS Calculator

Eye Opening (E)

Verbal Response (V)

Motor Response (M)

—

Select all three components

Pupil Assessment

👁️

Pupils — Size, Reactivity & Equality

▼

Unilateral dilated, non-reactive
Ipsilateral herniation / CN III compression — neurosurgical emergency

Bilateral fixed dilated
Bilateral herniation or hypoxic brain injury — immediate action

Unequal pupils
Anisocoria — may be pre-existing but treat as abnormal

Pinpoint bilateral
Opiates / pontine lesion — consider drug effect

Cushing's Triad = Hypertension + Bradycardia + Irregular/slow respirations → cerebral herniation → neurosurgical emergency

⚡

Focal Neurological Deficit

▼

Problems restricted to a particular part of the body or activity — any of these = red criteria:

Dysphasia / aphasia Reading / writing difficulty Decreased sensation Loss of balance General weakness (unilateral) Visual changes / field deficit Abnormal reflexes Gait disturbance

💀

Basal Skull Fracture Signs

▼

CSF rhinorrhoea / otorrhoea — clear watery fluid from nose or ear (late sign)

Bilateral periorbital haematoma — "panda eyes" / raccoon eyes

Battle's sign — mastoid bruising behind ear (late sign, 24–48 hrs)

Haemotympanum — blood behind tympanic membrane

Open skull fracture — visible through scalp laceration

Penetrating foreign body to scalp

Anticoagulants — Always Transport to ED

Warfarin

Vitamin K antagonist · INR-monitored

Always EDCT consideration + INR check. Reversal options available.

Rivaroxaban

DOAC · Factor Xa inhibitor

Always EDNo routine monitoring. Andexanet alfa reversal agent available.

Apixaban

DOAC · Factor Xa inhibitor

Always EDNo routine monitoring. Andexanet alfa reversal agent available.

Dabigatran

DOAC · Direct thrombin inhibitor

Always EDIdarucizumab (Praxbind) specific reversal agent.

Edoxaban

DOAC · Factor Xa inhibitor

Always EDNo routine monitoring. Andexanet alfa may be considered.

Heparin / LMWH

Heparin · Dalteparin · Enoxaparin · Tinzaparin

Always EDDocument dose and timing. Protamine sulphate for reversal.

Antiplatelets

Clopidogrel

ADP receptor antagonist

ED RequiredIncreased intracranial haemorrhage risk. Transport to ED.

Ticagrelor

P2Y12 inhibitor (reversible)

ED RequiredMore potent than clopidogrel. Transport to ED.

Prasugrel

P2Y12 inhibitor (irreversible)

ED RequiredHighly potent. Often post-ACS/PCI patients. Transport to ED.

Dipyridamole

Phosphodiesterase inhibitor

ED RequiredOften combined with aspirin (Asasantin). Treat as antiplatelet. Transport to ED.

Aspirin (monotherapy only)

COX-1 inhibitor · 75mg or 150mg daily

ConditionalMay discharge at scene IF: aspirin monotherapy only AND no other red criteria AND all green criteria met. If combined with any other antiplatelet/anticoagulant → transport to ED.

Key Decision Points

Dual antiplatelet therapy (e.g. aspirin + clopidogrel) = always transport to ED

Any anticoagulant + head injury = always transport to ED (even no symptoms)

Risk is low but important — do not base decision solely on expectation of CT scan

Decision to pause anticoagulation may be needed — must be made by ED/medical team

Involve the patient, clearly communicate risks, align with health priorities

If uncertain — seek clinical advice per local procedures before discharging

Always document: drug name, dose, last taken, indication if known

Flag explicitly at ED handover — do not assume it will be seen in notes

Fluid Targets by Scenario

Scenario	Target	Rationale
Isolated head injury No other objective injury	SBP ≥110 mmHg	Cerebral perfusion pressure must be maintained. Higher target than blunt polytrauma.
Head injury + blunt trauma Evidence of other blunt injury	Radial pulse palpable OR SBP ≥90 mmHg	Permissive hypotension approach. Balance haemorrhage vs cerebral perfusion.
Head injury + penetrating torso Penetrating abdominal/thoracic injury	Central pulse palpable OR SBP ≥60 mmHg	Damage control — lower target to avoid exacerbating haemorrhage.
Neurogenic shock Isolated head injury, haemodynamic instability	Radial pulse palpable OR SBP ≥110 mmHg	Neurogenic shock can cause cardiovascular instability without blood loss. Treat actively.
Hypertensive head injury No herniation signs	No fluid therapy	Fluids not normally required. Do not lower BP aggressively.
Cerebral herniation signs Cushing's triad present	Hypertonic saline (per local protocol)	Osmotic agent reduces ICP as temporising measure. Follow locally agreed guidelines.

TXA — Tranexamic Acid

NICE recommends TXA for all ages with GCS ≤12 — administer as soon as possible

Pre-hospital administration averages 62 minutes earlier than in-hospital — significant benefit

Administer IV/IO as soon as possible after injury recognition

Refer to TXA drug guideline for dose and route

O₂ & Ventilation Targets

Target SpO₂ 94–98% (88–92% if COPD risk)

Initial O₂: 10–15 L/min via NRB mask

Target normocapnia: 4.6–6.0 kPa (ETCO₂ 35–45 mmHg)

Avoid hyperventilation — causes cerebral vasoconstriction → worse hypoxia

Avoid hypercapnia — increases ICP via cerebral vasodilation

Impact Brain Apnoea

Immediate transient cessation of breathing following head injury — often without significant anatomical insult

Hypoxia is the leading cause of mortality — airway and breathing are the absolute priority

Caused by sudden mechanical force → autonomic dysfunction → neurogenic apnoea

Do not assume no significant brain injury just because mechanism seemed minor

C-Spine & Collar Considerations

Up to 6.5% of TBIs are complicated by cervical spine injury — consider immobilisation

Tightly/poorly fitted rigid collars can raise ICP via jugular vein compression — detrimental in TBI

Once patient is secured (head and body immobilised), consider loosening or removing collar

Collar removal is NOT clearance of the C-spine — document reasons clearly, hand over to hospital team

Head should remain above or level with feet throughout extrication and transfer

Midazolam in TBI

May be considered for agitation — amnesia, anxiolysis, facilitates oxygenation/ventilation

Unpredictable dose-response in TBI — can cause rapid deep sedation requiring immediate enhanced care

Sedating agents reduce systemic BP → decreased CPP → risk of secondary brain injury

Only use if specifically trained and capable of managing complications. Consider calling enhanced critical care.

Pain is a commonly overlooked cause of agitation — consider analgesia first

Opiates can be considered but monitor closely: respiratory depression, hypercapnia, raised ICP risk

Paediatric / Special Populations

25–30% of children <2 years hospitalised with head injury have abusive head injury — consider safeguarding

Irritability / altered behaviour in infants and children <5 = red criterion

Clinical judgement re: vomiting as criterion in ≤12 year olds

In dementia/cognitive impairment: use carer baseline, document multi-faceted assessment

HEMS & Evacuation

Consider HEMS early to minimise scene time

Balance: HEMS journey time benefit vs waiting for HEMS arrival

Divert to trauma unit ONLY for immediate airway compromise not manageable pre-hospital

Pre-alert all significant TBI — ATMIST handover to receiving unit

Normothermia throughout — hypothermia has not shown statistical benefit in TBI

Minimise on-scene time

Source: JRCALC Head Injury Guideline G0570, updated 23rd July 2024 (Version 24.76). NICE Head Injury Guideline NG232 (2023). For clinical use only — verify against current local protocols and NWAS guidelines.