Learning zone

CO N T I N U I N G P R O F E S S I O N A L D E V E L O P M E N T

4 Page 58

Head injury multiple

choice questionnaire

4 Page 59

Lucy Wards
practice profile
on skill analysis

4 Page 60

Guidelines on
how to write a
practice profile

Emergency care of children

and adults with head injury
NS649 Bethel J (2012) Emergency care of children and adults with head injury.
Nursing Standard. 26, 43, 49-56. Date of acceptance: February 17 2012.

Abstract
Head injury is common and accounts for a significant proportion of
patient attendances at emergency departments and minor injury units.
While most injuries will not be serious in nature, some will be severe.
Therefore assessment, investigation and early management of head
injury are essential to reduce the potential risk of disability or even death.
This article focuses on emergency care of children and adults with head
injuries. Advice about the signs and symptoms of severe head injury, the
importance of computed tomography and after care following head injury
are outlined.

Author
James Bethel
Senior lecturer and nurse practitioner, University of Wolverhampton,
West Midlands
Correspondence to: james.bethel@wlv.ac.uk

Keywords
Emergency care, head injury, minor injury unit, trauma

Aims and intended learning outcomes

This article aims to provide healthcare
professionals working in emergency care
settings with the skills and knowledge to
assess and manage patients presenting with
head trauma. After reading this article and
completing the time out activities you should
be able to:
Identify

relevant anatomical structures of
the head.
Examine

mechanisms of injury in head
trauma and identify red flag indicators
associated with serious or potentially
serious injury.
Recognise

and critically analyse principles
of assessment in head injury.
Outline

evidence-based management options
in adults and children with head injury.
Advise

patients regarding aftercare following
head injury.

Review

Introduction

All articles are subject to external double-blind peer review and checked
for plagiarism using automated software.

Head injury accounts for approximately

one million patient attendances at
emergency departments in the UK each
year; 5% of these injuries are classified as
severe, 10% as moderate and 85% as minor
(Headway 2009). It is critical to make the
distinction between minor, moderate and
severe head injury because there is a degree
of morbidity associated with moderate and
severe trauma to the head (Headway 2009).
Even patients with an apparently minor
head injury have the potential to become
unwell. Therefore thorough assessment and
safe discharge of patients with head injury
are essential.

Online
Guidelines on writing for publication are available at
www.nursing-standard.co.uk. For related articles visit the archive
and search using the keywords above.

NURSING STANDARD / RCN PUBLISHING

p49-56w43 49

june 27 :: vol 26 no 43 :: 2012 49

22/06/2012 11:54

Learning zone emergency care

Identifying injuries that may be moderate
or severe necessitates focused consultation
that takes account of dangerous mechanisms
of injury, in addition to red flag findings
during history taking and physical
examination. More than 20 million people
attended an emergency department in the
UK in 2009/10 (NHS Choices 2011), and
three million people attend minor injury
units in the UK each year (College of
Emergency Medicine 2008). Caring for
patients with head injury will become an
increasingly common aspect of the emergency
practitioners role. This article will examine
the mechanism of injury and how this
may inform the consultation, as well as
highlighting other important indicators of

FIGURE 1
Cranial bones
Frontal bone
Parietal bone

Sphenoid bone

Ethmoid bone
Nasal
bone
Lacrimal
bone
Occipital bone
paul banville

Maxilla
Temporal bone
Mandible

Zygomatic bone

FIGURE 2
Layers of the meninges
Skull bone

Dura mater

serious injury. Critical differences between

the care of head injury in children and adults
will also be discussed.
Complete time out activity 1

Anatomy
The cranium is the bony skull that surrounds
and protects the brain. It is composed of
eight bones: the ethmoid, frontal, occipital,
sphenoid, and two pairs of parietal and
temporal bones (Figure 1). The occipital,
temporal, parietal and frontal bones form
what may be thought of as the head rather
than the face. The nasal bone, maxillary and
zygomatic bones, and the mandible are the
major bony structures in the facial part of the
skull. The ethmoid and lacrimal bones are
smaller structures forming parts of the bony
orbits, and the sphenoid bone is a small bone
on each lateral aspect of the skull. The
occipital and frontal bones of the skull are
relatively strong and durable in comparison to
the parietal and temporal bones and are
therefore less likely to fracture.
An infants skull differs to that of an adult
in that it is much larger in relation to the face.
Beneath the skull there are three layers of
meninges the dura mater, arachnoid mater
and pia mater (Figure 2). Arterial blood is
provided by the meningeal arteries and their
sub-divisions. The major arterial vessels
traverse the areas underlying the parietal and
temporal bones (Crimando 2012).

