Head injury
Airway with the neck protected, GCS and pupils repeatedly, decide on CT using the criteria, reverse blood thinners, and call neurosurgery for any bleed.
A 28-year-old motorcyclist without a helmet hit a rickshaw. He was briefly knocked out, then talked normally for an hour. Now he is drowsy, GCS 11 (E3 V3 M5), and his right pupil is larger than the left. BP 168/80, pulse 56.
What is happening, and who do you call?
- ABCDE with C-spine protectionAssume a neck injury until cleared. Treat low oxygen and low BP: they worsen brain injury.
- GCS and pupilsRecord each part (E, V, M), and repeat every 30 minutes at first.
- Blood sugarLow sugar or alcohol can confuse the picture.
- Ask about blood thinnersWarfarin, DOACs, antiplatelets. Reverse if there is a bleed.
- Decide on CT headWithin 1 hour or within 8 hours, using the criteria.
- Pain relief and antiemeticParacetamol, small doses of opioid if needed. Avoid heavy sedation.
- Look for other injuriesNeck, chest, abdomen, pelvis, limbs.
- Neurosurgery for any bleedOr falling GCS, unequal pupils, new weakness.
- GCS 8 or less, or falling by 2 or more points
- Unequal or fixed pupils
- One-sided weakness
- Fit after the injury
- Any bleed on CT
- Signs of a basal skull fracture
- Extradural haematoma
- Subdural haematoma (elderly, anticoagulated)
- Raised intracranial pressure
- C-spine injury
- Non-accidental injury in children
| Brain protection | Keep SpO₂ above 94% and systolic BP above 110 |
| GCS 8 or less | Airway at risk: anaesthetist for intubation |
| GCS falling by 2 or more points | Senior and CT now |
| Tranexamic acid | Within 3 hours of injury in mild to moderate head injury, per protocol |
| Warfarin with bleed | Vitamin K plus PCC or FFP (doses in the treatment section) |
Check every dose against a current drug reference and your hospital protocol.
On this page
Why it matters
Head injury is common in Pakistan, especially from motorcycle accidents (often without helmets), falls from roofs and stairs, and assaults. The first injury to the brain cannot be undone. Your job is to prevent the second injury: low oxygen, low BP, low sugar, fits and an expanding blood clot that is not found in time.
GCS: do it properly
| Eyes (E) | Verbal (V) | Motor (M) |
|---|---|---|
| 4: open spontaneously | 5: orientated | 6: obeys commands |
| 3: open to voice | 4: confused | 5: localises to pain |
| 2: open to pressure | 3: words | 4: normal flexion (withdraws) |
| 1: none | 2: sounds | 3: abnormal flexion |
| 1: none | 2: extension | |
| 1: none |
- Always write the parts: "GCS 11 (E3 V3 M5)", not just 11.
- The motor score is the most important part.
- Use the GCS calculator if unsure.
Who needs a CT head?
- GCS below 13 when first assessed
- GCS below 15 two hours after the injury
- Suspected open or depressed skull fracture
- Signs of a basal skull fracture
- Fit after the injury
- New focal neurological deficit
- More than one episode of vomiting
- On anticoagulants (other than aspirin alone), with no other reason for an urgent CT
- Loss of consciousness or amnesia plus: age 65 or over, bleeding disorder, dangerous mechanism, or more than 30 minutes of amnesia for events before the injury
- CT not usually needed
- Observe and give written head injury advice
Blood or clear fluid from the nose or ears (CSF), blood behind the eardrum, bruising behind the ear (Battle's sign, appears late), bruising around both eyes (panda eyes).
Extradural and subdural
- Usually young, blow to the side of the head, skull fracture
- Torn middle meningeal artery
- Knocked out, wakes up (lucid interval), then deteriorates fast
- Lens-shaped bleed on CT
- Emergency surgery
- Often elderly, alcohol, on blood thinners
- Torn bridging veins
- Can be acute, or develop over days to weeks (chronic) after a minor fall
- Crescent-shaped bleed on CT
Raised intracranial pressure
- Falling GCS.
