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African Journal of Neurological Sciences
Pan African Association of Neurological Sciences
ISSN: 1015-8618
Vol. 16, Num. 2, 1997
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A SURVEY OF 371 HEAD INJURED PATIENTS ADMITTED TO THE
NEUROSURGICAL WARDSOF THE PARIREWYATWA HOSPITAL, HARARE, ZIMBABW£
Afri.Neur.Sci.Vol.16 No.2 July 1997
A SURVEY OF 371 HEAD INJURED PATIENTS ADMITTED TO THE
NEUROSURGICAL WARDSOF THE PARIREWYATWA HOSPITAL, HARARE, ZIMBABW£
.
Levy L.F., Makaraw O S. - Harare - Zimbabwe.
Code Number:NS97008
SUMMARY
A prospective study of all head injured
patients who were admitted to the Parirewyatwa Hospital under our
care between the months of May 1996 and August, 1997 inclusive was
undertaken. The purpose of the study was to document the cause and
nature oft he injury, the presence of other injuries and their
effects, the outcome, to review the post mortem in order to clearly
delineate the nature of the intracranial injury, to determine if
there were errors in the treatment, to see if there were other ways
in which the treatment of the head injuries could be improved.
RESUME
Une crude prospective a ere conduite chez
tousles patients ayant presente un traumatisme cranien, admis dans
notre service a l'Hopital Parirewyatwa entre les mois de Mai 1996
et d'Aout 1997 inclus. Le but de l'etude etait de rechercher les
causes et la nature du traumatisme, la presence d'autres blessures
et leurs effects, leur devenir. De plus, les rapports d'autopsies
ont ete examines pour rechercher la nature exacte des lesions
intracraniennes afin de determiner s'il y avait eu une erreur dans
le traitement, et pour rechercher s'il etait possible d' ameliorer
les therapeutiques des traumatismes craniens.
Key words: Head injuries - critical review
treatment.
A prospective study of all head injured
patients who were admitted to the Parewyatwa Hospital under our
care between the months of May and August, 1997 inclusive was
undertaken. The purpose of the study was to document:
1.The cause of and nature of the injury
2.The presence of other injuries and their effects
3.The outcome
4.To review the post mortem or similar findings
a) To clearly delineate the nature of the intracranial
injury.
b) To determine if there were errors in the treatment.
c) To see if there were other ways in which our treatment of
head injuries could be improved.
During the fifteen month period 371 patients were admitted under
our care. There were 269 adult males and 46 females, and 36 boys
and 20 girls of 12 years and under. None the less the age
distribution (apart from the group 21-30 was remarkably uniform).
(Table 1).
Table 1
0-10 |
56 |
20% |
11-20 |
40 |
145 |
21-30 |
89 |
325 |
31-40 |
43 |
16% |
41-50 |
28 |
205 |
50+ |
20 |
7% |
Road traffic accidents constituted the major incidence. (Table
2):
Table 2
RTA |
238 |
69% |
ASSAULT |
73 |
20% |
DOMESTIC |
21 |
6% |
INDUSTRIAL |
11 |
3% |
SPORT |
4 |
1% |
UNSTATED |
347 |
|
" |
24 |
|
" |
371 |
|
Admission policy at the Panreyatwa
Hospital decrees that head injuries take priority so that a
considerable number of patients with other injuries as well as
those of the head are brought into our ward. (Table 3):
Table 3
DISTRICUTION OF INJURIES |
ADMITTED |
DIED |
HEAD INJURY ONLY |
213 (62%) |
27 (11%) |
HEAD AND UPPER LIMB |
29(8%) |
(13%) |
HEAD AND LOWER LIMB |
24(6%) |
3(12%) |
HEAD AND THORAX |
12 (3%) |
3 (24%) |
HEAD AND ABDOMEN |
3 (1%) |
2 (66%) |
HEAD AND MULTIPLE INJURIES |
72(18%) |
11(15%) |
|
371 |
50 (13%) |
These figures are not strictly comparable except
to suggest that the chances of dying are slightly greater for those
with other injuries that with a head injury only, and for those
with a head injury it is just over 10% understandably multiple
injuries were commonest in the R.T.A. group.
The patients were classified according to their
Glasgow coma scores which were estimated soon after admission to
the ward or Casualty Department and it was frequently impossible to
determine exactly how long, post injury this was, patients
transferred from outside the town had the Coma Score assessed by
the referring doctor before their departure. The coma score was
measured out of 14 and the patients were divided into three groups
on that basis. (Table 4):
Table 4
OMA SCORE |
TOTAL NUMBER |
DIED |
MORTALITY |
GroupI(3-6) |
75 |
35 |
46.6% |
GroupII (7-10) |
79 |
10 |
12.6% |
GroupIII (11-14) |
217 |
5 |
2.2% |
As would be expected the mortality was highest
in the low coma score and lowest in the high coma score groups.
