The NICE head injury guideline NG232 – “Head injury: assessment and early management” was published on 18 May 2023, replacing the older guideline CG176. It covers babies, children, young people and adults, from pre-hospital triage through ED assessment, imaging, admission, discharge and follow-up. (NICE)


If you’re working in a UK ED (and especially if you’re revising for the FRCEM SBA), knowing the headline rules from NG232 is essential – for safe care, exam questions, and endless “Should this patient get a CT?” corridor consults.


This post gives you a revision-friendly summary of the NICE head injury guidelines, plus some tips on how to remember them and embed them into your practice.


What do NICE mean by “head injury”?


NICE define a head injury as any trauma to the head excluding purely superficial facial injuries, and they include both closed and penetrating head injuries.(NICE)


The guideline’s aims are to:

  • Identify patients at risk of clinically important traumatic brain injury (ciTBI)
  • Standardise who needs CT, who needs observation/admission, and who can be discharged safely
  • Ensure direct referral to specialist care (e.g. neurosurgical centres) when needed.(NICE)


For exam purposes, remember: head injury ≠ always brain injury – NG232 is about the whole process of assessing risk.


Where does NG232 fit in everyday ED practice?


NG232 doesn’t replace ATLS/APLS – it sits on top of them. NICE explicitly expect you to manage initial resuscitation according to major trauma and resus principles, then overlay the NG232 decision tools for imaging and ongoing care. (NICE)


Key messages:

  • ABC first, then worry about CT.
  • Don’t blame reduced GCS on alcohol or drugs until you’ve reasonably excluded significant TBI.(NICE)
  • Use standard head injury proformas and consistent documentation across the ED.(NICE)
  • Think safeguarding early – especially in children, vulnerable adults, unusual injury patterns or delayed presentation.(NICE)


CT head in adults (16+): the 1-hour and 8-hour rules


NICE are very clear that CT is the first-line investigation for suspected ciTBI.(NICE)


1-hour CT head criteria (adults ≥16)


Do a CT head within 1 hour of identifying any of these risk factors:(NICE)

  • GCS ≤12 on arrival in ED
  • GCS <15 at 2 hours after the injury
  • Suspected open or depressed skull fracture
  • Any base of skull signs (e.g. Battle’s sign, raccoon eyes, CSF leak, haemotympanum)
  • Post-traumatic seizure
  • Focal neurological deficit
  • >1 episode of vomiting


FRCEM tip: in adults, think “LOW GCS, BAD SKULL, FIT, FOCAL, VOM” = 1-hour CT.

8-hour CT head criteria (adults with LOC/amnesia)


If the person had any loss of consciousness or amnesia since the injury, they need a CT within 8 hours of the head injury (or within 1 hour if they present >8 hours after the injury) if they have any of:(NICE)


  • Age ≥65
  • Any current bleeding/clotting disorder
  • Dangerous mechanism (pedestrian/cyclist vs vehicle, ejected from vehicle, fall >1 m or >5 stairs)
  • >30 minutes retrograde amnesia before impact


Again, this is within 8 hours of injury, not 8 hours of arrival.


Anticoagulants & antiplatelets: what’s changed?


One of the big talking points in NG232 is how to handle asymptomatic patients on anticoagulant or antiplatelet therapy.


NICE say that if someone has had a head injury, has no other CT indications, but is on:(NICE)

  • Warfarin or other vitamin K antagonists
  • DOACs
  • Heparin / LMWH
  • Antiplatelets (excluding aspirin monotherapy)


…you should consider CT head:

  • Within 8 hours of injury, or
  • Within 1 hour if they present more than 8 hours after injury.


The word “consider” is important – it’s not the same as “must”. Clinical judgement and local policies matter. This has prompted debate, which led to a joint position statement from AACE, RCEM, BGS and SBNS in October 2023 to help services interpret this in practice for truly asymptomatic, low-risk patients.(AACE)


For FRCEM and real life, the safe summary is:

Any anticoagulant/antiplatelet (non-aspirin) + head injury = very low threshold for CT, even if exam looks benign.


CT head in children: high-risk vs intermediate risk


For under-16s, the rules are similar in concept but with age-specific thresholds and a bigger role for observation.


