Br. J. Surg. 1992, Vol. 79, January, 60-64
J. D. Miller, P. A. Jones, N. M. Dearden* and J. L. Tocher Departments of Clinical Neurosciences and *Anaesthesia, University of Edinburgh, UK Correspondence to: Professor J. D. Miller, Department of Clinical N e u r o s c i e n c e s , W e s t e r n General Hospital, Edinburgh E H 4 2XU, UK
Progress in the management of head injury Three I-year surveys of head injury management spanning a 9-year period in a single regional centre are presented, There was a reduction in total numbers of head injury admissions after guidelines f o r admission and referral were implemented. More liberal use of computed tomography resulted in detection of a greater number of intracranial haematomas with the majority detected in non-comatose patients. The early mortality rate in severe head injury fell f r o m 45 per cent to 34 per cent despite referral of large numbers of patients with multiple injuries and a substantial proportion (12per cent) of patients aged more than 70 years in whom outcome did not improve. Total occupied bednights and bednights occupied per surviving patient with severe head injury fell over the period of study. Care f o r patients with signiJcant head injury should be based on regional neurosurgical units associated with trauma services.
Throughout the UK, most patients with head injury requiring hospitalization are admitted primarily to general, orthopaedic or paediatric surgical units. A small proportion (3-5 per cent) are referred to a regional neurosurgical unit' because of deterioration in the level of consciousness, abnormal neurological signs or seizure activity, that suggest intracranial haemorrhage. Recently, referral to neurosurgical centres has been encouraged for patients who have not deteriorated, but who exhibit certain risk factors, raising the probability that an intracranial haematoma is present ; skull fracture in combination with depression of the level of consciousness, or focal neurological This pre-emptive approach is preferred because delayed or undiagnosed intracranial haematoma remains a major cause of morbidity and mortality after trauma4-". Other essential factors for prevention of secondary brain damage include adequate resuscitation, control of raised intracranial pressure and avoidance of craniospinal infection. Consideration should be given to the concept of head injury centres, based on regional neurosurgical units with clinical teams well versed in resuscitation and safe transport, facilities for computed tomography ( C T ) and neurointensive care to include monitoring of intracranial pressure. Throughout the study an 18-bed head and spinal injury unit, located in the principal area accident hospital, formed part of the regional clinical neurosciences service; 95 per cent of all head injuries requiring hospital admission and occurring in Edinburgh (referral population 0.6 million) were admitted directly to this unit. All severe and complicated head injuries occurring in south-east Scotland were accepted and the unit cared for 35 per cent of all head injuries requiring hospital admission in the area (referral population 1.2 million). A survey of patients admitted to this unit in 1981 was reported" and surveys in the years 1986 and 1989 have now been carried out. During this period a number of developments relevant to the management of head injury have taken place. In 1982, guidelines regulating admission of cases of minor head injury from the accident and emergency department were introduced. Emphasis was laid upon the identification and admission of patients with depression of the level of consciousness, neurological dysfunction and/or skull fracture3. Based o n data linking skull fracture with intracranial haematoma, from 1986 early C T was advised for all cases of severe head injury and patients with moderate and minor injury A more intensive approach was adopted plus skull to the management of compromised cerebral perfusion pressure after severe head injury.
The advantage of regionalization of head injury care in association with the regional neurosurgical service was examined. Is expenditure on a head injury unit justified by improvements in head injury management and outcome?
