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

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.

Impact of helmet use on traumatic brain injury from road traffic accidents in Cambodia.

OBJECTIVE: Rapid urbanization and motorization without corresponding increases in helmet usage have made traumatic brain injury due to road traffic accidents a major public health crisis in Cambodia. This analysis was conducted to quantify the impact of helmets on severity of injury, neurosurgical indication, and functional outcomes at discharge for motorcycle operators who required hospitalization for a traumatic brain injury following a road traffic accident in Cambodia. METHODS: The medical records of 491 motorcycle operators who presented to a major tertiary care center in Cambodia with traumatic brain injury were retrospectively analyzed using multivariate logistic regression. RESULTS: The most common injuries at presentation were contusions (47.0%), epidural hematomas (30.1%), subdural hematomas (27.9%), subarachnoid hemorrhages (12.4%), skull fractures (21.4%), and facial fractures (18.5%). Moderate-to-severe loss of consciousness was present in 36.3% of patients. Not wearing a helmet was associated with an odds ratio of 2.20 (95% confidence interval [CI], 1.15-4.22) for presenting with moderate to severe loss of consciousness compared to helmeted patients. Craniotomy or craniectomy was indicated for evacuation of hematoma in 20.0% of cases, and nonhelmeted patients had 3.21-fold higher odds of requiring neurosurgical intervention (95% CI, 1.25-8.27). Furthermore, lack of helmet usage was associated with 2.72-fold higher odds of discharge with functional deficits (95% CI, 1.14-6.49). In total, 30.1% of patients were discharged with severe functional deficits. CONCLUSIONS: Helmets demonstrate a protective effect and may be an effective public health intervention to significantly reduce the burden of traumatic brain injury in Cambodia and other developing countries with increasing rates of motorization across the world.

Epidemiology and Clinical Management of Traumatic Spine Injuries at a Major Government Hospital in Cambodia.

STUDY DESIGN: Cross sectional study. PURPOSE: To characterize the pattern of injury, describe the current clinical management, and determine the outcomes in traumatic spine injury (TSI) patients presenting to a major government hospital in Phnom Penh, Cambodia. OVERVIEW OF LITERATURE: There is a paucity of literature on epidemiology or current clinical practices for TSIs in Cambodia. The findings from this study can thus serve as a valuable resource for future progress in treating TSIs in low-income countries. METHODS: This study was a cross-sectional study of TSI patients admitted to Preah Kossamak Hospital in Phnom Penh, Cambodia. Demographics, cause of spinal injury, spinal level of injury, surgical procedures and techniques, complications, and American Spinal Injury Association (ASIA) grades were recorded and analyzed. RESULTS: Eighty patients were admitted with TSI between October 2013 and June 2014. Falls from heights were the most common cause of TSI, followed by road traffic accidents. 78% of the admitted patients underwent at least one surgical procedure. Without intraoperative imaging, 4 patients (6%) had wrong level surgery, and 1 patient (2%) had misplacement of pedicle screws. Sacral decubitus ulcers were the most common non-surgically related complication. Antibiotics were administered to >90% of patients. There were no in-hospital mortalities. Of the 60 spinal cord injury (SCI) patients, 32% (19/60) showed improvement in their ASIA grade at the time of discharge, and 52% (31/60) showed no change. At follow-up, 32% (19/60) of SCI patients reported improvement, and 8% (5/60) reported no change. However, 36 SCI patients (60%) were lost to follow-up. CONCLUSIONS: Despite technological limitations, outcomes of TSI patients in Cambodia appear favorable with evidence of clinical improvement and low mortality.

Impact of Helmet Use on Severity of Epidural Hematomas in Cambodia.

BACKGROUND: Traumatic brain injury is a major cause of morbidity and mortality worldwide, often necessitating neurosurgical intervention to evacuate intracranial bleeding. Since the early 2000s, Cambodia has been undergoing a rapid increase in motorcycle transit and in road traffic accidents, but the prevalence of helmet usage remains low. Epidural hematomas are severe traumatic brain injuries that can necessitate neurosurgical intervention. METHODS: This is a retrospective cohort study of patients with epidural hematoma secondary to motorcycle accidents who presented to a major national tertiary care center in Phnom Penh, Cambodia, between November 2013 and March 2016. All patients were diagnosed with computed tomography of the head. RESULTS: In this cohort, 21.6% of patients in motorcycle accidents presented with epidural hematoma and 89.1% of patients were men, 47.6% were intoxicated, and were 87.8% were not wearing helmets at the moment of impact. Not wearing a helmet was associated with a 6.90-fold increase in odds of presenting with a moderate-to-severe Glasgow coma scale score and a 3.76-fold increase in odds of requiring craniotomy or craniectomy for evacuation of hematoma. Male sex was also associated with increased odds of higher clinical severity at presentation and indication for craniotomy or craniectomy, and alcohol intoxication at the time of accident was not associated with either. CONCLUSIONS: Helmet usage is protective in reducing the severity of presentation and need for neurosurgical intervention for patients with epidural hematoma secondary to motorcycle accidents.