NICE HEAD INJURY GUIDELINES 2014

WHAT ARE THE GUIDELINES FOR THEIR INITIAL ASSESSMENT IN ED – All patients with a head injury should be assessed by an experienced clinician within 15 minutes of arrival All patients returning to an Emergency Department within 48 hours of injury with persistent symptoms should be assessed by a senior clinician If a patient has any features that would warrant a CT- as described within this guideline- they should have an immediate full clinical examination If there are no high risk features, they should be examined fully within 1 hour by a member of the ED team

CT HEAD WITHIN 1 HOUR (ADULTS) GCS <13 on initial assessment GCS <15 after 2 hours of observation Open or depressed skull fracture Signs suggestive of basal skull fracture Post-traumatic seizure Focal neurological deficit >1 episode of vomiting

CT HEAD WITHIN 8 HOURS (ADULTS) Loss of consciousness or amnesia with one of: a. >65 years old b. Bleeding or clotting disorders c. Dangerous mechanism of injury (fall >1M or >5 stairs; high speed RTC) Any patient on warfarin with a head injury

MAJOR CHANGE IN CT HEAD INDICATIONS IN THIS GUIDELINE ? Warfarin patients now get a CT when the sustain a head injury without any further factors being required for that imaging

RISK FACTORS THAT MERIT CT C- SPINE (ADULTS) GCS < 13 on initial assessment Intubated patient with suspicion of injury X-Rays technically inadequate Plain films are suspicious or abnormal Definitive diagnosis of c-spine injury is needed urgently (e.g. before surgery) Patient is having other body areas scanned for head injury or multi-region trauma and there is suspicion of c-spine injury There is clinical suspicion of injury and any of the following features apply: a. Age > 65 years b. Dangerous mechanism (fall >1M or 5 stairs; axial load to head, high speed RTC) c. Focal neurological deficit d. Paraesthesia in upper and lower limbs

ASSESSMENT OF C-SPINE IN ABSENCE OF HIGH RISK FACTORS (ADULTS) 1. If there are none of the indications for a CT of your c-spine but an injury is still suspected, the range of neck movement can be assessed prior to radiolography if a patient has any 1 of the following features: a. Involved in simple rear-end vehicular impact b. Patient is witnessed to be sitting comfortably within the ED c. Ambulatory at any time since injury d. No midline C-spine tenderness e. Delayed onset of neck pain If they can rotate 45 degrees left and right their c-spine may be cleared, if not you need to obtain plain films

GUIDELINES FOR CT HEAD WITHIN 1 HOUR (CHILDREN) 1.Any suspicion of non-accidental injury 2.Post traumatic seizure (and no history of epilepsy) 3.GCS < 14 or if under 12 months old < 15 4.GCS < 15 at two hours after injury 5.Suspected open or depressed skull fracture or tense fontanelle 6.Signs of basal skull fracture 7.Focal neurological deficit 8.Child 5cm on head 9.More than one of the following risk factors: a. LOC > 5mins (witnessed) b. Abnormal drowsiness c. Three or more discrete episodes of vomiting d. Dangerous mechanism of injury (high speed RTC as vehicle occupant, pedestrian or cyclist; fall from >3M; high speed projectile injury) e. Amnesia (anterograde or retrograde lasting > 5mins)

ARE THEIR ANY CRITERIA FOR WHICH KIDS WE SHOULD OBSERVATION Re. point 9 on previous slide If 1 risk factor present, observe for 4 hours If 2 risk factors perform a scan A CT Head scan should be performed if during the observation any of the following risk factors are observed: I.GCS < 15 II.Further vomiting III. Further episode of abnormal drowsiness

RISK FACTORS THAT MERIT CT C- SPINE (CHILDREN) GCS < 13 on initial assessment Intubated patient with suspicion of injury Focal peripheral neurological signs Paraesthesia in upper / lower limbs Definitive diagnosis of c-spine injury needed urgently (e.g. before surgery) Other body areas being scanned for head injury / multi-system trauma and clinical suspicion of c-spine injury Strong suspicion of injury despite normal X-Rays Technically difficult or inadequate X-Rays Significant injury on X-Rays

PLAIN FILM RADIOGRAPHY FOR SUSPECTED NECK INJURY (CHILDREN) C-Spine x-rays should be performed before assessing range of motion if: 1. DANGEROUS MECHANISM - fall >1M or >5 stairs - axial load to head - high speed RTC (rollover; ejection; bicycle incident; motorised recreational vehicle) 2. SAFE ASSESSMENT OF RANGE OF MOTION IS NOT POSSIBLE (i.e. none of the following features are present): - simple rear end vehicular impact - comfortable in a sitting position in the ED - ambulatory at any time since the injury - no midline tenderness -delayed onset of neck pain.

REFERENCES 2014 NICE HEAD INJURY GUIDELINE

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