The Royal College of Emergency Medicine  
 
Best Practice Guideline  
August  2022  Procedural Sedation in 
the Emergency 
Department

Summary of Recommendations  ................................ ................................ ...................  4 
Scope  ................................ ................................ ................................ ...............................  5 
Reason for Development  ................................ ................................ ................................ .. 5 
Introd uction  ................................ ................................ ................................ .......................  5 
RECOMMENDATIONS  ................................ ................................ ................................  6 
1. GOVERNANCE  ................................ ................................ ................................ ........  6 
2. STAFF & TRAINING  ................................ ................................ ................................ . 8

2. STAFF & TRAINING  ................................ ................................ ................................ . 8 
3. ENVIRON MENT  ................................ ................................ ................................ ..... 10 
4. CLINICAL DECISION MAKING  ................................ ................................ ..............  10 
a) Decision to undertake procedural sedation  ................................ ................................  10 
b) Timing of the procedure in relation to fasting ................................ ..............................  11 
c) Preparing for Procedural Sedation  ................................ ................................ .............  11 
d) Non -Sedative drugs  ................................ ................................ ................................ .... 12 
e) Choice of Procedural Sedation Agent  ................................ ................................ ........  13

e) Choice of Procedural Sedation Agent  ................................ ................................ ........  13 
f) Monitoring during AND after procedure  ................................ ................................ ....... 13 
5. CONSIDERATIONS IN YOUNGER PATIENTS  ................................ .....................  15 
a) Ketamine Procedural Sedation and Children ................................ ..............................  15 
6. CONSIDERATIONS IN OLDER PATIENTS  ................................ ...........................  16 
7. CONSIDERATIONS IN PREGNANT PATIENTS  ................................ ....................  16 
Authors  ................................ ................................ ................................ .......................  17 
Acknowledgements  ................................ ................................ ................................ ..... 17

Acknowledgements  ................................ ................................ ................................ ..... 17 
Review  ................................ ................................ ................................ ........................  17 
Declaration of Interes t ................................ ................................ ................................ . 17 
Disclaimers  ................................ ................................ ................................ .................  17 
Research Recommendations  ................................ ................................ .....................  17 
Audit standards  ................................ ................................ ................................ ...........  17 
Key words for search  ................................ ................................ ................................ .. 17

Key words for search  ................................ ................................ ................................ .. 17 
Referenc es ................................ ................................ ................................ .................  18 
Appendix 1  ................................ ................................ ................................ ..................  20 
Appendix 2  ................................ ................................ ................................ ..................  21 
Appendix 2 continued  ................................ ................................ ................................ . 22 
Appendix 3 – Tracking and Reporting Outcomes of Procedural Sedation (TROOPS) 
Quality Improvement Tool  ................................ ................................ ...........................  23 
Appendix 4 - Example of a Patient Information Leaflet  ................................ ...............  24

Appendix 4  ................................ ................................ ................................ ..................  25 
Appendix 5  ................................ ................................ ................................ ..................  26 
Appendix 6  ................................ ................................ ................................ ..................  27 
Appendix 7  ................................ ................................ ................................ ..................  28 
Appendix 8  ................................ ................................ ................................ ..................  29 
Appendix 9  ................................ ................................ ................................ ..................  30 
Appendix 9  ................................ ................................ ................................ ..................  31

Appendix 9  ................................ ................................ ................................ ..................  31 
Appendix 9  ................................ ................................ ................................ ..................  32 
Appendix 10  ................................ ................................ ................................ ................  33 
Appendix 11  Paediatric: Pharmacological Agents for Procedural Sedation  ...............  34

1. Every emergency department should have a sedation lead responsible for ensuring 
the appropriate governance structures are in place in relation to procedura l sedation . 
 
2. Emergency departments undertaking paediatric procedural sedation should have a 
nominated paediatric sedation lead and specific paediatric guidelines.  
 
3. The use of a sedation proforma or similar electronic equivalent is strongly 
recommended.  
 
4. Processes should be in place for adverse incident reporting arising from procedural 
sedation as well as rapid investigation  of significant events . 
 
5. Emergency departments should have clear policies with regards competencies for 
the provision o f procedural sedation in both adults and children as well as , up to date 
lists of those clinicians fulfilling the competencies.  
 
6. Simulation training sessions should be used to promote safe and effective procedural 
sedation in line with local policies.

sedation in line with local policies.  
 
7. Procedural sedation should take place in a designated area of the emergency 
department with the requisite staffing levels and equipment e.g., resuscitation room.  
 
8. Procedural sedation should not take place wit hout careful consideration of the 
analgesic require ment  for the procedure , taking into account any analgesics already 
administered . 
 
9. The clinician who will be responsible for providing the procedural sedation should 
undertake a pre -procedure Safety Brief with the other members of the team . 
 
10. The use of oxygen during procedural sedation is encouraged especially for at risk 
patient groups ( e.g., ischaemic heart disease) and those undergoing deep sedation 
procedures (increased risk of short periods of apnoea).

procedures (increased risk of short periods of apnoea).  
 
11. Monitoring  during procedural sedation  should i nclude:  3 lead ECG, oxygen 
saturations, continuous capnography, n on-invasive blood pressure.  
 
12. The use of a pa tient advice leaflet is  encouraged.

Procedural sedation in adult s and children (excluding neonates) in the Emergency 
Department (ED).  See separate guidance reg arding management of  Acute Behavioural 
Disturbance and the need for rapid tranquilisation (Acute Behavioural Disturbance in 
Emergency Departments Jan 2022 ).  
 
This guidance does not provide advic e regarding anaesthesia or use of Entonox® or 
methoxyflurane  or variable concentration nitrous oxide.  
 
This guidance seeks to amalg amate a number of existing Best Practi ce Guidance 
documents on the subject of procedural sedation . 
 
Procedural sedation (PS) is a core skill for emergency department clinicians .  The ED setting 
provides unique ch allenges , regarding  the need for emergency and  urgent (unscheduled) 
procedures in patients who may have co -existing injuries, illnesses, anxiety and pain who 
may have ingested fluid or food recently.  PS may avoid the need for admission for general

may have ingested fluid or food recently.  PS may avoid the need for admission for general 
anaesthesia both in adults a nd children, but this must not be to the detriment of patient 
safety or quality of care.  
  
Anecdotally, PS practi ce varies widely. This  document  provides guidance on governance 
structures as well as staffing, equipment and pharmacological agents and doses.         
 
Procedural sedation has been defined as ‘the administration of one or more pharmacological 
agents to facilitate a diagnostic or therapeutic procedure while targeting a state during which 
airway patency, spontaneous respiration, protective airway reflexes, and hemodynamic 
stability are preserved, while alleviating anxiety and pain’ [1].  The practice of procedural 
sedation differs from the practice of general anaesthesia, which targets an unarousable state

sedation differs from the practice of general anaesthesia, which targets an unarousable state 
in which airway inter vention is often required and spontaneous ventilation is frequently 
inadequate.  
 
Definitions that concentrate on the continuum between minimal sedation and general 
anaesthesia and the degree of responsiveness, have the advantage of emphasising the 
differi ng competencies required to manage any potential adverse consequences as well as 
the degree of monitoring required and recognise that ED PS is tailored to the individual and 
the intervention required (Appendix 1 ).  Ketamine, which produces a dissociative state,  does 
not fit neatly into the concept of the depth sedation being on a continuum.

The term ‘conscious sedation’ has fallen out of favour , which is unsurprising given most 
emergency physicians would recognise a desired sedation outcome for the majority of 
procedure s performed in the ED as lying somewhere between ‘moderate’ and ‘deep’ 
sedation , often due to the requirement for significant muscle relaxation .  This underlines the 
need for practitioners to be able to  deal with any consequences of the patient attaining a 
deeper level of sedation than was anticipated.  
 
Some of these definitions fail to take into account that the use of certain procedural sedation 
agents are associated with undesirable but not necessaril y unexpected outcomes which can 
be easily anticipated and treated e.g. a short uneventful period of apnoea in a well 
oxygenated patient whilst using propofol . 
 
Safe PS requires the careful consideration of patient factors ( e.g., fasting, co -morbidities,

Safe PS requires the careful consideration of patient factors ( e.g., fasting, co -morbidities, 
potential airway risks), timing of the procedure, the nature of the procedure and the overall 
running of the ED.  S enior emergency physicians are best placed to provide expert opinion 
and leadership  with regards to  decisions relating to procedural sedation f or patients 
presenting to emergency departments . 
 
Every ED should have a sedation lead.   The Sedation Lead should actively participate in 
the development and review of local Standard Operating Procedures (SOPs) for the 
administration of sedation.  The Sedation Lead should also review adverse clinical inc idents 
as well as having an overview of staff training and continuing professional development in 
sedation practice.  
 
ED’s undertaking paediatric PS should have a nominated paediatric sedation lead and 
specific paediatric guidelines.

specific paediatric guidelines.  
 
EDs should use a seda tion proforma or similar to prompt safe and effective care which is 
auditable (Appendix  2).  
 
All EDs should r outine ly audit procedural sedation focusing on compliance with the use of a 
sedation proforma, monitoring during se dation, drugs used for sedation, use of reversal 
agents as well as adverse incidents .  Six monthly audits involving, as a minimum, 20 -30 
patients depending on departmental size are recommended.  
 
Sedation relate d adverse incidents can be defined as ‘unexpected and undesirable 
response(s) to medication(s) and medical intervention used to facilitate procedural sedation 
and analgesia that threaten or cause patient injury or discomfort. ’ [2].

The TROOPS  reporting tool for adverse events should be considered (Appendix 3 ) as it 
focusses both on significant interventions ( e.g., positive pressure ventilation ) and outcomes 
(e.g., unplanned admission to hospital)  without the need to define events in terms of 
‘threshold ’ or ‘duration’ which are often subject to clinician disagreement .   
It should be noted that often certain interventions (e.g., airway re -positioning) are an 
accepted  part of PS and their performance does not necessarily signify a clinical error.   Box 
1 contains a list Never Event relevant to PS and the ED.  
 
The use of an adverse reporting system whether part of a sedation proforma or separate 
e.g., DATIX , is recommended.   There should be prompt analysis of any sentinel events (e.g., 
tracheal intubation , see appendix 3  for more detail)  by the sedation lead . The TROOPS 
reporting tool defines sentinel events as those which are life threatening and warrant

reporting tool defines sentinel events as those which are life threatening and warrant 
immediate reporting and the highest level of peer scrutiny.   Box 1. Never Event List [3] 
1. Wrong site surgery  
 
An invasive procedure  performed on the wrong patient or at the wrong 
site ( e.g., wrong knee, eye, limb). The incident is detected at any time 
after the start of the procedure.  
Includes:  
Interventions that are considered to be surgical but may be done 
outside a surgica l environment – for example, wrong site block 
(including blocks for pain relief), biopsy, interventional radiology 
procedure, cardiology procedure, drain insertion and line insertion ( e.g., 
peripherally inserted central catheter (PICC)/ Hickman lines).  
 
8. Mis-selection of high strength midazolam during 
conscious sedation  
 
Mis-selection refers to when:

Mis-selection refers to when:  
• a patient is given an overdose of midazolam due to the selection of a 
high strength preparation (5 mg/mL or 2 mg/mL) instead of the 1 mg/mL 
preparation, in a clinical area performing conscious sedation  
• excludes clinical areas where the use of high strength midazolam is 
appropriate; these are generally only those performing general 
anaesthesia, intensive care, palliative care, or areas where its use has 
been formally risk -assessed in the organisation.  
 
15. Unintentional connection of a patient requiring 
oxygen to an air flowmeter  
 
This applies when a patient who requires oxygen is connected to an air 
flowmeter when the intention was to connect them to an oxygen 
flowmeter.

Consent (ideally written), if time permits should be gained before any procedure ensuring 
that the rationale, risks , and benefits for both the procedure and the procedural sedation 
have been explained.  Written patient information should also be available addressing the 
likely areas of conc erns a patie nt may have following sedation ( Appendix 4 ). 
 
EM clinicians providing sedation to patients for therapeutic and diagnostic procedures in the 
ED should undergo documented training in the knowledge, skills and competencies 
necessary for safe sedation, to include an understanding of comorbidities that require 
consideration, monitoring during sedation, the recognition of the complications of sedation, 
and the competencies necessary to rescue patients from these complications. Competency 
in relation to both adult and children should be clear.  When appropriate, this train ing should 
be regularly updated  [4].  Relevant online learning can be found at:

be regularly updated  [4].  Relevant online learning can be found at:  
 https://www.rcemlearning.org/modules/propofol -for-procedural -sedation -in-adults/  
 https://www.rcemlearning.co.uk/reference/ketamine -sedation -in-children/  
 
Appendix 5  specifically addresses  issues related to emergency airway management . 
Training and competencies requirement s for the various levels of sedation are shown in the 
tables 1 and 2 below.  
 
 Table 1 Requirements  for Adult Procedural Sedation  [5] 
 
 Moderate 
Sedation  
“conscious 
sedation”  Deep 
Sedation  Dissociate 
Sedation  
Example  Benzodiazepines  Propofol  Ketamine  
 
Monitoring  Pulse Oximetry  
Capnography  
ECG  
NIBP  
 Pulse Oximetry  
ECG  
NIBP  Pulse Oximetry  
ECG  
NIBP  
Minimum 
Staffing  Nurse  
Sedationist  
Proceduralist  Nurse  
Sedationist

ECG  
NIBP  
ECG  
ECG  
NIBP  
Minimum 
Proceduralist  
 
Competencies  ILS / ALS  
Level 1 sedation 
training local sign -
off RCoA initial 
assessment of 
competencies  
 
Level 2 sedation 
 
off 
 
Location  Resus room 
facilities  
(appendix 6)  Resus room 
facilities 
(appendix 6)

Monitoring equipment is not a substitute for skilled staff.  When parenteral procedural 
sedation is taking place one emergency department clinician should be solely responsible 
for providing and monitoring sedation as well as a trained nurse, whilst another clinician 
should be responsible for the procedure.   The names of the two clinicians should be included 
on the sedation proforma.  
 
Both medical and nursing staff should have appropriate paediatr ic competencies in addition 
to the compete ncies above. Staff providing PS  for paediatric patients should have been 
observed by a competent senior clinician prior to independent paediatric sedation.   The 
number of observations necessary will depend on the clinician’s experience and the 
complexity of the procedures observed.  
 
See Appendix 7 regarding Emergency Medicine Advanced C linical Practitioners (EM -ACPs) 
providing safe sedation in the adult Emergency Department .

providing safe sedation in the adult Emergency Department . 
Simulation training sessions should be used to promote safe and effective procedura l 
sedation in line with local policies.  The use of regular simulation training sessions to 
rehearse both routine PS scenarios in the ED, as  well as rarer PS events such as 
laryngospasm during ketamine sedation is strongly recommended.  
 
 Table  2 Training requirements for adult procedural sedation  
 
Level 1 Sedation Training 
Requirements  Level 2  Sedation Training 
Requirements  
ASA grading  As per level 1  
 
Pre-procedural assessment incl. 
prediction of difficult airway  Drug selection with emphasis on 
potential alternative strategies and/or 
lighter sedation  
 
Pre-procedural fasting and risk benefit 
assessment  Monitoring, complications (eg. hypoxia, 
hypotension) and rescue strategies

hypotension) and rescue strategies  
 
Consen t and documentation  Safe use of propofol  
 
Drug selection and preparation: 
benzodiazepine/opiod combiantions; 
increments and reversal  
 Safe use of ketamine  
Monitoring, complications (eg. hypoxia, 
 Governance and audit  
Governance and audit

The ED is often referred to as VUCA (volatile, uncertain, complex, and ambiguous) 
environment, frequently compounded by crowding.  The decision to undertake PS not only 
requires an assessment of having the correct number of skilled staff, as well as the 
appropriateness of the procedure, but also whether the designated sedation area has 
adequate capacity without compromising whole department safety.  
 
PS should take place in a designated area of the ED e.g., Resuscitation Room or speci fically 
designated procedure room with appropriate equipment (Appendix 6 ).  Patients are often 
anxious prior to a sedation procedure and an environment that is as calm and controlled as 
possible will benefit patients.   
 
Paying particular attention to the environment in which a child is sedated (and rec overed) is 
important .  Many ED departments have a resus bay that is appropriately kitted out for

important .  Many ED departments have a resus bay that is appropriately kitted out for 
paediatric emergencies but not dedicated to paediatric patients and not separate d physically 
from other resus bays. Consequently,  these bays may not provide an appropriately calm 
environment for routinely performing paediatric sedation; however,  a pragmatic approach is 
required to balance patient safety  against the available resource within the ED.  
 
Alternatives to procedural sedation should be considered e.g., regional anaesthesia.  When 
considering PS in children, multiple st rategies (distraction, topical analgesia, intra -nasal 
analgesia) may need to be employed to avoid the need to sedate.  
 
Procedural sedation should only be embarked upon after the decision has taken into account  
i. The urgency of the procedure

i. The urgency of the procedure  
ii. Availability of appropriately trained staff  for the procedure and overall safety of the ED  
iii. Availability of appropriate space and equipment  
iv. Patient Assessment (Appendix 8 ) 
v. Patient consent where applicable

It is recognised that in the ED , patients may require emergency or urgent procedures when 
this is often not possible  to delay the procedure .  Emergency clinicians should undertake a 
risk assessment taking into account dynamic risk factors for aspiration e.g., alcohol 
ingestion, established risk factors e.g., obesity, pregnancy, proposed sedation agent ( e.g., 
ketamine helps preserve airway reflexes; propofol reduces airway reflexes) and the 
procedure to be p erformed.  There is no clear evidence that non -compliance with elective 
fasting guidance increases the risk of aspiration or other adverse events during procedural 
sedation; generally, concerns about aspiration vastly exceed the actual risk [6]. 
 
Effective procedural sedation requires:  
Analgesia:  Pain experienced by the patient should be treated with analgesia rather than 
sedation. Pain should be assessed and managed prior to starting sedation using the WHO

sedation. Pain should be assessed and managed prior to starting sedation using the WHO 
pain ladder principles and the need for ongoing pain relief post -procedure considered.  
 
Anxiolysis:  Non-pharmacological methods of reducing anxiety are often the most effective 
and include consideration of the environment and patient comfort. Environment is 
particularly important for children and patients with dementia or learning difficulties. Family 
members often provide invaluable support and distraction. Most painful procedures are best 
performed with the patient supine.  
 
Amnesia:  A degree of amnesia will minimise unpleasant memories associated with the 
procedure.  
 
In most circumstances a combination of short acting analgesics and sedatives are required 
as the only pharmacological agent that has the potential to provide analgesia, sedation, 
anxiolysis and amnesia is ketamine.

anxiolysis and amnesia is ketamine.  
 
The clinician who will be responsible for providing the procedural sedation should undertake 
a pre -procedure Safety Brief with the other members of the team (nurse, clinician performing 
the procedure) ; ensuring that the safety brief does not cause any undue anxiety to the 
patient, see box 2 .

i. Analgesics  
Consideration must be given to the type and duration of analgesic given prior to procedural 
sedation as well as any analgesic which may be needed during the procedure.  The synergist 
effects of some analgesic and sedative combinations e.g., opioids and ben zodiazepines 
must be borne in mind and in particular combinations of short acting opioids and sedation 
agents which depress airway reflexes ( e.g., fentanyl, and propofol).  Consider reducing the 
dose of sedative agents in those patients who have received s ignificant quantities of opiate 
medication . 
 
Whilst not an analgesic, for certain procedures the use of local anaesthetic as well as 
analgesic and sedative may be beneficial.  
 
ii. Oxygen  
The use of oxygen during procedural sedation is encouraged especially  for at risk patient 
groups ( e.g., ischaemic heart disease) and those undergoing deep sedation procedures

ii. Oxygen  
groups ( e.g., ischaemic heart disease) and those undergoing deep sedation procedures 
(increased risk of short periods of apnoea).  Oxygen saturation monitoring as well as 
capnography will be required for the majority of sedation proced ures,  and both must be used 
if a decision has been made not to provide oxygen.  
 
iii. Intravenous Fluids  
The decision to use intravenous fluids or not is likely to be patient dependent as we ll as 
procedural agent specific e.g., running drip prior to commencing propofol sedation.  
 
  Box 2.  The Safety Brief should include:  
 
- Roles  
- Intended plan , including intended depth and length of sedation as  
     well as determining when the procedure can commence.  
- Confirmation of correct side of patient (where applicable)  
- Confir mation of equipment checks have taken place (eg. suction  
         working)

         working)  
- Confirmation of location of rescue devices and drugs  
- Anticipated problems

The appropriate choice of  pharmacological agents for PS depends on:  
i.    The nature of the procedure  
ii.   The planned level of sedation  
iii.  Training and familiarity of the sedating practitioner with potential pharmacological  
 agents  
iv.  Patient factors e.g., cardiovascular stability, fasting status , age  
v.   The local environment  
 
Pharmacological Agents for Procedural Sedation  
There are many variations in the combinations of pharmacological agents described in the 
literature and many different ways of delivering the pharmacological agents. The most 
common agents are described along with the routes and doses for which there is most 
supportive e vidence.  
 
Having selected the appropriate drugs for the needs of the patient, doses of the 
pharmacological agents need to be tailored to the individual patient , as does the speed of 
administration (titration) . Great care should be used when administering sedatives because 
of:

of: 
i.  Slow and variable onset time  
ii. Inter-patient variability in dose requirement  
ii. Synergistic action between drugs  
 
Appendix 9  provide s information regarding  commo n pharmacological age nts used for PS 
and Appendices 10 and 11 provide adult and paediatric doses . 
There is a paucity of evidence for the  superiority of any one agent over another, and similarly 
there is no eviden ce that any agent has greater safety. There is some limited evidence of 
higher procedural success rates for some procedures with easily titratable sedative drugs.  
 
Full monitoring post -procedure should con tinue (with the same facilities available including 
staffing) until the pat ient has regained consciousness.   Monitoring should include:  
 
i.   3 lead ECG,  
ii.  Oxygen saturations,

ii.  Oxygen saturations,  
iii. Continuous capnography,  
iv. Non -invasive blood pressure  
 
The c linicia n performing the PS  should remain with the patient until the patient has ‘woken 
up’.  A nurse should remain with the patient until they have regained consciousness and the 
requirement for additional supportive interventions e.g., oxygen is no longer requir ed.

A senior EP should be responsible for making the decision when a patient’s care can be 
‘stepped down’ to another area within the ED e.g., observation ward, paediatric area . 
 
The decision to provide procedural sedation without any one of the above 4 k ey components 
need s to be justifiable in terms of patient safety based on  the depth of intended sedation, 
length of sedation and the use of supplemental oxygen.  
 
The reversal agents Flumazenil® and Naloxone® are likely to have a shorter half -life than 
their respective benzodiazepine or opiate agonist; therefore,  patients who have required a 
reversal agent should be monitored for a longer period post -sedation than t hose not 
receiving a reversal agent.  The use of a reversal agent  is a ‘TROOP’ recordable  
‘intervention’ and should trigger local review.  
 
Following PS patients should be reviewed by a clinician significantly experienced enough to

Following PS patients should be reviewed by a clinician significantly experienced enough to 
be able to ensure the effects of sedation have worn off and that the patient is safe to go 
home. An alternative approach is ‘nurse led dischar ge criteria’, an example is shown in Box 
3 below .  The use of a patient advice leaflet is strongly encouraged ( example - Appendix 4 ).  
The patient or their carer needs to be clear with regards any follow -up that may be requ ired 
(e.g., fracture clinic) following the procedure as well as the need for any additional 
medication ( e.g., analgesics).  
 
 Box 3. Example of Minimum Discharge Criteria  
 
● Vital signs returned to baseline (no additional oxygen requirement)  
● Alert & Orientated  
● Able to tolerate oral fluids    
● Adequate analgesia  
● No / minimal nausea    
● 2 hours elapsed since use of reversal agent**  
● Appropriate care available at home

● Appropriate care available at home  
 
**Flumazenil, naloxone

Children under the age of 1yr are not normally sedated in the ED.  Procedural sedation in 
the 1 -5yr age group in the emergency department needs to involve senior emergency 
medicine clini cal decision makers and be delivered by clinicians with the requisite additional 
competencies and experience as determined by local governance arrangements.  
 
Paediatric PS can reduce admission rates, reduce length of hospital stay and avoid the need 
for procedures to be performed in theatre. Procedures for which paediatric s edation is most 
frequently used in UK ED’s generally include suturing of lacerations, manipulation of 
dislocation and fractures, foreign  body removal and imaging (CT)  [7].  For many paediatric 
procedures that require sedation  involvement of partner specialities such as plastics, max 
fax, orthopaedics is warranted to ensure optimum outcome.  
 
Ensuring the child or young person is prepared psyc hologically for PS is essential.  Offer

Ensuring the child or young person is prepared psyc hologically for PS is essential.  Offer 
age-appropriate  informat ion about  the procedure itself,  what the child or young person 
should do, what the healthcare professional will do,  the sensation s associated with the 
procedure,  how to cope with the procedure.  
 
Offer parents and carers the opportunity to be present if appropriate and offer them advice 
about their role during the procedure.  
 
When parenteral sedation is used it is recommended that insertion of the cannula is 
achieved in a departmental  location away from the area  used for sedation and temporally  
separated from the sed ation process.  
   
Provision of age-appropriate  distraction techniques is strongly recommended, for example 
using a large computer screen / tablet or a parent’s mobile phone to play videos.  A parent

using a large computer screen / tablet or a parent’s mobile phone to play videos.  A parent 
accompanying the child is also strongly recommended, exce pt where the parent is unable 
to provide calm support. Where available, play specialists are invaluable.  
 
