The Utility of Local Anesthesia for Neurosurgical Interventions in a Low-Resource Setting: A Case Series.

INTRODUCTION: Trauma is a major contributor to global morbidity and mortality, and injury to the central nervous system is the most common cause of death in these patients. While the provision of surgical services is being recognized as essential to global public health efforts, specialty areas such as neurosurgery remain overlooked. METHOD: This is a retrospective case review of patients with operable lesions, such as extra-axial hematomas and unstable depressed skull fractures that underwent neurosurgical interventions under local anesthesia. RESULTS: A total of 13 patients underwent neurosurgical intervention under local anesthesia. Two and three patients with burr hole decompression of epidural and subdural hematomas, respectively; seven patients had elevation of depressed skull fractures and lastly one patient had an aspiration of a brain abscess. All patients survived with and without residual neurological deficits. CONCLUSION: Access to resources and staff required to deliver general anesthesia is challenging in resource-poor settings. We have therefore begun performing emergent interventions under local anesthesia, with or without conscious sedation. While some patients had some minor residual weakness after the procedure, the degree of neurological deficit was improved from that observed before the procedure in all patients.

Tracheostomy without mechanical ventilation in patients with traumatic brain injury at a tertiary referral hospital in Malawi: a cross sectional study.

Background: Tracheostomy alone, without mechanical ventilation, has been advocated to maintain a free airway in patients with traumatic brain injury in low-income settings with minimal critical care capacity. However, no reports exist on the outcomes of this strategy. We examine the results of this practice at a central hospital in Malawi. Methods: This is a retrospective review of medical records and prospectively gathered trauma surveillance data of patients admitted to Kamuzu Central Hospital, with traumatic brain injury from January 2010 to December 2015. In-hospital mortality rates were examined according to registered traumatic brain injury severity and airway management. Results: In our analysis, 1875 of 2051 registered traumatic brain injury patients were included; 83.3% were male, mean age 32.6 (SD 12.9) years. 14.2% (n=267) of the patients had invasive airway management (endotracheal tube or tracheostomy) with or without mechanical ventilation. Mortality in severe traumatic brain injury treated with tracheostomy without mechanical ventilation was 42% (10/24) compared to 21% (14/68) in patients treated without intubation or tracheostomy (p= 0.043). Tracheostomies had an overall complication rate of 11%. Conclusion: Tracheostomy without mechanical ventilation in severe traumatic brain injury did not improve survival outcomes in our setting. Tracheostomy for severe traumatic brain injury cannot be recommended when mechanical ventilation is not available unless there are sufficient specialized human resources for follow up in the ward. Efforts to improve critical care facilities and human resource capacity to allow proper use of mechanical ventilation in severe traumatic brain injury should be a high priority in low-income countries where the burden of trauma is high.

Epidemiology, Management, and Functional Outcomes of Traumatic Brain Injury in Sub-Saharan Africa.

BACKGROUND: Trauma accounts for 4.7 million deaths each year, with an estimated 90% of these occurring in low- and middle-income countries (LMICs). Approximately half of trauma-related deaths are caused by central nervous system injury. Because a thorough understanding of traumatic brain injury (TBI) in LMICs is essential to mitigate TBI-related mortality, we established a clinical and radiographic database to characterize TBI in our low-income setting. METHODS: This is a review of prospectively collected data from Kamuzu Central Hospital, a tertiary care center in the capital of Malawi. All patients admitted from October 2016 through May 2017 with a history of head trauma, altered consciousness, and/or radiographic evidence TBI were included. We performed descriptive statistics, a Cox regression analysis, and a survival analysis. RESULTS: There were 280 patients who met inclusion criteria; of these, 80.5% were men. The mean age was 28.8 ± 16.3 years. Median Glasgow Coma Scale (GCS) score was 12 (interquartile range, 8-15). Road traffic crashes constituted the most common injury mechanism (60.7%). There were 148 (52.3%) patients who received a computed tomography scan, with the most common findings being contusions (26.1%). Of the patients, 88 (33.0%) had severe TBI, defined as a GCS score ≤8, of whom 27.6% were intubated and 10.3% received tracheostomies. Overall mortality was 30.9%. Of patients who survived, 80.1% made a good recovery. Female sex was protective, and the only significant predictor of poor functional outcome was presence of severe TBI (hazard ratio, 2.98; 95% confidence interval, 1.79-4.95). CONCLUSIONS: TBI represents a significant part of the global neurosurgical burden of disease. Implementation of proven in-hospital interventions for these patients is critical to attenuate TBI-related morbidity and mortality.

