Discussion
In this study, we analyzed current resuscitation practices for patients with hemorrhagic shock in Cameroon as a first step toward developing a context-appropriate resuscitation protocol. CB resuscitation is the predominant strategy for treatment of hemorrhagic shock and is associated with a decreased time to treatment than blood product resuscitation. Blood transfusion was performed in less than 10% of patients with hemorrhagic shock and appeared to be triggered by high perceived injury severity, more extreme vital sign abnormalities, and lower hemoglobin levels. We can infer that there are no statistically significant differences between resuscitation cohort and SES EconomicCluster proxy variables.30 31 Moreover, blood transfusion was associated with considerable treatment delays and modest incremental improvements in blood pressure compared with CB resuscitation. Despite the physiologic superiority of blood as a resuscitation product, when adjusted for injury severity, the use of blood resuscitation strategy was not independently associated with improved survival in this setting. These findings suggest that in a severely blood-constrained context, either insufficient blood transfusion volume or treatment delays associated with blood product transfusion may offset the physiologic benefits of blood resuscitation. Although CB resuscitation is known to be an inferior overall strategy for the treatment of hemorrhagic shock with considerable potential for delayed morbidity, it nevertheless may be the best option to maintain early organ perfusion in this context.34
The results of this study should serve as an initial step toward the development of a hemorrhagic shock protocol that is appropriate for the Cameroonian context. Though patients with trauma in SSA require a significant amount of the limited blood supply, these patients receive far less blood than needed and experience disproportionately worse outcomes compared with the rest of the world.10–12 Although other LMICs have implemented massive blood transfusion (MBT) protocols, current resuscitation patterns at Cameroonian hospitals in this study demonstrate that reliance on an MBT is not feasible.2 9 Due to the profound scarcity of available blood in Cameroonian hospitals, a hemorrhagic shock protocol should prioritize initial crystalloid resuscitation to rapidly render treatment and maintain end-organ perfusion. Though increase in SBP in this study is a crude measure for organ perfusion, other research concludes that crystalloid resuscitation intermittently perfuses organs in the absence of blood products.34 35 While emphasizing crystalloid resuscitation, the protocol should allow blood transfusion to supersede crystalloid if blood is available and able to be administered without delay. Although this recommendation aligns with advanced trauma life support (ATLS) education, prohibitive costs and incompatibility with local capacities of standardized trauma education courses such as ATLS prevent LMIC provider participation.35–38 This accommodation reflects the reality of limited blood transfusions in Africa and also conforms with previous advocation of clear fluid resuscitation in blood-constrained settings.10–12 34 Significant controversy exists between CB and no intervention if no blood is available. Though a randomized controlled trial would best address this controversy, this article contains non-randomized, real-world data that demonstrate what treatment practices currently occur in this LMIC context. Whereas standardized trauma protocols (STPs) in LMICs can increase fluid resuscitation and lower mortality rates, a Cameroon-specific STP should collect patient data regarding clinical progress and hospital course over time, as CB resuscitation trauma patients experience delayed complications such as renal acidosis and dilutional coagulopathy.34 39
Furthermore, more research is needed to further understand the clinical nuances of blood transfusion demand in Cameroon. A comprehensive hemorrhagic shock protocol including blood transfusion must be developed with facility blood bank collaboration to equitably distribute this resource among other clinical illnesses (obstetrics, malaria, etc). Although the Cameroon NBTP has announced blood transfusion demand and supply deficits on a national scale, researchers must determine which hospitals and clinical conditions require the greatest proportions of blood products.22 23 Concurrently, Cameroon must expand public health initiatives to encourage voluntary blood donation and increase the national supply of blood products. Such an endeavor would require significant financial, public health, and political support as blood banking in SSA remains a very stigmatized issue.17 20 21
This study contains several limitations. Data missingness may reflect the practices influenced by the scarcities of Cameroonian health system. Specifically, it is possible that many patients lack recorded follow-up vital signs due to the large volume of clinical responsibilities placed on the limited amount of healthcare providers.40 41 Multiple imputation for missing variables tends to become unreliable with data missingness greater than 10%. Machine learning demonstrates that non-random variable missingness greatly contributes to trauma research, as the sickest patients are most likely unable to provide complete data.42 We included the percentage of data missingness to provide an accurate depiction of real-world prospective data collection in an LMIC. Finally, the inability to perform a reliable Fisher’s exact test of the injury mechanism and disposition categorical variables due to small sample size limited study conclusions.
Moreover, another limitation of this study is the inability to differentiate between early versus late mortality in the analysis. It is important to consider this limitation as crystalloid resuscitation in patients with trauma is associated with complications more than 24 hours after treatment.34 Likewise, the CTR data in this study period did not record the volume of blood or crystalloid administered to patients, limiting investigation of the effect of treatment volume on outcomes. An additional limitation is that the CTR did not record colloid resuscitation during the study period of data collection. Data regarding intravenous fluid volume and colloid administration have subsequently been added to the latest versions of CTR to support more comprehensive volume resuscitation analysis in the future. Additionally, the lack of balanced product transfusion in the Cameroonian context may affect clinical outcomes.6 7 Although SSA possesses a significant unmet need for packed red blood cells, the unmet needs for blood components such as plasma and platelets are even larger.11 This profound lack of blood and blood component supply impacts providers’ capacity to follow resuscitation guidelines developed in high-income countries (HICs) and may skew the results of the study BL cohort. Further, survivor bias is present in the CTR data as there is no formal system of prehospital care in Cameroon. Although prior CTR analyses recorded that 22% of all trauma deaths presented as dead on arrival to the ED, it is impossible to measure the number of unreported deaths that occur outside the hospital.25 Nevertheless, survivor bias does not invalidate these findings since research must understand the optimal treatment for injured patients who reach the hospital. Though the NR group has the lowest injury severity, the NR cohort remains important because a significant portion of patients evaluated by LMIC trauma care providers are discharged without treatment. The demonstration of all three cohorts—CB, BL, and NR—best depicts real-world clinical practice in this context and serves to instruct providers regarding the outcomes of their clinical decisions.