Predictors of outcome of treatment following severe head injury at Moi Teaching and Referral Hospital, (MTRH). Eldoret, Kenya.

Abstract

Background: Severe head injury (SHI) is one of the leading causes of morbidity, disability and mortality among trauma patients. SHI is a dual assault condition mainly primary and secondary. The primary assault results from the anatomic changes caused by the injury. The secondary assault results when the already injured brain tissue is subjected to further injury from hypoxia, hypotension, hypothermia, acidosis and raised intracranial pressure. These are the factors that can be modified to influence the outcome. MTRH receives most of the trauma patients from the larger Western Kenya and North Rift regions. There is no data on outcomes and factors influencing the outcome of these patients at MTRH. Objective: To establish the predictors of the outcome following severe head injury among patients treated at MTRH. Methods: A prospective study was conducted at MTRH for 12months between November 2013 and October 2014. Consecutive hospital-based sampling method was used. Multiple variables associated with outcome were identified. These were age, admission GCS, pupil size and its reaction to light, time interval between accident and admission, hypotension, hypothermia, hypoxia, acidosis and associated injuries. Each variable was analyzed and its effect on outcome documented. Those that showed significant associations at bivariate level were further analyzed using logistic regression. The statistical significance was at 95% confidence interval. The outcomes were favorable and unfavorable based on the functional disability. Results: A total of 84 patients were enrolled, their ages ranged between 1year and 80years, median age of 29.5 years. Majority were Males 72 (85.7%). A total of 62 (73.8%) patients were referred and 22 (26.2%) brought directly from the accident scene. Pre- hospital care lacked in both groups. Significant predictors of unfavorable outcomes were: old age p = 0.046, admission GCS of ≤ 6 p = 0.022 and unequal pupil size with non-reaction to light (anisocoria) p = 0.003. Non-significant predictors of outcome were blood pressure, pulse, hypoxia and other associated injuries with p = > 0.05. The outcomes were: favorable ranging from no disability 1.1% to severe disability 2.3% and unfavorable outcomes comprising of extremely severe disability 4.5% and death. The Case mortality rate was at 38.6%. Most patients with severe TBI required ICU care; however, only 6 patients accessed it. Conclusion: The study showed that the unfavorable outcome of severe head injuries at MTRH was associated with old age (> 60 yrs.), admitting GCS of below 6 and unequal pupil dilation with no reaction to light. Recommendations: The standard of care protocols for severe TBI patients managed at MTRH should be reviewed to include admission of; elderly patients (≥ 60 years) with severe TBI, those with a low GCS of below 6 and those with unequal pupil dilation with no reaction to light to ICU. This study should be confirmed in future using multicenter hospitals.