Discussion with neurosurgeon and/or referral to a neuroscience unit

It is important to differentiate between those patients whom may be managed by a general surgery team and those whom need special observation by a neurosurgical team. Guidance should be drawn up locally regarding transfer to a neurosurgical unit (see notes). Some suggested criteria might be:

• skull fracture plus any of:
  • confusion or worse impairment of consciousness
  • one or more seizures
  • neurological signs
• deterioration in level of consciousness
• coma persists after resuscitation } even if no fracture
• confusion or other neurological disturbance of more than 8 hours duration } even if no fracture
• depressed fracture of skull vault
• suspected fracture of skull base

Notes :

• local guidelines on the transfer of patients with head injuries should be drawn up between the referring hospital trusts, the neuroscience unit and the local ambulance service, and should recognise that (1):
  • transfer would benefit all patients with serious head injuries (GCS = 8), irrespective of the need for neurosurgery
  • if transfer of those who do not require neurosurgery is not possible, ongoing liaison with the neuroscience unit over clinical management is essential
• regardless of imaging, discuss a person's care plan with a neurosurgeon if they have (3):
  • persisting coma (a GCS score of 8 or less) after initial resuscitation
  • unexplained confusion that persists for more than 4 hours
  • deterioration in GCS score after admission (pay more attention to motor response deterioration)
  • progressive focal neurological signs
  • a seizure without full recovery
  • a definite or suspected penetrating injury
  • a cerebrospinal fluid leak

Reference:

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