Further experience in the management of severe head injury

TLDR

The study proposes redefining severe head injury to include all patients unable to obey commands or speak recognizable words upon admission after early resuscitation. The authors prospectively analyzed 225 consecutively managed severe head injury patients to relate outcomes to clinical variables. In 225 patients, 56% had good recovery or moderate disability, 10% were severely disabled or vegetative, and 34% died, and poor outcome was predicted by intracranial hematoma, older age, abnormal motor responses, impaired eye movements or pupil reflexes, early hypotension, hypoxemia/hypercarbia, and intracranial pressure >20 mm Hg, all assessed on admission, with similar predictive strength in a 158‑patient coma subset where mortality was 40%.

Abstract

✓ A prospective and consecutive series of 225 patients with severe head injury who were managed in a uniform way was analyzed to relate outcome to several clinical variables. Good recovery or moderate disability were achieved by 56% of the patients, 10% remained severely disabled or vegetative, and 34% died. Factors important in predicting a poor outcome included the presence of an intracranial hematoma, increasing age, abnormal motor responses, impaired or absent eye movements or pupil light reflexes, early hypotension, hypoxemia or hypercarbia, and elevation of intracranial pressure over 20 mm Hg despite artificial ventilation. Most of these predictive factors were assessed on admission, but a subset of 158 patients was identified in whom coma was present on admission and was known to have persisted at least until the following day. Although the mortality in this subset (40%) was higher than in the total series, it was lower than in several comparable reported series of patients with severe head injury. Predictive correlations were equally strong in the entire series and in the subset of 158 patients with coma. A plea is made for inclusion in the definition of “severe head injury” of all patients who do not obey commands or utter recognizable words on admission to the hospital after early resuscitation.