11/13/24, 7\:38 PM Guide | Traumatic head injury

Traumatic head injury

Table of contents

Introduction

Head injury is de
1
This guide provides an overview of the recognition and immediate management of a traumatic head injury using an ABCDE
approach.
The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working
through the following steps\:
Airway
Breathing
Circulation
Disability
Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed
as they are identi
This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not
intended to be relied upon for patient care.

Basic principles & pathophysiology

The severity of head injuries can vary from minor head injuries to life-threatening traumatic brain injury (TBI) and/or intracranial
haemorrhage.
Traumatic head injuries are a common presentation, with 1.4 million patients attending emergency departments in the United
Kingdom every year.
1
Although the incidence of death from head injuries overall is low (0.2%), the consequences of missing major pathology can be
catastrophic. Head injuries are the most common cause of death and disability in those under the age of 40 in the UK.
1
The Monro-Kellie doctrine
The Monro-Kellie hypothesis describes the relationship between the contents of the skull and intracranial pressure (ICP).
The skull is a closed rigid box with a
Within the skull there are three main substances\:
Brain tissue,
Cerebrospinal
Blood
If the volume of one of these substances increases, to maintain a constant ICP, the volume of one of the others must decrease.
Initially, this can be achieved through a process referred to as compliance.
An increase in the amount of blood in the skull leads to a compensatory decrease in the amount of CSF and normal ICP is
maintained.
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Once the compensatory compliance mechanism is overwhelmed, small increases in the volume of any one of the three
substances will lead to dramatic increases in ICP . In head injuries, the volume of brain tissue or blood within the skull can
increase secondary to swelling (i.e. oedema) or haemorrhage. If left untreated, rising ICP leads to a progressive reduction in
cerebral perfusion, herniation of the brainstem and ultimately death.
Clinical features of raised ICP
Clinical features of raised ICP can include\:
Headache
Nausea and vomiting
Restlessness, agitation or drowsiness
Slow slurred speech
Papilloedema
Ipsilateral sluggish dilated pupil which then becomes
Cranial nerve palsy (e.g. CN III palsy with 'down and out' pupil)
Seizures
Reduced GCS
Abnormal respiratory pattern
Abnormal posturing, initially decorticate and then decerebrate
Cushing’s re
hypertension, bradycardia, and an irregular breathing pattern.
Cerebral Perfusion Pressure (CPP)
Cerebral perfusion pressure is the pressure driving blood through the brain tissue, allowing the delivery of oxygen and
nutrients. CPP can be calculated using the equation below\:
CPP = Mean Arterial Pressure (MAP) – ICP
A rise in ICP will reduce CPP. If CPP drops too low for a signi
Herniation
Herniation can be de
brain structures leads to di
Herniation of the cerebellar tonsils through the foramen magnum leads to compression of the brainstem and respiratory
arrest. This is often referred to as ‘coning’
.
Herniation of the uncus of the temporal lobe through the tentorial notch often leads to compression of cranial nerve three
(oculomotor nerve) leading to the classical “blown pupil” that is often assessed for in TBI patients.
Primary and secondary brain injury
Primary brain injury is the initial injury caused to brain tissue from the forces of the traumatic event itself. This may be focal (e.g.
skull fractures, blood vessel injury and haematoma formation) or di
Secondary brain injury is indirect damage to brain tissue that that occurs after the primary insult, worsening the original injury.
Common causes include inadequate perfusion of the brain causing cerebral hypoxia, acidosis, hypoglycaemia and cerebral
oedema leading to raised ICP.
Primary brain injury has already occurred in patients who present with a head injury. A key part of head injury management is to
minimise secondary brain injury.
Table 1. Factors that may contribute to secondary brain injury, and the interventions to try to limit them.
Contributing factors Interventions
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Hypoxia and hypercapnia
Hypovolaemia and hypotension
Cerebral oedema and raised ICP
Expanding haematoma
Hypoglycaemia or hyperglycaemia
Increased metabolic demand (e.g. hyperthermia or
seizures)
Oxygen to maintain saturations of 94-98%
Intubation in patients unable to protect their airway or with poor
respiratory e
Resuscitate with intravenous
Vasopressors
Avoid tight C-spine collars
Position the patient at 30° to aid venous drainage
Mannitol or hypertonic saline to reduce ICP
Intubation and hyperventilation strategies
Reverse clotting abnormalities
Consider the use of tranexamic acid if \< 3 hours since injury
Neurosurgical intervention
Maintain blood glucose within normal range with insulin or dextrose
as required
Maintain normothermia
Anti-convulsant medications if seizure activity
Neuroprotective anaesthesia

