|Year : 2018 | Volume
| Issue : 1 | Page : 22-28
Traffic related injuries from a trauma registry: Pattern and outcome
Sydney E Ibeanusi, Tamunokro E Diamond
Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
|Date of Web Publication||30-Jul-2018|
Dr. Sydney E Ibeanusi
Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt
Source of Support: None, Conflict of Interest: None
Background: Road traffic trauma is a leading cause of death and disability in persons aged below 45 years. It has a global distribution, but its incidence and impact are greatest in low- and middle-income countries. Establishing pattern of injuries arising from traffic collisions and the outcome of such injuries helps to plan interventions effective in reducing the incidence, mortality and morbidity from road traffic crashes (RTCs). Methods: Data of patients presenting with injuries from RTCs from a trauma registry which was prospectively developed from a dedicated trauma centre based in south-south region of Nigeria were collected and analysed. Descriptive and inferential statistics of data of patients with injuries resulting from traffic collisions from the trauma registry seen between 1 January 2007 and 31 December 2012 were generated and presented. Results: During the study period, 61,820 (65.6%) patients presented with injuries resulting from RTCs. Majority of the patients were males aged between 20 and 40 years. Most of the patients (n = 51,620, 83.5%) presented after 1 h of the incident. Only about 5.2% (3215) of the victims were brought to the hospital by some type of ambulance. Majority of the patients had of injury involving the exterior in 77% (n = 47,601) and the extremities in 23.5% (n = 14,500) of the cases, respectively, but mortality was <1%. Conclusion: RTCs contributed significantly to the trauma burden in Port Harcourt, Nigeria. Delayed presentation, and improper transportation methods of injured victims to hospitals, may have contributed to poor outcome of some of the injuries.
Keywords: Outcome, presentation pattern, road traffic crashes, road traffic injuries, trauma
|How to cite this article:|
Ibeanusi SE, Diamond TE. Traffic related injuries from a trauma registry: Pattern and outcome. Niger J Orthop Trauma 2018;17:22-8
| Introduction|| |
Road traffic-related injuries (RTIs) are injuries resulting from vehicular crashes on the road. Such crashes are often unplanned and may result in injuries, loss of lives and properties. RTIs impact negatively on families, the society and the economy. Such injuries claim lives and are amongst the most serious public health problem all over the world. It has been established that road traffic crash (RTC) is the leading cause of death in adolescents and young adults. About 90% of estimated deaths from RTC occurring annually worldwide are in the middle- and low-income countries. Globally, the number of persons killed in RTC each year is estimated at almost 1.3 million, while the number of persons injured could be as high as 50 million.
RTI was ranked ninth in the order of global disease burden in 1990 and was projected to have risen to third position by 2020. Nearly three-quarters of deaths resulting from motor vehicle crashes occur in developing countries, and this problem appears to be increasing rapidly in these countries. Apart from health problems associated with traffic crashes, the socioeconomic burden of RTC can be huge with countries, incurring average losses of $65–$100 billion annually. These costs include high cost of treatment of injuries resulting from crashes, loss of income and wages of the injured victim from loss of person-hours, as well as the huge psychological and financial burden placed on families and the wider society from care for their injured relatives. The direct economic cost of traffic crashes can at best be understood in terms of labour lost to the nation's economy from deaths and disabilities and contributes to high disability-adjusted life years lost to injury to the nation., While there has been a dramatic increase in the proportion and absolute number of traffic fatalities recorded in developing countries, in the contrast, RTC decreased by >20% in developed nations. For instance, a 5-fold increase in traffic-related fatalities was recorded in Nigeria and Kenya between 1985 and 2015.
Injury patterns from RTC are the function of energy dissipation at the point of impact, which is directly related to the speed of the vehicle. Because of variations in levels of road safety legislation and enforcement of road safety issues such as speed regulation and control, the pattern of injuries resulting from RTCs varies amongst different countries. In addition, because of different levels of development in the trauma care amongst regions, outcome of treatment of injuries from road crashes also varies.
This study was therefore carried out to evaluate the pattern and outcome of injuries resulting from RTCs from a trauma registry in Nigeria.
| Methods|| |
Ethical approval was secured according to the Declaration of Helsinki 1975 and revised in 2000 from the Authority of International Trauma Care and Development (International Centre for Advanced Medical Care and Development [ICAMCAD]), the developers of the registry to use the data. Since there was no direct interaction with the patients, informed consent from the patients was waived. However, confidentiality of the patients' information was maintained throughout the study.
