Glasgow Coma Score (GCS)

• Eye opening: spontaneously (+4); verbal command (+3); to pain (+2); no eye opening (+1); not testable

• Verbal: orientated (+5); confused (+4); inappropriate words (+3); incomprehensible sounds (+2); no verbal response (+1); not testable

• Motor: obeys commands (+6); localises pain (+5); withdrawal from pain (+4); flexion to pain (+3); extension (+2); no motor response (+1); not testable

Indications for CT

Head CT is the primary investigation of choice for clinically important brain injury.

Adults

• GCS <13 on initial assessment in ED

• GCS <15 two hours after the injury

• Suspected open or depressed skull fracture

• Signs of basal skull fracture (haemotympanum, 'panda' eye, CSF from ear/nose, Battle's sign)

• Post-traumatic seizure

• Focal neurological deficit

• >1 episode of vomiting

Amnesia or LOC since the injury and:

• Age ≥ 65Y

• Bleeding disorders, coagulopathy (inc warfarin treatment) (all patients with HI who are on anticoagulation therapies such as warfarin or novel oral anticoagulants should have CT head within 8hrs of assessment)

• Dangerous mechanism of injury (e.g. fall from >1m or five stairs, pedestrian/cyclist struck by motor vehicle, ejected from motor vehicle)

• >30mins retrograde amnesia immediate before the head injury

Children

• Suspect NAI

• Post-traumatic seizure (no epilepsy)

• GCS <14 on initial ED assessment (<15 if aged <1Y)

• GCS <15 two hours after HI

• Suspected open or depressed skull fracture or tense fontanelle

• Signs of basal skull fracture (haemotympanum, 'panda' eye, CSF from ear/nose, Battle's sign)

• Focal neurological deficit

• Bruise, swelling, laceration >5cm (if age <1Y)

• >1 of LOC >5min (witnessed), abnormal drowsiness, vomiting ≥3, dangerous mechanism of injury (e.g. fall from >3m, high-speed RTA as pedestrian/cyclist, high-speed injury from a projectile or other object), >5mins amnesia (ante- or retrograde)

• Observation (minimum 4 hours) if only 1 of: of LOC >5min (witnessed), abnormal drowsiness, vomiting ≥3, dangerous mechanism of injury (e.g. fall from >3m, high-speed RTA as pedestrian/cyclist, high-speed injury from a projectile or other object), >5mins amnesia (ante- or retrograde) and CT scan if GCS<15, further vomiting, further episode of abnormal drowsiness during observation

When community services/minor injury units should refer to ED?

• GCS <15

• Any LOC

• Any focal neurological deficit

• Any signs of skull fracture

• Persistent headaches

• Vomiting episodes

• Any seizures

• History of previous neurosurgery

• High-energy head injuries (e.g. significant RTA or fall >1 m or height of 5 stairs)

• History of bleeding/clotting disorders

• Current anticoagulation therapy

• Current drug or alcohol intoxication

• Safeguarding concerns

• Ongoing clinical concerns

Clinical signs suggestive of a skull fracture are:

• Battle's sign – bruising of the mastoid process of the temporal bone

• Raccoon eyes – bruising around the eyes

• CSF rhinorrhoea or otorrhoea

• Cranial nerve palsy

• Haemotympanum

Resources

• Head Injury: assessment and early management (NICE CG 176, 2019)

• Head injury (CKS)

• Glasgow Coma Score (GCS) (coma severity assessment)