Clinical features

History
Patients who have sustained a head injury may not be able to provide an accurate history as a result of the injury itself (e.g. due
to reduced consciousness).
Where possible, obtain a collateral history. If the patient was bought in by ambulance, try to gather a detailed history and
description of the scene from the paramedics.
In the context of acute severe head trauma, taking a history should not delay performing an urgent ABCDE assessment to
identify and address serious pathology.
A more detailed history can be obtained once the patient is stable.
Typical symptoms of a traumatic head injury include\:
Pain localised to the area of trauma
Headache
Drowsiness or loss of consciousness
Nausea and vomiting
Confusion or irritability
Changes in hearing (ringing in ears, hearing loss) or vision (double vision, blurring, visual
Memory loss (amnesia) or concentration di
Weakness or sensory changes such as numbness or paraesthesia
Di
Dizziness or issues with balance
Other important areas to cover in the history include\:
A detailed account of the event. This includes when the head injury occurred, how it occurred, and which part of the head
took the impact. Find out if the patient was intoxicated or taking any illicit drugs at the time.
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Establishing if the patient has any neurological symptoms. This includes seizure activity, weakness, sensory or visual
changes.
Whether there was any loss of consciousness after the injury and establishing if the patient has any amnesia.
Whether the patient has any symptoms that may be due to raised ICP (covered previously).
Drug history\: establish whether the patient is taking any anticoagulants and if they have any drug allergies.
A focused past medical history\: establish if the patient has a bleeding disorder; has previously had brain surgery or
sustained a signi
A focused social history\: establish the patient's baseline functioning and what their home situation is. Take a brief alcohol
and drug history.
Whether the patient has sustained any other injures. Speciguidelines
on when c-spine immobilisation should be performed.
3
If the head injury was due to a fall, then this should be explored further, and the cause of the fall should be sought. See our
article on falls assessment and management.
Clinical signs
Typical clinical signs associated with a traumatic head injury include\:
Lacerations, abrasions, bruising and swelling over the area of the head that has sustained trauma
Decreased consciousness (GCS) or drowsiness
Confusion
Irritability
Focal neurological signs such as weakness or sensory loss
Abnormal
di
Impaired coordination on examination
Signs of basal skull fracture\: this includes CSF tracking from the nose or ears and bruising around the eyes or behind the
ears
Impairments in memory

Tips before you begin

General tips for applying an ABCDE approach in an emergency setting include\:
Treat all problems as you discover them.
Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
Make use of the team around you by delegating tasks where appropriate.
All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
Clearly communicate how often would you like the patient’s observations relayed to you by other sta
If you require senior input, call for help early using an appropriate SBARR handover
Review results as they become available (e.g. laboratory investigations).
Make use of your local guidelines and algorithms in managing speciacute asthma).
Any medications or will need to be prescribed at the time (in some cases you may be able to delegate this to another
member of sta
Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical
assessment, investigations and interventions.

