Questionnaire/history: When did it happen? How did it happen? Dangerous mechanism or high-energy head injury? - Fall from a height of greater 1 metre or 5 stairs? - Other? Symptoms? - Loss of consciousness? - Amnesia (antegrade or retrograde) lasting more than 5 minutes? - Any vomiting episode since the injury (particularly if more than one episode using clinical judgement)? - Persistent headache? - Neck pain? - Post-traumatic seizure without Questionnaire/history of epilepsy? Pre-injury level of consciousness and functioning? Recent alcohol or drug intake? Current alcohol or drug intoxication? Past medical history? Current medication (eg anticoagulant)? Drug allergies? Examination: GCS? - Eye opening spontaneously (4)? - Best verbal response orientated in time, place and person (5)? - Best motor response? Obeys commands (6)? Hypoxia or signs of shock? - Tachycardia? - Hypotension? - Reduced CRT? Signs of a penetrating injury or visible trauma to the scalp or skull? Suspected open or depressed skull fracture? Cranial nerves including pupil size and reactivity? Any focal neurological deficit? - Visual disturbance? - Speech disturbance? - Problems understanding speech? - Problems with reading? - Problems with writing? - Problems with balance or walking? - Loss of muscle power? - Paraesthesia in the upper or lower limbs or abnormal reflexes? Signs of basal skull fracture? - Clear fluid (possible cerebrospinal fluid) leaking from the ear(s) or nose? - Periorbital haematoma(s) with no associated damage around the eyes?

- Bleeding from one or both ears? - Blood behind the ear drum (haemotympanum)? - New deafness in one or both ears? - Battle's sign (bruising behind one or both ears over the mastoid process,suggesting fracture of the middle cranial fossa)? Neck tenderness (with midline cervical spine tenderness may indicate cervical spine injury)? (Note? if there is any suspicion of cervical spine injury, full cervical spine immobilization should be arranged before transfer to hospital) Range of neck movements (with an inability to rotate the neck 45 degrees to the left and right may indicate cervical spine injury)? (Note? safe examination of the neck should only be performed using clinical judgement if the person was involved in a simple rear-end motor vehicle collision, is comfortable in a sitting position, has been ambulatory at any time since the injury, has no midline cervical spine tenderness and presents with delayed onset neck pain) Diagnosis: Mild head injury Concussion Severe head injury - needs ED assessment Management: According to cause Advised: - To take paracetamol prn - To have a responsible adult present for 24 hours after the accident - To call back if new or worsening symptoms (eg worsening headache, vomiting, drowsiness) - To not drive, ride a motorbike or bicycle and to not operate machinery until patient feels completely recovered) - That mild symptoms (eg mild headache, feeling a bit sick without being sick (vomiting), being irritable and grumpy, tired, poor appetite, some difficulty concentrating) are not serious and usually go away within a couple of weeks - To read NHS info 'Head injury and concussion' with further details of the expected recovery process and information on persistent, new or delayed symptoms and signs which may indicate a possible complication and when to attend A&E or seek urgent medical advice Reference(s): NICE Clinical Guidance 176: Head injury: assessment and early management NICE CKS: Head injury Information for parents/carers: NHS Health A to Z: Head injury and concussion Patient UK: Head injuries