Head Injury (minor, mild) Nurse Management Guidelines

Red Flag Exclusion Criteria

  • Child at risk of significant harm

  • Suspected non-accidental injury

  • Unplanned repeat ED presentation

  • Infant ≤ 12 months

  • Adult > 65 years

  • Other body regions injured

  • Open or penetrating injury

  • Moderate or high risk mechanism

    • Any accident involving a motorised vehicle or other high-speed mechanism

    • Pedestrian/cyclist struck by vehicle

    • Focal blunt trauma (bat, ball, foot)

  • Fall > 1 metre

  • GCS < 15 on arrival to ED or at any time in ED

  • Loss of consciousness:

    • Child - any

    • Adult - > 5 minutes

  • Post-traumatic amnesia > 30 minutes

  • Seizures immediately prior to, or any time post injury

  • Mild agitation or altered behaviour

  • Abnormal drowsiness

  • Any focal neurological deficit

  • Clinical suspicion of a possible skull fracture

  • More than one vomit post injury

  • Headache:

    • Child - any

    • Adult - severe or persistent

  • Coagulopathic / bleeding disorder (including warfarin, clopidogrel, aspirin or new oral anticoagulant [NOAC] use)

  • Drug or alcohol ingestion

  • History of workplace injury

  • Yellow or Red Zones observations or additional criteria outlined in the NSW Health Standard Observation charts

Additional Observations

  • Neurological observations including GCS, pupil size, pupil response to light, limb movement and limb strength must be completed on all patients

  • For patients ≥ 16 years, within 24hrs of a suspected closed head injury and a GCS of 13-15, commence Abbreviated Westmead Post Traumatic Amnesia Scale (A-WPTAS) assessment

Additional History

  • Establish mechanism of injury

    • How injury was sustained

    • Date and time of injury

  • First aid / NSW ambulance treatment prior to arrival

Management Principles

  1. Provide analgesia as required according to pain scale. Refer to Pain (any cause) NMG

  2. Patient receives hourly observations as per additional observations above for 4 hours as a minimum

  3. If any deterioration in patient condition is detected then medical officer must be immediately notified

  4. If the patient requires increasing amounts of analgesia to manage their pain, notify the medical officer

  5. Patient must be discharged into the care of a responsible adult or carer

  6. Provide patient / carer with head injury discharge information in addition to discharge letter

  7. Document assessment findings, interventions and outcomes

References / Further Resources

  1. Patient Factsheet - Mild Head Injury (NSW Motor Accidents Authority)

  2. ECI Patient Factsheet - Headaches (non-migraine)

  3. NSW Health (2010) Infants and children: Acute management of Head Injury – Clinical Practice Guidelines (2nd Ed.) NSW Ministry of Health, Sydney

  4. NSW Health (2012) Initial Management of Closed Head Injury in Adults: Adult Trauma Clinical Practice Guidelines (2nd Ed.) NSW Ministry of Health, Sydney

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