Injury-to-Admission Delay Beyond 4 Hours Is Associated with Worsening Outcomes for Traumatic Brain Injury in Cambodia

Ernest J Barthélemy; Riccardo Spaggiari; Jacquelyn Corley; Jacob R Lepard; Steven J Staffa; Vycheth Iv; Franco Servadei; Kee B Park

doi:10.1016/j.wneu.2019.02.019

Injury-to-Admission Delay Beyond 4 Hours Is Associated with Worsening Outcomes for Traumatic Brain Injury in Cambodia

World Neurosurg. 2019 Jun:126:e232-e240. doi: 10.1016/j.wneu.2019.02.019. Epub 2019 Feb 27.

Authors

Ernest J Barthélemy¹, Riccardo Spaggiari², Jacquelyn Corley³, Jacob R Lepard⁴, Steven J Staffa⁵, Vycheth Iv⁶, Franco Servadei², Kee B Park⁷

Affiliations

¹ Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA. Electronic address: globalneurosurgeon@gmail.com.
² Humanitas University and Research Hospital, Milano, Italy.
³ Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Duke Department of Neurosurgery, Durham, North Carolina, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
⁴ Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA.
⁵ Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Massachusetts, USA.
⁶ Department of Neurosurgery, Preah Kossamak Hospital, Phnom Penh, Cambodia.
⁷ Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.

PMID: 30825623
DOI: 10.1016/j.wneu.2019.02.019

Abstract

Background: In Cambodia, the most common victims of traumatic brain injury (TBI) are men 20-30 years of age involved in motor vehicle collision. Secondary injury sustained by these patients occurs during the time period between initial insult and hospital admission. Strengthening prehospital systems for TBI in low- and middle-income countries (LMICs) such as Cambodia is therefore a key element of the development agenda for universal health equity. We report a retrospective analysis of the relationship between prehospital delays and TBI outcomes among patients from a large government hospital in Cambodia.

Methods: Data were collected from 3476 patients with TBI admitted to a major government hospital in Phnom Penh, Cambodia, from June 2013 to June 2018. Patients with missing data or those admitted >8 hours postinjury were excluded. Statistical analyses examined associations between injury-to-admission delay (IAD) and outcomes such as Glasgow Outcome Scale (GOS) score and length of stay (LOS).

Results: A total of 2125 patients with TBI (76.85% men) were included. The median age was 27 years (interquartile range, 22-37 years). Injury severity at presentation included 1406 mild (66%), 464 moderate (22%), and 240 severe cases (11%). No Glasgow Coma Scale (GCS) data were available for 15 patients (1%). We found an inverse relationship between IAD and GOS score, most evidently for mild and moderate TBI (n = 1870; 88%). Regression analysis revealed a marked decrease in GOS score at the IAD >4-hour threshold. Each 30-minute delay in IAD was correlated with >2-hour increase in LOS for mild (P < 0.001) and moderate TBI (P < 0.001).

Conclusions: In a retrospective cohort of >2000 patients with TBI from Cambodia, we found that increasing IAD was associated with worsening outcome, especially beyond the 4-hour threshold. These data should inform development of prehospital guidelines for TBI care in LMICs.

Keywords: Global health; Global neurosurgery; Global surgery; LMIC; Prehospital care; Sustainable development; TBI.

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Brain Injuries, Traumatic / epidemiology
Brain Injuries, Traumatic / surgery
Brain Injuries, Traumatic / therapy*
Cambodia / epidemiology
Cohort Studies
Emergency Medical Services
Female
Glasgow Coma Scale
Glasgow Outcome Scale
Humans
Length of Stay
Male
Middle Aged
Neurosurgical Procedures / statistics & numerical data
Retrospective Studies
Time-to-Treatment*
Treatment Outcome
Young Adult