|Year : 2014 | Volume
| Issue : 4 | Page : 293-297
Characteristics of patients who died from traumatic brain injury in two rural hospital emergency departments in Maharashtra, India, 2007-2009
Amit Agrawal1, Victor G Coronado2, Jeneita M Bell2, Nitish Baisakhiya3, Anand Kakani4, Sagar Galwankar3, Sankalp Dwivedi3
1 Department of Neurosurgery, Narayana Medical College and Hospital, Chintareddy Palem, Nellore, Andhra Pradesh, India
2 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, Atlanta, GA, USA
3 Maharshi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, Haryana, India
4 Datta Meghe Institute of Medical Sciences, Acharaya Vinoba Bhave Rural Hospital, Sawangi, Maharashtra, India
|Date of Web Publication||23-Dec-2014|
Dr. Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Trauma is one of the leading causes of morbidity and mortality in the world and in India.
Objective: To describe 1) selected epidemiological and clinical characteristics of persons with traumatic brain injury (TBI) who died within 24 h after admission to the emergency departments (EDs) of two medical facilities in rural India and 2) the methods used to transport these patients from the locale of the injury incident to the study sites.
Materials and Methods: Medical records of all injured patients regardless of age or sex who died within 24 h after admission to both EDs during January 31, 2007 through December 31, 2009 were reviewed and abstracted. Demographic variables and information on prehospital care, time and mechanism of injury, mode of transport to EDs, and primary hospital resuscitation were abstracted and analyzed.
Results: Of the 113 injured patients in this study, 42 had TBI and died within 24 h of ED admission. All of these TBI patients were transported to the ED by relatives or bystanders in non-ambulance vehicles. Most of the patients with TBI (78.5%) were 21-50-years-old; and overall 90.0% were males. Persons working near or along busy roads struck by vehicles accounted for 80.9% of all TBI cases. Severe TBIs were present in 97.6% of the patients; of these, 92.8% had a Glasgow Coma Scale (GCS) score of 3 on arrival. Other concurrent injuries included superficial lacerations (85.7%), facial injuries (57.1%), and upper (35.7%) and lower (30.9%) extremity fractures. Common lesions recognized on computed tomography (CT) scan were acute subdural hematoma (21.4%), subarachnoid hemorrhage with diffuse cerebral edema (16.6%), and skull base fracture with diffuse cerebral edema (14.2%); in 21.4% of cases, the CT scan were reported normal.
Conclusion: Most of the TBI patients who died within 24 h after admission to EDs in this study were not transported to EDs in emergency medical vehicles; most were of working age (ages 20-50 years); were male; and were day laborers working on busy interstate roads where they were hit by vehicles.
Keywords: Emergency department, head injury, mortality, rural, trauma systems, traumatic brain injury
|How to cite this article:|
Agrawal A, Coronado VG, Bell JM, Baisakhiya N, Kakani A, Galwankar S, Dwivedi S. Characteristics of patients who died from traumatic brain injury in two rural hospital emergency departments in Maharashtra, India, 2007-2009. Int J Crit Illn Inj Sci 2014;4:293-7
|How to cite this URL:|
Agrawal A, Coronado VG, Bell JM, Baisakhiya N, Kakani A, Galwankar S, Dwivedi S. Characteristics of patients who died from traumatic brain injury in two rural hospital emergency departments in Maharashtra, India, 2007-2009. Int J Crit Illn Inj Sci [serial online] 2014 [cited 2020 Feb 25];4:293-7. Available from: http://www.ijciis.org/text.asp?2014/4/4/293/147521
| Introduction|| |
Trauma is one of the leading causes of morbidity and mortality in young people across the world. ,,, According to the World Health Organization (WHO), injuries kill 5 million people each year. Road traffic injuries claimed nearly 3,500 lives each day in 2011-about 700 more than in the year 2000-making it among the top 10 leading causes of death globally in 2011.  In 2004, road traffic injuries were the ninth leading cause of death. However, with the trends of urbanization and motorization, road traffic injuries have increased dramatically worldwide and are now expected to become the fifth leading cause of death.  Traumatic brain injury (TBI) is a major cause of disability and death affecting people during the most productive period of their lives. , National level data in India are not available for TBI.  Local TBI data, however, are available. , Based on hospitalization data, the incidence and mortality from TBI in Bangalore is 160 and 20, respectively per 100,000 population;  and the case fatality rate was 9%.  These estimates, however, are largely derived from studies from urban India, and in the absence of any TBI registries, nationally representative data are not available. 