History taking
As recommended by the National Institute for
Health and Clinical Excellence (NICE) (2007),
all patients with head injury should be assessed
by a healthcare professional within 15 minutes
of presentation. This assessment should
establish whether the individual is high or low
risk for significant brain injury and/or cervical
spine injury.

Arachnoid mater

Mechanism of injury

Subarachnoid space
Pia mater

paul banville

Brain

50 june 27 :: vol 26 no 43 :: 2012

p49-56w43 50

It is critical to attempt to establish how the

patient has injured his or her head, although
in certain circumstances, such as unwitnessed
injuries in young children, this may prove
difficult. Certain mechanisms of injury
should serve as red flags and raise suspicion
of the potential for serious injury, irrespective
of how well the patient may appear at the
time of assessment. Red flag mechanisms

NURSING STANDARD / RCN PUBLISHING

22/06/2012 11:54

Learning zone emergency care

Identifying injuries that may be moderate
or severe necessitates focused consultation
that takes account of dangerous mechanisms
of injury, in addition to red flag findings
during history taking and physical
examination. More than 20 million people
attended an emergency department in the
UK in 2009/10 (NHS Choices 2011), and
three million people attend minor injury
units in the UK each year (College of
Emergency Medicine 2008). Caring for
patients with head injury will become an
increasingly common aspect of the emergency
practitioners role. This article will examine
the mechanism of injury and how this
may inform the consultation, as well as
highlighting other important indicators of

FIGURE 1
Cranial bones
Frontal bone
Parietal bone

Sphenoid bone

Ethmoid bone
Nasal
bone
Lacrimal
bone
Occipital bone
paul banville

Maxilla
Temporal bone
Mandible

Zygomatic bone

FIGURE 2
Layers of the meninges
Skull bone

Dura mater

serious injury. Critical differences between

the care of head injury in children and adults
will also be discussed.
Complete time out activity 1

Anatomy
The cranium is the bony skull that surrounds
and protects the brain. It is composed of
eight bones: the ethmoid, frontal, occipital,
sphenoid, and two pairs of parietal and
temporal bones (Figure 1). The occipital,
temporal, parietal and frontal bones form
what may be thought of as the head rather
than the face. The nasal bone, maxillary and
zygomatic bones, and the mandible are the
major bony structures in the facial part of the
skull. The ethmoid and lacrimal bones are
smaller structures forming parts of the bony
orbits, and the sphenoid bone is a small bone
on each lateral aspect of the skull. The
occipital and frontal bones of the skull are
relatively strong and durable in comparison to
the parietal and temporal bones and are
therefore less likely to fracture.
An infants skull differs to that of an adult
in that it is much larger in relation to the face.
Beneath the skull there are three layers of
meninges the dura mater, arachnoid mater
and pia mater (Figure 2). Arterial blood is
provided by the meningeal arteries and their
sub-divisions. The major arterial vessels
traverse the areas underlying the parietal and
temporal bones (Crimando 2012).

History taking
As recommended by the National Institute for
Health and Clinical Excellence (NICE) (2007),
all patients with head injury should be assessed
by a healthcare professional within 15 minutes
of presentation. This assessment should
establish whether the individual is high or low
risk for significant brain injury and/or cervical
spine injury.

Arachnoid mater

Mechanism of injury

Subarachnoid space
Pia mater

paul banville

Brain

50 june 27 :: vol 26 no 43 :: 2012

p49-56w43 50

It is critical to attempt to establish how the

patient has injured his or her head, although
in certain circumstances, such as unwitnessed
injuries in young children, this may prove
difficult. Certain mechanisms of injury
should serve as red flags and raise suspicion
of the potential for serious injury, irrespective
of how well the patient may appear at the
time of assessment. Red flag mechanisms