- A dilating pupil on one side (usually the same side as the clot), then fixed.
- Weakness on the opposite side.
- Cushing's response: rising BP with a slowing pulse and irregular breathing. This is a late, pre-terminal sign.
Call the senior, anaesthetist and neurosurgeon now.
- Head up 30 degrees, neck straight, collar not too tight.
- Keep SpO₂ above 94%, systolic BP above 110, sugar normal, temperature normal.
- Treat fits.
- Mannitol or 3% saline on neurosurgical or senior advice while arranging surgery.
Treatment
- On a DOAC with a bleed: senior advice; specific reversal agents if available, otherwise PCC.
- Antiplatelets: usually stopped. Platelet transfusion only on neurosurgical advice.
The neck
- Keep the neck immobilised if: GCS below 15, neck pain or tenderness, numbness or weakness, dangerous mechanism, or the patient cannot be assessed (drunk, distracted by other injuries).
- CT cervical spine if any of these apply, usually done with the CT head.
Observation and discharge
- Observations every 30 minutes until GCS 15, then hourly for 4 hours, then every 2 hours.
- Return immediately if: drowsiness, worsening headache, vomiting, confusion, a fit, weakness, problems with vision or speech, clear fluid from nose or ears.
- Discharge only with a responsible adult at home for the first 24 hours and written advice.
- Children: different CT criteria. Always consider non-accidental injury.
Common mistakes
- Writing "GCS 11" without the E, V and M parts.
- Blaming alcohol for a low GCS without a CT.
- Missing an elderly patient on warfarin who "only bumped his head".
- Letting the patient's oxygen or BP drop during transfer to CT.
- Forgetting the neck.
- Discharging a patient who lives alone.
Frequently asked questions
When is a CT head needed after a head injury?
Within 1 hour if GCS is below 13 at first, or below 15 at 2 hours, with a suspected open, depressed or basal skull fracture, a fit, a new focal deficit, or more than one vomit. Within 8 hours if on anticoagulants or with loss of consciousness or amnesia plus age 65 or over, a bleeding disorder, a dangerous mechanism or significant amnesia.
What is the lucid interval?
A period of normal consciousness after an initial loss of consciousness, before deterioration. It is classic for an extradural haematoma.
What are the signs of raised intracranial pressure after head injury?
Falling GCS, a unilateral dilating pupil, weakness on the opposite side, and late Cushing's response: high BP, slow pulse and irregular breathing.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A man was knocked out, then talked normally. Now his GCS is 11 with a dilated right pupil. What is the most likely diagnosis?
Answer: Extradural haematoma with herniation. A lucid interval followed by deterioration and a dilated ipsilateral pupil suggests an extradural haematoma. Airway, CT now, neurosurgery.
- Chronic subdural haematoma: Develops over weeks.
- Subarachnoid haemorrhage: Less likely with this sequence.
- Concussion: Doesn't cause a blown pupil.
- Diffuse axonal injury: No lucid interval.
2. A 78-year-old woman on apixaban fell and hit her head. GCS is 15 and she has no other features. Does she need a CT head?
Answer: Yes, within 8 hours. NICE recommends CT within 8 hours for anticoagulated patients with a head injury even without other risk factors.
- Only if she vomits: Anticoagulant use is enough.
- No CT needed: Anticoagulation alone is an indication.
- CT within 1 hour: Within 8 hours unless other high-risk features.
- Only after 48 hours: Too late.
3. A patient with head injury has bruising behind the ear and clear fluid from the nose. What do you suspect?
Answer: Basal skull fracture. Battle's sign, raccoon eyes, CSF rhinorrhoea or otorrhoea and haemotympanum suggest a basal skull fracture.
