G. M. Teasdale

Head-injured patients were examined by a number of observers whose assessments were compared. Considerable discrepancies occurred when overall "levels" of consciousness and coma were used, and also with some terms which are in common use. More consistent assessments were obtained by employing the "Glasgow Coma Scale," which describes eye opening, verbal behaviour, and motor responsiveness. Nurses and general surgeons were as consistent as neurosurgeons when using this scale, and it was relatively resistant to language or cultural differences between observers. The practical reliability of the Glasgow scale enhances its value, both for monitoring individual cases and for making meaningful comparisons between series of patients with acute brain damage.

OBJECTIVE: To determine the factors influencing the risk of an acute traumatic intracranial haematoma in children and adults with a recent head injury. DESIGN: Prospective study of incidence of risk factors in samples of patients attending accident and emergency departments and in all patients having an acute traumatic intracranial haematoma evacuated in one regional neurosurgical unit during 11 years. SETTING: Accident and emergency departments in Scotland or Teesside and regional neurosurgical centre in Glasgow. PATIENTS: 8406 Adults and children (less than or equal to 14 years) who attended accident and emergency departments and 1007 consecutive patients who had an operation for an acute traumatic intracranial haematoma. Data were complete in 8366 and 960 patients respectively. RESULTS: Overall, children were less at risk than adults (one in 2100 v one in 348 respectively). In both age groups the presence of a skull fracture and changes in conscious level permitted identification of subgroups of patients with widely differing degrees of risk. In children the absolute risk ranged from one in almost 13,000 without a fracture or altered conscious level to one in 12 for a child in a coma and with a fracture; the pattern was similar in adults, the risks in corresponding groups ranging from one in almost 7900 to one in four. CONCLUSIONS: Although children attending hospital after a head injury have a lower overall risk of a traumatic haematoma, the main indicators of risk, a skull fracture and conscious level, are the same as in adults, and the pattern of their combined effect is similar. Guidelines for managing adults with recent head injury may therefore be applied safely to children; with the increasing provision of facilities for computed tomography they should be revised to ensure early scanning of more patients with head injury.