Cause of decline in head-injury mortality rate in San Diego County, California.

Even with an increasing population, there were 100 fewer deaths due to head injury in San Diego County, California, in 1982 compared to 1980. During the 5 years from 1976 to 1980 there was nearly a constant death rate from head injuries, followed in the next 2 years by a decline of 24%. The number of deaths at the scene of injury declined 28%, and the number of individuals listed as dead on arrival at the hospital declined 68%. Mortality rates in the emergency room increased slightly and later death rates declined slightly. Mortality rates of hospitalized patients, adjusted for severity of injury, did not vary materially by year. This decline in deaths due to head injury followed a marked improvement in the county's emergency ground and prehospital air evacuation services. The data strongly suggest that advanced prehospital emergency medical services can substantially reduce mortality rates in head-injured patients. The authors postulate that some patients who ordinarily "would die now talk" because of early airway and circulatory management by highly trained paramedical personnel and airborne trauma specialists. Despite a search for other factors that might explain these observations, no satisfactory alternatives could be identified.

Traumatic acute epidural hematoma: unrecognized high lethality in comatose patients.

A series of 51 comatose patients suffering traumatic epidural hematoma after closed head injury is reviewed. This prospective series was accumulated from the National Pilot Traumatic Coma Data Bank during a 2-year period and represents 9% of all patients entered into the Data Bank. The overall mortality was 41%, with 4% remaining in the vegetative state. Fifty per cent of these patients, all of whom were in coma, also had an associated intracerebral contusion. There was no difference in outcome with regard to sex, mode of injury, or the presence or absence of contusion or shift on the computed tomographic (CT) scan. The motor score immediately before operation was the most powerful preoperative predictor of outcome. Sixty-seven per cent or two-thirds of the patients with a motor score of 4, 5, or 6 on the Glasgow coma scale had a satisfactory outcome at last follow-up examination. In contrast, in patients with a motor score of 3 or less, two-thirds either died or remained in a vegetative state. The acute traumatic epidural hematoma is often lethal in the comatose patient. We recommend early evacuation of epidural hematomas, i.e., when they are first noted on the CT scan, rather than waiting for clinical motor deterioration.

Absent or compressed basal cisterns on first CT scan: ominous predictors of outcome in severe head injury.

The relationship of outcome to the appearance of the basal cisterns as seen on initial computerized tomography (CT) scanning was assessed in 218 consecutive severely head-injured patients entered into the second phase of the National Pilot Traumatic Coma Data Bank. Outcome could be directly related to the status of the basal cisterns on the initial CT scan. The mortality rates were 77%, 39%, and 22% among those with absent, compressed, and normal basal cisterns, respectively. This association between cisterns and outcome was shown to be strong after adjusting for Glasgow Coma Scale (GCS) score (p less than 0.001). The state of the cisterns was more important for those with higher GCS scores (scores 6 to 8) than for those with lower scores (scores 3 to 5). Patients with GCS scores of 6 to 8, with cisterns absent or not visualized, suffered nearly a fourfold additional risk of poor outcome, compared to those with normal cisterns. This indicates that the status of the cisterns can be used as an early noninvasive method of identifying patients at high risk of death or severe disability, in whom the initial neurological examination would potentially suggest otherwise.

The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment.

The records of the first 325 patients entered into the pilot phase of the National Traumatic Coma Data Bank were reviewed. Thirty-four severely head-injured patients who talked prior to deteriorating to a Glasgow Coma Scale (GCS) score of 8 or less were identified. Of those 34 patients, 18 died or were left vegetative and 16 recovered. While there were certain common factors between those who talked and died and those who talked and recovered, there were also significant differences. The common factors between the two groups were the length of time to deterioration or operative intervention (16 versus 18 hours, respectively), and the initial GCS scores (12.6 versus 12.4, respectively). The primary differences between the groups included the mean age, the degree of midline shift seen on computerized tomography (CT), and the presence of subdural hematoma. Those who talked at some point postinjury, but who subsequently died, had a mean age of 50 years. Those who talked, deteriorated, and then recovered were found to have a mean age of 32 years. Seven of the 18 patients who talked and died had a shift of greater than 15 mm on CT, while this degree of shift was demonstrated in only one of 16 patients who talked, deteriorated, and recovered. Subdural hematomas were significantly more common in the "talk and die" group, as was the overall need for operation. Since the overwhelming majority of patients with marked shift on CT have surgical lesions, early operative intervention is strongly recommended in these patients, prior to their inevitable deterioration.