When should I consider referring a patient with TBI to a specialist for further evaluation or management?

Consider referring a patient with traumatic brain injury to a specialist for further evaluation or management if any of the following are present:

• A Glasgow Coma Scale (GCS) score less than 15 on initial assessment or persisting coma (GCS ≤ 8) after resuscitation.
• Any loss of consciousness due to the injury, even if recovered.
• Amnesia for events before or after the injury (noting difficulty assessing in children under 5).
• Persistent headache or vomiting since the injury.
• Any focal neurological deficit or progressive neurological signs.
• Any seizure since the injury, especially without full recovery.
• Suspicion or evidence of complex skull fracture, penetrating head injury, or cerebrospinal fluid leak.
• Previous brain surgery or history of bleeding/clotting disorders.
• Current anticoagulant or antiplatelet treatment (except aspirin monotherapy).
• Current drug or alcohol intoxication.
• High-energy head injury mechanism.
• Any safeguarding concerns (e.g., possible non-accidental injury or vulnerable person affected).
• Unexplained confusion persisting more than 4 hours or deterioration in GCS after admission.

Additionally, discuss with a neurosurgeon if there are new surgically significant abnormalities on imaging or if the above clinical features are present. For ongoing or persisting problems after initial management, consider referral to clinicians trained in traumatic brain injury consequences (neurologist, neuropsychologist, neurosurgeon, etc.) or multidisciplinary neurorehabilitation teams.

Use CT imaging as the primary investigation for clinically important traumatic brain injury and involve specialist services accordingly.

Ensure appropriate safeguarding involvement and follow local referral pathways.

These recommendations are based on NICE guideline NG232 on head injury: assessment and early management ¹.