Skip to content

Head Injuries Module


TopicHead injuries
AuthorChris Odedun
DurationUp to 2 hours
Equipment requiredNone
  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

We also recommend printing/sharing a copy of your local guideline.

Basics of head injury assessment 

RCEMLearning module on head injury (September 2018)

Managing more serious head injuries 

OPENPediatrics “Introduction to Traumatic Brain Injury” (February 2016)

Neuroprotective strategies for severe traumatic brain injury (Paediatric FOAM)

DFTB “Traumatic Brain Injury” (2013)

Your department/region’s guideline for managing head injuries in children.

Head injuries form a wide spectrum of clinical presentations. At their most simple, they can be defined as any impact to the body, proximal to the cervical spine & neck, excluding trivial impact to the face. Practitioners seeing any patient with head injuries should devote time to understanding the primary injury – the mechanism, including its biomechanics. 

How did the get the initial injury?

What can we change here and now to make the patient’s outcome as optimal as possible?


Using guidance for CT imaging

Key papers

A 6 year old girl is brought in by ambulance to the ED you work in. She was playing on a climbing frame and fell off the top onto concrete, onto her head. Handover states that she was briefly knocked unconscious, then returned to a GCS = 15, but has become more drowsy en route to hospital.

On your initial assessment, there is a large swelling to the left side of her scalp and forehead, and there appears to be some blood leaking from her left ear. Her GCS is 12 (E3V4M5) but the rest of her vital signs are within normal limits.

Outline your management steps.

How soon do you want this child to have CT imaging?

The scan shows an extradural haematoma. How can you direct your team to prevent secondary brain injury?

  • This child needs immediate CT imaging of the head and their cervical spine – they are ideally managed by a trauma team, where the primary survey should ensure detection of any other injuries. If as likely, the cervical spine cannot be cleared clinically, they will need immobilisation until this is completed. A written report from an appropriate radiologist will ideally be available within 60mins of the scan.
  • Significant CT findings (see ‘Basics’) will need urgent discussion with a neurosurgeon, to determine if the child needs emergency surgery. If not, a clear management plan – who will monitor the child, and where? will need to be agreed.
  • This child may require intubation, for airway, oxygenation & ventilatory control, or for secondary transfer. Tranexamic acid may be used. Attention should be paid to pain management, and neuroprotective initiatives should be put in place (control of ICP, blood pressure, CO2, O2 & glucose – see the referenced paediatric FOAM article which provides a good summary of clinical management) 

You see a 20 month old boy in your ED, who was playing with his 6 year old cousin when he ran into an opening door at home. He cried immediately, and vomited around 10 minutes later. 

Having been brought into the ED, which is 20 minutes from his home, he has vomited twice more. There was no LOC or seizure activity, and other than looking nauseated he appears to be behaving normally.

To scan or not to scan?

What guidance do the parents/nursing staff looking after this child in the ED need?

How long will you observe for, and what if the child vomits again?

  • This child can probably be safely observed without immediate CT scanning – this management approach would be supported by NICE (see sections 1.4.9 and 1.4.10).
  • This case will hopefully provoke discussion about what constitutes a ‘vomit’, and whether there are any other plausible causes of vomiting, other than the injury itself. 
  • Learners could discuss what local provision they have for more extended observation of a child.
  •  Discussion of provision of verbal + written advice would also be pertinent.

A 9 month old child presents after rolling off a bed onto the floor. You see a 7cm swelling on his occiput. In the trauma call, he is held in mum’s arms and is crying.

You are unsure over how to proceed – the child definitely needs CT imaging, but how should we ensure they keep still?

  • Recap of CT guidance – “For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head”
  • Options for CT sedation: benzodiazepines vs. diamorphine/opiates vs. ketamine vs. intubation & ventilation – given a significant CT finding is possible. This would be a good opportunity to mention the 2020 revisions to RCEM ketamine sedation guidance (with associated DFTB commentary)

An 8 year old girl is brought in by her dad. She clashed heads with another player at basketball two days previously, and did not initially seek medical advice as she was ‘fine’. She had to leave school early today because she had trouble seeing the board & teacher, and felt sick. There are no focal neurological findings but there is a bruise on the parietal part of the scalp on the right, and you cannot feel the scalp.

  • Need for detailed history-taking around the delay in presentation – actively look for any safeguarding concerns
  • Should we have an altered threshold for CT imaging when presentation is delayed? This DFTB post is a useful summary of a paper relating to this cohort of patients – finding of a nonfrontal scalp haematoma or strong suspicion of a basal skull fracture were significantly associated with a clinically significant brain injury.

A 15 year old girl re-attends 10 days after being knocked unconscious for 10-15 seconds while jumping for a header playing football. She passed a pitchside concussion test and continued to play, but was substituted after saying she felt dizzy, and was seen in an ED. A CT scan was performed – which showed no bleed, contusion or fracture. 

She says she found it hard to concentrate on schoolwork for a week afterwards, but this is now normal. She wants to know exactly when she can go back to playing as she has an important match in 3 days.

What do you do?

  • Concussion describes the symptoms & abnormal function experienced by patients after a head injury, without any evidence of macroscopic brain injury. Its management is commonly misunderstood and poorly explained to patients and carers.
  • Management focuses on cognitive rest, avoidance of activities that trigger symptoms, and graduated return to cognitive activity & education.
  • Return to sport should also be graduated, with trial of light activity, and avoidance of sport with a risk of head impact until the patient has been reviewed by a clinician.
  • There is a significant risk of secondary concussion if sport/normal activity is returned to too soon after the initial injury 

Some excellent resources from:

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

Please download our Facilitator and Learner guides



No data was found

Leave a Reply

Your email address will not be published. Required fields are marked *

1 thought on “Head Injuries Module”

  1. This module could do with more discussion in the advanced cases. As a registrar, I am unsure of some of the answers to the questions posed in the advanced modules (1 and 2) and I do not think the discussion is as good as in some of the other DFTB modules. Otherwise, a good topic choice. Thanks.