Head Injury (minor, mild) Nurse Management Guidelines
Red Flag Exclusion Criteria
Child at risk of significant harm
Suspected non-accidental injury
Unplanned repeat ED presentation
Infant ≤ 12 months
Adult > 65 years
Other body regions injured
Open or penetrating injury
Moderate or high risk mechanism
Any accident involving a motorised vehicle or other high-speed mechanism
Pedestrian/cyclist struck by vehicle
Focal blunt trauma (bat, ball, foot)
Fall > 1 metre
GCS < 15 on arrival to ED or at any time in ED
Loss of consciousness:
Child - any
Adult - > 5 minutes
Post-traumatic amnesia > 30 minutes
Seizures immediately prior to, or any time post injury
Mild agitation or altered behaviour
Abnormal drowsiness
Any focal neurological deficit
Clinical suspicion of a possible skull fracture
More than one vomit post injury
Headache:
Child - any
Adult - severe or persistent
Coagulopathic / bleeding disorder (including warfarin, clopidogrel, aspirin or new oral anticoagulant [NOAC] use)
Drug or alcohol ingestion
History of workplace injury
Yellow or Red Zones observations or additional criteria outlined in the NSW Health Standard Observation charts
Additional Observations
Neurological observations including GCS, pupil size, pupil response to light, limb movement and limb strength must be completed on all patients
For patients ≥ 16 years, within 24hrs of a suspected closed head injury and a GCS of 13-15, commence Abbreviated Westmead Post Traumatic Amnesia Scale (A-WPTAS) assessment
Additional History
Establish mechanism of injury
How injury was sustained
Date and time of injury
First aid / NSW ambulance treatment prior to arrival
Management Principles
Provide analgesia as required according to pain scale. Refer to Pain (any cause) NMG
Patient receives hourly observations as per additional observations above for 4 hours as a minimum
If any deterioration in patient condition is detected then medical officer must be immediately notified
If the patient requires increasing amounts of analgesia to manage their pain, notify the medical officer
Patient must be discharged into the care of a responsible adult or carer
Provide patient / carer with head injury discharge information in addition to discharge letter
Document assessment findings, interventions and outcomes
References / Further Resources
Patient Factsheet - Mild Head Injury (SIRA) State Insurance Regulatory Authority
ECI Patient Factsheet - Headaches (non-migraine)
NSW Health (2010) Infants and children: Acute management of Head Injury – Clinical Practice Guidelines (2nd Ed.) NSW Ministry of Health, Sydney
NSW Health (2012) Initial Management of Closed Head Injury in Adults: Adult Trauma Clinical Practice Guidelines (2nd Ed.) NSW Ministry of Health, Sydney