Introduction

Severe head injuries require immediate medical attention because there is a risk of potentially serious damage to the brain.

Signs of a severe head injury can include:



unconsciousness – either brief (concussion) or for a longer period of time



fits or seizures – when the body suddenly moves uncontrollably



difficulty speaking or staying awake



problems with the senses – such as loss of hearing or double vision



repeated vomiting



blood or clear fluid coming from the ears or nose



memory loss 



If you notice any of these symptoms after a head injury, immediately go to your nearest accident and emergency (A&E) department or call 999 and ask for an ambulance.

Diagnosing a severe head injury

Healthcare professionals use the Glasgow Coma Scale (GCS) to assess head injuries. This is a scale from 3 to 15 that uses your symptoms to identify how serious the injury is and whether the brain has been damaged (with 3 being most severe and 15 least severe).

A head injury is usually classed as being moderate if someone has a GCS score of 9-12 or severe if they have a score of eight or lower. Some people with significant head injuries have a high GCS score initially, but their score decreases when they are reassessed at a later stage.

Further tests may sometimes be necessary to determine how serious your injury is, such as a computerised tomography (CT) scan.

Treating a severe head injury

Severe head injuries should always be treated in hospital. Treatment in hospital may involve:



observing the condition for any changes



running tests to check for further damage



treating any other injuries



breathing support (ventilation) or brain surgery, in the most severe cases



Most people are able to go home within 48 hours. However, a small number of those admitted to hospital require surgery on their skull or brain.

When you are discharged from hospital, your doctor will give you advice about the best way to help your recovery when you return home.

Complications

A severe head injury may cause a build-up of pressure on the brain because of bleeding, blood clots or a build-up of fluid. This can sometimes lead to brain damage, which can be temporary or permanent.

A severe head injury can also cause other potentially serious complications, including:



an infection after a skull fracture



post-concussion syndrome – where you experience long-term symptoms after sustaining concussion



Around one in every 2,000 people who attend an A&E department with a head injury dies as a result of their injury.

Preventing head injuries

Although it can be difficult to predict or avoid a head injury, there are some steps you can take to help reduce the risk of serious injury to you or your child.

These include:



reducing hazards in the home that may cause a fall



‘childproofing’ your home



using the correct safety equipment for work, sport and DIY



Wearing a safety helmet during certain activities, such as skiing or cycling may also help prevent a serious head injury.

Symptoms of a severe head injury 

If a severe head injury is not correctly treated, it can cause serious brain damage.

The signs of a severe head injury can include:



unconsciousness, either briefly or for a longer period of time



difficulty staying awake or still being sleepy several hours after the injury



clear fluid leaking from the nose or ears (this could be cerebrospinal fluid, which normally surrounds the brain)



bleeding from one or both ears



bruising behind one or both ears



any sign of skull damage or a penetrating head injury



difficulty speaking, such as slurred speech



difficulty understanding what people say



reading or writing problems



balance problems or difficulty walking



loss of power or sensation in part of the body, such as weakness or loss of feeling in an arm or leg



general weakness



vision problems, such as blurred or double vision



having a seizure or fit (when your body suddenly moves uncontrollably)



memory loss (amnesia), such as not being able to remember what happened before or after the injury



a persistent headache



vomiting since the injury



irritability or unusual behaviour



If any of these symptoms are present, particularly loss of consciousness (even just for a short time), immediately go to your local accident and emergency (A&E) department or call 999 and ask for an ambulance.

You should also go to hospital if someone has injured their head and:



the injury was caused by a forceful blow to the head at speed (such as being hit by a car or falling one metre or more)



the person has had previous brain surgery



the person has had previous problems with uncontrollable bleeding or a blood clotting disorder, or is taking a drug that may cause bleeding problems (such as warfarin)



the person is intoxicated by drugs or alcohol



it is possible that the injury was not accidental, for example you deliberately hurt yourself or someone else hurt you on purpose



You should also call 999 for an ambulance if the person with the head injury is not breathing.

