Management of head injury

Sections 5.1-5.3 described in detail the specific skills, equipment and supplies needed to treat the immediately life-threatening injuries addressed in the initial evaluation and management. For more complicated issues, these guidelines provide less specific detail. Details of operating theatre equipment and supplies are beyond the scope of this publication. Hence, only a few exceptionally critical items are mentioned. Instead, the guidelines state the services that should be provided, with the implication that the training, equipment and supplies needed to provide these services successfully and safely are present. Hence, the following sections 5.4-5.14 of the guidelines list clinical services without division into skills and knowledge versus supplies and equipment.

Head injury is one of the major causes of trauma-related death and disability worldwide. The American Association of Neurological Surgeons (AANS) has developed a set of Guidelines for the management of severe traumatic brain injury (32). These have been shown to improve survival and functional outcome after severe head injury in high-income countries (33, 34). Unfortunately, optimal treatment of head injuries by these protocols requires some of the most expensive resources in the modern therapeutic armamentarium. It is unlikely that low- or even middle-income countries will be able to meet these guidelines fully. In the current guidelines, we have attempted to delineate the most effective diagnostic and therapeutic capabilities that are likely to be achievable at a reasonable and sustainable cost in low- and middle-income countries. It is acknowledged that full compliance with the AANS guidelines would be the most desirable.

Within the resource limitations of developing countries, the assessment of neurological status, including determination of level of consciousness using the Glasgow coma scale, recognition of lateralizing signs, and determination of pupillary size and reflexes, are considered essential at all levels of the health care system, in all countries. This requires only training and perhaps a source of artificial light such as a pocket torch. One of the most significant therapeutic modalities that needs to be applied broadly worldwide is the minimization of secondary brain injury through the maintenance of cerebral perfusion and oxygenation. Most (65%) of the mortality from head injury is associated with secondary brain injury resulting from hypoxia and hypotension (35). This reinforces the primary importance of the ABC outlined in sections 5.1-5.3 above. Recognition of the importance of these factors in patients with head injuries is deemed essential at all hospital levels.

A refinement on the above is to offset the propensity towards raised intracranial pressure (ICP) by avoiding overhydration, principally in haemodynamically stable patients. This knowledge and the understanding that head-injured patients with hypovolemia also require appropriate hydration to prevent hypotension is deemed essential at all hospital levels.

Intracranial pressure (ICP) monitoring for appropriate indications (e.g. Glasgow coma scale less than 9 and abnormal CT scan of the head) and the ability to treat raised ICP through such means as sedation, osmotic diuresis (with mannitol), paralysis, cerebrospinal fluid (CSF) drainage and hyperventilation are deemed desirable at the tertiary care level. They are also desirable at the specialist-level hospital if a neurosurgeon is present. They are also desirable at the specialist-level hospital if a general surgeon with considerable neurosurgical expertise is available, in a setting in which facilities for referral to a tertiary centre are limited.

Intracranial mass lesions with pressure effect account for only around 10-20% of comatose patients. However, timely decompression of these lesions significantly improves outcome. Treatment of these lesions is greatly facilitated by the availability of computerized tomography (CT). This is deemed desirable at all hospital levels. However, its high cost prevents it from being considered essential at any level. CT scans are indeed available in many locations, including low-income countries, but many factors preclude their ready availability to all patients with suspected intracranial mass lesions. These include cost, and in some cases associated mandatory fees, as well as prolonged periods of breakdown (15). Some countries may decide to make CT scanning essential in their own plans. This requires not only the physical presence of the machine, but also timely 24-hour availability to all severely head-injured patients, without regard to ability to pay. It also includes facilities for maintenance and rapid repair within 24 hours. In addition, basic quality improvement programmes should assure that all patients warranting CT scan of the head (generally Glasgow coma scale of 8 or less) are promptly scanned (generally within 2 hours of arrival to the hospital).

Surgical treatment of intracranial mass lesions is classified as basic (burr hole) or advanced (including craniotomy, craniectomy, treatment of intracerebral haematoma, etc.). CT scans facilitate such treatment, but they are not mandatory. It should be noted that increased survival with drainage of intracranial haematoma was widely documented in the era before CT scans (36). Relief of raised ICP from intracranial mass lesions by burr hole alone implies the skill to perform the operation and the drills or other suitable equipment needed. Some GP-staffed hospitals are situated in isolated places with minimal facilities for timely referral. In these locations, burr holes may reasonably be considered to be "possibly required".This would imply that a GP with suitable surgical experience would be authorized to perform them. Specialist-level hospitals in most low-income countries would not usually be expected to have a neurosurgeon. In these cases, especially if referral time to tertiary care facilities is prolonged, the ability to perform burr holes by general surgeons is deemed desirable. Moreover, many tertiary care hospitals in low-income countries do not have neurosurgeons. At these facilities, the capability to perform burr holes should be essential. More advanced neurosurgical procedures are deemed "possibly required" at specialistlevel hospitals. These would certainly be required if a neurosurgeon were present. However, they would also be reasonably performed by general surgeons in cases where referral to tertiary hospitals was significantly restricted. They would be desirable in any tertiary care environment. However, the dearth of neurosurgical expertise in low-income countries prevents them being deemed essential, even at the tertiary level.

A particular subset of neurosurgical procedures, elevation of open depressed skull fractures, is considered as possibly required at some very isolated GP hospitals, desirable at specialist facilities and essential at tertiary hospitals. Elevation of closed depressed skull fractures is less urgent and hence deemed possibly required at specialist-level hospitals (unless a neurosurgeon is present) and desirable at tertiary hospitals.

The AANS guidelines indicate that steroids are of no proven benefit in the treatment of traumatic head injury. Hence, they are not promoted in the Guidelines for essential trauma care.

Finally, malnutrition in head trauma patients has been associated with worsened outcome (32). Maintenance of at least baseline caloric and protein requirements should be assured, including NG feeding if the patient is comatose. This is deemed essential for all head-injured patients with altered neurological status at all hospital levels. This also applies to patients with a prolonged inability to eat, whether for head injury or other forms of trauma.

TABLE 4 Head injury

Facility level

TABLE 4 Head injury

Facility level

Resources

Basic

GP

Specialist

Tertiary

Recognize altered consciousness; lateralizing signs, pupils

E

E

E

E

Full compliance with AANS1 guidelines for head injury

I

I

D

D

Maintain normotension and oxygenation to prevent secondary brain injury

D

E

E

E

Avoid overhydration in the presence of raised ICP2 (with normal BP)

D

E

E

E

Monitoring and treatment of raised ICP

I

I

D

D

CT3 scans

I

D

D

D

Burr holes (skill plus drill or other suitable equipment)

I

PR

D

E

More advanced neurosurgical procedures

I

I

PR

D

Surgical treatment of open depressed skull fractures

I

PR

D

E

Surgical treatment of closed depressed skull fractures

I

I

PR

D

Maintenance of requirements for protein and calories

I

E

E

E

1 AANS: American Association of Neurological Surgeons.

2 ICP: Intracranial pressure.

3 CT: Computerized axial tomography.

1 AANS: American Association of Neurological Surgeons.

2 ICP: Intracranial pressure.

3 CT: Computerized axial tomography.

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