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Management of head injury patients who talked and deteriorated
Surg Neurol 1990;34:27-9
27
Management of Head Injury Patients Who Talked and Deteriorated Sanguansin Ratanalert, M.D., and Nakornchai Phuenpathom, M.D. Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
Ratanalert S, Phuenpathom N. Management of head injury patients who talked and deteriorated. Surg Neurol 1990;34:27-9.
KEY WORDS; Head injury; Deterioration; Glasgow Coma Scale
as "talked and deteriorated" patients. The initial verbal responses, as defined by their Glasgow Coma Scale (GCS) score, were oriented (verbal GCS score o f 5) in 16 cases, confused (verbal GCS score of 4) in nine cases, and inappropriate speech (verbal GCS score o f 3) in seven cases (Table 1). All deteriorated in neurological status to a GCS score of 7 or less within 48 hours after injury. Twenty cases were referred from other hospitals. Hospital records, computed tomography (CT) scan results, and operative findings were carefully scrutinized to determine the cause of deterioration as well as the cause of death for each patient. Outcome was classified by the Glasgow Outcome Scale [2]. Many variables were included to find what might be responsible for the differences between good and poor outcome. Poor outcome is defined as either severe disability, vegetative state, or death. A logistic regression model was used to analyze the variables.
Introduction
Result
Patients who initially talk after a head injury should have the greatest chance of survival. Deterioration and death in these patients are generally the result o f factors that presumably could be treated, such as intracranial hematoma, cerebral edema, some other complication of their head injury, or some other associated injuries [7]. Because these patients represent a potentially salvagable group, it was considered important to analyze 32 such patients cared for by the neurosurgical service at Songklanagarind Hospital.
O f the 32 patients who talked and then deteriorated, 13 died (40.6%), two survived in a vegetative state, and one is severely disabled. The remaining 16 had good outcome. T h e r e were 24 males and eight females. Their ages ranged from 3 to 72 years, with the average age being 37 years. The general profile o f patients who "talked, deteriorated, and recovered to good outcome" or "talked, deteriorated, and resulted in p o o r outcome" is shown in Tables 1 and 2. Our CT findings were modified from the classification of van Dongen et al [10]. Analysis of variables by the logistic regression method, using backward elimination, failed to indicate the following factors as significant independent outcome predictors: age, sex, lucid interval (hours), time from deterioration to operation (hours), initial verbal score, pupillary light reflex, intracranial hematoma, condition o f basal cisterns, and midline shift (p > 0.05). However, the GCS score before neurosurgical intervention was shown to be a significant outcome predictor (p = 0.016). Relative risk of p o o r outcome was found to be 17.7 per unit decrease in GCS score (between score o f 7 and 3) [ 9 5 % confidence limits 1.7, 184].
Of 203 patients with severe head injuries admitted from January 1986 to May 1989 at Songklanagarind Hospital, 32 cases who initially talked prior to deteriorating to a Glasgow Coma Scale score of 7 or less within 48 hours after injury were identified. Many variables were analyzed to ascertain what might be responsible for the differences in outcome. The Glasgow Coma Scale score before neurosurgical intervention was identified, using the logistic regression model, as a significant prognostic predictor. Mortality rate was 40.6%, with two patients left in a vegetative state. Surgically correctable intracranial mass lesions occurred in 29 cases. The most important factors in salvaging these patients are rapid diagnosis and immediate surgical decompression before irreversible brain damage sets in.
Materials and Methods T h e r e were 203 patients with severe, head injury admitted to Songklanagarind Hospital from January 1986 to May 1989, of which 32 (15.8%) cases were identified
Address reprint requests to: Sanguansin Ratanalert, M.D., Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112, Thailand. Received August 14, 1989; accepted February 16, 1990.
Publishedby ElsevierSciencePublishingCo., Inc., 1990
0090-3019/90/$0.00
Surg Neurol 1990;34:27-9
28
Ratanalert and Phuenpathom
Table 1. General Profile of Patients Who Talked, Deteriorated,
T a b l e 2.