Diagnosing a severe head injury 

Someone with a severe head injury should always be seen in an emergency department.

If any of the symptoms of a severe head injury are present, immediately go to your local accident and emergency (A&E) department or call 999 and ask for an ambulance.

The healthcare professionals treating you will first make sure you are in a stable condition, before asking some questions to help with the diagnosis and treatment of your injury. These may include:



how you were injured



when you were injured



if you have been drinking alcohol



if you have taken any illegal drugs



If you cannot remember how the injury occurred, they may ask someone who saw your accident to describe it.

You may also be asked about your symptoms, for example:



whether you have lost consciousness



whether you have a headache



whether you have been sick



If you are with someone who has a head injury, try to provide as much information as possible about the accident and the person’s symptoms.

The paramedics or doctors treating you will assess your condition using the Glasgow Coma Scale (GCS), described below.

Glasgow Coma Scale

After a head injury, healthcare professionals use the Glasgow Coma Scale (GCS) to assess how severely your brain has been damaged. The GCS scores you on:



verbal responses (whether you can make any noise)



physical movements



how easily you can open your eyes



Your score for each of these three areas is added up to give a total. A slightly different version of the GCS is used for children under five years old.

A score of 15 (the highest possible score) means that you know where and who you are, you can speak and move as instructed, and your eyes are open.

A score of three (the lowest possible score) means that you cannot open your eyes and you cannot move or make a noise. The score indicates that your body is in a coma (a state of unconsciousness where a person is unresponsive and cannot be woken).

Depending on your score, head injuries are classed as:



minor – a score of 13 or higher



moderate – a score of 9-12



severe – a score of 8 or lower



Based on your assessment, you may be allowed to go home or you may be referred for further testing and treatment in hospital.

The brain injury association Headway has more detailed information about the Glasgow Coma Scale.

Going home

You will usually only be allowed to go home after a head injury if an assessment suggests that you are at low risk of brain injury and a CT scan is not deemed necessary.

You will need someone to take you home because you will not be allowed to drive until you have completely recovered. If possible, you will also need someone to stay with you for the first 24 hours after your injury to keep an eye out for problems.

The health professionals will advise you about what to do and what not to do in the weeks following your injury.

CT scan

Based on the results of their assessment, emergency department staff will decide whether you need to have a computerised tomography (CT) scan to determine how serious your head injury is and whether you are at risk of developing any complications of a severe head injury.

A CT scan involves a series of X-rays being taken of your body from different angles. This produces a detailed image of the inside of your body. The scan can be used to examine the bone, muscle and tissue in your neck, to check for any damage and to identify whether there is any bleeding or swelling in your brain.

Depending on the results of your scan, you may be allowed to go home, but usually you will be kept in hospital for a short time to make certain that your injury has not caused any serious problems.

Admission to hospital

Some people need to be admitted to hospital for observation following a head injury. This may be because:



scans have shown a problem



you have persistent symptoms of a possible neurological problem (a problem with the nervous system)



your GCS score has not returned to 15



you have other injuries (such as broken bones) or health problems



you are under the influence of alcohol or drugs



there is no one at home to look after you



See how a severe head injury is treated for more information about what happens when you are admitted to hospital.

Treating a severe head injury 

A severe head injury must always be treated in hospital to minimise the risk of complications.

Initial treatment

When you arrive at the emergency department of a hospital, or before getting to hospital if you called an ambulance, the doctors or paramedics treating you will prioritise any injury that may be life threatening. This could mean:



checking your airway is clear



checking you are breathing, and starting cardiopulmonary resuscitation (CPR or mouth-to-mouth) if you are not



stabilising your neck and spine, for example using a neck brace



stopping any severe bleeding



providing pain relief if you are in a lot of pain



splinting any fractured or broken bones (strapping them into the correct position)



Once you are stable, further treatment will be arranged, as necessary, including any tests you need to help determine the severity of your injury.

