Closed Head Injury in Adults-Summary-2011

ADULT TRAUMA CLINICAL PRACTICE GUIDELINES
Initial Management of Closed

Head Injury in Adults
Summary Document
2nd Edition
NSW Ministry of Health
73 Miller St
NORTH SYDNEY NSW 2060
Tel (02) 9391 9000
Fax (02) 9391 9101
www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in part for study

or training purposes subject to the inclusion of an acknowledgement
of the source. It may not be reproduced for commercial usage or sale.
Reproduction for purposes other than those indicated above requires
written permission from the NSW Ministry of Health.
This Clinical Practice Guideline is extracted from PD2012_013 and as a

result, this booklet may be varied, withdrawn or replaced at anytime.
Compliance with information in this booklet is mandatory for NSW Health
© NSW Ministry of Health 2011
SHPN: (SSD) 110187

ISBN: 978-1-74187-581-2
For further copies contact:

NSW Institute of Trauma and Injury Management
PO Box 6314, North Ryde, NSW 2113
Ph: (02) 9887 5726
http://www.itim.nsw.gov.au
Furhter copies of this document can be downloaded from the

NSW Health website http://www.health.nsw.gov.au
November 2011
A revision of this document is due in 2015

Contents
Acknowledgements ................................................ii 5. What should be done when patients

with mild head injury deteriorate? .......................... 18
Introduction ........................................................... 3 6. When can patients with mild head

injury be safely discharged and what
discharge advice should be provided?................... 19
Changes from 2007 edition................................... 6 7. What are the proven treatments for
patients with moderate head injury? ...................... 20
Algorithm 1: Initial Management of 8. What are the proven treatments for

Adult Closed Head Injury ...................................... 8 patients with severe head injury? ........................... 21
9. When should patients with closed head

Algorithm 2: Initial Management of injury be transferred to hospitals with
Adult Mild Closed Head Injury .............................. 9 neurosurgical facilities?........................................... 22
10. What analgesia should patients with

closed head injury receive? .................................... 23
Understanding the grades of
recommendation ................................................. 10 11. Which patients with closed head
injury should receive anti-convulsants? ................. 24
Recommendations .............................................. 12
Appendices ......................................................... 25
1. What is the definition of a mild
head injury? ............................................................ 12 Appendix 1: Abbreviated Westmead
PTA Scale ................................................................ 25
2. What are the clinically important
complications of mild head injury? ......................... 13 Appendix 2: Mild head injury discharge
advice...................................................................... 28
3. How should patients with mild head
injury be assessed? ................................................ 15
4. Which patients with mild head injury References ........................................................... 30

require a CT scan?.................................................. 16
Initial Management of Closed Head Injury in Adults, 2nd Edition Summary Report NSW HEALTH PAGE i
Acknowledgements
The following individuals are acknowledged for their contribution to the development of this document.
Author
Dr Duncan Reed, Emergency Physician, Director of Trauma, Gosford Hospital.
Editorial team
Mr Glenn Sisson, NSW Trauma Education Manager, NSW Institute of Trauma and Injury Management
Ms Suzanne Davies, Research Fellow, Ambulance Research Institute, Ambulance Service of NSW
Assoc. Prof. Paul Middleton, Director, Ambulance Research Institute, Ambulance Service of NSW
Review Group
Dr Rod Bishop, Director Emergency Services, Nepean Hospital
Dr Peter Clark, Clinical Director, NSW ITIM
Dr Scott D’Amours, Trauma Director, Liverpool Hospital
Assoc. Prof. Michael Fearnside AM (Emeritus), Neurosurgeon, Westmead Hospital
Dr Adeline Hodgkinson, Director Brain Injury Rehabilitation Unit, Liverpool Hospital
Mr Peter Mackay, Trauma Clinical Nurse Consultant, Gosford Hospital
Assoc. Prof. Mark Sheridan, Neurosurgeon, Director of Neurosciences, Liverpool Hospital
Dr Declan Stewart, Emergency Physician, Central Coast Health
Dr Alan Tankel, Director Emergency Services, Coffs Harbour Hospital
Ms Nichole Woodward, Emergency Clinical Nurse Consultant, Central Coast Health
Ms Wendy Fischer, Project Manager, Trauma Service, Liverpool Hospital (2nd Ed.)
Ms Merridy Gina, Project Officer, Trauma Service, Liverpool Hospital (2nd Ed.)
Ms Joan Lynch, Project Manager, Trauma Service, Liverpool Hospital (1st Ed.)
Assoc. Prof. Michael Sugrue, Trauma Director, Trauma Service, Liverpool Hospital (1st Ed.)
Ms Gail Long, Secretary, Emergency Department, Gosford Hospital (1st Ed.)
Ms Nikole McCoy, Secretary, Emergency Department, Gosford Hospital (2nd Ed)
Art and Design Unit, Gosford Hospital (1st Ed.)
PAGE ii Initial Management of Closed Head Injury in Adults, 2nd Edition Summary Report NSW HEALTH
Introduction
Trauma is the leading cause of death and disability in significantly there have been very few large prospective
children and young adults in New South Wales and randomised controlled trials of sufficient power and quality
closed head injuries cause a significant proportion of this to guide management.11, 13, 14 However, in the past few
burden.1, 2 Closed head injury may result in lifelong physical, years there has been some progress in working toward
cognitive, behavioural and social dysfunction for patients uniform definitions and some better quality trials and meta-
which in turn may place major social and financial burdens analyses have been published.6, 8-10, 15-35
on their families and society.3 Recent Australian figures
indicate there are approximately 150 patients per 100,000 The variety of clinical practice observed worldwide
population admitted to hospital each year with closed head cannot be explained solely by the lack of uniformity of
injuries.3-5 Worldwide figures suggest an incidence range definitions and good quality studies. Much of the variation
of 200-350 per 100,000 population per year for patients in management strategies between the USA, Canada,
with closed head injury with mild head injury accounting Europe and Australasia is driven by local issues such as
for 80%.6 Despite the fact that closed head injuries are the availability of resources, the medico-legal environment
common, the classification and management of closed and in recent years the concerns about the potential harm
head injures remains surprisingly controversial and subject from CT radiation.6, 36, 37 Thus the USA has higher rates of
to variation in clinical practice.6-10 Due to the large numbers CT scanning for mild head injuries compared to Canada,
of patients involved it has been estimated that even Europe and the UK. Even within countries and within
small improvements in closed head injury management institutions, considerable variation in practice has been
could have significant impact.11 Furthermore, it has been shown to exist.7, 12, 35, 38 Whilst some variation in clinical
suggested that the greatest improvements can be made practice is to be expected, the introduction of clinical
in the better management of those patients with mild to practice guidelines can potentially improve care and ensure
moderate head injury rather than those with severe head adequate access to resources for more isolated areas.6, 35
injury.12 Furthermore, clinical guidelines can potentially reduce
unnecessary tests and hospital admissions for mild head
Much of the controversy that exists about closed head injury patients by identifying those patients at low risk of
injury management stems from the combination of a lack neurosurgically significant lesions.6, 13, 33-35
of uniformity in definitions with a paucity of large well
designed studies in the area.11, 13, 14 ‘Head injury’ is typically Scope of the guideline
used to describe the initial clinical presentation whilst
‘traumatic brain injury’ or “concussion” are used to describe The guideline is intended for use by clinicians managing
the subsequent functional outcome. The terms “mild head patients with closed head injury in major and regional
injury”, “mild traumatic brain injury” and “concussion” are trauma services, and urban and rural hospitals. The
largely interchangeable and which term is used depends on guideline is concerned with the initial care of the mild,
whether you are examining emergency medicine, trauma, moderate and severely head injured patient. The guideline
rehabilitation or sports medicine literature. It is difficult to will make evidence based recommendations on the
find two studies that define mild head injury in exactly the diagnosis, resuscitation, and disposal of patients with closed
same way so comparison of data can be difficult.6, 8-10, 13 head injuries.
Similarly, comparison of data in moderate to severe head

injury studies is made difficult because controversy exists
about how and when best to apply Glasgow Coma Scale
(GCS) to sedated or intubated patients.15 Perhaps most
Initial Management of Closed Head Injury in Adults, 2nd Edition Summary Report NSW HEALTH PAGE 3
The initial management plan for adults is based upon The broad objectives of the guideline are to reduce
recommendations to be followed subject to the clinician's morbidity and mortality in adult patients with closed head
judgement in each case. injury by providing clinicians with practical evidence based
recommendations to assist them in managing such patients.
The recommendations however, are not prescriptive nor It is also hoped that the guidelines may prevent unnecessary
are they rigid procedural paths. It is recognised that the diagnostic tests and hospital admissions especially in the
recommendations may not suit all patients in all clinical mild head injury group.
situations. They are intended to provide a clinically practical
approach to the initial management of closed head injuries The process of constructing the guideline began
based on the current best available evidence. However, as with the clinicians on the Trauma Clinical Guidelines
with all guidelines, it should be remembered that they are a Committee posing a series of questions about the initial
clinical tool and should not replace clinical judgement. The management of closed head injuries. The final questions
guideline relies on individual clinicians to decipher the needs were derived from the guideline priority areas identified
of individual patients. by the committee; that is, the management of mild head
injuries and the timing of transfer of patients with closed
All recommendations regarding pre-hospital care should be head injury from centres with limited resources. The
read and considered in conjunction with the Ambulance initial management of patients with moderate to severe
Service of NSW. head injury was felt to be less controversial. This edition
also includes recommendations in relation to the use of
Guidelines for the initial management of head injury in analgesia and anti-convulsants.
children can be found at http://www.health.nsw.gov.au/
policies/pd/2011/pdf/PD2011_024.pdf An extensive description of the methodology used for
this guideline can be found in the full guideline document
Aims and objectives at Appendix 8, together with the search terms used at
Appendix 9.
The guideline is intended to assist clinicians throughout
NSW in delivering optimal care to patients with closed head
injury. It aims to provide information to support clinical
decision making, rather than dictate what decisions should
be made.
The clinical questions addressed:

