Do we really need 24-h observation for patients with minimal brain injury and small intracranial bleeding? The Bernese Trauma Unit Protocol.

BACKGROUND: Traumatic brain injury is one of the most common reasons for admission to hospital emergency departments. However, optimal diagnosis and treatment protocols remain controversial. The aim of this study is to assess whether a specific group of patients can be discharged from the hospital without 24-h neurological observation.
METHODS: Retrospective analysis was performed for 1078 patients with a minor isolated head injury admitted to the authors' Emergency Department for 24-h observation. Exclusion criteria included intracranial bleeds with maximum diameter above 5 mm or multiple (>1) bleeds, a history of inherited coagulopathy or anticoagulant therapy, platelet aggregation inhibitor therapy, intoxication or multiple associated injuries. Furthermore, patients who had no-one to observe them at home or who lived more than 1 h away were excluded from the study.
RESULTS: 110 patients presented with an isolated small intracranial bleed (<5 mm) with a Glasgow Coma Scale (GCS) of 13-15. Of these patients, 46% exhibited small intracerebral haematomas, 23% traumatic subarachnoid haematomas, 9% epidural haematomas and 7% subdural haematomas. Nine patients presented with a GCS of 13/15, 30 patients with a GCS 14/15 and 71 patients with a GCS 15/15. 85% of all patients regained GCS 15/15 within 1 h after admission and 15% within 2 h after admission. All patients maintained their GCS 15/15 over the 24-h period.
CONCLUSIONS: Standard 24-h observation may not be required for adult patients with single intracranial bleeds with maximum diameter less than 5 mm, without a history of inherited coagulopathy or anticoagulant therapy, platelet aggregation inhibitor therapy, intoxication or multiple associated injuries. The decision for discharging patients may be made from the clinical picture. This might help to spare hospital resources and reduce unnecessary hospitalisations.