Minor head injuries: Guidelines for management

Head injuries represent more than 15% of the activity of the Fatebenefratelli Hospital emergency room (ER). Minor head injuries represent 90% of the total. Almost all (97%) patients with minor head injury are evaluated by a neurosurgeon. The guidelines described below were selected from the literature and tested during the months of March and April 1996 to determine their reliability, their applicability for neurosurgeons and for ER physicians, and their capacity of sparing skull X-rays that, in the past, were routinely obtained in these patients. Minor head injuries included, in this study, all cases with GCS 15 and negative neurological exam at admission. All patients with one or more of the following signs, symptoms or risk factors had an emergency CT scan of the head with parenchymal and bone settings. Signs: large subgaleal hematoma; Symptoms: loss of consciousness, amnesia, vomiting, confusion, and lack of cooperation; Risk factors: alcohol abuse, previous cranial surgery, epilepsy, drug abuse, clotting disease. Minor head injuries were observed in 762 patients, 13.9% of the 5470 patients seen in the ER during the same period. A male predominance was observed: 428 (56.2%) males Vs 334 (43.8%) females. The average age of minor head injury patients was 37.5 years, with a peak in the age group from 16 to 34 years 44.6%. A CT was obtained in 203 (26.6%) patients and in 24 (11.18%) of them the CT was abnormal. Among the 179 patients with negative CT, 31 (17.3%) were admitted for clinical reasons, or for trauma to other regions. All the 559 patients who did not have a CT and 148 with negative CT scan were discharged from the ER without further investigation and were seen on an outpatient basis 1 week after the trauma and none required further evaluation or treatment. Skull x-rays, that used to be the initial mean of evaluation in 95% of patients seen at the ER, were obtained in only 139 (18.3%) of patients during the study period. In most of the cases skull x-rays were independently ordered by the ER physician. Our experience shows the reliability of the selected guidelines, since no patient with intracranial complications was missed at the first evaluation. The guidelines are very simple and can be safely used by ER physicians. The use of skull x-rays is unreliable, expensive and time consuming and must not be advised on a regular basis.