Andres M. Rubiano

Assessment of the status of prehospital care in 13 low-and middle-income countries

Abstract Background. Injury and other medical emergencies are becoming increasingly common in low- and middle-income countries (LMICs). Many to most of the deaths from these conditions occur outside of hospitals, necessitating the development of prehospital care. Prehospital capabilities are inadequately developed to meet the growing needs for emergency care in most LMICs. Objective. In order to better plan for development of prehospital care globally, this study sought to better understand the current status of prehospital care in a wide range of LMICs. Methods. A survey was conducted of emergency medical services (EMS) leaders and other key informants in 13 LMICs in Africa, Asia, and Latin America. Questions addressed methods of transport to hospital, training and certification of EMS providers, organization and funding of EMS systems, public access to prehospital care, and barriers to EMS development. Results. Prehospital care capabilities varied significantly, but in general were less developed in low-income countries and in rural areas, where utilization of formal EMS was often very low. Commercial drivers, volunteers, and other bystanders provided a large proportion of prehospital transport and occasionally also provided first aid in many locations. Although taxes and mandatory motor vehicle insurance provided supplemental funds to EMS in 85% of the countries, the most frequently cited barriers to further development of prehospital care was inadequate funding (36% of barriers cited). The next most commonly cited barriers were lack of leadership within the system (18%) and lack of legislation setting standards (18%). Conclusions. Expansion of prehospital care to currently underserved or unserved areas, especially in low-income countries and in rural areas, could make use of the already-existing networks of first responders, such as commercial drivers and laypersons. Efforts to increase their effectiveness, such as more widespread first-aid training, and better encompassing their efforts within formal EMS, are warranted. In terms of existing formal EMS, there is a need for increased and more regular funding, integration and coordination among existing services, and improved organization and leadership, as could be accomplished by making EMS administration and leadership a more desirable career path.

The effect of admission spontaneous hypothermia on patients with severe traumatic brain injury

INTRODUCTION Recent information has emerged regarding the harmful effects of spontaneous hypothermia at time of admission in trauma patients. However the volume of evidence regarding the role of spontaneous hypothermia in TBI patients is inadequate. METHODS We performed secondary data analysis of 10 years of the Pennsylvania trauma outcome study (PTOS) database. Unadjusted comparisons of the association of admission spontaneous hypothermia with mortality were performed. In addition, full assessment of the association of hypothermia with mortality was conducted using multivariable logistic regressions reporting the odds ratios (OR) with the 95% confidence intervals (CI) and P-values. RESULTS There were 11,033 patients identified from the PTOS with severe TBI. There were 4839 deaths (43.9%). The proportion of deaths in hypothermic patients was higher than the proportion of deaths in normothermic patients (53.9% vs. 37.4% respectively; P value<0.001). In a multivariable logistic regression model adjusted for demographics, injury characteristics, and information at admission to the trauma centre, the odds of death among patients with hypothermia were 1.70 times the odds of death among patients with normothermia (OR 1.70, 95% CI 1.50-1.93), indicating that the probability of death was significantly higher when patients arrived hypothermic at the trauma centre. CONCLUSION The presence of spontaneous hypothermia at hospital admission is associated with a significant increase in the risk of mortality in patients with severe TBI. The benefit of maintaining normothermia in severe TBI patients, the impact of prolonged re-warming in patients with established hypothermia and the introduction of prophylactic measures to complications of hypothermia are key points that require further investigation.

Strengthening neurotrauma care systems in low and middle income countries.

Primary objective: To review basic elements to be considered in the development of effective neurotrauma care systems in low- and middle-income countries. Neurotrauma occurs more frequently in developing countries. The survival rate among neurotrauma patients depends in large part on the degree of sophistication of the trauma system. Research design: A critical review of the literature was undertaken. Results: In developing countries, there are difficulties in fully integrating the resources for care if the local and regional trauma systems are poorly structured. Factors like inadequate emergency and neurointensive care, low compensation compared with elective procedures or high medico-legal risks may result in a lack of interest from the few available neurosurgeons to be fully integrated in neurotrauma care. Appropriate structuring of trauma systems according to countries needs and their functionality is a key element that would facilitate the optimal use of resources for integral neurotrauma care. Conclusions: In order to implement an efficient trauma system, organization of low cost resources such as trauma registries and quality control programmes are required. The participation of medical associations in legislative and government processes is also an important factor for the appropriate development and organization of an effective trauma system in under-privileged areas.

Trauma Care Training for National Police Nurses in Colombia

Abstract Introduction. In response to a requirement for advanced trauma care nurses to provide combat tactical medical support, the antinarcotics arm of the Colombian National Police (CNP) requested the Colombian National Prehospital Care Association to develop a Combat Tactical Medicine Course (MEDTAC course). Objective. To evaluate the effectiveness of this course in imparting knowledge and skills to the students. Methods. We trained 374 combat nurses using the novel MEDTAC course. We evaluated students using pre- and postcourse performance with a 45-question examination. Field simulations and live tissue exercises were evaluated by instructors using a Likert scale with possible choices of 1 to 4. Interval estimation of proportions was calculated with a 95% confidence interval (95% CI). Differences in didactic test scores were assessed using a t-test at 0.05 level of statistical significance. Results. Between March 2006 and July 2007, 374 combat nursing students of the CNP were trained. The difference between examination scores before and after the didactic part of the course was statistically significant (p < 0.01). After the practical session of the course, all participants (100%) demonstrated competency on final evaluation. Conclusions. The MEDTAC course is an effective option improving the knowledge and skills of combat nurses serving in the CNP. MEDTAC represents a customized approach for military trauma care training in Colombia. This course is an example of specialized training available for groups that operate in austere environments with limited resources.

