Demographic and clinical profile of head injury in Western Uttar Pradesh-A study at SVBP hospital Meerut

Sex distribution

Out of 986 male patients were 690 i.e.70% and female were296 i.e.30%as shown in Table 1.

Age distribution of head injury patients

The ages of the patients ranged from 1.5 year to 80 years. The median age was 27 years (32 years for males, 25 years for females).  Children within the age range of 1.5 years to 5 years were 40 patients and age group 6-10 years of age where 161 patients were included. So total children were 201 in which male children were 131 and female were 70. So male children were more prone to head injury, the difference was significant. It was also observed that head injury due to fall from height is more common in winter months i.e. December, January and February because children and ladies bask in the sun on their terraces which usually do not have railings.

Pre hospital treatment and duration

Pre hospital care and transportation of road traffic accident victims to hospitals have a significant impact on the outcome of head trauma. Transportation of the patients by unprofessional ill-trained staff in ill- equipped ambulances or in equipped ambulances  may cause secondary central nervous system damage  as compared to well trained emergency management staff in a well equipped ambulance by

In our study as shown in Table 3, there were about10.54% patients admitted to hospital less than 2hours have received tertiary care early. About 25.96% of patients reached to level III hospital from 2 to 6 hours while 29% reached between 6 hrs to24 hrs. These patients first went to PHC, CHC OR Level -I or II hospital.  19.97% patients were shifted between 1day to 3days period from private hospitals either due to financial issues or when patients' condition deteriorated. Around 9.43% of patients were shifted to our hospital between 3 day to 7 days due to the same reasons. About 5% of patients were shifted for terminal care only as there was no hope of improvement.

The transportation of head injury patients to our hospital was mainly through private vehicles. In our study as shown in Table 4. About 64.60 % patients were transported through private vehicles like Cars, tempo, mini truck, and 27.38%Patients were shifted through ambulance with BLS but had no trained staff to manage patients during transportation. IT has been observed that about 30% patients deteriorated during transportation to tertiary care hospitals. About 10% of patients expired before reaching the hospital. Observations made by questionnaire from attendants whose patients expired before reaching to hospitals and considered as brought dead patients. Patients shifted from hospital to tertiary care hospital are usually transported through well equipped with ALS (advanced life support) and have trained para medical staff. So patients transported from primary site to first hospital i.e. Level I&II care hospitals usually don’t receive golden hour management. Hence the outcome of patients is affected. The current status of patient's transportation to the hospital, which has a direct impact on the deterioration of the patient's condition and increases the risk of mortality or severe morbidity is very disheartening. The study published [Asian J Neurosurg2018 Jul-Sep] revealed the failure of prehospital care in their country as none of the 830 patients, who are included in the study received any form of prehospital care and showed as well that 65.4% of these patients had been transported by what wrongly called ambulances! While 33.1 were transported by private vehicles. Transportation of the patients by nonprofessional unequipped and untrained emergency medical services (EMS) staff may cause secondary central nervous system damage. {Asian J Neurosurg. 2018 Jul-Sep; 13(3): 955–956.}.2

In our study as shown in Table 5. The most common cause of head injury was RTA (Road traffic accident) i.e. 48.37%. Male were more than females. The second most common cause was fall from height, in this group children were affected i.e. about 29%. About 19.07 % were due to physical assault, firearm injury were1.11%. Other causes like sport injury, domestic causes were about2.43%. Road conditions and driver’s temperament are also responsible for increased RTA.  Dangerous road conditions may be the result of natural events, such as tropical rains and flooding, that make driving unsafe. Dangerous conditions can also arise from the poor physical condition of a road and its surroundings. While driver errors such as speeding, distracted driving and drunk driving are among the leading causes of automobile accidents in most parts of India, the dangerous road conditions are also a significant contributor. There are few of the unsafe road conditions that can lead to a vehicular accidents   i.e. Cracks and potholes that can cause a driver to lose control of the vehicle; Signs that have fallen or can’t be seen because of overgrown foliage; Faded paint markings that are invisible from the driver’s seat; Inadequate guardrails on curves and overpasses; Lack of rumble strips on freeways; Poor traffic control in construction zones; Placing construction materials and utility poles in a way that obstructs a driver’s vision.

Use of Helmet in two wheelers and head injury

Helmets reduce the incidence of head trauma in low-speed accidents, at moderate and high speeds their sole function is to prevent brain matter from being spread over the highway. There is a classic line that goes, “Buy your son a motorcycle for his last birthday” This, in a way, summarizes motorcycle accidents. The motorcycle, by its design, is intrinsically dangerous. An accident that might result in minor injuries with an automobile can result in death with a motorcycle. Approximately 6% of all traffic fatalities involve motorcycles. In accidents involving automobiles, the most dangerous thing that can happen to an individual is to be ejected from the vehicle. Motorcycles involved in accidents always eject their operators or passengers. Individuals dying in motorcycle accidents typically die of either head or neck injuries, with the former more common.4 In our study 160 /477 RTA cases were with two wheelers. Analysis was done from history and questionnaire from attendants. Helmet use was found in 23.75% cases.