Data of the subset of patients presenting with RTC from the trauma registry prospectively developed from a dedicated trauma centre jointly run with an international humanitarian, non-for profit non-governmental organisation in south-south region of Nigeria were extracted and evaluated. There was no discrimination of patients to treatment in the centre as long as the patient fulfils the criteria to receive treatment in the hospital which include the patient presenting within 3 days of injury and had not commenced treatment in another health facility, except for exceptional cases where patients presenting after 3 days are accepted on compassionate basis, especially if the treatment required by the patient was determined not to be readily available in the locality.
Information of the patients from the time of presentation to discharge from the hospital, transfer to other facilities or death resulting from the injury or other related causes was extracted as to determine the pattern of presentation, the treatment received and the eventual outcome of the injury. Defaulted patients from treatment and/or follow-up were also highlighted. The patients were followed up after discharge in the outpatient clinic or by phone using the telephone numbers provided as at the time of presentation or thereafter till up to 12 months and in some cases up to 2 years, especially for persons who had fractures with delayed fracture union, non-union and internal fixation. Primary outcome assessment was the mortality amongst the patients. Secondary outcome assessment was done using Chertsey Outcome Score for Trauma (COST), which is a validated outcome scoring method used for orthopaedic trauma patients undertaken at 6 months and 1 year following discharge. Copy of the score is provided as appendix. The extent of healing of associated soft-tissue wounds and surgical wounds as well as other complications that resulted directly or indirectly from the injuries was also noted. Patients were seen in the outpatient clinic at 6 weeks, 3 months, 6 months and 1 year following discharge. Defaulting patients were followed up by telephone using numbers provided as at the time of admission.
COST value for the patients was considered satisfactory, 60–80; good, 30–60; fair, <30, poor.
Data were managed using Microsoft Excel (version 2007) (Microsoft Headquarters, Redmond, WA, USA) and SPSS Statistics for Windows, Version 17.0 (Chicago: SPSS Inc., IL, USA). Observed differences were tested for statistical significance using Chi-square as considered appropriate for categorical variables and Student's t-test for normally distributed parametric variables. The trauma demographics were established, and the results are presented as descriptive statistics with averages, proportions and tabulations; inferences were drawn as considered appropriate.
| Results|| |
There were a total of 94,240 patients with injuries recorded in the trauma register during the period under review from the centre only dedicated to receive trauma cases with 61,820 (65.6%) of the patients presenting with traffic-related injuries. A total of 45,870 (74.2%) patients amongst the group with injuries resulting from traffic collisions were males while 15,950 patients (25.8%) were females, giving a male-to-female ratio approximating to 3:1.
Age distribution of patients with road traffic injuries
[Table 1] shows that 64.7% (n = 39,998) of the patients were aged between 21 and 40 years while 3.9% (n = 2411) of the patients were aged between 1 and 10 years. A total of 3576 (5.3%) of the patients were older than 50 years while the ages of 62 patients (0.1%) who were brought in unconscious by unrelated persons could not be ascertained before they either died or transferred to other facilities. The mean age of the patients was 30.7 ± 26.5 years.
Role of patients in the road traffic crash
Majority of the patients were passengers in three- or more-wheeled vehicles, n = 18,979 (30.7%), pillion riders on motorcycles, n = 8098 (13.1%), and pedestrians, n = 16,877 (27.3%). Only 17,805 of the patients (28.8%) were drivers in motorised vehicles and bicycles, n = 62 (0.1%). Passive role players such as passengers and pedestrians were more affected as the active role players such as drivers and motorcycle riders, χ2 = 3070.869, P < 0.001 [Table 2].
Localisation of the injuries on the body
A total of 47,601 (77%) patients had injuries involving the external parts of the body such as the skin and soft tissues and 14500 (23.5%) of the patients had injuries involving. A total of 720 (1.2%) injuries involved the head and neck, while 872 (1.4%) patients had injuries involving the chest and 1625 (2.6%) patients had injuries involving the abdomen [Figure 1].
|Figure 1: Pattern of body location of injuries. χ2 = 121106.409, P < 0.001|
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Interval from injury to presentation to the hospital
[Table 3] shows that 11.2% (6024) of the patients arrived to the hospital between 30 min and 1 h (0.5–1 h) following the crash incident, whereas 5.3% (3276) arrived within 30 min of the incident. A total of 3786 (22.3%) patients arrived between 1 and 4 h (1–4 h) after the incident, whereas 37,839 (61.2%) arrived the hospital after 4 h of being injured including 247 (0.4%) patients who presented for treatment after 30 days of being injured. The number of patients presenting to the hospital within 1 h of the injury was 10,200 (16.5%), while 51,620 (85.5%) patients arrived after the golden hour of injury (χ2 = 27751.802, P < 0.001).