60
0007~1323/Y2/01006~~5 ft , 1992 Butterworth-Heinemann Ltd
Patients and methods During each of the study years (1981, 1986 and 1989), details of each patient admitted to the Edinburgh head and spinal injury unit were obtained prospectively using a standard proforma sheet, and entered into a microcomputer database (dBase" I V ; Ashton-Tate, San Jose, California, USA). Data included age, cause of injury, presence of skull fracture and other injuries, neurological status after resuscitation including level of consciousness on the Glasgow Coma Scale, findings of CT, operative treatment and subsequent use of artificial ventilation and intracranial pressure monitoring. Early outcome from injury was scored at discharge from the unit using the Glasgow Outcome Scale. Patients were divided into three groups according to Glasgow Coma Sumscore (GCS ) after resuscitation. Patients with severe head injuries remained in coma, scoring 8 or less with no eye opening, even to painful stimuli. Moderate head injuries included patients who scored 9 to 12 on the GCS and those who scored 7 or 8 but opened their eyes to pain. Minor head injuries scored 13 to 15 points on the GCS. This form of triage fails to take account of localized skull and brain injuries in patients who have not lost consciousness. There is, however, an approximately tenfold difference in mortality between these three grades of head injury". The admission rates, pattern of referral and the prevalence of multiple injuries were examined. These were defined as injuries requiring the services of another surgical speciality. The use and efficacy of C T in detecting intracranial haematoma was assessed. Utilization of beds was evaluated as total occupied bednights and as bednights occupied per surviving patient. Distribution of discrete variables was compared by the x2 test using Yates' correction throughout.
Results Number of' admissions and severity of injury
In 1981 a total of 1919 head-injured patients were admitted to the unit (Figure I ). From 1986, the annual number of head injury admissions averaged about 1000 and represented a 46 per cent reduction during the period following introduction of guidelines for admission and seat belt legi~lation'~. The distribution of head injuries by severity is shown in Figure I . Severe head injuries have remained fairly constant. The greatest reduction has been in the admission rates of patients with minor head injury (1616 to 702). The numbers of patients graded as having moderate head injury varied. Total occupied bednights are shown in Figure 2. The number
Management of head injury: J. D. Miller et al.
2000
1919
L
I635
m
r L 0)
a Ln
139 -
C
.-0
: 1000
1057
1064
1987
1988
.-
E
-0
m
L 1
.-3
C ._
-0
m
r 0
-
-
1979
1980
1981
1982
C
1983 S
1984
985
Figure 1 Head injury adminton7 ober I decade W , Severe, H , moderate. El, minor, I , intensive care unit opened
1986 I
1989
0, total G, guidelinesfor admission, S, seat belt legislatron
9000
2
6000
01 ._ C
-0
n m
t-
0
3000
0 58
6.3
2.6
1981
Figure 2
4.5
34
9.8 2 . 4
7.2
Total bednight7 occupied and hednights occupied per surviving patient
of bednights occupied per surviving patient with severe head injury fell from 58 in 1981 to 23 in 1989, while there was a small increase in this index in patients with moderate head injury. Referral pattern of head-injured putients
The proportion of patients with severe head injury referred from other hospitals remained constant. After 1981 the number of minor head injuries directly admitted from the accident and emergency department was reduced with a consequent increase in the proportion of referred cases of minor head injury (Table I ). The percentage of head-injured patients with other injuries remained high (Table 2). The prevalence of arterial hypotension (systolic blood pressure < 90 mmHg) present on arrival in severely head-injured patients did not change significantly over the period of the study, being 15 per cent (14 of93), 1 4 p e r c e n t ( 1 6 o f 1 1 3 ) a n d 8 p e r c e n t ( 8 o f 9 6 ) i n 1981, 1986 and 1989 respectively.