Organized emergency medical response systems (EMRS) are also lacking in rural India and other developing countries. This is of concern because even if patients are provided with optimum care in emergency departments,(ED) the lack of prehospital care may be associated with unfavorable health outcomes. ,,, All transportation is by personal and private ground vehicles, or ambulances without trained paramedics, and there is no air-based evacuation and transportation system. , When appropriate field triage, transfer and emergency services are available, the short- and long-term outcomes from injury can potentially be improved. ,,, Several studies have demonstrated that patients who receive proper triage and transport using land or air are more likely to survive compared to those who do not. , This improved outcome could reflect the benefit of earlier therapeutic interventions including endotracheal intubations, blood transfusions, and administration of electrolyte fluids prior to ED admission. , The purpose of this study is to describe (1) selected epidemiological and clinical characteristics of persons with TBI who died within 24-h after admission to the EDs of two EDs affiliated with a tertiary care facility in rural India: The Datta Meghe Institute of Medical Sciences and the affiliated Acharaya Vinoba Bhave Rural Hospital, Sawangi, Maharashtra, India and (2) the methods used to transport these patients from the locale of the injury incident to the study sites. At the time of this study, each of these facilities had two ambulances, one intensive care unit, and two emergency physicians and neurosurgeons. Each institution also had imaging and rehabilitation departments staffed with four radiologist and three physiatrists.
| Materials and Methods|| |
Medical records from all injured patients, including those with TBI, who were admitted to and died within 24-h of admission in the study sites from January 1, 2007 through December 31, 2009, were reviewed and abstracted. Information on the exact characteristics such as the locale of the injury, the type of road where injury occurred, pedestrian status, occupancy in a vehicle status, type of vehicle involved, and the occupation of case patients documented in the reviewed medical records was scant or incomplete.
TBI severity was determined using the Glasgow Coma Scale (GCS).  Patients with GCS scores between 3 and 8 were classified as cases of severe TBI; those with scores between 9 and 12 were classified as cases of moderate TBI; and those with scores between 13 and 15 were classified as cases of mild TBI. Selected demographic variables (i.e., age, sex, and occupation) and information on prehospital care including mode of transport to ED, external cause of injury, and injury locale were abstracted. Clinical data on primary hospital resuscitation hemodynamic parameters (e.g., blood pressure, heart rate, respiratory rate), and imaging were also collected. Facial injuries included abrasions, lacerations, contusions, and fractures of facial bones. All information was entered into a Microsoft Excel database and analyzed using Epi Info 7 TM . The study was approved by the Datta Meghe Institute of Medical Sciences Institutional Ethical Committee.
| Results|| |
During the 2-year study period, a total of 113 patients presented to the hospital with an injury and died within 24 h (median age = 35 years, range = 1-92 years). This study found that none of the 113 total patients received prehospital emergency care and only one patient was transported to the ED in an ambulance; the remaining were transported in other non-emergency medical vehicles. The duration from reported time of injury to presentation in the ED was not documented in the medical records.
Of the 113 injured patients, 37.2% (N = 42) had TBIs. The median age of the TBI patients was 35 years (range = 1-92 years); and the majority were men (90.5%) aged 20-50 years (78.6%) [Figure 1]. Most of the TBIs were due to road traffic collisions, including pedestrians being hit by moving vehicles (road traffic accidents (RTAs)) (81.0%) followed by falls (7.0%), and interpersonal violence (7.0%). Overall, 5.0% occurred in fixed workplaces (e.g. factory). Of those who sustained a TBI due to RTAs, 80.9% TBIs were sustained by persons working near or along busy roads where they were hit by vehicles.
|Figure 1: Numbers of injured patients who died within 24 h of admission by age-group and type of injury; January 2007-December 2009, rural Maharashtra, India|
Click here to view
A total of 39 (95.1%) patients with TBI had a GCS of 3 on arrival, two had GCS between 3 and 7, and one patient had a GCS of 13. All 42 patients were intubated in the ED, resuscitated, hemodynamically stabilized, and put on elective ventilation using the Advanced Trauma Life Support (ATLS) protocol. Thirty-seven (88.1%) of all TBI patients did not have indication for neurosurgical intervention and in 5 (11.9%)-despite indication-no neurosurgical procedure could be performed because of poor general and neurological condition [Table 1]. The most common concurrent injuries among the 42 patients with TBI were superficial lacerations/bruises/abrasions (85.7%), facial injuries (57.1%), ear-nose-throat bleeding (50%), and upper (35.7%) and lower (30.9%) extremity fractures [Table 1].