Initial steps

Acute scenarios typically begin with a brief handover from a member of the nursing sta
name, age, background and the reason the review has been requested.
You may be asked to review a patient with a traumatic head injury in the emergency department or following a fall on the
wards.
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Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient including your name and role.
Ask how the patient is feeling as this may provide some useful information about their current symptoms.
In the context of a head injury, this may not be possible due to impaired consciousness.
Preparation
Make sure the patient’s notes, observation chart and prescription chart are easily accessible.
Ask for another clinical member of sta
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines

Airway

In patients with head injuries, the airway may be compromised due to a number of factors such as\:
Blood or swelling in the airway
Vomit or secretions
Reduced consciousness (from the head injury itself or other factors e.g. intoxication)
Clinical assessment
Can the patient talk?
Yes\: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.
No\:
Look for signs of airway compromise\: these include cyanosis, see-saw breathing, use of accessory muscles, diminished
breath sounds and added sounds.
Open the mouth and inspect\: look for anything obstructing the airway such as secretions or a foreign object.
Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the
emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway
manoeuvres to help maintain the airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
The head tilt-chin lift manoeuvre should be avoided if there is any concern of a spinal injury.
Jaw thrust
If the patient is suspected to have su
than a head-tilt chin-lift manoeuvre\:
1. Identify the angle of the mandible.
2. With your index and other
lift the mandible.
3. Using your thumbs, slightly open the mouth by downward displacement of the chin.
Oropharyngeal airway (Guedel)
Airway adjuncts are often helpful and, in some cases, essential to maintain a patient’s airway. They should be used
in conjunction with the manoeuvres mentioned above as the position of the head and neck need to be maintained
to keep the airway aligned.
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An oropharyngeal airway is a curved plastic tube with a
palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly
tolerated and may induce gagging and aspiration.
To insert an oropharyngeal airway\:
1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign
material is present, attempt removal using suction.
2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft
palate, at which point you should rotate it 180°
. The reason for inserting the airway upside down initially is to
reduce the risk of pushing the tongue backwards and worsening airway obstruction.
3. Advance the airway until it lies within the pharynx.
4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and
feeling for signs of breathing.
Nasopharyngeal airway (NPA)
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a
better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways.
The use of nasopharyngeal airways in head injury is controversial. They are generally better tolerated than
oropharyngeal airways in patients who are partially or fully conscious and may be the only option in severe facial
fractures or trismus. However, the general consensus is that they should not be used if there is any concern that
the patient may have a basal skull fracture.
Basal skull fracture
Signs suggestive of a basal skull fracture include\:
CSF (clear
Raccoon eyes\: bruising around the eyes
Battle sign\: bruising behind the ear over the mastoid process
Haemotympanum\: blood noted behind the tympanic membrane on otoscopy
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash
call and commence CPR.
Re-assessment
Make sure to re-assess the patient following any intervention.

Breathing

Ventilation must be su
Abnormalities in the patient's respiratory pattern may indicate raised ICP.
Clinical assessment
Observations
Review the patient’s respiratory rate\:
A normal respiratory rate is between 12-20 breaths per minute.
Bradypnoea may be secondary to raised ICP and is seen as part of the Cushing’s re
Tachypnoea may be due to pain or agitation, acidosis or due to the presence of respiratory pathology.
Review the patient’s oxygen saturations (SpO )\:
2
A normal SpO 2 2
range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO retention.
Hypoxaemia may occur due to associated injuries or respiratory issues and can contribute to secondary brain injury.
See our guide to performing observations/vital signs for more details.
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Inspection
Look for signs of cyanosis, respiratory distress, use of accessory muscles, and abnormal breathing patterns.
Deep irregular breathing can be caused by raised ICP.
Assess for equal chest expansion with respiration and for any obvious chest wall trauma.
Palpation
Palpate the position of the patient’s trachea and assess chest expansion.
Assess for any chest wall tenderness that may signify chest wall trauma.
Auscultation
Auscultate both lungs\:
Assess for good air entry throughout the chest
Assess for any added sounds such as crackles and wheeze
Investigations and procedures
Arterial blood gas
Take an ABG if indicated (e.g. low SpO ) to quantify the degree of hypoxia.
2
Chest X-ray
A chest x-ray may be needed if examination suggests other respiratory pathology.
Intubation and ventilation
Indications for intubation and ventilation are\:
pO 2
\< 13kPa on supplemental oxygen
pCO > 6kPa
2
Spontaneous hyperventilation causing pCO 2
\< 3.5kPa
Interventions
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of
a non-rebreathe mask with an oxygen
your initial assessment.
4
If the patient has COPD and a history of CO 2
and titrate oxygen appropriately.
retention you should switch to a venturi mask as soon as possible
Assisted ventilation
If your patient is unconscious and their respiratory rate is inadequate (too slow or irregular with big pauses), you
can provide assisted ventilation through a bag-valve-mask (BVM)\: ventilate at a rate of 12-15 breaths per minute
(roughly one every 4 seconds).
Other interventions
Other interventions may be appropriate depending on examination
pneumothorax).
Re-assessment
Make sure to re-assess the patient following any intervention.

