Management of head-injured patients in the emergency department: A practical protocol

Cesare Arienta, Manuela Caroli, Sergio Balbi

Research output: Contribution to journalArticlepeer-review


BACKGROUND The management of head-injured patients admitted to emergency departments is not standardized. METHODS The authors performed a retrospective analysis of 10,000 head-injured patients admitted to the Emergency Department of our hospital in a 21-month period and, on the basis of a statistical correlation between each clinical parameter (symptoms and signs upon arrival at the hospital or risk factors) and the presence of intracranial lesions, they propose a practical protocol in an attempt to avoid the overuse of radiologic examinations and yet identify patients with possible life-threatening complications. RESULTS On the basis of this correlation the patients have been divided into four groups. In the first group (called group α) are patients with: no history of loss of consciousness, no vomiting or amnesia, a normal neurologic examination, and minimal if any subgaleal swelling. They can be released into the care of relatives who are given a special instruction sheet (X rays unnecessary). No patient in group α had complications of any kind. The second group (group β) is made up of patients with at least one of the following features: transient loss of consciousness, post-traumatic amnesia, a single episode of vomiting or significant subgaleal swelling. They undergo a computed tomography (CT) scan and if this is normal, only a short period of observation is needed. If CT scan is not available, the skull is X rayed and, if this X ray is negative, the patient is sent home with the warning sheet after an observation period. If a fracture is found, CT scan should be performed promptly. No patient in group β with normal skull X rays developed intracranial lesions. The third group (group γ) contains patients with at least one of the following symptoms: impaired consciousness, repeated episodes of vomiting, neurologic deficits, otorrhagia, otorrhea, rhinorrea, signs of basal skull fracture, seizures, penetrating or perforating wounds, lack of cooperation for varying reasons, patients who have undergone previous intracranial operations or been affected by coagulopathy or submitted to anticoagulant therapy, and finally, epileptic or alcoholic patients. They receive a CT scan immediately and, if necessary, again prior to discharge. Six patients in group γ with GCS = 15 upon admission were operated on for intracranial hematoma. The fourth group (group δ) is composed of comatose patients. Immediately following resuscitation maneuvers and prior to any surgical intervention, they undergo a CT scan. A linear association between the severity groups and the presence of intracranial lesions has been demonstrated. CONCLUSIONS The present protocol stresses the importance of the patient's clinical and anamnestic evaluation upon arrival in the Emergency Department, especially in minor head injuries.

Original languageEnglish
Pages (from-to)213-219
Number of pages7
JournalSurgical Neurology
Issue number3
Publication statusPublished - Sep 1997


  • Computed tomography
  • Emergency department
  • Head injury
  • Practical protocol

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery


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