The use of analgesia prior to and during the procedure should always be considered.  
 
The most frequently used sedation agent in the UK for paediatric patients is intravenous 
ketamine followed by variable concentration nitrous oxide. Sedation given should be the 
minimum necessary to facilitate the procedure.  
 
UK EDs have had significant experience in using ketamine sedation in children, initially using 
the intra -muscular route but latterly intravenously. Whilst the use of IM ketamine is still 
recognised as a pragmatic option when used by a senior decision maker , clinicians should

recognised as a pragmatic option when used by a senior decision maker , clinicians should 
be mindful of the perceived safety benefits of having intravenous access from the start of 
the procedure to m itigate a rare adverse event . IM ketamine has a higher risk of emesi s and 
a longer recovery time . IV access also facilitates re peat dosing for longer procedures.  
Please see separate RCEM guideline on Ketamine Procedural Sedation for Children in EDs . 
(also contains another example of a sedation proforma and a paediatric patient information 
leaflet).

When performing procedural sedation in the elderly patient, due care needs to be exercised 
in relation to drug choice, dosage and interactions (analgesics, sedatives and patient’s 
regular medications) as well as the need to take into account the often dela yed onset time 
for sedation agents in this group.  In general,  slower rates of administration and repeated 
doses at less  frequent intervals are recommended  e.g., halving the dose of propofol seems 
both safe and effective [8]. 
 
This group of patients are much more likely to have co -morbidities which impact their 
respiratory and cardiovascular functional reserves and these factors, as well as the patient’s 
regular medications, need to be considered during PS decision making; especially when 
considering fluid and oxygen supplementation.   
 
It is especially important to undertake an airway assessment which also includes the degree 
of neck movement, prior to undertaking procedural sedation.  The need fo r a prolonged

of neck movement, prior to undertaking procedural sedation.  The need fo r a prolonged 
recovery time in a suitable area should also be anticipated.  
 
The incidence of SIVA  sentinel adverse events1 in this high-risk group (over 75yr of age ) 
has been reported as 2.6% (0.5% hypoxia rate), with no adverse outcomes (77% receiving 
propofol) whilst the SIVA  sentinel adverse event rate for those aged 15 -97 years of age 
undergoing sedation with propofol has been reported as 1.1% [9,8].  Decision making 
regarding undertaking procedural sedation in this older age group should carefully bala nce 
the risk of sedation (or other option s) versus the impact on the patient’s quality of life and 
the prevention of significant rapid functional decline  if procedure not carried out.  
 
Procedural sedation in pregnant patients especially in the second and third trimester should

Procedural sedation in pregnant patients especially in the second and third trimester should 
be considered to be high risk and requires the early involvement of a senior clinical decision 
maker.  
 
Considerations include positioning, oxygenation, foetal monitoring,  and pre -procedu ral 
medication. In late second and third trimester, placing the patient on their left side  will reduce 
the risk of hypotension and foetal hypoxaemia  (left latera l displacement of the uterus may  
be an alternative manoeuvre ).  Oxygenation should be provided.  Pre-procedural 
administration of antacid and anti -emetic such as metoclopramide should be considered.  
 
Note : 
1. SIVA sentinel adverse events are slightly different to TROOPS sentinel events and include; Oxygen desaturation, severe or prolonged

Note : 
1. SIVA sentinel adverse events are slightly different to TROOPS sentinel events and include; Oxygen desaturation, severe or prolonged 
(defined as any oxygen saturation <75% or an oxygen saturation <90% for >60 s), apnoea, prolonged (defined as cessation o f respirations 
for >60 s); cardiovascular collapse/shock (defined as clinical evidence of inadequate perfusion); or cardiac arrest (defined as an absent 
pulse) and atropine to treat bradycardia; as well as the TROOPS sentinel events [2].

James Fr ance, Sian Thomas , Gavin Lloyd  
 
RCEM Quality in Emergency Care Committee   
 
Further review usually within three years or sooner if important information becomes 
available.  
 
None  
 
The College recognises that patients, their situations, Emergency Departments and staff all vary. 
This guideline cannot cover all possible scenarios. The ultimate responsibility for the interpretation 
and application of this guideline, the use of current infor mation and a patient’s overall care and 
wellbeing resides with the treating clinician.  
 
None  
 
Use of a sedation proforma  100% 
Consent written or verbal 100 % 
Adverse event monitoring 100 % 
Use of reversal Agents 100 % 
Evidenc e of pre -procedure assessment 100 % 
Measurement of patient’s pain or satisfaction post procedure 50%  
Departmental Sedation Lead and evidence of individual clinician’s competencies  
 
Procedural Sedation, Sedation , Ketamine sedation, Dissociative sedation, Safe sedation,

Procedural Sedation, Sedation , Ketamine sedation, Dissociative sedation, Safe sedation, 
Propofol sedation, Paediatric sedation, Adult sedation, Conscious sedation

1. Green SM, Irwin MG, Mason KP. Procedural sedation:  providing the missing definition. 
Anaesthesia 2 021, 76, 598 –601. 
 
2. Mason KP, Green SM, Piacevoli Q et al.  Adverse event reporting tool to standardize the 
reporting and tracking of adverse events during procedural sedation: a consensus document 
from World SIVA International Sedation Task Force. Br J  Anaesth 2012; 108: 13 -20 
 
3.  Never Events list 2018. First published January 2018 (last updated February 2021). NHS 
Improvement. https://www.england.nhs.uk/publication/never -events/  Accessd 09.02.2022  
 
4. Safe sedation practice for healthcare procedures. An update. Association of Medical 
Royal Colleges February 2021. https://www.aomrc.org.uk/wp -
content/uploads/2021/02/Safe_sedation_practice_for_healthcare_procedures_update_0521.pdf   
Accesse d 09.02.2022  
 
5. Safe Sedation of Adults in theEmergency Department  
Report and Recommendations by The Royal College of Anaesthetists and The College of

Report and Recommendations by The Royal College of Anaesthetists and The College of 
Emergency Medicine Working Party on Sedation, Anaesthesia and Airway Management in 
the Emergency Depart ment November 2012  
https://rcem.ac.uk/wpcontent/uploads/2021/10/Safe_Sedation_in_the_Emergency_Department_Re
port_and_Recom mendations.pdf       Accessed 09.02.2022  
 
6. Green SM et al.  Unscheduled Procedural Sedation: A mulitdisciplinary Consensus 
Practise Guideline.  American College of Emergency Physicians 2018. 
https://www.annemergmed.com/article/S0196 -0644(19)30144 -1/fulltext . Accessed 
09.02.2022  
 
7. Personal Commu nication from a PERUKI study into paediatric procedural sedation in UK 
& Irish emergency departments.  
 
8. Newstead BS,  Bradburn S et al.  Propofol for adult procedural sedation in a UK 
emergencyn department: safety profile in 1008 cases.  British Journal of Anaesthesia 2013;

emergencyn department: safety profile in 1008 cases.  British Journal of Anaesthesia 2013; 
111 (4): 651 –5  
 
9. Homfray G, Palmer A et al. Procedural sedation of elderly patients by emergenc y 
physicians: a safety analysis of 740 patients. British Journal of Anaesthesia, 2018; 121 (6): 
1236e1241  
 
10. American Society of Anesthesiologists. Continuum of Depth of Sedation: Definition of 
General Anesthesia and Levels of Sedation/Analgesia 2019  https://www.asahq.org/standards -
and-guidelines/c ontinuum -of-depth -of-sedation -definition -of-general -anesthesia -and-levels -of-
sedationanalgesia  Accessed 09.02.22

11. Roback  MG, Green  SM, Andolfatto  G et al. Tracking and Reporting Outcomes Of 
Procedural  
Sedation  (TROOPS): Standardized Quality Improvem ent and Research Tools from the 
International C ommittee for the Advancement of Procedural Sedation . Br Journal of Anaesth  
2018; 120(1): 164-172 
 
12. Emergency Airway Management : A joint position statement from the Royal College of 
Emergency Medicine and the Royal College of Anaesthetists, 2015.  
 
13. EM Advanced Clinical Practitioners providing safe sedation in the  adult Emergency 
Department  (November 2020). Accessed 09.02.2022

[10]
 
 Minimal 
Sedation 
Anxiolysis  Moderate 
Sedation/ 
Analgesia 
“Conscious 
Sedation”  Deep 
Sedation/ 
Analgesia  General 
Anesthesia  
Description  is a drug -induced 
state during which 
patients respond 
normally to verbal 
commands. 
Although cognitive 
function and 
physical 
coordination may 
be impaired, 
airway reflexes, 
and ventilatory and 
cardiovascular 
functions are 
unaffected.  is a drug -induced 
depression of 
consciousness 
during which  
purposefully (not 
reflex withdrawal)  
to verbal 
commands, either 
alone or 
accompanied by 
light tactile 
stimulation.  is a drug -induced 
during which 
patients cannot be 
easily aro used but 
respond 
following repeated 
or painful 
loss of 
patients are not 
arousable, even by 
painful stimulation.  
Airway  Unaffected  No intervention 
required  Intervention may

loss of 
required  Intervention may 
be required  Intervention often 
required  
Spontaneous 
Ventilation  Unaffected  Adequate  May be inadequate  Frequently 
inadequate  
Cardiovascular 
Function  Unaffected  Usually maintained  Usually maintained  May be impaired  
 
Dissociative Sedation  
Ketamine is a unique drug in sedation practice because it causes a dissociative state that does not 
fit the standard definitions of sedation listed above. Dissociative sedation is defined as ‘a trance 
like cataleptic state characterized by profound analges ia and amnesia, with retention of protective 
airway reflexes, spontaneous respirations, and cardiopulmonary stability.’

Example of a Procedural Sedation and Analgesia (PSA) Checklist and Monitoring 
Proforma

[12] 
 
Emergency Airway Management:   
A joint position statement from  the Royal College of Emergency Medicine and the Royal 
College of Anaesthetists , 2015.  
 
Building on the report of the 4th National Audit Project of the Royal College of 
Anaesthetists and the Difficult  Airway Society on major airway comp lications (2011),  which 
made several recommendations, the Royal College  of Emergency Medicine and the Royal 
College of Anaesthetists recommend the following:  
 
ENVIRONMENT  
In the Emergency Department (ED) patients with airway emergencies are initially managed 
in the resuscitation  room.  
 
Waveform capnography is always used  
(i) during intubation  
(ii) in patients wh o remain intubated  
(iii) during transfer of intubated patien ts. 
 
Rescue airway devices are immediately available and standardised within the hospital.  
 
All equipment is properly maintained and serviced regularly.  
 
PERSONNEL

PERSONNEL  
EDs should at all times have immediate availability of staff trained and skilled in rapid 
sequence induction and  tracheal intubation and assistants skilled in assistance of such.  
 
PROCESS  
A checklist is used before intubation in the ED. This should identify appropriate preparation 
of the patient, the correct range of equipment and drugs, suitable  team members for each 
role and plans for management of failure and complications.  
 
CLINICAL GOVERNANCE  
Designated leads from the ED and the Department of Anaesthesia/Intensive care should 
agree plans for the management of all common and predictable airway  emergencies.  
 
ED and the Department of Anaesthesia/Intensive Care should have formal proces ses to 
enable interdepartmental training, case discussion and quality improvement. Annual

enable interdepartmental training, case discussion and quality improvement. Annual 
meetings should be a minimum.  
 
TRAINING AND SKILLS MAINTENANCE  
The formal induction of all anaesthetists who may attend the ED resuscitation room should 
include  an inspection of its facilities.  
 
Opportunities for the maintenance of rapid sequence induction and tracheal  intubation 
skills by emergency physicians should be provided within each acute hospital.

Equipment required for Designate Procedural Sedation Room  
 
• Full resuscitation equipment for the administration of basic and advanced life 
support (including airway adjuncts , and equipment for intubation – ETT, 
laryngoscope, bougie etc. ).  Equipment should be cheked daily, and after each use. 
Auitable record of checks should be kept.  
• Continuous high f low oxygen and appropriate devices for administration (eg. non -
rebreath oxygen masks, bag -valve -mask)  
• High pressure suction and appropriate suction catheters  
• Trolley capable of beng tiped head down  
• Monitoring: pulse oximetery, ECG, NIBP, continuous quantit ative capnography  
• Apprpriate range of intrvenous cannulae  
• Appropriate range of intravenous fluid and infusion devices  
• Difficult airway equpment  
• Manual handling devices  
• Clock / event timer  
• Ability to summon help immediately if required  
 
Emergency Drug List (not exhaustive)  
 
• Adrenaline  
• Atropine

• Atropine  
• Dextrose 10% or 20%  
• Amiodarone  
• Naloxone  
• Flumazenil  
• Drugs for emergency intubation

Examples Pre-Procedural Sedation Assessment  
 
Any isues with previous sedation procedures / general anaesthesia  ? 
Allergies, medication, past medical history, last ate & drank, recent alcohol or drugs , 
pregnant.  
 
Assessment to include looking for any issues which may lead to airway obstruction, 
difficulties manipulating the airway or problems ventilating. There are various acronyms  
which may be helpful eg. LEMON, BOOTs as well as formal grading systems eg. Mallampa ti 
 
Risk of aspiration and hypotension should also be considered.  
 
Using the ASA physical status classification is a useful risk assessment tool, with senior 
involvement in those cases ASA III  and above, if procedural sedation canot be deferred.  
 
American Society of Anaesthesiologists  Physical Status (ASA PS) 
Classific ation System  
 
ASA I  Normal health  
ASA II  Mild systemic disease  
ASA III  Severe systemic disease

ASA III  Severe systemic disease  
ASA IV  Severe systemic disease that is a constant threat to life  
ASA V  Moribund, not expected to survive without operation

Commonly used pharmacological agents for Procedural Sedation  
 
Propofol:  
Properties: Phenol derivative, highly lipophilic, crosses blood brain barrier rapidly. Action 
thought to be through positive modulation of GABA inhibitory neurotransmission. Used 
widely for induction and maintenance of anaesthesia.  
 
Uses: Sedation and amnesia.  
 
Administration: Much smaller doses are required for sedation than for general 
anaesthesia, with initial doses as low as 10 mg in the elderly or those with significant co -
morbi dities although the initial action may be seen within 30 s, the peak effect may take 2 
min or more, particularly in the elderly. An alternative technique is to use a computer -
controlled infusion, which estimates the administration profile required for a ta rget plasma 
concentration, normally 0.5 -1.5 μg/ml for sedation.  
 
Children: Propofol is not licensed for use in sedation in children, however the NICE

Children: Propofol is not licensed for use in sedation in children, however the NICE 
Guideline Development Group recommend off -license use of propofol for sedation in 
children  
 
Side effects:  Hypotension, respiratory depression, pain at site of injection  
Allergens: soya and egg lecithin in formulation  
 
Midazolam:  
Properties: Short -acting benzodiazepine metabolised in the liver commonly used for 
sedation, it is also a powerful amnesic.  
  
Uses: Sedation and amnesia  
 
Administration: Can be administered orally, buccally,  or as an IV infusion.  
 
Children: Midazolam is not licensed for use in children under 6 months or for sedation 
either via the oral or buccal route in children. There is no UK marketing authority currently 
for oral or intran asal midazolam use in sedation.   
 
Side effects: respiratory depression, hypotension, paradoxical disinhibition and agitation at

Side effects: respiratory depression, hypotension, paradoxical disinhibition and agitation at 
low doses in children. Accumulates in adipose tissue, which can significantly  prolong 
sedation. The elderly, obese and patients with hepatic or renal disease are at risk of 
prolonged sedation.  
 
Ketamine:  
Properties: Phencyclidine derivative that produces a dissociative state and profound 
analgesia with superficial sleep. Ketamine  does not display a dose -response continuum as 
seen with other analgesic and sedative agents. There is a threshold dose for dissociation 
after which additional doses are required only to maintain the dissociative state. Sub -
dissociative doses provide analg esia with disorientation rather than dissociation.   The big 
advantage of ketamine is that airway reflexes are maintained and that it does not cause 
hypotension.

Uses:  
1. dissociative state, amnesia,  and analgesia  
2. analgesia  
 
Administration: Can be a dministered as a s low IV bolus titrated to effect or intramuscularly.  
 
Side effects: tachycardia, hypertension, laryngospasm, unpleasant hallucinations (reduced 
by pre -medication with a benzodiazepine), nausea and vomiting, hyper -salivation, 
increased intracranial and intraocular pressure.  
 
Contraindications: Absolute contra indications: age less than 3 months, known or 
suspected schizophrenia. Relative contraindications: age less than 1 year, active 
pulmonary disease or infection, known or suspected cardiovascular disease (including 
angina, hypertension and heart failure), CN S masses, abnormalities or hydrocephalus, 
globe injury or glaucoma.  
 
Co-administered pharmacological agents   
1. Prophylactic anticholinergics have been used in the past to reduce hyper -salivation; 
however, there is no support in the literature to any benef it of prophylactic co -

administration.  
2. Benzodiazepines (primarily midazolam) have been recommended in the past to 
minimize recovery reactions. The literature is not supportive of prophylactic use of 
midazolam in children but there may be benefit in adul ts (single controlled study). 
Benzodiazepines can be used, when required to treat unpleasant reactions if they occur.  
3. Anti -emetics are not considered mandatory, a trial using ondansetron showed a 
significant decrease in emesis (8%) in children; however , this evidence was not 
considered strong enough to mandate the use of anti -emetics.  
 
Ketofol:  
Properties: Combination of ketamine and propofol used at a 1:1 ratio in the same syringe 
in the belief that the lower doses reduce side -effects (hypotension a nd vomiting and

Ketofol:  
in the belief that the lower doses reduce side -effects (hypotension a nd vomiting and 
emergence phenomena respectively) of the agents and that  the agents act synergistically.  
  
Uses: sedation, amnesia and analgesia.   
 
Administration: 1:1 mixture in the same syringe.  
Side effects: as for propofol and ketamine  
 
Fentanyl:  
Properties: A synthetic opioid with 72 -125x potency of morphine. Rapid onset (2 -3 
minutes) duration of effect 30 -60mins.  
 
Uses: analgesia and sedation  
 
Administration: Best given a few minutes before sedation to maximise analgesic effect. 
Doses of no more than 0.5 mcg/kg with other sedation agents.

Side effects: Respiratory depression potentiated by sedatives (e.g. propofol). Patients with 
renal or hepatic disease and the elderly may experience more profound or prolonged 
effects.    
 
REVERSAL AGENTS  
 
Flumazenil:  
Properties:  Competitive antagonist at central benzodiazrpeine receptors  
 
Use:  Reversal of respiratory depression following benzodiazepine use.  
 
Administration:  100 -200mcg over 15 seconds, every minute.  Maximum dose 1mg 
(adults), acts 30 -60 seconds.  
 
Side E ffects: Use with caution in those on long tem benzo diazepines.  Hypertension, 
dysrhythm ias and vomiting.  
 
Naloxone:  
Proper ties:  Competitive antagonist at opiate receptors  
 
Use:  Reversal respiratory depression secondary to opioid administration  
 
Administration:  Adults: 100-200mcg every 1 -2 minutes ; Children 11month -11yrs 1 -
10mcg/kg (max 200mcg per dose, total max dose 2mg); children 12 -17yrs 100-200mcg

10mcg/kg (max 200mcg per dose, total max dose 2mg); children 12 -17yrs 100-200mcg 
every 1 -2 minutes  (max dos 2mg) . Acts within 2 minutes and lasts approximately 20 
minutes. Titrate to reverse respiratory depression without reversing analgesia.  
 
Side Effects: Precipit ation of withdrawal in chronic opiate use . Arrhythmias, nausea  
vomitng.

Adult: Pharmacological Agents for Procedural Sedation  
 
Agent 
(references)  Role Route  Initial dose - 
Adult  Repeat 
dose  Initial dose - 
dose  Initial onset 
time (min)  Peak 
effect time 
(min)  
   Elderly  Elderly  Adult  Adult    
Propofol  Sedation/Amnesia  IV 10 - 20 mg 
(given slowly)  10 - 20 mg 
(given 
slowly)  0.5– 1.0 mg/ 
kg 0.5mg/kg 
every 3 -
5mins  ½ - 1 1 - 2 
Midazolam  Sedation/Amnesia  IV (over 1 -
2mins)  0.5mg  0.5mg  1 - 2 mg 
(max single 
dose 2.5mg)  After 2 -
5mins  1 - 2 3 - 4 
Ketamine  
 Sedation/Amnesia/Analgesia  IV 
(give over 30-
60secs)  10 - 30 mg   1 mg/kg  0.25-
0.5mg/kg 
every 5 -10 
mins  ½ - 1 1 - 2 
Ketamine  Sedation/Amnesia/Analgesia  IM   4-5 mg/kg  2 – 2.5 
mg/kg 
every 5 -10 
Ketamine  Analgesia (sub -dissociative)  IV   0.3mg/kg   ½ - 1 1 - 2 
Fentanyl  Analgesia with other sedatives  IV   Up to 
0.5μg/kg  Up to 
0.5μg/kg 
every 2 
mins  1 - 2 3 - 5

0.5μg/kg 
every 2 
mins  1 - 2 3 - 5 
Fentanyl  Sedation/Analgesia  IV   Up to 0.5 to 
1μg/kg  0.5 -
1.0μg/kg 
every 2 
Ketofol 
(ketamine and 
propofol)  Sedation/Amnesia/Analgesia  IV   0.5mg/kg -
0.75mg/kg of 
both agents   ½ - 1 1-2

Paediatric: Pharmacological Agents for Procedural Sedation
 
Agent 
(reference)  Role Route   
Age 
 Initial dose - Paediatric  Maximum 
dose  Repeat dose  Maximum 
dose  Initial 
onset 
time 
(min)  Peak 
effect 
time 
(min)  
Propofol  Sedation/  
Amnesia  IV 6months – 2 years  1mg/kg -2mg/kg*  
  0.5mg/kg every 3 -
5mins*  3mg/kg*  ½ - 1 1 - 2 
> 2 years  0.5 – 1.0 mg/kg*   
Midazolam  Sedation/  
Amnesia  IV 6months - 5yrs  0.025 -0.05mg/kg **  2mg 
(single 
dose)  Up to 0.2mg/kg after 
2-5 mins  Total 6mg  
1 - 2 3 - 4 
6 – 12yrs  0.025 -0.05mg/kg  2mg 
(single 
dose)  0.1mg/kg  Total 10mg  
IM 
Ketamine  Sedation/  
Amnesia/ 
Analgesia  IM > 3months only  4-5mg/kg (many 
authorities/guidelines 
suggest 2 -2.5mg/kg)  
  Half of first dose:   2 -
2.5mg/kg (1mg/kg if 
using lower dose). 
IM after 5 -10mins   
½ - 1 1 - 2 
IV Ketamine   Sedation/  
Amnesia/ 
Analgesia  IV (over 
30-
60secs)  > 3months 
only  
1.0mg/kg***   0.5 mg/kg IV after 5 -
10mins   
½ - 1 1 - 2 
Ketofol

½ - 1 1 - 2 
Amnesia/ 
30-
only  
10mins   
½ - 1 1 - 2 
Ketofol 
(ketamine 
and 
propofol)  Sedation/  
Amnesia/ 
Analgesia  IV > 6months 
only 0.5mg/kg propofol and 
ketamine   
  
½ - 1 1-2 
 
*reduce dose significantly in patients who are debilitated or have decreased cardiac function  
** This is BNF dosing regime, many sources suggest higher dose range of 0.05-0.1mg/kg required  
*** See RCEM Ketamine Procedural Sedation for Children in EDs  (Feb 2020)

Royal College of Emergency Medicine  
Octavia House  
54 Ayres Street  
London  
SE1 1EU  
Tel: +44 (0)20 7400 1999  
Fax: +44 (0)20 7067 1267  
www.rcem.ac.uk   
Incorporated by Royal Charter, 2008  
Registered Charity number 1122689  
Excellence in Emergency Care

Head in jury: assessmen t 
and e arly manag emen t 
NICE guideline 
Published: 18 Ma y 2023 
www .nice.or g.uk/guidance/ng232 
© NICE 2023 . All right s reserved. Subject t o Notice of right s (https://www .nice.or g.uk/t erms-and-
conditions#notice-of -right s).