1 What is the definition of a mild head injury?
2 What are the clinically important complications of mild head injury?
3 How should patients with mild head injury be assessed?
4 Which patients with mild head injury require a CT scan?
5 What should be done with high risk mild head injury patients when CT scan is unavailable?
6 What should be done when patients with mild head injury deteriorate?
7 When can patients with mild head injury be safely discharged?
8 What discharge advice should be provided?
9 What are the proven treatments for patients with moderate head injury?
10 What are the proven treatments for patients with severe head injury?
11 When should patients with closed head injury be transferred to hospitals with neurosurgical facilities?
12 What analgesia should patients with closed head injury receive?
13 Which patients with closed head injury should receive anti-convulsants?
PAGE 4 Initial Management of Closed Head Injury in Adults, 2nd Edition Summary Report NSW HEALTH
Defining closed head injury situation where multiple post concussion symptoms persist
for several months they are called a “post concussion
This guideline uses the terms ‘closed head injury’ and ‘mild, syndrome”
moderate or severe head injury’ to identify and classify
patients on arrival to hospital. The outcome following As this guideline concentrates on the initial management
presentation with a ‘closed head injury’ will vary from rapid of the patients presenting to hospital, it was felt that the
complete recovery to a mixture of structural lesions and term ‘head injury’ was more relevant to the initial clinical
functional deficits ranging from trivial to life threatening. presentation than the term ‘traumatic brain injury’ that
The terms “concussion” and “traumatic brain injury” refer essentially refers to the subsequent functional outcome. It
to the patient outcome following their initial presentation was also felt that the clinicians at whom this guideline is
with a “closed head injury” and are retrospective aimed would be far more familiar and comfortable with
diagnoses. Important functional deficits following ‘closed using the term ‘head injury.’ The definition of closed head
head injury’ range from post concussion symptoms and injury is further discussed in Question 1.
post traumatic amnesia to a variety of disabling persistent
physical-cognitive-behavioural-social sequelae. Classification of closed head injury
Many patients who suffer a “mild head injury” will have This guideline has classified patients with initial GCS 14-15
“mild concussion symptoms” or “mild traumatic brain injury on admission as mild head injury. This system classifies
symptoms”. If these acute “concussion” symptoms persist patients with initial GCS score of 13 in the moderate head
beyond the first few hours they are usually referred to as injury group due to the patients having similarly patterns of
“post concussion symptoms”. The term “post concussion intracranial injury and cognitive behavioural sequelae. The
symptoms” is used to describe the clinical symptoms of following table gives a rough guide to classification and
mild brain injury that mild head injury patients may suffer outcome.15, 39-43
for a few days to weeks following their injury. In the
Table 1. Summary of closed head injury classification and outcome
Mild Head Injury Moderate Head Injury Severe Head Injury

Initial GCS 14-15 9-13 3-8
% of Total 80 10 10
Abnormal CT Scan (%) 1,2 5-15 30 - 50 60 - 90
Neurosurgical Intervention (%) 1,2 1-3 5-30 30-50

(excluding ICP monitoring)
Mortality (%) 1 <1 10-15 30-50
Good Functional Outcome (%) 1,2,3 >90 20-90 <20
Notes:
1. Generally the lower the GCS the worse the prognosis or the higher the rate of complications
2. Outcome deteriorates with increasing age - “children do better and elderly do worse”
3. Good functional outcome being return to independent ADL and to work or school at 6 months
Changes from 2007 edition
Background evolutionary rather than revolutionary. The basic principles

of management of closed head injury remain the same in
The first edition of this guideline was written in 2005 2010 as they were five years ago.
using evidence available until December 2004. The aim of
this new edition is to review the evidence published since The following section briefly outlines the most significant
December 2004 and to provide some additional information advances in knowledge from the recent literature
on specific topics including the role of anticonvulsants and incorporated in this update.
analgesics in the management of closed head injury.
Definition of mild head injury
The aim of the original guideline was to provide a clinically ■ Recent literature emphasises that significant intracranial
practical evidence based guideline that summarised injury may occur without loss of consciousness or
the initial management of adult closed head injury. It amnesia
was piloted by the NSW Institute of Trauma and Injury ■ Patients with initial GCS 13 have a significantly higher
Management (ITIM) and then formally adopted and rate of intracranial injury and should not be considered
published by NSW Health in January 2007. There was a as having mild head injury
conscious effort by the initial guideline team to provide a
clinically practical document with clinically useful resources
Clinically important complications of mild head injury
such as algorithms, summaries and discharge advice sheets
backed up by a detailed evidence review. The guideline ■ Recent literature emphasises that mild post concussion
team has continued the same principles for this update, symptoms are common and that patients should
incorporating feedback from clinicians to improve the receive appropriate discharge advice to assist recovery
guideline. The algorithms and mild head injury discharge ■ Acute neurosurgical complications are uncommon but
sheets have been revised to reflect the changes in the body important to identify
of the guideline and the feedback received.
Assessment of patients with mild head injury

The guideline team would emphasise that this guideline is a
clinical tool designed to assist clinicians and should be used ■ Recent literature emphasises that if structured clinical
to assist rather than replace the clinical judgement of an assessment indicates the risk of intracranial injury is
experienced clinician caring for an individual patient. low, the routine use of CT scanning is not warranted
and is potentially harmful.
The information provided is based on the best available ■ Structured clinical assessment should include initial
information at the time of writing, which is May 2010. clinical history and examination, serial clinical
These guidelines will be updated every five years and observations and clinical risk factor assessment to
consider new evidence as it becomes available. determine the need for CT scanning
■ A variety of clinical decision rules have been developed
New evidence to determine which patients are at higher risk of
intracranial injury and require CT scanning. However,
Since 2004 there have been many new studies and they all require that the clinician is familiar with their
guidelines published about the management of closed inclusion / exclusion criteria and should be used as
head injury. There have been some advances in our tools to support clinical decision making, rather than
understanding of the assessment and treatment of dictate management
closed head injury but these have been incremental and ■ Post traumatic amnesia testing in the emergency
Discharge advice for patients with mild head injury
department, eg Abbreviated Westmead PTA Scale
(A-WPTAS) can be useful in identifying patients with ■ New section to emphasise importance of discharge
cognitive impairment at increased risk of structural advice
lesions and post concussion symptoms. ■ Recent literature emphasises that all patients with
mild head injury should be given both verbal and
written discharge advice covering symptoms and signs
Indications for CT scan for mild head injury
of acute deterioration, when to seek urgent medical
■ Recent literature emphasises that patients can be risk attention, lifestyle advice to assist recovery, information
stratified according to clinical risk factors and clinical about typical post concussion symptoms and reasons
decision rules. Patients who are classified as high risk for seeking further medical follow up. As with all
should have CT scans to exclude clinically important discharge advice this should be time specific and action
intracranial lesions specific.
■ Significant head injuries can occur without loss of ■ An improved version of the original mild head injury
consciousness or amnesia and that the absence of advice sheet associated with this guideline has been
these features should not be used to determine the developed and is now available in several languages.
need for CT scanning.
■ Persistent abnormal mental status manifested by either
abnormal GCS or abnormal alertness, behaviour or Initial management of moderate head injury
cognition is a strong indication for CT scanning (GCS 9-13)
■ Known coagulopathy and particularly supra- ■ Recommendations essentially unchanged
therapeutic anticoagulation are significant risk factors
for intracranial injury and that these patients should
have early CT scans and be considered for reversal of Initial management of severe head injury
anticoagulation (GCS 3-8)
■ There have been several very large studies addressing ■ Recommendations essentially unchanged
this issue in the paediatric literature that have come up
with very similar risk factors to the adult literature and
Transfer of patients with closed head injury to
have also confirmed that it is safe to discharge low risk
hospitals with neurosurgical facilities
patients without CT scanning.
■ Recommendations essentially unchanged
Acute neurological deterioration

Analgesia for closed head injury
■ Recommendations essentially unchanged
■ Previously covered within guideline but now given ■ New section
separate question
Anticonvulsants for closed head injury

Discharge of patients with mild head injury
■ New section
■ Recent literature emphasises that patients can be safely
discharged for home observation if structured clinical
assessment reveals no clinical risk factors indicating the
need for CT scanning or following a normal CT scan if
indicated.
■ Deterioration of mild head injury patients following
a normal CT scan is rare. Caution is advised for
patients with known coagulopathy and elderly patients
where the risk of a delayed subdural haemorrhage is
increased.
Algorithm 1:
Initial Management of Adult Closed Head Injury
Initial Assessment and Stabilisation of ABCDEs

Trauma Team activation if initial GCS 3-13 or otherwise indicated
Commence minimum of hourly clinical observations of vital signs, GCS, pupils, PTA (if applicable) and clinical symptoms
GCS 3-8 GCS 9-13 GCS 14-15