- Simple scalp haematoma: Doesn't explain CSF leak.
- Sinusitis: Not this picture.
- Facial cellulitis: No.
- Concussion only: Signs of fracture present.
4. After a head injury, a man has bilateral periorbital bruising sparing the tarsal plates, bruising behind the ear and clear fluid from the nose. What is the diagnosis?
Answer: Base of skull fracture. Signs of base of skull fracture: periorbital ecchymoses (‘raccoon eyes’), Battle sign (mastoid bruising — appears after 24–48 h), CSF rhinorrhoea/otorrhoea, haemotympanum, cranial nerve palsies (VII, VIII). Needs CT head; avoid nasal tubes; watch for meningitis (pneumococcal vaccination for persistent leaks; prophylactic antibiotics not routine). Most CSF leaks resolve spontaneously.
- Le Fort I fracture: Le Fort I involves the palate and maxilla.
- Orbital floor blowout: An orbital blowout causes diplopia and cheek numbness.
- Extradural haematoma: Extradural haematoma is an intracranial bleed.
5. An 80-year-old on aspirin with alcohol excess has 3 weeks of fluctuating confusion, headache and mild left hemiparesis after a minor fall. CT shows a crescent-shaped hypodense collection. What is the treatment?
Answer: Burr-hole drainage. Chronic subdural haematoma: elderly, alcohol, anticoagulants/antiplatelets, brain atrophy; torn bridging veins after minor trauma; weeks later — fluctuating confusion, headache, focal signs. CT: crescentic, hypodense (or mixed), crossing suture lines. Symptomatic → burr-hole drainage (± drain); reverse/stop antithrombotics. Recurrence ~10–20%.
- Craniotomy for all: Burr holes usually suffice.
- Observation only with deficit: She is symptomatic.
- Thrombolysis: Thrombolysis is contraindicated.
6. A head-injured patient opens his eyes to pain, makes incomprehensible sounds and withdraws from pain. What is his Glasgow Coma Scale?
Answer: E2 V2 M4 = 8. Eyes: spontaneous 4, to voice 3, to pain 2, none 1. Verbal: oriented 5, confused 4, inappropriate words 3, incomprehensible sounds 2, none 1. Motor: obeys 6, localises 5, withdraws 4, abnormal flexion 3, extension 2, none 1. Total here 2 + 2 + 4 = 8. A GCS of 8 or less usually needs airway protection.
- E3 V3 M5 = 11: Overestimates each component.
- E2 V3 M4 = 9: Verbal is 2, not 3.
- E1 V2 M3 = 6: Underestimates.
- E2 V2 M5 = 9: Withdrawal is 4, not 5.
7. An elderly alcoholic on warfarin has fluctuating confusion over two weeks after a minor fall. CT shows a crescent-shaped collection crossing suture lines. Which vessels bled?
Answer: Bridging veins (subdural haematoma). Subdural haematoma: tearing of bridging veins between cortex and dural sinuses; crescent-shaped, crosses sutures; risk in elderly, alcoholics (brain atrophy) and anticoagulated patients; may be chronic with fluctuating consciousness. Extradural: middle meningeal artery after temporal fracture, lens-shaped, does not cross sutures, lucid interval.
- Middle meningeal artery: Extradural: lens-shaped.
- Berry aneurysm of the circle of Willis: Subarachnoid haemorrhage.
- Lenticulostriate arteries: Hypertensive intracerebral bleed.
- Superior sagittal sinus: Not the usual source.
References and dose sources
- NICE NG232: Head injury, assessment and early management (2023)
- CRASH-3 trial: tranexamic acid in traumatic brain injury
- Glasgow Coma Scale: official assessment aid
- Tranexamic acid dosing: Drugs.com: Tranexamic acid dosage (see also our tranexamic acid dose page)
- Levetiracetam dosing: Drugs.com: Levetiracetam dosage (see also our levetiracetam dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.