Tasty Morsels of EM 096 – #FRCEM NICE Head Injury and C-spine

31 Jul

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here

We all do this every day and likely use the NICE guidelines to guide us but there’s some details in here, especially with kids that i can never keep straight in my head


When should we order a urgent CT within 1 hour

  • GCS < 13 on initial assessment
  • GCS < 15 at 2 hours after injury on assessment in the emergency department
  • Suspected open or depressed skull fracture
  • Any sign of basal skull fracture
  • Post-traumatic seizure
  • Focal neurological deficit (note how this is poorly defined...)
  • More than one episode of vomiting since the head injury

When should we order a CT within 8 hour

  • anticoagulation
  • LOC or amnesia AND
    • age>65
    • bleeding disorder
    • dangerous MOI
    • >30 mins retrograde amnesia prior to injury

When should we order a urgent CT in a child within 1 hour

  • Suspicion of non-accidental injury
  • Post-traumatic seizure, but no history of epilepsy
  • On initial assessment GCS <14, or for children under 1 year GCS (paediatric) < 15
  • At 2 hours after the injury GCS < 15
  • Suspected open or depressed skull injury 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, presence of bruise, swelling or laceration of more than 5 cm on the head
  • more than one of the following
    • Witnessed loss of consciousness > 5 minutes
    • Abnormal drowsiness
    • 3 or more discrete episodes of vomiting
    • Dangerous mechanism of injury (high-speed road traffic accident either as a pedestrian, cyclist or vehicle occupant, fall from height of > 3 metres, high speed injury from an object
    • Amnesia (antegrade or retrograde) lasting > 5 minutes (assessment not possible in pre-verbal children and unlikely in any child < 5 years).
  • if only one of the above factors present then observe 4 hours

What is the paediatric GCS?

note MDcalc citing this paper has age <2 and some slightly different criteria

I’ve cited APLS 5th below

  • use in age <4 (otherwise use the normal one)
  • Eyes
    • the same as the big people
  • Verbal
    • 1: no response
    • 2: moans to pain
    • 3: cries only to pain
    • 4: less than usual words, spontaneous irritable cry
    • 5: alert, babbles, coos, usual ability
  • Motor (pretty much the same as the big people)
    • 1: no response
    • 2: abnormal extension
    • 3: abnormal flexion
    • 4: withdraws from pain
    • 5: localises to pain or withdraws to touch
    • 6: spontaneous or obeys verbal command

When to add the C-spine in adults?

  • if you’re scanning other areas
  • if they’re going for urgent surgery
  • if GCS<13
  • intubation
  • if c-spine injury suspected and
    • any neuro signs or symptoms
    • dangerous mechanisms
    • age >65
  • if not already meeting criteria then apply the canadian rule and if failing this then get a c-spine.
  • if any issues with the c-spine film then CT

When to add the C-spine in kids?

  • similar to above but without the dangerous mechanism bit
  • if dangerous MOI present then they encourage plain film first
    • note that dangerous MOI for paeds c-spine is 1 m fall but for head injury it’s 3m

What is the CCR?

(no not that CCR)


  • Immediate fail
    • Age>65
    • Extremity Paraesthesia
    • Dangerous MOI
      • high speed MVC/rollover/ejection
      • >3ft/5 stairs
      • bicyle
      • motorised recreational vehicle
      • axial load
  • If passes that then look for low risk features
    • sitting
    • walking at any time
    • delayed pain
    • no midline tenderness
    • simple rear end
  • if ANY low risk feature
    • actively range 45 degrees
    • if passed then no imaging


6 Replies to “Tasty Morsels of EM 096 – #FRCEM NICE Head Injury and C-spine

  1. Just to confound this, the NICE spine injury guidance from 2016 says CT scan if imaging needed for cervical spines in adults -no mention of plain films for grown ups! Nothing like a bit of inter guideline contradiction…

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