Patients who sustained an external compound
head injury with no serious systemic injury and no pre-established
infection and who continued the entire treatment were studied prospectively for their proposed grade of compound injury in relation to infective complications, unfavorable Glasgow Outcome Scale (GOS), delayed
seizures, mortality, and
hospital stay for 3 months. Appropriate univariate and multivariate analyses were performed.
RESULTS: Among a total of 344 patients, 182 (53%) had no dural violation or midline shift (Grade 1), 56 (16%) had
cerebrospinal fluid leak or
pneumocephalus (Grade 2), 34 (10%) had exposed brain (Grade 3), 47 (14%) had midline shift (Grade 4), and 25 (7%) had both exposed brain and midline shift (Grade 5). Each successive grade of compound injury had significant incremental impact on all the outcome measures studied. Infective complications in Grades 1 to 5 were noted among 7%, 9%, 27%, 28%, and 36% of patients, respectively (P < 0.001). There was a significant difference in unfavorable GOS (23% vs. 56%, odds ratio [OR] 4.3, P < 0.001) and mortality (17% vs. 42%, OR 3.5, P < 0.001) between Grades 1-2 and Grades 3-5. Delayed
seizures were noted in 4%, 4%, 9%, 13%, and 16% of patients in Grades 1-5 (P = 0.04). The median
hospital stay was 1, 3, 6, 6, and 8 days, respectively (P < 0.001). All patients in Grades 4-5 (72) underwent surgery. Only 32 of 182 (18%) patients in Grade 1, 9 of 56 (16%) patients in Grade 2, and 23 of 34 (68%) patients in Grade 3 underwent surgical
debridement, whereas the rest were managed conservatively. Patients who were managed conservatively had significantly lower infective complications (3% vs. 25%, OR 9.67, P < 0.001) in Grade 1, and (2% vs. 44%, OR 36.8, P = 0.002) in Grade 2, compared with those who underwent surgical
debridement. In multivariate analysis, the proposed grade had significant independent association with
infection (P < 0.001), unfavorable GOS (P = 0.01), delayed
seizures (P = 0.001), and
hospital stay (P < 0.001), and each successive grade had significant incremental impact on both infective complications and unfavourable GOS, independent of GCS and other prognostic factors.
CONCLUSION: The new grading scheme appears to be of practical clinical significance. It shows significant statistical associations with the rates of
infection, unfavorable neurologic outcome, delayed
seizures, mortality, and duration of
hospital stay. The incremental impact of each successive grade on infective complications and unfavorable GOS was independent of GCS and other prognostic factors.
Conservative management had significantly lower
infection compared to surgical
debridement, at least in patients with Grades 1 and 2.