Circulation

perfusion.
In patients with TBI, it is important to maintain an adequate mean arterial pressure to ensure adequate cerebral
Mortality is signi
less than 90mmHg.
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Aim for a MAP > 90mmHg or systolic BP > 110mmHg. A lower BP may sometimes be permitted in patients with
multiple injuries or major haemorrhage.
Clinical assessment
Observations
Review the patient's heart rate\:
Causes of tachycardia (HR>99) in the context of head injury include hypovolaemia, arrhythmia, pain or drugs.
Causes of bradycardia (HR\<60) in the context of head injury include Cushing's re
Review the patient’s blood pressure\:
A normal blood pressure (BP) range is between 90/60mmHg and 140/90mmHg but you should review previous readings to gauge the patient’s usual
baseline BP.
Causes of hypertension in the context of acute head injury include pain and Cushing's re
Causes of hypotension in the context of acute head injury include haemorrhage from other injuries, and drugs (e.g. opiates).
See our guide to performing observations/vital signs for more details.
General inspection
Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying
pathology\:
Pallor or mottled skin\: commonly associated with hypovolaemic shock (e.g. haemorrhage).
Palpation
Place the dorsal aspect of your hand onto the patient’s to assess temperature\:
In healthy individuals, the hands should be symmetrically warm, indicating adequate perfusion.
Cool hands indicate poor peripheral perfusion (e.g. hypovolaemic shock).
Measure capillary re
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia) and the need to assess central capillary re
Pulses and blood pressure
Assess the patient’s radial and brachial pulse to assess rate, rhythm, volume and character\:
An irregular pulse is associated with arrhythmias such as atrial
A thready pulse is associated with intravascular hypovolaemia (e.g. haemorrhage).
Auscultation
Auscultate the patient’s precordium to assess heart sounds, listening for evidence of murmurs.
Investigations and procedures
Intravenous cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
See our intravenous cannulation guide for more details.
Blood tests
Request the following blood tests\:
FBC
U&Es
LFTs
Coagulation screen
Group & save (+/- crossmatch)
Toxicology screen (if you suspect drug overdose)
Lactate (to assess for evidence of inadequate end-organ perfusion)
See our blood culture, blood bottle and investigation panel guides for more details.
ECG
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Perform an ECG if to identify any abnormal rhythms which may be contributing to poor perfusion.
Attach 3-lead continuous ECG monitoring if available.
See our guides to recording and interpreting an ECG for more details.
Interventions
Hypovolaemia
Hypovolaemic patients require
Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over less than 15 mins.
Administer 250ml boluses in patients at increased risk of
After each
JVP).
Repeat administration of
overload), reassessing the patient each time.
Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t
responding adequately to repeated boluses (e.g. persistent hypotension).
See our for more details on resuscitation
Hypertension
Hypertension in traumatic head injury is generally left alone unless it is dangerously elevated, as it is often a
homeostatic response to ensure there is adequate cerebral perfusion.
Coagulation abnormalities
If a patient is found to have coagulation abnormalities in the context of acute head injury (e.g. raised PT or INR)
they will likely require treatment to reduce their risk of further bleeding.
Correction of coagulation abnormalities is typically lead by the on-call haematologist.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash
call and commence CPR.
Re-assessment
Make sure to re-assess the patient following any intervention.