Severe Head Injury (10%) Moderate Head Injury (10%) Mild Head Injury (80%)
■ Supportive care of ABCDEs ■ Initial assessment followed by period of clinical
■ Early intubation
■ Prevent secondary brain injury by avoiding observation to detect risk factors for significant
■ Supportive care of ABCDEs
hypoxaemia and hypotension intracranial injury.
■ Prevent secondary brain injury by avoiding ■ CT scan not routinely indicated unless one or
■ Early CT scan
hypoxaemia and hypotension more risk factors listed below are present.
■ Period of clinical observation
■ Early CT scan ■ Discharge for home observation with head
■ Consider intubation in the event of clinical
■ Early neurosurgical consult injury advice sheet at 4 hours post injury if
deterioration or to facilitate management clinically improving with either no risk factors
■ Early retrieval consult if transfer required
■ Early neurosurgical consult if not clinically indicating the need for CT scan or normal CT
■ Consider use of anticonvulsants improving and/or abnormal CT scan scan if performed.
■ Consider ICP monitoring ■ Early retrieval consult if transfer required ■ Consider hospital admission and consult
■ ICU admission ■ network neurosurgical service if abnormal CT
Admit to hospital for prolonged observation
■ Brain injury rehabilitation consult unless rapid clinical improvement to GCS 15, scan.
normal CT scan and absence of other risk ■ Consider hospital admission for observation if
factors (as per mild head injury) clinically not improving at 4 hours post injury
NB. Minimum supportive care aims to ■ Routine post traumatic amnesia testing and irrespective of CT scan result.
prevent secondary brain injury: consider referral to brain injury rehabilitation ■ Consider hospital admission for observation
■ PaO2 >60 service due to significant risk of cognitive if elderly, known coagulopathy or socially
■ SaO2 >90 behavioural social sequelae isolated.
■ PaCO2 35-40 ■ Advise patients to see their local doctor if they
do not return to normal within 48 hours so
■ Systolic BP >90
they can be reassessed and monitored for post
■ Head up 30º concussion symptoms.
NB. Also see separate Mild Head Injury
Algorithm.
Risk factors indicating potentially significant mild head injury
■ GCS <15 at 2 hours post injury ■ Age >65 years ■ Large scalp haematoma or laceration.**
■ Deterioration in GCS ■ Post traumatic seizure ■ Multi-system trauma**
■ Focal neurological deficit ■ Prolonged loss of consciousness (>5 min). ■ Dangerous mechanism**
■ Clinical suspicion of skull fracture ■ Persistent post traumatic amnesia (AWPTAS <18/18)* ■ Known neurosurgery / neurological deficit.**
■ Vomiting (especially if recurrent) ■ Persistent abnormal alertness / behaviour / cognition* ■ Delayed presentation or representation**
■ Known coagulopathy / bleeding disorder ■ Persistent severe headache*
* particularly if persists at 4 hours post time of injury
**clinical judgement required
What should be done when patients with closed head When should patients with closed head injury be transferred
injury acutely deteriorate? to hospitals with neurosurgical facilities?
Early signs of deterioration Clinical approach Potential indications Clinical approach

■ Confusion ■ Resuscitate ABCDEs and exclude Patient with severe head injury ■ When in doubt consult you
■ Agitation non head injury cause network neurosurgical service.
■ Drowsiness ■ Supportive care of ABCDEs ■ Patients with closed head injuries
Patient with moderate head injury if:
■ Vomiting ■ Early intubation if indicated should be observed in facilities that
■ clinical deterioration
can manage any complications that
■ Severe headache ■ Immediate CT scan ■ abnormal CT scan are likely to arise. Clinical judgment
■ If clinical or CT evidence of raised ■ normal CT scan but not clinically regarding risk of deterioration
Late signs of deterioration ICP/mass effect consult with is required and neurosurgical
improving
■ Decrease in GCS by two or more network neurosurgical and retrieval consultation may be appropriate.
■ CT scan unavailable.
points services re; ■ Patients with closed head injuries
■ Dilated pupil(s) - short term hyperventilation to should be transferred to the
■ Focal neurological deficit PaCO2 30-35 Patient with mild head injury if: nearest appropriate hospital with
■ Seizure - bolus of mannitol (1g/kg) ■ clinical deterioration neurosurgical facilities if there is
■ abnormal CT scan significant risk of intracranial injury.
■ Cushing’s response – bradycardia - local burr holes/craniectomy
The transfer of patients to hospitals
and hypertension when more than 2 hours from ■ normal CT scan but not clinically
with CT scan facilities but without
neurosurgical care improving within 4-6 hours post neurosurgical services should be
- prophylactic anti-convulsants injury avoided.
■ mild head injury with CT scan
unavailable, particularly if:
- Persistent GCS<15
- Deterioration in GCS
AMRS (adult) 1800 650 004 - Focal neurological deficit
- Clinical suspicion of skull fracture
'formerly the MRU' - Persistent abnormal mental status
- Persistent vomiting
- Persistent severe headache
NETS (children) 1300 362 500 - Known coagulopathy (particularly
if age >65 or INR >4)
Network neurosurgical service
Algorithm 2:
Initial Management of Adult Mild Closed Head Injury
Initial GCS 14-15 on arrival following blunt head trauma

Stabilise ABCDEs and assess clinical risk factors.
Commence minimum of hourly clinical observations of vital signs, GCS, pupils, PTA and clinical symptoms
Low risk mild head injury High risk mild head injury
No indication for CT scan if all of... Strong indication for CT scan if...
■ GCS 15 at 2 hours post injury. ■ GCS <15 at 2 hours post injury. #1
■ No focal neurological deficit. ■ Deterioration in GCS.
■ No clinical suspicion of skull fracture. ■ Focal neurological deficit.
■ No vomiting ■ Clinical suspicion of skull fracture #2
■ No known coagulopathy or bleeding disorder. ■ Vomiting (especially if recurrent) #3
■ Age <65 years. ■ Known coagulopathy or bleeding disorder #4
■ No seizure ■ Age >65 years. #5
■ Brief loss of consciousness (<5 mins). ■ Seizure #6
■ Brief post traumatic amnesia (<30 mins) ■ Prolonged loss of consciousness (>5 mins).
■ No severe headache. ■ Persistent post traumatic amnesia (A-WPTAS <18/18 at 4hrs post injury) #7
■ No large scalp haematoma or laceration ■ Persistent abnormal alertness / behaviour / cognition #8
■ Isolated head injury ■ Persistent severe headache.
■ No dangerous mechanism.
■ No known neurosurgery / neurological impairment.
Relative indication for CT scan if…
■ Large scalp haematoma or laceration #9
■ No delayed presentation or representation
■ Multi-system trauma. #10
NOTE:
Mild acute clinical symptoms such as lethargy, nausea, dizziness, mild headache, mild ■ Dangerous mechanism. #11
behavioural change, amnesia for event and mild disorientation are common and are ■ Known neurosurgery / neurological impairment. #12
not associated with increased risk of intracranial injury. These clinical symptoms usually
start to improve within 2 to 4 hours of time of injury. ■ Delayed presentation or representation. #13
Note
The presence of multiple risk factors is more concerning than a single isolated risk
factor. In most uncomplicated mild head injury patients clinical symptoms start to
Continue minimum of hourly clinical observations until at improve by 2 hours post injury and are returning to normal by 4 hours post injury.
least four hours post time of injury. Clinical symptoms that are deteriorating or not improving by 4 hours post injury on
serial observation such as abnormal alertness / behaviour / cognition, PTA, vomiting or
severe headache are very concerning.
Clinically deteriorates or clinical symptoms not

improving during observation period Indication for CT scan. Continue clinical observations.
Normal CT scan Abnormal CT scan CT scan unavailable
Clinical Clinical Clinical Consider transfer for CT scanning particularly if:

symptoms symptoms symptoms NOT ■ Persistent GCS <15.
IMPROVING or IMPROVING IMPROVING at
■ Deterioration in GCS.
remain normal at 4-6 hours 4-6 hours post
during period post time of time of injury. ■ Focal neurological deficit.
of observation. injury. ■ Clinical suspicion of skull fracture
■ Known coagulopathy (esp if INR>4)
■ Persistent abnormal alertness, behaviour, cognition,
PTA, vomiting or severe headache at 4 hours post injury
Clinically safe for discharge for home observation if:
■ GCS 15/15
■ No persistent post traumatic amnesia (nb A-WPTAS 18/18)
■ Alertness / behaviour / cognition returning to normal Consult senior clinician and network neurosurgical service
■ Clinically improving after observation. regarding further management and disposition.
■ Normal CT scan or no indication for CT scan. Continue clinical observations in hospital.
■ Clinical judgment required regarding discharge and follow up of elderly
patients or patients with known coagulopathy or bleeding disorder due to
increased risk of delayed subdural haematoma. Explanatory notes for risk factors
1. Using GCS<15 at 2 hours post injury allows clinical judgement for patients who present soon after
injury or who have drug or alcohol intoxication. Drug or alcohol intoxication has not been shown to
be an independant risk factor for intracranial injury but persistent GCS<15 is a major risk factor and
mandates CT.
2. Clinical suspicion of skull fracture includes history of focal blunt assault or injury; palpable skull fracture;
Clinically safe for discharge for home observation if: large scalp haematoma or laceration; signs of base of skull fracture – haemotympanum / CSF leak /
raccoon eyes / Battles sign.
■ Responsible person available to take home and observe. 3. Recurrent vomiting more concerning than isolated vomiting but both are indications.
■ 4. Known coagulopathy is both a strong indication for early CT scan and to check the INR. Early reversal of
Able to return if deteriorates. anticoagulation if abnormal CT scan and consider reversal if initially normal CT scan with high INR (>4)
■ Discharge advice is understood. depending on clinical situation.
5. Elderly patients have increasing risk of intracranial injury with increasing age; routine CT scanning
indicated unless totally asymptomatic patient with no other risk factors.
6. Brief generalised seizures immediately following head injury are not significant risk factors. Prolonged,
focal or delayed seizures are risk factors for intracranial injury.
7. Post traumatic amnesia may manifest as repetitive questioning or short term memory deficits and can
be objectively tested using the A-WPTAS. PTA > 30 mins is a minor risk factor and PTA > 4 hours a
Discharge for home observation if above criteria met: major risk factor for intracranial injury.
■ 8. Abnormal alertness/behaviour/cognition detects subtle brain injury better than GCS and should be part
Provide written patient advice sheet of the bedside assessment. Family may help establish what is normal.
■ Provide discharge summary for GP 9. Multi-system trauma – beware patient with unstable vital signs or distracting injuries or who receive
analgesia or anaesthesia, as significant head injury is easily missed.
■ All patients should be advised to see their GP for follow up if they are not 10. Clinical judgement required as to what is a large scalp haematoma or laceration.
feeling back to normal within 2 days 11. Dangerous - MVA ejection / rollover; pedestrians / cyclists hit by vehicle; falls >own height or five stairs;
■ falls from horses / cycles etc; focal blunt trauma, eg bat / ball / club.
Any patients who have minor CT abnormalities, who suffered significant 12. Known neurosurgery/neurological impairment – conditions such as hydrocephalus with shunt or AVM
clinical symptoms or who had prolonged post traumatic amnesia should be or tumour or cognitive impairment such as dementia make clinical assessment less reliable and may
routinely referred to their GP for follow up due to an increased risk of post increase risk of intracranial injury.
concussion symptoms. 13. Delayed presentation should be considered as failure to clinically improve during observation. For
representation consider both intracranial injury and post concussion symptoms and have a low
threshold for CT scanning if not done initially.
Understanding the grades of recommendation
Strength of recommendations components are assessed according to the NHMRC body

