The patient with a closed head injury presents a different problem from the one with an obvious fracture, where the need and value of surgery are quite evident. For the patient who has a closed head injury, a decision must be made as to the opportune time for surgery or other means of treatment. Clinically, it is sometimes impossible to differentiate between a subdural hematoma and cerebral contusion with edema. Accordingly, if the patient's level of consciousness is becoming increasingly impaired or shows no improvement, the pathological neurologic signs are increasing, or the vital signs are indicative of increasing intracranial pressure, burr holes should be placed on both sides of the head. Bleeding from the cerebral vessels is usually easier to control if surgery can be delayed for 8 to 10 hours after trauma. Hence, surgery prior to that time is reserved for those patients who present a clinical picture
WANNAMAKER GT. Acute Head Injuries. AMA Arch Surg. 1957;75(5):738–739. doi:10.1001/archsurg.1957.01280170048028
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