EMERGENCY CRANIOTOMY IN A RURAL LEVEL-III TRAUMA CENTER

Patients with closed head injury and expanding epidural (EDH) or subdu ral (SDH) hematoma require urgent craniotomy for decompression and con trol of hemorrhage. In remote areas where neurosurgeons are not availa ble, trauma surgeons may occasionally need to intervene to avert progr essive neurologic injury and death. In 1990, a young man with rapidly deteriorating neurologic signs underwent emergency burr hole decompres sion of a combined EDH/SDH at our hospital, with complete recovery. In anticipation of future need, five surgeons at our rural, American Col lege of Surgeons-verified Level III trauma center participated in a ne urosurgeon-directed course in emergency craniotomy, Since January 1, 1 991, 792 patients have been entered into the trauma registry, includin g 60 with closed head injury and Glasgow Coma Scale (GCS) score of 13 or less. All but seven were transferred to a regional Level II trauma center, which is a minimum flight time of 1 hour each way. All patient s with EDH (5) and 2 of 14 with SDH were deemed too unstable for trans port and underwent burr hole decompression followed by immediate trans fer. All craniotomies were approved by the consulting neurosurgeon and were done for computed tomography-confirmed lesions combined with neu rologic deterioration as demonstrated by (1) GCS score of 8 or less, ( 2) lateralizing signs (dilated pupil, hemiparesis), or (3) development of combined bradycardia and hypertension. One patient with a GCS scor e of 3 on arrival died. Seven survivors (mean follow-up, 3.9 years; ra nge, 1-6.5 years), including the index case, function independently, a lthough one survivor has moderate cognitive and motor impairment. We c onclude that early craniotomy for expanding epidural and subdural hema tomas by properly trained surgeons may save lives and reduce morbidity in properly selected cases when timely access to a neurosurgeon is no t possible.