Mode of transportation of the patients to hospital after incident
[Figure 2] shows that 31,034 (50.2%) of the patients walked into the hospital, 15,640 (25.3%) of the patients were brought to the hospital by private or commercial four- or more-wheeled vehicles (cars and buses), 4822 (7.8%) of the patients were brought on motorcycles and another 7109 (11.5%) of the patients were brought with tricycles whereas 3215 (5.2%) were brought to the hospital by some forms of ambulance.
|Figure 2: Mode of transportation to hospital after incident. χ2 = 42664.353, P < 0.001|
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Severity of injury at presentation
[Table 4] and [Figure 3] show the distribution of the anatomic and physiological categorisation of injuries as assessed by injury severity score (ISS) and revised trauma score (RTS), respectively, amongst the patients. A total of 37,998 (64.7%) of the patients had an ISS <9; 16,753 (27.1%) had an ISS between 9 and 15, while 5069 (8.2%) of the patients had an ISS higher than 16, including 1731 (2.8%) patients with ISS >25.
|Figure 3: Distribution of revised trauma scores. χ2 = 52543.251, P < 0.001|
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The distribution of the RTS showed that 47,101 (76.2%) patients had had RTS higher than 7.0; 11,189 (18.1%) had RTS between 5 and 7 and 3584 (5.7%) had RTS between 0 and 5.
Treatment given to the patients
[Table 5] shows the distribution of treatment received by the patients; 47,347 (65.5%) patients with minor injuries received ambulatory care, 5521 (8.9%) of the patients had external fixation for associated fractures, 5440 (8.8%) of the hospitalised patients received wound dressing care only and 1230 (2.0%) had split skin grafting. A total of 3615 (5.8%) patients had open reduction and internal fixation, 4316 (8.9%) had casts (had Cast either synthetic resin cast or Plaster of Paris (POP)) applied for associated fractures and 122 (0.2%) patients had amputation. A sizable number of the patients had combined options of treatment occasionally in multiple stages.
Outcome of treatment
The distribution of treatment outcomes assessed using the COST method showed that 39,007 (63.10%) patients had satisfactory outcome following treatment (mean COST value = 87 ± 10.2); 15,035 (24.32%) had good outcome (mean COST = 65 ± 14.1); 1620 (2.6%) patients had poor outcome while 223 (0.36%) patients died just after arrival or following treatment in the hospital. Majority of the patients died from consequences of severe head injury (122), other major organ injury (52), extensive blood loss (32) and septic shock and multiple organ failure (17). Some of the patients had multiple complications resulting from polytrauma involving multiple body regions [Table 6].
Relationship between interval to arrival at the hospital and mortality
Forty-seven of the patients who died were amongst the group that presented within the golden hour (n = 10,200) whereas 176 patients who died arrived the hospital after the golden hour of injury (n = 516,200) [Figure 4].
|Figure 4: Relationship between interval to arrival and mortality. χ2 = 328.8202, P = 0.0001|
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| Discussion|| |
The pattern of injuries from traffic crashes from this study is similar to patterns observed from previously published studies.,, The high number of injuries resulting from traffic crashes recorded in this study may be related to safety conditions of Nigerian roads. Such crashes may be related to human factors, environmental factors and mechanical factors arising from the vehicles involved in the crashes., Unfortunately, Nigeria still ranks low in the World Health Organization (WHO) road safety ratings.
The relative high number of patients seen in this centre when compared to other hospitals in the region may have been influenced by the fact that treatment in the centre was free as long as the patient met the strict criteria for admission set by the hospital. The free service provided in the facility encouraged many patients to come for treatment from other neighbouring states beyond the state the hospital is domiciled. In addition, the years during which this study was undertaken witnessed several and multiple industrial actions and strikes by various categories of workers in the public healthcare in the country, thereby leaving patients with few options to access medical services.
