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Assessment of the Severity of Head Injury

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Assessment of the Severity of Head Injury J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.7.647 on 1 July 1976. Downloaded from Journal ofNeurology, Neurosurgery, andPsychiatry, 1976, 39, 647-655 Assessment of the severity of head injury BRYAN JENNETT From the University Department of Neurosurgery, Institute of Neurological Sciences, Glasgow SYNOPSIS Ranking of head injuries by severity is an essential part of clinical management, of prognosis, oftreatment trials, and oflegal assessment for compensation. Various methods ofassessing severity are reviewed. No one scale is appropriate for all types of injury, or in all circumstances. A check list is provided which should enable every injury to be assessed; its use would facilitate comparison between individual cases of head injury, and between reports from different studies. 'Head injury' is used much more commonly than skull, and there is only a possibility ofintracranial the several rubrics of the International Classifica- complications. This accounts for classifications Protected by copyright. tion of Disease (ICD) which it encompasses; yet based on aposteriori evidence-deciding that the the term itself is not recognized as an entity in injury was not severe because the patient has this classification. In practice it can embrace all made a good recovery. Contemporary concepts degrees of severity from a symptomless bump to of the pathological basis of milder injuries have a blow which causes overwhelming brain damage. exposed the fundamental fallacy ofthis argument, Yet what is necessary for an incident to qualify in that mild concussion is now believed to produce as a head injury is by no means self-evident. Such permanent brain damage, albeit of a minor minimum requirements must indeed be arbitrary degree. For some practical purposes, however, it and may differ according to circumstances; they may be legitimate to construct a classification should therefore always be stated. For more which depends on outcome, because this can take serious head injuries it is important to have a account of the net effect of the initial impact and practical scale of severity for the use of staff of subsequent complications. This is certainly dealing with the early care of individual cases, as what matters to the patient and his family-not well as to facilitate communication between how hard he was hit, but what the consequences http://jnnp.bmj.com/ doctors and those concerned with outcome were. However, those concerned with manage- (relatives, employers, and lawyers). Without ment in the acute stage, whether dealing with some such scale prognosis and the efficacy of individual patients or with evolving a strategy for alternative methods of management cannot be hospitals or regions, must have a means of properly discussed, nor can epidemiological assessing severity at an early stage-before the surveys be undertaken. Much of the confusion in consequences of the injury are known. As one the field of head injury arises from failure to of the main goals of head injury management is on September 27, 2021 by guest. describe severity in terms which can be generally the prevention of complications, of what some understood and applied. have called the 'second accident', it is necessary to devise means of recognizing soon after injury what has already happened, in order to dis- INITIAL AND ULTIMATE SEVERITY tinguish this from secondary events. Clinicians What matters in a head injury is brain damage, may feel a need to include a risk factor for specific whether actual or potential. In the majority of complications as part of the categorization of patients, however, the brunt falls on the scalp or the initial injury. But to do this would make the classification much more complex, involving (Accepted 2 March 1975.) probability statistics. 647 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.7.647 on 1 July 1976. Downloaded from 6486Bryan Jennett Classification of severity, as a practical rather While it is true in general that death is an indicator than a theoretical exercise, has therefore to serve of the most severe injuries, it seems likely that a different purposes. It seems inevitable that more number of pre-hospital deaths ascribed to head than one scale will be necessary, according to injury are due to other causes, such as fracture- circumstances. What then becomes important is dislocation of the cervical spine or multiple to indicate clearly how these relate to each other. injuries; also that some deaths occurring in It is important also to use only terms which are hospital are in patients in whom the impact descriptive and unambiguous; they should injury was not overwhelming. A recent analysis describe what is or what has been observed, of 151 injuries in a neurosurgical unit revealed rather than what has been deduced or guessed. that 38% had talked at some stage after injury In particular, attempts to describe clinical head (Reilly et al., 1975). Many ofthese had developed injuries in respect of the presumed pathology intracranial haematoma; others had suffered should be avoided, because in most cases that brain swelling and raised intracranial pressure, pathology will never be known. Nothing has ischaemic/hypoxic brain damage, or meningitis. done more to confuse this field than continuing Had these complications not developed, many of to classify cases according to the supposed these patients might have been regarded as occurrence of concussion, contusion, and lacera- having sustained only a minor or moderately tion of the brain. No laboratory test is available severe head injury. Some ofthose who died before which will measure brain damage or dysfunction, admission to hospital may likewise have suffered such as can be used to assess tissue damage in the only minor brain damage, but have developed Protected by copyright. lungs or the kidneys. That is why classification respiratory obstruction or circulatory failure due must rest on descriptive terms, with all the either to complications of their unconscious state problems of definition which inevitably result. or to a combination of multiple injuries. Clearly Wisely chosen and adequately validated, however, there are certain fallacies in using death as an there is no reason why such terms should not indicator of the most severely injured. become operationally useful. hOSPITAL ADMISSION The fact of hospital admission is a frequently used measure of ADMINISTRATIVE CLASSIFICATION severity. No central statistics are kept for The only regularly collected statistics about head accident/emergency departments so there is no injuries in Britain apply to registered deaths and evidence to confirm whether even most of those to patients admitted to hospital. These provide a admitted are definitely more severe than most of readily available data source, and consequently those sent home. There is no generally agreed statements about the prevalence of injuries of admission policy in British hospitals, and practice http://jnnp.bmj.com/ different severities are frequently based on them. varies from place to place. Only partly does this For this reason they are discussed first, although, depend on variations in medical opinion; the as will become clear, they are subject to serious availability of facilities may be a more important limitations. factor. If accident and emergency equipment and staffing are of a high standard admission rates DEATH AS A MEASURE OF SEVERITY Deaths are may be kept relatively low; this may also happen commonly reported as due to 'head injury' on if there are overnight beds in which patients are on September 27, 2021 by guest. the basis of the cause stated on the death certifi- not recorded as inpatient admissions. About a cate. There is no formal restriction on the terms third of patients admitted to hospital with head used on the certificates but presumably there is a injury have another injury, and it may be this convention which determines inclusion under rather than the head injury which leads to 'head injury' by those responsible for assembling hospital admission, or which determines the statistics from them. As 60% of deaths ascribed length of stay; this is another fallacy in regarding to head injury occur before there is time for inpatient statistics as a reliable indicator of the admission to hospital (Field, 1976), the decision severity of head injury. that head injury is in fact the cause of death often Hospital admissions are ascribed to head depends on the coroner and his pathologist. injury according to which ICD rubrics have been J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.7.647 on 1 July 1976. Downloaded from Assessment of the severity ofhead injury 649 used by the hospital submitting data for central DURATION OF HOSPITAL STAY The hospital in- analysis. A recent survey of head injury statistics patient inquiry provides information about included the rubrics in Table 1. Notice that this duration of stay in hospital. The patients excludes wound, contusion, and haematoma of discharged within one to two days are likely to the scalp; but it includes fractures of the face have suffered only a mild injurv; it is less certain bones, which in fact comprise 10% ofthe 140 000 that those detained more than seven days admissions annually under the above rubrics. necessarily have a severe injury, because discharge The distribution of cases between these different may have been delayed by an associated injury, rubrics may well reflect the custom of the or by the ready availability of beds. Nonetheless personnel completing
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