NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Collaborating Centre for Acute Care (UK). Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults. London: National Collaborating Centre for Acute Care (UK); 2007 Sep. (NICE Clinical Guidelines, No. 56.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Head Injury

Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults.

Show details

9Admission and observation

9.1. Introduction

These guidelines place the emphasis on the early diagnosis of clinically important brain and cervical spine injuries, using a sensitive and specific clinical decision rule with early imaging. Admission to hospital is intrinsically linked to imaging results, on the basis that patients who do not require imaging are safe for discharge to the community (given that no other reasons for admission exist) and those who do require imaging can be discharged following negative imaging (again, given that no other reasons for admission exist). However, observation of patients will still form an important part of the acute management phase, for patients with abnormal CT results that do not require surgery and/or for patients with unresolved neurological signs. Observation should occur throughout the patient’s hospital episode, whether in the emergency department or after admission following abnormal imaging results. As noted above, all care professionals should use a standard head injury proforma in their documentation when assessing and observing patients with head injury. Separate adult, and child/infant specific proformas should be used. Again, the adult and paediatric GCS and derived scores should form the basis of observation, supplemented by other important observations.

An important result of these guidelines will be that the typical patient admitted for in hospital observation after head injury will have a more severe profile. It is presumed that the guidelines will lead to a substantially lower number of patients requiring admission, but these patients will have either confirmed abnormal imaging, have failed to return to normal consciousness or have other continuing signs and symptoms of concern to the clinician. The emphasis will shift therefore from vigilance for possible deterioration, to active care of patients where an ongoing head injury complication has been confirmed.

9.2. Admission

The following patients meet the criteria for admission to hospital following a head injury:

-

Patients with new, clinically significant abnormalities on imaging.

-

Patients who have not returned to GCS equal to 15 after imaging, regardless of the imaging results.

-

When a patient fulfils the criteria for CT scanning but this cannot be done within the appropriate period, either because CT is not available or because the patient is not sufficiently cooperative to allow scanning.

-

Continuing worrying signs (for example, persistent vomiting, severe headaches) of concern to the clinician.

-

Other sources of concern to the clinician (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak).

[Amended] Some patients may require an extended period in a recovery setting because of the use of general anaesthesia during CT imaging.

Patients with multiple injuries should be admitted under the care of the team that is trained to deal with their most severe and urgent problem.

These recommendations are based on level five evidence and are considered to be grade D recommendations.

9.3. Good practice in observation of patients with head injury

There is some evidence that Emergency Deparment observation wards are more efficient than general acute wards at dealing with short stay observation patients, with more senior supervision, fewer tests and shorter stays.157 There have also been concerns about the experience and skills of staff on general and orthopaedic acute wards in head injury care.12 This lead to a recommendation by the Royal College of Surgeons of England in 1999 that adult patients needing a period of observation should be admitted to a dedicated observation ward within or adjacent to an emergency department.12

[Amended] In circumstances where a patient with a head injury requires hospital admission, it is recommended that the patient be admitted only under the care of a team led by a consultant who has been trained in the management of this condition during his/her higher specialist training. The consultant and his/her team should have competence (defined by local agreement with the neuroscience unit) in assessment, observation and indications for imaging (see recommendations 3.7); inpatient management; indications for transfer to a neuroscience unit (see recommendations 3.6); and hospital discharge and follow up (see recommendations 3.8).

It is recommended that in-hospital observation of patients with a head injury should only be conducted by professionals competent in the assessment of head injury.

These recommendations are based on level five evidence and are considered to be grade D recommendations.

The service configuration and training arrangements required to ensure this occurs are beyond the scope of these guidelines but it is hoped that this issue will be addressed by future NHS policy guidance.

9.4. Minimum documented observations

For patients admitted for head injury observation the minimum acceptable documented neurological observations are: GCS; pupil size and reactivity; limb movements; respiratory rate; heart rate; blood pressure; temperature; blood oxygen saturation.

This recommendation is based on level five evidence and is considered to be a grade D recommendation.

9.5. Frequency of observations

As the risk of an intracranial complication is highest in the first 6 hours after a head injury, observations should have greatest frequency in this period.158

Observations should be performed and recorded on a half-hourly basis until GCS equal to 15 has been achieved. The minimum frequency of observations for patients with GCS equal to 15 should be as follows, starting after the initial assessment in the emergency department:

-

half-hourly for 2 hours;

-

then 1-hourly for 4 hours;

-

then 2-hourly thereafter.

Should a patient with GCS equal to 15 deteriorate at any time after the initial 2-hour period, observations should revert to half-hourly and follow the original frequency schedule.

