Extradural haematomas: how many deaths can be avoided? Protocol for early detection of haematoma in minor head injuries

Abstract

Since 1988 in the referral area of the Neurosurgical Unit of Cesena, Italy, a protocol for prevention of deterioration in minor head injury was adopted. Adult patients admitted to any hospital with a GCS score of 15 and 14 (transient) without neurological deficit are submitted to skull x-ray: if a fracture is present the patient is sent for CT to the nearest regional Center. In children skull x-ray is not routinely performed and the patients are admitted for observation to the nearest regional hospital. To assess the effects of such a protocol on morbidity and mortality of extradural haematoma (EDH), from June 1989 to September 1991 a consecutive series of 95 patients harbouring a significant acute EDH was collected. Mean age was 31 years; in 70% trauma was caused by a road traffic accident. The patients were divided into 3 categories: a) Clinical deterioration: mean GCS at surgery was 7.7; out of 27 patients, 12 had anysocoria and 3 bilaterally fixed pupils; the outcome showed only two deaths, one related to the EDH and the other to cardiac arrythmia. Most of the patients deteriorated either during transport after being recognized as at risk or already in Neurosurgery allowing rapid surgical treatment. b) Impaired consciousness (18 cases) and c) Minor head injury (50 cases) are groups of patients treated without morbidity and mortality. If we compare these results with those of a previous study of our group done in 1980-86, there is a statistically significant difference concerning both mortality and morbidity. Our protocol proved therefore to be adequate in preventing most deaths that occurred following clinical deterioration in an apparently low risk patient.