Your r esponsi bility 
The r ecommendations in t his guideline r epresent t he view of NICE, arriv ed at aft er car eful 
consideration of t he evidence a vailable. When e xercising t heir judgement, pr ofessionals 
and practitioners ar e expect ed to tak e this guideline fully int o account, alongside t he 
individual needs, pr eferences and v alues of t heir patient s or t he people using t heir ser vice. 
It is not mandat ory to apply t he recommendations, and t he guideline does not o verride t he 
responsibility t o mak e decisions appr opriat e to the cir cumstances of t he individual, in 
consultation wit h them and t heir f amilies and car ers or guar dian. 
All pr oblems (adv erse e vents) related to a medicine or medical de vice used f or treatment 
or in a pr ocedur e should be r epor ted to the Medicines and Healt hcare product s Regulat ory 
Agency using t he Yellow Car d Scheme . 
Local commissioners and pr oviders of healt hcare have a responsibility t o enable t he

Local commissioners and pr oviders of healt hcare have a responsibility t o enable t he 
guideline t o be applied when individual pr ofessionals and people using ser vices wish t o 
use it. The y should do so in t he cont ext of local and national priorities f or funding and 
developing ser vices, and in light of t heir duties t o have due r egar d to the need t o eliminat e 
unlawful discrimination, t o adv ance equality of oppor tunity and t o reduce healt h 
inequalities. Not hing in t his guideline should be int erpreted in a wa y that w ould be 
inconsist ent wit h complying wit h those duties. 
Commissioners and pr oviders ha ve a responsibility t o promot e an en vironmentally 
sustainable healt h and car e syst em and should assess and r educe t he en vironmental 
impact of implementing NICE r ecommendations  wher ever possible. Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 2 of
74

Contents 
Overview .................................................................................................................................... 5 
Who is it f or? ......................................................................................................................................... 5 
Recommendations ..................................................................................................................... 6 
1.1 Decision making and mental capacity ........................................................................................... 6 
1.2 Pr e-hospital assessment, advice and r eferral t o hospital .......................................................... 6 
1.3 Immediat e management at t he scene and transpor t to hospital .............................................. 10 
1.4 Assessment in t he emer gency depar tment ................................................................................. 14

1.4 Assessment in t he emer gency depar tment ................................................................................. 14 
1.5 Investigating clinically impor tant traumatic brain injuries .......................................................... 17 
1.6 Investigating injuries t o the cer vical spine ................................................................................... 22 
1.7 Information and suppor t for families and car ers ......................................................................... 26 
1.8 Transf er from hospital t o a neur oscience unit ............................................................................. 27 
1.9 Admission and obser vation ........................................................................................................... 30 
1.10 Dischar ge and f ollow up ............................................................................................................... 35

1.10 Dischar ge and f ollow up ............................................................................................................... 35 
Terms used in t his guideline ................................................................................................................ 39 
Recommendations f or resear ch ............................................................................................... 45 
Key recommendations f or resear ch ................................................................................................... 45 
Other r ecommendations f or resear ch ................................................................................................ 47 
Rationale and impact ................................................................................................................. 50 
Decision making and mental capacity ................................................................................................ 50

Decision making and mental capacity ................................................................................................ 50 
Transpor t to hospital ............................................................................................................................ 50 
Tranexamic acid ................................................................................................................................... 51 
Direct access fr om t he community t o imaging .................................................................................. 53 
Assessment in t he emer gency depar tment ...................................................................................... 54 
Criteria f or doing a CT head scan ....................................................................................................... 55 
Post-concussion syndr ome ................................................................................................................. 60

Post-concussion syndr ome ................................................................................................................. 60 
Investigating injuries t o the cer vical spine ........................................................................................ 62 
Admission and obser vation ................................................................................................................. 63 Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 3 of
74

Early diagnosis of h ypopituitarism ...................................................................................................... 66 
Dischar ge and f ollow up ...................................................................................................................... 67 
Follow up ............................................................................................................................................... 68 
Investigations f or hypopituitarism ...................................................................................................... 69 
Cont ext ....................................................................................................................................... 71 
Finding mor e information and committ ee details ................................................................... 73

Finding mor e information and committ ee details ................................................................... 73 
Updat e information ................................................................................................................... 74 Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 4 of
74

This guideline r eplaces CG17 6. 
This guideline is t he basis of QS7 4. 
Overview 
This guideline co vers assessment and early management of head injur y in babies, childr en, 
young people and adult s. It aims t o ensur e that people ha ve the right car e for the se verity 
of their head injur y, including dir ect r eferral t o specialist car e if needed. 
See NICE's guideline on major trauma: ser vice deliv ery for recommendations on pr e-
hospital triage, transf er and pr e-aler t procedur es, pr ocedur es for receiving people in 
trauma unit s and major trauma centr es, documentation, monit oring and audit, and access 
to major trauma ser vices. 
Who is i t for? 
• Healt hcare professionals 
• People wit h a head injur y, their f amilies and car ers 
• Commissioners and pr oviders Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 5 of
74

Recommenda tions 
People ha ve the right t o be in volved in discussions and mak e informed decisions 
about t heir car e, as described in NICE's inf ormation on making decisions about y our 
care. 
Making decisions using NICE guidelines  explains ho w we use w ords to sho w the 
strengt h (or cer tainty) of our r ecommendations, and has inf ormation about 
prescribing medicines (including off -label use), pr ofessional guidelines, standar ds 
and laws (including on consent and mental capacity), and saf eguar ding. 
For the purposes of t his guideline, a head injur y is defined as an y trauma t o the head ot her 
than super ficial injuries t o the face. Also, babies ar e defined as being under 1  year, and 
childr en and y oung people as being 1  year t o under 16  years. 
1.1 Decision making and men tal c apaci ty 
1.1.1 For recommendations on pr omoting wa ys for healt hcare professionals 
and people using ser vices t o work t oget her t o mak e decisions about

and people using ser vices t o work t oget her t o mak e decisions about 
treatment and car e, see NICE's guideline on shar ed decision making . 
[2023] 
1.1.2 For recommendations on decision making in people 16 and o ver who ma y 
lack capacity no w or in t he futur e, including inf ormation on adv ance car e 
plans, see NICE's guideline on decision making and mental capacity . 
[2023] 
For a shor t explanation of wh y the committ ee made t hese r ecommendations and ho w 
they might aff ect practice or ser vices, see t he rationale and impact section on 
decision making and mental capacity . 
1.2 Pre-hospi tal assessmen t, ad vice and r eferral to Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 6 of
74

hospi tal 
1.2.1 Public healt h literatur e and ot her non-medical sour ces of advice (f or 
example, St John Ambulance and police officers) should encourage 
people who ha ve any concerns aft er a head injur y to themselv es or t o 
anot her person, r egar dless of t he injur y severity, to seek immediat e 
medical advice. [2003] 
Remote ad vice ser vices 
1.2.2 Remot e advice ser vices (f or example, NHS 111) should r efer people who 
have sustained a head injur y to the emer gency ambulance ser vices (t hat 
is, 999) f or emer gency transpor t to the emer gency depar tment if t here 
are any of t hese risk f actors (see NICE's guidelines on shar ed decision 
making  and decision making and mental capacity ): 
• unconsciousness or lack of full consciousness (f or example, pr oblems k eeping 
eyes open) 
• any focal neur ological deficit  since t he injur y 
• any suspicion of a comple x skull fractur e or penetrating head injur y

eyes open) 
• any suspicion of a comple x skull fractur e or penetrating head injur y 
• any seizur e ('con vulsion' or 'fit') since t he injur y 
• a high-ener gy head injur y 
• there is no ot her wa y of saf ely transpor ting t he person t o the hospital 
emer gency depar tment (see r ecommendation  1.2.3). [2003 , amended 200 7, 
2014 and 2023] 
1.2.3 Remot e advice ser vices (f or example, NHS 111) should r efer people who 
have sustained a head injur y to a hospital emer gency depar tment if t here 
making and decision making and mental capacity): 
• any loss of consciousness ('knock ed out') because of t he injur y, from which t he 
person has no w recovered Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 7 of
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• amnesia f or events bef ore or aft er the injur y ('pr oblems wit h memor y'; it will not 
be possible t o assess amnesia in childr en who ar e preverbal and is unlik ely to 
be possible in childr en under 5) 
• a persist ent headache since t he injur y 
• any vomiting episodes since t he injur y 
• any previous brain sur gery 
• any hist ory of bleeding or clotting disor ders 
• current anticoagulant and antiplat elet ( except aspirin monot herap y) treatment 
• current drug or alcohol int oxication 
• any saf eguar ding concerns (f or example, possible non-accidental injur y or a 
vulnerable person is aff ected) 
• irritability or alt ered beha viour ( easily distract ed, not t hemselv es, no 
concentration, no int erest in t hings ar ound t hem), par ticularly in babies and 
childr en under 5 
• continuing concern b y helpline staff about t he diagnosis. [2003 , amended 
Comm unity health ser vices and in patient uni ts wi thou t an 
emer gency depar tmen t

emer gency depar tmen t 
1.2.4 Community healt h ser vices (GPs, ambulance cr ews, NHS walk -in or 
minor injur y centr es, dental practitioners) and inpatient unit s wit hout an 
emer gency depar tment should r efer people who ha ve sustained a head 
injury to a hospital emer gency depar tment, using t he ambulance ser vice 
if necessar y, if there are any of t hese risk f actors (see NICE's guidelines 
on shar ed decision making  and decision making and mental capacity ): 
• a Glasgo w Coma Scale  (GCS) scor e of less t han 15 on initial assessment 
• any loss of consciousness because of t he injur y 
• any focal neur ological deficit  since t he injur y Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 8 of
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• any suspicion of a comple x skull fractur e or penetrating head injur y since t he 
injury 
• amnesia f or events bef ore or aft er the injur y (it will not be possible t o assess 
amnesia in childr en who ar e preverbal and is unlik ely to be possible in childr en 
under 5) 
• any vomiting episodes since t he injur y (use clinical judgement about t he cause 
of vomiting in childr en 12 y ears or under and t he need f or referral) 
• any seizur e since t he injur y 
• continuing concern b y the pr ofessional about t he diagnosis. [2003 , amended 
200 7, 2014 and 2023]

200 7, 2014 and 2023] 
1.2.5 In the absence of an y risk f actors in r ecommendation  1.2.4, consider 
referral t o an emer gency depar tment if an y of t hese f actors ar e present, 
depending on judgement of se verity (see NICE's guidelines on shar ed 
decision making and decision making and mental capacity): 
• irritability or alt ered beha viour , par ticularly in babies and childr en under 5 
• visible trauma t o the head not co vered in r ecommendation  1.2.4 but still of 
concern t o the pr ofessional 
• no one is able t o obser ve the injur ed person at home Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 9 of
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• continuing concern b y the injur ed person, or t heir f amily or car er, about t he 
diagnosis. [2003 , amended 2014 and 2023] 
Transpor t to hospi tal fr om c omm unity health ser vices and 
inpatient uni ts wi thou t an emer gency depar tmen t 
1.2.6 Ensur e people r eferred fr om community healt h ser vices ar e accompanied 
by a compet ent adult during transpor t to the emer gency depar tment. 
[2003] 
1.2.7 The r eferring pr ofessional should det ermine if an ambulance is needed, 
based on t he person's clinical condition. If an ambulance is not needed, 
provided t he person is accompanied, public transpor t or being driv en in a 
car ar e appr opriat e means of transpor t. [2003] 
1.2.8 The r eferring pr ofessional should inf orm t he destination hospital (b y 
phone) of t he impending transf er. In non-emer gencies, a lett er 
summarising signs and sympt oms should be sent wit h the person. 
[2003] 
Training in risk assessmen t

[2003] 
Training in risk assessmen t 
1.2.9 Train GPs, nurse practitioners, dentist s and ambulance cr ews, as 
necessar y, to ensur e that t hey are capable of assessing t he pr esence or 
absence of t he risk f actors list ed in t he section on community healt h 
services and inpatient unit s wit hout an emer gency depar tment . [2003 , 
amended 200 7] 
1.3 Imme diate manag emen t at the sc ene and 
transpor t to hospi tal 
Glasgow Coma Sc ale 
1.3.1 Base monit oring and e xchange of inf ormation about people wit h a head 
injury on t he 3 separat e responses on t he GCS (f or example, describe a 
person wit h a GCS scor e of 13 based on scor es of 4 on e ye opening, 4 Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 10 of
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on verbal r esponse and 5 on mot or response as E4 , V4, M5). [2003] 
1.3.2 When r ecording or passing on inf ormation about t otal GCS scor e, giv e 
this as a scor e out of 15 (f or example, 13 out of 15). [2003] 
1.3.3 Describe t he individual component s of t he GCS in all communications 
and e very patient r ecord and ensur e that t hey alwa ys accompan y the 
total scor e. [2003] 
1.3.4 In the paediatric v ersion of t he GCS, include a 'grimace' alt ernativ e to the 
verbal scor e to enable scoring in childr en who ar e preverbal. [2003] 
1.3.5 In some people (f or example, people wit h dementia, underlying chr onic 
neurological disor ders or learning disabilities), t he pr e-injur y baseline 
GCS scor e ma y be less t han 15 . Establish t his when possible and tak e it 
into account during assessment. [2014] 
Initial assessmen t and c are 
1.3.6 Initially assess people 16 and o ver who ha ve sustained a head injur y and

1.3.6 Initially assess people 16 and o ver who ha ve sustained a head injur y and 
manage t heir car e accor ding t o clear principles and standar d practice, as 
embodied in t he: 
• Advanced T rauma Lif e Suppor t course or Eur opean T rauma course 
• International T rauma Lif e Suppor t course 
• Pre-hospital T rauma Lif e Suppor t course 
• Advanced T rauma Nurse Course 
• Trauma Nursing Cor e Course 
• Joint R oyal Colleges Ambulance Ser vice Liaison Committ ee Clinical Practice 
Guidelines f or Head T rauma. [2003 , amended 200 7] 
1.3.7 Initially assess people under 16 who ha ve sustained a head injur y and 
manage t heir car e accor ding t o clear principles out lined in t he: Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 11 of
74

• Advanced Paediatric Lif e Suppor t course or Eur opean Paediatric Lif e Suppor t 
course 
• Pre-hospital Paediatric Lif e Suppor t course 
• Paediatric Education f or Pr e-hospital Pr ofessionals course. [2003 , amended 
200 7] 
1.3.8 When administ ering immediat e car e, first tr eat t he gr eatest t hreat t o life 
and a void fur ther harm. F or advice on v olume r esuscitation f or people 
with a traumatic brain injur y and haemorrhagic shock, see NICE's 
guideline on major trauma: assessment and initial management . [2003] 
1.3.9 For recommendations on when t o carr y out full in-line spine 
immobilisation and ho w long immobilisation is needed if indicat ed, see 
NICE's guideline on spinal injur y. [2003 , amended 200 7] 
1.3.10 Make pre-aler t calls t o the destination emer gency depar tment f or 
anyone wit h a GCS scor e of 8 or less t o ensur e appr opriat ely 
experienced pr ofessionals ar e available f or their tr eatment and t o 
prepar e for imaging. [2003]

prepar e for imaging. [2003] 
1.3.11 Manage pain eff ectiv ely because it can lead t o a rise in intracranial 
pressur e. Pr ovide r eassurance, splint limb fractur es and cat heterise a full 
bladder when needed. Also see NICE's guideline on major trauma: 
assessment and initial management. [200 7, amended 2014] 
1.3.12 Alwa ys follow best practice in paediatric coma obser vation and 
recording, as detailed b y the National Paediatric Neur oscience 
Benchmarking Gr oup. [2003] 
Transpor t to hospi tal 
1.3.13 Transpor t people who ha ve sustained a head injur y directly to a major 
trauma centr e or trauma unit t hat has t he age-appr opriat e resour ces t o 
further r esuscitat e them, and t o investigat e and initially manage multiple 
injuries. [2023]

injuries. [2023] 
1.3.14 For guidance on t he car e of people wit h major trauma, see NICE's Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 12 of
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guideline on major trauma: ser vice deliv ery. [2023] 
transpor t to hospital . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview B: 
transpor t to a distant specialist neur oscience centr e. 
Training f or ambulanc e crews and par amedics 
1.3.15 Ambulance cr ews and paramedics should be fully trained in t he use of 
the adult and paediatric v ersions of t he GCS and it s deriv ed scor e. 
[2003] 
1.3.16 Ambulance cr ews and paramedics should be trained in t he saf eguar ding 
of people under 16 and people 16 and o ver who ar e vulnerable. The y 
should document and v erbally inf orm emer gency depar tment staff of an y 
safeguar ding concerns. [2003 , amended 2014] 
Tranexamic acid 
1.3.17 For people wit h a head injur y and a GCS scor e of 12 or less who ar e not

1.3.17 For people wit h a head injur y and a GCS scor e of 12 or less who ar e not 
thought t o have activ e extracranial bleeding, consider: 
• a 2 g intra venous bolus injection of trane xamic acid f or people 16 and o ver 
• a 15 mg/k g to 30  mg/k g (up t o a maximum of 2  g) intra venous bolus injection of 
trane xamic acid f or people under 16 . 
Give the trane xamic acid as soon as possible wit hin 2  hours of t he injur y, in the 
pre-hospital or hospital setting and bef ore imaging. In Mar ch 2023 , these w ere 
off-label uses of trane xamic acid. See NICE's inf ormation on pr escribing 
medicines . [2023] 
1.3.18 For people wit h a head injur y, and suspect ed or confirmed e xtracranial 
bleeding, see t he recommendations in t he section on haemostatic agent s Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 13 of
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in pre-hospital and hospital settings in NICE's guideline on major trauma: 
assessment and initial management . [2023] 
trane xamic acid . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview A: 
Direct access fr om the c omm unity to imag ing 
1.3.19 Do not r efer people who ha ve had a head injur y for neur oimaging b y 
direct access fr om t he community . [2023] 
For a shor t explanation of wh y the committ ee made t his recommendation and ho w it 
might aff ect practice or ser vices, see t he rationale and impact section on dir ect 
access fr om t he community t o imaging . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview C: 
direct access fr om t he community t o imaging .

direct access fr om t he community t o imaging . 
1.4 Assessmen t in the emer gency depar tmen t 
1.4.1 Be awar e that t he priority f or all people admitt ed to an emer gency 
depar tment is t o stabilise t he air way, breathing and cir culation (ABC) 
before att ending t o other injuries. See NICE's guideline on major trauma: 
assessment and initial management . [2003] 
1.4.2 Only assume a depr essed conscious le vel is due t o intoxication aft er an 
impor tant traumatic brain injur y has been e xcluded. [2003] 
1.4.3 Ensur e all emer gency depar tment clinicians in volved in assessing people 
with a head injur y are capable of assessing t he pr esence or absence of 
the risk f actors f or CT head imaging list ed in t he recommendations on Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 14 of
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the crit eria f or doing a CT head scan  and t he criteria f or doing a cer vical 
spine scan in people 16  and o ver and people under  16. Mak e training 
available as needed t o ensur e this. [2003] 
1.4.4 Ensur e people pr esenting t o the emer gency depar tment wit h impair ed 
consciousness (a GCS scor e of less t han 15) ar e assessed immediat ely 
by a trained member of staff . [2003] 
1.4.5 For people wit h a GCS scor e of 12 or less, see t he recommendations on 
trane xamic acid . [2023] 
1.4.6 For people wit h a GCS scor e of 8 or less, ensur e early in volvement of an 
appr opriat ely trained clinician t o provide adv anced air way management, 
as described in recommendations 1 .8.7 and 1 .8.8 in t he section on 
transf er of people 16  and o ver, and t o assist wit h resuscitation. [2003] 
1.4.7 Ensur e a trained member of staff assesses an yone pr esenting t o an 
emer gency depar tment wit h a head injur y wit hin a maximum of

emer gency depar tment wit h a head injur y wit hin a maximum of 
15 minut es of arriv al at hospital. Par t of t his assessment should establish 
whet her t hey are at high or lo w risk f or clinically impor tant traumatic 
brain or cer vical spine injur y, as described in t he recommendations on 
the crit eria f or doing a CT head scan and t he crit eria f or doing a CT 
cervical spine scan in people  16 and o ver and people under  16. [2003] 
1.4.8 In people consider ed to be at high risk f or clinically impor tant traumatic 
brain or cer vical spine injur y, extend assessment t o full clinical 
examination t o establish an y need f or CT imaging of t he head, or imaging 
of the cer vical spine and ot her body ar eas. Use t he recommendations on 
cervical spine scan in people 16  and o ver and people under  16 as t he

cervical spine scan in people 16  and o ver and people under  16 as t he 
basis f or the final decision on imaging aft er discussion wit h the radiology 
depar tment. [2003 , amended 200 7] 
1.4.9 Anyone triaged t o be at lo w risk f or clinically impor tant traumatic brain or 
cervical spine injur y at initial assessment should be r e-examined b y an 
emer gency depar tment clinician. The y should establish whet her CT 
imaging of t he head or cer vical spine will be needed. Use t he 
recommendations on t he crit eria f or doing a CT head scan and t he Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 15 of
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criteria f or doing a cer vical spine scan in people 16  and o ver and people 
under  16 as t he basis f or the final decision on imaging aft er discussion 
with the radiology depar tment. [2003 , amended 200 7 and 2023] 
1.4.10 Review people who r eturn t o an emer gency depar tment wit h any 
persist ent complaint r elating t o the initial head injur y and discuss t hem 
with a senior clinician e xperienced in head injuries. Consider whet her a 
CT scan is needed. [2003 , amended 2023] 
1.4.11 Manage pain eff ectiv ely to help pr event an y rise in intracranial pr essur e. 
Provide r eassurance, splint limb fractur es and cat heterise a full bladder 
when needed. See NICE's guideline on major trauma: assessment and 
initial management f or inf ormation on pain management. [200 7] 
1.4.12 Consider or suspect abuse, neglect or ot her saf eguar ding issues as a 
contribut ory factor to, or cause of , a head injur y. See NICE's guidelines

contribut ory factor to, or cause of , a head injur y. See NICE's guidelines 
on child maltr eatment , child abuse and neglect , domestic violence and 
abuse  and safeguar ding adult s in car e homes  for clinical f eatur es that 
may be associat ed wit h maltr eatment. [2023] 
might aff ect practice or ser vices, see t he rationale and impact section on assessment 
in the emer gency depar tment . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview D: 
clinical decision rules selecting people wit h head injur y for imaging . 
1.4.13 Involve a clinician wit h training in saf eguar ding in t he initial assessment 
of an y person wit h a head injur y presenting t o the emer gency 
depar tment. If t here are any concerns identified, document t hese and

depar tment. If t here are any concerns identified, document t hese and 
follow local saf eguar ding pr ocedur es appr opriat e to the person's age. 
[2003 , amended 2014] 
1.4.14 Use a standar d head injur y proforma f or documentation when assessing 
and obser ving people wit h a head injur y throughout t heir time in hospital. 
This f orm should be of a consist ent f ormat acr oss all clinical depar tment s 
and hospitals in which a person might be tr eated. Use a separat e Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 16 of
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proforma f or people under  16. Include ar eas t o allo w extra documentation 
(for example, in cases of non-accidental injur y). [2003 , amended 200 7] 
Involving the neur osur gical depar tmen t 
1.4.15 Discuss wit h a neur osurgeon t he car e of an yone wit h new and sur gically 
significant abnormalities on imaging. The definition of 'sur gically 
significant' should be de veloped b y local neur osurgical centr es and 
agreed wit h referring hospitals, along wit h referral pr ocedur es. [2003 , 
amended 2014] 
1.4.16 Regar dless of imaging, discuss a person's car e plan wit h a neur osurgeon 
if they have: 
• persisting coma (a GCS scor e of 8 or less) aft er initial r esuscitation 
• unexplained confusion t hat persist s for mor e than 4  hours 
• deterioration in GCS scor e aft er admission (pa y mor e att ention t o mot or 
response det erioration) 
• progressiv e focal neur ological signs 
• a seizur e wit hout full r ecovery 
• a definit e or suspect ed penetrating injur y

• a definit e or suspect ed penetrating injur y 
• a cer ebrospinal fluid leak. [2003] 
1.5 Investig ating clinic ally im portant trauma tic 
brain in juries 
1.5.1 The curr ent primar y investigation of choice f or det ecting an acut e 
clinically impor tant traumatic brain injur y is CT imaging of t he head. 
[2003] 
1.5.2 For saf ety, logistic and r esour ce reasons, do not do MRI scanning as t he 
primar y investigation f or clinically impor tant traumatic brain injur y in 
people who ha ve sustained a head injur y. But additional inf ormation of Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 17 of
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impor tance t o prognosis can sometimes be det ected using MRI. [2003] 
1.5.3 Ensur e that t here is appr opriat e equipment f or monit oring people wit h a 
head injur y who ar e having an MRI scan. Also ensur e that all staff 
involved ar e awar e of t he dangers and necessar y precautions f or 
working near an MRI scanner . [2003] 
1.5.4 Do not use plain X -rays of t he skull t o diagnose impor tant traumatic brain 
injury bef ore a discussion wit h a neur oscience unit. Ho wever, people 
under  16 pr esenting wit h suspect ed non-accidental injur y ma y need a 
skeletal sur vey. [200 7] 
1.5.5 Arrange transf er to a suitable hospital f or people wit h indications f or a CT 
scan who pr esent t o a hospital wher e CT scans ar e not a vailable (see t he 
recommendations on t he crit eria f or doing a CT head scan  and t he 
criteria f or doing a CT cer vical spine scan in people 16  and o ver and 
people under  16). [200 7, amended 2023]

people under  16). [200 7, amended 2023] 
1.5.6 Trauma netw orks should mak e sur e that people can be transf erred as 
indicat ed in r ecommendation  1.5.5. [200 7, amended 2023] 
1.5.7 In line wit h good radiation e xposur e practice, mak e every eff ort to 
minimise radiation dose during imaging of t he head and cer vical spine, 
while ensuring t hat image quality and co verage is sufficient t o achie ve an 
adequat e diagnostic study . [2003] 
Criteria f or doing a CT he ad sc an 
People 16  and o ver 
1.5.8 For people 16  and o ver who ha ve sustained a head injur y, do a CT head 
scan wit hin 1  hour of an y of t hese risk f actors being identified: 
• a GCS scor e of 12 or less on initial assessment in t he emer gency depar tment 
• a GCS scor e of less t han 15 at 2  hours aft er the injur y on assessment in t he

• a GCS scor e of less t han 15 at 2  hours aft er the injur y on assessment in t he 
emer gency depar tment Head injur y: assessment and early management (NG232)
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• suspect ed open or depr essed skull fractur e 
• any sign of basal skull fractur e (haemotympanum, 'panda' e yes, cer ebrospinal 
fluid leakage fr om t he ear or nose, Batt le's sign) 
• post-traumatic seizur e 
• focal neur ological deficit 
• more than 1  episode of v omiting. [2023] 
1.5.9 For people 16  and o ver who ha ve had some loss of consciousness or 
amnesia since t he injur y, do a CT head scan wit hin 8  hours of t he head 
injury, or wit hin the hour in someone pr esenting mor e than 8  hours aft er 
the injur y, if they have any of t hese risk f actors: 
• age 65  or over 
• any curr ent bleeding or clotting disor ders 
• danger ous mechanism of injur y (a pedestrian or cy clist struck b y a mot or 
vehicle, an occupant eject ed fr om a mot or vehicle or a f all from a height of 
more than 1  m or 5  stairs) 
• more than 30  minut es' retrograde amnesia of e vents immediat ely bef ore the 
head injur y. [2023] 
People under  16

