Accident & Emergency Department

Mater Dei Hospital

Msida MSD 2090

G u i d e l i n e N o . AE S 0 6 G u i d e 2 0 1 2 v 0 1 . 0
rd
Date First Issued: 23 February 2012

HEAD INJURY ADMISSION TO OBSERVATION UNIT

EXCLUSION CRITERIA
1. GCS <13 on initial assessment
2. GCS< 15, 2 hours post Head injury
3. Suspected open or depressed skull #
4. Sign of base of skull # ie
a. Periorbital haematomas
b. Bruising over mastoid bone (Battle’s sign)
c. CSF Oto/rhinohorroea
d. Haemotympanum
5. >1 episode of vomiting
6. Post traumatic seizures
7. Focal neurological deficits
8. Patients on anticoagulants in the presence of amnesia and /or LOC
9. Recurrent falls
10. Age >65 years

Inclusion Criteria
1. Minor Head injury (GCS 14-15) not needing CT Brain
2. Minor HI with GCS of 14-15 on admission, with no other associated injuries
awaiting CT scan Brain
3. Minor HI with GCS of 14-15 on admission, with no other associated injuries
having normal CT scan Brain, but who do not meet the criteria for discharge.
GUIDELINES FOR CT BRAIN IMAGING

IMMEDIATE DELAYED UP TO EIGHT HOURS

1. GCS <13 on initial assessment 1. Any Retrograde amnesia or LOC,

2. GCS< 15, 2 hours post Head injury of less than 30 mins. if associated
3. Retrograde amnesia of >30 mins with
4. Suspected open or depressed skull # a. Age equal or more than 65
5. Sign of base of skull # ie years, or
a. Periorbital haematomas b. Dangerous mechanism of
b. Bruising over mastoid bone (Battle’s injury
sign)
c. CSF Oto/rhinohorroea (NB Early imaging rather than admission
d. Haemotympanum and observation for neurological
6. >1 episode of vomiting deterioration will reduce the time to
7. Post traumatic seizures detection of life threatening complication
8. Focal neurological deficits and is associated with a better outcome)
9. Patients on anticoagulants in the
presence of amnesia and /or LOC

WHEN ADMITTED PATIENTS NEED TO HAVE THE FOLLOWING PARAMETERS MONITORED

1) GCS ( individual E, M & V scoring)
2) Pupil size and reaction
3) Limb movement
4) Respiratory rate
5) Heart rate
6) Blood pressure
7) Temperature
8) Oxygen saturation

FREQUENCY OF MONITORING
 Every ½ hour until GCS reaches 15 and continue same for further 2 hrs.
Then
 Every hour for 4 hrs.
Then
 Every 2 hrs.
URGENT REASSESSMENT BY SUPERVISING DOCTOR IS NEEDED IF
1) Development of agitation/ abnormal behaviour
2) Sustained drop of one point in GCS for > 30 mins. Especially.in motor respons.
3) Drop of 3 points in eye response or verbal response scores
4) Drop in 2 points in movement response scores
5) Development of severe or increasing headache
6) Development of persistent vomiting
7) New/evolving neurological. signs such as pupil inequality, facial or limb movement asymmetry

IF ANY CHANGES OF THE ABOVE ARE CONFIRMED AN IMMEDIATE CT SCAN SHOULD BE CONSIDERED AND THE
PATIENT’S CLINICAL CONDITION SHOULD BE REASSESSED AND MANAGED APPROPRIATELY.

Most senior doctor on shop floor should be informed. Surgeon or Neurosurgeon on call should be informed of
the development of patient and arrangement for transfer of patient to surgical or neurosurgical ward should be
arranged

Discharge Criteria from the OU

Patients can be discharged from the OU if:

 GCS is 15 and the ward observations have been consistently normal for at least 12 hours.
 Indicated CT scan is completely normal

Discharge Plan

1. All patient who needed a CT and/or were admitted need a follow up in primary health care (GP)
within one week from discharge.
2. Supervision of a responsible adult
3. Head injury advice before discharge