.,
Bednights per survivor
2 3 11.4 2.6 4.8
1986
1989
Severe H , moderate; 0 , minor, 0, total
Table 1 Source uf referral of head injury admissions ~
~
1981 Severe Direct Other hospital/GP Total Moderate Direct Other hospital/GP Total Minor Direct Other hospital/GP Total
~~~
1986
1989
49 (53) 44 (47) 93
51 (45) 62 (55) 113
49 (51) 47 (49) 96
163 (78) 47 (22) 210
109 (56) 84 (44)* 193
43 (48) 46 (52)t 89
1413 (87) 203 (13) 1616
520(74) 182 (26)l 702
530 (69) 240 (31)g 770
Values in parentheses are percentages. * P < 0,001 (1986 versus 1981, x2 = 19.54); t P < 0901 (1989 versus 1981, xz = 23.70); f.P < 0901 (1986 uersus 1981, xz = 164.93); §P
J. D. Miller, P. A. Jones, N. M. Dearden* and J. L. Tocher Departments of Clinical Neurosciences and *Anaesthesia, University of Edinburgh, UK Correspondence to: Professor J. D. Miller, Department of Clinical N e u r o s c i e n c e s , W e s t e r n General Hospital, Edinburgh E H 4 2XU, UK
Progress in the management of head injury Three I-year surveys of head injury management spanning a 9-year period in a single regional centre are presented, There was a reduction in total numbers of head injury admissions after guidelines f o r admission and referral were implemented. More liberal use of computed tomography resulted in detection of a greater number of intracranial haematomas with the majority detected in non-comatose patients. The early mortality rate in severe head injury fell f r o m 45 per cent to 34 per cent despite referral of large numbers of patients with multiple injuries and a substantial proportion (12per cent) of patients aged more than 70 years in whom outcome did not improve. Total occupied bednights and bednights occupied per surviving patient with severe head injury fell over the period of study. Care f o r patients with signiJcant head injury should be based on regional neurosurgical units associated with trauma services.
Throughout the UK, most patients with head injury requiring hospitalization are admitted primarily to general, orthopaedic or paediatric surgical units. A small proportion (3-5 per cent) are referred to a regional neurosurgical unit' because of deterioration in the level of consciousness, abnormal neurological signs or seizure activity, that suggest intracranial haemorrhage. Recently, referral to neurosurgical centres has been encouraged for patients who have not deteriorated, but who exhibit certain risk factors, raising the probability that an intracranial haematoma is present ; skull fracture in combination with depression of the level of consciousness, or focal neurological This pre-emptive approach is preferred because delayed or undiagnosed intracranial haematoma remains a major cause of morbidity and mortality after trauma4-". Other essential factors for prevention of secondary brain damage include adequate resuscitation, control of raised intracranial pressure and avoidance of craniospinal infection. Consideration should be given to the concept of head injury centres, based on regional neurosurgical units with clinical teams well versed in resuscitation and safe transport, facilities for computed tomography ( C T ) and neurointensive care to include monitoring of intracranial pressure. Throughout the study an 18-bed head and spinal injury unit, located in the principal area accident hospital, formed part of the regional clinical neurosciences service; 95 per cent of all head injuries requiring hospital admission and occurring in Edinburgh (referral population 0.6 million) were admitted directly to this unit. All severe and complicated head injuries occurring in south-east Scotland were accepted and the unit cared for 35 per cent of all head injuries requiring hospital admission in the area (referral population 1.2 million). A survey of patients admitted to this unit in 1981 was reported" and surveys in the years 1986 and 1989 have now been carried out. During this period a number of developments relevant to the management of head injury have taken place. In 1982, guidelines regulating admission of cases of minor head injury from the accident and emergency department were introduced. Emphasis was laid upon the identification and admission of patients with depression of the level of consciousness, neurological dysfunction and/or skull fracture3. Based o n data linking skull fracture with intracranial haematoma, from 1986 early C T was advised for all cases of severe head injury and patients with moderate and minor injury A more intensive approach was adopted plus skull to the management of compromised cerebral perfusion pressure after severe head injury.
The advantage of regionalization of head injury care in association with the regional neurosurgical service was examined. Is expenditure on a head injury unit justified by improvements in head injury management and outcome?