This study like other similar studies confirms that the bulk of victims of RTC are young healthy males with majority of the patients aged between 20 and 40 years [Table 1] who are often the breadwinners of their family and constitute majority of the workforce.,
The exterior (skin and soft tissues) and extremities were the body region mostly affected n = 47,601 (77%) and n = 14,500 (23.5%), respectively [Figure 1]; however, a good number of the patients had injuries involving multiple body regions. This is a common pattern in blunt mechanism of injury arising from traffic collisions.,
About half of the patients arrived the hospital as walking wounded. This may be attributed to the fact that majority of the patients had minor injuries with 54,751 (91.8%) of the patients having the ISS >16. This pattern was similar to the findings of the major trauma outcome study., It had been reported that patients with lower value ISS at the time of the incidents most likely present as walking wounded to the hospitals.
Delayed arrival to the hospital and improper methods of transportation of injured victims to the hospital were worrisome findings from this study as <20% of the victims arrived the hospital 'within the golden hour' of trauma, P < 0.001. The golden hour is the initial hour after the incident when most lives could be saved and morbidity that may result from the incidents best reduced by appropriate and timely interventions. In fact, some patients even arrived for treatment after 30 days of the incident. Incidentally, the delayed arrival to the hospital after the golden hour may have influenced the observed mortality from the study as about 79% (n = 176) among the patients that died were brought to the hospital after the golden hour, χ2 = 328.8202, P = 0.0001. These were the group that would have visited other facilities including the traditional bone setters and herbal treatment centres before arriving to the hospital., In addition, the study revealed that only about 5% of the victims were brought to the hospital with vehicles designated as ambulance. These so-called ambulance vehicles included ordinary wagon vehicles which were conventionally not designed as ambulance but were just converted to ambulance by removing the regular seats in the vehicles by the owners to transport ill and injured persons and occasionally corpses as a means of earning income. In fact, most of such nonconventional ambulances are often used in the locality to transport corpses as hearse wagons and occasionally to transport injured and ill persons to hospitals, especially as conventional ambulances are usually not readily available and often not easily affordable for the majority of persons requiring the services. A fall out of this situation is that a sizable number of the victims were brought to the hospital in private and commercial four-wheeled vehicles (25.3%, n = 15,640) or on motorcycles (7.8%, n = 4822) and 7109 (11.5%) in tricycles called KEKE-NA-PEP in local parlance by persons without any form of training in handling injured victims. These methods of transportation in unprofessional manner by untrained persons could have contributed in worsening the injury of the victims, especially those involving the cervical spine and fractures. Reasons adduced for these patterns of transportation of crash-injured victims include absence of organised emergency medical services (EMSs), pre-hospital care system and organised ambulance services in many parts of the country., More worrisome is that there was an established emergency ambulance scheme in the state which was grossly inefficient and necessitating reorganisation of the scheme to improve efficiency. A proportion (about 1500) of the patients who were brought by ambulance were by those of the state EMS. A study from Iran observed that about 47% of victims of RTC either make their own way to hospitals or were transferred by members of the public, such as taxi drivers, commercial drivers, police officers or laypeople. A WHO Report 2016 confirms that as at 2013, up to 75% of patients in Iran arrived hospitals by ambulance, thus suggesting that Iran has a better organised pre-hospital system than Nigeria as at the time of this study.
Properly organised and effective pre-hospital care systems with trained personnel and resources help to increase the number of RTC victims arriving to the hospital alive for treatment. It has been shown that mortality for the severely injured with potentially survivable injuries was 6-fold higher in the developing world (36%) as compared with the developed countries (6%). This pattern was attributable to the quality of EMSs and level of trauma services available to the injured in the following the injury. A 6-h training of commercial drivers in Ghana improved ability to provide basic first aid to the injured allowing more victims of RTC to reach healthcare facilities for treatment. Nigeria can adapt such approach by training commercial drivers and laypersons on basic first aid so as to fill the existing gaps from the absence of trained pre-hospital caregivers for victims of medical emergencies including road crashes. Evidence confirms that improved organisation of trauma services decreased deaths from injuries by 15%–20% for treated trauma patients and decreases medically preventable deaths by up to 50%.,
A total of 54,042 patients in this study (87.42%) had satisfactory and good outcome following treatment, but 6756 patients (11.09%) had fair or poor outcome including 122 patients who died from the incidents. The adoption of COST system for assessing outcome was to provide a validated objective method of assessment of outcome of the patients. COST system which is a validated patient-reported outcome measures method considers, symptoms, physical, mental and overall status of the patient at the time of assessment. The result from this study would imply optimal trauma care for the victims that presented to the hospital.
