Traumatic subdural haematoma: integrating case-based clinical judgement with guidelines

Reference: Samitinjay AKarri SRKhairkar P, et al. Traumatic subdural haematoma: integrating case-based clinical judgement with guidelines,

Samitinjay et al. bring up two very crucial points in this case report: the importance of being able to deviate from guidelines which were not written with developing country resources in mind, and the necessity to train surgical residents in providing basic neurosurgical care.

Guidelines are frameworks for how to work up and treat your patients according to either clinical, laboratory or imaging results. Whether it be in diagnosis or treatment of the patient, these flow charts are drawn up assuming the presence of resources and adequately trained physicians. In this case report, we are offered a glimpse into the medical management of a patient with severe Traumatic Brain Injury whom, according to the Brain Trauma Foundation guidelines should have undergone surgical removal of the hematoma. Through a global health perspective we come to understand the conservative and efficient management of this patient in an environment where the proposed guideline interventions are not attainable due to financial limitations as well as sparse level 1 trauma centers in the area. Henceforth the author brings to our attention the imperative necessity to deviate from such guidelines, use our acumen, design a patient centered treatment plan which not only encompasses medical considerations but his socioeconomic and family status as a whole.

Secondly, a valuable suggestion, that of training surgical residents in basic neurosurgical procedure, such as drilling bore holes. The bore holes can relieve intracranial pressure, potentially evacuate a epidural hematoma and prevent potential herniation through the foramen magnum. There are global initiatives in regions where there is a lack of medically trained personnel which train non physicians to perform basic neurosurgical procedures[1]. These can be incredibly successful, do not require years of training and improve patient outcome at a local level.

Through this global health case report we understand the importance of working with the tools we have on board, which does not necessarily preclude good patient outcome. Secondly there are ways in which we can train local healthcare givers life saving procedures which they can provide throughout hospitals across the country.

Author: Chloe Pinto

[1] S1474-4422(17)30246-6