Papers

Effect of patients' age on management of acute intracranial haematoma: prospective national study

Philip T Munro, consultant in accident and emergency medicine, ^a Rik D Smith, statistician, ^b Timothy R J Parke, consultant in accident and emergency medicine. ^a

^a Accident and Emergency Department, Southern General Hospital, Glasgow G51 4TF, ^b Scottish Trauma Audit Group, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW

Correspondence to: P T Munro phil.munro{at}sgh.scot.nhs.uk

Objective: To determine whether the management of head injuries differs between patients aged 65 years and those <65.
Design: Prospective observational national study over four years.
Setting: 25 Scottish hospitals that admit trauma patients.
Participants: 527 trauma patients with extradural or acute subdural haematomas.
Main outcome measures: Time to cranial computed tomography in the first hospital attended, rates of transfer to neurosurgical care, rates of neurosurgical intervention, length of time to operation, and mortality in inpatients in the three months after admission.
Results: Patients aged 65 years had lower survival rates than patients <65 years. Rates were 15/18 (83%) v 165/167 (99%) for extradural haematoma (P=0.007) and 61/93 (66%) v 229/249 (92%) for acute subdural haematoma (P<0.001). Older patients were less likely to be transferred to specialist neurosurgical care (10 (56%) v 142 (85%) for extradural haematoma (P=0.005) and 56 (60%) v 192 (77%) for subdural haematoma (P=0.004)). There was no significant difference between age groups in the incidence of neurosurgical interventions in patients who were transferred. Logistic regression analysis showed that age had a significant independent effect on transfer and on survival. Older patients had higher rates of coexisting medical conditions than younger patients, but when severity of injury, initial physiological status at presentation, or previous health were controlled for in a log linear analysis, transfer rates were still lower in older patients than in younger patients (P<0.001).
Conclusions: Compared with those aged under 65 years, people aged 65 and over have a worse prognosis after head injury complicated by intracranial haematoma. The decision to transfer such patients to neurosurgical care seems to be biased against older patients.

What is already known on this topic Older patients with acute intracranial haematomas have significantly higher mortality and poorer functional outcome than younger patients with similar injuries Intracranial haematomas are larger and more common in older patients with head injury than in younger patients Early diagnosis and surgical intervention for operable lesions is a crucial factor in determining patients' outcomes What this study adds Older patients with acute intracranial haematomas were less likely to be transferred for specialist neurosurgical care than younger patients with similar severities of injuries, extracranial injuries, and physiological status at presentation Significant differences in transfer rates related to age were still seen after pre-existing medical conditions were controlled for