Moderate head injury: A system of neurotrauma care

A prospective study of a consecutive sample of 110 patients with a moderate head injury (GCS 9-12) were studied to determine factors contributing to outcome and to establish principles of management within a trauma program. Whereas for severe head injury, the motor score was the major determinant of the GCS, for a moderate head injury, eye opening and vocal response are more important. As the Injury Severity Score (ISS) increased, so did the proportion of deaths, although the majority of patients had only one or two regions injured and most were classified as minor or moderate, using the Abbreviated Injury Score (AIS). All patients underwent a CT scan of the head and 61% of scans were abnormal. No patient with a normal scan (Traumatic Databank category 1) developed neurological worsening from any cause. Sixteen patients underwent a craniotomy for intracranial hematoma. Intracranial pressure (ICP) monitoring was performed in 20 patients and was raised, requiring treatment in 11 (55%). Indications for ICP monitoring were CT appearance, multitrauma or postoperative. Nine patients died, 4 from complications of the head injury and all of these had an intracanial hematoma. Those who died were, as a group, older and had more severe injuries generally. A good outcome (GOS 1) was achieved in 70%, moderate disability (GOS 2) 21%, GOS 3 (severe disability) 1% and 8% died. No patient remained in a vegetative state. Specific management of moderate head injury within the trauma program is discussed. Particular attention needs to be directed to those patients with moderate head injury who are over 40 years of age, with multitrauma or with an abnormal CT scan.