Algorithm 1: selecting people 16 and over for a CT head scan

Person 16 or over presenting to the emergency department with a head injury

Are any of these risk factors present:

• a GCS score of 12 or less on initial assessment in the emergency department
Moderate
• a GCS score of 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, cerebrospinal fluid leakage from the ear or nose, Battle's sign)
• post-traumatic seizure
• focal neurological deficit
• more than 1 episode of vomiting

No

Is there loss of consciousness or amnesia since the head injury?

Yes Yes No

Are any of these risk factors present:

• age 65 years or over
• any bleeding or clotting disorders (liver failure, haemophilia,
taking anticoagulants or antiplatelets)
• dangerous mechanism of injury (a pedestrian or cyclist
struck by a motor vehicle, an occupant ejected from
a motor vehicle, or 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

Yes No

Are they taking anticoagulants (including vitamin K

antagonists, direct-acting oral anticoagulants,
heparin and low molecular weight heparins) or
antiplatelets (excluding aspirin monotherapy)?

No Yes

Do a CT head scan within 1 Do a CT head scan within 8 CT head scan Consider a CT head scan
hour of any of the risk hours of the injury, or within not needed within 8 hours of injury, or
factors being identified 1 hour if they present more within 1 hour if they present
than 8 hours after injury more than 8 hours after
Make a provisional written injury
radiology report available Make a provisional written
within 1 hour of the scan radiology report available Make a provisional written
within 1 hour of the scan radiology report available
within 1 hour of the scan

© NICE 2023. All rights reserved. Subject to Notice of rights.

 Algorithm 2: selecting people under 16 for a CT head scan
Person under 16 presenting to the emergency department with a head injury

Are any of these risk factors present:

• suspicion of non-accidental injury
• post-traumatic seizure but no history of epilepsy
• a GCS score of less than 14 or, for children under 1, a GCS (paediatric) score of less than 15, on initial assessment in the
emergency department
• a GCS score of less than 15 at 2 hours after the injury
• suspected open or depressed skull fracture, or tense fontanelle
• any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign)
• focal neurological deficit
• for children under 1 year, a bruise, swelling or laceration of more than 5 cm on the head

Yes No

Are any of these risk factors present:

• loss of consciousness lasting more than 5 minutes (witnessed)
• any bleeding or clotting disorders (liver failure, haemophilia, taking
anticoagulants or antiplatelets)
• abnormal drowsiness
• 3 or more discrete episodes of vomiting
• dangerous mechanism of injury (high-speed road traffic accident as
a pedestrian, cyclist or vehicle occupant, fall from a height of more than 3 m,
high-speed injury from a projectile or other object)
• amnesia (antegrade or retrograde) lasting more than 5 minutes
(it will not be possible to assess amnesia in children who are preverbal and
is unlikely to be possible in children under 5)

Yes, more than 1 factor Yes, 1 factor No

Observe for at least 4 hours after the head injury

Are any of these risk factors present while observing:

• a GCS score of less than 15
• further vomiting
• further episodes of abnormal drowsiness

Yes No

Are they taking anticoagulants (including vitamin K antagonists,

direct-acting oral anticoagulants, heparin and low molecular weight
heparins) or antiplatelets (excluding aspirin monotherapy)?

Yes No

Do a CT head scan within 1 hour Consider a CT head scan within 8 CT head scan not needed
of any of the risk factors being hours of injury, or within 1 hour if
identified they present more than 8 hours Use clinical judgement to
after injury determine when further
Make a provisional written observation is needed
radiology report available within 1 Make a provisional written
hour of the scan radiology report available within 1
hour of the scan

© NICE 2023. All rights reserved. Subject to Notice of rights.

 Algorithm 3: selecting people 16 and over for imaging of the
cervical spine
Person 16 or over presenting to the emergency department with a head injury

Are any of these high-risk factors present:

• a GCS score of 12 or less on initial assessment
• intubation
• a definitive diagnosis of cervical spine injury is needed urgently (for example, if cervical spine manipulation is needed during
surgery or anaesthesia)
• clinical suspicion of cervical spine injury and other body areas are being scanned for a head injury or multiregion trauma
• they are alert and stable, there is suspicion of cervical spine injury and any of these factors:
• age 65 years or over
• dangerous mechanism of injury (fall from a height of more than 1 m or 5 stairs, axial load to the head such as from diving,
high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised
recreational vehicles, bicycle collision)
• focal peripheral neurological deficit
• paraesthesia in the upper or lower limbs

Yes No

Is there suspicion of cervical spine injury (neck pain or tenderness)?

Yes No

Does the person have a condition predisposing them to a higher risk

Yes of injury to the cervical spine (for example, axial spondyloarthritis)?

No

Are any of these low-risk factors present, which indicate it is safe to

assess range of movement of the neck:
• involved in a simple rear–end motor vehicle collision
No • is comfortable in a sitting position in the emergency department
• has been ambulatory at any time since injury
• absence of midline cervical tenderness
• presents with delayed onset of neck pain

Yes

On safe assessment, can the person actively rotate their neck to

No 45 degrees to the left and right?

Yes

Do a CT scan of the cervical spine within 1 hour of any

of the risk factors being identified

Make a provisional written radiology report available

within 1 hour of the scan No imaging or no further imaging needed

© NICE 2023. All rights reserved. Subject to Notice of rights.

 Algorithm 4: selecting people under 16 for imaging of the
cervical spine
Person under 16 presenting to the emergency department with a head injury

Are any of these high-risk factors present:

• a GCS score of 12 or less on initial assessment
• intubation
• a definitive diagnosis of cervical spine injury is needed urgently (for example, if cervical spine manipulation is needed during
surgery or anaesthesia)
• clinical suspicion of cervical spine injury and other body areas are being scanned for a head injury or multiregion trauma
• focal peripheral neurological signs
• paraesthesia in the upper or lower limbs

Yes No

Is there suspicion of cervical spine injury (neck pain or tenderness)?

Yes No

Are any of these further risk factors present:

• dangerous mechanism of injury (fall from a height of more than 1 m or 5 stairs, axial load to the
head such as from diving, high-speed motor vehicle collision, rollover motor accident, ejection
from a motor vehicle, bicycle collision)?
• the person has a condition predisposing them to a higher risk of injury to the cervical spine (for
example, collagen or bone disease, axial spondyloarthritis)

Yes No

Are any of these low-risk factors present, which indicate it is safe to assess
range of movement of the neck:
• involved in a simple rear–end motor vehicle collision
• is comfortable in a sitting position in the emergency department
• has been ambulatory at any time since injury
• absence of midline cervical tenderness
• presents with delayed onset of neck pain

No Yes

On safe assessment, can the person actively rotate their neck to

45 degrees to the left and right?

No Yes

Do 3-view cervical spine X-rays within 1 hour of a risk factor being identified

Is there a strong clinical suspicion of injury despite normal X-rays, were the X-rays
technically difficult or inadequate, or did they identify a significant bony injury?

Yes No

Do a CT scan of the cervical spine within 1 hour of any

of the risk factors being identified

Make a provisional written radiology report available

within 1 hour of the scan No imaging or no further imaging needed

© NICE 2023 All rights reserved. Subject to Notice of rights.

ISBN: 978-1-4731-5084-3