of evidence matrix (Table 2). The overall grade of the
This guideline uses the National Health and Medical recommendation is determined based on a summation of
Research Council's (NHMRC) overall grades of the rating for each individual component of the body of
recommendation to indicate the strength of the body of evidence. Please note that a recommendation cannot be
evidence underpinning each recommendation. The body graded A or B unless the evidence base and consistency of
of evidence reflects the evidence components of all the the evidence are both rated A or B.44
studies relevant to each recommendation. The evidence
Table 2: Body of evidence matrix44
A B C D
Components
Excellent Good Satisfactory Poor
Evidence base one or more level I one or two level II one or two level III level IV studies, or
studies with a low risk studies with a low risk studies with a low level I to III studies/SRs
of bias or several level of bias or a SR/several risk of bias, or level with a high risk of bias
II studies with a low level III studies with a I or II studies with a
risk of bias low risk of bias moderate risk of bias
Consistency all studies consistent most studies some inconsistency evidence is

consistent and reflecting genuine inconsistent
inconsistency may be uncertainty around
explained clinical question
Clinical Impact very large substantial moderate slight or restricted
Generalisability population/s studied in population/s studied in population/s studied population/s studied

body of evidence are the body of evidence in body of evidence in body of evidence
the same as the target are similar to the differ to target differ to target
population for the target population for population for population and hard
guideline the guideline guideline but it is to judge whether it is
clinically sensible to sensible to generalise
apply this evidence to to target population
target population
Applicability directly applicable to applicable to probably applicable to not applicable to

Australian healthcare Australian healthcare Australian healthcare Australian healthcare
context context with few context with some context
caveats caveats
Overall grade A or B recommendations are generally based The recommendation boxes of each clinical question
on a body of evidence that can be trusted to guide clinical addressed in this guideline contain clear recommendations
practice, whereas Grades C or D recommendations must with an associated strength of recommendation grade as
be applied carefully to individual clinical and organisational detailed below. Where appropriate, the author has also
circumstances and should be interpreted with care (see added relevant clinical points which support the given
table below).44 This guideline also utilises an additional recommendation.
grade of “Consensus” where appropriate.
Grade of
Description
recommendation
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its
application
D Body of evidence is weak and recommendation must be applied with caution
Consensus When limited literature was available, the author and editorial group utilised the best available
clinical expertise, practices and accepted teachings to reach a consensus on the recommendation
Level of evidence in accordance with the NHMRC publication: A guide to the

development, evaluation and implementation of clinical
‘Level of Evidence’, applied to individual articles, refers practice guidelines.45 From this, each article was allocated a
to the study design used to minimise bias. Each article is level of evidence as follows:
classified according to their general purpose and study type
Level I Evidence obtained from a systematic review of all relevant randomised control trials
Level II Evidence obtained from at least one properly-designed randomised control trial
Level III-1 Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or
some other method)
Level III-2 Evidence obtained from comparative studies (including systematic reviews of such studies) with
concurrent controls and allocation not randomised, cohort studies, case-control studies, or
interrupted time series with a control group
Level III-3 Evidence obtained from comparative studies with historical control, two or more single arm studies
or interrupted time series without a parallel control group
Level IV Evidence obtained from a case-series, either post-test or pre-test/post-test
For more information on the methodology please see Appendix 8 in the full guideline document.
Recommendations
The following is a summary of the evidence based see the associated discussion in the Adult Trauma Clinical
recommendations for the management of head injury. For a Practice Guidelines: Initial Management of Closed Head
more detailed explanation of the recommendations, please Injury in Adults, 2nd Edition.
1. What is the definition of a mild head injury?
Strength of
Mild Head Injury Definition
recommendation
A patient with an initial GCS score of 14-15 on arrival at hospital following acute blunt CONSENSUS
head trauma with or without a definite history of loss of consciousness or post traumatic
amnesia.
Typical characteristics
■ Direct blow to the head or acceleration / deceleration injury.
■ Transient loss of consciousness or brief post traumatic amnesia.
■ Transient abnormal alertness, behaviour or cognition.
■ Rapid clinical improvement
■ Neurosurgical intervention rare (1-3%)
■ Abnormality on CT scan relatively uncommon (5-15%)
■ Post concussion symptoms common.
■ Long term functional outcome good.
Specific exclusions:
■ Clinically obvious penetrating head injury.
■ Non-traumatic brain injury.
Risk Stratification
Patients may be classified into “high” and “low” risk groups based on the risk of suffering complications
of their mild head injury. This risk stratification can be used to assist clinical judgement in determining
the need for further assessment (eg CT scan), management and follow up. Stratification into “high” and
“low” risk groups is based on the presence or absence of specified clinical risk factors identified by:
■ initial clinical history
■ initial clinical examination
■ serial clinical observation
“Complicated” Mild Head Injury

A “complicated” mild head injury is a mild head injury resulting in one of the following:
■ significant structural lesion on CT scan
■ significant acute clinical symptoms
■ significant post concussion symptoms
2. What are the clinically important complications of mild head injury?
Strength of
RECOMMENDATION
recommendation
The clinically important complications of mild head injury are: CONSENSUS

■ structural lesions on CT scan requiring acute neurosurgical intervention
■ structural lesions on CT scan requiring hospital admission and/or neurosurgical consultation
■ acute clinical symptoms requiring acute hospital admission
■ post concussion symptoms causing disabling cognitive behavioural social sequelae
Structural lesions on CT scan requiring acute neurosurgical intervention are rare (1-3%). A
Typical lesions include:

■ acute extradural haematoma
■ acute subdural haematoma
■ depressed skull fractures
Structural lesions on CT scan requiring hospital admission and/or neurosurgical consultation are relatively
uncommon (5-15%). Not all of these lesions will require hospital admission.
Typical lesions include:

■ small intracranial haematomas/haemorrhages
■ minor skull fractures
Clinicians and patients should be aware that the absence of a structural lesion on CT scan following A
mild head injury does not exclude the possibility of significant acute clinical symptoms or significant post
concussion symptoms.
Acute clinical symptoms are common immediately following mild head injury but should be starting to
improve in most patients within two to four hours of time of injury.
Common acute clinical symptoms include:

■ post traumatic amnesia
■ disorientation
■ confusion
■ drowsiness
■ dizziness
■ nausea
■ vomiting
■ headache
Patients with persistent acute clinical symptoms at four hours post time of injury require prolonged
clinical observation and a CT scan should be performed (if not already done) to exclude a structural
lesion.
Patients with persistent post traumatic amnesia and/or other persistent significant acute clinical CONSENSUS
symptoms that are not improving require prolonged clinical observation and should be admitted to
hospital even if their initial CT scan is normal.
Strength of
RECOMMENDATION
recommendation
Post concussion symptoms are relatively common following mild head injury and may have B
significant cognitive-behavioural-social impact on patients and their families.
Many patients will have minor post concussion symptoms that will resolve within a few days while some
patients will have more significant post concussion symptoms that will take a few weeks to resolve.
A small number of patients with mild head injury will have persistent disabling post concussion
symptoms after 3 months and will require referral for brain injury rehabilitation assessment. Most of
these patients will improve by 12 months.
Mild head injury patients with structural lesions on CT scan, a history of significant acute clinical
symptoms or documented persistent post traumatic amnesia are at increased risk of post concussion
symptoms but post concussion symptoms can occur in the absence of these features.
The only interventions that have been shown to be beneficial for post concussion symptoms are
education, reassurance and time. Therefore, it is important to provide education about post concussion
symptoms to all mild head injury patients. All patients should be given written advice and advised to see
a doctor if they are not feeling better within a few days of injury.
Typical post concussion symptoms include:

■ headaches
■ dizziness
■ fatigue
■ memory impairment
■ poor concentration
■ mood swings
■ behavioural changes
■ sleep disturbance
■ social dysfunction
3. How should patients with mild head injury be assessed?
Strength of
RECOMMENDATION
recommendation
Mild head injury patients should be assessed by a process of structured clinical assessment involving a A
combination of:
■ initial clinical history and examination
■ serial clinical observations
■ CT scanning if clinically indicated by risk factors identified on initial or serial assessment
Serial clinical observation should include minimum hourly observations of : B

■ vital signs.
■ pupillary reactions
■ GCS
■ alertness / behaviour / cognition
■ post traumatic amnesia (PTA) (eg A-WPTAS)
If patients have no significant risk factors for complications of mild head injury and are clinically judged
to be “low risk” then they should be observed until at least four hours post time of injury.
If patients have any significant risk factors for complications of mild head injury then they should
continue to be clinically observed while further assessment is performed.
Serial clinical observations should be continued on any mild head injury patients who fail to clinically
improve at four hours post injury or who are found to have structural lesions on CT scan.
Assessment for PTA should be performed on all mild head injury patients in the emergency department. C
Mild head injury patients who are admitted to hospital because they have structural lesions, persistent
PTA or clinical symptoms should have daily PTA testing until they are shown to be out of PTA.
Clinical assessment using clinical risk factors or clinical decision rules can identify those patients at A
increased risk of intracranial injury requiring further investigation.
CT scanning is indicated for those mild head injured patients identified by structured clinical assessment A
as being at increased risk of intracranial injury.
CT scanning is the most appropriate investigation for the exclusion of neurosurgically significant lesions A
in mild head injured patients
If structured clinical assessment indicates the risk of intracranial injury is low, the routine use of CT B
scanning is neither clinically beneficial nor cost effective.
Skull x-rays are not sufficiently sensitive to be used as a routine screening investigation to identify A
significant intracranial lesions.
4. Which patients with mild head injury require a CT scan?
Strength of
RECOMMENDATION
recommendation
'High risk’ mild head injury requiring CT scan A

