Any person, 16 years and over, presenting with a GCS 13–15 and with a history of mild head trauma.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
If patient meets major trauma criteria or has a GCS 12 or less, switch to major trauma protocol.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Mechanism of injury
- Preceding events, including loss of consciousness
- Pain assessment – PQRST
- Associated injuries
- Pre-hospital treatment
- Past admissions
- Medical and surgical history, including haematological disorders
- Current medications, including anticoagulant therapy
- Non-prescription alcohol or drugs intake
- Known allergies
Signs and symptoms
- Amnesia, either pre or post event
- Confusion or disorientation
- Difficulty concentrating
- Dizziness
- Headache
- Face or scalp contusions
- Ringing in ears
- Nausea
- Vomiting
- Fatigue
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Loss of consciousness
- Alcohol and/or drug intoxication
- Bleeding disorder
- 65 years and over
- On anticoagulant or antiplatelet therapy
Clinical
- Altered level of consciousness
- GCS less than 14, two hours post incident
- Persistent amnesia
- Focal neurology
- Behaviour differing from baseline
- Ataxia
- Agitation
- Seizure
- Change in speech, e.g. slurring
- Severe headache
- Large scalp haematoma or laceration
- Neck stiffness or soreness
- Racoon eyes (periorbital ecchymosis)
- Battle’s sign (mastoid bruising)
- Persistent vomiting
- Palpable skull fracture
- Boggy swelling
- Unequal pupils
- Visual disturbances
- Clear fluid or blood from ears and/or nose
Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Position
Assessment | Intervention |
---|---|
General appearance/first impressions | Position of comfort Elevate head to 30o unless contraindicated |
Suspected C-spine injury | Stabilise the C-spine with in-line immobilisation and/or foam collar (appendix) |
Airway
Assessment | Intervention |
---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
Assessment | Intervention |
---|---|
Respiratory rate and effort Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2) | Assist ventilation as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92% |
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Pulse rate Blood pressure Cardiac rhythm | Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern |
IVC and/or pathology | Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained See pathology section |
Signs of shock: tachycardia and CRT 3 seconds or over and/or abnormal skin perfusion and/or hypotension | If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Disability
Assessment | Intervention |
---|---|
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment, as clinically indicated Commence A-WPTAS |
Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
Assessment | Intervention |
---|---|
Temperature | Measure temperature |
Skin inspection, including posterior surfaces | Examine head and face for:
Assess gait and coordination if patient is safe to mobilise |
Fluids
Assessment | Intervention |
---|---|
Hydration status: last ate, drank, bowels opened, passed urine or vomited | Commence fluid balance chart, as required |
Nausea and/or vomiting | If present, see nausea and/or vomiting section If the patient has ongoing nausea and/or vomiting, and is not responding to treatment escalate as per local CERS protocol |
Glucose
Assessment | Intervention |
---|---|
BGL | Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol |
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Complete a neurological focused assessment.
Precautions and notes
- If any deterioration in patient condition is detected escalate as per local CERS protocol immediately.
- Patients can have a mild traumatic brain injury without losing consciousness.
Interventions and diagnostics
Specific treatment
Repeat A-WPTAS if score less than 18/18.
Analgesia
If pain score 1–6 (mild–moderate), give:
- paracetamol 1000 mg orally once only
- and/or ibuprofen 400 mg orally once only.
If severe pain present, give analgesia and escalate as per local CERS protocol.
Nausea and/or vomiting
If nausea and/or vomiting is present, give:
- metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
- or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
- or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only
Choice of antiemetic should be determined by cause of symptoms.
Radiology
Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.
Pathology
Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.
- Warfarinised: INR
Medications
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
Drug | Dose | Route | Frequency |
---|---|---|---|
Ibuprofen H, R | 400 mg | Oral | Pain score 1–10
Once only |
Over 20 years: | Oral/IV/IM | Once only | |
4 mg Maximum dose 8 mg | Oral/IV/IM | Repeat once if required after 60 minutes | |
Oxygen | 2–15 L/min, device dependent | Inhalation | Continuous |
1000 mg | Oral | Pain score 1–10 Once only | |
5 mg | Oral | Once only | |
OR | |||
12.5 mg | IV/IM | Once only | |
250 mL Maximum dose 1000 mL | IV/intraosseous | Bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Agency for Clinical Innovation (ACI). Key Principles: Use of foam collars for cervical spine immobilisation. NSW, Australia: NSW Health; 2018 [cited 22 February 2023]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/450882/ACI-Foam-collars-cervical-spine-immobilisation-initial-management.pdf
- Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- NSW Health. Clinical resources: Abbreviated Westmead Post-traumatic Amnesia Scale A-WPTAS. NSW Health Form261113 NSW, Australia: NSW Government; 2012 [cited 22 Feb 2023]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0008/274067/awptas-form.pdf
- NSW Health. Initial Management of Adult Mild Closed Head Injury. ITIM, Australia: Australian Government; 2016 [cited 22 Feb 2023]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0006/195153/NSW-Health-Initial-management-closed-head-injuries-algorithm2.pdf
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 13 Apr 2022]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- NSW Ministry of Health. Adult Trauma Clinical Guidlines: Initial Management of Closed Head Injury in Adults, 2nd Edition. Sydney, Australia: NSW Government 2011 [cited 22 Feb 2023]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/195150/NSW-Health-Initial-management-closed-head-injuries-full.pdf
- Pearce KL, Sufrinko A, Lau BC, et al. Near point of convergence after a sport-related concussion: measurement reliability and relationship to neurocognitive impairment and symptoms. The American journal of sports medicine. 2015;43(12):3055-61.
- Queensland Brain Institute. How is concussion treated? Queensland, Australia: The University of Queensland; 2018 [cited 22 Feb 2023]. Available from: https://qbi.uq.edu.au/brain/concussion/how-is-concussion-treated
- Queensland Brain Institute. Signs and symptoms of concussion. Queensland, Australia: The University of Queensland; 2018 [cited 22 Feb 2023]. Available from: https://qbi.uq.edu.au/concussion/signs-and-symptoms-concussion
- Queensland Brain Institute. Concussion tests and diagnosis. Queensland, Australia: The University of Queensland; 2018 [cited 22 Feb 2023]. Available from: https://qbi.uq.edu.au/concussion/concussion-tests-and-diagnosis
Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
Currency | Due for review: Jan 2026. Based on a regular review cycle. |
Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/mild-head-injury