369 TABLE I-REASONS FOR ADMISSION
Hospital Practice WERE YOU KNOCKED OUT?
RICHARD BUXTON JOHN TOTTEN Birmingham Accident Hospital, Birmingham B15 1NA In the period 1970-75 inclusive 5152 patients were admitted to an accident hospital after an uncomplicated injury to their head. This group was compared with the 116 patients who needed craniotomy in the same period. It is suggested that precautionary admission of patients with minor
Summary
TABLE II-DURATION OF ADMISSION
head injuries is excessive. INTRODUCTION
injuries account for approximately 25% of surgical admissions to an average general hospiand this proportion is increasing.2 Since these intal,’ juries absorb a considerable amount of resources (particularly nursing), attempts have been made to define a low-risk group which could safely be discharged from the casualty department.3 HEAD
acute
In the present survey we have taken advantage of the almost unique position of an accident hospital (the Birmingham Accident Hospital) where all severities of head injuries, together with their immediate complications, can be dealt with, thus avoiding the loss of continuity involved in transfer of patients to a specialist unit.’ Particular emphasis has been placed on the outcome in patients with minor head injuries who were admitted as a precautionary measure only, under the "24-hour rule". PATIENTS AND METHODS
By scrutiny of the case-notes (and X-rays where vant), two groups of patients were defined:
Craniotomies rele-
Minor Head Injuries
Patients in this group had
a
ate violence to their heads but no skull fracture or signs of cerebral irritation sufficient in their own right to warrant admission. Patients with other significant bodily injuries were excluded. This group of patients could conceivably have been sent home. Analysis was by reason for admission (table I), and duration of stay (table II). Patients staying more than 48 h were further categorised according to symptoms and signs on admission, together with reason for prolonged stay.
history of mild or moder-
Patients in this group had suffered all degrees of violence to their heads but no skull fracture had been detected at first attendance. All subsequently required craniotomy after a lucid interval (Glasgow Coma Scale),4some after being allowed home (table in).
TABLE III-DETAILS OF PATIENTS WHO CAME TO CRANIOTOMY AFTER APPARENTLY UNCOMPLICATED HEAD
Cer ced.=cerebral oedema. Ch. s.D.=chromc subdural hxmatoma. D)ast.=-d!astasis of the temporoparietal E D =extradural hxmatoma.
INJURY
Fr.=fracture. Intravent.=intraventricuiar haemorrhage.
M.I.U.=major-injuries umt. Subarach.=subarachnoid haemorrhage. ’I’atients 1-5 had no skull fracture noticed on admission, had no other serious injury, and had been lucid at some s-8 also came to craniotomy after apparently uncomplicated head injury, but they had other injuries also. suture.
time since
injury. Patients
370 RESULTS
5152 patients fell within the definition of a minor head injury. This was 85% of all injuries reported to involve the head, irrespective of complications or associated injuries. Of this 5152, 83% (4290) were dismissed within 24 h, and at 48 h only 9% (458) stayed on because their head injury was causing concern. A further 3% stayed because of a variety of soft-tissue or doubtful intra-abdominal complaints or social problems. 0-5% stayed beyond the 7th day. 20% of children under 12 yr stayed because pyrexia developed. Craniotomies Of the 116 craniotomies performed within the same period, 20 were in patients who had been lucid. 8 of these had no skull fracture noticed on admission; and of these, 5 had no other serious injury. It is these 5 who form the overlap between the "minor head injury" and the "craniotomy" groups, and it is therefore these 5 who stood to gain from precautionary admission (table III, patients 1-5). 3 of the 5 were, in fact, sent home. 1 was erroneously discharged with a missed skull fracture and died 56 h later with cerebral oedema (after readmission). The other 2 returned many days later for evacuation of chronic subdural hxmatomas. The fatal subarachnoid and intraventricular hxmorrhages occurred in the casualty department while the patients were being examined and have a doubtful relation to trauma. None of the 5, therefore, benefited from their precautionary
