Recommendations
Urgent
Take an Airway, Breathing, Circulation (ABC) approach to assessing and stabilising patients with a traumatic brain injury.[42]
If you suspect a cervical spine injury, ensure full cervical spine immobilisation.[42] See Acute cervical spine trauma in adults.
Manage pain effectively because it can lead to a rise in intracranial pressure. Provide reassurance, splint limb fractures and catheterise a full bladder when needed.[42]
Admit any patient with a traumatic brain injury (TBI) if any of the following is present:[42]
New, clinically significant abnormalities on imaging
Glasgow Coma Scale (GCS) score has not returned to 15 or a GCS score that has not returned to the pre-injury baseline after imaging, regardless of the imaging results [ Glasgow Coma Scale Opens in new window ]
There are indications for computed tomographic (CT) scanning but this cannot be done within the appropriate period (i.e., CT not available or patient not sufficiently co-operative to allow scanning)
Continuing worrying signs (e.g., persistent vomiting, severe headaches)
Other sources of concern (e.g., drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak).
Tranexamic acid should be used as soon as possible in patients with major trauma and active or suspected active bleeding.[71] In the absence of major trauma and active or suspected active bleeding, consider tranexamic acid as soon as possible within 2 hours of the injury, in the pre-hospital or hospital setting and before imaging, in patients with a head injury and a GCS score of 12 or less who are not thought to have active extracranial bleeding.[42]
Discuss with a neurosurgeon any patient with any of the following (which by definition suggest the patient has a moderate or severe traumatic brain injury):[42]
New, surgically significant (as defined locally) abnormalities on imaging
Any of the following regardless of imaging results:
Persisting coma (GCS score ≤8) after initial resuscitation
Unexplained confusion that persists for >4 hours
Deterioration in GCS score after admission (pay greater attention to motor response deterioration)
Progressive focal neurological signs
A seizure without full recovery
Definite or suspected penetrating injury
A cerebrospinal fluid leak
Ongoing worrying signs (e.g., persistent vomiting, severe headaches) even with a normal CT.
Consider transfer to the neurosciences unit for observation. See Assessment of traumatic brain injury, acute.
Reassess the patient and consider an immediate CT scan if there are any signs of neurological deterioration such as:[42]
Development of agitation or abnormal behaviour
A sustained (for at least 30 minutes) drop of 1 point in GCS score (give greater weight to a drop of 1 point in the motor response score of the GCS)
Any drop of ≥3 points in the eye-opening or verbal response scores of the GCS, or ≥2 points in the motor response score
Development of severe or increasing headache or persistent vomiting
New or evolving neurological symptoms or signs, such as pupil inequality or asymmetry of limb or facial movement.
A supervising doctor should conduct the appraisal.[42]
Key Recommendations
Consider the need for appropriate analgesia in all patients. Consider giving an antiemetic (particularly in children).[42]
If after 24 hours of observation the patient has not achieved a GCS score of 15 and has had a normal CT scan, consider further CT scan or magnetic resonance imaging (MRI) scanning and discuss with the radiology department.[42]
In children without indications for an urgent CT scan, request a CT scan if during a period of observation of 4 hours from the time of injury any of these risk factors is identified: GCS <15, further vomiting, or a further episode of abnormal drowsiness.[42] If none of these risk factors occur during observation, use clinical judgement to determine whether a longer period of observation is needed.[42]
Consider discharging patients from the accident and emergency department or observation ward and transferring to the community for subsequent care if:[42]
CT scan is not indicated and the patient is considered at low risk of clinically important brain injury (based on history and examination)
CT scan is normal, the patient is considered at low risk of clinically important brain injury, the GCS has returned to 15, clinical examination is normal, and no other factors that would warrant a hospital admission are present (e.g., drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak).
Discuss with a senior colleague and consider for CT scan any patient returning to the accident and emergency department within 48 hours of discharge with any persistent complaint.[42]
Take an Airway, Breathing, Circulation (ABC) approach to assessing and stabilising patients with a traumatic brain injury.[42]
If you suspect cervical spine injury, ensure full cervical spine immobilisation.[42] See Acute cervical spine trauma in adults.
