• P Mathew, D M Nott, and D Gentleman.
• Department of Surgery, Medicins Sans Frontiers , Paris , France.
• Ann R Coll Surg Engl. 2016 Mar 1; 98 (3): 198-205.

IntroductionIn many parts of the world, access to a CT scanner remains almost non-existent, and patients with a head injury are managed expectantly, often with poor results. Recent military medical experience in southern Afghanistan using a well-equipped surgical facility with a CT scanner has provided new insights into safe surgical practice in resource-poor environments.MethodsAll cases of children aged under 16 years with penetrating head injury who were treated in a trauma unit in southern Afghanistan by a single neurosurgeon between 2008 and 2010 were reviewed. Based on a previously published retrospective review, a clinical strategy aimed specifically at generalist surgeons is proposed for selecting children who can benefit from surgical intervention in environments with no access to CT scanners.ResultsFourteen patients were reviewed, of whom three had a tangential wound, 10 had a penetrating wound with retained fragments and one had a perforating injury. Two operations for generalist surgeons are described in detail: limited wound excision; and simple decompression of the intra-cranial compartment without brain resection or dural repair.ConclusionsIn resource-poor environments, clinically-based criteria may be used as a safe and appropriate strategy for selecting children who may benefit from relatively straightforward surgery after penetrating brain injury.

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