Emergency Department Outcome of Patients with Traumatic Brain Injury – A Retrospective Study from Pakistan

Introduction: Traumatic brain injury (TBI) is a leading cause of global morbidity and mortality in both adults and children. As with other severe injuries, the outcome of TBIs is also gravely related to the quality of emergency care. Effective emergency care significantly contributes to reduced morbidity and mortality. This study was ensued to evaluate the characteristics of TBIs in Pakistan and their outcomes in the emergency department (ED).

Methods: This retrospective review included records of all TBI patients seen in the Neurosurgical ED of Jinnah Postgraduate Medical Centre, Karachi, Pakistan from 1st September 2019 till 7th December 2019.

Results: During the study period, 5,546 patients with TBI were seen in the ED; an estimated 56.5 patients per day. There were 4,054 (73.1%) male and 1,492 (26.9%) female patients. Most of these (26%) were of age <10 years. The most common culprit of TBI was road traffic accidents (RTAs) (n=2,163; 39%) followed by accidental fall (n=1,785; 32.2%). Head injury was mostly mild (n=4,034; 72.8%) and only 265 (4.7%) had a severe injury. Only 10% (n=549) patients were admitted for further treatment, 16% were managed in the ED then discharged, and 67% were immediately discharged from the ED after the first examination and necessary management. The ED mortality rate of TBIs was 2.2% (n=123/5,546) in our study. All of these cases had severe head injuries.

Conclusion: Major culprits of TBI are RTAs and accidental falls. TBIs are mostly mild-to-moderate and the ED mortality rate is low.

A Consensus Statement for Trauma Surgery Capacity Building in Latin America

Background: Trauma is a significant public health problem in Latin America (L.A.), contributing to substantial death and disability in the region. Several LA countries have implemented trauma registries and injury surveillance systems. However, the region lacks an integrated trauma system. The consensus conference’s goal was to integrate existing L.A. trauma data collection efforts into a regional trauma program and encourage the use of the data to inform health policy.

Methods: We created a consensus group of 25 experts in trauma and emergency care with previous data collection and injury surveillance experience in the L.A. region. Experts participated in a consensus conference to discuss the state of trauma data collection in L.A. We utilized the Delphi method to build consensus around strategic steps for trauma data management in the region. Consensus was defined as the agreement of ≥ 70% among the expert panel.

Results: The consensus conference determined that action was necessary from academic bodies, scientific societies, and ministries of health to encourage a culture of collection and use of health data in trauma. The panel developed a set of recommendations for these groups to encourage the development and use of robust trauma information systems in L.A. Consensus was achieved in one Delphi round.

Conclusions: The expert group successfully reached a consensus on recommendations to key stakeholders in trauma information systems in L.A. These recommendations may be used to encourage capacity-building in trauma research and trauma health policy in the region

Decompressive Craniectomy in Traumatic Brain Injury: An Institutional Experience of 131 Cases in Two Years

Decompressive craniectomy (DC) effectively reduces intracranial pressure (ICP), but is not considered to be a first-line procedure. We retrospectively analyzed sociodemographic, clinical, and surgical characteristics associated with the prognosis of patients who underwent DC to treat traumatic intracranial hypertension (ICH) at the Restauração Hospital (HR) in Recife, Brazil between 2015 and 2016, and compared the clinical features with surgical timing and functional outcome at discharge. The data were collected from 131 medical records in the hospital database. A significant majority of the patients were young adults (age 18-39 years old; 75/131; 57.3%) and male (118/131; 90.1%). Road traffic accidents, particularly those involving motorcycles (57/131; 44.5%), were the main cause of the traumatic event. At initial evaluation, 63 patients (48.8%) were classified with severe traumatic brain injury (TBI). Pupil examination showed no abnormalities for 91 patients (71.1%), and acute subdural hematoma was the most frequently observed lesion (83/212; 40%). Glasgow Outcome Scale (GOS) score was used to categorize surgical results and 51 patients (38.9%) had an unfavorable outcome. Only the Glasgow Coma Scale (GCS) score on admission (score of 3-8) was more likely to be associated with unfavorable outcome (p-value = 0.009), indicating that this variable may be a determinant of mortality and prognostic of poor outcome. Patients who underwent an operation sooner after injury, despite having a worse condition on admission, presented with clinical results that were similar to those of patients who underwent surgery 12 h after hospital admission. These results emphasize the importance of early DC for management of severe TBI. This study shows that DC is a common procedure used to manage TBI patients at HR.

Emergency department management of traumatic brain injuries: A resource tiered review

Introduction
Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma.

Objectives
Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework.

Methods
A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings.

Key recommendations
Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.

A systematic review and quality analysis of pediatric traumatic brain injury clinical practice guidelines.

Traumatic brain injuries (TBI) are a significant cause of mortality and morbidity for children globally. Adherence to evidence-based treatment guidelines have been shown to improve TBI outcomes. To inform the creation of a pediatric TBI management guideline for a low and middle income country context, we assessed the quality of available clinical practice guidelines (CPGs) for the acute management pediatric TBI.Articles were identified and retrieved from MEDLINE, EMBASE, Cochrane Library, LILACS, Africa-Wide Information and Global Index Medicus. These articles were screened by four reviewers independently. Based on the eligibility criteria, with the exception of literature reviews, opinion papers and editor’s letters, articles published from 1995 to November 11, 2016 which covered clinical recommendations, clinical practice or treatment guidelines for the acute management of pediatric TBI (within 24 hours) were included for review. A reference and citation analysis was performed. Seven independent reviewers from low, middle and high income clinical settings with knowledge of pediatric TBI management appraised the guidelines using the AGREE II instrument. Scores for the CPGs were aggregated by domain and overall assessment was determined.We screened 2372 articles of which 17 were retained for data extraction and guideline appraisal. Except for one CPG from a middle income country, the majority (16/17) of the guidelines were developed in high income countries. Seven guidelines were developed specifically for the pediatric population, while the remaining CPGs addressed the acute management of TBI in both adult and pediatric populations. The New Zealand Guideline Group (NZGG, 2006) received the highest overall assessment score of 46/49 (93.88%) followed by the Scandinavian Neurotrauma Committee (SNC, 2016) with a score of 45/49 (91.84%) followed by the Scottish Intercollegiate Guideline Network (SIGN, 2009) and Brain Trauma Foundation (BTF 2012) both with scores of 44/49 (89.80%). CPGs from Cincinnati Children’s Hospital (CCH 2006) and Sao Paulo Medical School Hospital/Brazilian Society of Neurosurgery (USP/BSN, 2001) received the lowest score of 27/49 (55.10%) subsequently followed by the Appropriateness Criteria (ACR, 2015) with 29/49 (59.18%). The domains for scope and purpose and clarity of presentation received the highest scores across the CPGs, while applicability and editorial independence domains had the lowest scores with a wider variability in score range for rigor of development and stakeholder involvement.To our knowledge, this is the first systematic review and guideline appraisal for pediatric CPGs concerning the acute management of TBI. Targeted guideline creation specific to the pediatric population has the potential to improve the quality of acute TBI CPGs. Furthermore, it is crucial to address the applicability of a guideline to translate the CPG from a published manuscript into clinically relevant local practice tools and for resource limited practice settings.