Journal Article

Factors affecting mortality after traumatic brain injury in a resource-poor setting

Tom Richard Okello, D. Ezati, D. Nyeko, W. Kyegombe, Neil J Scolding, Ronald Okidi, D. M. Ogwang

2020

Overview

Background Traumatic brain injury (TBI) is a major cause of long‐term disability and economic loss to society. The aim of this study was to assess the factors affecting mortality after TBI in a resource‐poor setting. Methods Chart review was performed for randomly selected patients who presented with TBI between 2013 and 2017 at St Mary's Hospital, Lacor, northern Uganda. Data collected included demographic details, time from injury to presentation, and vital signs on arrival. In‐hospital management and mortality were recorded. Severe head injury was defined as a Glasgow Coma Scale score below 9. Results A total of 194 patient charts were reviewed. Median age at time of injury was 27 (i.q.r. 2–68) years. The majority of patients were male (M : F ratio 4·9 : 1). Some 30·9 per cent of patients had severe head injury, and an associated skull fracture was observed in 8·8 per cent. Treatment was mainly conservative in 94·8 per cent of patients; three patients (1·5 per cent) had burr‐holes, four (2·1 per cent) had a craniotomy, and three (1·5 per cent) had skull fracture elevation. The mortality rate was 33·0 per cent; 46 (72 per cent) of the 64 patients who died had severe head injury. Of the ten surgically treated patients, seven died, including all three patients who had a burr‐hole. In multivariable analysis, factors associated with mortality were mean arterial pressure (P = 0·012), referral status (P = 0·001), respiratory distress (P = 0·040), severe head injury (P = 0·011) and pupil reactivity (P = 0·011). Conclusion TBI in a resource‐poor setting remains a major challenge and affects mainly young males. Decisions concerning surgical intervention are compromised by the lack of both CT and intracranial pressure monitoring, with consequent poor outcomes. Antecedentes La lesión cerebral traumática (traumatic brain injury, TBI) es un insulto al cerebro causado por una fuerza física externa que produce un estado de conciencia disminuido o alterado, lo que resulta en un deterioro de las capacidades cognitivas o del funcionamiento físico. Es una causa importante de discapacidad a largo plazo y pérdida económica para la sociedad. El objetivo de este estudio fue evaluar los factores que afectan a la mortalidad después de una TBI en un entorno de escasos recursos. Métodos Se realizó la revisión de historias clínicas de pacientes seleccionados al azar que habían presentado una TBI entre 2013 y 2017 en el Hospital St. Mary's, un hospital privado sin ánimo de lucro ubicado en el distrito de Gulu, Lacor, en el norte de Uganda. Se recogieron datos de las características demográficas, intervalo de tiempo entre la lesión y la atención médica, y signos vitales a la llegada al hospital. Se registró también el manejo hospitalario y la mortalidad. El traumatismo craneal grave se definió como aquel con una escala de coma de Glasgow (Glasgow Coma Scale, GCS) por debajo de 9. Resultados Se revisaron 194 historias clínicas de pacientes. La mediana de edad en el momento del traumatismo fue de 27 (rango intercuartílico de 2 a 68) años. La mayoría eran varones con una relación varón:mujer de 4,9:1. En el 38,1% de los casos los traumatismos craneales fueron calificados como graves y se observó una fractura de cráneo asociada en el 8,8% de los pacientes. Los tratamientos ofrecidos fueron principalmente conservadores en el 94,9%; tres pacientes (1,6%) precisaron trépanos, en cuatro pacientes (2,1%) se realizó una craneotomía y otros tres pacientes (1,6%) precisaron elevación de una fractura craneal con hundimiento. La mortalidad fue del 33,0%; El 71,9% de ellos tenían un traumatismo craneal grave. Entre los pacientes tratados quirúrgicamente, siete (70%) murieron, incluidos los tres pacientes en los que se realizó un trépano. Los factores asociados con la mortalidad en el análisis multivariable fueron la presión arterial media (P < 0,05), el estado en el traslado (P < 0,05), la dificultad respiratoria (P = 0,040), el traumatismo craneal grave (P = 0,012) y la reactividad pupilar (P = 0,011). Conclusión El TBI en un entorno con pocos cursos continúa siendo un desafío importante, afectando principalmente a varones jóvenes. Las decisiones relativas a la intervención quirúrgica y el momento de su práctica están seriamente comprometidas por la falta de disponibilidad de tomografía computarizada (TAC) y monitorización de la presión intracraneal, lo que conlleva unos pobres resultados. Traumatic brain injury (TBI) in 194 patients in a resource‐poor setting was analysed. Some 30·9 per cent had severe TBI, and associated skull fracture was observed in 8·8 per cent. Treatments offered were mainly conservative. The mortality rate was 33·0 per cent, with 72 per cent resulting from severe head injury. Seven of ten surgically treated patients died, including all three patients who had received a burr‐hole. Factors associated with mortality in multivariable analysis were mean arterial pressure, referral status, respiratory distress, severe head injury and pupil reactivity. TBI remains a major challenge in resource‐poor settings, with the younger male population mainly involved. Decisions regarding interventions are greatly compromised by the lack of CT and intracranial pressure monitoring. Mortality remains high

• Publisher: Oxford University Press (OUP),John Wiley & Sons, Ltd,Oxford University Press
• Subject: Adolescent / Adult / Age / Aged / Brain Injuries, Traumatic / Brain Injuries, Traumatic - diagnostic imaging / Brain Injuries, Traumatic - mortality / Brain Injuries, Traumatic - therapy / Child / Child, Preschool / Coma / Conservative Treatment / Conservative Treatment - statistics & numerical data / Female / Fractures / Glasgow Coma Scale / Head injuries / Hospitals / Humans / Logistic Models / Male / Males / Marital status / Middle Aged / Morbidity / Mortality / Multivariate Analysis / Original / Original Articles / Patients / Pupil / Radiography / RD1-811 / Retrospective Studies / Skull Fractures / Skull Fractures - complications / Skull Fractures - epidemiology / Statistical analysis / Studies / Surgery / Tomography, X-Ray Computed / Trauma / Traumatic brain injury / Trephining / Trephining - statistics & numerical data / Uganda / Uganda - epidemiology / Ventilation / Ventilators / Young Adult