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Head Injury in Adults - Initial Management, Neurosurgical Referral & MTC Transfer 

Last update 16th March 2018

V1 Approved by Policy and Guideline Committee on 16th March 2018 Trust Ref: B38/2018 

This guideline has been developed for the East Midlands Major Trauma Network (EMMTN) and
was approved by its Executive Board on 16th February 2018.


1. Introduction and who guidelines apply to
It describes key steps in the initial management of adult patients presenting to the regional Trauma Units (TU) with a head injury in whom CT imaging of the head is indicated as per NICE CG176 [1]; including indications for immediate transfer to the Major Trauma Centre (MTC) and for
obtaining emergent / urgent neurosurgical advice at Nottingham University Hospitals (NUH) via the online system referapatient.


NB - The following patient groups are outside the scope of this document:
• Those in whom the need for MTC transfer has already been clearly established;
• Those who due to advanced frailty [2] are deemed not to benefit from CT by an experienced ED doctor or ANP as part of a shared decision-making process involving patient and family.

This guideline applies to all UHL staff involved in the initial management of adult patients presenting to the Leicester Royal Infirmary (LRI) Emergency Department (ED) with head injuries.

2. Guideline Standards and Procedures

2.1 ED management and disposition should follow the algorithm shown in Appendix A
2.2 Referrals to the neurosurgical team at NUH via referapatient. Watch the video guide below to see how to do this.
2.3 It is NOT necessary to sign up or log in to make a referral. Begin your referral here

Upon completing your first referapatient referral a referapatient account will be automatically generated for you with a password and PIN sent to your email and phone.

ED Clinicians can access to the LRI ED Referapatient ‘Referrals From My Department’ view by emailing Dr Martin Wiese.

3. Education and Training


No additional skills are required to follow this guideline.

Awareness will be raised through the relevant members of the Major Trauma Governance Group (MTGG).



4. Monitoring and compliance

5. Supporting References

1. NICE (2014) Head injury: Triage, assessment, investigation and early management of head injury in children, young people and adults. CG176. London: National Institute for Health and Care Excellence.

2. Rockwood K et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489-495.

6. Key Words

Major trauma, head injury, traumatic brain injury, TBI, NICE, GCS, Glasgow Coma Scale, Major Trauma Centre, MTC, frail, frailty, extradural, subdural, subarachnoid, RSI, rapid sequenceintubation, adult, referapatient, neurosurgeon, neurosurgery, Queen’s Medical Centre, QMC,
Nottingham University Hospital, NUH, EMMTN, East Midlands Major Trauma Network,
hydrocephalus, pneumocephalus, fracture

7. Contact and Review details

Guideline Lead, Martin Wiese, Emergency Physician and UHL Clinical Lead for Major Trauma 

Executive Lead, Andrew Furlong, Medical Director 

Details of Changes made during review:


Adult with Head Injury in Trauma Unit: Initial Management, neurosurgical referral and MTC Transfer

Appendix A
Head Injury UHL.png
Video Guide

Video Guide (no need to switch on speakers as there is NO sound)

Still need help using referapatient? Click here to webchat with an in-application technician (available 24/7).

Install our Chrome Extension called Litebox to video-record scans on your screen and upload to your referral in HD

Always ask:
'Does this patient require transfer to QMC?' If not how long should the patient be observed?'
Other questions (if applicable) might include:
For how long should anticoagulation be withheld?
Are any follow-up arrangements necessary?
Does the patient require Pneumovax or other drugs?

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