Manage pain effectively because it can lead to a rise in intracranial pressure. Provide reassurance, splint limb fractures and catheterise a full bladder when needed.[42]
Most patients with a mild traumatic brain injury (TBI) do not require hospital admission. Admit patients with mild TBI, however, if any of the following is present:[42]
New, clinically significant abnormalities on imaging
Glasgow Coma Scale (GCS) has not returned to 15 after imaging or a GCS score that has not returned to the pre-injury baseline after imaging, regardless of the imaging results
There are indications for computed tomographic (CT) scanning but this cannot be done within the appropriate period (i.e., CT not available or patient not sufficiently co-operative to allow scanning). Admit the patient for observation
Continuing worrying signs (e.g., persistent vomiting, severe headaches)
Other sources of concern (e.g., drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak).
Consider or suspect abuse, neglect, or other safeguarding issues as a contributory factor to, or cause of, a head injury.[42]
Practical tip
Discuss with a neurosurgeon any patient with any of the following (which by definition suggest the patient has a moderate or severe traumatic brain injury):[42]
New, surgically significant (as defined locally) abnormalities on imaging
Any of the following regardless of imaging results:
Persisting coma (GCS score ≤8) after initial resuscitation
Unexplained confusion that persists for >4 hours
Deterioration in GCS score after admission (pay greater attention to motor response deterioration)
Progressive focal neurological signs
A seizure without full recovery
Definite or suspected penetrating injury
A cerebrospinal fluid leak
Ongoing worrying signs (e.g., persistent vomiting, severe headaches) even with a normal CT.
Consider transfer to the neurosciences unit for observation. See Assessment of traumatic brain injury, acute.
Tranexamic acid
Tranexamic acid should be used as soon as possible in patients with major trauma and active or suspected active bleeding.[71] In the absence of major trauma and active or suspected active bleeding, consider tranexamic acid as soon as possible within 2 hours of the injury, in the pre-hospital or hospital setting and before imaging, in patients with a head injury and a GCS score ≤12 who are not thought to have active extracranial bleeding.[71]
Bear in mind that this is standard practice in some countries, including the UK, but not a routine approach worldwide.
Evidence: Tranexamic acid
In the UK, the National Institute for Health and Care Excellence (NICE) does not make a recommendation for the use of tranexamic acid in people with mild traumatic brain injury, stating that more research is required to assess whether the benefits outweigh the risk of blood clots in this population. NICE does make a recommendation to consider tranexamic acid in patients with a head injury and a GCS score of 12 or less who are not thought to have active extracranial bleeding.
At part of the 2023 update of the NICE head injury guideline, two randomised controlled trials (RCTs) were identified assessing the use of tranexamic acid in adults with traumatic brain injury and no suspicion of extracranial bleeding.[42][72][73] NICE did not find any evidence for children or infants.
Adults
After reviewing the evidence from these two RCTs, the NICE committee made a weak recommendation to consider giving tranexamic acid as soon as possible within 2 hours of injury to adults with traumatic brain injury and no suspicion of extracranial bleeding, but only if the GCS score is ≤12.[42]
The first RCT was the CRASH-3 trial, a large, pragmatic RCT of tranexamic acid versus placebo in adults (aged 16 years and over) with traumatic brain injury and a GCS score of ≤12, or any intracranial bleed on CT scan, and no extracranial bleeding, treated in a hospital setting (n=12,737, mean age 42 years, 175 centres in 29 countries).[72][74]
A regimen of an initial tranexamic acid intravenous infusion given over 10 minutes followed by a second over 8 hours, was compared with a saline placebo.
According to the trial protocol, patients had to be treated within 8 hours of injury; however, this was changed to less than 3 hours from injury part way through the trial.
Overall 9202 (72%) of participants were enrolled within 3 hours.
28% of participants had a mild traumatic brain injury (33% moderate and 38% severe).
There was no significant difference in the primary outcome of head injury-related death at 28 days (18.5% tranexamic acid vs. 19.8% placebo; relative risk [RR] 0.94, 95.0% CI 0.86 to 1.02, moderate quality evidence as assessed by GRADE).
There was also no significant difference when patients with severe injury (GCS score 3 or bilateral unreactive pupils) were excluded from the analysis, or in all-cause mortality for the whole population.
There were, however, fewer head injury-related deaths within the first 24 hours (RR 0.81, 95% CI 0.69 to 0.95).
There were also fewer head injury-related deaths at 28 days in the subgroup of patients with less severe injuries (GCS score 9-15: 5.8% tranexamic acid versus 7.5% placebo; RR 0.78, 95% CI 0.62 to 0.95; patients with bilateral reactive pupils: 11.5% tranexamic acid versus 13.2% placebo; RR 0.87, 95.0% CI 0.77 to 0.98).
