How can I differentiate between mild and severe whiplash injuries in a primary care setting?

To differentiate between mild and severe whiplash injuries in a primary care setting, assess the following key clinical features:

• Neck pain and tenderness: Mild whiplash typically presents with neck pain without midline cervical spine tenderness, whereas severe injury may have significant midline tenderness indicating possible cervical spine injury.
• Range of neck movement: In mild cases, patients can actively rotate their neck 45 degrees left and right without significant pain; inability or severe limitation suggests a more severe injury requiring urgent imaging.
• Neurological symptoms: Presence of paraesthesia, weakness, or altered sensation in upper or lower limbs indicates severe injury and possible nerve involvement.
• Mechanism of injury: Mild whiplash often results from low-risk mechanisms such as simple rear-end collisions; severe injury is more likely with high-risk mechanisms like high-speed collisions, falls from height, or axial load to the head.
• Functional status: Mild injury patients are usually ambulatory and comfortable sitting; severe injury patients may be unable to sit comfortably or walk due to pain or neurological deficits.

Patients with any high-risk features or neurological signs should be referred urgently for imaging and specialist assessment, while those with low-risk features and preserved neck movement can be managed conservatively in primary care with advice and follow-up NICE NG232,NICE NG41.