A head injured patient should be referred to hospital if any of the following is present:

• Impaired consciousness (GCS < 15/15) at any time since injury
• Amnesia for the incident or subsequent events
• Neurological symptoms, e.g.
  • severe and persistent headache
  • nausea and vomiting
  • irritability or altered behaviour
  • seizure
• Clinical evidence of a skull fracture (e.g. CSF leak, periorbital haematoma)
• Significant extracranial injuries
• A mechanism of injury suggesting:
• a high energy injury (e.g. road traffic accident, fall from height)
• possible penetrating brain injury
• possible non-accidental injury (in a child)
• Continuing uncertainty about the diagnosis after first assessment
• Medical comorbidity (e.g. anticoagulant use, alcohol abuse)
• Adverse social factors (e.g. no-one able to supervise the patient at home

CT scanning should be done in a patient who has any of the following features:

1. The patient is eye opening only to pain or does not converse
   (GCS 12/15 or less)
2. A deteriorating level of consciousness or progressive focal neurological signs
3. Confusion or drowsiness (GCS 13 or 14/15) followed by failure to improve within at most four hours of clinical observation
4. Radiological/clinical evidence of a fracture, whatever the level of consciousness
5. New focal neurological signs which are not getting worse
6. Full consciousness (GCS 15/15) with no fracture but other features, e.g.:
   • severe and persistent headache
• nausea and vomiting
• irritability or altered behaviour
• a seizure.

Skull films should be carried out if any of the following apply and if CT is not being performed:

1. If the patient is alert and orientated and obeying commands (GCS 15/15) but:
   • the mechanism of injury has not been trivial; or
   • consciousness has been lost; or
   • the patient has loss of memory or has vomited; or
   • the scalp has a full thickness laceration or a boggy haematoma; or
   • the history is inadequate.
     or
2. If the level of consciousness is impaired (GCS =< 14/15).

Imaging of the cervical spine, including the cervico-thoracic junction should be carried out:

• in a fully conscious patient (GCS 15/15) if clinical symptoms or signs or the mechanism of injury indicate the possibility of injury
• in a patient with persisting impaired consciousness (GCS 14/15 or less)
• in an unconscious patient, not localising pain (GCS 6/15 or less) CT scanning of the cervical spine down to C2 should be undertaken routinely, at the time of head scanning.

A patient should be admitted to hospital if:

• the level of consciousness is impaired (GCS < 15/15)
• the patient is fully conscious (GCS 15/15) but any of the following risk factors are present:
  • continuing amnesia (for at least five minutes after injury)
  • continuing nausea and/or vomiting
  • a seizure at any time after injury
  • focal neurological signs
  • irritability or abnormal behaviour
  • clinical or radiological evidence of a recent skull fracture or suspected penetrating injury
  • an abnormal CT scan
  • severe headache or other neurological symptoms
• the patient has significant medical problems, e.g. anticoagulant use
• the patient has social problems or cannot be supervised by a responsible adult.

Any of the following examples of neurological deterioration should prompt urgent reappraisal by a doctor:

• the development of agitation or abnormal behaviour
• a sustained decrease in conscious level of at least one point in the motor or verbal response or two points in the eye opening response of the GCS
• the 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.

A head injured patient should be discussed with a neurosurgeon:

• when a CT scan in a general hospital shows a recent intracranial lesion
• when a patient fulfils the criteria for CT scanning but this cannot be done within an appropriate period
• irrespective of the result of any CT scan, when the patient has clinical features that suggest that neurosurgical assessment, monitoring, or management are appropriate.

Features suggesting that neurosurgical assessment, monitoring, or management are appropriate include:

1. persisting coma (GCS score 8/15 or less) after initial resuscitation
2. confusion which persists for more than four hours
3. deterioration in level of consciousness after admission (a sustained drop of one point on the motor or verbal subscales, or two points on the eye opening subscale of the GCS)
4. progressive focal neurological signs
5. a seizure without full recovery
6. compound depressed skull fracture
7. definite or suspected penetrating injury
8. a CSF leak or other sign of a basal fracture.