Severe traumatic brain lesions in Sweden. Part I: Aspects of management in non-neurosurgical clinics

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Abstract
This paper reports a study of 587 consecutive patients treated for severe traumatic brain lesions (coma greater than 6 hours) during 1977-1984. Epidemiology, management and outcome were documented in 425 patients during the first part of the study (1977-1982) as a basis for future efforts at improvements. A total of 70-80 patients with severe head injuries were admitted annually to the Department of Neurosurgery in Lund and 88.6% of these patients were referred from 14 local hospitals, most of which are situated more than 50 km from Lund. Half of the patients were older than 40 years and 25% older than 60. Focal intracranial mass lesions were diagnosed in 64% of the patients. In the total study 41% of the patients were described as 'talk and deteriorate' and 13% as 'talk and die'. In 1983 a protocol for primary management was introduced in all local hospitals in the region. The management protocol caused a significant decrease (p less than or equal to 0.05) in the number of explorative craniotomies in local hospitals and a virtual disappearance of late surgical procedures (greater than 6 hours after injury). A fall was observed in the number of patients arriving at the Department of Neurosurgery with respiratory insufficiency. The study illustrates the epidemiology of severe head injuries in Sweden and the present state of management of these patients in non-neurosurgical departments. It is concluded that an overall outcome comparable to other reported series is also feasible in regions with a relatively sparse population and large geographical distances provided that strict recommendations for initial management are given to the local hospitals.