  Observation  

If you need to stay in hospital for observation, doctors and nurses treating you will check:



your level of consciousness and how alert you are



the size of your pupils, and how well they react to light



how well you can move your arms and legs



your breathing



your heart rate



your blood pressure



your temperature



the level of oxygen in your blood



These checks will be made every half an hour until it is clear you know where and who you are, you can speak and move as instructed, and your eyes are open. After this, checks will be made less frequently.

Any changes in your condition or behaviour will also be closely monitored. If your condition worsens, you may need to have further tests, such as a computerised tomography (CT) scan. 

If there has been any bleeding or swelling inside the skull, a small device called an intracranial pressure (ICP) monitor may be fitted. This involves inserting a thin wire into the space between the skull and the brain, through a small hole drilled into the skull. This wire is attached to an electronic device that alerts hospital staff about any changes in the pressure inside your skull.

  Cuts and grazes   

 If you have any external cuts or grazes to your head, these will be cleaned and treated to prevent further bleeding or infection. If there are any foreign bodies in the wound, such as broken glass, these will need to be removed.

Deep or large cuts may require stitches (sutures) to keep them closed until they heal. Local anaesthetic may be used to numb the area around the cut so you do not feel any pain.

 Neurosurgery 

Neurosurgery is any kind of surgery used to treat a problem with the nervous system (the brain, spinal cord and nerves). In cases of severe head injury, neurosurgery is usually carried out on the brain.

Possible reasons for neurosurgery include:



a haemorrhage – severe bleeding inside your head, such as asubarachnoid haemorrhage, which puts pressure on the brain and may result in brain injury and, in severe cases, death



a haematoma – a blood clot inside your head, such as a subdural haematoma, which can also put pressure on the brain



cerebral contusions – bruises on the brain, which can develop into blood clots



skull fracture (see below)



These conditions will be identified during tests, such as a CT scan, and a neurosurgeon (an expert in surgery of the brain and nervous system) may come and speak to you or your family about whether surgery is necessary.

As the above conditions can be serious and may require urgent treatment, in some cases there may not be time to discuss the surgery before it is carried out. After the operation, your surgeon will take the time to discuss the details of the surgery with both you and your family.

 Craniotomy 

One of the main types of surgical operation carried out to treat severe head injuries is called a craniotomy.

A craniotomy involves making a hole in your skull so that the surgeon can access your brain. This will be carried out under general anaesthetic, which means you will be unconscious and will not feel anything while it is performed.

Once your surgeon has access to your brain, they will remove any blood clots that may have formed and repair any damaged blood vessels. When any bleeding inside your brain has stopped, the piece of skull bone will be replaced. In many cases, the piece of skull is reattached using small metal screws.

 Skull fractures 

Your skull can fracture during an injury to your head. If this happens, you will usually have a CT scan to determine the extent of the injury.

There are different types of skull fractures, including:



simple (or closed) fracture – where the skin has not broken and the surrounding tissue is not damaged



compound (or open) fracture – where the skin has broken and the surrounding tissue may be damaged



linear fracture – where the break in the bone looks like a straight line



depressed fracture – where part of the skull is crushed inwards



basal fracture – a fracture to the base of the skull



Open fractures may be more serious because there is a higher risk of infection by bacteria if the skin is broken. Depressed fractures can also be very serious because small pieces of bone can press inwards against the brain.

 Treating skull fractures 

Most skull fractures will heal by themselves, particularly if they are simple, linear fractures. The healing process can take many months, although any pain will usually disappear in around five to 10 days.

If the fracture is open, you may be prescribed antibiotics to prevent an infection.

If the fracture is severe or depressed, you may need surgery to help prevent any damage to the brain. This will usually be carried out under general anaesthetic.