admission. Table III gives details of another 3 patients in whom the head injury was initially thought to be irrelevant to other bodily injury but who also subsequently came to craniotomy. These had apparently uncomplicated head injuries, but 2 of the 3 patients clearly had diastasis of one or both temporoparietal sutures on their admission skull X-rays. This undoubtedly reflects the severe violence absorbed by the various parts of the body in modern trauma, and we should like to draw attention to it as a much-neglected skull "fracture" in the danger area of the temples.5 The diastasis is easily appreciated in the Towns view, and its serious prognostic significance is demonstrated by the extradural haematoma and cerebral oedema which resulted in the 2 cases cited. The further point is illustrated that extradural hsemorrhage is not the only fatal intracranial complication which can rapidly overcome the lucid patient even in the absence of a skull fracture (see cases 7 and 8, table III).6 None of the remaining 108 craniotomies was performed on patients who would be in any way affected by an admission policy. DISCUSSION
patient admitted after
head injury, 4 or sent home.’ It is to the interface these two are between 5 that an admission must policy apply. Accepting groups that all patients with complicated head injuries must be admitted, the task of defining a high-risk group within the remainder becomes one of quantifying trivial injuries, dubious historical details, and very subjective clinical signs. Any policy built on such insecure foundations is bound to be open to criticism, and in practice it is not surprising that at casualty-officer level, the "policy" often ceases to exist. For every
If the present study is representative, then the cleardivision between the groups studied indicates room for improvement. Despite over 5000 "precautionary admissions" (all without major complication), the only patient who could conceivably have benefited from admission was sent home with a missed skull fracture and subsequently died of cerebral oedema (no. 3, table III). We suggest, therefore, that such elaborate precautions are unnecessary. Patients with uncomplicated head injuries can safely be discharged, provided the following points are borne in mind: cut
Minor Head Injuries
a
1. Most people are aware of the dangers of a head injury and will attend for X-rays. Fractures are detected, and appropriate action can then be taken to minimise further risk. A pre-requisite for this advantage to be gained is an efficient department able to X-ray and report to a high standard. 2. Discharge should depend on (a) thorough clinical examination with (b) adequate written and spoken instruction to return if any (unspecified) change in the patient’s condition causes concern, and (c) ideally the patient should be left in the care of a responsible adult with access to transport who can return the patient speedily. Distances should be considered. 3. Head injuries are not the only result of modern high-velocity injuries. A latent period often follows a splenic tear or a small-bowel perforation. 31% of patients staying beyond 24 h in the present series did so because of secondary soft-tissue injuries which had become troublesome.
An admission policy therefore seems to serve a useful purpose if it is focused on the whole patient rather than
single dreaded complication, the extradural haemorrhage. If the patient presents with a head injury only, then that must be evaluated. A critical evaluate of the mechanism of injury is pivotal to the management of such an injury, for without an estimation of the nature and degree of violence involved the doctor cannot speculate on the bleeding that may follow an acceleration/deceleration injury or the cerebral oedema that might complicate a rotational (whiplash) injury. This is the basis on which minor head injuries should be divided into significant injuries at risk from hidden bodily injury and trivial injuries. This study did not set out to define risk factors, but the medicolegal authorities would agree with the comthat
on
observation that if negligence is to be avoided, then the cryptic comment "K.o.’d" on the casualty card must be supplemented by more information. This accomplished, the need for precautionary admission could be approached more confidently and some of the potential for improvement realised. The size of the saving would vary between centres (depending on the rates of alcoholism, the proximity of trunk roads; &c), but the additional risk to the patient would seem to be very small. We thank the surgeons of the Birmingham Accident Hospital for permission to study their patients. In particular, we thank Mr J. E. M. Smith and Mr R. F. Evans for their helpful criticism and
monsense
advice.
Requests for reprints should be addressed to R. B., Royal Infirmary, Edinburgh. REFERENCES 1. 2.
Jennett, B. Br. med. J. 1975, iii, 267. Field, J. H. Epidemiology of Head Injuries in England and Wales. H.M.
Stationery Office, 1976. 3. Galbraith, S. Lancet, 1973, i, 1217. 4. Teasdale, G., Jennett, B. ibid. 1974, ii, 81. 5. Smith, J. E. M. Personal communication. 6. Reilly, P. I., Adams, J. H., Graham, D. I., Jennett, B. Lancet, 1975, ii, 375. 7. Jennett, B. Proc. Medical Protection Society Symp. on Problems in Accident and Emergency Department; p. 18. 1976. 8. Potter, J. M. Lancet, 1973, i, 1381.
