Traumatic brain injury is a leading cause of death and disability worldwide, especially among young people. Road traffic crashes, including motorcycle (“okada” and “boda boda”) crashes, are a major cause in Africa and Asia; falls are the commonest cause in older adults. Most head injuries are minor, but a small number of patients develop bleeding inside the skull that can kill within hours. Nurses’ observations are often what detects it.
Initial assessment
- A–E, with cervical spine protection if a neck injury is possible (dangerous mechanism, neck pain, reduced consciousness).
- Glasgow Coma Scale, pupils and limb movements. See our GCS guide.
- Blood glucose: low glucose can mimic or worsen brain injury.
- History: mechanism, loss of consciousness, amnesia, vomiting, seizures, headache, alcohol or drugs, anticoagulant or antiplatelet medicines, bleeding disorders.
- Look for scalp wounds, signs of skull fracture: bruising behind the ear (Battle’s sign), bruising around both eyes (“raccoon eyes”), clear fluid from the nose or ear (CSF leak), or blood behind the eardrum.
Who needs a CT scan urgently?
NICE guidance in the UK recommends a CT head scan within 1 hour for adults with any of: GCS below 13 on initial assessment, GCS below 15 two hours after injury, suspected open or depressed skull fracture, signs of base of skull fracture, a post-traumatic seizure, a focal neurological deficit, or more than one episode of vomiting. Patients taking anticoagulants (such as warfarin or apixaban) are scanned within 8 hours even without other signs. Other countries use similar rules; follow your local pathway.
Neurological observations
For patients admitted with a head injury and GCS below 15, NICE recommends observations at least:
- Every 30 minutes until GCS reaches 15;
- Then every 30 minutes for 2 hours;
- Then every hour for 4 hours;
- Then every 2 hours.
- If the patient deteriorates at any point, return to half-hourly observations.
Each set includes GCS, pupil size and reactivity, limb movements, respiratory rate, heart rate, blood pressure, temperature and SpO₂.
Warning signs: escalate immediately
- A drop in GCS of 2 points or more, or of 1 point in the motor score.
- Agitation or abnormal behaviour.
- Severe or increasing headache, or persistent vomiting.
- New or unequal pupils, or pupils that react sluggishly.
- New weakness on one side.
- Seizures.
- Cushing’s triad: rising blood pressure, falling heart rate and irregular breathing. This is a late, life-threatening sign of raised pressure inside the skull.
Beware the “lucid interval”: in an extradural haematoma, a patient may be knocked out, wake up and seem fine, then deteriorate rapidly hours later.
Nursing care for moderate to severe head injury
- Head of bed at 30 degrees (if the spine is cleared or as instructed), head in a neutral position, to help venous drainage.
- Avoid tight cervical collars or ties around the neck that obstruct venous return.
- Avoid low oxygen and low blood pressure: both worsen brain injury.
- Keep blood glucose and temperature normal; treat fever.
- Manage pain and agitation; keep the environment calm.
- Seizure precautions.
- Pressure area, eye and mouth care in unconscious patients.
Discharge advice for minor head injury
Patients should go home with a responsible adult and written advice. They should return immediately if they have: drowsiness or difficulty waking; confusion; problems speaking, seeing or understanding; weakness; repeated vomiting; severe headache; a seizure; or clear fluid from the ears or nose. Advise rest, no alcohol, no driving until recovered, and a gradual return to work, school and sport. Some people have ongoing headaches, poor concentration or mood changes for weeks (post-concussion symptoms) and should see their doctor if these persist.
Prevention
Helmets for motorcyclists and cyclists, seat belts, child car seats and falls prevention for older adults save lives. Nurses can champion these in their communities. See our guide to preventing falls in hospital.
Based on NICE NG232 (Head injury: assessment and early management) and WHO road traffic injury information. Educational content: follow your local head injury pathway.