Summary of Computed Tomography Scan Findings
and Had a Good Outcome or Poor Outcome Good outcome No. of cases Mean age (years) Median lucid interval (hours -+ Q.D.) Median time from deterioration to neurosurgery (hours -+ Q.D.) Initial verbal GCS score 5 (Oriented) 4 (Confused) 3 (Inappropriate) Significant mass lesion GCS score 7 6 5 4 3
16 35 7.5 -+ 8.25 6 -+ 5.0
16 39 4 -+ 10.75 2.5 -+ 1.75
7 5 4 14
9 4 3 15
7 8 1 --
2 5 3 6
- -
PupiUary light reflex Normal Unilaterally fixed Sluggish both Fixed both
Poor outcome
- -
7 3 3 3
-3 3 10
Abbreviation: GCS, Glasgow Coma Scale; Q.D., quartile deviation.
Extracerebral lesion Normal S D H -< 8 mm SDH > 8 mm E D H -< 8 mm E D H > 8 mm Basal cisterns Partial obliteration Complete obliteration Complete obliteration with occipital lobe infarction Midline shift <5 mm 5 - 1 0 mm > 1 0 mm Parenchymatous lesion Hypodensity Single Multiple Diffuse Hyperdensity Mixed density Single Multiple Normal
Good
Poor
outcome
outcome
6 1 --9
2 5 6 1 2
7 9 --
1 13 2
6 4 6
3 5 8
1 1 2 --
2 2 2 --
3 7 2
2 8 --
Abbreviations: EDH, epidural hematoma; SDH, subdural hematoma.
Discussion Marshall [ 5 ] had emphasized that the number of patients who talk and deteriorate and then die is a very reliable marker of the quality of regional trauma care and can be used to assess the quality of prehospital and in-hospital care. The incidence of the so-called talk and deteriorate patients among those with traumatic intracranial hematoma in the Glasgow study was reduced from 31% to 16% after applying a new policy of management, especially by incorporating early CT scanning [9]. Twenty patients in our series were referred from nearby regional hospitals, the farthest hospital being 156 miles away from our center. This delay in transferring is a definite unfortunate situation for those patients. Marsh et al [4] pointed out that harmful, avoidable delay did occur at the District General Hospital itself either from failure to institute appropriate treatment for noncranial injuries or from failure to realize the necessity of transferring. Some patients, although they can talk after head injury, have sustained lethal injury to the brain [7]. It seems that while the impact damage might be subacute in its course, it is, nevertheless, very serious. Deterioration might occur rapidly, and some of the patients might not recover. In our study, eight patients with poor outcome were judged to be nonpreventable regardless of treatment because they deteriorated very rapidly and had
overwhelming brain injury. One patient with a huge epidural hematoma died from delay in transportation because the event occurred on a ship at sea. Seven cases of patients who "talked and died" were initially thought not to have significant operative lesions (Table 3).
Table 3. Deaths Complicated by Preventable Factor
Patient no.
Lucid interval (hours)
Time from coma to operation (hours)
10 11
39 40
5 3
13
35
2
18 25
4 44
4 8
29
10
7
30
4
2
Preventable factors Large left subdural hematoma Cerebellar and right intrafrontal hematoma S/P occipital epidural hematoma Right intrafrontotemporal hematoma, sudden apnea, deep coma, and fixed dilated pupils Large left subdural hematoma Bifrontal contusion and hematoma Bifrontal contusion and hematoma Large right epidural hematoma
Abbreviation: S/P, status postoperative.
Head Injury Patients
Many variables have been studied to demonstrate the statistical correlation with outcome such as age, intracranial pressure, mass lesion, and midline shift. Length of time to deterioration or to operation, or miles from the scene of the accident to a hospital, was not related to outcome [6]. Our study pointed to the GCS as prognostically significant. This indicated that neurosurgical intervention must be done before the irreversible secondary brain damage developed. The appropriate time varied in each case depending on the growth rate of the mass lesion, intracranial structure or pathology, and preoperative management. The observation of Seelig et al [8] showed that rapid evacuation of an acute subdural hematoma (ie, within 4 hours) was associated with a remarkably improved outcome in these patients. Klauber et al [3] have indicated that the patients at greatest risk of inadequate diagnosis and treatment are not those at high risk of dying, who might or might not be saved by highly sophisticated intensive care, but rather those who are predicted to be at a relatively low risk of dying. Several methods have been advocated to minimize delay in detection of a traumatic intracranial hematoma [9]. The view that all head injury patients should be managed by a neurosurgeon is unrealistic because of a dearth of neurosurgeons and neurosurgical units, particularly in poorer countries [1]. Computed tomography scanners are unlikely to become generally available in general hospitals because of the high cost, and, moreover, their use may also increase the delay. A regional trauma system should be planned. Good intentions within the hospital setting, either during the initial stages of evaluation and resuscitation or following admission, are not enough. There is a need for keener awareness of the danger signs and for the experienced surgeons who can care for the head injurY patient in facilities that have the capability to provide timely surgical intervention to avoid an adverse outcome. Our data suggested
Surg Neurol 1990;34:27-9
29
that patients who deteriorated to the conscious level of GCS score of 4 or 3 might not tolerate any further delay caused by transportation to a referral center. Immediate investigation and surgical decompression, if necessary, should be done at the initial receiving hospital. Case records of those who deteriorated and died should be reviewed by the traumatic team to produce a greater awareness of problems in the management of head injury. The authors would like to thank Dr. Alan F. Geater, Ph.D., for correcting the English of the manuscript, and Dr. Sophon Ladpli, M.D., F.A.C.S., for comments on our manuscript.