Disability

Clinical assessment
Consciousness
Assess the patient’s level of consciousness by using the Glasgow Coma Scale (GCS).
A summary of the Glasgow coma scale is shown below. For a more detailed explanation, see the Geeky Medics
guide to the Glasgow Coma Scale.
Table 2. An overview of the Glasgow Coma Scale.
Behaviour/domain Response Score
Eyes opening spontaneously 4
Eyes opening to sound 3
Eye-opening response
Eyes open to pain 2
No eye opening 1
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Orientated to time, place and
person
5
Confused 4
Verbal response
Inappropriate sounds 3
Incomprehensible sounds (e.g.
groaning)
2
No response 1
Obeys commands for movement 6
Moves towards pain/localises to
pain 5
Withdraws away from pain 4
Motor response
Abnormal
posturing
3
Abnormal extension/decerebrate
posturing
2
No motor response 1
Head injuries are classi
Mild head injury\: GCS of 14/15
Moderate head injury\: GCS 9-13
Severe head injury\: GCS \<8
Assess if the patient is orientated to person, place and time.
Pupils
Assess the patient’s pupils\:
Assess the size and shape of the patient’s pupils. A normal pupil diameter ranges from two to
Assess the pupils for both direct and consensual response to light using a pen torch.
An oval-shaped pupil, sluggish reaction to light,
“blown pupil” or deviated pupil suggests raised ICP or herniation.
Bilaterally small or “pinpoint” pupils may be due to opioid toxicity.
Neurological examination
Perform a neurological examination in patients who are able to follow commands, assessing\:
Cranial nerves
Power in each limb (see our upper limb and lower limb neurological examination guides)
Sensation in each limb
Cerebellar function
A new neurological de
Investigations
Blood glucose
Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g.
hypoglycaemia or hyperglycaemia).
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
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Hypoglycaemia is de
glucose ≤4.0 mmol/L should be treated if the patient is symptomatic.
See our blood glucose measurement and hypoglycaemia guides for more details.
Imaging
In the UK, NICE has produced guidance on head injuries including when to perform a CT head scan.
Typical pathologies which may be shown on the CT scan include\:
Intracranial bleeds\: extradural haemorrhage, subdural haemorrhage, subarachnoid haemorrhage and intracerebral haemorrhage
Brain contusions
Skull fractures
Cerebral oedema
Any injuries identi
See our CT head interpretation guide for more details.
Interventions
Maintain the airway
Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or
below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain
the patient’s airway as explained in the airway section of this guide.
Opioid toxicity
If opioid toxicity is suspected as the cause for the patient’s reduced level of consciousness (e.g. pinpoint pupils)
interventions such as naloxone should be considered.
See our opioid toxicity guide for more details.
Hypoglycaemia
The management of hypoglycaemia involves the administration of glucose (e.g. oral or intravenous).
See our hypoglycaemia guide for more details.
Re-assessment
Make sure to re-assess the patient following any intervention.