The following risk factors identify patients with mild head injury (initial GCS 14-15) at increased
risk of clinically significant lesions requiring acute neurosurgical intervention or prolonged
observation in hospital. These patients should have early CT scanning if available, if they have any
of the following features:
On initial assessment
■ GCS<15 at two hours post injury**
■ Focal neurological deficit
■ Clinical suspicion of skull fracture
■ Vomiting
■ Known coagulopathy or bleeding disorder
■ Age >65
■ Witnessed seizure
■ Prolonged loss of consciousness (>5min)
On serial assessment
■ Decrease in GCS
■ Persistent GCS<15 at two hours post injury
■ Persistent abnormal alertness/behaviour/cognition
■ Persistent post traumatic amnesia (A-WPTAS<18/18 at 4hrs post injury)
■ Persistent vomiting ( 2 occasions)
■ Persistent severe headache
■ Post traumatic seizure
Clinical judgement required if

■ Initial GCS 14 within two hours of injury**
■ Large scalp haematoma or laceration
■ Associated multi-system injuries
■ Dangerous mechanism
■ Known neurosurgery/neurological impairment
■ Delayed presentation or representation
** NOTE: Includes patients with abnormal GCS due to drug or alcohol ingestion.
If CT scanning is unavailable CONSENSUS

“High risk” mild head injury patients should be closely observed and be considered for transfer to a
hospital with neurosurgical and CT scan facilities when CT scan is unavailable.
A clear decision about the need for transfer for CT scanning for “high risk” patients should be made
at the time of initial assessment or after a brief period of observation. A local senior clinician should be
consulted and the patient discussed with the network neurosurgical service.
The clinical symptoms of patients with mild head injury typically improve within two to four hours post
time of injury. Patients with persistently abnormal or worsening clinical symptoms are at “high risk” of
intracranial injury. A clear decision about the need for transfer for CT scanning should be made no later
than 4 hours post time of injury.
Strength of
RECOMMENDATION
recommendation
Patients at “highest risk” of intracranial injury who should be discussed with the network neurosurgical A
service regarding urgent transfer for CT scanning include those with:
■ Persistent GCS<15 at two hours post injury
■ Clinical suspicion of skull fracture
■ Any deterioration in GCS
■ Post traumatic seizure in ED
■ Known coagulopathy (particularly if age >65 or INR >4)
■ Persistent vomiting or severe headache
■ Persistent abnormal alertness, behaviour, cognition or PTA at 4 hours post injury.
If it is decided, after consultation with a network neurosurgical service, that a “high risk” patient does CONSENSUS
not require urgent transfer for CT scanning, then that patient should have close clinical observation
in hospital for at least 24 hours and until clinically improving. If there are any signs of deterioration
or no improvement, the network neurosurgical service should again be consulted. Rapid transfer to a
neurosurgical centre in the event of deterioration must be available if this strategy is to be used.
If patients are transferred for CT scanning they should ideally be transferred to a hospital with CONSENSUS
neurosurgical facilities to avoid secondary transfer.
A skull x-ray may be useful to confirm the presence of a skull fracture that mandates an early CT scan B
due to the increased risk of deterioration.
‘Low risk’ mild head injury not requiring CT scan A

The following features indicate patients with mild head injury (initial GCS 14-15) at low risk of
having clinically significant lesions requiring acute neurosurgical intervention or prolonged
observation in hospital. These patients should not routinely have CT scanning if they have all of
the following features:
On initial assessment
■ GCS 15 at two hours post injury.
■ No focal neurological deficit.
■ No clinical suspicion of skull fracture.
■ No vomiting.
■ No known coagulopathy or bleeding disorder.
■ Age <65 years.
■ No post traumatic seizure
■ Nil or brief loss of consciousness (<5min).
■ Nil or brief post traumatic amnesia (<30min)
■ No severe headache.
■ No large scalp haematoma
■ Isolated head injury
■ No dangerous mechanism
■ No known neurosurgery / neurological impairment
■ No delayed presentation or representation.
After a period of observation (until at least four hours post time of injury)
■ GCS 15/15
■ No post traumatic amnesia (A-WPTAS 18/18)
■ Normal mental status including alertness, behaviour and cognition.
■ No clinical deterioration during observation.
■ Clinically returning to normal
5. What can be done when patients with mild head injury deteriorate?
Strength of
RECOMMENDATION
recommendation
Early signs of deterioration: B

■ Confusion
■ Agitation
■ Drowsiness
■ Vomiting
■ Severe headache
Late signs of deterioration: A

■ Decrease in GCS by two or more points
■ Dilated pupil
■ Seizure
■ Cushing’s response – bradycardia and hypertension
Clinical approach to neurological deterioration: B

■ Resuscitation and stabilisation of ABCDEs to exclude non head injury cause
■ Supportive care of ABCDEs
■ Early intubation if indicated
■ Immediate CT scan if available
■ Early neurosurgical consult
■ Early retrieval consult
■ If clinical or CT evidence of raised ICP/mass effect consider in consultation with network
neurosurgical service:
- short term hyperventilation to PaCO2 30-35
- bolus of mannitol (1g/kg)
- surgical decompression if more than 2 hours from neurosurgical care
- prophylactic anti-convulsants
6. When can patients with mild head injury be safely discharged and what
discharge advice should be provided?
Strength of
RECOMMENDATION
recommendation
Mild head injury patients can be safely discharged for home observation after an initial period of in- CONSENSUS
hospital observation if they meet the following clinical, social and discharge advice criteria:
1. Clinical criteria: A
■ Normal mental status (alertness / behaviour / cognition) with clinically improving minor post
concussion symptoms after observation until at least four hours post injury.
■ No clinical risk factors indicating the need for CT scanning or normal CT scan if performed due to
risk factors being present.
■ No clinical indicators for prolonged hospital observation (irrespective of CT scan result) such as:
- clinical deterioration
- persistent abnormal GCS or focal neurological deficit
- persistent abnormal mental status
- persistent severe clinical symptoms (vomiting / severe headache)
- presence of known coagulopathy (clinical judgement required)
- persistent drug or alcohol intoxication (clinical judgement required)
- presence of multi-system injuries (clinical judgement required)
- presence of concurrent medical problems (clinical judgement required)
- age >65 (clinical judgement required)
2. Social criteria: CONSENSUS

■ Responsible person available to take patient home.
■ Responsible person available for home observation.
■ Patient able to return easily in case of deterioration.
■ Written and verbal discharge advice able to be understood.
3. Discharge advice criteria: CONSENSUS

■ Discharge summary for local doctor.
■ Written and verbal head injury advice given to patient and nominated responsible person covering:
- symptoms and signs of acute deterioration
- reasons for seeking urgent medical attention
- typical post concussion symptoms
- reasons for seeking routine follow up.
Written and verbal head injury discharge advice should be given to the patient and a nominated A
responsible person covering:
■ symptoms and signs of acute deterioration
■ reasons for seeking urgent medical attention
■ lifestyle advice to assist recovery
■ typical post concussion symptoms
■ reasons for seeking further medical follow up.
7. What are the proven treatments for patients with moderate head injury?
Strength of
RECOMMENDATION
recommendation
Moderate head injury B
Standard care:
■ Initial systematic assessment and resuscitation of ABCDEs
■ Supportive care of ABCDEs with appropriate attention to positioning (30° head up), basic nursing
care and avoidance of hyperventilation or hypoventilation.
■ Prevention of secondary brain injury by avoiding hypoxaemia (O2 saturation <90%) and hypotension
(systolic BP <90)
■ Early CT scan to identify acute neurosurgical lesions
■ Period of clinical observation
■ Consider intubation in the event of clinical deterioration to facilitate resuscitation of ABCDEs or to
facilitate management of agitated patients
■ Early neurosurgical consult if not clinically improving and/or abnormal CT scan
■ Admit to hospital unless rapid clinical improvement to GCS 15, normal CT scan and absence of other
risk factors (as per mild head injury)
■ Repeat CT scan at 24 hours if not clinically improving or abnormal initial CT scan
■ Routine post traumatic amnesia testing and consider referral to brain injury rehabilitation service.
Outcome:
■ Approximately 80-90% of moderate head injury patients improve and should be managed as
complicated mild head injury while 10-20% deteriorate and require management as per severe head
injury..
■ The majority of patients who suffer moderate head injuries will have some degree of cognitive
behavioural social sequelae and should be considered for routine follow up with a brain injury
rehabilitation service or a neurologist (see Appendix 7 in the full guideline document).
8. What are the proven treatments for patients with severe head injury?
Strength of
RECOMMENDATION
recommendation
Severe head injury A
Standard care:
■ Initial systematic assessment and resuscitation of ABCDEs
■ Early intubation
■ Supportive care of ABCDEs with appropriate attention to positioning (30° head up), basic nursing
care and avoidance of hyperventilation or hypoventilation.
■ Prevention of secondary brain injury by avoiding hypoxaemia (O2 saturation <90%) and hypotension
(systolic BP<90)
■ Early CT scan to identify acute neurosurgical lesions
■ Early neurosurgical consult
■ Consider use of anticonvulsants to prevent early post traumatic seizures
■ Consider ICP monitoring to guide management of cerebral perfusion pressure.
■ Low threshold to repeat CT scan if patient condition changes
■ ICU admission
■ Routine repeat CT scan at 24 hours
■ Brain injury rehabilitation consult
Minimum supportive care aims:

