An exploratory assessment of the management of pediatric traumatic brain injury in three centers in Africa

Abstract

Purpose: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs.

Methods: We completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests.

Results: Fifty-six children presented with TBI (age 0-17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge.

Conclusion: Inpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.

Keywords: Africa South of the Sahara; brain injuries; critical care; global health; pediatrics; traumatic.

Figure 1

Patient flow diagram. This figure demonstrates the flow of our patients from the pre-hospital, emergency department, and in-hospital settings. OR, operating room; PICU, pediatric intensive care unit.

Figure 2

Abnormal computed tomography findings by TBI severity. This figure demonstrates the distribution of abnormal head computed tomography findings in patients between TBI severity groups (mild TBI [GCS score 14–15, black columns], moderate TBI [GCS 9–13, checkerboard columns], severe TBI [GCS 3–8, dotted columns]). The x-axis contains the various abnormal intracranial findings noted on imaging; the “n” at the top of the bar represents total number of patients that had that particular radiographic finding while total group n of patients with imaging in each TBI severity is given in the lower legend (mild TBI, n = 26; moderate TBI, n = 8; severe TBI, n = 11). The y-axis represents the percentage of patients that had those radiographic findings. TBI, traumatic brain injury.

Figure 3

Intracranial hypertension directed therapy compared by TBI severity. This figure compares the use of various intracranial hypertension (ICH) directed therapies between TBI severity groups (mild TBI [GCS score 14–15, black columns], moderate TBI [GCS 9–13, checkerboard columns], severe TBI [GCS 3–8, dotted columns]). The x-axis contains the various therapies separated by TBI severity; the “n” under the bar represents total number of patients who had that particular ICH therapy available to them during their hospitalization. Of note, the only therapy not available to all 25 patients who were treated for presumed ICH was hypertonic saline, which was available only for those patients with presumed ICH at the Kenya site (n = 5). The y-axis represents the percentage of patients that received ICH directed therapies. Notably, there was no significant difference in utilization of decompressive craniectomy between severity groups. TBI, traumatic brain injury; GCS, Glasgow Coma Scale.

Figure 4

Presenting Glasgow Coma Scale score compared to discharge PCPC score. This figure is a scatter plot with the x-axis containing the presenting Glasgow Coma Scale score and the y-axis representing the PCPC score on discharge. Higher GCS score on arrival to the hospital was associated with a favorable PCPC score, defined as a score of 1–2, on discharge (p < 0.001). A line of best fit was abstracted. GCS, Glasgow Coma Scale; PCPC, Pediatric Cerebral Performance Score.