There was no evidence of increased complications or adverse events including vascular occlusive events, seizures, sepsis, or renal failure with tranexamic acid.
CRASH-3 did not report outcomes separately for patients with mild and moderate traumatic brain injury. Correspondence from the study authors, requested by the NICE committee, suggested significant uncertainty about the effectiveness of tranexamic acid in people with mild traumatic brain injury, although no additional data was shared.[42]
The second RCT (n=1280, 20 centres and 39 emergency medical services agencies in the US and Canada) compared a single bolus of tranexamic acid with placebo within 2 hours of traumatic brain injury given in a prehospital setting.[73]
4% of participants had a mild traumatic brain injury (39% moderate and 57% severe). Subgroup results for outcomes by severity of injury were not reported.
The evidence suggested a reduced all-cause mortality with tranexamic acid compared to placebo at 28 days (absolute effect 49 fewer per 1000, 95% CI 89 fewer to 9 more) and at 6 months (absolute effect 40 fewer per 1000, 95% CI 87 fewer to 30 more).
There was no clinically important difference in hospital free days at 28 days, neurosurgical intervention at 28 days, degree of disability at discharge and 6 months (measured by Glasgow Outcome Scale-Extended >4) or serious adverse events (myocardial infarction, pulmonary embolism, deep vein thrombosis or thrombotic stroke).
The NICE 2023 guideline did not make a separate recommendation for older adults as they were awaiting results from the CRASH-4 trial looking specifically at this population.[42][75]
Children and infants
Due to the lack of evidence in children and infants, the NICE guideline committee extrapolated from the evidence in adults to people aged <16 years in the same recommendation, just with separate advice regarding dosage.[42]
Analgesia and antiemetics
Consider the need for analgesia in all patients with mild TBI.[42] Consider giving an antiemetic (particularly in children).
Observation of admitted patients
Reassess the patient and consider an immediate CT scan if there are any signs of neurological deterioration such as:[42]
Development of agitation or abnormal behaviour
A sustained (for at least 30 minutes) drop of 1 point in GCS score (give greater weight to a drop of 1 point in the motor response score of the GCS)
Any drop of ≥3 points in the eye-opening or verbal response scores of the GCS, or ≥2 points in the motor response score
Development of severe or increasing headache or persistent vomiting
New or evolving neurological symptoms or signs, such as pupil inequality or asymmetry of limb or facial movement.
Practical tip
Observations should be made every 30 minutes until the GCS score has returned to 15, including the following as minimum:[42]
GCS plus pupil size and reactivity
Limb movements
Respiratory rate
Heart rate
Blood pressure
Temperature
Blood oxygen saturation.
For patients with a GCS score of 15 the frequency of observations (starting after the initial assessment) should be:[42]
Half-hourly for 2 hours, then
1-hourly for 4 hours, then
2-hourly thereafter.
Revert to every 30 minutes if the patient deteriorates at any time after the initial 2-hour period.[42]
Observation of admitted infants and children aged <5 years should only be performed by experienced staff.[42]
If after 24 hours of observation the patient has not achieved a GCS score of 15 and has had a normal CT scan, consider further CT scan or magnetic resonance imaging scanning and discuss with the radiology department.[42]
Analgesia and antiemetics
Consider the need for analgesia in all patients with mild traumatic brain injury (TBI). Consider giving an antiemetic (particularly in children).
Discharge from A&E or observation ward (home observation)
People admitted after a head injury may be discharged after resolution of all significant symptoms and signs, provided they have suitable supervision arrangements at home, in custody or in continued care.[42]
Consider discharging the patient from the accident and emergency (A&E) department or observation ward and transfer to the community for subsequent care if:[42]
Computed tomographic (CT) scan is not indicated (based on history and examination) and the patient is considered at low risk of clinically important brain injury
CT scan is normal and the patient is considered at low risk of clinically important brain injury and the Glasgow Coma Scale (GCS) score has returned to 15, clinical examination is normal, and no other factors that would warrant a hospital admission are present (e.g., drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak)
See below for indications for Observation of children and infants prior to discharge.
Discharge patients only if there is somebody suitable at home to supervise them.[42]
If there is no carer at home, only discharge the patient if suitable supervision arrangements have been organised, or when the risk of late complications is deemed negligible.