NURSING STANDARD / RCN PUBLISHING

22/06/2012 11:54

of injury include falls from height, axial

loading injuries in which the individual
lands on his or her feet or head pedestrians
hit by vehicles and high speed injuries such
as those incurred during deceleration injuries
in a motor vehicle collision (NICE 2007).
Where practitioners establish that there has
been a red flag mechanism of injury, but the
patient appears well at the time of assessment,
advice should be sought from a senior
clinician before a decision about management
is made. Such patients may benefit from a
computed tomography (CT) scan of the brain
and/or a period of observation in hospital
(NICE 2007). This may be of particular
significance in cases of extradural bleeding,
which occurs between the outermost
meningeal layer (the dura mater) and the bony
layer of the skull. In a minority of situations,
there is a well-documented history of the
patient enduring a lucid period, appearing
well before rapid deterioration that is
usually secondary to arterial bleeding in the
extradural space (Rangel-Castilla et al 2011).

Signs and symptoms

In addition to attempting to establish how

the head was injured, history taking should
also seek to identify any clinical signs and
symptoms associated with the injury and
their significance in relation to intracerebral
bleeding. Practitioners should enquire about
any period of loss of consciousness; however,
there is no consensus on whether transient or
short-lived periods of loss of consciousness
are a significant indicator of intracerebral
bleeding. In children, a witnessed period
of loss of consciousness for five minutes or
longer is an indication for CT scanning of the
brain (NICE 2007).
The significance of amnesia is also outlined
in the literature and in the NICE (2003, 2007)
guidelines. Retrograde amnesia (failure to
recall information about the time preceding
the injury) may be secondary to syncope or
cerebral ischaemia or, in the child, secondary
to a convulsion associated with fever.
Anterograde amnesia (failure to recollect
information about the time following the
injury) may be associated with intracerebral
bleeding. In the infant and young child,
particularly where injuries were not witnessed,
eliciting information about amnesia may be
challenging because the child may be too
young to speak or may not readily comprehend
the concept of amnesia (NICE 2007).
Complete time out activity 2

NURSING STANDARD / RCN PUBLISHING

p49-56w43 51

A history of vomiting following head injury

is of particular clinical significance in the
adult, and more than one episode should
warrant consideration for CT scanning of
the brain. In children, vomiting after head
injury may be of less clinical significance
because it may be related to previous
vomiting behaviour during illness or injury
(for example, vomiting may be a normal
feature of a childs behaviour following
any sort of trauma or illness and therefore
he or she is more likely to vomit following
head injury) (NICE 2007). Children who
vomit should be observed closely and the
practitioner should exclude other signs
and symptoms such as those detailed in
the guidelines. These include abnormal
drowsiness, irritability or altered behaviour
that may indicate intracerebral bleeding.
Given the parental anxiety that
head injury in children may cause (Wade
et al 2006, Falk et al 2008), it is often
expedient to observe children who vomit
following head injury. There is no set period
of time for such observation, although the
Scottish Intercollegiate Guidelines Network
(SIGN) (2009) makes the distinction,
depending on the type and severity of
presenting symptoms, between children
who require a CT scan within eight hours
and those who require this intervention
more urgently. Generally, children may
be observed for a period of not more than
four hours in emergency care settings and
they should be admitted to the paediatric
assessment unit or paediatric ward if further
observation is needed. Prolonged or delayed
onset of vomiting is of particular concern and
should prompt further assessment to exclude
intracerebral bleeding (NICE 2007).
Abnormal drowsiness and irritability may
be of clinical significance in any age group, but
particularly in infants who are too young to
speak (NICE 2007). Parents reports of concern
about their infants seeming unusually subdued
or tired, or just not appearing to be their usual
selves, should be noted. Parents know their
child better than the practitioner and will have
a detailed and intimate knowledge of their
childs normal behaviour and demeanour,
therefore any information parents can provide
is helpful. Given that head injury may cause
disproportionate parental anxiety (Wade
et al 2006, Falk et al 2008), it is important to
ensure that parents feel they are being listened
to during the consultation. Failure to recognise
parental concerns may lead to undue anxiety

1 Using an anatomy
and physiology textbook
of your choice, revise the
structure of the head
and identify the main
bones that form the skull.
Note the comparative
fragility and thickness of
the frontal and occipital
bones compared to the
parietal and temporal
bones.
2 A child is admitted
to the emergency
department following
a head injury and has
vomited several times.
List the actions you
would take, giving the
rationale for each.

june 27 :: vol 26 no 43 :: 2012 51

22/06/2012 11:54

Learning zone emergency care

on discharge of the child and subsequent
re-attendance at the emergency department,
or in the worst case scenario may mean that a
potentially serious injury is missed.

