Head injury - criteria for referral to an emergency department

Criteria for head injury referral to a hospital emergency department by community health services e.g. general practice and NHS minor injury clinics

• GCS less than 15 on initial assessment
• any loss of consciousness as a result of the injury
• any focal neurological deficit since the injury (examples include problems understanding, speaking, reading or writing; decreased sensation; loss of balance; general weakness; visual changes; abnormal reflexes; and problems walking)
• any suspicion of a skull fracture or penetrating head injury since the injury (for example, clear fluid running from the ears or nose, black eye with no associated damage around the eyes, bleeding from one or both ears, new deafness in one or both ears, bruising behind one or both ears, penetrating injury signs, visible trauma to the scalp or skull of concern to the professional)
• amnesia for events before or after the injury. The assessment of amnesia will not be possible in pre-verbal children and is unlikely to be possible in any child aged under 5 years
• persistent headache since the injury
• any vomiting episodes since the injury
• any seizure since the injury
• any previous cranial neurosurgical interventions
• a high-energy head injury (for example, pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from a height of greater than 1 m or more than five stairs, diving accident, high-speed motor vehicle collision, rollover motor accident, accident involving motorized recreational vehicles, bicycle collision, or any other potentially high-energy mechanism)
• history of bleeding or clotting disorder
• current anticoagulant and antiplatelet (except aspirin monotherapy) treatment
• current drug or alcohol intoxication
• any safeguarding concerns (for example, possible non-accidental injury or a vulnerable person is affected)
• irritability or altered behaviour (easily distracted, not themselves, no concentration, no interest in things around them), particularly in babies and children under 5
• continuing concern by the professional about the diagnosis

If absence of any the factors listed, the professional should consider referral to an emergency department if any of the following factors are present depending on their own judgement of severity:

• irritability or altered behaviour, particularly in infants and young children (that is, aged under 5 years)
• visible trauma to the head not covered above but still of concern to the professional
• adverse social factors (for example, no one able to supervise the injured person at home)
• continuing concern by the injured person or their carer about the diagnosis

Transport to the emergency department

• patients referred from community health services and NHS minor injury clinics should be accompanied by a competent adult during transport to the emergency department
• referring professional should determine if an ambulance is required, based on the patient's clinical condition. If an ambulance is deemed not required, public transport and car are appropriate means of transport providing the patient is accompanied
• referring professional should inform the destination hospital (by phone) of the impending transfer and in non-emergencies a letter summarising signs and symptoms should be sent with the patient

Reference:

1. NICE (September 2007). Head injury guideline
2. NICE (January 2014). Triage, assessment, investigation and early management of head injury in infants, children and adults
3. NICE (May 2023). Head injury: assessment and early management