What criteria should I use to determine whether to refer a patient with suspected extradural haematoma to secondary care?

Refer a patient with suspected extradural haematoma to secondary care (hospital emergency department) if any of the following criteria are present:

• Glasgow Coma Scale (GCS) score less than 15 on initial assessment.
• Any loss of consciousness due to the injury, even if recovered.
• Any focal neurological deficit since the injury.
• Suspicion of a complex skull fracture or penetrating head injury.
• Amnesia for events before or after the injury (noting difficulty assessing in children under 5 years).
• Persistent headache since the injury.
• Any vomiting episodes since the injury.
• Any seizure since the injury.
• Previous brain surgery.
• High-energy head injury.
• History of bleeding or clotting disorders.
• Current anticoagulant or antiplatelet treatment (except aspirin monotherapy).
• Current drug or alcohol intoxication.
• Any safeguarding concerns (e.g., possible non-accidental injury or vulnerable person affected).
• Continuing concern by the healthcare professional about the diagnosis.

Additionally, urgent referral via emergency ambulance (999) is indicated if there is unconsciousness or lack of full consciousness, any focal neurological deficit, suspicion of complex skull fracture or penetrating injury, any seizure, or a high-energy head injury and no other safe transport method is available.

Discuss with a neurosurgeon urgently if there are new and surgically significant abnormalities on imaging, persisting coma (GCS ≤8), unexplained confusion lasting more than 4 hours, deterioration in GCS, progressive focal neurological signs, seizures without full recovery, suspected penetrating injury, or cerebrospinal fluid leak.