Any person, 4 weeks to 15 years, presenting with a history of 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 presents with multiple injuries, escalate as per local CERS protocol and continue treatment.
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
- Pre-hospital treatment
- Actual or potential injuries sustained, including multi-trauma and/or non-accidental injury
- Past admissions
- Medical and surgical history, including neurological or bleeding disorders
- Current medications
- Known allergies
- Immunisation status
- Current weight
Signs and symptoms
- Amnesia, either pre or post event
- Irritability
- Drowsy
- Dizziness
- Headache
- Face or scalp contusions
- Haematoma and/or bruising
- Nausea and/or 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
- Known bleeding disorder or anticoagulation
- Ventriculoperitoneal shunt
- Neurodevelopmental disability
- Age less than 6 months
- Drug and/or alcohol intoxication
- Severe mechanism of injury
- motorbike or cyclist over 30 km/hr
- motor vehicle accident over 60 km/hr
- unrestrained in MCA or not in age-appropriate restraint
- agricultural machinery, quad bike or buggy
- fall from twice the height of the patient
- vehicle vs pedestrian, cyclist or motorbike
- vehicle rollover
- prolonged extrication
- passenger death in the same car
- explosion
- livestock accident
- Signs of non-accidental injury:
- inconsistency in history
- mechanism of injury not consistent with developmental age
Clinical
- Altered level of consciousness
- Persistent amnesia
- Behaviour differing from baseline
- Focal neurology
- Seizure
- Ataxia
- Agitation
- Change in speech, e.g. slurring
- Severe headache
- Any neurological abnormality
- Penetrating head injury
- Large scalp haematoma or laceration
- Neck stiffness or soreness
- Racoon eyes (periorbital ecchymosis)
- Battle’s sign (mastoid bruising)
- Persistent vomiting
- Skull fracture, open, complex or depressed
- Boggy swelling
- Unequal pupils
- Visual disturbances
- Clear fluid or blood from ear and/or nose
- Multiple injuries
Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, 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 |
Suspected cervical spine injury | Stabilise the C-spine with in-line immobilisation 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 work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2) | Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93% |
Circulation
| Assessment | Intervention |
|---|---|
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm | Assess circulation Attach cardiac monitor 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 Consider 12 lead ECG If hypotensive, consider raised intracranial pressure If hypertensive, bradycardic and irregular breathing pattern, i.e. Cushing’s triad, escalate as per local CERS protocol |
IVC and/or pathology | Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present, give sodium chloride 0.9% at 10 mL/kg IV/intraosseous bolus, maximum dose 1000 mL If further fluid resuscitation is required, give sodium chloride 0.9% at 10 mL/kg IV/intraosseous bolus, maximum dose 1000 mL |
Disability
| Assessment | Intervention |
|---|---|
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment as clinically indicated |
| Seizure activity | Switch to seizures protocol |
Severe head injury GCS 3–8 | Immediate escalation as per local CERS protocol Prepare for intubation Maintain inline immobilisation Maintain head position at 30° head up Neurological observations every 5 minutes with continuous BP and cardiac monitoring |
Moderate head injury GCS 9–13 or presence of the following:
| Immediate escalation as per local CERS protocol Maintain inline immobilisation Maintain head position at 30° head up Neurological observations every 15–30 minutes with continuous BP and cardiac monitoring Escalate and treat as severe head injury if any deterioration |
Mild head injury GCS 14–15 | Neurological observations every 30 minutes If signs of deterioration, new or persistent symptoms, reassess severity grading and escalate as per local CERS protocol |
| Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
| Assessment | Intervention |
|---|---|
| Temperature | Measure temperature |
Head-to-toe inspection, including posterior surfaces | Check and document any abnormalities Escalate as per local CERS protocol if multiple injuries are present Examine head and face for:
Assess gait and coordination if patient is safe to mobilise |
Fluids
| Assessment | Intervention |
|---|---|
Hydration status | Assess fluids in and out. Document on fluid balance chart. Include gastrointestinal losses |
| Nausea and/or vomiting | If present, see nausea and/or vomiting section |
| NBM | Consider clear fluids or NBM based on red flags and clinical severity |
Glucose
| Assessment | Intervention |
|---|---|
|
BGL |
Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):
If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:
|
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.
Complete a secondary survey.
Precautions and notes
- Patients less than one year require close observation due to difficulty in clinical assessment and greater risk of non-accidental injuries. A longer observation period may be necessary.
- Complete a cervical spine assessment in all patients with a head injury.
- Clinical signs of raised intracranial pressure are less specific in younger patients.
- A head injury may still be significant without loss of consciousness.
- Patients with suspected drug or alcohol intoxication may be more difficult to assess – assume conscious level relates to injury and have a lower threshold for escalation.
- Give all patients written post-head injury advice.
- Consider the possibility of non-accidental injury.
Interventions and diagnostics
Specific treatment
Treatment will be determined by the severity of the head injury.