Other factors

3 List some of the

signs and symptoms that
might indicate a patient
has intracerebral
bleeding following a
head injury.

Other important factors to exclude or

identify during history taking include enquiry
about the patients medical and drug history.
Previous neurosurgery has been found, in some
circumstances, to increase the risk of bleeding
following head trauma (NICE 2007). Patients
taking anticoagulants such as warfarin, or
who have a primary clotting disorder, are
also at increased risk of intracerebral bleeding
(SIGN 2000, Itshayek et al 2006, Yadav
et al 2006, NICE 2007, Childrens Hospital
of Wisconsin 2009). Given this evidence,
these patients may also benefit from a period
of observation even after apparently minor
head injury. Some anticoagulated patients
with normal CT scans of the brain have bled
in a short space of time following injury
(Cohen et al 2006). It has been suggested that
all anticoagulated patients with head injury
should have their international normalised
ratio (INR) checked, and if it this is abnormal,
reversal of anticoagulation should be
considered (Cohen et al 2006). There should be
a low threshold for CT scanning in any patient
with a primary or induced clotting disorder
and the decision whether to scan is made by
the clinician (SIGN 2000, NICE 2007).
Age is another pertinent factor in history
taking. Certain characteristics associated
with physiological ageing, particular
medication and medication interactions,
and co-existing illness may make older
people more prone to intracerebral bleeding
following head trauma (Lizerbram and Moffit
2001, Ohio Emergency Medical Services
2007). Any patient over the age of 65 with a
history of loss of consciousness or retrograde
or anterograde amnesia should be considered
for a CT scan of the brain (NICE 2007).
There is little consensus about the predictive
value of headache for risk of intracerebral
bleeding (NICE 2007), and this information
may be difficult to elicit in children where a
local injury or wound may be reported as a
generalised headache.
Complete time out activity 3

FIGURE 3
Battles sign: bruising in the mastoid area

Physical examination
Physical examination should include
inspection for signs and symptoms associated

52 june 27 :: vol 26 no 43 :: 2012

p49-56w43 52

with skull fracture. NICE (2007) guidelines

emphasise the need for early CT scanning
where intracerebral bleeding is suspected
following head trauma skull X-rays should
have a limited role in investigation, for
example when an abusive injury is suspected
in children or vulnerable adults. It is known
that intracerebral bleeding is up to 12 times
more likely when the skull is fractured
(NICE 2007). Skull fractures fall into four
categories (Khan et al 2011):
Depressed.

Linear.

Basal.

Diastatic.

Depressed fractures occur when a portion of
the bony skull becomes detached from the
rest of the structure and is driven into the soft
tissue of the brain. This type of fracture is
not common, but should be suspected if the
mechanism of injury suggests potential for
this sort of lesion, for example in a penetrating
injury or where significant force occurs over
a small area of bone. The potential for
penetrating trauma should serve as a red flag
indicator and urgent consideration should be
given to CT scanning.
Linear fractures undisplaced, non-depressed
injuries that follow a straight line across a
portion of the skull are the most common
form of skull fracture. They occur generally as
a consequence of comparatively minor blunt
trauma over a wide area of bone. They are of
little significance unless they are associated with
bleeding (Khan et al 2011).
Basal skull fractures, sited in the
posterior aspect of the skull close to the
neck, are also rare, accounting for around
4% of skull fractures. However, they have a
higher association with intracerebral bleeding
secondary to dural tears, which are lesions in