■ PaO2 > 60
■ SaO2 > 90
■ PaCO2 35-40
■ Systolic BP > 90
■ Head up 30°
Poor prognostic indicators:

■ Low GCS (especially motor component).
■ Age >60 years (prognosis deteriorates with increasing age).
■ Absent pupillary reflexes (after systemic resuscitation).
■ Hypotension (systolic BP <90).
■ Hypoxaemia (oxygen saturation <90%).
9. When should patients with closed head injury be transferred to hospitals
with neurosurgical facilities?
Strength of
RECOMMENDATION
recommendation
A clear decision about the potential need for transfer should be made at the time of initial assessment or CONSENSUS
after a brief period of observation. A senior clinician should be consulted.
The network neurosurgical and retrieval services should be consulted as soon as possible to facilitate
early transfer. The following patients should be considered for transfer and discussed with the network
neurosurgical service.
All patients with severe head injury (GCS 3-8) A
Patients with moderate head injury (GCS 9-13) if: CONSENSUS

■ abnormal CT scan
■ normal CT scan but not clinically improving
■ CT scan unavailable.
Patients with mild head injury (GCS 14-15) if: CONSENSUS

■ abnormal CT scan
■ normal CT scan but not clinically improving at 4-6 hours post injury
■ high risk mild head injury with CT scan unavailable if:
- Persistent GCS<15 at two hours post injury
- Focal neurological deficit
- Clinical suspicion of skull fracture
- Persistent abnormal mental status
- Persistent vomiting
- Persistent severe headache
- Any deterioration in GCS
- Post traumatic seizure in ED
- Known coagulopathy (particularly if age >65 or INR >4)
Note – the Ambulance Service of NSW Pre Hospital Major Trauma Triage Protocol (T1), attempts to ensure that, wherever
possible, trauma patients with moderate to severe head injury are transferred directly from the pre-hospital setting to a
Tertiary Trauma Centre.
10. What analgesia should patients with closed head injury receive?
Strength of
RECOMMENDATION
recommendation
Analgesia in isolated mild head injury CONSENSUS

■ Persistent severe headache or worsening severe headache is an indication for a CT scan to exclude a
significant intracranial lesion
■ Most headaches associated with isolated mild head injury will respond to simple analgesia such as
paracetamol.
■ Isolated mild head injury patients who require more than paracetamol for headache should be
considered for a CT scan to exclude a significant intracranial injury
Analgesia guide for isolated mild head injury: CONSENSUS

■ Paracetamol, 1g, q 4-6 hours, maximum 4g/24 hours*
If paracetamol is ineffective as a sole agent then stronger analgesia such as oral opioids or parenteral
opioids should not be prescribed to patients with isolated mild head injury unless the need for an initial
or repeat CT scan to exclude clinically important intracranial lesions has been considered and a senior
clinician has been consulted. After further clinical assessment consider adding;
■ Codeine Phosphate, 30-60mg, q 4-6 hours*

or
■ Oxycodone (immediate release), 5-10mg q 4-6 hours*
NB Avoid the use of aspirin / NSAIDS due to increased risk of bleeding

* See standard texts for detailed prescribing information
Analgesia guide for mild head injury with associated systemic injuries: CONSENSUS
■ More likely to need titrated intravenous opioids, procedural sedation or general anaesthesia for their
associated injuries.
■ Have a lower threshold for performing CT scans.
■ Require close clinical assessment and observation.
■ Appropriate pain relief should not be withheld due to concerns of masking head injury symptoms
and signs
■ Analgesia needs to be individualised under the supervision of a senior clinician.
Analgesia in moderate to severe head injury CONSENSUS

■ Likely to require titrated intravenous analgesia and sedation for associated injuries, clinical
management or intubation.
■ Will require close clinical observation in a high dependency area following initial clinical assessment
and CT scanning.
■ Analgesia needs to be individualised under the supervision of a senior clinician.
Clinical approach to pain management in closed head injury (all severities) CONSENSUS
■ Consult a senior clinician if any significant change in the patient’s condition
■ Clinically re-assess if:
- inadequate analgesia or worsening headache
- excessive drowsiness, or other clinical deterioration
■ Before using stronger analgesia:
- clinically re-assess patient
- consider need for CT scan
- consult senior clinician
11. Which patients with closed head injury should receive anti-convulsants?
Strength of
RECOMMENDATION
recommendation
Consult a senior clinician or your network neurosurgical service before commencing prophylactic anti- CONSENSUS
convulsants in patients with acute closed head injury
Prophylactic anti-convulsants are not indicated for patients with uncomplicated mild head injury B
Prophylactic anti-convulsants should be considered in patients with complicated mild head injury or B
moderate to severe head injury.
Specific indications to consider prophylactic anti-convulsants in the first week following a head injury B
include:
■ Extradural, subdural or intracerebral haematoma on CT
■ Depressed skull fracture on CT
■ Early post traumatic seizure in hospital (especially if focal or prolonged)
■ Severity of head injury (low initial GCS / prolonged coma / prolonged PTA)
■ Any suspicion of penetrating injury
Prophylactic anti-convulsants decrease the incidence of early post traumatic seizures within seven days B
of closed head injury.
Early post traumatic seizures have not been shown to be associated with worse patient outcomes in B
large population studies.
Clinical judgment is required on whether to prescribe anti-convulsants for individual patients. CONSENSUS
Indications for anti-convulsants by post traumatic seizure type B

Immediate post traumatic seizures (at time of injury)
■ Anti-convulsants not warranted unless specific indication present (see above)
Early post traumatic seizures ( up to 7 days post injury)

■ Anti-convulsants should be considered especially if any of the other specific indications are also
present (see above)
Late post traumatic seizures (more than 7 days post injury)

■ Long term anti-convulsants should be considered after the first late post traumatic seizure due to the
increased risk of developing post traumatic epilepsy
■ There is no evidence that the routine use of anti-convulsants following closed head injury reduces
the risk of late post traumatic seizures.
Recommended drugs and loading doses* B

Standard therapy:
Phenytoin:
■ Intravenous loading dose: 20 mg/kg in NS (<6.7mg/ml) no faster than 50mg/min
Standard adult IVI loading dose: 1000mg phenytoin diluted in 150ml normal saline over 60 mins with in
line micron filter
Alternative therapies: C
Levetiracetam:
■ Intravenous loading dose: 10mg /kg (max 1000mg)
■ Standard adult IVI loading dose: 1000mg levetiracetam in 100ml normal saline over 15 mins
Sodium Valproate:
■ Intravenous loading dose: 10mg /kg (max 800mg)
■ Standard adult IVI loading dose: 800mg in 100ml normal saline over 15 mins
* See standard texts for detailed prescribing information
Appendix 1: Abbreviated Westmead PTA Scale
ABBREVIATED WESTMEAD PTA SCALE (A-WPTAS)

GCS & PTA testing of patients with MTBI following mild head injury
Abbreviated Westmead PTA Scale (A-WPTAS)

incorporating Glasgow Coma Scale (GCS)
MRN sticker here
Date: T1 T2 T3 T4 T5 Use of A-WPTAS and GCS for patients with MTBI

The A-WPTAS combined with a standardised GCS
Time assessment is an objective measure of post traumatic
amnesia (PTA).
Motor Obeys 6 6 6 6 6 Only for patients with current GCS of 13-15 (<24hrs
commands post injury) with impact to the head resulting in confusion,
Localises 5 5 5 5 5 disorientation, anterograde or retrograde amnesia, or brief
LOC. Administer both tests at hourly intervals to gauge
Abnormal flexion 4 4 4 4 4
patient’s capacity for full orientation and ability to retain new
Withdraws 3 3 3 3 3 information. Also, note the following: poor motivation,
Extension 2 2 2 2 2 depression, pre-morbid intellectual handicap or possible
medication, drug or alcohol effects. NB: This is a screening
None 1 1 1 1 1
device, so exercise clinical judgement. In cases where
Eye Opening Spontaneously 4 4 4 4 4 doubt exists, more thorough assessment may be
To speech 3 3 3 3 3 necessary.
To pain 2 2 2 2 2
Admission and Discharge Criteria:
None 1 1 1 1 1
Verbal Oriented ** 5 5 5 5 5 A patient is considered to be out of PTA when they score
18/18.
(tick if correct)
Name Both the GCS and A-WPTAS should be used in conjunction
with clinical judgement.
Place
Patients scoring 18/18 can be considered for discharge.
Why are you here
For patients who do not obtain 18/18 re-assess after a
Month further hour.
Year Patients with persistent score <18/18 at 4 hours post time
Confused 4 4 4 4 4 of injury should be considered for admission.
Inappropriate 3 3 3 3 3 Clinical judgement and consideration of pre-existing
words conditions should be used where the memory component
Incomprehensible 2 2 2 2 2 of A-WPTAS is abnormal but the GCS is normal (15/15).
sounds Referral to GP on discharge if abnormal PTA was present,
None 1 1 1 1 1 provide patient advice sheet.
GCS Score out of 15 /15 /15 /15 /15 /15
Picture 1 Target set of picture cards
Show
pictures
Picture 2
(see
Picture 3 over)
A-WPTAS Score out of 18 /18 /18 /18 /18

** must have all 5 orientation questions correct to score 5 on verbal score for
GCS, otherwise the score is 4 (or less).
PUPIL T1 T2 T3 T4 T5 + = REACTS
ASSESSMENT BRISKLY
R L R L R L R L R L SL = SLUGGISH
Size C = CLOSED
Reaction - = NIL
Comments Pupil Size (mm)