People under  16 
1.5.10 For people under  16 who ha ve sustained a head injur y, do a CT head 
• suspicion of non-accidental injur y 
• on initial emer gency depar tment assessment, a GCS scor e of less t han 14 or , 
for babies under 1  year, a GCS scor e (paediatric) of less t han 15 
• at 2 hours aft er the injur y, a GCS scor e of less t han 15 
• suspect ed open or depr essed skull fractur e, or t ense f ontanelle Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 19 of
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• for babies under 1  year, a bruise, sw elling or laceration of mor e than 5  cm on 
the head. [2023] 
1.5.11 For people under  16 who ha ve sustained a head injur y and ha ve mor e 
than 1 of t hese risk f actors, do a CT head scan wit hin 1  hour of t he risk 
factors being identified: 
• loss of consciousness lasting mor e than 5  minut es (witnessed) 
• abnormal dr owsiness 
• 3 or mor e discr ete episodes of v omiting 
• danger ous mechanism of injur y (high-speed r oad traffic accident as a 
pedestrian, cy clist or v ehicle occupant, f all from a height of mor e than 3  m, 
high-speed injur y from a pr ojectile or ot her object) 
• amnesia (ant erograde or r etrograde) lasting mor e than 5  minut es (it will not be 
possible t o assess amnesia in childr en who ar e preverbal and is unlik ely to be

possible t o assess amnesia in childr en who ar e preverbal and is unlik ely to be 
possible in childr en under  5) 
• any curr ent bleeding or clotting disor der. [2023] 
1.5.12 Obser ve people under 16 who ha ve sustained a head injur y but ha ve only 
1 of the risk f actors in r ecommendation  1.5.11 for a minimum of 4  hours in 
hospital. If , during obser vation, an y of t he following risk f actors ar e 
identified, do a CT head scan wit hin 1  hour: 
• a GCS scor e of less t han 15 
• further v omiting 
• a fur ther episode of abnormal dr owsiness. 
If none of t hese risk f actors occur during obser vation, use clinical judgement t o 
determine whet her a longer period of obser vation is needed. [2023] Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 20
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People taking anticoagulant or antiplat elet medication 
1.5.13 For people who ha ve sustained a head injur y and ha ve no ot her 
indications f or a CT head scan, but ar e on anticoagulant tr eatment 
(including vitamin  K antagonist s, dir ect-acting oral anticoagulant s, 
heparin and lo w molecular w eight heparins) or antiplat elet tr eatment 
(excluding aspirin monot herap y), consider doing a CT head scan: 
• within 8  hours of t he injur y (for example, if it is difficult t o do a risk assessment 
or if t he person might not r eturn t o the emer gency depar tment if t hey have 
signs of det erioration) or 
• within the hour if t hey present mor e than 8  hours aft er the injur y. 
For advice on r eversing vitamin  K antagonist s and dir ect-acting oral 
anticoagulant s for people wit h traumatic intracranial haemorrhage, see NICE's 
guideline on blood transfusion  and NICE's t echnology appraisal guidance on

guideline on blood transfusion  and NICE's t echnology appraisal guidance on 
ande xanet alf a for reversing anticoagulation fr om apixaban or riv aroxaban . 
[2023] 
Timing of r adiology r epor t 
1.5.14 Make a pr ovisional writt en radiology r epor t available wit hin 1  hour of a CT 
scan. [2014] 
they might aff ect practice or ser vices, see t he rationale and impact section on crit eria 
for doing a CT head scan . 
Full details of t he evidence and t he committ ee's discussion ar e in: 
• evidence r eview  D: clinical decision rules selecting people wit h head injur y for 
imaging 
• evidence r eview E: selecting adult s, childr en and inf ants wit h head injur y for CT or 
MRI head scan in sub-gr oups . Head injur y: assessment and early management (NG232)

imaging 
conditions#notice-of -right s).Page 21 of
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Investig ation to pr edict post -concussion syndr ome 
1.5.15 For inf ormation on r eferring people wit h possible post-concussion 
syndr ome, see recommendation  1.10.14 in t he section on f ollow up . 
[2023] 
might aff ect practice or ser vices, see t he rationale and impact section on post -
concussion syndr ome. 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview F: 
brain injur y biomark ers and/or MRI f or pr edicting post -concussion syndr ome. 
1.6 Investig ating in juries to the c ervical spine 
Assessing r ange of mo vemen t in the ne ck 
1.6.1 Be awar e that range of mo vement in t he neck when t here is clinical 
suspicion of a cer vical spine injur y can only be assessed saf ely bef ore 
imaging in people wit h a head injur y if they have no high-risk f actors (see 
recommendation  1.6.2, and recommendations  1.6.4 and  1.6.6). Only do

recommendation  1.6.2, and recommendations  1.6.4 and  1.6.6). Only do 
the assessment if t hey have at least  1 of t hese lo w-risk f eatur es: 
• they were in a simple r ear-end mot or vehicle collision 
• they are comf ortable in a sitting position 
• they have been ambulat ory at an y time since injur y 
• there is no midline cer vical spine t enderness 
• they present wit h dela yed onset of neck pain. 
See also NICE's guideline on spinal injur y: assessment and initial management . 
[2014] Head injur y: assessment and early management (NG232)
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Criteria f or doing a CT c ervical spine sc an in pe ople 16  and o ver 
1.6.2 For people 16  and o ver who ha ve sustained a head injur y (including 
people wit h dela yed pr esentation), do a CT cer vical spine scan wit hin 
1 hour of t he risk f actor being identified if an y of t hese high-risk f actors 
apply: 
• the GCS scor e is 12  or less on initial assessment 
• the person has been intubat ed 
• a definitiv e diagnosis of a cer vical spine injur y is ur gent ly needed (f or example, 
if cer vical spine manipulation is needed during sur gery or anaest hesia) 
• there has been blunt polytrauma in volving t he head and chest, abdomen or 
pelvis in someone who is aler t and stable 
• there is clinical suspicion of a cer vical spine injur y and an y of t hese f actors: 
－ age 65  or over 
－ a danger ous mechanism of injur y (that is, a f all from a height of mor e than 
1 m or 5  stairs, an axial load t o the head such as fr om diving, a high-speed

1 m or 5  stairs, an axial load t o the head such as fr om diving, a high-speed 
motor vehicle collision, a r ollover mot or accident, ejection fr om a mot or 
vehicle, an accident in volving mot orised r ecreational v ehicles or a bicy cle 
collision) 
－ focal peripheral neur ological deficit 
－ paraest hesia  in the upper or lo wer limbs. [2023] 
1.6.3 For people 16  and o ver who ha ve sustained a head injur y, and ha ve neck 
pain or t enderness but no high-risk indications f or a CT cer vical spine 
scan (see r ecommendation 1 .6.2), do a CT cer vical spine scan wit hin 
1 hour f or an y of t hese risk f actors: 
• it is not t hought t o be saf e to assess t he range of mo vement in t he neck (see 
recommendation 1 .6.1) 
• safe assessment of range of neck mo vement sho ws that t he person cannot

• safe assessment of range of neck mo vement sho ws that t he person cannot 
activ ely rotate their neck 45  degr ees t o the left and right Head injur y: assessment and early management (NG232)
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• the person has a condition pr edisposing t hem t o a higher risk of injur y to the 
cervical spine (f or example, axial spondyloar thritis). [2023] 
Criteria f or doing a CT c ervical spine sc an in pe ople under  16 
1.6.4 For people under  16 who ha ve sustained a head injur y (including t hose 
with dela yed pr esentation), only do a CT cer vical spine scan if an y of 
these risk f actors apply: 
• there are focal peripheral neur ological signs 
• there is paraest hesia  in the upper or lo wer limbs 
• a definitiv e diagnosis of a cer vical spine injur y is needed ur gent ly (for example, 
if manipulation of t he cer vical spine is needed during sur gery or anaest hesia) 
• the person is ha ving ot her body ar eas scanned f or head injur y or multisyst em 
trauma, and t here is clinical suspicion of a cer vical spine injur y

trauma, and t here is clinical suspicion of a cer vical spine injur y 
• there is str ong clinical suspicion of injur y despit e normal X -rays 
• plain X -rays ar e technically difficult or inadequat e 
• plain X -rays identify a significant bon y injur y. 
Do the scan wit hin 1  hour of t he risk f actor being identified. [2023] 
1.6.5 For people under  16 who ha ve sustained a head injur y, and ha ve neck 
pain or t enderness but no indications f or a CT cer vical spine scan (see 
recommendation 1 .6.4), do 3-view cer vical spine X -rays bef ore assessing 
range of mo vement in t he neck if an y of t hese risk f actors ar e identified: 
• there was a danger ous mechanism of injur y (that is, a f all from a height of mor e 
than 1  m or 5  stairs, an axial load t o the head such as fr om diving, a high-speed 
motor vehicle collision, a r ollover mot or accident, ejection fr om a mot or vehicle,

motor vehicle collision, a r ollover mot or accident, ejection fr om a mot or vehicle, 
an accident in volving mot orised r ecreational v ehicles or a bicy cle collision) Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 2 4
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• safe assessment of range of mo vement in t he neck is not possible (see 
• the person has a condition t hat pr edisposes t hem t o a higher risk of injur y to 
the cer vical spine (f or example, collagen v ascular disease, ost eogenesis 
imper fecta, axial spondyloar thritis). 
The X -rays should be done wit hin 1  hour of t he risk f actor being identified and 
review ed by a clinician trained in t heir int erpretation. [2023] 
1.6.6 If range of neck mo vement can be assessed saf ely (see r ecommendation 
1.6.1) in a person under  16 who has sustained a head injur y, and has neck 
pain or t enderness but no indications f or a CT cer vical spine scan, do 
3-view cer vical spine X -rays if t hey cannot activ ely rotate their neck 
45 degr ees t o the left and right. When t he person is unable t o 
understand commands or open t heir mout h, a peg view ma y be omitt ed. 
The X -rays should be done wit hin 1  hour of t his risk f actor being

The X -rays should be done wit hin 1  hour of t his risk f actor being 
identified, and r eview ed by a clinician trained in t heir int erpretation. 
[2014] 
Timing o f radio logy repor t 
1.6.7 Make a pr ovisional writt en radiology r epor t available wit hin 1  hour of a CT 
Imag ing in vestig ations 
1.6.8 Ensur e that imaging r epor ts are based on high-r esolution sour ce data 
and multiplanar r eformatting of t he entir e cer vical spine. [2003 , 
amended 2014 and 2023] 
1.6.9 Do MRI in addition t o CT if t here are neur ological signs and sympt oms 
suggesting injur y to the cer vical spine. [2003 , amended 2014 and 2023] 
1.6.10 Do CT or MRI angiograph y of t he neck v essels if t here is a suspicion of 
vascular injur y, for example, because of: 
• vertebral malalignment Head injur y: assessment and early management (NG232)

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• a high-risk fractur e (that is, a high-grade or comple x facial fractur e or a base of 
skull fractur e likely to involve the int ernal car otid ar tery or v ertebral ar tery) 
• posterior cir culation syndr ome. [2003 , amended 2014 and 2023] 
1.6.11 Consider MRI f or assessing ligament ous and disc injuries suggest ed by 
CT or clinical findings. [2003] 
they might aff ect practices or ser vices, see t he rationale and impact section on 
investigating injuries t o the cer vical spine . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview  H: 
CT, MRI and X -ray of t he cer vical spine in people wit h head injur y – diagnostic . 
1.7 Informa tion and suppor t for families and 
carers 
1.7.1 Staff caring f or people wit h a head injur y should intr oduce t hemselv es to 
family members or car ers, and briefly e xplain what t hey are doing. 
[2003 , amended 2014]

carers 
1.7.2 Ensur e that inf ormation f or families and car ers e xplains t he natur e of t he 
head injur y and t he lik ely car e pat hway. [2003] 
1.7.3 Staff should t hink about ho w best t o shar e information wit h people 
under  16, and intr oduce t hem t o the possibility of long-t erm comple x 
changes in t heir par ent or sibling who has had a head injur y. Literatur e 
produced b y patient suppor t groups ma y be helpful. [2003] 
1.7.4 Encourage f amily members and car ers t o talk t o and mak e physical 
contact (f or example, holding hands) wit h the person wit h a head injur y. 
But ensur e that r elativ es and friends do not f eel obliged t o spend long 
periods at t he bedside. If t hey wish t o sta y wit h the person wit h a head

periods at t he bedside. If t hey wish t o sta y wit h the person wit h a head 
injury, encourage t hem t o tak e regular br eaks. [2003 , amended 200 7] 
1.7.5 Ensur e there is a boar d or ar ea displa ying leaflet s or contact details f or Head injur y: assessment and early management (NG232)
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local and national patient suppor t organisations t o help f amily members 
and car ers gat her fur ther inf ormation. [2003] 
1.8 Transf er fr om hospi tal to a neur oscienc e uni t 
Transf er of people 16  and o ver 
1.8.1 Ensur e local guidelines on t he transf er of people wit h a se vere traumatic 
brain injur y are drawn up betw een t he referring hospital trust s, the 
neuroscience unit and t he local ambulance ser vice, and r ecognise t hat: 
• transf er would benefit an yone wit h serious head injuries (a GCS scor e of 8 or 
less), irr espectiv e of t he need f or neur osurgery 
• if transf er of people who do not need neur osurgery is not possible, ongoing 
liaison wit h the neur oscience unit o ver clinical management is essential. Also 
see t he recommendations on transf er betw een emer gency depar tment s in 
NICE's guideline on major trauma: ser vice deliv ery. [2003 , amended 200 7] 
1.8.2 Think about t he possibility of occult e xtracranial injuries in people 16  and

1.8.2 Think about t he possibility of occult e xtracranial injuries in people 16  and 
over wit h multiple injuries, and do not transf er them t o a ser vice t hat is 
unable t o deal wit h other aspect s of trauma. [200 7] 
1.8.3 Ensur e there is a designat ed consultant in t he referring hospital wit h 
responsibility f or establishing arrangement s for the transf er of people 
with head injuries t o a neur oscience unit. Also ensur e there is anot her 
consultant at t he neur oscience unit wit h responsibility f or establishing 
arrangement s for communication wit h referring hospitals, and f or 
receiving people transf erred. [2003] 
1.8.4 Ensur e that people wit h traumatic brain injuries needing emer gency 
transf er to a neur oscience unit ar e accompanied b y healt hcare staff wit h 
appr opriat e training and e xperience in t he transf er of people wit h an

appr opriat e training and e xperience in t he transf er of people wit h an 
acute traumatic brain injur y. The y should: 
• be familiar wit h the pat hoph ysiology of traumatic brain injuries, t he medicines 
and equipment t hey will use, and w orking in t he confines of an ambulance ( or 
helicopt er if appr opriat e) Head injur y: assessment and early management (NG232)
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• have a dedicated and adequat ely trained assistant 
• be pr ovided wit h appr opriat e clot hing f or the transf er, medical indemnity and 
personal accident insurance. 
Ensur e that people needing non-emer gency transf er ar e accompanied b y 
appr opriat e clinical staff . [2003 , amended 200 7] 
1.8.5 Provide t he transf er team r esponsible f or transf erring a person wit h a 
head injur y wit h a means of communicating changes in t he person's 
status wit h their base hospital and t he neur osurgical unit during t he 
transf er. [2003 , amended 2014] 
1.8.6 Although it is underst ood t hat transf er is oft en ur gent, complet e the 
initial r esuscitation and stabilisation of t he person, and establish 
compr ehensiv e monit oring bef ore transf er, to avoid complications during 
the journe y. Do not transpor t someone wit h persist ent h ypot ension, 
despit e resuscitation, until t he cause has been identified and t hey are 
stabilised. [2003 , amended 200 7]

stabilised. [2003 , amended 200 7] 
1.8.7 Intubat e and v entilat e anyone wit h a GCS scor e of 8 or less needing 
transf er to a neur oscience unit, and an yone wit h the indications detailed 
in recommendation  1.8.8. [2003] 
1.8.8 Intubat e and v entilat e the person immediat ely when t here is: 
• coma, t hat is, t hey are not obe ying commands, not speaking and not e ye 
opening (a GCS scor e of 8 or less) 
• loss of pr otectiv e laryngeal r eflexes 
• ventilat ory insufficiency , as judged b y blood gases: h ypoxaemia (PaO 2 less 
than 13  kPa on o xygen) or h ypercarbia (PaCO 2 more than 6  kPa) 
• irregular r espirations. [2003 , amended 200 7] 
1.8.9 Use intubation and v entilation bef ore the star t of t he journe y when t he 
person has: Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 28
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• significant ly det eriorating conscious le vel (1 or mor e point s on t he mot or 
score), even if not coma 
• unstable fractur es of t he facial sk eleton 
• copious bleeding int o the mout h (for example, fr om a skull base fractur e) 
• seizur es. [2003 , amended 200 7] 
1.8.10 Anyone whose trachea is intubat ed should ha ve appr opriat e sedation 
and analgesia along wit h a neur omuscular blocking drug. A im for a PaO 2 
of mor e than 13  kPa, and a PaCO 2 of 4.5 kPa t o 5.0 kPa, unless t here is 
clinical or radiological e vidence of raised intracranial pr essur e, in which 
case mor e aggr essiv e hyper ventilation is justified. If h yper ventilation is 
used, incr ease t he inspir ed oxygen concentration. Maintain t he mean 
arterial pr essur e at 80  mmHg or mor e by infusion of fluid and 
vasopr essors, as indicat ed. [2003 , amended 200 7] 
1.8.11 Give family members and car ers as much access t o the person wit h a

1.8.11 Give family members and car ers as much access t o the person wit h a 
head injur y as is practical during transf er. If possible, giv e them an 
oppor tunity t o discuss t he reasons f or transf er and ho w the transf er 
process w orks wit h a member of t he healt hcare team. [2003 , amended 
2014] 
Transf er of people under  16 
1.8.12 Recommendations 1 .8.1 to 1.8.9 and 1 .8.11 were writt en for people 16  and 
over, but apply t hese principles t o people under  16, providing t hat t he 
paediatric modification of t he GCS is used f or pr everbal and non-v erbal 
childr en. V entilat e people under  16 accor ding t o the age-appr opriat e 
level of o xygen saturation and maintain blood pr essur e at a le vel 
appr opriat e for their age. [2003 , amended 2023] 
1.8.13 Ensur e that ser vice pr ovision f or transf er to tertiary car e follows the

1.8.13 Ensur e that ser vice pr ovision f or transf er to tertiary car e follows the 
principles out lined in t he NHS England ser vice specification f or paediatric 
intensiv e car e retrie val (transpor t) and t he Paediatric Critical Car e 
Society quality standar ds for the car e of critically ill or injur ed childr en. 
[2003] Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 29
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1.8.14 Think about t he possibility of occult e xtracranial injuries f or people 
under  16 wit h multiple injuries. Do not transf er them t o a ser vice t hat is 
1.8.15 Ensur e that transf er of people under  16 to a specialist neur osurgical unit 
is done eit her b y staff e xperienced in t he transf er of people under  16 
who ar e critically ill or accor ding t o local guidelines wit h specialist 
paediatric r etrie val teams. [2003 , amended 2023] 
1.8.16 Give family members and car ers as much access t o their child as is 
practical during transf er. If possible, giv e them an oppor tunity t o discuss 
the reasons f or transf er and ho w the transf er pr ocess w orks wit h a 
member of t he healt hcare team. [2003 , amended 2014] 
1.9 Admission and obser vation 
1.9.1 Use t hese crit eria f or admitting people t o hospital aft er a head injur y:

1.9.1 Use t hese crit eria f or admitting people t o hospital aft er a head injur y: 
• new, clinically impor tant abnormalities on imaging (an isolat ed simple linear 
non-displaced skull fractur e is unlik ely to be a clinically impor tant abnormality 
unless t hey are taking anticoagulant or antiplat elet medication) 
• after imaging, a GCS scor e that has not r eturned t o 15 or t heir pr e-injur y 
baseline, r egar dless of t he imaging r esult s 
• when t here are indications f or CT scanning but t his cannot be done wit hin the 
appr opriat e time period, eit her because CT is not a vailable or because t he 
person is not sufficient ly cooperativ e to allo w scanning 
• continuing w orrying sympt oms (f or example, persist ent v omiting, se vere 
headaches or seizur es) of concern t o the clinician 
• other sour ces of concern t o the clinician (f or example, drug or alcohol

• other sour ces of concern t o the clinician (f or example, drug or alcohol 
intoxication, ot her injuries, shock, suspect ed non-accidental injur y, meningism, 
cerebrospinal fluid leak, or suspicion of ongoing post -traumatic amnesia). 
See t he section on dischar ge and f ollow up  for recommendations about ot her 
factors t o consider , such as whet her super vision at home is a vailable. [2003 , 
amended 2023] Head injur y: assessment and early management (NG232)
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1.9.2 Be awar e that some people ma y need an e xtended period in a r ecovery 
setting because of ha ving general anaest hesia during CT imaging. 
[2003 , amended 200 7] 
1.9.3 Admit people wit h multiple injuries under t he car e of t he team t hat is 
trained t o deal wit h their most se vere and ur gent pr oblem. [2003] 
1.9.4 When someone wit h a head injur y needs hospital admission, admit t hem 
under t he car e of a t eam led b y a consultant who has been trained in 
managing t his condition. The consultant and t heir t eam should ha ve 
compet ence ( defined b y local agr eement wit h the neur oscience unit) in: 
• assessment, obser vation and indications f or imaging (see t he sections on t he 
criteria f or doing a CT head scan  and t he criteria f or doing a CT cer vical spine 
scan in people 16  and o ver and people under  16) 
• inpatient management 
• indications f or transf er to a neur oscience unit (see t he section on transf er from

