Head Injury: Initial Assessment

Assess and stabilise
Calculate the GCS
Ask about and record
Measure and record the vital signs
Examine patient
Initial management post-examination and stabilisation

All patients presenting with a head injury should be assessed by a trained member of staff within a maximum of 15 minutes of initial contact.

GOAL: To determine if high or low risk for brain and cervical spine injury

Assess and stabilise

• Airway
• Breathing
• Circulation

Calculate the GCS

If < 4 years old, use the Children’s GCS.

Ask about and record

• Type of head injury (e.g. MVA, stab)
• How it happened
• Alcohol, drugs
• Amnesia for events
• Vomiting
• Previous brain surgery
• Medications (especially warfarin)

Measure and record the vital signs

BP, pulse, respiratory rate

Examine patient

Look for signs of significant head injury (refer to page 5)

Initial management post-examination and stabilisation

• Immobilise the c-spine (if not already done) if: GCS <15, Neck pain or tenderness, Focal signs, Paraesthesia or if not able to test for range of motion
• Monitor every 15 minutes: GCS, pupil size and reactivity, limb movement, HR, RR, BP, O2 sats
• Skull and c-spine x-rays as appropriate