Exposure

It may be necessary to expose the patient during your assessment\: remember to prioritise patient dignity and
conservation of body heat.
Clinical assessment
Begin by asking the patient if they have pain anywhere, which may be helpful to guide your assessment.
Other injuries +/- bleeding
Fully expose the patient looking for evidence of other injuries or bleeding.
If active bleeding is identi
Estimate the total blood loss and the rate of blood loss.
Re-assess for signs of hypovolaemic shock (e.g. hypotension, tachycardia, pre-syncope, syncope).
Temperature
Measure the patient’s temperature\:
Temperature >38°C may be due to infection. This may provide clues as to how the patient sustained the head injury (e.g. delirium secondary to
infection in an elderly patient leading to a fall).
Hypothermia (temperature \< 36°C) may be seen in patients who have been immobilised by their injury for a prolonged period of time.
Interventions
Injuries
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Treat other injuries identi
Explore any wounds and clean/close if con
Super
Deeper or complex wounds may require sutures
Haemorrhage
If the patient is actively bleeding seek urgent senior input (e.g. surgical registrar, anaesthetics) and consider the
need for blood products (e.g. packed red cells, platelets).
Large-bore intravenous access (x2) should be established and relevant blood tests should be sent (e.g. FBC,
U&Es, coagulation studies, group and crossmatch) if not done so already.
In severe haemorrhage, consider initiating the major haemorrhage protocol (with senior approval).
See our blood transfusion guide for more details.
Warming
Consider warming (e.g. Bair Hugger™) in hypothermia (seek senior input).
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash
call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.

Exposure

It may be necessary to expose the patient during your assessment\: remember to prioritise patient dignity and
conservation of body heat.
Clinical assessment
Begin by asking the patient if they have pain anywhere, which may be helpful to guide your assessment.
Other injuries +/- bleeding
Fully expose the patient looking for evidence of other injuries or bleeding.
If active bleeding is identi
Estimate the total blood loss and the rate of blood loss.
Re-assess for signs of hypovolaemic shock (e.g. hypotension, tachycardia, pre-syncope, syncope).
Temperature
Measure the patient’s temperature\:
Temperature >38°C may be due to infection. This may provide clues as to how the patient sustained the head injury (e.g. delirium secondary to
infection in an elderly patient leading to a fall).
Hypothermia (temperature \< 36°C) may be seen in patients who have been immobilised by their injury for a prolonged period of time.
Interventions
Injuries
Treat other injuries identi
Explore any wounds and clean/close if con
Super
Deeper or complex wounds may require sutures
Haemorrhage
If the patient is actively bleeding seek urgent senior input (e.g. surgical registrar, anaesthetics) and consider the
need for blood products (e.g. packed red cells, platelets).
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Large-bore intravenous access (x2) should be established and relevant blood tests should be sent (e.g. FBC,
U&Es, coagulation studies, group and crossmatch) if not done so already.
In severe haemorrhage, consider initiating the major haemorrhage protocol (with senior approval).
See our blood transfusion guide for more details.
Warming
Consider warming (e.g. Bair Hugger™) in hypothermia (seek senior input).
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash
call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.

Re-assess ABCDE

Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the
e
Deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Support
You should have another member of the clinical team aiding you in your ABCDE assessment, such as a nurse, who
can perform observations, take samples to the lab and catheterise if appropriate.
You may need further help or advice from a senior sta
have concerns about your patient.
Use an eSBARR handover to communicate the key information e

Next steps

Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…
Take a history
Take a thorough history to help narrow the di
See our history taking guides for more details.
Review
Review the patient’s notes, charts and recent investigation results.
Review the patient’s current medications and check any regular medications are prescribed appropriately.
Regular review
Ask the nursing sta
and the patient’s condition.
Make a regular clinical review of the patient so any deterioration is identi
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations,
interventions, and the patient’s response.
See our documentation guides for more details.
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Discuss
Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.
Questions which may need to be considered include\:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Does the patient need reviewing by a specialist (e.g. neurosurgery)?
Should any changes be made to the current management of their underlying condition(s)?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has recently
deteriorated.

Reviewer

Dr Frances Balmer
ST4 in Emergency Medicine

References

1. Head injury\: assessment and early management. Published 2014, updated 2019. Available from\: [LINK].
2. Pixabay. S i d e o n s k u l l . License\: [FFCU].
3. Spinal injury\: assessment and initial management. Published in 2016. Available from\: [LINK].
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/emergency/traumatic-head-injury/ 14/14