Analgesia
Select pain score:
Pain score 1–3 (mild)
Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
Pain score 4–6 (moderate)
Give oxycodone (immediate release):
- 1–12 months: 0.05 mg/kg orally once only, maximum dose 0.5 mg
- 12 months and over: 0.1 mg/kg orally once only, maximum dose 5 mg
and/or paracetamol 15 mg/kg orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
If severe pain present, give analgesia and escalate as per local CERS protocol.
Consider non-pharmacological pain relief (appendix).
Nausea and/or vomiting
If nausea and/or vomiting is present and over 6 months give:
ondansetron:
- 8–15 kg: 2 mg, orally once only
- 15–30 kg: 4 mg, orally once only
- Over 30 kg: 8 mg, orally once only.
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 indicated for minor head injury unless concerns about aetiology of fall.
Moderate or severe head injury or deteriorating neurological status: FBC, UEC, VBG, coags, group and hold
Medications
The patient’s weight is mandatory for calculating fluid and medication doses.
The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.
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 |
|---|---|---|---|
Glucose 40% gel | 4 weeks–1 year: 1–5 years: 5 g 6–11 years: 10 g 12 years and over : 15 g | Buccal | Repeat after 15 minutes if required |
Ibuprofen H, R | 3 months and over: Maximum dose 400 mg | Oral | Pain score 1–10 Once only |
Over 6 months and 8–15 kg: 15–30 kg: Over 30 kg: | Oral | Once only | |
1–12 months: 12 months and over: | Oral | Pain score 4–6 Once only | |
0.25–15 L/min, device dependent | Inhalation | Continuous | |
15 mg/kg Maximum dose 1000 mg | Oral | Pain score 1–10 Once only | |
10 mL/kg Maximum dose 1000 mL | IV/intraosseous | Bolus Repeat once if required |
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
- Babl FE, Tavender E, Ballard DW, et al. Australian and New Zealand guideline for mild to moderate head injuries in children. Emergency Medicine Australasia. 2021 Apr;33(2):214-31. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33528896 DOI: 10.1111/1742-6723.13722
- Australian Medicines Handbook. Adelaide: AMH; c2023 [cited 28 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- Australian Medicines Handbook Children’s Dosing Companion. Adelaide: AMH; c2023 [cited 03 May 2023]. Available from: https://childrens.amh.net.au.acs.hcn.com.au/
- The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Acute otitis media. Melbourne: Victoria Health; 2021 [cited 24 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Acute_Otitis_Media/
- 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
- The Sydney Children's Hospital Network. Concussion and mild head injury. NSW Health; 2015 [cited 28 Feb 2023]. Available from: https://www.schn.health.nsw.gov.au/fact-sheets/concussion-and-mild-head-injury
- Meehan WP, O’Brien MJ. Concussion in children and adolescents: clinical manifestations and diagnosis. UpToDate Waltham, MA: UpToDate Inc Updated on October. 2017;10. [cited 28 Feb 2023]. Available from: https://www.uptodate.com/contents/concussion-in-children-and-adolescents-clinical-manifestations-and-diagnosis
- McTague A, Martland T, Appleton R. Drug management for acute tonic‐clonic convulsions including convulsive status epilepticus in children. Cochrane Database of Systematic Reviews. 2018 Jan 10;1(1):CD001905. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29320603 DOI: 10.1002/14651858.CD001905.pub3
- The Royal Children's Hospital Melbourne. Head injury. Melbourne: Victoria Health; 2020 [cited 28 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Head_injury/
- National Institute for Health Care Excellence. Head Injury: Assessment and Early Management| Guidance and Guidelines. London, United Kingdom: NICE; 2019 [cited 28 Feb 2023]. Available from: https://www.nice.org.uk/guidance/cg176
- Lewis SR, Evans DJW, Butler AR, et al. Hypothermia for traumatic brain injury. Cochrane Database of Systematic Reviews. 2017 Sep 21;9(9):1-95. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28933514 DOI: 10.1002/14651858.CD001048.pub5
- Agency for Clinical Innovation. Infants and Children: Acute Management of Seizures. Sydney: NSW Health; 2016 [cited 27 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/pages/doc.aspx?dn=GL2016_005
- The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
- Schutzman S, Nordli Jr DR. Minor blunt head trauma in infants and young children (< 2 years): Clinical features and evaluation. The Netherland: Wolters Kluwer; 2020 [cited 27 Feb 2023]. Available from: https://www.medilib.ir/uptodate/show/6559
- The Royal Children's Hospital Melbourne. Nitrous Oxide - oxygen mix. Melbourne: Victoria Health; 2021 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Nitrous_Oxide_Oxygen_Mix/
- The Royal Children's Hospital Melbourne. Oxygen delivery. Melbourne: Victoria Health; 2017 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Oxygen_delivery/
| 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/paediatric/head-injury