Hospital Practice WERE YOU KNOCKED OUT?
RICHARD BUXTON JOHN TOTTEN Birmingham Accident Hospital, Birmingham B15 1NA In the period 1970-75 inclusive 5152 patients were admitted to an accident hospital after an uncomplicated injury to their head. This group was compared with the 116 patients who needed craniotomy in the same period. It is suggested that precautionary admission of patients with minor
Summary
TABLE II-DURATION OF ADMISSION
head injuries is excessive. INTRODUCTION
injuries account for approximately 25% of surgical admissions to an average general hospiand this proportion is increasing.2 Since these intal,’ juries absorb a considerable amount of resources (particularly nursing), attempts have been made to define a low-risk group which could safely be discharged from the casualty department.3 HEAD
acute
In the present survey we have taken advantage of the almost unique position of an accident hospital (the Birmingham Accident Hospital) where all severities of head injuries, together with their immediate complications, can be dealt with, thus avoiding the loss of continuity involved in transfer of patients to a specialist unit.’ Particular emphasis has been placed on the outcome in patients with minor head injuries who were admitted as a precautionary measure only, under the "24-hour rule". PATIENTS AND METHODS
By scrutiny of the case-notes (and X-rays where vant), two groups of patients were defined:
Craniotomies rele-
Minor Head Injuries
Patients in this group had
a
ate violence to their heads but no skull fracture or signs of cerebral irritation sufficient in their own right to warrant admission. Patients with other significant bodily injuries were excluded. This group of patients could conceivably have been sent home. Analysis was by reason for admission (table I), and duration of stay (table II). Patients staying more than 48 h were further categorised according to symptoms and signs on admission, together with reason for prolonged stay.
history of mild or moder-
Patients in this group had suffered all degrees of violence to their heads but no skull fracture had been detected at first attendance. All subsequently required craniotomy after a lucid interval (Glasgow Coma Scale),4some after being allowed home (table in).
TABLE III-DETAILS OF PATIENTS WHO CAME TO CRANIOTOMY AFTER APPARENTLY UNCOMPLICATED HEAD
Cer ced.=cerebral oedema. Ch. s.D.=chromc subdural hxmatoma. D)ast.=-d!astasis of the temporoparietal E D =extradural hxmatoma.
INJURY
Fr.=fracture. Intravent.=intraventricuiar haemorrhage.
M.I.U.=major-injuries umt. Subarach.=subarachnoid haemorrhage. ’I’atients 1-5 had no skull fracture noticed on admission, had no other serious injury, and had been lucid at some s-8 also came to craniotomy after apparently uncomplicated head injury, but they had other injuries also. suture.
time since
injury. Patients
370 RESULTS
5152 patients fell within the definition of a minor head injury. This was 85% of all injuries reported to involve the head, irrespective of complications or associated injuries. Of this 5152, 83% (4290) were dismissed within 24 h, and at 48 h only 9% (458) stayed on because their head injury was causing concern. A further 3% stayed because of a variety of soft-tissue or doubtful intra-abdominal complaints or social problems. 0-5% stayed beyond the 7th day. 20% of children under 12 yr stayed because pyrexia developed. Craniotomies Of the 116 craniotomies performed within the same period, 20 were in patients who had been lucid. 8 of these had no skull fracture noticed on admission; and of these, 5 had no other serious injury. It is these 5 who form the overlap between the "minor head injury" and the "craniotomy" groups, and it is therefore these 5 who stood to gain from precautionary admission (table III, patients 1-5). 3 of the 5 were, in fact, sent home. 1 was erroneously discharged with a missed skull fracture and died 56 h later with cerebral oedema (after readmission). The other 2 returned many days later for evacuation of chronic subdural hxmatomas. The fatal subarachnoid and intraventricular hxmorrhages occurred in the casualty department while the patients were being examined and have a doubtful relation to trauma. None of the 5, therefore, benefited from their precautionary