NURSING STANDARD / RCN PUBLISHING

22/06/2012 11:54

the outermost of the three meningeal layers

that may lead to subsequent bleeding (Khan
et al 2011).
Red flag signs and symptoms that should
raise suspicion of basal skull fracture and
prompt CT scanning of the brain include
(NICE 2007):
Leakage

of cerebrospinal fluid (CSF) from
the ears (otorrhoea) or nose (rhinorrhoea).
Raccoon

eyes or panda eyes bilateral
peri-orbital bruising.
Battles

sign bruising in the mastoid area
behind the auricle of the ear, which is usually
unilateral (Figure 3).
Haemotympanum

presence of blood
behind the eardrum.
CSF leakage may be seen as clear or
straw-coloured fluid draining from the nostrils
or ears. Haemotympanum, as mentioned
above, is characterised by the presence of
blood behind the eardrum when examined
with an otoscope. Patients who sustain a
basal skull fracture are at increased risk of
developing meningeal infections and require
intravenous antibiotics.
Diastatic fractures are injuries involving
suture lines, where the bony plates of the
skull join together in young children. Their
clinical relevance is dependent on the extent to
which underlying bleeding is present.
Physical examination should also include
inspection of the head for undulating, soft
swellings of the scalp that may be associated
with underlying fractures of the skull, and
for lacerations and bruising to the scalp.
Large lacerations to the scalp may occur as a
result of significant force and any such injury
greater than 5cm in size on the scalp of an
infant should prompt a request for a CT scan
(NICE 2007).
Complete time out activity 4

Glasgow Coma Scale

The Glasgow Coma Scale (GCS) was
developed as a means of standardising the
assessment of level of consciousness in patients
with traumatic or atraumatic head injury
(Teasdale and Jennett 1974) (Figure 4). In
addition to providing standardisation, the
GCS is also useful as a predictor of severity of
injury and subsequent intracerebral bleeding
(Yadav et al 2006). Patients with a GCS score
of 15 since injury are at less risk of intracerebral
bleeding than patients whose GCS score has
dropped by one or two points to 14 or 13
(Yadav et al 2006, NICE 2007).

NURSING STANDARD / RCN PUBLISHING

p49-56w43 53

figure 4
Glasgow Coma Scale
Feature

Response

Score

Eye opening

Spontaneously

To speech

To pain

No response

Total

E:
Verbal response

Orientated

Confused

Inappropriate words

Incomprehensible words

No response

Obeys commands

Localises pain

Withdraws from pain

Flexion to pain

Extension to pain

No response

V:
Motor response

M:
TOTAL: E+V+M

GCS

/15

(Teasdale and Jennett 1974)

A simpler and less time-consuming

framework for the assessment of conscious
level is the AVPU tool (Gaichas et al 2006).
Using this system the patient is either alert
(A), responsive only to voice (V), responsive
only to pain (P) or unresponsive (U). There is
some debate about the usefulness and clinical
validity of the AVPU system. It may be more
open to inter-rater unreliability than the GCS
and is less able to identify subtle changes in
consciousness level (Bjorn 2006, Gill et al
2007). Some authors suggest that the AVPU
tool is quick to use and easy to memorise and
may therefore be a more effective triage tool
than the GCS, which involves referring to a
chart to calculate the score (Kelly et al 2004,
Bailey 2006).
The practitioner should be aware of the
potential advantages and disadvantages of
whichever framework they use. Use of the GCS
in young children may be problematic because
the verbal component will not be applicable to
infants who cannot yet speak. Modified GCS
scoring charts are available for use in infants
who are too young to speak (Figure 5).

4 Make a list of
the advantages and
disadvantages of using
the Glasgow Coma Scale
and the AVPU tool to
assess consciousness.
Which tool do you use
in your place of work?
Consider whether it is
the most appropriate
system. Discuss your
thoughts with a more
senior colleague.

june 27 :: vol 26 no 43 :: 2012 53

22/06/2012 11:54

Learning zone emergency care

Head injury in the pre-mobile infant is less
readily sustained than when the child begins
to stand upright at approximately 12 months.
Head injury in the pre-mobile infant should
therefore prompt an exclusion of abusive
injury. The head is the most common site
for bruising secondary to abuse, and bruising
and other minor injury is more common after
the child has begun to mobilise (National
Society for the Prevention of Cruelty to
Children 2009).
The reflex that enables an individual to
put out an outstretched hand instinctively
when falling develops at approximately
eight to nine months. Despite this, infants
when first mobilising may sustain head and
facial injuries as the head of the infant is
proportionately much larger than that of
the adult. In addition, the skull of the infant
has patent fontanelles (unfused apertures in
the bony skull). The posterior fontanelle is
patent until approximately five months and
the anterior fontanelle is patent until around
18 months of age. During intracerebral
bleeding the fontanelles may become full or

figure 5
Paediatric Glasgow Coma Scale for pre-verbal children
Feature

Response

Eye opening

Spontaneously

Score

Total

To speech

To pain

No response

1
E:

Verbal response

Coos or babbles normally

Irritable or continually cries

Cries in pain

Moans in pain

No response

1
V:

Motor response

Obeys commands

Localises pain

Withdraws from pain

Flexion to pain

Extension to pain

No response

1
M:

TOTAL: E+V+M
(National Institute for Health and Clinical Excellence 2007)

54 june 27 :: vol 26 no 43 :: 2012

p49-56w43 54

GCS

/15

turgid (bulging), although this is not an early

sign of intracerebral bleeding (Advanced Life
Support Group 2005).

Computed tomography scanning

Criteria necessitating a CT scan of the brain
are different for adults and children. However,
irrespective of age, the presence of any of these
criteria should serve as red flag indicators for
intracerebral bleeding.
Criteria for CT scanning in the adult includes
(NICE 2007):
GCS

below 13 when first assessed, or below
15 two hours after injury.
Suspected

open or depressed skull fracture or
signs of basal skull fracture.
Post-injury

seizure or focal neurological
deficit.
More

than one episode of vomiting.
Pre-injury

amnesia of more than 30 minutes
duration.
Age
 over 65 with amnesia or loss of
consciousness.
Anticoagulated

patient with amnesia or loss
of consciousness.
Loss

of consciousness or amnesia in
association with a dangerous mechanism
of injury, such as falls from height.
The pertinent differences in signs and
symptoms of intracerebral bleeding in infants
and young children have been highlighted and
guidelines for CT scanning in children include
(NICE 2007):
Witnessed

loss of consciousness of more than
five minutes duration.
Anterograde

or retrograde amnesia of more
than five minutes duration.
Abnormal

drowsiness.
Post-injury

seizure with no history of epilepsy.
Evidence

of basal skull fracture.
Suspicion

of abusive injury.
Three

or more separate episodes of vomiting
within four hours of injury.
Infant

younger than 12 months with GCS
below 15 on assessment.
Child

12 months to 16 years with GCS
below 14 on assessment.
Tense

fontanelle or suspicion of open or
depressed fracture.
Infant

with bruise, swelling or laceration
bigger than 5cm on the head.
Dangerous

mechanism of injury.
NICE (2007) guidelines acknowledge that
access to CT scanning may be problematic,
particularly during evenings and at weekends,
and state that skull X-rays may play a part

NURSING STANDARD / RCN PUBLISHING

22/06/2012 11:54

in the assessment of patients to quantify

risk. Skull X-rays may also be important
in situations where there is suspicion of
physical abuse leading to injury in children
(NICE 2007).
Complete time out activity 5

Management and discharge

If after the consultation the practitioner
concludes that the injury is minor, attention
should be given to the management and
discharge of the patient. All patients being
discharged after sustaining a head injury
should be given written advice concerning
the signs and symptoms that should
prompt re-attendance at the hospital (Box 1).
Patients with extradural or subdural
haematomas may have what is known as a
lucid period in the time following injury and
then experience progressive neurological
deterioration (Babu et al 2005, Engelhard
et al 2007). Such patients may even have
normal CT scans and subsequently
experience delayed intracerebral bleeding
(Engelhard et al 2007). The importance of
providing advice about head injury is evident
given these patterns of intracerebral bleeding
in some patients.
Advice about head injury should be given
in written form, but practitioners should
also ensure that patients have understood the
advice by discussing it with them. A contact
telephone number that patients may use for
advice should be included and individuals
should be advised that they should return to
the emergency department or minor injury
unit if they are concerned or have any
relevant symptoms.
Patients who live alone should only be
discharged when the practitioner feels that
the risk of intracerebral bleeding is low and
when attempts have been made to ensure
supervision of the patient by family members,
friends or neighbours (NICE 2007). If there
is any doubt about safe discharge of the
patient then the practitioner should seek
advice from a senior colleague or consider
referring the patient for further assessment
and observation.
Patients who re-attend emergency
departments or minor injury units in the first
few days after injury should be assessed by
a senior practitioner and a CT scan of the
brain considered (NICE 2007). Practitioners
working in the absence of senior colleagues,
such as those working in minor injury units,

NURSING STANDARD / RCN PUBLISHING

p49-56w43 55

BOX 1
Advice about signs and symptoms following head injury
Patients should re-attend the emergency department or minor injury unit if
they experience:
Loss of consciousness.
Confusion.
Abnormal drowsiness one hour after injury or difficulty waking up.
Problems walking, speaking or visual disturbance.
Severe and persistent headache.
Vomiting.
Blood or clear fluid draining from the nose or ears.
Limb weakness.
Convulsions.
(Scottish Intercollegiate Guidelines Network 2000, National Institute for Health and
Clinical Excellence 2007)

BOX 2
Aftercare advice following head injury
Avoid staying at home alone for the first 48hours after leaving hospital.
Stay within easy reach of a telephone and medical help.
Have plenty of rest and avoid stressful situations.
Avoid taking any alcohol or drugs.
Avoid taking sleeping pills, sedatives or tranquillisers unless they are given
by a doctor.
Avoid playing any contact sport (for example, rugby or football) for at least
threeweeks without consulting a doctor.
Avoid returning to school, college or work activity until completely
recovered.
Avoid driving a car or motorbike, riding a bicycle or operating machinery
unless completely recovered.
(National Institute for Health and Clinical Excellence 2007)

should seek advice by telephone from a senior

clinician in the emergency department and
refer the patient to a facility where further
assessment and CT scanning is available.
Patients should be advised to avoid
contact sport for approximately three weeks
after injury, to avoid alcohol and sedative
medication and to ensure that they have
access to the means to summon help such
as from relatives or carers they should be
advised not to be alone for 48 hours
following injury (Box 2) (SIGN 2000,
NICE 2007).
Patients should also be advised that they
may develop symptoms of concussion, which
can persist for up to two weeks following
injury. These symptoms include nausea, mild
headache, dizziness, irritability, lethargy,
poor concentration, loss of appetite and
insomnia (NICE 2007). If these symptoms
develop, patients should be advised to seek
help from their general practitioner or other
healthcare professional in primary care
(NICE 2007).

5 You are preparing

to discharge an
adult patient who
was admitted to the
emergency department
with a minor head
injury. What advice
would you give to the
patient? Think about
the signs and symptoms
that the patient may
need to be made aware
of and in what cases
re-attendance at the
emergency department
might be necessary.

june 27 :: vol 26 no 43 :: 2012 55

22/06/2012 11:54

Learning zone emergency care

Conclusion
Head injury is a common presentation in a
variety of first-contact settings, such as GP
surgeries, urgent care and walk-in centres and
emergency departments. Clinical experience
and the appropriate use of validated clinical
guidelines should enable the healthcare

professional, whatever his or her role in the

care of the patient, to identify patients at high
risk of intracerebral complications effectively
and safely, and to manage the care of the
majority of patients who are not prone to such
complications but need adequate assessment
and aftercare to maintain their safety NS

6 Now that you have

completed the article,
you might like to write
a practice profile.
Guildelines to help you
are on page 60.

References
Advanced Life Support Group
(2005) Advanced Paediatric Life
Support: The Practical Approach.
Fourth edition. BMJ Books, London.
Babu ML, Bhasin SK, Kumar A
(2005) Extradural haematoma:
an experience of 300 cases.
JK Science. 7, 4, 205-207.
Bailey P (2006) AVPU. www.
trauma.org/index.php/community/
list/url/http:list.ftech.net/
pipermail/trauma-list/2006-May/
032245.html (Last accessed: June
12 2012.)
Bjorn P (2006) AVPU. www.trauma.
org/index.php/community/list/
url/http:list.ftech.net/pipermail/
trauma-list/2006-May/032245.
html (Last accessed: June 12 2012.)
Childrens Hospital of Wisconsin
(2009) Hemophilia. http://tinyurl.
com/cnq2d64 (Last accessed:
June 12 2012.)
Cohen DB, Rinker C,
Wilberger JE (2006) Traumatic
brain injury in anticoagulated
patients. Journal of Trauma. 60, 3,
553-557.
College of Emergency Medicine
(2008) The Way Ahead
2008-2012: Strategy and Guidance
for Emergency Medicine in the
United Kingdom and the Republic
of Ireland. College of Emergency
Medicine, London.
Crimando J (2012) Skull Anatomy
Tutorial. www.gwc.maricopa.edu/

