Head Injury Assessment Checklist

How to use this Tick what's present. Nothing here replaces your clinical judgement or local guidance — this is a structured prompt sheet, especially for the elderly patient where symptoms are an unreliable guide to underlying pathology. Absence of ticks does not mean absence of risk.

Immediate Red Flags

Convey / pre-alert

GCS <15 at any point, or GCS <15 persisting 2 hours post-injuryLower threshold than 13 — NICE uses <15 at 2 hrs as a standalone CT trigger
Focal neurological deficit — new weakness, sensory loss, visual disturbance, gaze deviation
Signs of basal skull fractureHaemotympanum, panda/raccoon eyes, CSF leak from ear or nose, Battle's sign (mastoid bruising)
Suspected open or depressed skull fracture
Post-traumatic seizure
Vomiting — more than one episode
Severe or worsening headache

Age & Risk Gradient

Context-dependent

Age ≥65 — NICE risk factor, but only triggers CT when combined with LOC or amnesia
Age ≥80 — no separate NICE escalation, but cortical atrophy, vessel fragility and anticoagulant prevalence all increase with age, not just past 65
Frailty — Clinical Frailty Scale 6 or 7 independently associated with higher TBI risk on falls
Cognitive impairment / dementia — reduces reliability of LOC and amnesia history; raises threshold of suspicion rather than lowering it

Why this matters Research (Coffeng et al. 2023, J Clin Med) found 5–8% of elderly patients with age as their only risk factor had an intracranial lesion on CT. Symptom-negative does not mean risk-negative in this group — NICE's literal criteria are known to underperform here.

Mechanism

CT trigger

Dangerous mechanismFall >1m or 5 stairs, pedestrian/cyclist struck by vehicle, ejection from vehicle, high-speed RTC, rollover, diving/axial load injury
Fall onto a hard/fixed surface (e.g. concrete) — aggravating factor even from standing height, especially in the elderly where most significant bleeds follow low-energy falls
Large or rapidly expanding haematoma at point of impact — marker of impact force, independent indication regardless of symptoms
Unwitnessed fall — mechanism and any LOC cannot be confirmed; treat history as unreliable

Consciousness

Core criterion

Loss of consciousness (LOC) — any duration; document approximate length if known
GCS deterioration — even 1 point, from any baseline
Fluctuating consciousness level — lucid interval followed by deterioration is classically associated with extradural haematoma

Memory & Cognition

Core criterion

Post-traumatic amnesia (PTA)Inability to lay down new memories from the time of injury onward — not just "can't remember the event"
Retrograde amnesia ≥30 minutes — gap in memory for events before the injury
PerseverationPathological repetition — same question, phrase or action repeated despite being answered/completed. A recognisable bedside sign of active PTA.
ConfabulationFilling memory gaps with fabricated but plausible content — distinct from perseveration, can coexist with it
DisorientationGenuine loss of time/place/person orientation — distinct from amnesia and confabulation
New confusion not explained by baseline (dementia, intoxication) — only assume intoxication explains reduced GCS after TBI has been excluded

Focal Neurological Findings

Core criterion

Pupil asymmetry or sluggish/fixed pupil — raised ICP / herniation concern
Limb weakness or sensory change — new, asymmetric
Facial droop / facial palsy
Speech disturbance — dysarthria or dysphasia
Gait disturbance not explained by other injury
Cushing's triadHypertension, bradycardia, irregular respirations — late sign of critically raised ICP

Medication & Bleeding Risk

Standalone trigger

Anticoagulant therapy — warfarin, DOACs (apixaban, rivaroxaban, dabigatran, edoxaban)Indicates CT regardless of GCS or focal findings; warfarin and dabigatran carry higher bleed risk than apixaban in cohort data
Antiplatelet therapy — clopidogrel, dual antiplatelet (aspirin monotherapy alone does not meet this criterion)
Known bleeding or clotting disorder
Alcohol or drug intoxication — complicates assessment; does not lower suspicion

Occult bleed risk Anticoagulated patients can have a completely unremarkable initial presentation and still bleed — some studies show occult/delayed ICH around 3–7% even with normal first assessment, which is why observation periods exist even after a normal first CT.

Skull, Scalp & Wounds

Independent indications

Visible trauma above the clavicle — bruising, swelling, laceration
Significant scalp haematoma — size, tension, and rate of growth all matter
Laceration requiring closure — independent transport/treatment indication, separate from head injury risk itself
Contusion of the skull (excluding face)

Systemic & Associated Signs

Supporting context

Other significant injuries competing for attention — document head injury findings independently; don't let a more dramatic injury (e.g. limb/shoulder) eclipse head injury assessment
Cervical spine concern — dangerous mechanism or midline neck tenderness alongside head injury
Pituitary dysfunction signs — rare, may present hours to months later; not an acute prehospital concern but worth noting for discharge advice
Family/carer report of behaviour change since injury — treat as equivalent in weight to a witnessed clinical sign, especially in dementia where baseline is hard to establish

Conveyance reasoning, independent of symptoms Age, dangerous mechanism, anticoagulation, and a large haematoma are each independent grounds for conveyance/CT in their own right under NICE — none require LOC or amnesia to be present. In the elderly especially, the absence of "soft" signs should not be read as reassurance; it is a known limitation of the decision rules themselves.

Decision rule	Age threshold	Age treated as
NICE (NG232)	65	Minor — needs LOC/amnesia alongside it
Canadian CT Head Rule	65	Major — standalone trigger
New Orleans Criteria	60	Major — standalone trigger
CHIP rule (original)	60	Major — standalone trigger
Dutch national guideline	60	Minor (CHIP-derived, downgraded)

Glossary — Correct Terminology

Reference

Perseveration: Pathological repetition of the same question, phrase, or action despite it already being answered or completed. A recognisable bedside sign of active post-traumatic amnesia. (Not "preservation".)
Confabulation: Unintentional fabrication of plausible but false memories to fill gaps — distinct from lying, as the patient believes what they're saying.
Post-traumatic amnesia (PTA): The period during which a patient cannot lay down continuous new memories following injury. Duration is itself a marker of severity.
Retrograde amnesia: Loss of memory for events that occurred before the injury. NICE specifically flags ≥30 minutes as a CT trigger.
Disorientation: Genuine loss of awareness of time, place, or person — separate from amnesia (can be oriented but amnesic, or disoriented but later recall the period normally once reoriented).
Dangerous mechanism: A defined list under NICE: fall >1m or 5 stairs, pedestrian/cyclist vs vehicle, ejection from vehicle, high-speed RTC, rollover, or axial load (e.g. diving).
Basal skull fracture signs: Haemotympanum, panda/raccoon eyes (periorbital bruising), CSF leak (otorrhoea/rhinorrhoea), Battle's sign (mastoid bruising — typically delayed onset).
Cushing's triad: Hypertension, bradycardia, irregular respiration — a late and ominous sign of critically raised intracranial pressure, not an early warning sign.