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Late presentations of minor head injury
  1. Anna Barrow1,
  2. John Ndikum1,
  3. Tim Harris1,2
  1. 1Emergency Department, The Royal London Hospital, London, UK
  2. 2Pre-Hospital Care, London HEMS, London, UK
  1. Correspondence to Dr Anna Barrow, ST3 Anaesthesia, Department of Anaesthesia, The Royal London Hospital, Whitechapel, London E1 1BB, UK; annarachelbarrow{at}


Objective To determine the frequency with which a CT head is performed in patients presenting more than 4 h after minor head injury and the clinical features that predict an abnormal scan.

Design Observational cohort study.

Setting Emergency department (ED) of the Royal London Hospital, London, UK.

Participants 500 patients presenting to the ED of the Royal London Hospital.

Methods Chart review of all patients with minor head injury presenting more than 4 h from insult to the ED between December 2007 and May 2009. Inclusion criteria were: age over 16 years, Glasgow coma scale (GCS) 14 or 15 on first assessment, over 4 h post-injury. Exclusion criteria were: age under 16 years, GCS 13 and less, injuries limited to the face with no risk of intracranial injury; presentation less than 4 h after injury.

Results 497 patients were identified: 147 patients had CT head; 11 had intracranial injuries on CT. Loss of consciousness (p=0.0005), potential coagulopathy (p=0.0015), injuries above the clavicles (p=0.0150), open/depressed skull fracture (p=0.0221), alcohol/drug intoxication (p=0.0406) and focal neurology (p=0.0562) were predictors of positive CT scan. Five patients (1% of sample, 45% of patients with abnormal CT) required a neurosurgical procedure. Two (18.2%) self-discharged and four (36.4%) were followed up as outpatients. One patient (0.09%) died as a result of intracranial injury.

Discussion Patients with minor head injury who present over 4 h post-insult exhibit a similar risk of intracranial pathology to those presenting within 4 h. The risk factors previously identified to predict intracranial injury are similar in this study.

  • Clinical management
  • CT head
  • CT/MRI
  • emergency care systems
  • emergency departments
  • GCS 14/15
  • head
  • head imaging
  • late presentation
  • minor head injury
  • trauma

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  • Competing interests None.

  • Ethics approval The study was registered as an audit of current practice with the Department of Clinical Governance in the authors' trust. A written application to the local ethics committee was made. However, as the work involved no deviation from normal practice, no change to department guidelines, no interventions and all data were retrospective and anonymised, the authors were advised that formal IRAS application and written consent were not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.