Cuba and the management of traumatic brain injury
The recent study published by MRC CRASH Trial Collaborators in BMJ,1 in
which our group participated, developed an interesting prognosis model for
patients with traumatic brain injury (TBI). The most important thing we
consider that it has is pragmatism, so necessary for doctors directly
related to daily medical practice. Our comment will be focused on the
dichotomy between high or low-middle income countries and their relation to
the management of TBI in Cuba. We have commented previously on two diseases that have an important burden in mortality:
acute myocardial infarction2 and stroke3 (1st and 3rd cause of death).
Trauma takes the fourth place in the death causes and the main burden is
due to TBI.
Ten years ago in our intensive care unit 47% of trauma admissions were
TBI and the mortality rate was 88%.4
In the last years, 25% of all the patients admited with trauma have a
head injury and 10% of them have severe TBI (8 points or less on the Glasgow
Come Scale [GCS]). The risk of death is double in patients with GCS
between 3-5 points compared with those that have 6-8 points, taking GCS at
the admission and after non quirurgic reanimation.
On the other hand, we can relate the decrease of points in GCS in the time
have a worse prognosis.
Through the years, we have been working to reduce our mortality
rate and we have ben able to lower it to 40-45%.5 In this reduction take place many
factors, one of the most important is the application of neuromonitoring
because it can show us the intracranial pressure (ICP) and brain metabolic
variables like venous jugular oxygen saturation (SvjO2). Other factors
that helped us are the possibility of imaging 24 hours a day: computer tomography (CT scan) and
resonance imaging (MRI). We have too, the possibility to modify medical or
surgery treatment because we have clinical practice guidelines that help
us to avoid secondary lessions and to mantain the best conditions to
recover the brain from the primary lession. Is very important to evacuate
the lesions that take space like haematomas higher than 20 ml and the
practice of decompressive craniectomy with wide duramadre flap. This
procedure can improve brain compliance in severe brain injury. In our
experience, extracranial injury is related to mortality when low blood
pressure (systolic pressure below 90 mm Hg) and hypoxemic events (oxygen
arterial pressure below 60 mmHg) are present.
The management of patients with TBI is complicated because it needs a
qualified team and enough conditions to offer patients quality care, but
our results show that it is possible to do this in low or middle income
1. MRC CRASH Trial Collaborators. Predicting oucome after traumatic
brain injury: practical prognostic models based on large cohort of
international patients. BMJ, doi:10.1136/bmj.39461.643438.25 (published 12
2. Orduñez PO, Iraola MD, La Rosa Y. Experience in Cuba shows
optimising thrombolysis may reduce death rates in poor countries. BMJ
2005; 330: 1271-1272.
3. Orduñez PO, Iraola MD, Bembibre R. Cuba better care for stroke.
BMJ 2006; 332: 551.
4. Iraola MD, Rodríguez R, Santana A, Pons F. Valor del indice de
trauma en la unidad de cuidados intensivos. Rev Cubana Med Int Emerg 2003;
5. Pons F. Mortalidad por trauma craneoencefalico en la provincia de
Cienfuegos. Conferencia presentada en la Primera Jornada Territorial de
Medicina Intensiva. Matanzas, 23 de octubre 2007.