Association of Primary Trauma Care training with mortality in isolated traumatic brain injury: A sub-analysis of the PISTACHIO study in Vietnam.

Abstract

The association of the Primary Trauma Care (PTC) program with Isolated Traumatic Brain Injury (TBI), where mortality is driven by secondary brain injury rather than haemorrhagic shock, remains underexplored in Low- and Middle-Income Countries. This prospective before-and-after study analysed 1388 patients with isolated TBI (head injury without significant extracranial trauma) at two provincial hospitals in Vietnam. Patients were stratified by admission Glasgow Coma Scale (GCS). The primary outcomes were 24-hour and 30-day mortality. Sensitivity analyses, including best- and worst-case scenarios, were performed to assess attrition bias. Of 1388 patients (Pre: 712; Post: 676), baseline neurological severity was comparable (p = 0.100). Overall, 24-hour mortality decreased significantly from 6.7% to 1.8% (adjusted Odds Ratio-aOR 0.25, 95% CI 0.13-0.47, p < 0.001). This survival benefit was sustained at 30 days (10.8% vs. 4.1%; aOR 0.35, 95% CI 0.20-0.64, p = 0.001). The 30-day loss to follow-up rate was 38.7%, primarily due to pandemic disruptions. Although sensitivity analysis suggested no significant difference in Injury Severity Score (p = 0.416) or GCS (p = 0.706) between lost and retained patients, best- and worst-case scenario modelling (aOR 0.27 and 1.66, respectively) indicated that the potential for attrition bias remains a significant consideration. Following the intervention, 24-hour mortality for Severe TBI (GCS 3-8) decreased significantly from 48.1% to 17.5% (aOR 0.23, 95% CI 0.08-0.63, p = 0.004). PTC training was associated with a substantial reduction in early mortality for isolated TBI, supporting the hypothesis that early airway and breathing stabilization may provide neuroprotective benefit in resource-limited settings.