Head Injury and Concussion: NICE NG232 Care Staff Guide

A bump to the head in a care home, a hospital ward or a community setting is rarely dramatic, which is exactly why it is easy to under-react. NICE guideline NG232, Head injury: assessment and early management, sets out when a head injury needs urgent imaging, how people should be observed, and what advice they must be given when they go home. This guide turns the guideline into plain language for care and health staff, and shows where it links to falls prevention, anticoagulant safety and safeguarding. It is not a clinical protocol: always follow your employer's policy and the advice of the clinician or emergency service you contact.

Why head injuries matter in care settings

Falls are the usual cause of head injury among older and frailer people. The risk of a bleed inside the skull is higher if the person takes a blood thinner, has a bleeding or clotting disorder, is aged 65 or over, or has dementia or a learning disability that makes it hard to describe symptoms. NG232 recognises this by treating these groups as higher risk and by asking services to plan for people whose baseline cognition is already impaired. Good falls prevention reduces the number of head injuries in the first place, but staff still need a clear plan for the ones that happen.

What NICE NG232 says about imaging

The guideline separates adults aged 16 and over from children under 16. For adults, NICE advises a CT head scan within 1 hour if, for example, the Glasgow Coma Scale (GCS) score is 12 or less on initial assessment, the GCS is below 15 at 2 hours after the injury, a skull fracture is suspected, there has been a seizure after the injury, or there has been more than one episode of vomiting. A scan within 8 hours is advised when the person lost consciousness or has amnesia and also has a risk factor, such as being 65 or older, having a bleeding or clotting disorder, a dangerous mechanism of injury, or more than 30 minutes of memory loss before the injury. For people taking anticoagulant or antiplatelet medicines with no other indication, NICE says to consider a CT scan within 8 hours.

For children, the thresholds are different and there is a separate list of criteria, including suspected non-accidental injury, which calls for a scan within 1 hour. Staff in children's services should rely on the guideline itself and local paediatric advice rather than the adult criteria above.

Observations: what to expect

NG232 describes neurological observations that include the GCS score, pupil size and reaction, limb movement, breathing rate, pulse, blood pressure, temperature and oxygen saturation. For a person whose GCS is 15, the guideline gives a schedule of half-hourly observations for 2 hours, then hourly for 4 hours, then 2-hourly. That schedule is written for hospital settings. In a care home or the community, staff should follow local policy, call 111 or 999 as directed, and pass on exactly what they have seen.

The warning signs that call for urgent reassessment are worth memorising: agitation or unusual behaviour, a sustained drop of one point in the GCS (for at least 30 minutes), a larger sudden drop, a severe or worsening headache, persistent vomiting, or new neurological signs such as unequal pupils or weakness on one side. If any of these appear, the response is to escalate, not to wait and see.

What to do in the first minutes

• Check for danger and call for help in line with your emergency policy; call 999 if there is reduced consciousness, a seizure, repeated vomiting, a suspected fracture or clear fluid from the nose or ears.
• Do not move the person if a neck injury is possible, unless there is immediate danger.
• Record the time, the mechanism of injury, whether there was any loss of consciousness, and the person's usual baseline, because a change from baseline is the key signal in someone with dementia.
• Note whether they take warfarin or a direct oral anticoagulant and tell the clinician straight away.

Discharge and the first 24 hours

Before someone is discharged after a head injury, NG232 expects a GCS of 15 (or their usual baseline if they have cognitive impairment) and a safe place to go with competent supervision. A responsible adult should stay with the person for the first 24 hours. Advice must be given both verbally and in writing, covering the nature of the injury, the symptoms that mean returning to hospital, who to contact about delayed problems, and guidance on returning to work, school, sport and driving. The guideline also asks for a letter to the person's GP within 48 hours of discharge.

For care staff receiving a resident back, that means asking for the written advice, putting the 24-hour supervision into the care plan, and sharing the return-to-hospital symptoms with every shift.

Concussion symptoms that can appear later

NG232 asks that people are told some symptoms can persist or appear later even after an apparently quick recovery. These include headache, dizziness, nausea, tiredness, sensitivity to light and noise, balance problems, brain fog, difficulty finding words, slowed responses, memory and concentration problems, and low mood or anxiety. Children under 5 may show changes in behaviour, feeding or sleep. In someone with dementia these symptoms can look like a decline in the condition, so a clear record of what was normal before the injury is invaluable. Where the injury was serious, see our guide to acquired brain injury in care home residents.

Safeguarding and unexplained injuries

NICE asks that a clinician trained in safeguarding is involved in the initial assessment where abuse, neglect or another safeguarding issue may have contributed, and that concerns are documented and handled under local procedures. In practice, any head injury without a credible explanation, or a pattern of injuries to the same person, should be raised with your safeguarding lead.

Frequently asked questions

Does every bump to the head need a hospital visit?

No, but the decision should be made against the guideline criteria and clinical advice, not on a hunch. Anyone on a blood thinner, aged 65 or over, or with the warning signs above needs prompt clinical advice.

Can a person with concussion sleep?

Staff should follow the advice given by the clinician who assessed the person. NG232 stresses supervision for the first 24 hours rather than a fixed rule about sleep.

Where does CPD fit in?

Recognising deterioration, recording observations and escalating clearly are skills worth refreshing every year. Browse the Learnsignal CPD hub for healthcare compliance courses that can evidence this training.

Source: NICE guideline NG232, Head injury: assessment and early management. This article is general information, not clinical advice.