• indications f or transf er to a neur oscience unit (see t he section on transf er from 
hospital t o a neur oscience unit ) 
• hospital dischar ge and f ollow up (see t he section on dischar ge and f ollow up ). 
Admission and obser vation o f people wi th concussion sym ptoms 
1.9.5 For people wit h concussion sympt oms aft er normal brain imaging or no 
indication f or early imaging, f ollow the indications f or admission in 
recommendation  1.9.1. Also see t he section on dischar ge advice . [2023] Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 31 of
74

admission and obser vation . 
• evidence r eview I: admission and obser vation in hospital of people wit h head 
injury who ar e on anticoagulant or antiplat elet t herap y aft er normal brain imaging 
or no indication f or early imaging 
• evidence r eview J: admission and obser vation of people wit h concussion 
sympt oms 
• evidence r eview K: hospital admission in people wit h small intracranial injuries 
• evidence r eview L: isolat ed skull fractur e. 
Early diagnosis o f hypopi tuitarism 
1.9.6 Be awar e that an y severity of head injur y can cause pituitar y dysfunction. 
This ma y present immediat ely, hours, w eeks or mont hs aft er the injur y. A 
variety of sympt oms could indicat e hypopituitarism . [2023]

variety of sympt oms could indicat e hypopituitarism . [2023] 
1.9.7 In people admitt ed to hospital wit h a head injur y who ha ve persist ently 
abnormal lo w sodium le vels or lo w blood pr essur e, consider 
investigations f or hypopituitarism. [2023] 
1.9.8 In people pr esenting t o primar y or community car e wit h persist ent 
sympt oms consist ent wit h hypopituitarism in t he w eeks or mont hs aft er a 
head injur y, consider in vestigations or r eferral f or hypopituitarism. [2023] Head injur y: assessment and early management (NG232)
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they might aff ect practice or ser vices, see t he rationale and impact section on early 
diagnosis of h ypopituitarism . 
• evidence r eview M: identification of h ypopituitarism (who t o investigat e) 
• evidence r eview N: identification of h ypopituitarism (when t o investigat e). 
Obser vation o f people who ar e admi tted 
1.9.9 Ensur e that in-hospital obser vation of people wit h a head injur y is only 
done b y professionals compet ent in assessing head injuries. [2003] 
1.9.10 For people admitt ed for head injur y obser vation, t he minimum acceptable 
document ed neur ological obser vations ar e: GCS scor e, pupil siz e and 
reactivity , limb mo vement s, respirat ory rat e, hear t rate, blood pr essur e, 
temperatur e and blood o xygen saturation. [2003]

temperatur e and blood o xygen saturation. [2003] 
1.9.11 Carry out and r ecord obser vations on a half -hourly basis until t here is a 
GCS scor e of 15. Obser vations f or people wit h a GCS scor e of 15 should 
start after the initial assessment in t he emer gency depar tment and t he 
minimum fr equency should be: 
• half-hourly f or 2 hours, t hen 
• 1 hourly f or 4 hours, t hen 
• 2 hourly . [2003] 
1.9.12 Revert to half -hourly obser vations and f ollow the original fr equency 
schedule f or people wit h a GCS scor e of 15 who det eriorat e at an y time 
after the initial 2-hour period. [2003] 
1.9.13 Urgent ly reassess a person wit h a head injur y if they have any of t hese 
signs of neur ological det erioration: Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 33
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• agitation or abnormal beha viour 
• a sustained (t hat is, f or at least 30  minut es) dr op of 1  point in GCS scor e (give 
more weight t o a dr op of 1  point in t he mot or response scor e of t he GCS scor e) 
• any drop of 3  or mor e point s in t he eye opening or v erbal r esponse scor es of 
the GCS scor e, or 2  or mor e point s in t he mot or response scor e 
• severe or incr easing headache, or persist ent v omiting 
• new or e volving neur ological sympt oms or signs such as pupil inequality or 
asymmetr y of limb or f acial mo vement. 
A super vising doct or should do t he appraisal. [2003 , amended 200 7] 
1.9.14 To reduce int erobser ver variability and unnecessar y referrals, get a 
second member of staff compet ent in obser vations t o confirm 
deterioration bef ore involving t he super vising doct or. Do t his immediat ely 
if possible. If not possible (f or example, because no staff member is

if possible. If not possible (f or example, because no staff member is 
available t o do t he second obser vation), contact t he super vising doct or 
without t he confirmation being done. [2003] 
1.9.15 If any of t he changes not ed in r ecommendation  1.9.13 ar e confirmed, 
consider doing an immediat e CT scan, and r eassess t he person's clinical 
condition and manage appr opriat ely. [2003 , amended 200 7] 
1.9.16 If a person has had a normal CT scan but does not ha ve a GCS scor e 
of 15 aft er 24 hours of obser vation, consider a fur ther CT or MRI scan 
and discuss wit h the radiology depar tment. [2003] 
Obser vation o f babies and childr en under  5 
1.9.17 Be awar e that obser vation of babies and childr en under  5 is difficult, so 
should only be done b y unit s wit h staff e xperienced in t he obser vation of 
under  5s wit h a head injur y. Babies and childr en under  5 ma y be

under  5s wit h a head injur y. Babies and childr en under  5 ma y be 
obser ved in normal paediatric obser vation settings, as long as staff ha ve 
the appr opriat e experience. [2003] Head injur y: assessment and early management (NG232)
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Training in obser vation 
1.9.18 All staff caring f or people wit h a head injur y admitt ed for obser vation 
should be trained in doing t he obser vations list ed in recommendations 
1.9.10 to 1.9.14 in t he section on obser vation of people who ar e admitt ed, 
and t he recommendation on obser vation of babies and childr en under  5. 
[2003] 
1.9.19 Make dedicat ed training a vailable t o all r elevant staff t o enable t hem t o 
acquir e and maintain obser vation and r ecording skills. Specific training is 
needed f or the obser vation of people under  16. [2003] 
1.10 Dischar ge and f ollow up 
1.10.1 If CT is not indicat ed based on hist ory and e xamination and t here is no 
suspicion of clinically impor tant traumatic brain injur y, dischar ge the 
person fr om hospital if t here are: 
• no ot her f actors t hat w ould warrant a hospital admission (f or example, drug or 
alcohol int oxication, ot her injuries, shock, suspect ed non-accidental injur y,

alcohol int oxication, ot her injuries, shock, suspect ed non-accidental injur y, 
meningism, or cer ebrospinal fluid leak) 
• appr opriat e suppor t structur es for saf e dischar ge to the community and f or 
subsequent car e (for example, compet ent super vision at home). [2003] 
1.10.2 If imaging of t he head is normal and t he risk of clinically impor tant 
traumatic brain injur y is lo w, transf er the person t o the community if: 
• the GCS scor e has r eturned t o 15 or t he pr e-injur y baseline GCS scor e 
• there are no ot her f actors t hat w ould warrant a hospital admission (f or 
example, drug or alcohol int oxication, ot her injuries, shock, suspect ed non-
accidental injur y, meningism, or cer ebrospinal fluid leak) 
• there are appr opriat e suppor t structur es for saf e transf er to the community and 
for subsequent car e (for example, compet ent super vision at home). [2003]

for subsequent car e (for example, compet ent super vision at home). [2003] 
1.10.3 After normal imaging of t he cer vical spine, risk of injur y to the cer vical 
spine is lo w enough t o warrant transf er to the community if: Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 35
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• the GCS scor e is 15 
• clinical e xamination is normal 
• there are no ot her f actors t hat w ould warrant a hospital admission pr esent (f or 
1.10.4 Do not dischar ge people pr esenting wit h a head injur y until t heir GCS 
score is 15 or , in pr everbal and non-v erbal childr en, consciousness is 
normal as assessed b y the paediatric v ersion of t he GCS. In people wit h 
pre-injur y cognitiv e impairment, t heir GCS scor e should be back t o that 
document ed bef ore the injur y. [2003] 
1.10.5 Only transf er people wit h any degr ee of head injur y to their home if t here 
is somebody suitable at home t o super vise t hem. Dischar ge people wit h

is somebody suitable at home t o super vise t hem. Dischar ge people wit h 
no car er at home only if suitable super vision arrangement s have been 
organised, or when t he risk of lat e complications is t hought t o be 
negligible. [2003] 
People wi th pr e-injury cogni tive im pairmen t 
1.10.6 Ensur e that people wit h pre-injur y cognitiv e impairment (f or example, 
dementia or a learning disability) and people r eturning t o a cust odial 
setting ar e super vised and monit ored. Also, mak e sur e that 
arrangement s are in place should t here be an y signs of det erioration. 
[2023] 
might aff ect practice or ser vices, see t he rationale and impact section on dischar ge 
and f ollow up . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview E:

Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview E: 
selecting adult s, childr en and inf ants wit h head injur y for CT or MRI head scan in sub-
groups . Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 36
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Dischar ge after obser vation 
1.10.7 People admitt ed aft er a head injur y ma y be dischar ged aft er resolution of 
all significant sympt oms and signs, pr ovided t hey have suitable 
super vision arrangement s at home, in cust ody or in continued car e. 
[2003 , amended 2023] 
Dischar ge advice 
1.10.8 Give verbal and print ed dischar ge advice t o people wit h any degr ee of 
head injur y who ar e dischar ged fr om an emer gency depar tment or 
obser vation war d. This should also be pr ovided t o the person r esponsible 
for their car e aft er dischar ge. This ma y include t heir f amilies, car ers, 
social w orkers or cust odial staff . Follow the recommendations in NICE's 
guidelines on patient e xperience in adult NHS ser vices  and babies, 
childr en and y oung people's e xperience of healt hcare, including on 
providing inf ormation in an accessible f ormat. [2014 , amended 2023] 
1.10.9 Ensur e that print ed advice f or people wit h a head injur y, and t heir

1.10.9 Ensur e that print ed advice f or people wit h a head injur y, and t heir 
families and car ers, is age appr opriat e and includes: 
• details of t he natur e and se verity of t he injur y 
• risk f actors t hat mean people need t o return t o the emer gency depar tment 
(see t he recommendations on community healt h ser vices and inpatient unit s 
without an emer gency depar tment ) 
• a specification t hat a r esponsible adult should sta y wit h the person f or the first 
24 hours aft er their injur y 
• details about t he recovery process, including t he fact t hat some people ma y 
appear t o mak e a quick r ecovery but lat er ha ve difficulties or complications 
• contact details of community and hospital ser vices in case of dela yed 
complications 
• information about r eturn t o everyday activities, including school, w ork, spor ts 
and driving

and driving 
• details of suppor t organisations. [2014] Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 37
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1.10.10 Offer inf ormation and advice on alcohol or drug misuse t o people who 
present ed to the emer gency depar tment wit h drug or alcohol int oxication 
when t hey are fit f or dischar ge. [2003] 
1.10.11 Inform people wit h a head injur y, and t heir f amilies and car ers, about t he 
possibility of persist ent or dela yed sympt oms aft er a head injur y and who 
to contact if t hey have ongoing pr oblems. [2014] 
1.10.12 For an yone who has att ended t he emer gency depar tment wit h a head 
injury, writ e to their GP wit hin 48  hours of dischar ge, giving details of 
clinical hist ory and e xamination. Also shar e this lett er wit h healt h visit ors 
(for pr eschool childr en) and school nurses (f or school-age childr en and 
young people). If appr opriat e, pr ovide a cop y of t he lett er for the person 
with a head injur y, and t heir f amily or car ers, cust odial staff or social 
worker. [2014] 
Follow up

Follow up 
1.10.13 Refer people wit h a head injur y to investigat e its causes and manage 
contributing f actors, if appr opriat e. This could include, f or example, 
referral f or a f alls assessment or t o saf eguar ding ser vices. [2023] 
1.10.14 Consider r eferring people who ha ve persisting pr oblems t o a clinician 
trained in assessing and managing t he consequences of traumatic brain 
injury (for example, a neur ologist, neur opsy chologist, clinical 
psychologist, neur osurgeon or endocrinologist, or a multidisciplinar y 
neurorehabilitation t eam). [2003 , amended 2023] Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 38
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they might aff ect practice or ser vices, see t he rationale and impact section on f ollow 
up. 
sympt oms 
Investig ations f or hypopi tuitarism 
1.10.15 Consider fur ther endocrinology in vestigations f or people who ha ve been 
dischar ged aft er a head injur y if they have persist ent sympt oms 
consist ent wit h hypopituitarism  or ar e not r ecovering as e xpect ed. 
[2023] 
might aff ect practice or ser vices, see t he rationale and impact section on 
investigations f or hypopituitarism . 
Full details of t he evidence and t he committ ee's discussion ar e in:

Terms use d in this guideline 
This section defines t erms t hat ha ve been used in a par ticular wa y for this guideline. Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 39
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Com plex skull fr acture or pene trating he ad in jury 
Signs of a basal, open or depr essed skull fractur e or penetrating head injur y include: 
• clear fluid running fr om t he ears or nose 
• a black e ye wit h no associat ed damage ar ound t he eyes 
• bleeding fr om 1  or bot h ears 
• bruising behind 1  or bot h ears 
• penetrating injur y signs 
• visible trauma t o the scalp or skull of concern t o the pr ofessional. 
Focal neur ological defici t 
Neur ological pr oblems r estrict ed to a par ticular par t of t he body or a par ticular activity , for 
example: 
• difficulties wit h understanding, speaking, r eading or writing 
• decr eased sensation 
• loss of balance 
• weakness 
• visual changes 
• nystagmus 
• abnormal r eflexes 
• problems walking 
• amnesia since t he injur y. 
In people wit h a head injur y, the Glasgo w Coma Scale (GCS) is an early assessment of t he Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 40
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severity of an y associat ed traumatic brain injur y. It is a standar dised syst em used t o 
assess t he degr ee of brain impairment and t o identify t he seriousness of injur y in r elation 
to out come. The scale has 3  domains: e ye opening, v erbal and mot or responses. These 
are all e valuat ed independent ly in t he scale accor ding t o a numerical v alue t hat indicat es 
the le vel of consciousness and degr ee of dysfunction. The scor es in each element of t he 
GCS ar e summed t o giv e the overall GCS scor e, which ranges fr om 3 (unr esponsiv e in all 
domains) t o 15 (no deficit s in r esponsiv eness): 
• Mild traumatic brain injur y is a GCS scor e of 13  to 15. 
• Moderat e traumatic brain injur y is a GCS scor e of 9  to 12. 
• Severe traumatic brain injur y is a GCS scor e of 8  or less. 
High-ener gy head in jury 
An injur y arising fr om, f or example, a pedestrian being struck b y a mot or vehicle, an

An injur y arising fr om, f or example, a pedestrian being struck b y a mot or vehicle, an 
occupant being eject ed fr om a mot or vehicle, a f all from a height of mor e than 1  m or mor e 
than 5 stairs, a diving accident, a high-speed mot or vehicle collision, a r ollover mot or 
accident, an accident in volving mot orised r ecreational v ehicles, a bicy cle collision or an y 
other pot entially high-ener gy mechanism. 
Hypopi tuitarism 
Underactivity of t he pituitar y gland t hat can lead t o: 
• adrenocor ticotr opic hormone deficiency causing w eakness, f atigue, w eight loss, 
hypot ension, h yponatraemia, h ypogly caemia, h ypercalcaemia, anaemia and f atigue 
• growth hormone deficiency causing decr eased ener gy, low mood, neur opsy chiatric 
and cognitiv e sympt oms, decr eased lean body mass, incr eased f at mass, alt ered 
metabolic pr ofile and decr eased e xercise capacity

metabolic pr ofile and decr eased e xercise capacity 
• lack of se x hormones t hat can cause lat er puber ty, hot flushes, f atigue, tir edness, loss 
of body hair , reduced se x driv e, irr egular periods, er ectile dysfunction and r educed 
fertility 
• thyroid-stimulating hormone deficiency pr esenting wit h slo w growth, fatigue, let hargy, 
cold int olerance and w eight gain Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 4 1 of
74

• vasopr essin deficiency causing polyuria, poly dipsia, nocturia and incontinence. 
Isolated sim ple line ar non -disp laced skull fr acture 
A single or solitar y linear fractur e that does not e xhibit an y inwar d or outwar d 
displacement, does not consist of multiple fractur e lines and does not in volve or cr oss t he 
normal sutur es of t he skull. 
Paraesthesia 
Pins and needles, or a prickling sensation, tingling or it ching in an y par t of t he body . 
Post-concussion syndr ome 
Post-concussion syndr ome ( or post -concussion sympt oms) is seen in all se verities of head 
injury and is under -recognised in mild head injuries. It is t he term used in evidence r eview 
F: brain injur y biomark ers and/or MRI f or pr edicting post -concussion syndr ome. The t erm 
'concussion' is used in evidence r eview J: admission and obser vation of people wit h 
concussion sympt oms. Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 42
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Examples of sympt oms in t hese r eviews include, but ar e not limit ed to: 
Sensor y and mot or: 
• headache 
• dizziness 
• nausea 
• changes in vision, such as blurr ed vision, double vision, 'seeing stars' and 'looking 
through a haz e' 
• visual pr ocessing pr oblems, such as not taking in what y ou ar e seeing 
• difficulties sta ying awak e, sleeping f or man y mor e hours t han usual and chr onic 
fatigue when awak e 
• unusual sensitivity t o noise (h yperacusis) 
• unusual sensitivity t o bright light s (phot ophobia) 
• difficulties wit h balance, coor dination and mobility , often resulting in f alls, 
banging int o object s and, at times, fur ther traumatic brain injuries 
• speech pr oblems. 
Cognition: 
• cognitiv e difficulties (as long as t he GCS scor e is 15), sometimes described as 
'brain f og', which ma y include pr oblems finding w ords or numbers, difficulty 
speaking, slo wed responsiv eness, shor t-term memor y problems, difficulty

speaking, slo wed responsiv eness, shor t-term memor y problems, difficulty 
concentrating and pr oblems wit h information pr ocessing, such as f ollowing 
conversations, digesting t ext and finding w ords 
• difficulties wit h executiv e functions, such as or ganising, planning and 
multitasking 
• amnesia Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 43
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• problems wit h spatial awar eness and pr oprioception, including t he sensation of 
touching somet hing as if t hrough a la yer of numbness. 
Emotional: 
• lability , such as unusual laughing or cr ying (because of being o verwhelmed b y 
sense impr essions) or irritability 
• depr ession 
• anxiety . 
Additional sympt oms t hat ma y present in childr en under  5: 
• changes in normal beha viour aft er a head injur y, such as cr ying a lot or irritability 
• changes in f eeding or sleeping habit s 
• loss of int erest in people or object s 
• listlessness. 
Trauma tic br ain in jury 
An alt eration in brain function, or ot her e vidence of brain pat hology , caused b y an e xternal 
force. Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 44
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Recommenda tions f or research 
The guideline committ ee has made t hese r ecommendations f or resear ch. 
Key recommenda tions f or research 
1 Indic ations f or admission in pe ople wi th a mild he ad in jury and 
a confirme d abnormali ty on a CT sc an 
What ar e the indications f or admission using clinical decision rules in people wit h a 
Glasgo w Coma Scale (GCS) scor e of 13  to 15 (a mild head injur y) and a confirmed 
abnormality on a CT scan? [2023] 
For a shor t explanation of wh y the committ ee made t his recommendation f or 
resear ch, see t he rationale section on admission and obser vation . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview K: 
hospital admission in people wit h small intracranial injuries . 
2 Using biomar kers for pr edicting acu te post -trauma tic br ain 
injury complications 
What is t he diagnostic accuracy of brain injur y biomark ers for pr edicting acut e

What is t he diagnostic accuracy of brain injur y biomark ers for pr edicting acut e 
complications aft er a traumatic brain injur y? [2023] 
resear ch, see t he rationale section on post -concussion syndr ome. 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview  G: 
brain injur y biomark ers for pr edicting acut e post -brain injur y complications . 
3 Indic ations f or imag ing f or pe ople wi th a histor y of recurr ent Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 45
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head in juries 
What is t he risk of intracranial injuries in people wit h a hist ory of r ecurr ent head injuries, 
including fr om spor ts and f alls, and no ot her indications f or a CT scan? [2023] 
resear ch, see t he rationale section on crit eria f or doing a CT head scan . 
groups . 
4 Risk o f bleeding f or pe ople wi th a pr e-injury coagulopa thy 
What is t he risk of an y intracranial bleeding or intracranial bleeding associat ed wit h clinical 
deterioration aft er head injur y in people wit h a pr e-injur y coagulopat hy? This includes 
medical conditions such as liv er failure or haemophilia, or taking anticoagulant s or 
antiplat elets in people who:

antiplat elets in people who: 
• have a GCS scor e of 15 at 2  hours aft er the head injur y and medium risk f actors f or 
intracranial bleeding or 
• loss of consciousness or amnesia wit h no additional risk f actors (t hat is, t hey are 
under  65, had a lo w-ener gy transf er injur y and an y retrograde amnesia has last ed for 
less t han 30 minut es) or 
• there is no loss of consciousness or amnesia [2023] 
groups . 
5 Indic ations f or imag ing f or pe ople wi th a pr e-injury cogni tive Head injur y: assessment and early management (NG232)

groups . 
conditions#notice-of -right s).Page 46
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impairmen t 
What ar e the indications f or selecting imaging in adult s, young people, childr en and babies 
with a head injur y sustained t hrough a lo w-ener gy fall and wit h suspect ed pr e-injur y 
cognitiv e impairment when loss of consciousness or amnesia is difficult t o assess or t he 
pre-injur y GCS scor e is not  15? [2023] 
groups . 
Other r ecommenda tions f or research 
6 Transpor t to a neur oscienc e centre 
What is t he clinical and cost eff ectiv eness of pr e-hospital strat egies t o tak e people wit h a 
head injur y to a distant specialist neur oscience centr e inst ead of a closer non-specialist 
unit? [2023]

unit? [2023] 
resear ch, see t he rationale section on transpor t to hospital . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview  B: 
transf er to a distant specialist neur oscience centr e. 
7 Tranexamic acid 
What is t he clinical and cost eff ectiv eness of trane xamic acid bef ore imaging in people 
presenting wit hin 2  hours of a head injur y wit h a GCS scor e of 13 to 15 and high-risk 
indications f or intracranial bleeding? [2023] Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 47
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resear ch, see t he rationale section on trane xamic acid . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview  A: 
8 Indic ations f or sele cting pe ople for imag ing w hen the y presen t 
more than 2 4 hour s after a he ad in jury 
What ar e the indications f or selecting people of an y age who pr esent mor e than 2 4 hours 
after a head injur y for a CT or MRI head scan? [2023] 
groups . 
9 Using biomar kers and MRI f or pr edicting post -concussion 
syndr ome

groups . 
syndr ome 
What is t he pr ognostic accuracy of brain injur y biomark ers or MRI f or pr edicting post -
concussion syndr ome? [2023] 
brain injur y biomark ers and/or MRI f or pr edicting post -concussion syndr ome. Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 48
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10 Timing o f testing f or hypopi tuitarism 
When should people wit h a head injur y be in vestigat ed for hypopituitarism? [2023] 
resear ch, see t he rationale section on early diagnosis of h ypopituitarism . 
Full details of t he evidence and t he committ ee's discussion ar e in evidence r eview N: 
identification of h ypopituitarism (when t o investigat e). Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 49
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Rationale and im pact 
These sections briefly e xplain wh y the committ ee made t he recommendations and ho w 
they might aff ect practice or ser vices. 
Decision making and men tal c apaci ty 
Recommendations 1 .1.1 and 1 .1.2 
Why the c ommi ttee made the r ecommenda tions 
The committ ee recognised t he need t o involve people wit h a head injur y, and t heir f amily 
and car ers, in decisions about t heir car e, including r eferral t o the emer gency depar tment. 
They also highlight ed the impor tance of making decisions f or people who ma y lack 
capacity no w or in t he futur e, and t o follow an y adv ance car e plans. 
How the r ecommenda tions mig ht affect practice or ser vices 
Ther e is not e xpect ed to be an y change t o practice or ser vices. 
Return t o recommendations 
Recommendations 1 .3.13 and 1 .3.14 
Why the c ommi ttee made the r ecommenda tions

Evidence fr om 1  randomised contr olled trial (RCT) and 1  retrospectiv e cohor t study was 
identified. This compar ed transpor t for a head injur y to a specialist neur oscience centr e 
with transpor t to the near est non-specialist acut e hospital or general hospital emer gency 
depar tment. All t he evidence was in people 16  and o ver. No e vidence was a vailable f or 
people under  16. 
The e vidence fr om t he RCT suggest ed some benefit f or transf er to a non-specialist Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 50
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general hospital f or the out come of mor tality , but t his was uncer tain. The e vidence fr om 
the retrospectiv e cohor t study suggest ed that t here was no diff erence betw een t he 
2 groups f or the out come of sur vival benefit. The committ ee agr eed t hat t here was limit ed 
evidence of a possible benefit f or transf er to a specialist neur oscience centr e for some 
outcomes but t hat t his was uncer tain. The y agr eed t hat t here was no compelling e vidence 
to change practice, and  to cross r efer to NICE's guideline on major trauma: ser vice 
deliv ery. 
The committ ee not ed that t he data collection f or the RCT was in 2012. This was when 
trauma car e was r eorganised in t he UK t o enable rapid and saf e transf er of people t o major 
trauma centr es. So, t he evidence does not r eflect t he recent trauma car e syst em, which 
includes mor e consultant s, quick er CT scans and r ehabilitation. So, t he committ ee agr eed

includes mor e consultant s, quick er CT scans and r ehabilitation. So, t he committ ee agr eed 
that fur ther r esear ch should be done in t his ar ea to det ermine t he eff ectiv eness of 
transpor t to specialist neur oscience centr es in people wit h a head injur y. The y developed 
a recommendation f or resear ch on transpor t to a neur oscience centr e. 
Ther e is not e xpect ed to be an y change. 
Recommendations 1 .3.17 and 1 .3.18 
Ther e was e vidence fr om 2  RCTs for trane xamic acid, bot h of which included adult s wit h 
no suspicion of e xtracranial bleeding. One trial was in a pr e-hospital ( out-of-hospital)

no suspicion of e xtracranial bleeding. One trial was in a pr e-hospital ( out-of-hospital) 
setting and t he ot her was in a hospital setting. Ther e was no e vidence a vailable f or people 
under  16 (1  trial included a f ew people aged 15  and 16). 
In the pr e-hospital setting, a single 2  g bolus dose of trane xamic acid was giv en wit hin 
2 hours of a head injur y. The e vidence suggest ed that it r educed all-cause mor tality at Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 51 of
74

28 days and 6  mont hs in people wit h moderat e or se vere traumatic brain injur y. But t here 
was no clinically impor tant diff erence betw een trane xamic acid and placebo f or hospital-
free da ys at 28  days, degr ee of disability at dischar ge and aft er 6 mont hs (Glasgo w 
Outcome Scale–Ext ended mor e than 4), and serious adv erse e vents (that is, m yocardial 
infarction, pulmonar y embolism, deep v ein thrombosis and str oke). 
In the hospital setting, a 1  g bolus dose of trane xamic acid was giv en wit hin 3  hours of 
injury, followed by an 8-hour intra venous infusion of 1  g of trane xamic acid. The e vidence 
suggest ed that t his reduced deat h from traumatic brain injur y at 28  days in gr oups wit h 
mild or moderat e traumatic brain injur y. Evidence suggest ed reduced mor tality r elated to 
severe traumatic brain injur y at 28  days in high-income countries, but t here was no

severe traumatic brain injur y at 28  days in high-income countries, but t here was no 
difference in mor tality r elated to traumatic brain injur y in lo w- and middle-income 
countries. No e vidence was a vailable separating t he mild fr om moderat e severity gr oups 
for mor tality r elated to traumatic brain injur y and all-cause mor tality , but communication 
with the study aut hors suggest ed significant uncer tainty about trane xamic acid's eff ect in 
mild traumatic brain injur y. Ther e was no clinically impor tant diff erence betw een 
trane xamic acid and placebo f or serious adv erse e vents (that is, m yocardial inf arction, 
pulmonar y embolism, deep v ein thrombosis and str oke) and disability rating scale scor es 
in a mix ed se verity gr oup (mild, moderat e and se vere) acr oss all income gr oups.

in a mix ed se verity gr oup (mild, moderat e and se vere) acr oss all income gr oups. 
The committ ee consider ed that, despit e the uncer tainty in t he clinical e vidence, t here was 
a benefit wit h trane xamic acid in t erms of r educing all-cause mor tality and mor tality fr om 
traumatic brain injur y. The y also consider ed that t he evidence sho wed that it caused v ery 
few adv erse e vents. Based on t he evidence, t hey agr eed t hat a 2  g intra venous bolus dose 
of trane xamic acid, giv en wit hin 2  hours of a head injur y and bef ore imaging, could be 
consider ed for people 16 and o ver wit h moderat e or se vere traumatic brain injur y. The 
committ ee recommended a 2  g intra venous bolus injection of trane xamic acid because t his 
dose was f ound t o be t he most saf e and eff ectiv e. 
An economic model was de veloped t hat look ed at each traumatic brain injur y severity