During your operation, any pieces of bone that have been pressed inwards can be removed and returned to their correct position. If necessary, metal wire or mesh may be used to reconnect the pieces of your skull.

Once the bone is back in place, it should heal naturally. Your surgeon can explain the procedure you are having in more detail.

After surgery

Depending on how serious your operation was, you may need to recover in an intensive care unit (ICU). This is a small, specialised ward where your condition will be constantly monitored. 

In an intensive care unit, you may be placed on a ventilator. This is an artificial breathing machine that moves oxygen-enriched air in and out of your lungs.

Once you are well enough, you will be moved to a high-dependency unit (HDU) or another ward and your condition will continue to be observed (see above) until you are well enough to leave hospital.

Recovering from a severe head injury 

When your doctor discharges you from hospital, they will give you advice to help your recovery when you return home.

Your recovery programme will depend on your specific injury and individual needs.

Advice for adults

If you are recovering from a severe head injury, you may be advised to:



not be by yourself for the first 24 hours and stay within easy reach of a phone in case any problems develop and you need medical help



get plenty of rest and avoid stressful situations



not drink alcohol or take recreational drugs



not take sleeping pills, sedatives or tranquilizers (unless prescribed by your doctor)



take paracetamol if you have a headache, but avoid non-steroidal anti-inflammatory drug (NSAIDs), such as ibuprofen and aspirin, unless advised or prescribed by a doctor



not play any contact sports, such as football or rugby, for at least three weeks, and speak to your doctor before you start playing these sports again



not return to work or college until you have completely recovered and feel well enough to do so



not drive a car or motorbike, ride a bicycle or operate machinery until you feel completely recovered and it is safe and legal to do so



When to seek medical attention

Return to an accident and emergency (A&E) department if you develop any further symptoms of a severe head injury while recovering at home.

Advice for children

If your child is recovering from a severe head injury, you may be advised to:



give them paracetamol if they have a headache, but avoid NSAIDs, such as ibuprofen and aspirin (aspirin should never be given to children under 16 years of age)



only give them light meals for the first day or two



avoid getting them too excited



avoid having too many visitors when they return home



not let them play contact sports until a doctor advises you that it is safe to do so



not let them play roughly for a few days



 

Take your child back to an A&E department if they develop any further symptoms of a severe head injury while recovering at home. 

 

You should see your GP in the week following your discharge from hospital to check how you are coping after your head injury.

You may also need to attend one or more outpatient appointments, which is a hospital appointment where you will not need to stay overnight. An outpatient appointment will usually be with a specialist, such as a neurologist (an expert in the brain and nervous system). They will check on the progress of your recovery.

The speed at which you recover from a severe head injury will depend entirely on the severity and nature of your injury, as well as your individual needs and your general health. Do not rush your recovery. It may take several months or sometimes years before you feel fully recovered.

After a head injury, a number of different healthcare professionals may help with your recovery. The treatment you receive will depend on how your head injury has affected you. Some of the treatments and the healthcare professionals you may see are described below.

 

If you experience physical problems after your injury, such as weakness, stiffness or poor co-ordination, you may be referred to a physiotherapist.

A physiotherapist uses a variety of treatments, such as massage, exercise and hydrotherapy (special exercises in warm, shallow water) to help you recover physically.

 

The aim of occupational therapy is to get you to live as independently as possible. After a head injury, you may struggle with everyday tasks and activities, either at work or home. An occupational therapist can give you practical support to make those tasks easier.

 

Sometimes, a head injury can affect your speech and you may struggle to communicate in the same way you did before the injury. A speech therapist will help you regain your communication skills.

 

After a severe head injury, you may have problems adjusting back to everyday life.

Psychotherapy is a type of therapy that involves talking to a trained mental health professional. They will help you talk through your worries and problems so that you can better understand and deal with your thoughts and feelings.

Cognitive behavioural therapy (CBT) helps change the way you think about things so that you deal with problems and difficulties more positively and effectively.

