Postconcussive hospital observation of alert patients in primary trauma center

The medical justification for many postconcussive hospital admissions (one fourth of all trauma admissions) is unsettled, as are the potential legal consequences of nonadmission. Three hundred thirty-three patients with Class I level of consciousness (9) (alert, responsive to questions and complex commands, may be disoriented and/or confused) were admitted during a 6-month period. Seventy-nine per cent had sustained loss of consciousness. Eighty-one per cent were admitted solely for neurologic observation. Thirteen per cent of the patients had skull fractures. Patients admitted with localized neurologic findings were most likely to have skull fractures (8/16). Thirty per cent of the confirmed skull fractures occurred in patients without 'high yield' criteria for skull roentgenograms. No deaths and no neurologic sequelae occurred among the patients without skull fractures. In contrast, among the 43 patients with skull fractures, one patient died of neurologic injuries, seven patients developed major neurologic sequelae, and eight patients required neurosurgical intervention. In our series, only the presence of a skull fracture was of grave prognostic significance among patients with Class I level of consciousness following closed head injuries. No benefit was derived from the precautionary admission of patients with Class I level of consciousness following closed head injuries who did not sustain skull fractures.