NCEPOD: Trauma - Who Cares? - London Health Programmes

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CHAPTER 8 - Head injury managementKey findingsHead trauma is very common in the severely injuredpatient and has a negative impact on outcome.Secondary insults (hypoxia, hypercapnia andhypotension) are common and these are known toworsen eventual outcome (higher mortality and moresevere disability).Only 9/48 (18.8%) patients who had major neurosurgicalprocedures as a result of trauma were operated on byconsultant surgeons.Less than half of the severely injured patients whosuffered head trauma received a standard of care thatwas judged to be good practice.The prehospital management of the airway andventilation was inadequate in 14.3% and 10.6% of casesrespectively.In a small number of cases steroids are being used inthe routine management of the head injured patient,despite evidence that this therapy may cause harm.One in fi ve patients who required a head CT scan didnot have this performed in a timely fashion.Delays in CT scanning were primarily due toorganisational factors rather than patient factors.More than half of the patients who required neurosurgicaladvice or input were taken to hospitals where there wasno onsite neurosurgical service.Only 6/43 (14.0%) patients who required a secondarytransfer to access neurosurgical services had anoperation within four hours of injury.There were delays to neurosurgery in 13/81 (16.0%)cases. Most of these cases were evacuation of traumaticspace occupying lesions.108
8Head injury managementRecommendationsPrehospital assessment of neurological status should beperformed in all cases where head injury is apparent orsuspected. This should be performed using the GlasgowComa Scale. Pupil size and reactivity should also berecorded. (Ambulance trusts)A pre-alert should be made for all trauma patients witha GCS less than or equal to 8, to ensure appropriatelyexperienced professionals are available for theirtreatment and to prepare for imaging. (Ambulance trusts)Patients with severe head injury require early defi nitiveairway control and rapid delivery to a centre with onsiteneurosurgical service. This implies regional planningof trauma services, including prehospital physicianinvolvement, and reconfi guration of services. (Ambulanceand hospital trusts)Patients with severe head injury should have a CT headscan performed as soon as possible after admissionand within one hour of arrival at hospital. (Trauma teamleader and radiology heads)All patients with moderate or severe head injuryshould have case and CT fi ndings discussed with aneurosurgical service. (Trauma team lead)All patients with severe head injury should be transferredto a neurosurgical/critical care centre irrespective of therequirement for surgical intervention. (Strategic healthauthorities, hospital trusts, trauma team leaders)Consultant presence should be increased at operationsrequiring major neurosurgery. (Hospital trusts)References1. Teasdale GH. J Neurol Neurosurg Psychiatry 1995; 58:855-8872. Rose J, Valtonen S, Jennett B. Avoidable factorscontributing to death after head injury. BMJ 1977; 2:615-83. Jennett B, Carlin J. Preventable mortality and morbidityafter head injury. Injury 1978; 10: 31-94. Rockswold GL, Leonard PR, Nagib MG. Analysis ofmanagement in thirty-three closed head injury patientswho ‘talked and deteriorated’. Neurosurgery 1987; 21:51-55. Mendelow AD, Karma MZ, Paul KS, Fuller GA, GillinghamFJ. Extradural haematoma: effect of delayed treatment.BMJ 1979; I: 1240-26. Klauber MR, Marshall LF, Luerssen TG, FrankowskiR, Tabaddor K, Eisenberg HM. Determinants of headinjury mortality: importance of the low risk patient.Neurosurgery 1989; 24: 31-67. O’Sullivan MG, Gray WP, Buckley TF. Extraduralhaematoma in the Irish Republic: an analysis of 82 caseswith emphasis on delay. Br J Surg 1990; 77: 1391-48. Brain Trauma Foundation, American Association ofNeurological Surgeons, Joint Section on Neurotraumaand Critical Care. Guidelines for the management ofsevere head injury. J. Neurotrauma 1996; 13: 641-7349. The management of acute head injury: seminar papers.London: DHSS 1983109
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Trauma: Who cares?A report of the N
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ContentsAcknowledgements 4Foreword
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AcknowledgementsThis is the twenty
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AcknowledgementsThe organisations t
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ForewordSevere injury - a car crash
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Summary of fi ndingsThis study show
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Principal recommendationsOrganisati
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IntroductionTrauma remains the four
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IntroductionReferences1. Chaira 0,
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MethodQuestionnaires and casenotesT
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MethodQuality and confidentialityA
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CHAPTER 1 - Data overviewFigure 2.
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CHAPTER 1 - Data overviewMode of ar
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CHAPTER 2 - Organisational dataTabl
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CHAPTER 3 - Overall assessmentAll c
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CHAPTER 3 - Overall assessmentKey f
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CHAPTER 4 - Prehospital careRespons
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CHAPTER 4 - Prehospital careAdequac
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CHAPTER 5 - Hospital receptionIntro
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CHAPTER 5 - Hospital receptionTraum
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Page 114 and 115: CHAPTER 9 - Paediatric careOrganisa
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Page 120 and 121: CHAPTER 10 - TransfersIntroductionM
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Page 128 and 129: CHAPTER 11 -Incidence of trauma and
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Page 144 and 145: APPENDIX F - ParticipationTrustCase
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