Severe traumatic brain injury management in Tanzania: analysis of a prospective cohort

Abstract

OBJECTIVEGiven the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania.METHODSA neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model.RESULTSIn total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model.CONCLUSIONSThe 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.

Affordability impacts therapeutic intensity of acute management of severe traumatic brain injury patients: An exploratory study in Tanzania

“…Patients with severe TBI had a high overall two-week mortality of 59.7% in this study, which is consistent with our earlier published results ( Mangat et al., 2021 ). Our data show a high rate of patients dependent on financial aid (50.7%), a low insurance coverage (7.5%) and high risk of inability to pay (22.3%) amongst severe TBI victims arriving at MNH in urban Dar-es-Salaam.…”

“…Several studies have examined the epidemiology of severe TBI in LMIC and reported gaps in the management of patients due to economic barriers ( Abiiro et al., 2014 ; Bonow et al., 2018 ; Kabore et al., 2017 ; Stewart et al., 2015 ). Our group has recently demonstrated excess mortality of 24% in a large cohort of patients at a tertiary referral center in Tanzania, from gaps in in-hospital care of severe TBI patients resulting in a 2-week mortality of 67% ( Mangat et al., 2021 ). However, data on how economic factors directly influence management and outcomes of severe TBI patients in LMIC are lacking.…”

The effect of the Dar es Salaam neurosurgery training course on self-reported neurosurgical knowledge and confidence

“…This is supported by the finding of lower self-reported knowledge and confidence prior to the course for these topics. Traumatic brain injury and traumatic spinal injury may be more familiar due to the longer and more extensive neurosurgical provision for trauma in East Africa, with traumatic brain and spine injuries research and teaching at MOI for nearly 10 years, ( Leidinger et al., 2019 ; Mangat et al., 2021 ) and possibly the success of previous courses in disseminating principles of trauma care throughout Tanzania and East Africa. ( Santos et al., 2018 ; Kahamba et al., 2013 ; Mangat et al., 2018 )…”

Evaluating the effectiveness of the pre‑hospital trauma life support (PHTLS) program for the management of trauma patients in the pre-hospital emergency based on Kirkpatrick’s evaluation model

“…The collected information focused on treatment details and the clinical progress of each individual. Following the methodology outlined in Mangat et al’s study (2021), the indicators were assessed, and calculations were performed for each patient over 2 weeks [ 22 ]. The information for all trauma patients was collected within 3 months after the course, and this data was then compared in 2- to 5-month period (3 months on average) after the course.…”