60
0007~1323/Y2/01006~~5 ft , 1992 Butterworth-Heinemann Ltd
Patients and methods During each of the study years (1981, 1986 and 1989), details of each patient admitted to the Edinburgh head and spinal injury unit were obtained prospectively using a standard proforma sheet, and entered into a microcomputer database (dBase" I V ; Ashton-Tate, San Jose, California, USA). Data included age, cause of injury, presence of skull fracture and other injuries, neurological status after resuscitation including level of consciousness on the Glasgow Coma Scale, findings of CT, operative treatment and subsequent use of artificial ventilation and intracranial pressure monitoring. Early outcome from injury was scored at discharge from the unit using the Glasgow Outcome Scale. Patients were divided into three groups according to Glasgow Coma Sumscore (GCS ) after resuscitation. Patients with severe head injuries remained in coma, scoring 8 or less with no eye opening, even to painful stimuli. Moderate head injuries included patients who scored 9 to 12 on the GCS and those who scored 7 or 8 but opened their eyes to pain. Minor head injuries scored 13 to 15 points on the GCS. This form of triage fails to take account of localized skull and brain injuries in patients who have not lost consciousness. There is, however, an approximately tenfold difference in mortality between these three grades of head injury". The admission rates, pattern of referral and the prevalence of multiple injuries were examined. These were defined as injuries requiring the services of another surgical speciality. The use and efficacy of C T in detecting intracranial haematoma was assessed. Utilization of beds was evaluated as total occupied bednights and as bednights occupied per surviving patient. Distribution of discrete variables was compared by the x2 test using Yates' correction throughout.
Results Number of' admissions and severity of injury
In 1981 a total of 1919 head-injured patients were admitted to the unit (Figure I ). From 1986, the annual number of head injury admissions averaged about 1000 and represented a 46 per cent reduction during the period following introduction of guidelines for admission and seat belt legi~lation'~. The distribution of head injuries by severity is shown in Figure I . Severe head injuries have remained fairly constant. The greatest reduction has been in the admission rates of patients with minor head injury (1616 to 702). The numbers of patients graded as having moderate head injury varied. Total occupied bednights are shown in Figure 2. The number
Management of head injury: J. D. Miller et al.
2000
1919
L
I635
m
r L 0)
a Ln
139 -
C
.-0
: 1000
1057
1064
1987
1988
.-
E
-0
m
L 1
.-3
C ._
-0
m
r 0
-
-
1979
1980
1981
1982
C
1983 S
1984
985
Figure 1 Head injury adminton7 ober I decade W , Severe, H , moderate. El, minor, I , intensive care unit opened
1986 I
1989
0, total G, guidelinesfor admission, S, seat belt legislatron
9000
2
6000
01 ._ C
-0
n m
t-
0
3000
0 58
6.3
2.6
1981
Figure 2
4.5
34
9.8 2 . 4
7.2
Total bednight7 occupied and hednights occupied per surviving patient
of bednights occupied per surviving patient with severe head injury fell from 58 in 1981 to 23 in 1989, while there was a small increase in this index in patients with moderate head injury. Referral pattern of head-injured putients
The proportion of patients with severe head injury referred from other hospitals remained constant. After 1981 the number of minor head injuries directly admitted from the accident and emergency department was reduced with a consequent increase in the proportion of referred cases of minor head injury (Table I ). The percentage of head-injured patients with other injuries remained high (Table 2). The prevalence of arterial hypotension (systolic blood pressure < 90 mmHg) present on arrival in severely head-injured patients did not change significantly over the period of the study, being 15 per cent (14 of93), 1 4 p e r c e n t ( 1 6 o f 1 1 3 ) a n d 8 p e r c e n t ( 8 o f 9 6 ) i n 1981, 1986 and 1989 respectively.
.,
Bednights per survivor
2 3 11.4 2.6 4.8
1986
1989
Severe H , moderate; 0 , minor, 0, total
Table 1 Source uf referral of head injury admissions ~
~
1981 Severe Direct Other hospital/GP Total Moderate Direct Other hospital/GP Total Minor Direct Other hospital/GP Total
~~~
1986
1989
49 (53) 44 (47) 93
51 (45) 62 (55) 113
49 (51) 47 (49) 96
163 (78) 47 (22) 210
109 (56) 84 (44)* 193
43 (48) 46 (52)t 89
1413 (87) 203 (13) 1616
520(74) 182 (26)l 702
530 (69) 240 (31)g 770
Values in parentheses are percentages. * P < 0,001 (1986 versus 1981, x2 = 19.54); t P < 0901 (1989 versus 1981, xz = 23.70); f.P < 0901 (1986 uersus 1981, xz = 164.93); §P
