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Criteria for CT head scan following a head injury

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Current primary investigation of choice for the detection of acute clinically important brain injuries is CT imaging of the head.

For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:

With respect to CT scan for an adult with a head injury:

  • adult patients who have sustained a head injury and present with any one of the risk factors outlined should have CT scanning of the head requested immediately
    • risk factors suggesting need for immediate CT scan
      • GCS less than 13 on initial assessment in the emergency department
      • GCS less than 15 at 2 hours after the injury on assessment in the emergency department
      • suspected open or depressed skull fracture
      • any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign)
      • post-traumatic seizure
      • focal neurological deficit
      • more than one episode of vomiting

    • for people 16 and over who have had some loss of consciousness or amnesia since the injury, do a CT head scan within 8 hours of the head injury, or within the hour in someone presenting more than 8 hours after the injury, if they have any of these risk factors:
      • age 65 or over
      • any current bleeding or clotting disorders
      • dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of more than 1 m or 5 stairs)
      • more than 30 minutes' retrograde amnesia of events immediately before the head injury

  • CT should also be requested immediately in patients with any of the risk factors outlined below, provided they have experienced some loss of consciousness or amnesia since the injury
    • risk factors for immediate CT scan if patient has experienced some loss of consciousness
      • age 65 years or older
      • coagulopathy (history of bleeding, clotting disorder, current treatment with warfarin)
      • dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 m or five stairs)
  • a provisional written radiology report should be made available within 1 hour of the scan being performed

For patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having anticoagulant treatment (1)

  • perform a CT head scan within 8 hours of the injury or
    • within the hour if they present more than 8 hours after the injury
    • a provisional written radiology report should be made available within 1 hour of the scan being performed.

With respect to CT scan for a child (under 16 years of age) with a head injury:

  • for people under 16 who have sustained a head injury, do a CT head scan within 1 hour of any of these risk factors being identified:
    • suspicion of non-accidental injury
    • post-traumatic seizure
    • on initial emergency department assessment, a GCS score of less than 14 or, for babies under 1 year, a GCS score (paediatric) of less than 15
    • at 2 hours after the injury, a GCS score of less than 15
    • suspected open or depressed skull fracture, or tense fontanelle
    • any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign)
    • focal neurological deficit
    • for babies under 1 year, a bruise, swelling or laceration of more than 5 cm on the head

  • for people under 16 who have sustained a head injury and have more than 1 of these risk factors, do a CT head scan within 1 hour of the risk factors being identified:
    • loss of consciousness lasting more than 5 minutes (witnessed)
    • abnormal drowsiness
    • 3 or more discrete episodes of vomiting
    • dangerous mechanism of injury (high-speed road traffic accident as a pedestrian, cyclist or vehicle occupant, fall from a height of more than 3 m, high-speed injury from a projectile or other object)
    • amnesia (anterograde or retrograde) lasting more than 5 minutes (it will not be possible to assess amnesia in children who are preverbal and is unlikely to be possible in children under 5)
    • any current bleeding or clotting disorder

    • observe people under 16 who have sustained a head injury but have only 1 of the risk factor for a minimum of 4 hours in hospital. If, during observation, any of the following risk factors are identified, do a CT head scan within 1 hour:
      • a GCS score of less than 15
      • further vomiting
      • a further episode of abnormal drowsiness. If none of these risk factors occur during observation, use clinical judgement to determine whether a longer period of observation is needed

Reference:

  1. NICE (May 2023). Triage, assessment, investigation and early management of head injury in infants, children and adults

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