MANAGEMENT OF HEAD-INJURED PATIENTS IN THE EMERGENCY DEPARTMENT - A PRACTICAL PROTOCOL

BACKGROUND The management of head-injured patients admitted to emergen cy departments is not standardized. METHODS The authors performed a re trospective analysis of 10,000 head-injured patients admitted to the E mergency Department of our hospital in a 21-month period and, on the b asis of a statistical correlation between each clinical parameter (sym ptoms and signs upon arrival at the hospital or risk factors) and the presence of intracranial lesions, they propose a practical protocol in an attempt to avoid the overuse of radiologic examinations and yet id entify patients with possible life-threatening complications. RESULTS On the basis of this correlation the patients have been divided into f our groups, In the first group (called group alpha) are patients with: no history of loss of consciousness, no vomiting or amnesia, a normal neurologic examination, and minimal if any subgaleal swelling. They c an be released into the care of relatives who are given a special inst ruction sheet (X rays unnecessary). No patient in group alpha had comp lications of any kind. The second group (group beta) is made up of pat ients with at least one of the following features: transient loss of c onsciousness, posttraumatic amnesia, a single episode of vomiting or s ignificant subgaleal swelling. They undergo a computed tomography (CT) scan and if this is normal, only a short period of observation is nee ded. If CT scan is not available, the skull is X rayed and, if this X ray is negative, the patient is sent home with the warning sheet after an observation period. If a fracture is found, CT scan should be perf ormed promptly. No patient in group beta with normal skull X rays deve loped intracranial lesions. The third group (group gamma) contains pat ients with at least one of the following symptoms: impaired consciousn ess, repeated episodes of vomiting, neurologic deficits, otorrhagia, o torrhea, rhinorrea, signs of basal skull fracture, seizures, penetrati ng or perforating wounds, lack of cooperation for varying reasons, pat ients who have undergone previous intracranial operations or been affe cted by coagulopathy or submitted to anticoagulant therapy, and finall y, epileptic or alcoholic patients. They receive a CT scan immediately and, if necessary, again prior to discharge. Six patients in group ga mma with GCS = 15 upon admission were operated on for intracranial hem atoma. The fourth group (group delta) is composed of comatose patients . Immediately following resuscitation maneuvers and prior to any surgi cal intervention, they undergo a CT scan. A linear association between the severity groups and the presence of intracranial lesions has been demonstrated. CONCLUSIONS The present protocol stresses the importanc e of the patient's clinical and anamnestic evaluation upon arrival in the Emergency Department, especially in minor head injuries. (C) 1997 by Elsevier Science Inc.