TBI Guidelines Low- and Middle-Income Countries Perspective

1. TBI Guidelines: Low and
Middle Income Countries
Perspective
Dr Amit Agrawal, MCh
Department of Neurosurgery
All India Institute of Medical Sciences
Saket Nagar
Bhopal 462020
Madhya Pradesh (India)

2.  TBI is the leading cause of morbidity, mortality and disability in
young adults
 It has been estimated that TBI costs the global economy
approximately $US400 billion annually
 Disproportionate burden of disability and death occurring in low-
income and middle-income countries (LMICs)
Global Burden of TBI
*Maas et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol.
2017 Dec;16(12):987-1048

3. Patient
Provider
Payer
Policy
maker
Stakeholders

4. Health Care
System
Community
Family
Person
Scope of guidelines
Post-
hospital
Pre-
hospital
In-
Hospital
• Primary Health Centre
• Community Health
Centre
• District Hospital
• Hospitals
• Teaching institutions

5. Basic
Advanced
Intermediate
Minimum yet optimum strategy
Essential

6.  A comparison of publication to TBI burden ratio of low- and middle-income countries
versus high-income countries: how can we improve worldwide care of TBI? - PubMed
(nih.gov)
 Traumatic brain injury (TBI) outcomes in an LMIC tertiary care centre and performance of
trauma scores | BMC Anesthesiology | Full Text (biomedcentral.com)
 The Application of Guideline-Based Care for Traumatic Brain and Spinal Cord Injury in
Low- and Middle-Income Countries: A Provider-Based Survey – ScienceDirect
 Recommendations of the Colombian Consensus Committee for the Management of
Traumatic Brain Injury in Prehospital, Emergency Department, Surgery, and Intensive
Care (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol
[BOOTStraP]) - PMC (nih.gov)
 Managing Severe Traumatic Brain Injury Across Resource Settings: Latin American
Perspectives | Neurocritical Care (springer.com)
 Contemporary Management of Traumatic Brain Injury: Low and Middle-Income
Countries — Monash University
 Full article: Management of severe traumatic brain injury in regions with limited
resources (tandfonline.com)
 Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review
of the Literature - PubMed (nih.gov)
Do we have guidelines?

7.  Are these fulfilling expectations?
 Are these being implemented?
 Without implementing or testing can we identify challenges,
limitations or propose solutions?
If we have guidelines?

8.  Disparity between countries with a high burden of TBI and those in
which most of the research is conducted
 High-income countries (HICs) versus low-income and middle-income
countries (LMICs)
Ongoing debate
*Tropeano MP, Spaggiari R, Ileyassoff H, Park KB, Kolias AG, Hutchinson PJ, Servadei F. A comparison of publication to TBI
burden ratio of low- and middle-income countries versus high-income countries: how can we improve worldwide care of TBI?
Neurosurg Focus. 2019 Nov 1;47(5):E5. doi: 10.3171/2019.8.FOCUS19507. PMID: 31675715

9.  High-income countries (HICs) versus low-income and middle-income
countries (LMICs) with limited resources
 High-income countries (HICs) have unlimited resources
 Low-income and middle-income countries (LMICs) have limited
resources
Is it same?

10.  Identify stakeholders
 Classify each stakeholder relationship including role and
expectations
 Develop, formulate and validate guidelines as per local needs
 Formulate strategies for delivery i.e. implementation
 Periodic evaluation and continuous research
 Comparisons across the regions including periodical updating
Conclusions

11.  Preventative Strategies and Preventative programs!