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SUMMARY:
Background; Trauma remains the leading killer of children and young
adults, specially head trauma injuries of different types from fall from height (FFH) in
children to road traffic accident (RTA) and quarrelling in adolescence and young adults.
Every day many victims with head trauma will arrive the Surgical Casualty
Department of STH, managed first by house officer and senior house officers in general
Surgery.
Aim: to compare a study group with controle group to evaluate the role of
different lines and grugs in the management of head injured patients.
Patients, Methods and Materials: A retrospective review was undertaken of
160 patients admitted with headinjuries over a period of years from 1st April 2003 to 1st April
2004 ,in Sulemani Teaching Hospital. Demographic data obtained from the patients files ,study
has been designed that may predict the
outcome of these two types of managements. Eiety patients (Group- A) managed in the
authors surgical unit and the rest (Group B) managed by a colleague surgeons in another
surgical unit.
Comparative analysis between the two groups through multiple variables was
done to identify any different between them in the aspect of management and outcome.
Results: Most of the patients in both groups were males , most of the
injuries were mild. The most common type of trauma was fall from height, there was no
any correlation between # skull and physical findings as most of the patients with
physical findings.Differnt unneccessory drugs and lines of managements were used in the
controlled group , which add no any benefit to the patients, but increase the
complications.
Conclusion: we need a uniform standard revised updated schedule
for management of head injured patients in our casualty, aiming in saving lives and time
of the physician, nursing and radiological Staffs
Most of the patients (63 patients in group-A, 56 patients in group –B) remained in
hospital for up to 47 hours as shown in table IV. .
GCS scoring was full (15 scores) in most (64patients in group-A) of the patients
Within 24 hours of admission, while there was no any records of this in the files of the
(group-B) as shown in Table V.
These patients were managed in the casualty department and later in the surgical
unite on follow up as showing in table IX.
On the other hand there was no hard correlation between findings in the skull
radiographs and the physical findings for example (table VI), there was seven cases of
rhinorrhea and rhinorrhagia which means anterior cranial fossa #, with only radiological
finding in one of them. Also there was four cases of otorrhagia with only one radiological
report of # in one of them.
These may be either due to the fact that most of the # usually are in the base of
skull, which are not evident on AP & lateral skull views, but need Special (Town view)
which in not in practice at least in Surgical Casualty Department or there is a gush of
routing skull X-rays (100%) which will put a have burden on radiological staff who is
alone on duty personal, the result will be bad quality skull radiographs which add nothing
to the clinical evaluation and decision
Few patients (9 patients) send selectively for CT-scanning of the skull & brain
(Table IIX), with (4) normal results, one extradural haematoma, and unfortunately there
is no paper or report or data recording in the files of the patents with the rest (5 patients in
group B). Majority of our patients were with minor hand injury which need just
observation and elevation of the head, unfortunately we found the elevation of the head
not practiced for all the patients in group-B (Table IX). Different drugs used in most of
the patients which is not necessary for patients with full GCS scoring for example patient
with file number (21211) had full Scoring (15), had no any injury, but received all the
types of the drugs & lines of treatment which you will see in (Table IX).
ELEVATION OF THE HEAD
Now it is clear that cerebral edema & hemorrhage within the cranial vault will
rapidly increase intracranial pressure (ICP), because the brain, unlike other organs is
rigidly confined with the skull (4) and in trauma the Brain Blood Barrier (BBB) will
disrupt. So elevation of the head will help in facilitation of venous drainage, which is the
only way, as there are no lymphatic vessels in the brain, and the veins are thin walled,
containing no muscle fibers in their wall which make them capable to distend
considerably.
IVF
It is better not to give intravenous fluid (IVF) routinely for head injured patients,
specially when there is no vomiting & the patient is conscious, and able to take orally.
When IVF is indicated, it is better to restrict the IVF therapy at least to 2/3 of that of
normal maintenance. Also it is better to avoid 5% glucose in water as it enhances the
edema process. So IVF “Should be administered Judiousely to prevent overhydration
which augments cerebral edema as mild dehydration wile protect the brain from insult
secondary to fluid over load
(5)
.
PHENOBARBITONE:
It will help in decreasing agitation, controls Seizures and decreases brain edema.
STEROIDES:
Are not recommended for the treatment of acute head injury.
DIURETICS:
In the emergency department should be administered only with the consent of a
neurosurgeon or to gain time when neurosurgical capabilities will be delayed and the
patient’s condition is deteriorating, because its beneficial effect is transient, the drug can
severely alter serum electrolyte and osmolarity
Patients who are given Steroid, osmotic diuretics, anticonvulsant & hyperosmolar
feeding are prone to develop hyperosmolar state, some times leading to hyperglycemic
nonketotic coma (6).
when may be analyzed as deterioration of the neurosurgical condition of the
patient.
ANTIBIOTICS
Prophylactic antibiotics are not used routinely because recent prospective studies
have failed to demonstrate any benefit from their use (7), so rarely indicated.
ANALGESIA
Aspirin & other nonsteroidal Analgesia all increase the risk of upper GIT bleeding
and peptic stress ulcers, so it is better not to be used routinely.
DIAZEPAM
Sedation reduces posturing & combat activity, both of which elevate ICP.
ANTIEMETIC
When used, it has symptomatic benefit but also may induces occulogyric crises,
which will be misinterpreted for unwary personal. There is a large difference between the
line of treatment in these two groups, but the mortality was same in both groups (A&B),
one patient in each group.
CONCLUSION
We may conclude from this audit, that skull radiographs and many drugs with
steroid, antibiotics, IVF, diuretics were used routinely without any additional benefit to
the standard management of the head injured patients, we need a uniform standard
revised updated schedule for management of head injured patients in our casualty, aiming
in saving lives and time of the physician, nursing and radiological Staffs
AKWOWLEAAEMENT
I would like to thank all the house officers & nursing staffs in my surgical unite &
statistical staffs in STH, Forensic medicine for their valuable technical help.
REFERENCES
1. B. R. Duns, T. Boesen, prognostic Signs in the evaluation of patients
with minor head injuries, British journal of surgery. 1997, Vol. 80, No. 8
,page (989)