Head-injury risk assessment and CT indications — Rapid

Synopsis

Identify intracranial and cervical injury promptly, apply current NICE CT criteria and timing, prevent secondary brain injury, and discharge only with reliable supervision and safety-net advice.

Record GCS eye, verbal and motor components, pupils, focal neurology, amnesia, loss of consciousness, vomiting, seizure, mechanism, alcohol or drugs, anticoagulants and time since injury.
Stabilise airway, oxygenation and circulation with cervical protection before imaging; one episode of hypotension or hypoxaemia can worsen neurological outcome.
Adults need CT head within 1 hour for GCS 12 or less initially, GCS below 15 at 2 hours, suspected open or depressed fracture, basal-skull sign, post-traumatic seizure, focal deficit or more than one vomiting episode.
Adults with loss of consciousness or amnesia need CT within 8 hours, or within 1 hour if presenting after 8 hours, when age 65 or over, a bleeding or clotting disorder, dangerous mechanism or more than 30 minutes retrograde amnesia is present.
Children use age-specific NICE criteria and observation: do not transfer adult vomiting or GCS rules uncritically to infants and younger children.
Consider CT within 8 hours for anticoagulant treatment or antiplatelet treatment other than aspirin alone even when no other CT indication exists; use 1-hour imaging if presenting more than 8 hours after injury.
Discuss surgically significant CT findings, persistent coma, unexplained deterioration or refractory symptoms promptly with neurosurgery and include image transfer, physiology and anticoagulant status.
Discharge only when GCS is 15 or baseline, significant injury is excluded, supervision is reliable and written and verbal advice covers deterioration, rest, return to activity, driving and responsible-adult observation.

Key red flags

GCS below 15 at 2 hours, suspected open or depressed fracture, basal-skull signs, post-traumatic seizure, focal neurological deficit or more than one vomiting episode triggers adult CT within 1 hour under NICE criteria.

Any GCS 12 or less initially, GCS below 15 in a baby under 1 year, tense fontanelle, suspected non-accidental injury or a dangerous paediatric mechanism requires urgent senior assessment and NICE-timed imaging.

Anticoagulant or antiplatelet treatment other than aspirin alone increases concern for intracranial bleeding and may justify CT even without another listed indication, especially when presentation is delayed or follow-up is unreliable.

Investigation priorities

First-line CT head for acute structural injuryFirst stepFirst line

Identify haemorrhage, fracture, mass effect and surgical lesions within NICE timing.

Management branches

ImmediateStabilise and risk stratify

Any patient presents after head trauma with symptoms, altered consciousness or concerning mechanism.

Run ABCDE with cervical protection, correct hypoxia, hypotension and glucose, control bleeding and call anaesthetic help for an unprotected airway.
Record GCS components, pupils, focal neurology, fracture signs, vomiting, seizure, amnesia, mechanism, medicines and time from injury.
Apply adult or paediatric NICE CT criteria and book the scan within the required one-hour or eight-hour interval from risk identification.
Escalate falling GCS, pupil change or posturing to trauma, anaesthetic and neurosurgical teams while resuscitation and imaging proceed.

Key medicines

Paracetamol for uncomplicated head-injury painGive 1 g orally up to four times daily when required, at least 4 hours apart, with a maximum of 4 g in 24 hours; use a lower maximum for low body weight, frailty, malnutrition or liver risk.Check combination products and overdose risk, avoid exceeding the total daily maximum and do not use symptom relief to dismiss worsening intracranial signs.

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