 

Psychiatry is a medical field concerned with the diagnosis, treatment and prevention of mental health conditions. Psychiatrists are medically qualified doctors who have chosen to specialise in psychiatry. This means they can prescribe medication as well as recommending other forms of treatment.

 

Headway, the brain injury association, is a charity that provides help and support to people affected by head injuries.

For more information about all aspects of head injuries, call the Headway helpline on 0808 800 2244 between 9am and 5pm, Monday to Friday. The helpline staff can:



advise you about other sources of support



help you find local rehabilitation services



give you support and advice if you experience problems



You can use the Headway website to search for local Headway services. They offer a wide range of services, including rehabilitation programmes, carer support, social re-integration, community outreach and respite care (when short-term support is provided for someone who needs care, for example to give the usual carers a break).


Driving after a head injury

If you have a serious head injury, it may affect your ability to drive. You are legally required to inform the Driver and Vehicle Licensing Agency (DVLA) and your insurance company.

You will not be able to drive until you receive DVLA approval and your doctor has confirmed you have made a full recovery.

See the GOV.UK website for more information about driving with a health condition.

Complications of a severe head injury 

Severe head injuries can cause serious complications. This is mainly because a serious injury can damage the brain, sometimes permanently.

In particularly severe cases, a serious head injury can be fatal. People with these injuries are closely monitored when admitted to hospital to help ensure any complications that arise are dealt with promptly and effectively.

Infection

If your skull is fractured during a head injury, your risk of developing an infection may be increased. Skull fractures can occasionally tear the membrane (the thin layer of cells) that surrounds the brain. If this happens, bacteria can enter the wound and cause an infection.

It is important to keep any external wounds on your head clean so they do not become infected. You may also be prescribed antibiotics.

Post-concussion syndrome

Some people may experience long-term symptoms after sustainingconcussion from a head injury. This could be post-concussion syndrome.

Symptoms of post-concussion syndrome can include:



having trouble looking after yourself



not being able to work



a persistent headache



dizziness



feeling weak



tinnitus (a perception of sound coming from inside their body, rather than from an outside source)



nausea (feeling sick)



trouble sleeping and fatigue (extreme tiredness)



memory problems



problems understanding other people



poor concentration



These symptoms usually clear up in around three months but, if necessary, you may need to be referred for further assessment by your GP. You may be seen by a neurologist, who specialises in problems of the nervous system (brain, spinal cord and nerves), or a psychiatrist (a mental health specialist).

Impaired consciousness

Some people who sustain a severe head injury enter a state of impaired consciousness, such as a coma, vegetative state or minimally conscious state.

These disorders of consciousness affect wakefulness (the ability to open your eyes and have basic reflexes) and awareness (more complex thoughts and actions, such as following instructions, remembering and communicating).

These states sometimes only last a few weeks, after which time a person may wake up or progress into a different state of impaired consciousness. However, they can last years and some people will never regain consciousness.

If a person is in a state of impaired consciousness for a long time, usually at least a year, it may be recommended that nutritional support is withdrawn because there is almost no chance of a recovery by this point.

If agreement is reached about withdrawing life support, the decision has to be referred to the courts in England and Wales before any further action can be taken.

Brain injury

A severe head injury can damage the brain in several ways. For example, it can occur as a result of increased pressure on the brain, caused by a blood clot between the skull and the surface of the brain (subdural haematoma) or bleeding in and around the brain (subarachnoid haemorrhage).

Injuries to the brain can lead to a variety of problems. Some types of brain injury are only temporary, whereas others result in permanent damage. The effect of any brain injury will depend on:



where on the head the injury occurs



the type of injury, for example if the skull is fractured



the severity of the injury, for example if it requires surgery



The different effects of a brain injury are described below.

Physical effects

Physical effects of a brain injury can include difficulty moving or keeping your balance and loss of co-ordination. You may also experience headaches or increased tiredness.