1-hour CT head in children


Do a CT head within 1 hour if any of the following are present:(NICE)

  • Suspected non-accidental injury
  • Post-traumatic seizure
  • GCS <14 (or <15 in babies <1 year) on ED assessment
  • GCS <15 at 2 hours post-injury
  • Suspected open/depressed skull fracture or tense fontanelle
  • Any base of skull signs
  • Focal neurological deficit
  • In babies <1 year, a scalp bruise/swelling/laceration >5 cm


Intermediate risk: 1 risk factor vs >1 risk factor


If a child has more than one of the following, CT within 1 hour:(NICE)


  • LOC >5 minutes (witnessed)
  • Abnormal drowsiness
  • ≥3 episodes of vomiting
  • Dangerous mechanism (e.g. high-speed RTC, fall >3 m)
  • Amnesia (≥5 minutes, if assessable)
  • Current bleeding/clotting disorder


If they have only one of these intermediate risk factors, NICE recommend observation for at least 4 hours from the time of injury. CT within 1 hour if:

  • GCS drops <15
  • Further vomiting
  • Further abnormal drowsiness develops.(NICE)


Clinical reality: for kids, you’ll often be balancing CT vs observation vs parental anxiety. The guideline gives you a solid framework to justify either approach.


Cervical spine imaging: CT first in high-risk adults


NG232 also gives criteria for CT cervical spine, which broadly mirror NEXUS/Canadian C-spine rules.(NICE)


Adults (16+): high-risk → CT C-spine within 1 hour


Do a CT C-spine within 1 hour if any of:(NICE)

  • GCS ≤12
  • Intubated
  • Need an urgent, definitive C-spine diagnosis (e.g. surgical positioning)
  • Blunt polytrauma involving head and torso
  • Clinical suspicion of C-spine injury plus any of: 
    • Age ≥65
    • Dangerous mechanism (fall >1 m / 5 stairs, axial load, high-speed RTC, rollover, ejection, motorised recreational vehicles, bicycle collision)
    • Focal peripheral neurology
    • Limb paraesthesia


If neck pain/tenderness but not high-risk:

  • CT if you can’t safely assess neck range of movement or they cannot actively rotate 45° left and right, or they have a condition predisposing to C-spine injury (e.g. ankylosing spondylitis).(NICE)


Children


In under-16s, CT C-spine is reserved for higher-risk situations (GCS ≤12, intubation, neuro deficit, strong suspicion despite x-ray, or when scanning other body areas for major trauma).(NICE)


Admission, observation, discharge and follow-up


Who needs admission?


NICE expect admission for, e.g.:

  • Persistent GCS <15
  • Significant intracranial findings on CT
  • Ongoing symptoms (e.g. persistent severe headache, vomiting, confusion)
  • Concerning safeguarding or social issues
  • People who cannot be safely observed at home.(NICE)


Discharge requirements


People can be discharged when:(NICE)


  • Symptoms and signs have resolved or stabilised, and
  • They have suitable supervision at home, in custody, or in care.


NICE emphasise discharge advice:


  • Written and verbal, age-appropriate
  • Explain what to expect in recovery, red flags needing ED return, and who to contact
  • Specify that a responsible adult should stay with them for the first 24 hours
  • Cover return to school, work, driving and sport
  • Include contact details and support organisations.(NICE)


They also advise sending a letter to the GP within 48 hours, and sharing with health visitors/school nurses where appropriate.(NICE)


Longer-term issues


NG232 explicitly mentions:(NICE)

  • Post-concussion symptoms – patients and carers should be warned these can be delayed and persistent, with clear pathways for follow-up.
  • Endocrine complications – consider hypopituitarism in people not recovering as expected, and investigate if symptoms suggest this.


What’s new in NG232 compared to CG176?