An economic model was de veloped t hat look ed at each traumatic brain injur y severity 
subgr oup separat ely. It was based primarily on t he pr e-hospital clinical trial because: 
• that pr ovided data f or moderat e traumatic brain injur y separat ely fr om t hat f or mild 
injury 
• the benefit s of trane xamic acid w ere found t o be gr eater when it was giv en earlier . 
For moderat e traumatic brain injur y, the healt h benefit s associat ed wit h a 2  g bolus giv en 
in the pr e-hospital setting outw eighed t he cost s in all scenarios. F or se vere traumatic brain Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 52
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injury, the cost -effectiv eness estimat e was mor e bor derline. But, when limitations in t he 
modelling w ere tak en int o account, t he committ ee concluded t hat t he healt h benefit s were 
likely to outw eigh t he cost s in t his gr oup t oo. 
Because of a lack of trial e vidence f or trane xamic use in people under 16 , the committ ee 
used e xtrapolat ed evidence fr om t he trials in adult s, and t heir e xper tise and kno wledge. In 
NHS clinical practice, a trane xamic acid dose of 15  mg/k g is used in people under 16 wit h 
extracranial injuries. But, in t his age gr oup, trane xamic acid is not curr ently widely used f or 
isolat ed head injur y and dosing is v ariable (15  mg/k g to 30  mg/k g). Evidence f or people 16 
and o ver wit h a head injur y from a pr e-hospital setting suggest ed that a 2  g dose of 
trane xamic acid r educed all-cause mor tality (at 28  days and 6  mont hs), wit h no e vidence

trane xamic acid r educed all-cause mor tality (at 28  days and 6  mont hs), wit h no e vidence 
of negativ e eff ects. So, t he committ ee concluded t hat it could r ecommend t he equiv alent 
of a 2  g dose of trane xamic acid f or people under 16 . The y discussed t hat, based on t he 
average w eight of people 16 and o ver being 7 0 kg, a 2  g dose of trane xamic acid f or 
people 16 and o ver would equat e to a 30  mg/k g dose f or people under 16 . So, t hey 
concluded t hat a dose range of 15  mg/k g to 30  mg/k g was appr opriat e for people under 
16. 
For people wit h mild traumatic brain injur y, it is less clear whet her t he benefit s of 
trane xamic acid outw eigh t he pot ential risk of blood clot s. So, t he committ ee made a 
recommendation f or resear ch on trane xamic acid  for this gr oup. 
How the r ecommenda tions mig ht affect practice or ser vices

Tranexamic acid is alr eady used f or people who ha ve a head injur y and ot her major 
trauma. NICE has not pr eviously r ecommended it f or people wit h an isolat ed head injur y. It 
is expect ed that doing so will incr ease trane xamic acid use b y paramedics. This should 
lead t o impr oved sur vival for people wit h a head injur y. Mor e resour ces might be needed 
for treatment, r ehabilitation and car e for the people who w ould not ha ve sur vived wit hout 
trane xamic acid. 
Recommendation 1 .3.19 Head injur y: assessment and early management (NG232)
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Why the c ommi ttee made the r ecommenda tion 
No e vidence was identified f or dir ect access fr om t he community f or CT scans or MRI of 
the head compar ed wit h usual car e for a suspect ed or confirmed head injur y (including 
people wit h dela yed pr esentation, and people in r esidential and car e homes). The 
committ ee discussed t hat imaging or dered in t he community setting is mainly used t o 
exclude intracranial bleeding or pr ovide r eassurance. The y not ed that t he timing of 
imaging depends on whet her t here is an acut e injur y or t he person has post-concussion 
syndr ome. Based on t heir e xperience, t he committ ee agr eed t hat people should go t o 
hospital if: 
• there has been impor tant traumatic brain injur y wit hin 2 4 hours or 
• there is a r educed Glasgo w Coma Scale  (GCS) scor e. 
The committ ee w ere awar e that some trust s have referral pat hways that allo w for imaging

The committ ee w ere awar e that some trust s have referral pat hways that allo w for imaging 
to be r equest ed dir ectly from t he community setting or primar y car e. But t hey not ed the 
logistical challenges in t he acut e phase of a head injur y in getting access t o, and timely 
repor ting of , imaging. The y also not ed the challenges f aced in primar y car e and general 
practice in int erpreting comple x neur oradiology r epor ts. The committ ee therefore agr eed 
that people should not be r eferred to imaging dir ectly from t he community . 
How the r ecommenda tion mig ht affect practice or ser vices 
This is e xpect ed to be a change in practice f or a f ew centr es that will no w ha ve to send 
people f or imaging b y the emer gency depar tment r oute. 
Return t o recommendation 
Assessmen t in the emer gency depar tmen t 
Recommendation 1 .4.12 
Why the c ommi ttee made the r ecommenda tion

The committ ee highlight ed the need t o follow relevant guidance if abuse or ot her 
safeguar ding issues ma y be f actors in a head injur y. Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 54
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Recommendations 1 .5.8 to 1.5.14 
Several diagnostic accuracy studies w ere identified but t here were no diagnostic RCT s. 
Most of t he evidence was of lo w to very low quality and was in people wit h a mild head 
injury (defined as a GCS scor e of 13  to 15 in man y studies, but sometimes limit ed to a GCS 
score of 14  to 15). The committ ee not ed that t he existing r ecommendations f or clinical 
decision rules f or head imaging in people 16  and o ver were largely based on t he Canadian 
CT Head Rule (CCHR). This in volves identifying high and medium risk f actors, wit h some 
modifications aimed at impr oving sensitivity . Updat ed evidence f or this decision rule

modifications aimed at impr oving sensitivity . Updat ed evidence f or this decision rule 
showed that it has good sensitivity when used as int ended but t hat it s specificity v alues 
are poor . The committ ee not ed that specificity v alues of decision rules ar e oft en lo w 
because t hey prioritise v ery high sensitivity . 
Evidence identified f or ot her decision rules sho wed sensitivity v alues similar t o those of 
the CCHR. Ho wever, specificity v alues w ere lower compar ed wit h the CCHR high and 
medium risk rule. Limit ed evidence sho wed that t he NEXUS  2 decision rule has specificity 
values similar t o those of t he CCHR. 
Only 1  study had assessed t he per formance of t he 2014 updat e of NICE's head injur y 
guideline r ecommendations f or head imaging. This r epor ted sensitivity v alues t hat w ere

guideline r ecommendations f or head imaging. This r epor ted sensitivity v alues t hat w ere 
poor er than t hose f or the CCHR. But t he specificity v alues w ere bett er compar ed wit h 
other decision rules. The committ ee agr eed t hat it was unclear wh y the sensitivity of t he 
NICE r ecommendations w ould be w orse t han t hose of CCHR. The y also agr eed t hat it was 
unclear wh y the CCHR did not do as w ell in t his study as in ot her studies. The y thought 
that t his possibly suggest ed some diff erences betw een study populations, which ma y Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 55
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have aff ected the result s. The committ ee also agr eed t hat, in t heir clinical e xperience, t he 
sensitivity of t he NICE r ecommendations was not as lo w as suggest ed in t his study . 
The committ ee agr eed t hat t here was insufficient e vidence t o suppor t changing t he 
clinical decision rule r ecommendations f or head imaging in people 16  and o ver. Because 
the NICE r ecommendations w ere largely based on t he CCHR rule, t his decision was fur ther 
suppor ted by cost -effectiv eness e vidence. This sho wed the CCHR rule t o be t he most 
cost eff ectiv e of t he multiple decision rules assessed. 
The committ ee not ed that t he existing r ecommendations f or clinical decision rules f or 
head imaging in people under  16 w ere largely based on t he CHALICE rules wit h some 
modifications. These modifications w ere based on curr ent practice and e xperience 
allowing f or the option of an obser vation period wit h imaging if t he condition of some

allowing f or the option of an obser vation period wit h imaging if t he condition of some 
people det eriorat ed, rat her t han immediat e imaging. 
Updat ed evidence identified f or this decision rule sho wed that it had good sensitivity when 
considering clinically impor tant injuries or neur osurgical out comes. In t he 2014 updat e of 
this guideline, t he committ ee stat ed that an impr ovement in specificity r elativ e to the NICE 
recommendations w ould be needed t o warrant swit ching t o anot her decision rule f or 
people under  16. The y not ed that PECARN and CA TCH-7 ma y have slight ly bett er 
sensitivity v alues compar ed wit h CHALICE, but agr eed t hat, o verall: 
• the specificity v alues f or CHALICE ar e much bett er than f or ot her rules assessed 
• the sensitivity v alues f or CHALICE ar e still o ver 90% f or clinically impor tant injuries and 
neurosurgical out comes.

neurosurgical out comes. 
The committ ee not ed that, in t erms of t he cont ent of t he rules, PECARN and t he NICE 
guideline ar e not v ery diff erent but t hat PECARN is v aguer and does not giv e timings. The y 
thought t his less useful. In addition, t hey not ed that t he PECARN and CA TCH-7 rules apply 
to mor e specific populations t han t he NICE guideline r ecommendations. 
The committ ee agr eed t hat t he recommendations in t he NICE guideline ar e in widespr ead 
use in curr ent practice, and used wit h little variation. Their opinion was t hat t hey are 
currently well-accept ed and used wit h good eff ect. The committ ee therefore agr eed t hat 
there was insufficient e vidence t o suppor t changing t he clinical decision rule 
recommendations f or head imaging in people under  16. Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 56
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The committ ee agr eed t o keep t he existing r ecommendations in fr om t he 2014 updat e of 
NICE's head injur y guideline f or people wit h bleeding and clotting disor ders. This was 
because t here was no new e vidence t o change practice in adult s, and t he committ ee 
agreed t o extrapolat e from an e xisting r ecommendation t o mak e a new r ecommendation 
for people under 16 . However, they changed t he recommendation w ording fr om 'hist ory of 
bleeding or clotting disor ders' t o 'curr ent bleeding or clotting disor ders' . In childr en, some 
disor ders ar e shor t-lived or r esolv e in a couple of mont hs. In adult s, a hist ory of bleeding 
or clotting disor ders is used t o help scr een people bef ore sur gery. However, this is a crude 
tool and ma y not be appr opriat e in t his setting. So, t he committ ee agr eed t o keep t he 
changed w ording f or all age gr oups t o help pr ovide a consist ent message. 
People ha ving anticoagulant s or antiplat elets

People ha ving anticoagulant s or antiplat elets 
Ther e was conflicting e vidence fr om cohor t studies on whet her people who ar e on 
anticoagulant s or antiplat elets are at higher risk of intracranial haemorrhage t han people 
not on anticoagulant s or antiplat elets. CT scans could be limit ed to people wit h sympt oms 
of traumatic brain injur y such as loss of consciousness or amnesia. Ho wever, the 
committ ee thought t hat t he new e vidence was not str ong enough t o warrant st opping 
imaging in people wit h a head injur y who ar e on anticoagulant s but ha ve no ot her 
indication f or imaging. So, t hey decided CT scanning should be consider ed rat her t han 
automatically done in t his gr oup. The y also agr eed t hat antiplat elets other t han aspirin 
monot herap y should be included in t his. The r eview findings suggest ed that people on

monot herap y should be included in t his. The r eview findings suggest ed that people on 
anticoagulant s (including war farin and dir ect-acting oral anticoagulant s) or antiplat elets 
(excluding people on aspirin monot herap y) wit h low-risk f actors (no loss of consciousness, 
amnesia, a GCS scor e of 15 and no ot her indications f or CT brain scan) can be risk 
assessed (including f or ot her injuries, super vision at home, cause of incident and risk of 
further f alls). Then, if t here are no risk f actors and aft er shar ed decision making, t hey 
could be dischar ged saf ely wit hout a CT scan, wit h the usual dischar ge advice (see t he 
section on dischar ge and f ollow up ). The committ ee highlight ed that clinicians w ould eit her 
scan or admit someone f or monit oring if an y risks w ere identified. This might be, f or

scan or admit someone f or monit oring if an y risks w ere identified. This might be, f or 
example, if a person (wit h pre-existing cognitiv e impairment) ma y be less lik ely to return t o 
the emer gency depar tment ur gent ly if t hey have any signs of det erioration. The committ ee 
noted that, if an intracranial haemorrhage is not det ected at initial pr esentation, dela yed 
recovery is mor e likely rat her t han deat h. The y also discussed t hat neur osurgical 
intervention f or traumatic brain injur y is less lik ely to be off ered for people o ver 74 
because risks outw eigh t he benefit s. 
In curr ent practice, in accor dance wit h the 2014 updat e of NICE's head injur y guideline Head injur y: assessment and early management (NG232)
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recommendations, a CT head scan is done wit hin 8  hours of a head injur y in people wit h 
no ot her indications f or a CT head scan who ar e having anticoagulant tr eatment. The 2014 
updat e did not mak e specific r ecommendations f or people on antiplat elets. The committ ee 
agreed t hat, in clinical practice, t here is v ariation, wit h some ser vices off ering imaging t o 
people on antiplat elets. Based on t he evidence, t hey also agr eed t hat antiplat elets other 
than aspirin monot herap y should be included but did not specify which antiplat elets. This 
was because t hey did not want t o be pr escriptiv e and e xclude an y new er antiplat elets in 
development. Based on t heir e xperience and e xtrapolation of e vidence in people 
presenting wit hin 8  hours of injur y, the committ ee agr eed t hat t hese r ecommendations 
could be applicable t o people pr esenting mor e than 8  hours aft er their injur y. However,

could be applicable t o people pr esenting mor e than 8  hours aft er their injur y. However, 
they agr eed t hat imaging should be done wit hin an hour of confirming t hat t he person wit h 
head injur y is on anticoagulant or antiplat elet medication. 
Ther e was limit ed evidence on aspirin. F rom t heir kno wledge and clinical e xperience, t he 
committ ee highlight ed that t he risk of intracranial haemorrhage is lo w wit h aspirin. This is 
even so in people wit h neur ological sympt oms such as loss of consciousness or amnesia. 
So, t hey agr eed t hat people on aspirin monot herap y could be dischar ged wit hout a CT 
head scan aft er shar ed decision making if t here is no ot her indication f or a CT brain scan 
or hospital admission. 
The committ ee made a recommendation f or resear ch on risk of bleeding f or people wit h 
pre-injur y coagulopat hy.

pre-injur y coagulopat hy. 
People wit h liv er or coagulopat hy disor ders 
Ther e was no e vidence f or people wit h liver or coagulopat hy disor ders. Curr ent practice is 
variable, wit h some ser vices off ering imaging t o people wit h liver disease who ha ve no 
sympt oms. P eople wit h liver or coagulopat hy disor ders ar e at incr eased risk of bleeding, 
although some people will ha ve a tendency f or incr eased clotting. P eople wit h acquir ed 
coagulation def ects can be a het erogenous and comple x group. The y can include people 
with acquir ed haemophilia t hrough t o people wit h other abnormalities such as 
disseminat ed intra vascular coagulation. 
The committ ee agr eed t o keep t he existing r ecommendations fr om t he 2014 updat e of 
NICE's head injur y guideline f or people wit h bleeding and clotting disor ders. This was

because t here was no new e vidence t o change practice. But t hey changed t he 
recommendation w ording fr om 'hist ory of bleeding or clotting disor ders' t o 'curr ent 
bleeding or clotting disor ders' . In people under  16, some disor ders ar e shor t-lived or Head injur y: assessment and early management (NG232)
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resolv e in a couple of mont hs. In adult s, a hist ory of bleeding or clotting disor ders is used 
to help scr een people bef ore sur gery. However, this ma y not be appr opriat e in t he 
emer gency depar tment setting. So, t he committ ee agr eed t o keep t he changed w ording 
for all age gr oups t o help pr ovide a consist ent message. 
People wit h pre-injur y cognitiv e impairment who ha ve a head injur y through lo w-ener gy 
impact or lo w-le vel falls 
Limit ed evidence fr om cohor t studies suggest ed that, in people 16  and o ver, falling fr om a 
standing position, being o ver 70, having a r educed GCS scor e compar ed wit h normal, 
taking antiplat elet medication including aspirin, and ha ving neur ological sympt oms (loss of 
consciousness, v omiting aft er fall) w ere risk f actors associat ed wit h the diagnosis of an 
intracranial bleed. Anticoagulant medication in t his population was not associat ed wit h an

intracranial bleed. Anticoagulant medication in t his population was not associat ed wit h an 
intracranial bleed. It was not clear if people in t he studies had pr e-injur y cognitiv e 
impairment, so t he applicability of t his e vidence is limit ed. 
The committ ee discussed t he challenges in assessing risk in people wit h cognitiv e 
impairment. F or example, people wit h dementia ma y under -repor t or ma y be unawar e of 
sympt oms such as loss of consciousness or amnesia. It is also difficult t o diff erentiat e 
head injur y sympt oms fr om t he pr e-existing dementia in t hese people. Ther e was no 
evidence f or people under  16. 
The committ ee ackno wledged t he limit ed evidence f or this gr oup. The y made a 
recommendation f or resear ch on indications f or imaging f or people wit h pre-injur y 
cognitiv e impairment . 
People wit h recurr ent head injuries

People wit h recurr ent head injuries 
Ther e was no e vidence f or recurr ent head injuries in an y age gr oup. R ecurr ent head 
injuries could occur in people wit h epilepsy , people wit h mobility issues at high risk of f alls 
and wit h some spor ts activities. Par ticularly in t he cont ext of spor ts injuries, t hese injuries 
can be r epeat ed and lead t o cumulativ e risks. Because of a lack of e vidence, t he 
committ ee decided t o mak e a recommendation f or resear ch on indications f or imaging f or 
people wit h a hist ory of r ecurr ent traumatic head injuries . 
People pr esenting mor e than 2 4 hours aft er a head injur y 
Evidence fr om 1  obser vational  study suggest ed that t here was an incr eased risk of an y Head injur y: assessment and early management (NG232)

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traumatic brain injur y or impor tant traumatic brain injur y on a CT head scan in babies and 
childr en under  2 years: 
• the younger t heir age 
• if they have a GCS scor e of less t han 15 
• if they present mor e than 2 4 hours aft er head injur y. 
Ther e was no e vidence f or people 2  years or o ver. The committ ee discussed t hat people 
16 and o ver pr esenting mor e than 2 4 hours aft er injur y have incr eased risk f actors such as 
vomiting and loss of consciousness. This is because t hey would be att ending because of 
worsening sympt oms. The 2014 updat e of NICE's head injur y guideline r ecommendations 
are for people pr esenting wit hin 2 4 hours of injur y. But, because of a lack of e vidence, t he 
committ ee agr eed t hat t hese could be e xtrapolat ed to people pr esenting mor e than 
24 hours aft er a head injur y (see t he recommendations on t he crit eria f or doing a CT head

24 hours aft er a head injur y (see t he recommendations on t he crit eria f or doing a CT head 
scan ). The y also agr eed t hat t his was an impor tant ar ea, so pr oposed a recommendation 
for resear ch on indications f or selecting people f or imaging when t hey present mor e than 
24 hours aft er a head injur y. 
Weakening t he recommendation f or people wit h a head injur y who ar e on anticoagulant s 
but ha ve no ot her indication f or imaging fr om 'off er' to 'consider' is e xpect ed to result in 
fewer scans. But e xpanding t he recommendation t o include people wit h a head injur y who 
are on clopidogr el, prasugr el or ticagr elor is e xpect ed to result in mor e scans. It is 
uncer tain whet her t his will lead t o an o verall incr ease or decr ease in scanning. 
Post-concussion syndr ome

Recommendation 1 .5.15 Head injur y: assessment and early management (NG232)
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The committ ee agr eed t hat high specificity is needed f or brain injur y biomark ers for post -
concussion syndr ome. This was because t he population wit h a mild head injur y is lar ge but 
only a small pr opor tion go on t o develop post -concussion syndr ome. So, f alse positiv es 
would ha ve a negativ e eff ect on r esour ces if biomark ers w ere to be used t o direct 
everyone t owards int erventions or monit oring. 
Overall, t he committ ee agr eed t hat t he evidence was t oo limit ed to be able t o mak e 
recommendations f or using biomark ers (including fluid biomark ers or MRI) t o predict post -
concussion syndr ome in people wit h mild traumatic brain injur y. Ther e was no e vidence 
from pr ognostic t est-and-tr eat studies comparing clinical out comes, so t he committ ee 
agreed t o highlight t he crit eria f or doing a CT head scan. The y also made a

agreed t o highlight t he crit eria f or doing a CT head scan. The y also made a 
recommendation f or resear ch on using biomark ers and MRI f or pr edicting post -concussion 
syndr ome. 
Using biomark ers f or pr edicting acut e complications aft er a tr aumatic br ain 
injur y 
Evidence fr om diagnostic accuracy studies suggest ed that t here were high sensitivity 
values f or some biomark ers at cer tain t hresholds f or pr edicting acut e complications aft er a 
traumatic brain injur y, but t he specificity v alues w ere not high enough acr oss t he 
evidence. Also, man y biomark ers w ere only t ested in small samples, which led t o impr ecise 
estimat es. The committ ee not ed that accuracy diff ered quit e widely betw een diff erent 
studies looking at t he same biomark er test measur ed wit h diff erent assa ys on diff erent

studies looking at t he same biomark er test measur ed wit h diff erent assa ys on diff erent 
platf orms. Also, t he evidence was het erogenous, wit h variable t hresholds and time point s 
for diff erent biomark ers. Most people wit h a head injur y present t o hospital wit hin 3  hours, 
and t he manuf actur ers r ecommend t his timeframe f or optimal t est result s. Man y of t he 
studies assessed biomark ers be yond t his time point. 
The committ ee agr eed t hat t he specificity v alues w ere equally as impor tant as t he 
sensitivity v alues, giv en the consequences of unnecessar y radiation fr om CT scans. The y 
thought t his was par ticularly impor tant in people under  16. But, aft er considering t he 
limitations of t he evidence, t he committ ee w ere unable t o mak e recommendations f or

limitations of t he evidence, t he committ ee w ere unable t o mak e recommendations f or 
using biomark ers t o predict acut e complications aft er a mild traumatic brain injur y. They 
did t hink t hat biomark er tests had pr omise, so t hey proposed a recommendation f or Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 61 of
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resear ch on using biomark ers for pr edicting acut e post -traumatic brain injur y 
complications . 
Biomark ers ar e not r outinely used in people wit h acut e head injur y and t he 
recommendation f or MRI has not changed. So, t here is not e xpect ed to be a change in 
practice. 
Investig ating in juries to the c ervical spine 
Recommendations 1 .6.1 to 1.6.11 
The committ ee consider ed sensitivity t o be t he most impor tant measur e for types of 
investigation f or cer vical spine injuries in people wit h head injuries. This is t o ensur e the 
investigation does not miss impor tant cer vical spine injuries, which could r esult in 
subsequent negativ e consequences such as disability . The e vidence was limit ed because 
the pr opor tion of people wit h a confirmed head injur y was not r epor ted in t he diagnostic

the pr opor tion of people wit h a confirmed head injur y was not r epor ted in t he diagnostic 
accuracy studies, but it suggest ed that X -rays ha ve poor sensitivity compar ed wit h CT 
scans in people 16  and o ver. 
Based on t he evidence, and t he committ ee's e xperience and kno wledge of curr ent 
practice, t he committ ee agr eed t hat X -rays of t he cer vical spine should not be done 
initially in people 16  and o ver wit h a head injur y. The y also agr eed t hat CT scans of t he 
cervical spine should be used in people 16  and o ver in a wa y consist ent wit h curr ent 
clinical practice. Ther e was limit ed evidence f or MRI (less accurat e at sho wing bon y 
injuries, tak es longer t o do and y ounger people might need sedation). Also, MRI is rar ely 
used as an initial imaging strat egy. So, MRI is r ecommended as an additional f orm of

used as an initial imaging strat egy. So, MRI is r ecommended as an additional f orm of 
imaging in cer tain cir cumstances (as in pr evious v ersions of t he guideline). F or people 
under  16, limitations in t he evidence, and radiation e xposur e and risk of cancer , 
contribut ed to the committ ee's decision not t o mak e any major changes t o the 
recommendations. Head injur y: assessment and early management (NG232)
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CT scanning of t he neck in people 16  and o ver wit h a head injur y has alr eady r eplaced 
X-rays when t here is at least a medium risk of serious spinal injur y. So, t here is not 
expect ed to be a change in practice. 
Admission and obser vation 
Recommendations 1 .9.1 to 1.9.5 
Small intr acranial injuries 
Limit ed evidence fr om cohor t studies in people wit h intracranial injuries suggest ed that 
effect siz es for the clinical decision rules w ere larger o verall t han t hose f or individual risk 
factors. So, t he committ ee agr eed t hat clinical decision rules w ere likely to be t he wa y to 
identify people who should be admitt ed in t he futur e. This was because t hey thought it 
would be difficult t o mak e decisions based on individual risk f actors in clinical practice. But

would be difficult t o mak e decisions based on individual risk f actors in clinical practice. But 
the evidence f or clinical decision rules was all r etrospectiv e. So, t he committ ee did not 
think an y specific clinical decision rules could be r ecommended, par ticularly because t hey 
would be new t o clinical practice. 
For individual risk f actors, t he committ ee not ed that t here was consist ent e vidence acr oss 
all studies (including 1  study in people under  16) that GCS scor es of  13 and  14 w ere 
associat ed wit h a w orse out come t han a GCS scor e of 15. But t his is alr eady an e xisting 
indication f or admission (see recommendation 1 .9.1). 
Evidence f or specific t hresholds and findings on CT (including t hresholds f or subdural or 
epidural haemorrhage siz e, or findings such as midline shift or mass eff ect on CT) also

epidural haemorrhage siz e, or findings such as midline shift or mass eff ect on CT) also 
indicat ed lar ger eff ect siz es than f or some ot her risk f actors. But, f or factors such as 
midline shift, t he committ ee not ed that a t hreshold f or degr ee of shift w ould be mor e 
useful in practice. The y also not ed that t he varying t hresholds used f or subdural and 
epidural haemorrhage acr oss t he diff erent studies made t he ideal t hreshold t o use unclear . Head injur y: assessment and early management (NG232)
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The e vidence also suggest ed that t hresholds f or age could be associat ed wit h a w orse 
outcome in higher age gr oups. But t he committ ee not ed that older age w ould not solely be 
used in practice t o mak e decisions about admission. This is par ticularly because admission 
in older age gr oups can also be associat ed wit h harms such as hospital-acquir ed 
infections. The committ ee agr eed t hat age or frailty ma y be a concern but should not be a 
sole indicat or for admission. Ov erall, t he committ ee agr eed t hat pr ospectiv e studies ar e 
needed in people wit h a GCS scor e of 13, 14 or 15 and a head injur y of an y siz e confirmed 
with CT t o validat e existing clinical decision rules f or pr edicting det erioration. The aim 
would be t o refine indications f or admission in t his gr oup. So, t he committ ee made a 
recommendation f or resear ch on indications f or admission in people wit h a mild head injur y 
and a confirmed abnormality on a CT scan .

