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Background The COVID-19 pandemic has caused unprecedented disruptions to surgical care worldwide, particularly in low-resource countries. We sought to characterize the association between pre-and intra-pandemic trauma clinical outcomes at a busy tertiary hospital in Malawi. Methods We analyzed trauma patients that presented to Kamuzu Central Hospital in Lilongwe, Malawi, from 2011 through July 2021. Burn patients were excluded. We compared patients based on whether they presented before or during the pandemic (defined as starting March 11, 2020, the date of the official WHO designation). We used logistic regression modeling to estimate the adjusted odds ratio of death based on presentation. Results A total of 137,867 patients presented during the study period, with 13,526 patients during the pandemic. During the pandemic, patients were more likely to be older (mean 28 vs. 25 years, p < 0.001), male (79 vs. 74%, p < 0.001), and suffer a traumatic brain injury (TBI) as their primary injury (9.7 vs. 4.9%, p < 0.001). Crude trauma-associated mortality was higher during the pandemic at 3.7% vs. 2.1% ( p < 0.001). The odds ratio of mortality during the pandemic compared to pre-pandemic presentation was 1.28 (95% CI 1.06, 1.53) adjusted for age, sex, initial AVPU score, transfer status, injury type, and mechanism. Conclusions During the pandemic, adjusted trauma-associated mortality significantly increased at a tertiary trauma center in a low-resource setting despite decreasing patient volume. Further research is urgently needed to prepare for future pandemics. Potential targets for improvement include improving pre-hospital care and transportation, planning for intensive care utilization, and addressing nursing shortages.

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