Immediate management in primary care

History from patient, parent or witness - note:

• loss of consciousness
• amnesia
• any neurological symptoms

Examination:

• site of injury, level of consciousness, pupils and co-ordination
• reassures patient or parents of no significant injury
• examination may not be needed to make clinical decision

Give head injury advice.

In significant injury:

• do not move patient until neck is properly stabilised
  • patients who have sustained a head injury and present with any of the following risk factors should have full cervical spine immobilisation attempted unless other factors prevent this:
    • GCS less than 15 on initial assessment by the healthcare professional
    • neck pain or tenderness
    • focal neurological deficit
    • paraesthesia in the extremities
    • any other clinical suspicion of cervical spine injury
  • cervical spine immobilisation should be maintained until full risk assessment including clinical assessment (and imaging if deemed necessary) indicates it is safe to remove the immobilisation device
• maintain airway
• attend to other significant injuries
• pain should be managed effectively because it can lead to a rise in intracranial pressure (1). Reassurance and splintage of limb fractures are helpful; catheterisation of a full bladder will reduce irritability
  • with respect to emergency department assessment
    • significant pain should be treated with small doses of intravenous opioids titrated against clinical response and baseline cardiorespiratory measurements (1)
• make baseline record for A/E staff: history of injury, symptoms, pulse, BP, level of consciousness(description), pupils, limb co-ordination and any observed changes

Notes:

• standby calls to the destination emergency department should be made for all patients with a GCS less than or equal to 8, to ensure appropriately experienced professionals are available for their treatment and to prepare for imaging (1)

Reference:

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