What are the key clinical features to assess in a patient presenting with a head injury to determine the need for imaging?

When assessing a patient presenting with a head injury to determine the need for imaging, key clinical features to evaluate include:

• Level of consciousness using the Glasgow Coma Scale (GCS), with particular attention if the GCS is less than 15 on initial assessment.
• Mechanism of injury, especially dangerous or high-energy mechanisms such as falls from >1 metre or 5 stairs, high-speed motor vehicle collisions, rollovers, ejections, diving accidents, or bicycle collisions.
• Symptoms since injury including loss of consciousness, confusion, amnesia lasting more than 5 minutes, seizures, vomiting (noting number of episodes), persistent headache, neck pain, and visual disturbances such as diplopia.
• Signs of focal neurological deficit such as speech or visual disturbances, problems with balance or walking, loss of muscle power, paraesthesia, or abnormal reflexes.
• Signs of skull fracture including suspected open or depressed skull fracture, basal skull fracture signs (clear fluid from ear/nose, periorbital haematoma without eye trauma, bleeding from ears, Battle's sign), or visible trauma to scalp or skull.
• Neck examination for tenderness or inability to rotate neck 45 degrees each side, indicating possible cervical spine injury.
• Risk factors such as current anticoagulant medication, bleeding disorders, recent alcohol or drug intake, previous brain surgery, or clinical suspicion of non-accidental injury especially in children under 2 years.
• Other clinical concerns including ongoing irritability or altered behaviour (particularly in children under 5), inability to be observed safely at home, or continuing concern by patient or carers.

Presence of any of these features warrants consideration of urgent CT imaging of the head to detect clinically important traumatic brain injury and guide management decisions.

These assessments should be performed promptly and documented clearly, with involvement of trained clinicians and safeguarding procedures as appropriate.

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