References 1. Bucy PC. How many neurosurgeons? Surg Neuro11983; 1:190-3. 2. Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet 1975;2:480-4. 3. Klauber MR, Marshall LF, et al. Determinants of head injury mortality: importance of the low risk patient. Neurosurgery 1989;24:31-6. 4. Marsh H, Maurice-Williams RS, Hatfield R. Closed head injuries: where does delay occur in the process of transfer to neurosurgical care? Br J Neurosurg 1989;3:13-20. 5. Marshall LF. Comment on analysis of management in thirty~three closed head injury patients who "talked and deteriorated." Neurosurgery 1987;21:55. 6. Marshall LF, Toole BM, Bowers JA. The National Traumatic Coma Data Bank: part 2. Patients who talk and deteriorate: implication for treatment. J Neurosurg 1983;57:285-8. 7. Rose J, Valtonen S, Jennett B. Avoidable factors contributing to death after head injury. Br M e d J 1977;2:615-8. 8. SeeligJM, Becker DP, et al. Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. N Engl J Med 1981;304:1511-8. 9. Teasdale G, Galbraith S, et al. Management of traumatic inrracranial hematoma. Br Med J 1982;285:1695-7. 10. van Dongen KJ, Braakman R, Gelpke GJ. The prognostic value of computerized tomography in comatose head-injured patients. J Neurosurg 1983;59:951-7.
27
Management of Head Injury Patients Who Talked and Deteriorated Sanguansin Ratanalert, M.D., and Nakornchai Phuenpathom, M.D. Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
Ratanalert S, Phuenpathom N. Management of head injury patients who talked and deteriorated. Surg Neurol 1990;34:27-9.
KEY WORDS; Head injury; Deterioration; Glasgow Coma Scale
as "talked and deteriorated" patients. The initial verbal responses, as defined by their Glasgow Coma Scale (GCS) score, were oriented (verbal GCS score o f 5) in 16 cases, confused (verbal GCS score of 4) in nine cases, and inappropriate speech (verbal GCS score o f 3) in seven cases (Table 1). All deteriorated in neurological status to a GCS score of 7 or less within 48 hours after injury. Twenty cases were referred from other hospitals. Hospital records, computed tomography (CT) scan results, and operative findings were carefully scrutinized to determine the cause of deterioration as well as the cause of death for each patient. Outcome was classified by the Glasgow Outcome Scale [2]. Many variables were included to find what might be responsible for the differences between good and poor outcome. Poor outcome is defined as either severe disability, vegetative state, or death. A logistic regression model was used to analyze the variables.
Introduction
Result
Patients who initially talk after a head injury should have the greatest chance of survival. Deterioration and death in these patients are generally the result o f factors that presumably could be treated, such as intracranial hematoma, cerebral edema, some other complication of their head injury, or some other associated injuries [7]. Because these patients represent a potentially salvagable group, it was considered important to analyze 32 such patients cared for by the neurosurgical service at Songklanagarind Hospital.
O f the 32 patients who talked and then deteriorated, 13 died (40.6%), two survived in a vegetative state, and one is severely disabled. The remaining 16 had good outcome. T h e r e were 24 males and eight females. Their ages ranged from 3 to 72 years, with the average age being 37 years. The general profile o f patients who "talked, deteriorated, and recovered to good outcome" or "talked, deteriorated, and resulted in p o o r outcome" is shown in Tables 1 and 2. Our CT findings were modified from the classification of van Dongen et al [10]. Analysis of variables by the logistic regression method, using backward elimination, failed to indicate the following factors as significant independent outcome predictors: age, sex, lucid interval (hours), time from deterioration to operation (hours), initial verbal score, pupillary light reflex, intracranial hematoma, condition o f basal cisterns, and midline shift (p > 0.05). However, the GCS score before neurosurgical intervention was shown to be a significant outcome predictor (p = 0.016). Relative risk of p o o r outcome was found to be 17.7 per unit decrease in GCS score (between score o f 7 and 3) [ 9 5 % confidence limits 1.7, 184].
