Is Mechanical Ventilation Mandatory for the Management of Severe Head Injury? Outcome in 53 Medically Managed Severe Head Injury Patients, Without Ventilatory Support: A Prospective Study

BACKGROUND: Severe head injury (SHI) is a major cause of mortality and morbidity across the world. The current paradigm of management of SHI involves admission in Intensive Care Unit (ICU), mechanical ventilation (MV), and intracranial pressure (ICP) monitoring. Such resources are expensive and often unavailable in the developing world. OBJECTIVE: MV or ICP monitoring was unavailable for our patients due to the scarcity of resources. Hence, other alternatives were considered to prevent secondary brain injury due to hypoxia. This study assessed the outcome after SHI when managed with an early tracheostomy (ET). METHODS: This prospective observational study over 13 months included all medically managed SHI patients without MV or ICP monitoring. The Glasgow outcome scale (GOS) was assessed at discharge and compared with published historical data reported after treatment in an ICU environment. RESULTS: Our study included 53 unoperated patients with SHI among 1862 patients with traumatic brain injury. Overall mortality was 24.5% (13/53) and compared favorably with reported mortality of 25%–40% reported from centers using intensive management. At discharge, the favorable outcome with a GOS of 4 or 5 was seen in 39.6% (21/53). CONCLUSION: With ET, the results of management of SHI in our patients were comparable to results reported after MV in an ICU environment. Hence, ET is a cost-effective alternative when resources are scarce. MV should be used if hypoxia persists after tracheostomy. Although MV effectively prevents hypoxia, it has complications. We conclude that although MV was unavailable for our patients, they did not have the complications associated with it.