2 3 4 5 6 7 8
Shores & Lammel (2007) - further copies of this score sheet can be
downloaded from http://www.psy.mq.edu.au/GCS
GLASGOW COMA SCALE (GCS) AND ABBREVIATED WESTMEAD PTA SCALE (A-WPTAS)
Administration and Scoring
1. Orientation Questions
Question 1: WHAT IS YOUR NAME?
The patient must provide their full name.
Question 2: WHAT IS THE NAME OF THIS PLACE?
The patient has to be able to give the name of the hospital. For example: Westmead Hospital. (NB: The
patient does not get any points for just saying ‘hospital’.) If the patient can not name the hospital, give them a
choice of 3 options. To do this, pick 2 other similar sized hospitals in your local area or neighbouring region. In
Westmead Hospital’s case the 3 choices are ‘Nepean Hospital, Westmead Hospital or Liverpool Hospital’.
Question 3: WHY ARE YOU HERE?
The patient must know why they were brought into hospital. e.g. they were injured in a car accident, fell,
assaulted or injured playing sport. If the patient does not know, give them three options, including the correct
reason.
Question 4: WHAT MONTH ARE WE IN?
For emphasis the examiner can ask what month are we in now? The patient must name the month. For
example, if the patient answers ‘the 6th month’, the examiner must ask the further question ‘What is the 6th
month called?’.
Question 5: WHAT YEAR ARE WE IN?
It is considered correct for patients to answer in the short form ‘08’, instead of ‘2008’. Also, an acceptable
alternative prompt (for the rest of the 2000’s) is ‘The year is 2000 and what?’
2. Picture recognition
Straight after administering the GCS (standardised questions), administer the A-WPTAS by presenting the 3
Westmead PTA cards. Picture Cards the first time - T1 : Show patients the target set of picture cards for
about 5 seconds and ensure that they can repeat the names of each card. Tell the patient to remember the
pictures for the next testing in about one hour. Picture Cards at each subsequent time T2-T5: Ask patient,
“What were the three pictures that I showed you earlier?” Scoring:
UÊ For patients who free recall all 3 pictures correctly, assign a score of 1 per picture and add up the patient’s
GCS (out of 15) and A-WPTAS memory component to give the A-WPTAS score (total = 18). Present the 3
target pictures again and re-test in 1 hour.
UÊ For patients who can not free recall, or only partially free recall, the 3 correct pictures, present the 9-object
recognition chart. If patient can recognise any correctly, score 1 per correct item and record their GCS
and A-WPTAS score (total = 18). Present the target set of pictures again and re-test in 1 hour.
UÊ For patients who neither remember any pictures by free call nor recognition, show the patient the target
set of 3 picture cards again for re-test in 1 hour.
Shores & Lammel (2007) - further copies of this score sheet can be downloaded from http://www.psy.mq.edu.au/GCS
Research and development of the A-WPTAS supported by the Motor Accidents Authority NSW
Shores & Lammel (2007) - further copies of this score sheet can be downloaded from http://www.psy.mq.edu.au/GCS
Appendix 2: Mild Head Injury Discharge Advice
Mild Head Injury Advice 2008
Important points about Mild Head Injury

You had a mild head injury. Most people recover rapidly following a mild head injury. A few people may suffer from
symptoms over a longer period.
There is a small risk of you developing serious complications so you should be watched closely by another adult for
24 hours after the accident. Please read the following. It outlines what signs to look out for after a head injury
and what you need to do if you have problems.
! Warning Signs
If you show any of these symptoms or signs after your head injury, or you get worse , go to
the nearest hospital, doctor or telephone an ambulance immediately.
❖ Fainting or drowsiness - or you can’t wake up
❖ Acting strange, saying things that do not make sense (change in behaviour)
❖ A constant severe headache or a headache that gets worse
❖ Vomiting or throwing up more than twice
❖ Cannot remember new events, recognise people or places (increased confusion)
❖ Pass out or have a blackout or a seizure (any jerking of the body or limbs)
❖ Cannot move parts of your body or clumsiness
❖ Blurred vision or slurred speech
❖ Continual fluid or bleeding from the ear or nose
The first 24-48 hours after injury

Warning Signs You should be observed and return to hospital if you develop any of
! the above warning signs.
Rest / Sleeping Rest and avoid strenuous activity for at least 24 hours. It is alright for you to
zz
sleep tonight but you should be checked every four hours by someone to make
sure you are alright.
Driving Do not drive for at least 24 hours. You should not drive until you feel much
better and can concentrate properly. Talk to your doctor.
Drinking / Do not drink alcohol or take sleeping pills or recreational drugs in the next 48
Drugs hours. All of these can make you feel worse.They also make it hard for other
people to tell whether the injury is affecting you or not.
Pain Relief Use paracetamol or paracetamol/codeine for headaches. Do not use

aspirin or anti inflammatory pain reliever such as ibuprofen or naproxen
(NSAIDs), which may increase the risk of complications.
Sports Do not play sports for at least 24 hours.
See your local doctor if you are not starting to feel better within a few days of your injury.
Adapted from “Mild Head Injury Discharge Advice” author Dr Duncan Reed (2007) Director of Trauma Gosford Hospital. NSW Institute of Trauma and Injury Management
This discharge advice information is taken from the Motor Accidents Authority of NSW, Guideline for mild traumatic brain injury following closed
head injury – first edition 2008, ISBN 978-1-921422-08-9
The first 4 weeks after injury
You may have some common effects from the head injury which usually resolve in several weeks to three months. These are
called post concussive symptoms (see below). Tiredness can exaggerate the symptoms. Return to your normal activities
gradually (not all at once) during the first weeks or months. You can help yourself get better by:
Rest / Sleeping Your brain needs time to recover. It is important to get adequate amounts of sleep
zz as you may feel more tired than normal.
Driving Do not drive or operate machinery until you feel much better and can concentrate
properly. Talk to your doctor.
Drinking / Drugs Do not drink alcohol or use recreational drugs until you are fully recovered . They
will make you feel much worse. Do not take medication unless advised by your
doctor.
Work / Study You may need to take time off work or study until you can concentrate better. Most
people need a day or two off work but are back full time in less than 2 weeks. How
much time you need off work or study will depend on the type of job you do. See
your doctor and let your employer or teachers know if you are having problems at
work or with study. You may need to return to study or work gradually.
Sport / Lifestyle It is dangerous for the brain to be injured again if is has not recovered from the first
injury. Talk to your doctor about the steps you need to take to gradually increase
sports activity and return to play. If in doubt “sit it out”.
Relationships Sometimes your symptoms will affect your relationship with family and friends. You
may suffer irritability and mood swings. See your doctor if you or your family are
worried.
Recovery
You should start to feel better within a few days and be ‘back to normal’ within about 4 weeks. See your
local doctor if you are not starting to feel better.
Your doctor will monitor these symptoms and may refer you to a specialist if you do not improve over 4
weeks up to 3 months.
Post Concussion Symptoms

There are common symptoms after a mild head injury. They usually go away within a few days or weeks.
Sometimes you may not be aware of them until sometime after your injury like when you return to work.
❖ Mild headaches (that won’t go away) ❖ Feeling more tired than usual and lacking energy
(fatigue)
❖ Having more trouble than usual with attention &
concentration ❖ Irritability. Losing your temper and getting annoyed
easily
❖ Having more trouble than usual with remembering
things (memory difficulties/forgetfulness) ❖ Mood swings
❖ Feeling dizzy or sick without vomiting (nausea) ❖ Anxiety or depression
❖ Balance problems ❖ Mild behavioural change
❖ More difficulty than usual with making decisions ❖ More sensitive to sounds or lights
and solving problems, getting things done or being
❖ Change in sleep patterns. Trouble sleeping or sleeping
organised
too much
❖ Feeling vague, slowed or “foggy” thinking
❖ Reduced tolerance to alcohol
Local service information
References
1. Newcombe R, Merry G. The management of acute 9. Jagoda AS, Bazarian JJ, Bruns JJ, Jr., Cantrill
neurotrauma in rural and remote locations: A set of SV, Gean AD, Howard PK, et al. Clinical policy:
guidelines for the care of head and spinal injuries. J neuroimaging and decisionmaking in adult mild
Clin Neuro 1999;6(1):85-93. traumatic brain injury in the acute setting. Ann
Emerg Med 2008;52(6):714-48.
2. NSW Institute of Trauma and Injury Management.
NSW Trauma Registry Profile of Serious to Critical 10. Vos PE, Battistin L, Birbamer G, Gerstenbrand F,
Injuries: 2007. NSW Health; 2010. Potapov A, Prevec T, et al. EFNS guideline on mild
traumatic brain injury: report of an EFNS task force.
3. Khan F, Baguley IJ, Cameron ID, Khan F, Baguley IJ, Eur J Neurology 2002;9(3):207-19.
Cameron ID. 4: Rehabilitation after traumatic brain
injury. MJA 2003;178(6):290-5. 11. Dickinson K, Bunn F, Wentz R, Edwards P, Roberts
I. Size and quality of randomised controlled trials
4. Fortune N. The definition, incidence and prevalence in head injury: review of published studies. BMJ.
of acquired brain injury in Australia. Australian 2000;320(7245):1308-11.
Institute of Health and Welfare; 2009.
12. Klauber M, Marshall L, Luerssen T, Frankowski R,
5. Tate R, McDonald S, Lulham J. Incidence of hospital- Tabaddor K, Eisenberg H. Determinants of Head
treated traumatic brain injury in an Australian Injury Mortality: Importance of the Low Risk
community. ANZ J Pub Health 1998;22(4):419. Patient. Neurosurgery 1989;24(1):31-6.
6. Servadei F, Teasdale G, Merry G, 13. Mower W, Hoffman J, Herbert M, Wolfson A,