These recommendations are based on level five evidence and are considered to be grade D recommendations.

9.6. Patient changes requiring review while under observation

[Amended] Any of the following examples of neurological deterioration should prompt urgent reappraisal by the supervising doctor:

-

Development of agitation or abnormal behaviour.

-

A sustained (that is, for at least 30 minutes) drop of one point in GCS (greater weight should be given to a drop of one point in the motor response score of the Glasgow Coma Scale).

-

Any drop of three or more points in the eye-opening or verbal response scores of the Glasgow Coma Scale, or two or more points in the motor response score.

-

Development of severe or increasing headache or persisting vomiting.

-

New or evolving neurological symptoms or signs such as pupil inequality or asymmetry of limb or facial movement.

To reduce inter-observer variability and unnecessary referrals, a second member of staff competent to perform observation should confirm deterioration before involving the supervising doctor. This confirmation should be carried out immediately. Where a confirmation cannot be performed immediately (for example, no staff member available to perform the second observation) the supervising doctor should be contacted without the confirmation being performed.

These recommendations are based on level five evidence and are considered to be a grade D recommendation.

9.7. Imaging following confirmed patient deterioration during observation

[Amended] If any of the changes noted in recommendation 1.7.5.1 are confirmed, an immediate CT scan should be considered, and the patient’s clinical condition should be re-assessed and managed appropriately.

This recommendation is based on level five evidence and is considered to be a grade D recommendation.

9.8. Further imaging if GCS equal to 15 not achieved at 24 hours

In the case of a patient who has had a normal CT scan but who has not achieved GCS equal to 15 after 24 hours observation, a further CT scan or MRI scanning should be considered and discussed with the radiology department.

This recommendation is based on level five evidence and is considered to be a grade D recommendation.

9.9. Observation of children and infants

Observation of infants and young children (that is, aged under 5 years) is a difficult exercise and therefore should only be performed by units with staff experienced in the observation of infants and young children with a head injury. Infants and young children may be observed in normal paediatric observation settings, as long as staff have the appropriate experience.

This recommendation is based on level five evidence and is considered to be a grade D recommendation.

9.10. Training in observation

Medical, nursing and other staff caring for patients with head injury admitted for observation should all be capable of performing the observations listed in 9.4 and 9.6 above.

The acquisition and maintenance of observation and recording skills require dedicated training and this should be available to all relevant staff.

Specific training is required for the observation of infants and young children.

This recommendation is based on level five evidence and is considered to be a grade D recommendation.

9.11. Support for families and carers

Early support can help the patient’s family or carer(s) prepare for the effects of head injury. This support can reduce the psychological sequelae experienced by the family or carer and result in better long term outcomes for both the patient and their family. Patient’s family members can find the hospital acute care setting overwhelming and this can cause additional tension or stress. It can be a particularly traumatic experience for a child visiting a sibling or parent with a head injury.

There should be a protocol for all staff to introduce themselves to family members or carers and briefly explain what they are doing. In addition a photographic board with the names and titles of personnel in the hospital departments caring for patients with head injury can be helpful.

Information sheets detailing the nature of head injury and any investigations likely to be used should be available in the emergency department. The patient version of these NICE guidelines may be helpful.

Staff should consider how best to share information with children and introduce them to the possibility of long term complex changes in their parent or sibling. Literature produced by patient support groups may be helpful.

These recommendations are based on level five evidence and are considered to be grade D recommendations.

The presence of familiar friends and relatives at the early stage following admission can be very helpful. The patient recovering consciousness can easily be confused by strange faces and the strange environment in which they find themselves. Relatives or carers are often willing to assist with simple tasks which, as well as helping nursing staff, helps families to be part of the recovery process rather than just an observer.

[Amended] Healthcare professionals should encourage carers and relatives to talk and make physical contact (for example, holding hands) with the patient. However, it is important that relatives and friends do not feel obliged to spend long peiods at the bedside. If they wish to stay with the patient, they should be encouraged to take regular breaks.

This recommendation is based on level five evidence and is considered to be a grade D recommendation.

Voluntary support groups can speak from experience about the real life impact post head injury and can offer support following discharge from hospital. This is particularly important where statutory services are lacking.

There should be a board or area displaying leaflets or contact details for patient support organisations either locally or nationally to enable family members to gather further information.

This recommendation is based on level five evidence and is considered to be a grade D recommendation.

Copyright © 2007, National Collaborating Centre for Acute Care.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of National Collaborating Centre for Acute Care to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

Bookshelf ID: NBK53028

Views

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...