Of 203 patients with severe head injuries admitted from January 1986 to May 1989 at Songklanagarind Hospital, 32 cases who initially talked prior to deteriorating to a Glasgow Coma Scale score of 7 or less within 48 hours after injury were identified. Many variables were analyzed to ascertain what might be responsible for the differences in outcome. The Glasgow Coma Scale score before neurosurgical intervention was identified, using the logistic regression model, as a significant prognostic predictor. Mortality rate was 40.6%, with two patients left in a vegetative state. Surgically correctable intracranial mass lesions occurred in 29 cases. The most important factors in salvaging these patients are rapid diagnosis and immediate surgical decompression before irreversible brain damage sets in.
Materials and Methods T h e r e were 203 patients with severe, head injury admitted to Songklanagarind Hospital from January 1986 to May 1989, of which 32 (15.8%) cases were identified
Address reprint requests to: Sanguansin Ratanalert, M.D., Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, 90112, Thailand. Received August 14, 1989; accepted February 16, 1990.
Publishedby ElsevierSciencePublishingCo., Inc., 1990
0090-3019/90/$0.00
Surg Neurol 1990;34:27-9
28
Ratanalert and Phuenpathom
Table 1. General Profile of Patients Who Talked, Deteriorated,
T a b l e 2.
Summary of Computed Tomography Scan Findings
and Had a Good Outcome or Poor Outcome Good outcome No. of cases Mean age (years) Median lucid interval (hours -+ Q.D.) Median time from deterioration to neurosurgery (hours -+ Q.D.) Initial verbal GCS score 5 (Oriented) 4 (Confused) 3 (Inappropriate) Significant mass lesion GCS score 7 6 5 4 3
16 35 7.5 -+ 8.25 6 -+ 5.0
16 39 4 -+ 10.75 2.5 -+ 1.75
7 5 4 14
9 4 3 15
7 8 1 --
2 5 3 6
- -
PupiUary light reflex Normal Unilaterally fixed Sluggish both Fixed both
Poor outcome
- -
7 3 3 3
-3 3 10
Abbreviation: GCS, Glasgow Coma Scale; Q.D., quartile deviation.
Extracerebral lesion Normal S D H -< 8 mm SDH > 8 mm E D H -< 8 mm E D H > 8 mm Basal cisterns Partial obliteration Complete obliteration Complete obliteration with occipital lobe infarction Midline shift <5 mm 5 - 1 0 mm > 1 0 mm Parenchymatous lesion Hypodensity Single Multiple Diffuse Hyperdensity Mixed density Single Multiple Normal
Good
Poor
outcome
outcome
6 1 --9
2 5 6 1 2
7 9 --
1 13 2
6 4 6
3 5 8
1 1 2 --
2 2 2 --
3 7 2
2 8 --
Abbreviations: EDH, epidural hematoma; SDH, subdural hematoma.
Discussion Marshall [ 5 ] had emphasized that the number of patients who talk and deteriorate and then die is a very reliable marker of the quality of regional trauma care and can be used to assess the quality of prehospital and in-hospital care. The incidence of the so-called talk and deteriorate patients among those with traumatic intracranial hematoma in the Glasgow study was reduced from 31% to 16% after applying a new policy of management, especially by incorporating early CT scanning [9]. Twenty patients in our series were referred from nearby regional hospitals, the farthest hospital being 156 miles away from our center. This delay in transferring is a definite unfortunate situation for those patients. Marsh et al [4] pointed out that harmful, avoidable delay did occur at the District General Hospital itself either from failure to institute appropriate treatment for noncranial injuries or from failure to realize the necessity of transferring. Some patients, although they can talk after head injury, have sustained lethal injury to the brain [7]. It seems that while the impact damage might be subacute in its course, it is, nevertheless, very serious. Deterioration might occur rapidly, and some of the patients might not recover. In our study, eight patients with poor outcome were judged to be nonpreventable regardless of treatment because they deteriorated very rapidly and had
overwhelming brain injury. One patient with a huge epidural hematoma died from delay in transportation because the event occurred on a ship at sea. Seven cases of patients who "talked and died" were initially thought not to have significant operative lesions (Table 3).
