Outcome of head injuries in general surgical units with an off-site neurosurgical service.

Abstract

In order to cope with bed shortages in the only neurosurgical unit (NSU) in KwaZulu-Natal, it has become necessary to manage head injured patients in a general surgical unit (GSU) at the referral hospitals in consultation with the NSU. This study was undertaken to assess the outcome of patients with head injuries managed in a GSU in consultation with a regional NSU. A prospective pilot study was carried out in a single surgical unit over an 18-month period (July 1997-December 1998), followed by a larger prospective study over a 6-month period (January-June 2001). All patients with head injuries severe enough to warrant admission to hospital (GCS < or =15 or 15 with localising signs) were included. The pilot study comprised 86 patients and the subsequent study comprised 230 patients, giving a total of 316 patients in the whole study. The mean age was 31 +/- 12 years. Following consultation with the NSU, 265 (84%) patients were managed in the GSU and 51 (16%) required transfer to the NSU. Forty-one patients died giving a mortality rate of 13%. Twenty eight of the 42 patients with GCS < or =8 died (67%) compared to 13 out of 274 with GCS >8 (5%) (p<0.0001). Eleven of the 51 patients destined to the NSU died (22%) compared to 30 of 265 in the GSU (11%) (p=0.046). The average hospital stay was 10 +/- 18 days. Forty surviving patients (17%) from the GSU and 20 from the NSU (51%) were discharged with neurological sequelae (p<0.001). Head trauma is associated with high morbidity and mortality. Non-surgical treatment of traumatic brain injury at the referral hospital by the GSU is acceptable practice. Outcome is determined primarily by the GCS on presentation. NSU patients had a significantly higher mortality rate. A delay before surgery did not seem to affect outcome.