class/bio201/skull/skulltt.htm (Last
accessed: June 12 2012.)
Engelhard HH, Sinson G, Reiter T
(2007) Subdural Hematoma
Surgery. http://emedicine.medscape.
com/article/247472-overview (Last
accessed: June 12 2012.)
Falk AC, von Wendt L, Klang B
(2008) Informational needs in
families after their childs mild
head injury. Patient Education and
Counseling. 70, 2, 251-255.
Gaichas A, Roesler J, Tsai A, Reid S,
Schiff J, Kinde M (2006) AVPU
as a severity score for pediatric
traumatic brain injury. Journal
of Head Trauma Rehabilitation.
21, 5, 411.
Gill M, Martens K, Lynch EL,
Salih A, Green SM (2007) Interrater
reliability of 3 simplified neurologic
scales applied to adults presenting
to the emergency department with
altered levels of consciousness.
Annals of Emergency Medicine. 49,
4, 403-407.
Headway (2009) Key Facts and
Statistics: Traumatic Brain Injury.
www.headway.org.uk/key-factsand-statistics.aspx (Last accessed:
June 12 2012.)
Itshayek E, Rosenthal G, Fraifeld S,
Perez-Sanchez X, Cohen JE,
Spektor S (2006) Delayed
posttraumatic acute subdural
hematoma in elderly patients on
anticoagulation. Neurosurgery. 58,
5, E851-E856.

56 june 27 :: vol 26 no 43 :: 2012

p49-56w43 56

Kelly CA, Upex A, Bateman

DN (2004) Comparison of
consciousness level assessment
in the poisoned patient using the
alert/verbal/painful/unresponsive
scale and the Glasgow Coma Scale.
Annals of Emergency Medicine. 44,
2, 108-113.

Departments. http://tinyurl.
com/74uk7nv (Last accessed: June
12 2012.)
Ohio Emergency Medical Services
(2007) Geriatric Trauma Task Force:
Report and Recommendations.
http://tinyurl.com/chzrdo7 (Last
accessed: June 12 2012.)

Khan AN, Turnbull I, MacDonald S,

Al-Okaili R (2011) Imaging in
Skull Fractures. http://emedicine.
medscape.com/article/343764overview (Last accessed: June 12
2012.)

Rangel-Castilla L, GascoJ, Hanbali

F, Salinas P (2011) Closed Head
Trauma. http://emedicine.medscape.
com/article/251834-overview (Last
accessed: June 12 2012.)

Lizerbram E, Moffit B (2001)

Neuroimaging in acute brain injury.
Advanced Emergency Nursing
Journal. 23, 2, 47-59.

Scottish Intercollegiate Guidelines

Network (2000) Early Management
of Patients with a Head Injury. SIGN,
Edinburgh.

National Institute for Clinical

Excellence (2003) Head
Injury: Triage, Assessment,
Investigation and Early
Management of Head Injury in
Infants, Children and Adults.
http://guidance.nice.org.uk/CG4
(Last accessed: June 12 2012.)

Scottish Intercollegiate Guidelines

Network (2009) Early Management
of Patients with a Head Injury.
http://tinyurl.com/cdgsuf4 (Last
accessed: June 12 2012.)

National Institute for Health

and Clinical Excellence (2007)
Head Injury: Triage, Assessment,
Investigation and Early
Management of Head Injury in
Infants, Children and Adults. Clinical
Guideline No. 56. NICE, London.
National Society for the Prevention
of Cruelty to Children (2009)
Core-Info: Bruises on Children.
http://tinyurl.com/bvmfqhs (Last
accessed: June 12 2012.)
NHS Choices (2011) A&E

Teasdale G, Jennett B (1974)

Assessment of coma and impaired
consciousness. A practical scale.
The Lancet. 2, 7872, 81-84.
Wade SL, Carey J, Wolfe CR (2006)
An online family intervention to
reduce parental distress following
pediatric brain injury. Journal of
Consulting and Clinical Psychology.
74, 3, 445-454.
Yadav YR, Basoor A, Jain G,
Nelson A (2006) Expanding
traumatic intracerebral contusion/
hematoma. Neurology India. 54, 4,
377-381.

NURSING STANDARD / RCN PUBLISHING

22/06/2012 11:54