and a confirmed abnormality on a CT scan . 
Isolat ed skull fr actur e 
Evidence fr om se veral case series suggest ed that t here was lo w risk of deat h, 
neurosurgery, admission t o critical car e, unplanned hospital admission and dela yed 
intracranial injur y in babies and childr en (age cut -off v aried acr oss studies) wit h an 
isolat ed skull fractur e. The e vidence suggest ed that t here was a slight ly higher risk of 
seizur e (at pr esentation) and e valuation f or suspect ed non-accidental injur y in t his gr oup. 
Accor ding t o curr ent guidelines ( recommendations 1 .5.8 and 1 .5.10), people wit h seizur es 
and suspect ed non-accidental injuries will be admitt ed to hospital aft er a head injur y. 
Based on t he evidence, t he committ ee agr eed t hat simple linear non-displaced fractur es

Based on t he evidence, t he committ ee agr eed t hat simple linear non-displaced fractur es 
are not lik ely to be a clinically impor tant injur y. So, t hey agr eed t hat, aft er shar ed decision 
making, people under  16 wit h such fractur es can be saf ely dischar ged if t hey have normal 
neurological status and t here are no saf eguar ding concerns. 
Ther e was no dir ect e vidence f or people 16  and o ver wit h an isolat ed skull fractur e. 
Indirect e vidence fr om cohor t studies suggest ed that t here was lo w risk of clinical 
deterioration fr om a simple skull fractur e compar ed wit h: 
• a comple x skull fractur e 
• 1 to 2 bleeds 
• bleeds less t han 5  mm in diamet er 
• no or minimal mass eff ect 
• significant midline shift Head injur y: assessment and early management (NG232)

conditions#notice-of -right s).Page 64
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• a high- or mix ed-density lesion 
• cerebellar or brain st em injur y. 
Clinical det erioration was measur ed by a composit e of deat h due t o traumatic brain injur y, 
neurosurgery, seizur e, a f all in GCS scor e of mor e than 1, admission int o intensiv e car e for 
traumatic brain injur y, intubation or hospital r eadmission f or traumatic brain injur y. The 
simple skull fractur e group included bot h isolat ed and non-isolat ed skull fractur es. But t he 
committ ee agr eed t hat t he evidence is still lik ely to be br oadly applicable f or people 16  and 
over wit h an isolat ed skull fractur e. Based on t he evidence and t heir collectiv e experience, 
the committ ee agr eed t hat, aft er shar ed decision making, people 16  and o ver wit h an 
isolat ed skull fractur e can be dischar ged saf ely (except f or people on anticoagulant s or 
antiplat elets) if t here are no saf ety concerns. 
Anticoagulant s and antiplat elets

Anticoagulant s and antiplat elets 
The e vidence was limit ed on admission t o and obser vation in hospital of people who ha ve 
a head injur y and ar e on anticoagulant s (war farin and ot her vitamin  K antagonist s, and 
direct-acting oral anticoagulant s) or antiplat elets (including aspirin, ticlopidine, clopidogr el, 
prasugr el and ticagr elor), and ha ve normal brain imaging or no indication f or early imaging. 
Limit ed evidence fr om non-randomised studies suggest ed that t here was no clinically 
impor tant diff erence betw een pr e-injur y anticoagulant or no anticoagulant tr eatment in 
terms of dela yed bleeding. The e vidence included at least 1  propensity mat ched study 
including about 7 0,000 people. 
The committ ee agr eed t hat t he evidence was not str ong enough t o recommend using

The committ ee agr eed t hat t he evidence was not str ong enough t o recommend using 
anticoagulation status as a sole indicat or for admission f or people wit h a negativ e initial CT 
head scan. The y highlight ed that admission based solely on t his could cause harm in 
people alr eady vulnerable (because of , for example, frailty , an underlying condition such as 
delirium or risk of hospital-acquir ed inf ections). This is par ticularly so if t here is not a lar ge 
increase in risk of dela yed bleeding. Also, when t hese e vents do occur , they are usually not 
clinically impor tant. 
Evidence fr om non-randomised studies f or antiplat elet comparisons was mor e limit ed than 
that f or anticoagulant s. Ther e were no lar ge studies, and all r epor ted eff ects were based 
on a diff erence of only 1  to 2 events betw een pr e-injur y antiplat elet and no-antiplat elet

on a diff erence of only 1  to 2 events betw een pr e-injur y antiplat elet and no-antiplat elet 
groups per study . The committ ee agr eed t hat t he evidence was not str ong enough t o 
recommend using antiplat elet status as a sole indicat or for admission f or people wit h a Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 65
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negativ e initial CT or no indication f or a CT . The committ ee did not mak e a 
recommendation f or resear ch for this gr oup because t hey did not consider it t o be a 
priority f or resear ch. 
Concussion sympt oms 
Ther e was no e vidence on admission or dischar ge of people wit h concussion sympt oms 
after normal imaging or no indication f or imaging. The committ ee agr eed t hat t heir 
dischar ge is based on clinical discr etion, and admission is consider ed if non-accidental 
injury is suspect ed. F rom t heir e xperience, t he committ ee also agr eed t hat most people 
with concussion sympt oms and normal imaging do not need fur ther int ervention and ar e 
safe to be dischar ged fr om t he emer gency depar tment. The y highlight ed that curr ent 
practice is t o not admit people wit h concussion sympt oms unless t hey have any of t he 
indications in recommendation 1 .9.1. The committ ee w ere unawar e of an y evidence

indications in recommendation 1 .9.1. The committ ee w ere unawar e of an y evidence 
indicating t hat curr ent practice was causing harm ( coroners r epor ts, saf ety r epor ts, 
patient gr oup f eedback). The y also not ed that someone's condition ma y worsen if t hey are 
admitt ed, for example, because of being in a noisy and unf amiliar en vironment, and 
because t he risk of hospital-acquir ed inf ections could incr ease. When people wit h 
concussion sympt oms ar e dischar ged, inf ormation is pr ovided on when t o return t o 
hospital t o seek fur ther immediat e car e and ongoing suppor t for persist ent sympt oms (see 
the recommendations on dischar ge advice ). The committ ee agr eed t hat t his is impor tant 
and did not t hink t here was an y evidence on which t o base a change in practice. 

Currently, most people wit h an isolat ed skull fractur e are admitt ed for obser vation. It is 
expect ed that man y of t hese people could be dischar ged fr om t he emer gency depar tment 
without admission t o hospital unless t here are other indications f or admission. F or people 
on anticoagulant s or antiplat elets, and people wit h concussion sympt oms, t here are no 
significant changes in practice r ecommended, and t he recommendations ar e thought t o 
reflect curr ent practice. 
Recommendations 1 .9.6 to 1.9.8 Head injur y: assessment and early management (NG232)
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The committ ee highlight ed that t here is a higher risk of hypopituitarism  with mor e severe 
head injuries, but not ed that it can be caused b y a mild head injur y. Also, t he condition can 
occur immediat ely aft er a head injur y or in t he w eeks t o mont hs aft erwards. This, and t he 
wide v ariety of sympt oms of h ypopituitarism, can mak e the condition difficult t o diagnose. 
The committ ee supplement ed the small amount of obser vational e vidence ( cohor t studies) 
with their e xper tise. The y discussed t hat wh y head injur y causes h ypopituitarism is not 
fully underst ood, and t hat t here could be v arious r easons. Curr ent practice f or scr eening 
for hypopituitarism is v ariable, but it is not commonly identified on CT scanning in t he 
emer gency depar tment. The clinician's f amiliarity and suspicion of h ypopituitarism ma y

emer gency depar tment. The clinician's f amiliarity and suspicion of h ypopituitarism ma y 
affect diagnosis rat es. Also, t esting in t he emer gency depar tment ma y not be useful 
because t he acut e injur y phase stimulat es cor tisol secr etion. This mak es it difficult t o tell if 
there is h ypoadr enalism. So, t he committ ee agr eed t hat it w ould be bett er to investigat e 
for hypopituitarism in people admitt ed to hospital wit h a head injur y if they have clinical 
sympt oms or biochemical findings such as h ypot ension or h yponatraemia. The committ ee 
suggest ed this w ould pr ovide an oppor tunity f or referral t o a specialist. 
In the absence of e vidence on t he timing of in vestigations, t he committ ee also made a 
recommendation f or resear ch on timing of t esting f or hypopituitarism . 

Hospital staff ar e advised t o look out f or sympt oms of h ypopituitarism in people admitt ed 
to hospital aft er a head injur y. So, t here might be an incr ease in t esting f or hypopituitarism 
in hospital. It is also int ended t hat people will get r eferred for specialist car e sooner . 
Dischar ge and f ollow up 
Recommendation 1 .10.6 Head injur y: assessment and early management (NG232)
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People wit h pre-injur y cognitiv e impairment 
Pre-existing cognitiv e impairment such as dementia, Parkinson's disease or str oke was 
repor ted in some studies in people taking anticoagulant s and antiplat elets, but t he studies 
did not r epor t the eff ect of pr e-injur y cognitiv e impairment on t he out comes. Examples of 
pre-injur y cognitiv e impairment s and neur odivergence seen in people of an y age include 
developmental dela y, Down's syndr ome, cer ebral palsy , fetal alcohol syndr ome, a learning 
disability , autism spectrum disor der and ot her conditions wit h altered sensation. Examples 
of pr e-injur y cognitiv e impairment seen only in adult s include depr ession, dementia and 
medication side eff ects. The committ ee not ed fr om t heir e xperience t hat people wit h pre-
existing conditions aff ecting cognition ar e less lik ely to recognise and t o raise an alarm

existing conditions aff ecting cognition ar e less lik ely to recognise and t o raise an alarm 
about t he early signs of a lat e intracranial bleed (such as a se vere headache, dr owsiness 
and v omiting) t han people wit h no pr e-existing cognitiv e impairment. So, in curr ent 
practice, a shor t overnight admission f or obser vation is arranged f or people wit h a pr e-
existing cognitiv e impairment when no super vision at home is a vailable. The committ ee 
agreed t hat people wit h a pr e-existing cognitiv e impairment will need t o be appr opriat ely 
super vised and monit ored to ensur e that t heir sympt oms ar e not w orsening if t hey are 
dischar ged fr om t he emer gency depar tment. Super vision and monit oring was also not ed 
to be impor tant f or people dischar ged t o cust odial settings. The committ ee not ed that, at

to be impor tant f or people dischar ged t o cust odial settings. The committ ee not ed that, at 
dischar ge, it is impor tant f or people and t heir car ers t o be giv en a writt en cop y of t he head 
injury dischar ge advice. 
Ther e might be a small incr ease in o vernight admissions f or people wit h a pr e-existing 
cognitiv e impairment when no super vision is a vailable at home. This should lead t o bett er 
outcomes f or people who do det eriorat e and r educed longer -term car e cost s. 
Follow up 
Recommendations 1 .10.13 and 1 .10.14 Head injur y: assessment and early management (NG232)
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People wit h a head injur y ma y need in vestigation f or the causes of t he injur y or t o manage 
contributing f actors. P eople wit h a head injur y ma y have persisting pr oblems, including 
physical, sensor y, mot or, cognitiv e, emotional and hormonal (h ypopituitarism). These can 
occur e ven in people who ar e not admitt ed to hospital or ha ve normal imaging at t he time 
of their injur y. It is impor tant t hat people kno w ho w to seek help and ongoing suppor t for 
these sympt oms. It is also impor tant f or healt hcare professionals t o mak e appr opriat e 
outpatient r eferrals t o other healt hcare professionals trained in managing t hese sympt oms. 
Some people who ha ve had a head injur y will be at incr eased risk of fur ther injur y. It is 
impor tant t hat t hese people can access r elevant ser vices. 
How the r ecommenda tion mig ht affect practice or ser vices

Ther e might be an incr ease in r eferrals fr om primar y car e to hospital outpatient clinics f or 
people who w ere not admitt ed to hospital, or had a normal scan or no scan at t he time of 
their head injur y. This should mean t hat people get earlier access t o eff ectiv e treatment 
for persisting sympt oms r esulting fr om t heir head injur y and pr evention ser vices. 
Recommendation 1 .10.15 
The committ ee discussed fur ther endocrinology in vestigations f or suspect ed 
hypopituitarism in people who ha ve been dischar ged aft er a head injur y if sympt oms 
persist or t hey are not r ecovering as e xpect ed. The y not ed that some of t he sympt oms of 
hypopituitarism ma y be non-specific and caused b y other conditions, making diagnosis

hypopituitarism ma y be non-specific and caused b y other conditions, making diagnosis 
difficult. The y agr eed t hat in vestigation in endocrinology ma y be needed. 
In people under  16, dela yed sympt oms ma y include slo w growth, tir edness and lat e 
puber ty. The committ ee emphasised t hat, if h ypopituitarism is suspect ed, it is impor tant t o 
urgent ly refer the person under  16 to a paediatric endocrinologist. Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 69
of 74

The guideline raises awar eness of t he sympt oms of h ypopituitarism f or people wit h a head 
injury, and t heir car ers and clinicians. So, t here might be an incr ease in t esting f or 
hypopituitarism in primar y car e. It is also int ended t hat people will get r eferred for 
appr opriat e car e sooner . 
Return t o recommendation Head injur y: assessment and early management (NG232)
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Context 
Head injuries ar e a major cause of deat h and disability in people aged 1  to 40  in the UK. 
Each y ear, over 1 million people att end emer gency depar tment s in England and W ales wit h 
a recent head injur y. Betw een 33% and 50% of t hese people ar e aged under  15. About 
200,000 people ar e admitt ed to hospital wit h a head injur y every year. Of t hese, about 
40,000 ha ve evidence of traumatic brain injur y. Most people wit h a head injur y recover 
without specific or specialist int ervention. Ot hers ha ve long-t erm disability or e ven die 
from associat ed traumatic brain or ot her injuries. An incr easing pr opor tion of people 
presenting wit h head injur y are over 65. Man y people ar e injur ed through lo w-level falls, 
which can be sustained in t he cont ext of acut e illness. 
The incidence of deat h from head injuries is lo w. As f ew as 0 .2% of people att ending

The incidence of deat h from head injuries is lo w. As f ew as 0 .2% of people att ending 
emer gency depar tment s wit h a head injur y die because of t heir injur y. Of people who ha ve 
sustained a head injur y, 95% pr esent wit h a normal or minimally impair ed conscious le vel, 
that is, a Glasgo w Coma Scale  (GCS) scor e of 13 or mor e. Most f atal out comes ar e in t he 
groups wit h a moderat e (GCS scor e of 9  to 12) or se vere (GCS scor e of 8 or less) head 
injury, and account f or only 5% of att enders. This means emer gency depar tment s need t o 
identify t he small number who will go on t o have serious acut e intracranial complications. It 
is estimat ed that, in 25% t o 30% of childr en under  2 who ar e hospitalised wit h a head 
injury, it is caused b y abuse. This guideline has updat ed some of t he terminology used in

injury, it is caused b y abuse. This guideline has updat ed some of t he terminology used in 
relation t o saf eguar ding people under  18 and vulnerable adult s. This updat e addr esses 
these ar eas, including in par ticular: 
• indications f or transpor ting people wit h a head injur y from t he scene of injur y directly 
to the near est neur oscience centr e, bypassing t he near est emer gency depar tment 
• indications f or, and timing of , CT head scans and imaging of t he cer vical spine in t he 
emer gency depar tment, wit h par ticular r eference t o anticoagulant tr eatment and 
levels of cir culating brain injur y biomark ers 
• the clinical and cost eff ectiv eness of administ ering trane xamic acid t o people who 
have sustained a head injur y and ha ve suspect ed intracranial bleeding

have sustained a head injur y and ha ve suspect ed intracranial bleeding 
• consideration of traumatic injur y to the pituitar y gland in people wit h a head injur y Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 71 of
74

• information t hat should be pr ovided t o people wit h a head injur y, and t heir f amily 
members and car ers, on dischar ge fr om t he emer gency depar tment or obser vation 
ward. Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 72
of 74

Finding mor e inf orma tion and c ommi ttee 
details 
To find NICE guidance on r elated topics, including guidance in de velopment, see t he NICE 
topic page on injuries, accident s and w ounds . 
For full details of t he evidence and t he guideline committ ee's discussions, see t he 
evidence r eviews . You can also find inf ormation about how the guideline was de veloped , 
including details of t he committ ee. 
NICE has pr oduced tools and r esour ces t o help y ou put t his guideline int o practice . For 
general help and advice on putting our guidelines int o practice, see resour ces t o help y ou 
put NICE guidance int o practice . Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 7 3
of 74

Update inf orma tion 
May 2023:  We have review ed the evidence on pr e-hospital int erventions, assessment and 
management in t he emer gency depar tment, and dischar ge and f ollow up, including f ollow 
up of people wit h a head injur y and normal scans f or det erioration. These 
recommendations ar e mark ed [2023] . 
We have also made some changes wit hout an e vidence r eview: 
• For recommendations [2003 , amended 2023] , [200 7, amended 2023]  and [2014 , 
amended 2023] , we have made changes t hat could aff ect t he int ent wit hout 
reviewing t he evidence. 
• For recommendations ending [2003] , [200 7], [2014] , [2003 , amended 200 7], [2003 , 
amended 2014]  and [2003 , amended 200 7 and 2014] , we have not r eview ed the 
evidence. In some cases, minor changes ha ve been made (f or example, t o updat e 
links, or bring t he language and style up t o dat e) wit hout changing t he int ent of t he 
recommendation.

recommendation. 
June 2017 : Recommendation 1 .3.8 was updat ed wit h a cr oss-r eference t o a related NICE 
guideline. 
ISBN: 9 78-1-47 31-5026- 3 
Accreditation Head injur y: assessment and early management (NG232)
conditions#notice-of -right s).Page 7 4
of 74

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 1   The Royal College of Emergency Medicine  
 
June  2023 Suspected Cannabinoid 
Hyperemesis Syndrome  
in Emergency 
Departments

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 2 Summary of R ecommendations  
 
1. A diagnosis of Cannabinoid Hyperemesis Syndrome  (CHS)  should be considered 
in presentations of nausea and vomiting  with a cyclical  pattern and where there is 
associated cannabis use . 
 
2. Patients should be encouraged to disclose their cannabis use and be reassured 
that this disclosure will not affect them adversely  and will remain confidential . Care 
should be taken to ensure that p atients do not feel stigmatised for their use of 
cannabis . 
 
3. Failure of standard ant iemetic therapy to improve symptoms should lead to 
consideration of the use of haloperidol or capsaicin.  
 
4. Patients  may struggle to accept a diagnosis of CHS for a variety of reasons. They  
should be supported with written information  when a diagnosis of suspected CHS  
is made. This information  should also identify  sources of support  and advice for

is made. This information  should also identify  sources of support  and advice for 
helping those cannabis users wishing to achiev e abstinence.

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 3 Scope  
Cannabinoid Hyperemesis Syndrome (CHS) is a n episodic  syndrome of cyclical vomiting in 
the context of the prolonged use of cannabis. It can be a challenging diagnosis to make, as 
vomiting episodes are not  necessarily  temporally -related to increased cannabis use, and 
patients may find that cannabis use during an episode actually improves  their symptoms . 
Identifying a relationship is made more difficult as patients may have weeks  or months 
between episodes, and may develop the syndrome after many years of cannabis use . 
Identifying cannabis as the cause of symptoms may also be difficult due to patient s’ 
reluctance to disclose cannabis use.  
 
It is important to recognise that CHS  is unlikely to be definitively diagnosed in the Emergency 
Department  (ED) due to the current diagnostic criteria . However, there are many clinical

Department  (ED) due to the current diagnostic criteria . However, there are many clinical 
features which can lead clinicians to suspect  a diagnosis of  CHS  and there are several  non-
conventional  treatments that may be efficacious in treating the symptoms of CHS and may 
help to confirm  it. The essential prerequisite for a CHS diagnosis is the long -term use of 
cannabinoids. There are no laboratory or radiographic investigations that can be used to 
diagnose CHS. 
 
The process of creating this guideline has included contemporaneous literatu re reviews for 
high-level evidence in the medical literature on all aspects of CHS , as well as searches for 
consensus agreement publications where they exist. The guideline group have formed 
consensus on areas lacking clear answers.  
 
Reason for Development

Reason for Development  
There are current gaps in accurately defining the optimal classification, pathophysiology and 
treatment of CHS. This best practice guideline has been written to bridge the current gap 
between evidence and the need for emergency clinicians to pr ovide quality care and advice 
to patients suffering from this syndrome.  
 
Patients presenting with CHS often experience a delay  to diagnosis . They will typically have 
repeated visits to emergency departments , several hospital admissions and often describe 
poor symptom control with standard therapies , such as anti emetic medications . 
 
This guideline has been written to increase  Emergency Medicine clinician  awareness of 
CHS , support the care of patient s presenting to the ED with symptoms of  CHS a nd help

CHS , support the care of patient s presenting to the ED with symptoms of  CHS a nd help 
clinicians communicate the concept and management of CHS to patients.

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 4 Background  
7.8% of UK adults age 16 -59 use cannabis, of whom 25. 6% use cannabis at least weekly.1 
 
The pathophysiology of CHS is not clearly understood. While cannabis can act as an 
antiemetic at low doses, repeated high -dose use can result in vomiting. A clinical syndrome 
of hyperemesis in the context of cannabis use has been recognised as early as 200 4, but 
overall recognition remains poor.2,3 
 
CHS is thought to be the cause of a significant proportion of presentations for recurrent 
vomiting and abdominal pain in emergency departments  (EDs) .4  The diagnosis is frequently 
not considered, and the journey  from onset to diagnosis can take an average of 4.1 years.5  
Patients may be reluctant to volunteer information about cannabis use in the emergency 
department unless reassured that the y will not face legal consequences.

department unless reassured that the y will not face legal consequences.  
 
Patients are typically regular cann abis users, presenting with cyclic episodes of vomiting or 
abdominal pain. They often report relief of symptoms with hot showers or baths.  
 
At its most severe, CHS can be fatal , but many other patients experience significant pain 
and distress, electrolyte abnormalities, hypoglycaemia, or renal failure .6  There is significant  
value in an early diagnosis for  both treatment of the current episode, and  prevention of future 
harm.  Additionally,  CHS often fails to resolve with standard antiemetic treatments . Some 
alternative  therapies  (which may not be routinely considered) have the potential to improve 
symptoms and avoid hospital admission.  
 
Recognition  
The features in Table 1 should prompt suspicion of a diagnosis of CHS .

The features in Table 1 should prompt suspicion of a diagnosis of CHS . 
 
• Severe nausea and vomiting that recurs in a cyclic pattern 
over months (100%)  
• Age <50 at time of evaluation (100%)  
• At least weekly cannabis use (97.4%)  
• Resolution of symptoms after cannabis cessation (96.8%)  
• Compulsive hot showers or baths with symptom relief (92.3%)  
• Abdominal pain (85.1%)  
• History of regular cannabis use for >1 year (74.8%)  
Table 1. Frequency of features identified in diagnosis of CHS.  
Adapted from Sorensen et al.7

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 5 The Rome IV diagnostic  criteria for functional gastrointestinal disorders were defined in 
2016.8  One of the three criteria for definitive diagnosis of CHS is “relief of vomiting episodes 
by sustained cessation of cannabis use”, and therefore a confirmed diagnosis of CHS is 
unlikely to be made in an ED. Unfortunately , this criteri on has limited the ability of 
researchers to definitively identify research populations in patients attending the ED.9 
 
Consideration should also be given to re -evaluating previous diagnoses for recurrent 
vomiting disorders. One study  identified that large numbers of patients with  a diagnosis of  
cyclic vomiting syndrome were current cannabis users , though it is difficult to know if this 
represents management of cyclic vomiting syndrome symptoms with cannabis use, or a 
cohort of patients with undiagnosed CHS .10

cohort of patients with undiagnosed CHS .10 
 
Given the lack of specificity of many features  of CHS , exclusion of a major medical or 
surgical aetiolo gy as the cause for the patient’s symptoms is essential . Potential  other  
causes may include  (but are not limited to) : 
 
• Vomiting due to a central nervous system pathology  
• Intra-abdominal pathology  
• Infection , especially gastrointestinal  
• Chronic nausea and vomiting syndrome  
• Cyclic al vomiting syndrome  
• Diabetic gastroparesis  
 
Investigation  
Complications of CHS are predominantly driven by poor food and fluid intake , and  gastric 
losses  due to intractable vomiting . 
 