Neurotraumatology Committee of the World Pollack C, Zucker M, et al. Developing a clinical
Federation of Neurosurgical S. Defining acute decision instrument to rule out intracranial injuries
mild head injury in adults: a proposal based on in patients with minor head trauma: methodology
prognostic factors, diagnosis, and management. J of the NEXUS II investigation. Ann Emerg Med
Neurotrauma 2001;18(7):657-64. 2002;40(5):505-14.
7. Bellner J, Ingebrigtsen T, Romner B. Survey of 14. Narayan R, Michel ME, Ansell B, Baethmann A,
the management of patients with minor head Biegon A, Bracken MB, et al. Clinical trials in head
injuries in hospitals in Sweden. Acta Neurol Scand injury. J Neurotrauma 2002;19(5):503-57.
1999;100(6):355-9.
15. Brain Trauma Foundation, American Association of
8. Cushman J, Agarwal N, Fabian T, Garcia V, Nagy K, Neurological Surgeons, Congress of Neurological
Pasquale M, et al. Practice management guidelines Surgeons, Joint Section on Neurotrauma and
for the management of mild traumatic brain injury: Critical Care. Guidelines for the Management
the EAST practice management guidelines work of Severe Traumatic Brain Injury J Neurotrauma
group. J Trauma 2001;51(5):1016-26. 2007;24(S1):1-106.
16. Alderson P, Roberts I. Corticosteroids for acute

traumatic brain injury. Cochrane Database of
Systematic Reviews 2005(1).
17. Arango MF, Bainbridge D. Magnesium for acute 28. Sydenham E, Roberts I, Alderson P. Hypothermia
traumatic brain injury. Cochrane Database of for traumatic head injury. . Cochrane Database of
Systematic Reviews 2008(4). Systematic Reviews. 2009(2).
18. Bennett MH, Trytko B, Jonker B. Hyperbaric oxygen 29. Wakai A, Roberts IG, Schierhout G. Mannitol for
therapy for the adjunctive treatment of traumatic acute traumatic brain injury. Cochrane Database of
brain injury. Cochrane Database of Systematic Systematic Reviews. 2007(1).
Reviews. 2004(4).
30. Willis C, Lybrand S, Bellamy N. Excitatory amino
19. Fleminger S, Greenwood R, Oliver D. acid inhibitors for traumatic brain injury. Cochrane
Pharmacological management for agitation and Database of Systematic Reviews. 2003(1).
aggression in people with acquired brain injury.
Cochrane Database of Systematic Reviews 2006(4). 31. Fabbri A, Servadei F, Marchesini G, Morselli-Labate
A, Dente M, Iervese T, et al. Prospective validation
20. Forsyth R, Wolny S, Rodrigues B. Routine of a proposal for diagnosis and management of
intracranial pressure monitoring in acute coma. patients attending the emergency department for
Cochrane Database of Systematic Reviews. 2010(2). mild head injury. J Neurol Neurosurg Psychiatry
2004;75(3):410-6.
21. Ker K, Blackhall K. Bradykinin beta-2 receptor
antagonists for acute traumatic brain injury. 32. Haydel M, Preston C, Mills T, Luber S, Blaudeau E,
Cochrane Database of Systematic Reviews. 2008(1). DeBlieux P. Indications for computed tomography
in patients with minor head injury. NEJM
22. Langham J, Goldfrad C, Teasdale G, Shaw D, Rowan 2000;343(2):100-5.
K. Calcium channel blockers for acute traumatic
brain injury. Cochrane Database of Systematic 33. Ibanez J, Arikan F, Pedraza S, Sanchez E, Poca MA,
Reviews. 2003(4). Rodriguez D, et al. Reliability of clinical guidelines in
the detection of patients at risk following mild head
23. Roberts I. Aminosteroids for acute traumatic brain injury: results of a prospective study. J Neurosurgery
injury. Cochrane Database of Systematic Reviews. 2004;100(5):825-34.
1999(3).
34. Palchak MJ, Holmes JF, Vance CW, Gelber RE,
24. Roberts I, Schierhout G. Hyperventilation therapy Schauer BA, Harrison MJ, et al. A decision rule
for acute traumatic brain injury. Cochrane Database for identifying children at low risk for brain
of Systematic Reviews. 2009(3). injuries after blunt head trauma. Ann Emerg Med
2003;42(4):492-506.
25. Roberts I, Sydenham E. Barbiturates for acute
traumatic brain injury. Cochrane Database of 35. Stiell IG, Wells GA, Vandemheen K, Clement C,
Systematic Reviews. 1999(3). Lesiuk H, Laupacis A, et al. The Canadian CT Head
Rule for patients with minor head injury. Lancet
26. Sahuquillo J, Arikan F. Decompressive craniectomy 2001;357(9266):1391-6.
for the treatment of refractory high intracranial
pressure in traumatic brain injury. Cochrane 36. Dunham C, Coates S, Cooper C. Compelling
Database of Systematic Reviews. 2006(1). evidence for discretionary brain computed
tomographic imaging in those patients with mild
27. Schierhout G, Roberts I. Anti-epileptic drugs for cognitive impairment after blunt trauma. J Trauma
preventing seizures following acute traumatic brain 1996;41(4):679-86.
injury. Cochrane Database of Systematic Reviews.
2001(4).
37. Stiell IG, Wells GA, Vandemheen K, Laupacis A,
Brison R, Eisenhauer MA, et al. Variation in ED Use
of Computed Tomography for Patients With Minor
Head Injury. Ann Emerg Med 1997;30:14-22.
38. Bulger E, Nathens A, Rivara F, Moore M, MacKenzie

E, Jurkovich G, et al. Management of severe head
injury: institutional variations in care and effect on
outcome. Crit Care Med 2002;30(8):1870-6.
39. Af Geijerstam J, Britton M. Mild head injury:

reliability of early computed tomographic findings in
triage for admission. Emerg Med J 2005;22(2):103-
7.
40. American College of Surgeons Committee on

Trauma. Advanced Trauma Life Support for Doctors.
8th ed2007.
41. Fabbri A, Servadei F, Marchesini G, Stein S,

Vandelli A. Observational approach to subjects
with mild-to-moderate head injury and initial non-
neurosurgical lesions. J Neurol Neurosurg Psychiatry
2008;79(10):1180-5.
42. Myburgh JA, Cooper DJ, Finfer SR, Venkatesh

B, Jones D, Higgins A, et al. Epidemiology
and 12-month outcomes from traumatic brain
injury in australia and new zealand. J Trauma
2008;64(4):854-62.
43. Styrke J, Stalnacke B-M, Sojka P, Bjornstig

U. Traumatic Brain Injuries in a Well-Defined
Population: Epidemiological Aspects and Severity. J
Neurotrauma. 2007;24(9):1425-36.
44. National Health & Medical Research Council.

NHMRC levels of evidence and grades for
recommendations for developers of guidelines.
2009: Available from: www.nhmrc.gov.au/_files_
nhmrc/file/guidelines/evidence_statement_form.pdf.
45. National Health & Medical Research Council. A

guide to the development, implementation and
evaluation of clinical practice guidelines. Canberra
ACT. NHMRC; 1999.
SHPN (SSD) 110187

Closed Head Injury in Adults-Summary-2011

Uploaded by

Copyright:

Available Formats

Closed Head Injury in Adults-Summary-2011

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Closed Head Injury in Adults-Summary-2011

Uploaded by

Copyright:

Available Formats

ADULT TRAUMA CLINICAL PRACTICE GUIDELINES

Initial Management of Closed

This work is copyright. It may be reproduced in whole or in part for study

This Clinical Practice Guideline is extracted from PD2012_013 and as a

© NSW Ministry of Health 2011

SHPN: (SSD) 110187

For further copies contact:

Furhter copies of this document can be downloaded from the

A revision of this document is due in 2015

Acknowledgements ................................................ii 5. What should be done when patients

Introduction ........................................................... 3 6. When can patients with mild head

Algorithm 1: Initial Management of 8. What are the proven treatments for

9. When should patients with closed head

10. What analgesia should patients with

4. Which patients with mild head injury References ........................................................... 30

Similarly, comparison of data in moderate to severe head

The clinical questions addressed:

2 What are the clinically important complications of mild head injury?

3 How should patients with mild head injury be assessed?

4 Which patients with mild head injury require a CT scan?

7 When can patients with mild head injury be safely discharged?

8 What discharge advice should be provided?

12 What analgesia should patients with closed head injury receive?

13 Which patients with closed head injury should receive anti-convulsants?

Table 1. Summary of closed head injury classification and outcome

Mild Head Injury Moderate Head Injury Severe Head Injury

Abnormal CT Scan (%) 1,2 5-15 30 - 50 60 - 90

Neurosurgical Intervention (%) 1,2 1-3 5-30 30-50

Mortality (%) 1 <1 10-15 30-50

Good Functional Outcome (%) 1,2,3 >90 20-90 <20

Background evolutionary rather than revolutionary. The basic principles

Assessment of patients with mild head injury

Acute neurological deterioration

Anticonvulsants for closed head injury

Initial Management of Adult Closed Head Injury

Initial Assessment and Stabilisation of ABCDEs

GCS 3-8 GCS 9-13 GCS 14-15

Risk factors indicating potentially significant mild head injury

Early signs of deterioration Clinical approach Potential indications Clinical approach

Network neurosurgical service

Initial Management of Adult Mild Closed Head Injury

Initial GCS 14-15 on arrival following blunt head trauma

Clinically deteriorates or clinical symptoms not

Normal CT scan Abnormal CT scan CT scan unavailable

Clinical Clinical Clinical Consider transfer for CT scanning particularly if:

Strength of recommendations components are assessed according to the NHMRC body

Table 2: Body of evidence matrix44

Consistency all studies consistent most studies some inconsistency evidence is

Clinical Impact very large substantial moderate slight or restricted

Generalisability population/s studied in population/s studied in population/s studied population/s studied

Applicability directly applicable to applicable to probably applicable to not applicable to

A Body of evidence can be trusted to guide practice

B Body of evidence can be trusted to guide practice in most situations

D Body of evidence is weak and recommendation must be applied with caution

Level of evidence in accordance with the NHMRC publication: A guide to the

Level IV Evidence obtained from a case-series, either post-test or pre-test/post-test

1. What is the definition of a mild head injury?

“Complicated” Mild Head Injury

The clinically important complications of mild head injury are: CONSENSUS

Typical lesions include: