CT head and C-spine, decided properly.

Do a CT head scan within 1 hour of any of these being identified:

• GCS 12 or less on initial assessment in the emergency department
• GCS less than 15 at 2 hours after the injury on assessment in the emergency department
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture (haemotympanum, 'panda' eyes, CSF leakage from ear or nose, Battle's sign)
• Post-traumatic seizure
• Focal neurological deficit
• More than 1 episode of vomiting

For people who have had some loss of consciousness or amnesia since the injury, do a CT head within 8 hours of the injury — or within the hour if they present more than 8 hours after the injury — if they have any of:

• Age 65 or over
• Any current bleeding or clotting disorder
• Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle, or a fall from a height of more than 1 m or 5 stairs)
• More than 30 minutes' retrograde amnesia of events immediately before the head injury

Within 1 hour — any one of:

• Suspicion of non-accidental injury
• Post-traumatic seizure
• On initial ED assessment, GCS less than 14 — or, for babies under 1 year, paediatric GCS less than 15
• At 2 hours after the injury, GCS less than 15
• Suspected open or depressed skull fracture, or tense fontanelle
• Any sign of basal skull fracture
• Focal neurological deficit
• For babies under 1 year: a bruise, swelling or laceration of more than 5 cm on the head

Within 1 hour if more than one of:

• Witnessed loss of consciousness lasting more than 5 minutes
• Abnormal drowsiness
• 3 or more discrete episodes of vomiting
• Dangerous mechanism (high-speed road traffic accident as pedestrian, cyclist or vehicle occupant; fall from more than 3 m; high-speed injury from a projectile or other object)
• Amnesia, anterograde or retrograde, lasting more than 5 minutes
• Any current bleeding or clotting disorder

Exactly one of those six: observe for a minimum of 4 hours from the time of injury. If GCS falls below 15, further vomiting, or a further episode of abnormal drowsiness occurs during observation, do a CT head within 1 hour. If none occur, use clinical judgement about whether longer observation is needed.

For people who have sustained a head injury and have no other indications for a CT head, but are on anticoagulant treatment (including vitamin K antagonists, DOACs, heparin and low molecular weight heparins) or antiplatelet treatment (excluding aspirin monotherapy), consider a CT head:

• within 8 hours of the injury — for example if it is difficult to do a risk assessment, or if the person might not return to the emergency department if they deteriorate; or
• within the hour if they present more than 8 hours after the injury.

Note the two deliberate features of this wording: it is "consider", not "do"; and aspirin monotherapy is explicitly outside it.

Recommendation 1.6.2 opens by covering people 16 and over who have sustained a head injury “(including people with delayed presentation)” — the criteria do not lapse because the patient arrived late.

Within 1 hour if any high-risk factor applies:

• GCS 12 or less on initial assessment
• The person has been intubated
• A definitive diagnosis of cervical spine injury is urgently needed (for example if manipulation is needed during surgery or anaesthesia)
• Blunt polytrauma involving the head and chest, abdomen or pelvis in someone alert and stable
• Clinical suspicion of cervical spine injury and any of: age 65 or over; dangerous mechanism (fall from more than 1 m or 5 stairs, axial load to the head such as diving, high-speed motor vehicle collision, rollover, ejection, motorised recreational vehicle accident, bicycle collision); focal peripheral neurological deficit; paraesthesia in the upper or lower limbs

Neck pain or tenderness without high-risk indications — CT within 1 hour if:

• It is not thought safe to assess range of movement in the neck
• Safe assessment shows the person cannot actively rotate their neck 45° left and right
• The person has a condition predisposing to higher risk of cervical spine injury (for example axial spondyloarthritis)

As with adults, 1.6.4 covers people under 16 who have sustained a head injury “(including those with delayed presentation)”.

Only do a CT cervical spine if any of these apply (within 1 hour):

• GCS 12 or less on initial assessment
• The person has been intubated
• Focal peripheral neurological signs
• Paraesthesia in the upper or lower limbs
• A definitive diagnosis of cervical spine injury is needed urgently
• The person is having other body areas scanned for head injury or multisystem trauma, and there is clinical suspicion of cervical spine injury
• Strong clinical suspicion of injury despite normal X-rays
• Plain X-rays are technically difficult or inadequate
• Plain X-rays identify a significant bony injury

Otherwise, with neck pain or tenderness — 3-view X-rays first if:

• Dangerous mechanism of injury (as defined above), or
• Safe assessment of range of movement is not possible, or
• A condition predisposing to higher risk of cervical spine injury (for example collagen vascular disease, osteogenesis imperfecta, axial spondyloarthritis)

If range of movement can be assessed safely, do 3-view X-rays if the child cannot actively rotate the neck 45° left and right. Where the person cannot understand commands or open their mouth, a peg view may be omitted. X-rays within 1 hour, reviewed by a clinician trained in their interpretation.

Range of movement in the neck when there is clinical suspicion of a cervical spine injury can only be assessed safely before imaging in someone with a head injury if they have no high-risk factors, and only if they have at least one of these low-risk features:

• They were in a simple rear-end motor vehicle collision
• They are comfortable in a sitting position
• They have been ambulatory at any time since injury
• There is no midline cervical spine tenderness
• They present with delayed onset of neck pain

Focal neurological deficit (NG232 terms)

Neurological problems restricted to a particular part of the body or a particular activity, for example: difficulties with understanding, speaking, reading or writing; decreased sensation; loss of balance; weakness; visual changes; nystagmus; abnormal reflexes; problems walking; amnesia since the injury.

Signs of a complex skull fracture or penetrating head injury

Clear fluid running from the ears or nose; a black eye with no associated damage around the eyes; bleeding from one or both ears; bruising behind one or both ears; penetrating injury signs; visible trauma to the scalp or skull of concern to the professional.

High-energy head injury

For example: a pedestrian struck by a motor vehicle; an occupant ejected from a motor vehicle; a fall from more than 1 m or more than 5 stairs; a diving accident; a high-speed motor vehicle collision; a rollover; an accident involving motorised recreational vehicles; a bicycle collision; or any other potentially high-energy mechanism.

Paraesthesia

Pins and needles, or a prickling sensation, tingling or itching in any part of the body.

GCS severity bands

Mild traumatic brain injury GCS 13–15; moderate GCS 9–12; severe GCS 8 or less.

NG232's recommendations do not name the Canadian C-Spine Rule, NEXUS, the Canadian CT Head Rule or PECARN. The NICE criteria were developed with reference to that decision-rule literature — the underlying evidence review is titled "clinical decision rules selecting people with head injury for imaging" — and the family resemblance is obvious in the age, mechanism and rotation elements. But NG232 is not a restatement of any of them, and the thresholds differ in places.

For UK practice, NG232 is the standard you will be audited against. The original rules remain worth knowing for exams and for reading non-UK literature, but where they disagree with NG232, follow NG232 and document your reasoning. This tool implements NG232 only, deliberately.