Severity of head injury

Traumatic brain injury severity is commonly described as mild, moderate, or severe. Injury severity is traditionally based on duration of loss of consciousness and/or coma rating scale or score, post-traumatic amnesia (PTA), and brain imaging results. The Glasgow Coma Scale (GCS) is a tool for measuring the degree of unconsciousness and is thus a useful tool for determining the severity of the injury. Mild, moderate, and severe TBI may be characterized as follows:

Mild TBI

GCS between 15 to 13,Brief loss of consciousness, usually a few seconds or minutes, PTA(Post traumatic amnesia) for less than 1 hour of the TBI, Normal brain imaging results

Moderate TBI

GCS between 12-9, Loss of consciousness for 1 – 24 hours, PTA for 1 – 24 hours of the TBI, Abnormal brain imaging results.

Severe TBI

GCS below 8, Loss of consciousness or coma for more than 24 hours, PTA for more than 24 hours of the TBI, Abnormal brain imaging results.

In our study out of total 986 cases severe head injury cases were 510/986 i.e. 51.72%. moderate head injuries were 256/986i.e. 25.96%. and mild head injury cases were noted in 22.31%, i.e.220/986Cases.

Clinical presentation of head injury cases

Head injuries include both injuries to the brain and those to other parts of the head, such as the scalp and skull. Head injuries can be closed or open. A closed (non-missile) head injury is where the dura mater remains intact. The skull can be fractured, but not necessarily. A penetrating head injury occurs when an object pierces the skull and breaches the dura mater. Brain injuries may be diffuse, occurring over a wide area, or focal, located in a small, specific area. A head injury may cause skull fracture, which may or may not be associated with injury to the brain. Some patients may have linear or depressed skull fractures. If intracranial haemorrhage occurs, a hematoma within the skull can put pressure on the brain. Types of intracranial haemorrhage include subdural, subarachnoid, extradural, and intraparenchymal haematoma. Brain injury can occur at the site of impact, but can also be at the opposite side of the skull due to a contrecoup effect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact). If the impact causes the head to move, the injury may be worsened, because the brain may ricochet inside the skull causing additional impacts, or the brain may stay relatively still (due to inertia) but be hit by the moving skull (both are contrecoup injuries).

In our study loss of consciousness (LOC), vomiting and bleeding from ENT are the common presentations. LOC present in about 79.72 % cases. vomiting was present in69.98% cases. Bleeding from ENT (Ears, Nose, Throats)were present in  32.555% cases .Patients gain consciousness  commonly in mild and  moderate head  injury cases.  Headache vertigo and decline cognitive function were noted frequently in such patients. Others sign and symptoms were shown in Table 8

Head injury associated with poly Trauma

The management of a head injury patient with multiple other injuries presents one of the most challenging and difficult clinical scenarios in trauma critical care. This is, in part, due to the fact that the treatment of other injuries, such as orthopaedic, spine, and craniofacial fractures, has the potential for worsening the neurologic outcome. This potential worsening is not necessarily directly related to the primary repair or the timing of surgery, but more to the fact that additional surgery with potential blood loss and possible resultant hypotension or hypoxia can adversely affect an injured brain. A single episode of hypotension or hypoxia can adversely affect the outcome of all severities of head injury. Chest injury and abdominal injury, fractures of long bones are commonly seen in major road traffic accidents.in our study about 34.78% patients have other injuries (polytrauma) along with head injury. Chest injury 8.82%and long bone fractures 12.77% were usually associated with bad outcomes in patients. Rest results of our study are shown in table no.9.

CT scan finding analysis

CT Scan head was done in all the patients i.e.986, admitted in emergency as a case of head injury. In about 151 patients i.e.15.31% CT Scan was normal. Cerebral oedema was found in 531/986 i.e.53.85% In rest of the CT Scan the common lesions were SDH 233/986 i.e.23.63% and hemorrhagic contusion was in 160/986 i.e.16.22%.EDH was in 156/986 i.e. in15.82%.

Outcome of head injury patients

The Glasgow Outcome Score applies to patients with brain damage allowing the objective assessment of their recovery in five categories. This allows a prediction of the long-term course of rehabilitation to return to work and everyday life.5

Patients having normal CT scans were usually discharged after 24 hours in satisfactory conditions GCS 15/15. Overall in-hospital mortality was 44% (434/986 cases). 30% (328/986) died within one week of injury. About 8%(79/986) of  minor and moderate head injury died and 36%(355/986) of severe head injured patients expired; Amongst those who survived 552/986 i.e.55.98%. About 394/986 i.e.40% had good outcomes (GOS 4 or 5), 10.34% i.e.102/986 were severely disabled (GOS 3) and 5.89% i.e.56/986 were vegetative (GOS 2).