St Emlyn’s Lesson Plans

Head injury: imaging, deterioration and concussion

Work through a deteriorating head injury and a concussion consultation, including imaging, observation and advice for home.

Early-career Emergency Medicine · 45-minute session

For learners

Before: Allow about 18 minutes in total.

When we meet: We will discuss care while a patient waits for CT and how to advise a footballer with concussion.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: NICE pathway, GCS chart, observation sheet and current discharge leaflet. A scan is optional; this session is about decisions before and after imaging.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 18 minutes in total.

Core preparation

NICE NG232: Head injury · About 10 minutes

Read the adult CT criteria and discharge recommendations in NG232. Focus on findings that change the urgency of imaging.

https://www.nice.org.uk/guidance/ng232/chapter/recommendations

UK concussion guidance for grassroots sport · About 5 minutes

Read the recognition and return-to-activity advice, with the footballer's wish to return to sport in mind.

https://www.sportengland.org/news/new-concussion-guidelines-grassroots-sport

Think about (allow 3 minutes): What would you still need to explain to someone with concussion if their CT were normal?

Picture the scene

A footballer has a clash of heads and answers the pitch-side questions correctly. They want to play tomorrow. What else do you need to know?

By the end of the session

Record GCS components and prioritise immediate threats after head injury.
Apply the appropriate NICE CT pathway with timing, medication and mechanism made explicit.
Explain why normal imaging or correct orientation answers do not exclude concussion, and give practical safety-netting.

After the session

Review the last head-injury discharge advice you gave: did the person leave knowing what to do about work, sport and worsening symptoms?

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 18 minutes in total.

Before learners arrive

Open NG232 and the local anticoagulant/head-injury pathway. Confirm where observation charts, discharge advice and neurosurgical contacts are located.
Choose a current concussion leaflet approved locally. Screening answers alone must not be used to rule out concussion.

Equipment: NICE pathway, GCS chart, observation sheet and current discharge leaflet. A scan is optional; this session is about decisions before and after imaging.

Setup: Give pairs a minute to decide on the initial plan before comparing answers. For the second case, let each pair prepare the advice they would give the footballer and housemate.

If the preparation has not been completed

Use the five-minute opening for shared preparation. Put the two case summaries beside the NICE adult CT and discharge recommendations. Ask pairs to identify information needed for imaging and information needed for safe discharge, then compare one answer from each pair. In the 30-minute plan, use five minutes here and reduce the ladder case from 12 to 10 minutes.

Suggested session plan

0–5 min — The footballer’s assessment. Ask what “normal answers” actually establishes. Invite uncertainty before showing the guidance.
5–20 min — Deteriorating injury. Work through GCS, CT and observation responsibilities. Make learners state the actions occurring in parallel.
20–32 min — Concussion consultation. Role-play the footballer and housemate; pause when advice is too vague to act on.
32–40 min — Check the pathway. Verify imaging and treatment decisions in the source; discuss medication and timing variations.
40–45 min — Close. Ask for a one-sentence distinction between structural injury assessment and concussion recovery.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

Confused after falling from a ladder

A 56-year-old fell approximately two metres forty minutes ago. Eyes open to voice, speech is confused and the best motor response is localisation to pressure. They are not following commands. There is a scalp bruise.

Add this information as the discussion develops:

Ask for ABCDE priorities and GCS components before revealing a total.
E3 V4 M5 gives GCS 12. The patient begins vomiting while the CT request is being made.
A relative reports apixaban use. Ask how the information changes the wider plan, rather than simply repeating the already-met CT indication.

Ask the group:

What can and cannot be inferred from the fact that this patient speaks?
What does a change in one GCS component mean for reassessment and escalation?
Who remains with the patient while imaging is organised?
Which time-critical treatments and specialist discussions should be checked in the local pathway?

Discussion notes

Points to draw out:

A total must be accompanied by components and trends. This presentation meets an adult NICE indication for urgent CT; the scan must not displace stabilisation, cervical-spine assessment and repeated observations.
For head injury with GCS 12 or less and no suspected active extracranial bleeding, NICE advises considering early tranexamic acid within two hours; use the exact age-specific regimen and local protocol. Separate this decision from treatment for major extracranial haemorrhage.
Anticoagulant exposure, deterioration and associated injuries need active communication to senior, radiology and relevant specialist teams. A single reassuring observation does not close the assessment.

Common misconceptions:

Treating a talking patient as having a permanently safe airway.
Calling localisation “obeys commands”, or recording only 12/15 without the components.

For a more experienced group: Ask a senior group to prepare a transfer handover including clinical trend, anticoagulant timing, imaging status and outstanding actions.

The footballer who wants to play tomorrow

A 21-year-old has headache and slowed thinking after a clash of heads. There was no witnessed loss of consciousness. They answered orientation questions correctly and want permission to play a match tomorrow.

Add this information as the discussion develops:

Give learners two minutes to take a focused history and decide whether the CT criteria apply.
The examination is normal but reading a phone worsens symptoms. A housemate can stay with them tonight.

Ask the group:

Which symptoms support concussion despite the orientation answers?
What can a CT scan answer, and what can it not answer?
How would you explain return to study, work, driving and sport without an unrealistic fixed promise?
What would you ask the housemate to look out for?

Discussion notes

Points to draw out:

Use current UK concussion guidance: recognise suspected concussion and remove the person from play. Correct screening answers do not rule it out. A normal CT does not establish recovery.
Use written and verbal advice, a responsible adult, clear deterioration triggers and a graduated return to activity appropriate to symptoms and sport-specific guidance. Check that the person understands where to seek review for persistent difficulties.

Common misconceptions:

Using a negative CT as permission for immediate return to contact sport.
Giving a long generic leaflet without checking the person’s work, home support and priorities.

For a more experienced group: Change the patient to a delivery driver on a zero-hours contract. Practise acknowledging the practical consequences while giving safe advice.

Important clinical points

Use age-specific NG232 criteria; do not transfer adult thresholds into children.
Do not let a normal early test replace reassessment when symptoms or consciousness change.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

How would you describe this GCS unambiguously?
What is the plan while the patient waits for CT?
How would you explain suspected concussion to someone who is reassured by a normal scan?

Key teaching points:

Record GCS components and how they change over time.
Continue stabilisation and observation while imaging is arranged.
Concussion advice should cover the person’s work, study, driving, sport and support at home.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

Concussion recovery is variable. Screening tools support assessment and do not provide an all-purpose exclusion test. Paediatric cases require their own pathway and are outside the main case exercise.

If the discussion drifts

What dangerous process are you trying to detect, and what action follows your answer?

For a more experienced group

Add intoxication or unreliable history and discuss observation, capacity and appropriate senior review without assuming altered consciousness is alcohol-related.

A 30-minute version

30-minute option: opening 3, ladder case 12, football case 10, consolidation 5. Omit transfer rehearsal and the employment variation.

Evidence and guidance

NICE NG232: Head injury — Current assessment, CT, observation, tranexamic acid and discharge recommendations.https://www.nice.org.uk/guidance/ng232/chapter/recommendations
UK concussion guidance for grassroots sport — Recognition, removal from play and graduated return; follow sport-specific medical pathways where applicable.https://www.sportengland.org/news/new-concussion-guidelines-grassroots-sport