Results of early cranial decompression as an initial approach for damage control therapy in severe traumatic brain injury in a hospital with limited resources.

Introduction: Severe traumatic brain injury (sTBI) is a disease that generates significant mortality and disability in Latin America, and specifically in Colombia. The purpose of this study was to evaluate the 12-month clinical outcome in patients with sTBI managed with an early cranial decompression (ECD) as the main procedure for damage control (DC) therapy, performed in a University Hospital in Colombia over a 4-year period. Materials and Methods: A database of 106 patients who received the ECD procedure, and were managed according to the strategy for DC in neurotrauma, was analyzed. Variables were evaluated, and the patient outcome was determined according to the Glasgow Outcome Score (GOS) at 12 months postinjury. This was used to generate a dichotomous variable with “favorable” (GOS of 4 or 5) or “unfavorable” (GOS of 1–3) outcomes; analysis of variance was performed with the Chi-square, Wilcoxon–Mann–Whitney and Fisher tests. Results: An overall survival rate of 74.6% was observed for the procedure, At 12 months postsurgery, a favorable clinical outcome (GOS 4–5) was found in 70 patients (66.1%), Unfavorable outcomes in patients were associated with the following factors: Closed trauma, an Injury Severity Score >16 , obliterated basal cisterns, subdural hematoma as the main injury seen on the admission computed tomography, and nonreactive pupils observed in the emergency department. Conclusion: Twelve months outcome of patients with sTBI managed with ECD in a neuromonitoring limited resource University Hospital in Colombia shows an important survival rate with favorable clinical outcome measure with GOS.

Penetrating Orbital-Cranial Injuries Management in a Limited Resource Hospital in Latin America.

Penetrating orbital-cranial injuries (POCIs) are difficult cases especially in hospitals in low-middle-income countries (LMIC) where resources are limited. We present a case series of POCI managed in a university hospital in such scenario. A retrospective case series was conducted including patients with POCI in 2011. Mechanism of injury, Glasgow Coma Scale score, imaging, medical and surgical management, complications, and Glasgow Outcome Scale (GOS) score were analyzed. A total of 30 patients with penetrating orbital injuries were admitted from March 2011 to December 2011. Of this group, only four patients were diagnosed with cranial penetration. Computed tomography (CT) angiography revealed orbital fractures and injury to frontal, temporal, or occipital lobes. Urgent craniotomy with isolation of ipsilateral carotid artery was performed. GOS score at discharge was 5 in three patients and 4 in one patient. POCIs are not uncommon in hospitals of LMIC. In such scenarios, a standard approach with CT angiography and early neurosurgical intervention results in good outcome.

Antioxidant therapies in traumatic brain injury: a review

Abstract Oxidative stress constitute one of the commonest mechanism of the secondary injury contributing to neuronal death in traumatic brain injury cases. The oxidative stress induced secondary injury blockade may be considered as to be a good alternative to improve the outcome of traumatic brain injury (TBI) treatment. Due to absence of definitive therapy of traumatic brain injury has forced researcher to utilize unconventional therapies and its roles investigated in the improvement of management and outcome in recent year. Antioxidant therapies are proven effective in many preclinical studies and encouraging results and the role of antioxidant mediaction may act as further advancement in the traumatic brain injury management it may represent aonr of newer moadlaity in neurosurgical aramamentorium, this kind of therapy could be a good alternative or adjuct to the previously established neuroprotection agents in TBI.

Intracranial foreign body in a child

Abstract Intracranial foreign bodies are rare events that occur accidentally and depending on the extent and involvement of the brain parenchymal, generate focal neurological deficit, bleeding and even long-term complications. In present article we describe a case of 4 year child and discuss the approach, management and prognosis.

Management of subdural chronic hematoma in Colombia: national survey

Abstract Chronic subdural hematoma is a growing neurological pathology, especially in older people. Thus, describing how this entity is approached in Colombia is of great importance because it allows to evaluate and contrast this approach with that of other countries, comparing the techniques used, therapeutic management and additional measures. In this study, this comparison was carried out using a self-administered survey with 16 multiple-choice items. The results were evaluated in Microsoft Excel, determining measures of central tendency accompanied by frequencies and percentages. As an initial management, 75.5% preferred to use 1Burr Hole and, in cases of recurrence, craniotomy is the choice in 50% of cases. Regarding the placement of drainage, its use was estimated to be 83.3%, especially the subdural system closed to external drainage, with a preference of 85.2%, and without use of corticosteroids as adjuvant therapy in 88.9 % of respondents. These data are consistent with the results of studies in other countries regarding the management of this pathology.

Unilateral traumatic hemorrhage of the basal ganglion and bihemisferic cerebral infarction

Abstract Among the various injuries caused by the cerebral tramatic lesion are traumatic brain contusions. Hemorrhagic contusions of the basal ganglia are unusual. Different injuries such as cranial fractures, epidural hemorrhage, subdural hematoma, subarachnoid hemorrhage among others may be associated with brain contusions. In some cases traumatic brain injury arises. We present a case of a patient with unilateral cerebral contusion associated with bihemispheric cerebral infarction.