As well as following local policy for the inve stigation of abdominal pain and vomiting, specific 
consideration should be given to assessment for:  
 
• Hypoglycaemia  
• Acute kidney injury

• Acute kidney injury  
• Electrolyte abnormalities  (sodium, potassium, calcium, chloride, magnesium)  
• Metabolic acidosis/alkalosis  
 
The presence of certain red flag signs or symptoms should alert clinicians to the possibility 
of an alternative diagnosis, such as:  
 
• Unintentional weight loss , especially age >50 years  
• Abdominal mass  and/or change in bowel habit  
• Anaemia  or LFT abnormality

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 6 Communication  
Clinicians should have sympathetic and non -judge mental discussions with the patient about 
their cannabis use, and recognise that patients may be nervous or reluctant to disclose their 
cannabis use.  A variety of societal  or health factors  may lead to the use of cannabis, and 
harm from its use has been su ggested to be  lower than that of alcohol or tobacco.11  
Although th ere is limited data from randomised controlled trials , many patient advocacy 
groups have reported cannabis to be a helpful substance when standard therapies have 
failed.12  Examples include Parkinsons disease, Multiple sclerosis or chronic pain . 
 
The role of cannabis in medicine is increasing, and s ome cannabis -based products are 
available on prescription in the UK.13  Despite the number of current NHS prescriptions

available on prescription in the UK.13  Despite the number of current NHS prescriptions 
remaining  low, it is recognised that thousands of private prescriptions have been issued.  
 
Patients may struggle to accept the diagnosis of CHS for a variety of reasons:  
• Vomit ing episodes are not temporally -related to an increase in cannabis use.  
• Acute cannabis use  often improves nausea.  
• Patients may have weeks to months between episodes.  
• Patients can develop the syndrome after using cannabis for less than 1 year, or 
greater than 11 years.7 
 
Additionally, although it is easy to inform a patient they should stop usin g cannabis, 
cessation may be  prove to be  challenging .14  Sign-posting  advice, or referral  to local services 
for help with drug use , may improve the likelihood of successful cessation .

for help with drug use , may improve the likelihood of successful cessation . 
 
It is recommended that  written information on CHS be provided to patients . An example of 
such a leaflet is included with this guideline  (Appendix 1). 
 
Symptom m anagement  
Acute episode  
CHS is recognised as  often be ing resistant  to routine anti emetic treatment s such as 
cyclizine, dexamethasone, domperidone, metoclopramide , ondansetron , prochlorperazine  
and promethazine .15,16  Additionally, pain relief with opiates is frequently unsuccessful.  
 
Normal departmental processes for the management of nausea and vomiting should be 
followed in the first instance.  A potential exception to this is a patient presenting with a known 
diagnosis of CHS and continued cannabis use . 
 
Patients with an established diagnosis of CHS who have continued to use cannabis may

Patients with an established diagnosis of CHS who have continued to use cannabis may 
present in the prodromal s tage of an episode,  with nausea, abdominal discomfort and fear 
of vomiting. Initiating treatment prior to vomiting may be helpful in this group.

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 7 Refractory symptoms  
For refractory nausea or vomiting in CHS, consider the use of haloperidol or capsaicin , which 
are both supported by small RCTs .17,18 
 
Medication  Route  Suggested d ose 
Haloperidol  Intramuscular*  0.05mg/kg (max 5mg)  
Capsaicin 0.1% 
cream† Topical  5g of 0.1% cream applied to abdomen  
Table 2. Treatment for refractory nausea & vomiting in CHS.  
 
(*Although the  trial used intravenous haloperidol, there is no UK intravenous licence . 
There  is a UK  licence for postoperative nausea  and vomiting, though doses are lower ). 
 
Prior to administering haloperidol, obtain  an ECG to check for QTc prolongation and correct 
any electrolyte abnormalities  if conduction defects are present. Do not give haloperidol if the 
QTc is prolonged , or if a patient has Parkinson’s disease or Lewy body dementia (LBD) .

QTc is prolonged , or if a patient has Parkinson’s disease or Lewy body dementia (LBD) . 
Patients should be monitored fo r acute dystonia  after administration . Do not discharge 
patients from the ED with a prescription for haloperidol unless this forms part of a  specialty 
management  plan. 
If treatment fails to relieve symptoms and a patient requires admission, access to a hot 
shower or bath should be offered for symptom relief . 
Other treatments , supported by extremely limited evidence  (insufficient data to make dosing 
recommendations ) incl ude: 
• Benzodiazepines  
• Droperidol  
• Tricyclic antidepressants  
• Olanzapine  
• Levetiracetam  
• Proton -pump inhibitors  
• Beta-blockers  
Long-term management  
The only definitive treatment that has been identified to prevent CHS is abstinence  from 
cannabis . 
Special populations

cannabis . 
Special populations  
Pregnancy – CHS may be mistaken for hyperemesis gravidarum, highlighting the need for 
a careful history -taking in such cases.  
Paediatrics – CHS has been described in adolescent  patients and exposure to cannabinoids 
may be through passiv e smoking.  
 
† The evidence supports use of 0.1% cream, which do es not have a UK license. 0.075% capsaicin 
(Axsain®) is a licensed medication for neuropathic pain and post -herpetic neuralgia and  may be 
more easily sourced. However, there is insufficient evidence to make recommendations on the 
efficacy of this strength .

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 8  
Authors   
Christopher Humphries , Marianne Gillings . 
 
Acknowledgements   
RCEM Quality in Emergency Care Committee  
 
Review  
June 2023, minor update to document in relation to capsaicin strength . 
 
Further review usually within three years or sooner if important information becomes available.  
 
Declaration  of Interest  
Christopher Humphries  - Dept. of Health and Social Care Drug Harms Assessment and Response 
Team . 
 
Marianne Gillings  - nothing to declare.  
 
Disclaimers  
and application of this guideline, the use of current information and a patient’s overall care and 
wellbeing resides with the treating clinicia n. 
 
Research Recommendations

Research Recommendations  
Research is required to establish the prevalence of CHS in a UK setting, and optimal treatment 
strategies.  
 
Audit standards  
None  
 
Key words for search  
Cannabinoid hyperemesis syndrome, cannabis hyperemesis, cannabis hyperemesis syndrome

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 9 References  
1. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/datasets/drugmisu
seinenglandandwalesappendixtable  Accessed 02 Nov 2022  
2. Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid hyperemesis: cyclical 
hyperemesis in association with chronic cannabis abuse. Gut. 2004 ; 53(11):1566 -70. 
3. Lua J, Olney L, Isles C. Cannabis hyperemesis syndrome: still under recognised after all 
these years. J R Coll Physicians Edinb . 2019; 49(2):132 -134. 
4. Simonetto DA, Oxentenko  AS, Herman ML, Szostek JH. Cannabinoid hyperemesis: a case 
series of 98 patients. In : Mayo Clinic Proceedings  2012 (Vol. 87, No. 2, pp. 114 -119). 
Elsevier.  
5. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. Cannabinoid hyperemesis 
syndrome: diagnos is, pathophysiology, and treatment —a systematic review. J Med Toxicol . 
2017 ;13(1):71 -87.

2017 ;13(1):71 -87. 
6. Nourbakhsh M, Miller A, Gofton J, Jones G, Adeagbo B. Cannabinoid Hyperemesis 
Syndrome: Reports of Fatal Cases. J Forensic Sci. 2019;  64(1):270 -274. 
7. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. Cannabinoid Hyperemesis 
Syndrome: Diagnosis, Pathophysiology, and Treatment -a Systematic Review. J Med Toxicol . 
2017;13(1):71 -87. 
8. Stanghellini V, Chan FK, Hasler WL, et al. Gastroduodenal Disorders.  Gastroenterology . 
2016;150(6):1380 -92. 
9. Bonnet U. Cannabis -Related Cyclic/Episodic Hyperemesis Conditions: From Suspected to 
Definitive Cannabinoid Hyperemesis Syndrome. Med Princ Pract . 2022. Epub ahead of print.  
10. Venkatesan T, Hillard CJ, Rein L, Banerjee  A, Lisdahl K. Patterns of Cannabis Use in Patients

10. Venkatesan T, Hillard CJ, Rein L, Banerjee  A, Lisdahl K. Patterns of Cannabis Use in Patients 
With Cyclic Vomiting Syndrome. Clin Gastroenterol Hepatol . 2020;  18(5):1082 -1090.  
11. Nutt DJ, King LA, Phillips LD; Independent Scientific Committee on Drugs. Drug harms in the 
UK: a multicriteria decision analysis. Lancet . 2010;  376(9752):1558 -65. 
12. Schlag AK, O'Sullivan SE, Zafar RR, Nutt DJ. Current controversies in medical cannabis: 
Rece nt developments in human clinical applications and potential therapeutics. 
Neuropharmacology . 2021 ; 191:108586.  
13. https://www.england.nhs. uk/medicines -2/support -for-prescribers/cannabis -based -products -
for-medicinal -use/ Accessed 02 Nov 2022  
14. Bonnet U, Preuss UW. The cannabis withdrawal syndrome: current insights. Subst Abuse 
Rehabil . 2017 ; 8:9-37.

Rehabil . 2017 ; 8:9-37. 
15. Burillo -Putze G, Richards JR, Rodríguez -Jiménez C, Sanchez -Agüera A. Pharmacological 
management of cannabinoid hyperemesis syndrome: an update of the clinical literature. 
Expert Opin Pharmacother . 2022 ; 23(6):693 -702. 
16. Bhatt S, Queen J. Cannabinoid Hypereme sis Syndrome. Curr Emerg Hosp Med Rep  2019;  
7:14–18. 
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of Cannabinoid Hyperemesis Syndrome. Acad Emerg Med . 2020 ; 27(11):1166 -1172.  
18. Ruberto AJ, Sivilotti MLA, Forrester  S, et al. Intravenous Haloperidol Versus Ondansetron for 
Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Ann Emerg 
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Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 10 Appendix 1 – Example text for p atient information factsheet  
Content reproduced  and adapted  with permission from University Hospital Southampton 
NHS Foundation Trust.  
 
Cannabinoid hyperemesis syndrome (CHS)  
We have written this factsheet to give you more information about cannabinoid  
hyperemesis syndrome (CHS). It explains what cannabinoid hyperemesis syndrome is,  the 
symptoms to look out for and how it is treated. We hope it will help to answer some  of the 
questions you may have. If you have any further questions or concerns, please  speak to a 
member of your healthcare team.  
 
What is cannabinoid hyperemesis syndrome?  
Cannabinoid hyperemesis syndrome (CHS) is a rare condition caused by a regular (daily) 
and long-term use of marijuana. The syndrome is characterised by repeated and severe 
bouts of  vomiting.

bouts of  vomiting.  
Marijuana has several act ive substances. These substances bind to molecules found in 
the body and affect the way they work. For example, they affect the molecules found in the 
brain  and cause the drug ‘high’ that users feel. They also affect the way the molecules in 
the gut  functi on and can change the time it takes the stomach to empty. The drug also 
affects the  oesophageal sphincter, which is the tight band of muscle that opens and closes 
to let food  pass from the oesophagus (food pipe) into the stomach. The effects of 
marijuana o n your  digestive system are what lead to the main symptoms of CHS.  
 
What causes CHS?  
Marijuana is a complex substance that affects everyone differently. The main ingredient in

Marijuana is a complex substance that affects everyone differently. The main ingredient in  
marijuana is called THC, which has anti -nausea (anti -sickness) effects. This is why 
marijuana  is regularly prescribed for nausea caused by chemotherapy treatment. 
However, if you use  it over a long period of time, marijuana seems to have the opposite 
effect on the digestive  system and makes you more likely to feel and be sick.  Rese arch is 
being carried out to explain why only some long -term users of marijuana  experience CHS.  
 
What are the symptoms?  
Symptoms are divided into three stages:  
 
1. Prodromal phase  
This is the first phase and symptoms may include early morning nausea, tummy 
(abdominal)  pain and a fear of vomiting. During this phase, most people will keep to 
their normal eating  patterns. Some people may continue to use marijuana because

their normal eating  patterns. Some people may continue to use marijuana because 
they think it will help stop the  nausea. This phase may last for weeks, months or 
years.  
 
2. Hyperemetic phase  
Symptoms may include:  
o ongoing nausea (feeling sick)  
o repeated episodes of vomiting  
o tummy pain  
o reduced food intake and weight loss  
o dehydration  
During this phase, vomiting may often be intense and overwhelming. Many people 
will take a  lot of hot showers during the day to ease their nausea.

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 11 3. Recovery phase  
During this phase, the  symptoms will go away and you will be able to eat normally 
again. This phase can last days or  months. If you try marijuana again, your 
symptoms are likely to return.  
 
When should I seek help ? 
Call your healthcare provider if you have had severe vomiting for a day or more , or are 
concerned that you may need medical treatment . 
 
How is CHS diagnosed?  
Many health problems can cause repeated vomiting. To make a diagnosis, yo ur healthcare  
provider will ask you about your symptoms and your past health. They will also per form a  
physical exam, including an examination of your tummy.  Your healthcare provider may 
also do further tests to rule out other causes of vomiting.  
Disclosin g to your healthcare provider that you use marijuana daily can speed up the  
diagnosis.  
 
How is CHS treated?

How is CHS treated?  
If you have had severe vomiting, you may need to stay in hospital for a short time. During 
the hyperemesis phase, you may need the following treatments:  
 
• IV (intravenous) fluid replacement for dehydration  
• anti-sickness medicines  
• pain-relief medicines  
• proton -pump inhibitors (to treat stomach inflammation)  
• frequent hot showers  
• Capsaicin cream (to reduce pain and nausea)  
 
Symptoms will often ease after a day or two, unless marijuana is used again.  In order to 
fully recover, you will need to stop using marijuana all together. Some people may  need 
support from drug rehab ilitation  programmes to achieve this.  If you stop using marijuana , 
your symptoms should not  come back.  
 
What are the possible complications of CHS?

What are the possible complications of CHS?  
Very severe, prolonged vomiting may lead to dehydration. It may also lead to electrolyte  
problems in your blood. If left untreated, these can cause rare complications, such as:  
 
• muscle spasms or weakness  
• seizures  
• kidney failure  
• heart rhythm abnormalities  
• shock  
• brain swelling (cerebral oedema)  
 
What can I do to prevent CHS?  
Only stopping marijuana use completely will prevent CHS. Cutting down your use will not 
get rid of CHS.  You may not want to believe that marijuana may be the underlying cause 
of your symptoms.  This might be because you have used it for many years without having 
any problems, but  CHS can take several years to develop.  Quitting marijuana ma y lead to 
other health benefits, including:

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 12 • better lung function  
• improved memory and thinking skills  
• better sleep  
• reduced risk of depression and anxiety  
 
Where to get help for drugs  
Below are some of the services available to help you quit marijuana and other drugs : 
 
FRANK  
Telephone: 0300 123 6600  
Website: www.talktofrank.com  
 
DEPARTMENTS SHOULD INSERT DETAILS FOR LOCAL DRUG SERVICES HERE. 
Details should include:  
• Service name  
• Any limitations on population (e.g. age, gender , substance s used ) 
• Contact details  
• Whether patients can self -refer or require provider referral

Suspected Cannabinoid Hyperemesis Syndrome in Emergency Departments (Jun 2023)  Page 13  
 
London  
SE1 1EU  

Case 1, Patient Name: Jerry Tylor
Situation:
A 56-year-old male with a history of presents to the emergency department with sudden onset of severe chest pain.
Background:
PMHX: hypertension and type 2 diabetes.
Medication : metformin 1000 mg twice daily, lisinopril 20 mg once daily. 
Events: While In the gym 2 hours ago, he developed sudden onset central chest pain, heavy in nature , Radiating to his left arm. It was relieved by rest and GTN given to him by the ambulance crew.
This was associated with SOB and sweating.
Assessment:
His vital signs are BP 180/110, HR 110, RR 24, SpO2 95% on room air, and Temp 36.6C. Physical exam reveals diaphoresis, cool extremities, and distant heart sounds.
Chest examination was clear.
Cardiac: Normal heart sounds with no lower limb edema, and his JVP was Normal.
Abdomen : soft lax.
ECG: showed ST elevation on the inferior lead 	II, III aVF
Differential diagnosis: Acute Myocardial Infarction (AMI).
Recommendation:
FBC clotting UE, LFT , Troponin.

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Two nitro-glycerine sublingual puffs+aspirin 300 mg.
Contact cardiology team for PCI(Percutaneous Coronary Intervention).
Case 2, Patient Name: Sophia Johnson  
A 25-year-old female presents with Right lower quadrant (RLQ) abdominal pain.
The patient has no significant past medical history 
No regular medication 
No  Allergies
Events: 8 hours ago while on her desk developed  central abdominal pain which later shifted to her  RLQ. Associated with nausea and vomiting.
Denies any urinary symptoms as frequency , dysuria, fever or chills and rigors. He bowels are open with no diarrhea. This is the first time she has this pain.

Upon assessment, her vital signs are BP 110/70, HR 95, RR 18, SpO2 99% on room air, and Temp 100.4°F. Physical exam reveals guarding and rebound tenderness in the right lower quadrant.
Vital signs are BP 110/70, HR 95, RR 18, SpO2 99% on room air, Temp 37.8 C.
 Physical exam Showed, normal tonsils, 
Chest: clear
Abdomen :guarding and rebound tenderness in the right lower quadrant. Positive rovsing sign.
No Masses or hernia and organomegaly
Her urine dip showed +1 ketones , no leucocytes or blood\Negative pregnancy test
Differential diagnosis :  Acute appendicitis.
FBC, UE, CRP, amylase.
Abdominal ultrasound. 
Refer to surgeon to consider appendicectomy.
Case  3, Patient Name: David Moore
73 male patient who  presented with sudden onset of weakness and numbness on the right side of his body.

PHX(past medical History): Hypertension, Hyperlipidemia, and type 2 diabetes. Smoker. Family History if ischemic heart disease (IHD)
Medication ;lisinopril 10mg daily, atorvastatin 40mg daily, and metformin 1000mg twice daily. 
Social history:  retired and live alone, independent
Events:  The patient reports he suddenly noticed weakness and numbness in his right arm and leg while watching TV at home 2 hours ago. His wife reported his speech was abnormal. 
Blood pressure 165/95 mmHg (High), heart rate 75 beats per minute and regular.
Respiration 18 and oxygen saturations 97% air T.

The patient is alert .He has a left-sided facial droop, Slurred speech with left arm weakness , and left leg weakness. The power in both upper and lower limbs were 2/5.Rest of the body was 5/5. He had normal muscle tone.
The National Institutes of Health Stroke Scale (NIHSS) score is 12.
Differential diagnosis: Acute Cerebral Stroke.
FBC, clotting, UE lft lipids, CRP
Urgent CT+CTA
Inform stroke team urgently for thrombolysis or thrombectomy
Case  4, Patient Name: Isabella Brown
A 25 female presents to the emergency department with severe SOB(Shortness of breath)
PMHX: Brittle Asthma with ITU admissions.
Medication: salbutamol inhaler PRN.

Events: The patient has a recent upper respiratory tract infection and has been using her inhalers more frequently. And gradually becoming worse and now no improvement with them.
Her vital signs are BP 100/55, HR 120, RR 35, SpO2 82% on room air, and Temp 36 C.
Physical exam showed the patient is tired, central cyanosis, clammy and sweaty, using accessory respiratory muscle, unable to speak more than 2 words. She was unable to do Peak flow rate test
She had a Silent chest with poor respiratory effort
Arterial blood gas showed
pH: 7.21
PaCO2: 74 mmHg
PaO2: 47 mmHg
HCO3-: 30 mEq/L
SaO2: 86%
Differential diagnosis : life threatening asthma
Recommendation: 
FBC ue CRP
arterial line for sequal ABG.

pH: 7.21
SaO2: 86%
FBC ue CRP
Administer high-flow oxygen via a non-rebreather mask to increase the patient's SpO2 to at least 94%
Obtain an IV access and administer back to back nebulized salbutamol with ipratropium every 20 minutes as needed to relieve bronchospasm
Hydrocortisone 200 mg IV.
Administer magnesium sulfate IV to further relax the bronchial smooth muscle
if no imporovement then Administer aminophylline 5 mg/kg IV to improve bronchodilation and oxygenation.
Monitor the patient's response to treatment, including vital signs, SpO2, and ABG levels.
refer to  ITU as patient need close monitor and high chance of intubation of no improvement despite treatment.
Case  5, Patient Name: Benjamin Martinez
A 65-year-old male presents with acute confusion, fever, and productive cough.

PMHX: COPD and takes 
Smoker , 30-pack-year smoking history.
Meds: tiotropium 18 mcg daily. 
Social He lives in a nursing home and has a Upon assessment, his vital signs are BP 100/60, HR 115, RR 28, SpO2 82% on room air, and Temp 101.8°F. Physical exam reveals crackles in lower lung fields bilaterally and altered mental status.
Community-acquired pneumonia.
Fbc ue crp
CXR
ABG(arterial blood gas)
Admission under medics for IV antibiotcs. 
Case  6, Patient Name: Olivia Thomas
Subjective: 
A 32-year-old female presents to the emergency department with a 3-day history of dysuria, urinary frequency, and lower abdominal pain. No fever chills or rigors. She denies any drug or alcohol abuse.
Objective:

Objective: 
Upon assessment, her vital signs are BP 120/75, HR 80, RR 16, SpO2 98% on room air, and Temp 38 C. Physical exam reveals suprapubic tenderness. Soft lax abdomen and no flank pain.
Assessment: 
A a urinary tract infection (UTI).
Plan: 
Urinalysis and culture. Empiric antibiotics per guidelines  (e.g., nitrofurantoin) and recommend over-the-counter analgesics for pain relief.Patient to review he GP/Family physician.
Case  7, Patient Name: Jackson Lee
An 18-year-old male presents to the emergency department with a swollen, painful, and erythematous left knee after a fall during a basketball game.
Upon assessment, his vital signs are BP 130/85, HR 90, RR 16, SpO2 99% on room air, and Temp 36C. Physical exam reveals left knee effusion, limited range of motion, and point tenderness along the joint line. Difficult to fo full examination due to pain. The patient can walk but limbing.

Suspicion of  a left knee injury with possible ligament or meniscus tear.
Plan: 
X-ray  to rule out fractures. 
Immobilize the knee with a cricket splint or brace and provide analgesics for pain relief. Referral to the  orthopedics/Knee clinic for further management and reassessment , which might include MRI or surgery.
Case  8, Patient Name: William Anderson
A 42-year-old male presents to the emergency department with a 2-day history of nausea, vomiting, and abdominal pain. He has a history of alcohol abuse and admits to binge drinking before the symptoms started. Bowels are open, no melena or haematemesis.
Upon assessment, his vital signs are BP 140/90, HR 110, RR 20, SpO2 97% on room air, and Temp 36 C. Physical exam shows  Jaundice (yellow discoloration of sclera) diffuse abdominal tenderness and hepatosplenomegaly.
The doctor suspects alcoholic hepatitis.
Plan: 
Fbc, clotting ue lft crp

Plan: 
 CT scan, to evaluate the liver and other abdominal organs. T
IVI for fluid and electrolyte replacement, thiamine supplementation
management of withdrawal symptoms. 
Referral to alcohol support group
Case  9, Patient Name: Mason Jones 
Subjective:
The patient is a 50-year-old male who presented to the emergency department with complaints of severe lower back pain, bilateral leg weakness, and difficulty with urination and bowel movements. The patient reports that the symptoms started suddenly and have been progressively worsening over the past 24 hours. He denies any recent trauma, fever, or chills.

On physical examination, the patient appears uncomfortable and is lying flat on his back. Vital signs are stable. Neurological examination reveals bilateral lower extremity weakness, decreased sensation to light touch, and absent ankle reflexes. PR examination showed altered anal sensation and loss of anal tone.Examination of the lumbar spine reveals tenderness to palpation and a positive straight-leg raise test. There is no evidence of skin lesions, joint swelling, or deformities.
Based on the patient's symptoms and examination findings, the patient is suspected to have cauda equina syndrom. Other potential differential diagnoses include spinal stenosis, herniated disc, spinal cord injury, and infectious or inflammatory disorders.
Plan:
Immediate transfer to a neurosurgical center for urgent evaluation and management.

Plan:
Magnetic resonance imaging (MRI) of the lumbar spine to assess for spinal cord compression and identify the underlying cause of the cauda equina syndrome.
Administration of intravenous methylprednisolone to reduce inflammation and prevent further neurological damage.
Initiation of bladder and bowel management program to prevent urinary retention and fecal incontinence.
Pain management with intravenous opioids and non-steroidal anti-inflammatory drugs (NSAIDs) as needed.
Consultation with Spine specialist  and physical therapist, to provide comprehensive care and rehabilitation services.
Case  10, Patient Name: Samual Harris  
A 17-year-old male presents to the emergency department with a 2-day history of fever, sore throat, and swollen lymph nodes in the neck. He denies any recent travel or sick contacts.

Upon assessment, his vital signs are BP 110/70, HR 80, RR 18, SpO2 98% on room air, and Temp 38.1 C.  Physical exam reveals erythematous tonsils with exudate and tender anterior cervical lymphadenopathy.
Abdomen is soft lax with no organomegaly.
Bacterial pharyngitis, such as strep throat.
Plan: 
Arapid strep test and a throat culture to confirm the diagnosis.
Antibiotics, penicillin  ,if the rapid test is positive or the culture results are pending. 
Over-the-counter analgesics and fluids, for symptom relief.

Author: Dr. One Clinic
Publisher: Clinic First Medical Publishers.
Publishing date: 26/08/2023

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