Table 3. Deaths Complicated by Preventable Factor
Patient no.
Lucid interval (hours)
Time from coma to operation (hours)
10 11
39 40
5 3
13
35
2
18 25
4 44
4 8
29
10
7
30
4
2
Preventable factors Large left subdural hematoma Cerebellar and right intrafrontal hematoma S/P occipital epidural hematoma Right intrafrontotemporal hematoma, sudden apnea, deep coma, and fixed dilated pupils Large left subdural hematoma Bifrontal contusion and hematoma Bifrontal contusion and hematoma Large right epidural hematoma
Abbreviation: S/P, status postoperative.
Head Injury Patients
Many variables have been studied to demonstrate the statistical correlation with outcome such as age, intracranial pressure, mass lesion, and midline shift. Length of time to deterioration or to operation, or miles from the scene of the accident to a hospital, was not related to outcome [6]. Our study pointed to the GCS as prognostically significant. This indicated that neurosurgical intervention must be done before the irreversible secondary brain damage developed. The appropriate time varied in each case depending on the growth rate of the mass lesion, intracranial structure or pathology, and preoperative management. The observation of Seelig et al [8] showed that rapid evacuation of an acute subdural hematoma (ie, within 4 hours) was associated with a remarkably improved outcome in these patients. Klauber et al [3] have indicated that the patients at greatest risk of inadequate diagnosis and treatment are not those at high risk of dying, who might or might not be saved by highly sophisticated intensive care, but rather those who are predicted to be at a relatively low risk of dying. Several methods have been advocated to minimize delay in detection of a traumatic intracranial hematoma [9]. The view that all head injury patients should be managed by a neurosurgeon is unrealistic because of a dearth of neurosurgeons and neurosurgical units, particularly in poorer countries [1]. Computed tomography scanners are unlikely to become generally available in general hospitals because of the high cost, and, moreover, their use may also increase the delay. A regional trauma system should be planned. Good intentions within the hospital setting, either during the initial stages of evaluation and resuscitation or following admission, are not enough. There is a need for keener awareness of the danger signs and for the experienced surgeons who can care for the head injurY patient in facilities that have the capability to provide timely surgical intervention to avoid an adverse outcome. Our data suggested
Surg Neurol 1990;34:27-9
29
that patients who deteriorated to the conscious level of GCS score of 4 or 3 might not tolerate any further delay caused by transportation to a referral center. Immediate investigation and surgical decompression, if necessary, should be done at the initial receiving hospital. Case records of those who deteriorated and died should be reviewed by the traumatic team to produce a greater awareness of problems in the management of head injury. The authors would like to thank Dr. Alan F. Geater, Ph.D., for correcting the English of the manuscript, and Dr. Sophon Ladpli, M.D., F.A.C.S., for comments on our manuscript.
References 1. Bucy PC. How many neurosurgeons? Surg Neuro11983; 1:190-3. 2. Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet 1975;2:480-4. 3. Klauber MR, Marshall LF, et al. Determinants of head injury mortality: importance of the low risk patient. Neurosurgery 1989;24:31-6. 4. Marsh H, Maurice-Williams RS, Hatfield R. Closed head injuries: where does delay occur in the process of transfer to neurosurgical care? Br J Neurosurg 1989;3:13-20. 5. Marshall LF. Comment on analysis of management in thirty~three closed head injury patients who "talked and deteriorated." Neurosurgery 1987;21:55. 6. Marshall LF, Toole BM, Bowers JA. The National Traumatic Coma Data Bank: part 2. Patients who talk and deteriorate: implication for treatment. J Neurosurg 1983;57:285-8. 7. Rose J, Valtonen S, Jennett B. Avoidable factors contributing to death after head injury. Br M e d J 1977;2:615-8. 8. SeeligJM, Becker DP, et al. Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. N Engl J Med 1981;304:1511-8. 9. Teasdale G, Galbraith S, et al. Management of traumatic inrracranial hematoma. Br Med J 1982;285:1695-7. 10. van Dongen KJ, Braakman R, Gelpke GJ. The prognostic value of computerized tomography in comatose head-injured patients. J Neurosurg 1983;59:951-7.