Outcomes Following Exploratory Burr Holes for Traumatic Brain Injury in a Resource Poor Setting.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. The incidence of TBI in low- and middle-income countries (LMICs) is disproportionately high, with an associated increased risk of mortality from TBI relative to high-income countries. Although computed tomography is the diagnostic method of choice, this is often unavailable in LMICs. Exploratory burr holes may provide a suitable choice for diagnosis and treatment of TBI. METHODS: We performed a retrospective review of prospectively collected data at KCH, a tertiary care center in Lilongwe, Malawi. All trauma patients presenting between June 2012 and July 2015 with a deteriorating level of consciousness and localizing signs and who underwent exploratory burr holes were included. Additionally, we included all patients admitted with TBI, requiring higher-level care during 2011. No patients underwent exploratory burr hole during this time. We performed logistic regression to identify predictors of mortality in the total population of TBI patients. RESULTS: Among the 241 patients who presented to KCH with TBI requiring higher-level care, the total mortality was 16.4%. More than half (163, or 68%) underwent exploratory burr hole with a mortality of 6.8%. Mortality in patients who did not undergo exploratory burr hole was 43.9%. Upon adjusted logistic regression, not undergoing exploratory burr hole significantly increased the odds of mortality (odds ratio = 12.0, P = 0.000, 95% confidence interval = 4.48-31.9). CONCLUSION: Exploratory burr holes remain an important diagnostic and therapeutic procedure for TBI in LMICs. Exploratory burr hole technique should be integrated into general surgery education to attenuate TBI-related mortality.

The effect of anatomic location of injury on mortality risk in a resource-poor setting.

INTRODUCTION: Injury is a significant cause of death, with approximately 4.7 million people mortalities each year. By 2030, injury is predicted to be among the top 20 causes of death worldwide. We sought to characterize and compare the mortality probability in trauma patients in a resource-poor setting based on anatomic location of injury. METHODS: We performed a retrospective analysis of prospectively collected data using the trauma database at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. We included all adult trauma patients (≥16years) admitted between 2011 and 2015. We stratified patients according to anatomic location of injury, and used descriptive statistics to compare characteristics and management of each group. Bivariate analysis by mortality was done to determine covariates for our adjusted model. A Cox proportional hazard model was performed, using upper extremity injury as the baseline comparator. Descriptive statistics were used to describe the trend in incidence and mortality of head and spine injuries over five years. RESULTS: Of the 76,984 trauma patients who presented to KCH from 2011 to 2015, 49,126 (63.8%) were adults, and 8569 (17.4%) were admitted. The most common injury was to the head or spine, seen in 3712 patients (43.6%). The highest unadjusted hazard ratio for mortality was in head and spine injury patients, at 3.685 (95% CI=2.50-5.44), which increased to 4.501 (95% CI=2.78-7.30) when adjusted for age, sex, injury severity, transfer status, injury mechanism, and surgical intervention. Abdominal trauma had the second highest adjusted hazard of mortality, at 3.62 (95% CI=1.92-6.84) followed by thoracic trauma (HR=1.3621, 95% CI=0.49-3.56). CONCLUSION: In our setting, head or spine injury significantly increases the hazard of mortality significantly compared to all other anatomic injury locations. The prioritization of timely operative and non-operative head injury management is imperative. The development of head injury units may help attenuate trauma- related mortality in resource poor settings.