On the contrary, the number of patients with satisfactory and good outcome may be due to the fact that most of the patients (91.8%) had minor injuries with ISS <16. In addition, more than 80% of the patients had injuries involving the external and the musculoskeletal system which often are not life-threatening injuries but may occasionally be life deforming if not properly treated. Therefore, the use of crude mortality as the only tool of assessment for the quality of care may be misleading as the morbidity from improper medical care may be enormous. The extent of healing of the associated soft-tissue and surgical wounds, as well as other complications that resulted directly or indirectly from the injuries were noted. These variables will influence the parameters considered in the COST system, especially the overall status of the patient. The COST was especially designed for orthopaedic trauma patients to measure the extent the patient manages to return to his or her pre-injury state. This scoring system uses as baseline the pre-injury status of the patient and also has the aim to determine the percentage of rehabilitation after treatment for any injury. The COST system was considered appropriate as the majority of patients in this study has musculoskeletal trauma. The scoring system uses simple wording and design and can be easily and quickly filled by or for the patients in the outpatient clinics or even by phone conversation. The use of telephone follow-up assisted in the follow-up of defaulting patients. This was made easier with the improved use of telephone, especially the global satellite mobile telephone system in the locality. Other outcome scoring systems such as SF-36 and SF-12, were considered, but these systems are more generic to patients' general health and mental status as such may not completely reflect status for trauma patients, especially those with orthopaedic trauma. Other limitations of the SF scoring system is well established including high default rates among adolescents who incidentally constituted the bulk of patients and its selective discrimination among persons older than 65 years who incidentally constituted <2.5% of the patients in this study.
Another worrisome observation was the number of persons who were discharged against medical advice. These included the patients with extensive extremity injuries who would not accept offered amputation as an option of treatment to save life. Earlier study in the locality shoed that amputation as an option of treatment is not readily accepted in the locality for various reasons.
Furthermore, the fact that only 223 of the patients amongst the victims who arrived the hospital died, giving a case fatality rate of <1% that could have been attributed to natural selection where most of the severely injured died before they got to the hospital and only those that had survivable injuries who are not expected to die reached the hospital alive. Patients brought in dead to the hospital were certified dead and handed back to the relations without admission into the facility as such were not part of the recorded mortality.
Majority of the deaths resulted from associated severe head injury (n = 122), other major organ injury (n = 52), extensive blood loss on or before arrival from the hospital (n = 32) and septic shock and multiple organ failure (n = 17). A good number of the patients who died had multiple injuries and complications that would have contributed to mortality. This is a common pattern in blunt mechanism of injury following RTCs. Some patients who were brought in dead before arrival to the hospital were certified dead and were handed over to the persons that brought the victim to the hospital. The observed low mortality could be misleading particularly when one considers the existing poorly established pre-hospital and emergency medical care in Nigeria at the time of this study. This fact was further buttressed by the fact that over 90% of the patients presented with minor injuries with ISS >16 affecting the external and musculoskeletal system which are often not life-threatening but could be life deforming. This pattern may not have changed considerably much in the country considering that EMSs have not remarkably improved since this study was undertaken. Furthermore, the comparatively better results in outcome when compared to results from other hospitals in the region may be related to the strict criteria to qualify for free treatment in the hospital which encouraged patients to arrive the hospital fresh with fewer complications that would have arisen from initial treatment by quacks and herbalist which could have altered the outcome of treatment in the patients studied.
| Conclusion|| |
RTIs remain a menace and contributed significantly to the huge trauma burden in Port Harcourt, Nigeria. Delayed presentation, improper transportation of injured victims to the hospital and limitations in the availability of material and human resources for quality trauma care contribute to the challenge in managing injuries from RTCs. Improved pre-hospital care in a better-organised health system may help to improve the outcome of injuries arising from traffic crashes. Establishing a comprehensive database of RTI with the integration of reports from various hospitals including those from various road traffic management agencies in the country will help to determine the actual incidence and pattern of RTI in the country. This policy will help to plan better remediation measures for this preventable public health burden in the country.
We acknowledge the Board and Management of International Centre for Advanced Medical Care and Development for allowing us access to the data from their trauma registry.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]