Ensure that people with pre-injury cognitive impairment (for example, dementia or a learning disability) and people returning to a custodial setting are supervised and monitored. Also, make sure that arrangements are in place should there be any signs of deterioration.[42]
Write to the general practitioner of all patients attending A&E within 48 hours of discharge and provide details of the clinical history and examination.[42]
Give the patient and/or family/carers verbal and written advice, including signs and symptoms that should prompt a return to A&E (e.g., focal weakness, persistent or worsening headache or vomiting, decrease in consciousness, rhinorrhoea, otorrhoea, or agitation) and self-care advice.[42]
Explain that some potentially frightening symptoms, such as depersonalisation, are not a cause for alarm.
Advise that mild TBI symptoms, including somatic (e.g., headaches, dizziness), cognitive (eg, poor attention and memory), and emotional (eg, irritability, depression) symptoms, usually resolve within 3 months.[76] However, a subset of patients may have ongoing symptoms. See Patient Discussions and Prognosis.
Practical tip
Do not discharge infants and children aged <5 years until they have achieved a GCS score of 15 or have normal consciousness as assessed using the paediatric version of the GCS.[42] BPNA: Child’s Glasgow Coma Scale Opens in new window
Observation of children and infants
Children who do not meet the criteria for an urgent CT scan (see the Diagnosis section) should be observed in A&E or an observation ward for a minimum of 4 hours prior to consideration for discharge if they have only 1 of the following risk factors:[42]
Loss of consciousness lasting >5 minutes (witnessed)
Abnormal drowsiness
≥3 discrete episodes of vomiting
Dangerous mechanism of injury (a high-speed road traffic accident either as a pedestrian, cyclist, or vehicle occupant; a fall from a height >3 metres; a high-speed injury from a projectile or other object)
Amnesia (antegrade or retrograde) lasting >5 minutes.
Note that having >1 of the above risk factors is a criterion for requesting an urgent CT scan (see the Diagnosis section).[42]
If any of the following risk factors occurs during observation, request an urgent (i.e, within 1 hour) CT head scan:[42]
GCS score <15
Further vomiting
A further episode of abnormal drowsiness.
If none of these risk factors occurs during observation, use your clinical judgement to determine whether a longer period of observation is needed.[42]
Discuss with a senior colleague and consider for computed tomographic scan any patient who returns to the accident and emergency department with any persistent complaint relating to the initial head injury.[42]
Referral to hospital
Refer any adult or child with a head injury to the accident and emergency department if you identify any of the following risk factors (which may indicate an intracranial complication or cervical spine injury):[42]
A Glasgow Coma Scale (GCS) score <15 on initial assessment
Any loss of consciousness as a result of the injury
Any focal neurological deficit since the injury
Any suspicion of a skull fracture or penetrating head injury since the injury
Amnesia for events before or after the injury
Persistent headache since the injury
Any vomiting episodes since the injury (use clinical judgement regarding the cause of vomiting in those aged 12 years or younger and the need for referral)
Any seizure since the injury
Any previous brain surgery
A high-energy head injury
Any history of bleeding or clotting disorders
Current anticoagulant therapy or antiplatelet treatment (excluding aspirin monotherapy)
Current drug or alcohol intoxication
Any safeguarding concerns (e.g., possible non-accidental injury or a vulnerable person is affected)
Continuing concern about the diagnosis.
In the absence of any risk factors above, consider referral to an emergency department if any of these factors are present, depending on judgement of severity:[42]
Irritability or altered behaviour, particularly in babies and children aged under 5 years
Visible trauma to the head not covered in the recommendations above but still of concern to the professional
No one is able to observe the injured person at home
Continuing concern by the injured person, or their family or carer, about the diagnosis.
If you suspect a cervical spine injury, ensure full cervical spine immobilisation before transfer of the patient to hospital.[42] See Acute cervical spine trauma in adults.
Management of mild traumatic injury
For adults and children who are at low risk of an intracranial complication or cervical spine injury:
Advise that a responsible adult stays with the patient for the first 24 hours after the injury
Give simple analgesics (e.g., paracetamol, ibuprofen) to treat headache and consider giving an antiemetic (particularly in children)
Give the patient and/or family/carers verbal and written information including signs and symptoms that should prompt a further clinical review (e.g., focal weakness, persistent or worsening headache or vomiting, decrease in consciousness, rhinorrhoea, otorrhoea, or agitation) and self-care advice.
Use of this content is subject to our disclaimer