Headline changes (high-yield for FRCEM):

  • Updated CT criteria and clearer timing (1-hour vs 8-hour rules, including >8-hour presentations).(NICE)
  • Specific section on anticoagulants/antiplatelets, including DOACs, LMWH and non-aspirin antiplatelets.(NICE)
  • Tranexamic acid: consider a 2 g IV bolus (or 15–30 mg/kg up to 2 g in under-16s) for head injury with GCS ≤12, within 2 hours of injury, when extracranial bleeding isn’t the main concern.(NICE)
  • More explicit emphasis on safeguarding and standardised documentation.(NICE)
  • Stronger recommendations on follow-up, post-concussion symptoms and endocrine sequelae.(NICE)


How to remember the NICE head injury rules (and not die in triage)


A few mental hooks that work well in busy EDs and FRCEM prep:


  • Adults, 1-hour CT: “LOW GCS, BAD SKULL, FIT, FOCAL, VOM”
  • Adults, 8-hour CT with LOC/amnesia: “Old, Coag, Dangerous, Long amnesia”
  • Children: think “big bruise / big mechanism / big symptoms → CT or at least 4-hour obs”
  • Anticoagulants: if it’s anything more than aspirin alone, strongly consider CT
  • C-spine: if they’re high-risk or you can’t safely clear clinically → CT C-spine


Learning NICE head injury guidelines for FRCEM with StudyMedical


If you’re revising for the FRCEM SBA, NG232 appears everywhere:


  • Imaging indications questions (“Who needs CT?”, “When?”)
  • Anticoagulant head injury scenarios
  • C-spine clearance
  • Discharge/advice and follow-up, including endocrine issues and post-concussion syndrome.


A good question bank helps you move from memorising lists to recognising patterns in real clinical vignettes. With a mapped FRCEM SBA bank you can:


  • Drill head injury & trauma categories specifically
  • Use image-based questions (CTs, x-rays, proformas) to mirror real-life decisions
  • Repeatedly test yourself on borderline cases – where examiners love to sit the pass mark
  • Flag and revisit every question you get wrong until the NG232 logic feels automatic.


On StudyMedical, that means using:

  • Category-based sessions (e.g. “Head injury & trauma”)
  • Modes for new questions only, incorrect questions, and flagged questions
  • Exam-style timed papers for full-length practice
  • Lightning image-only questions to practise recognising CT findings and subtle signs quickly.


FAQs about the NICE head injury guidelines


Do all patients on DOACs need a CT after minor head injury?


Not automatically, but NICE say you should consider CT even if there are no other risk factors, because anticoagulation increases the risk of intracranial bleeding and delayed deterioration. Clinical judgement and local policies (and the joint AACE/RCEM/BGS/SBNS position statement) help you decide when it’s reasonable to observe rather than scan.(NICE)


How quickly should CT scans be done and reported?


For those meeting 1-hour criteria, the scan should be done within 1 hour of the risk factor being identified. NICE also recommend a provisional written radiology report within 1 hour of the scan.(NICE)


Do we still use skull x-rays?


No. NICE advise not using plain skull x-rays to diagnose significant TBI. CT is the investigation of choice; the exception is in suspected non-accidental injury in children, where a skeletal survey (including skull views) may be needed.(NICE)


When can I discharge a patient with a minor head injury?


Once their symptoms/signs have resolved or stabilised, there are no CT criteria or CT is normal, and they have reliable supervision at home. They must receive clear written and verbal safety-netting advice, and their GP should be informed within 48 hours.(NICE)


What about patients who present >24 hours after head injury?


NICE recognise that late presenters still carry a risk of ciTBI; CT criteria (e.g. persistent symptoms, anticoagulants, high-risk features) still apply and may need a 1-hour CT even if the original 8-hour window has passed. There’s an explicit research recommendation about how best to select these patients for CT, highlighting ongoing uncertainty and the need for senior review.(NICE)


Final thoughts


The NICE NG232 head injury guideline is now baked into UK ED practice and appears frequently in FRCEM SBA questions. You don’t need to memorise the entire PDF – but you do need to internalise the CT rules, C-spine criteria, and admission/discharge principles, and be able to apply them to messy real-world scenarios.


If you’d like to turn this into active learning, you can:


  • Build a “Head injury & trauma” revision block
  • Hammer through SBA vignettes that deliberately sit on the guideline boundaries
  • Use detailed explanations and references to lock the NG232 logic in your long-term memory.