Now I hope you will agree that any patient who
comes into hospital alive but subsequently demises has been failed
by us as medical science. It is true that at the current state of
our knowledge we may not have the "know how" to avert death but
none the less the patients death represents a failure by us as
medical scientists, of equal, if not greater significance, is the
question as to whether we are missing any lesions which, in the
light of our current knowledge, we could have cured. It is very
important therefore that we look closely at the post mortem and
other diagnostic findings in an effort to see if we failed and
patients in one way or another and to see what other problems there
are.
50 patients died overall. 36 of these were the
subject of post mortem examination and 5 others had a clear
definition of their intracranial status by CT Scanning. Nine
patients had neither CT Scan nor autopsy but seven of these had
been admitted deeply unconscious and died 48 hours without
improvement, so I think we have a fair idea what was going out
there.
In group I, where 35 out of 75 patients died,
there were three interesting cases:- The patients had normal scans
yet they died after four and 21 days, in the third case at autopsy
there was only subarachnoid heamorrhage and a very small subdural
blood collection and it was difficult to see why these three
patients died.
In group II where 10 out of 79 patients died one
showed a mild diffuse brain swelling but nothing else, while a
second showed small occipital haemorrhage, a small subdural
haemorrhage and extensive cerebral oedema. Another patient showed a
severe bronchopneumonia with only minor brain change. A fourth
patient, a 25 year old male suffered a fractured tibia and fibula
as well as a head injury, his conscious level dropped from 14/4 to
9/14 after reduction of the fracture. A Clinical diagnosis of fat
embolism was made - post mortem examination confirmed the
diagnosis.
Five patients out of 217 died in group III
(2.2%) and in some ways these are the most interesting because at
admission they all had scores above 11/14. A young man was admitted
following a mine injury in which he temporarily lost consciousness.
There was a linear fracture of the frontal region, he died suddenly
the following morning and post mortem showed an epidural hematoma.
A second case had a pnemothorax, fracture of the long bones and a
bilateral subdural effusion all of which were treated. He died
suddenly and the pathologist gave the cause of the death as cardiac
tamponade. Two patients had diffuse injuries and one died without a
post mortem.
COMMENT
Three problems seem to arise from this:-
1) Failure to recognise potentially curable
lesions.
2).Inadequate care of the patients overall condition.
3).Patients who die intracranial death with little to show
for it.
(1) Epidural haematoma, provided it follows the classical
pattern is very curable if intervention occurs in time. How can
this be facilitated? It is clear that simple clinical observation
is inadequate in some cases, where there is easy access to a CT
Scanner there should be no problem but where there is not some
easier and cheaper method must be employed. Early Angiography is
one possibly but it needs a reasonable set up and it is invasive.
Basically what is needed is a non invasive, non damaging, easily
applied test will show the position of the midline of the brain
relative to the centre of the skull - where the midline is
centrally placed we can be sure there is no surgical lesion. I am
suggesting that we try to revamp ultrasound scanning which proved
itself most valuable in the past. There was an instrument called
the "Midline" which anyone could use and which could accurately
locate the midline structures without difficulty or danger. We used
it for many years - unfortunately no one in the northern
hemispheres makes it now - though I have tried hard to get one made
no one will do so because the first world does not want it. I
believe that a cheap reliable model could help us tremendously in
the third world. One of these machines in each District
Hospital could help the resident doctor to
decide whether urgent transfer is necessary.
(2).The second point reveals a different aspect
of head injury care - that of care of the airway. When I first came
into neurosurgery the importance of airway clearance was not
appreciated and I have seen patient literally roaring with
laryngeal spasm and tracheal mucous. We eventually got the idea
that this had to be removed and started to bronchoscope the
patients. We then went over to tracheostomy with very gratifying
results and later to endotracheal tubing with what I believe, have
been less successful results. In a number of the cases reported
here there was evidence of inadequate airway clearance. The patient
with cardiac tamponade was a surprise.
(3)In six cases the brain injury appeared
minimal and at CT Scanning or autopsy various authors have pointed
out how trauma, and particular bruising or the brain with haematoma
formation and neuron distracted liberates toxic cytokines as well
as electrolytes in the extra cellular fluids with resulting brain
swelling and dsyfunction. There were more of these cases than those
requiring surgery. This means that while we must tighten up on our
diagnosis and observations and on our general and especially
airways care, it also means that the main focus of our attention
has to be on the development of techniques to mitigate the
deleterious effects of these liberated substances that has to be
the main thrust of head injury research now.
REFERENCES:
1. Bakay RAE, Sweeney KM, Wood JH.
Pathophysiology of CSF in head injury (Part 1). Neurosurgery, 1986;
18:234-43.
2. Bakay RAE, Sweeney KM. Wood JH. The
Pathophysiology.
Copyright 1995 Pan African Association of Neurological
Sciences
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