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Prehospital Factors Associated with Discharge Outcomes: Baseline Data from the Andhra Pradesh Traumatic Brain Injury

Kodanda Ram¹, Kadali VaraPrasad¹, Murali K Krishna¹

¹Department of Neurosurgery, King George Hospital, Andhra Medical College Visakhapatnam, KGH, Opp KGH OP Gate, Maharani Peta, Visakhapatnam, Andhra Pradesh, India.

World Neurosurgery: X

|June 21, 2019

Insights

Prehospital care for traumatic brain injury (TBI) in India needs improvement. Key factors like bleeding and lack of airway management are linked to poor TBI outcomes.

Area of Science:

Neurology
Emergency Medicine
Public Health

Background:

Traumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide.
Effective prehospital (PH) care is crucial for improving TBI outcomes.
Strategies for optimizing TBI care in India are not well-established.

Purpose of the Study:

To investigate prehospital factors influencing outcomes in traumatic brain injury (TBI) patients in India.
To identify specific prehospital care elements associated with in-hospital mortality and unfavorable outcomes.

Main Methods:

A prospective observational cohort study was conducted on adult TBI patients.
Data collected included injury mechanisms, prehospital care, transport details, and in-hospital outcomes.
Statistical analyses, including Poisson regression, were used to determine factors associated with outcomes.

Main Results:

The study enrolled 447 TBI patients, predominantly male, with injuries from road traffic accidents and falls.
Significant findings include high rates of scalp/facial bleeding (61%) and infrequent prehospital airway management (31% for severe TBI).
Bleeding was associated with increased mortality (aRR 1.56) and unfavorable outcomes (aRR 1.60); respiratory distress was linked to unfavorable outcomes (aRR 1.23).

Conclusions:

Many TBI patients in India bypass closer facilities, receiving treatment at distant hospitals.
Prehospital care gaps, including inadequate airway management and hemorrhage control, are prevalent.
Improving prehospital interventions like ambulance use, airway management, and stabilization is critical for better TBI patient outcomes.

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Abstract

Objective:

Strategies to improve traumatic brain injury (TBI) outcomes in India are ill defined. The objective of this study was to examine baseline prehospital (PH) factors associated with outcomes from the Andhra Pradesh Traumatic Brain Injury Project.

Methods:

We conducted a prospective observational cohort study of adult patients with TBI admitted to the primary referral hospital. Modes of injury, prehospital care and transport, and factors associated with increased in-hospital mortality were evaluated. Poisson regression with robust error variance and adjusted attributable risk percent estimates determined factors associated with outcomes.

Results:

A total of 447 adults (38% with mild TBI, 30% with moderate TBI, and 32% with severe TBI; 81% men) with isolated TBI (89%) from road traffic accidents (48.1%) or falls (46.5%) were enrolled. Of the patients, 45.7% were transported by ambulance, 61% had scalp/facial bleeding, 11% had respiratory distress, and 7% had cervical spine stabilization. Of these, 25.3% died and 34% had unfavorable outcomes. Among 335 direct admits, 45% traveled more than 50 km and nearly 20% traveled more than 100 km. Bleeding was associated with higher mortality (adjusted relative risk [aRR], 1.56; 95% confidence interval [CI], 1.05-2.31) and unfavorable outcome (aRR, 1.60; 95% CI, 1.18-2.17). Of the patients, 45 (31%) with severe TBI received PH airway management prior to definitive treatment, and respiratory distress was associated with unfavorable discharge outcomes (aRR, 1.23; 95% CI, 1.00-1.51).

Conclusions:

Patients with TBI often received treatment far away from injury, bypassing closer hospitals. Scalp/facial bleeding was common and associated with unfavorable outcomes. Ambulance use was infrequent, and few patients received PH airway management, hemorrhage control, or cervical spine stabilization when needed.

Keywords:

AR%, Adjusted attributable risk percent CI, Confidence interval CT, Computed tomography ED, Emergency department GCS, Glasgow Coma Scale ICU, Intensive care unit IQR, Interquartile range KGH, King George Hospital LOS, Length of stay OR, Operating room Outcomes PH, Prehospital Risk factors TBI, Traumatic brain injury Trauma Trauma system Traumatic brain injury Triage aRR, Adjusted relative risk

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