admission. Table III gives details of another 3 patients in whom the head injury was initially thought to be irrelevant to other bodily injury but who also subsequently came to craniotomy. These had apparently uncomplicated head injuries, but 2 of the 3 patients clearly had diastasis of one or both temporoparietal sutures on their admission skull X-rays. This undoubtedly reflects the severe violence absorbed by the various parts of the body in modern trauma, and we should like to draw attention to it as a much-neglected skull "fracture" in the danger area of the temples.5 The diastasis is easily appreciated in the Towns view, and its serious prognostic significance is demonstrated by the extradural haematoma and cerebral oedema which resulted in the 2 cases cited. The further point is illustrated that extradural hsemorrhage is not the only fatal intracranial complication which can rapidly overcome the lucid patient even in the absence of a skull fracture (see cases 7 and 8, table III).6 None of the remaining 108 craniotomies was performed on patients who would be in any way affected by an admission policy. DISCUSSION
patient admitted after
head injury, 4 or sent home.’ It is to the interface these two are between 5 that an admission must policy apply. Accepting groups that all patients with complicated head injuries must be admitted, the task of defining a high-risk group within the remainder becomes one of quantifying trivial injuries, dubious historical details, and very subjective clinical signs. Any policy built on such insecure foundations is bound to be open to criticism, and in practice it is not surprising that at casualty-officer level, the "policy" often ceases to exist. For every
If the present study is representative, then the cleardivision between the groups studied indicates room for improvement. Despite over 5000 "precautionary admissions" (all without major complication), the only patient who could conceivably have benefited from admission was sent home with a missed skull fracture and subsequently died of cerebral oedema (no. 3, table III). We suggest, therefore, that such elaborate precautions are unnecessary. Patients with uncomplicated head injuries can safely be discharged, provided the following points are borne in mind: cut
Minor Head Injuries
a
1. Most people are aware of the dangers of a head injury and will attend for X-rays. Fractures are detected, and appropriate action can then be taken to minimise further risk. A pre-requisite for this advantage to be gained is an efficient department able to X-ray and report to a high standard. 2. Discharge should depend on (a) thorough clinical examination with (b) adequate written and spoken instruction to return if any (unspecified) change in the patient’s condition causes concern, and (c) ideally the patient should be left in the care of a responsible adult with access to transport who can return the patient speedily. Distances should be considered. 3. Head injuries are not the only result of modern high-velocity injuries. A latent period often follows a splenic tear or a small-bowel perforation. 31% of patients staying beyond 24 h in the present series did so because of secondary soft-tissue injuries which had become troublesome.
An admission policy therefore seems to serve a useful purpose if it is focused on the whole patient rather than
single dreaded complication, the extradural haemorrhage. If the patient presents with a head injury only, then that must be evaluated. A critical evaluate of the mechanism of injury is pivotal to the management of such an injury, for without an estimation of the nature and degree of violence involved the doctor cannot speculate on the bleeding that may follow an acceleration/deceleration injury or the cerebral oedema that might complicate a rotational (whiplash) injury. This is the basis on which minor head injuries should be divided into significant injuries at risk from hidden bodily injury and trivial injuries. This study did not set out to define risk factors, but the medicolegal authorities would agree with the comthat
on
observation that if negligence is to be avoided, then the cryptic comment "K.o.’d" on the casualty card must be supplemented by more information. This accomplished, the need for precautionary admission could be approached more confidently and some of the potential for improvement realised. The size of the saving would vary between centres (depending on the rates of alcoholism, the proximity of trunk roads; &c), but the additional risk to the patient would seem to be very small. We thank the surgeons of the Birmingham Accident Hospital for permission to study their patients. In particular, we thank Mr J. E. M. Smith and Mr R. F. Evans for their helpful criticism and
monsense
advice.
Requests for reprints should be addressed to R. B., Royal Infirmary, Edinburgh. REFERENCES 1. 2.
Jennett, B. Br. med. J. 1975, iii, 267. Field, J. H. Epidemiology of Head Injuries in England and Wales. H.M.
Stationery Office, 1976. 3. Galbraith, S. Lancet, 1973, i, 1217. 4. Teasdale, G., Jennett, B. ibid. 1974, ii, 81. 5. Smith, J. E. M. Personal communication. 6. Reilly, P. I., Adams, J. H., Graham, D. I., Jennett, B. Lancet, 1975, ii, 375. 7. Jennett, B. Proc. Medical Protection Society Symp. on Problems in Accident and Emergency Department; p. 18. 1976. 8. Potter, J. M. Lancet, 1973, i, 1381.