Hormonal effects

Some head injuries can damage the pituitary gland. The pituitary gland is a pea-sized gland in the centre of the head. It hangs below the brain and produces hormones (powerful chemicals that have a wide range of effects on the body). If the pituitary gland is damaged, it may lead to a reduction in the production of hormones.

Sensory effects

Your senses may be affected by a brain injury. For example, you may lose your sense of taste or smell. You may also notice blind spots in your vision or you may not be able to control your body temperature as well as before, so that you feel too hot or too cold.

Cognitive effects

Following a head injury, your ability to think, process information and solve problems may be affected. You may also experience memory problems, particularly with your short-term memory, and have difficulty with speech and communication skills.

Emotional or behavioural effects

After a severe head injury, you may experience changes to your feelings and behaviour. For example, you may have feelings of irritation, anger or selfishness.

You may be less sensitive to other people’s feelings, or lose your inhibitions and behave in a way other people may not consider appropriate. You may also laugh or cry more than you did before the injury.

Getting support

As everyone’s brain injury will be different, it is a good idea to seek further information about the possible effects and rehabilitation techniques. A number of charities and organisations may be able to help, including:



BASIC (Brain and Spinal Injury Centre)



Headway (the brain injury association)



Brain and Spine Foundation



Preventing a severe head injury 

Many head injuries are the result of accidents that are difficult to predict or avoid. However, there are some ways to reduce your risk.

Safety helmets

Cyclists and motorcyclists can protect their head by wearing a properly fitting safety helmet. British Standard safety helmets are a legal requirement for motorcyclists.

Research commissioned by the Department for Transport found that bicycle helmets 'should be effective at reducing the risk of head injury'.

However, it is difficult to know for certain the benefit of cycle helmets. This is because data about road accidents that involve cyclists may not contain all of the relevant information. For example, the data may not explain where exactly the head injury occurred, which makes it difficult to determine whether a helmet might have prevented the injury.

The National Institute for Health and Care Excellence (NICE), the Royal Society for the Prevention of Accidents (RoSPA) and the World Health Organization (WHO) all support the use of cycle helmets and suggest that they may help to reduce head injuries.

As well as wearing a helmet when cycling, you should also make sure that both you and your children:



use lights and wear reflective clothing when cycling in the dark



are aware of the dangers of the road and know how to stay safe



always follow the Highway Code (see an online version of theHighway Code on GOV.UK)



check that the bike is in good working order



Safety in the home

Following sensible health and safety guidelines can help prevent accidents in the home. Some advice to help keep your home and garden as safe as possible includes:



keep stairways tidy so that you do not trip over anything



use appropriate safety equipment if you are doing any kind of DIY



do not stand on an unstable chair to change a light bulb – use a stepladder



clean up any spillages to prevent someone slipping over



For more information, see the RoSPA website.

Childproofing your home

It is not possible to childproof your home completely. However, you can take steps to keep toddlers and young children safe at home, for example by:



checking that windows are lockable and cannot be opened by your child, especially bedroom windows



moving furniture, such as beds, sofas and chairs away from windows to prevent your child climbing up and falling out



fitting safety gates at the top and bottom of the stairs



Safety at work

To reduce the risk of sustaining a head injury at work, always follow any necessary health and safety guidelines. For example, you may have to wear a hard hat when working in potentially hazardous areas.

Only use ladders in a workplace environment for short-term, light work. Any work that requires spending a considerable amount of time at height, or involves heavy lifting, should be carried out on scaffolding or another suitable platform.

The Health and Safety Executive (HSE) provides more information about the correct use of ladders in the workplace, including a list of common tasks that involve working at height.

Any work that involves going up onto a roof should also be considered high-risk and therefore high standards of safety are essential.

Sport safety

Wear any necessary safety equipment when playing sports, particularly contact sports. Do not play any contact sports after a head injury without first consulting your GP.




Severe head injury