|Table 1: Concurrent injuries among 42 patients with traumatic brain injury who died within 24 h of admission to two tertiary care facilities in rural Maharashtra, India. January 2007-December 2009|
Click here to view
Computed tomography (CT) scans were performed in 38 (90.5%) of the 42 TBI patients. Common CT diagnoses included acute subdural hematoma (21.4%), subarachnoid hemorrhage with diffuse cerebral edema (16.6%), and skull base fracture with diffuse cerebral edema (14.2%). All of the 42 patients with TBI had other concurrent injuries. In nine patients (21.4%) who had no other reason for their loss of consciousness and had a definite history of trauma, CT scans were reported as normal [Table 2]. No other imaging modality was available at these hospitals.
|Table 2: Selected CT scan findings among patients with TBI who died within 24 h of admission to two tertiary care facilities in rural Maharashtra, India. January 2007-December 2009|
Click here to view
| Discussion|| |
To our knowledge, this study is the first one that collected data on the methods used to transport all injured patients to the study hospitals in rural Maharashtra, India. This study found that most of the TBI patients who died within 24 h after admission to the EDs of two rural medical facilities in India were not transported in emergency medical vehicles; 65% of cases were 21-50 years of age; were male; and were day laborers working near or along busy roads where they were hit by vehicles. These findings highlight the need to develop reliable and accessible EMRS and to implement preventive measures for those at risk.
In this study, the way patients were transported to the EDs may reflect the lack of appropriate communication systems, ambulances, and/or proper EMRS that include appropriate prehospital emergency care in India, particularly in rural areas. A well-implemented EMRS can potentially have a beneficial impact and result in less catastrophic outcomes. For example, in Malawi, improved triage and emergency care for children reduced inpatient mortality from 10 to 18% prior to an intervention to 6-8% after the changes.  Other factors may have also influenced the patients' transportation method observed in our study. In Pakistan, researchers found that people may not call an ambulance in health-related emergencies because these ambulances reportedly did not respond in a timely fashion.  Mortality in rural areas may also increase due to other limitations (not elucidated in our study); for example, lack of pre-arrival notification systems and proper emergency care, lack of ventilators and beds in the intensive care unit, imaging, and availability of full time admitting and decision making neurosurgical team.  Additionally, one study in Trinidad showed improvement in trauma patient outcome post ATLS training for resuscitation of patients with a decrease in mortality (67 vs 34%) among the most severely injured patients.  This warrants further study of the use and benefits of ATLS in rural Maharashtra. The benefits of using ATLS to evaluate patients, as was done in the two EDs we studied, may have contributed to reduce the observed mortality.
The economic impact of injury and TBI also needs to be elucidated in rural India. In our study, the age in which most of the TBI patients died suggest major economic impact as it affected mostly people of working age. The impact of this finding may be higher in developing countries where two-thirds of the global burden of injury deaths occur, consuming substantial personal  as well as healthcare sector resources. 
This analysis indicates that 81% of the TBI fatalities were persons working on interstate roads where they were hit by vehicles. This is an issue in developing countries where rapid motorization contributes to the injury problem  A study in Nepal found that day laborers were the largest group (27.6%) involved in RTAs;  in this study, the authors found that road laborers hit by vehicles while working on the busy interstate roads experienced most of these injuries. Examples of additional factors that may contribute to this problem of road traffic injuries include lack of traffic signals, lack of or poor enforcement of alcohol-impaired driving laws, nonuse of seatbelts and helmets, lack of safe places for pedestrians to walk,  lack of barriers between workers and traffic, and lack of protection for road workers, such as reduced traffic speed in work zones. 
The findings of this study are subject to some limitations. Some epidemiological and clinical information may have been underreported due to the lack of proper documentation on the medical records; examples of missing information include: Alcohol use, type of road where the injury occurred, pedestrian status, occupancy in a vehicle status, and type of vehicle. Properly documented epidemiological and clinical information in the medical record is important to understand the mechanisms of injury, the clinical characteristics, and to postulate how many deaths were preventable. ,,,,, This information can be used to develop preventive interventions, EMRS, and clinical guidelines and to educate decision-makers about the preventability of this public health problem.  Our study also does not account for patients who sought care in other nearby healthcare facilities, died on site, died after the first 24 h, or those who survived their injuries; therefore, the results of this study should be interpreted with caution as they may not be representative of all cases of TBI in rural Maharashtra. Information on the level of training of healthcare providers and the type of care or procedures they provided was also missing. According to Gerardo et al., the implementation of a dedicated full-time trauma team incorporating both trauma surgeons and emergency medicine-trained, board-certified or -eligible emergency physicians was associated with decreased mortality rates in trauma patients treated at a level I academic medical center, including those patients presenting with the most severe injuries. 
| Conclusions and Recommendations|| |
Findings of this study indicate that in rural areas of Maharashtra, India, road traffic injuries are a leading cause of TBI-related death. Our findings underscore the need to develop a comprehensive prevention, surveillance, and response system for pre- and in-hospital care, including police reports and use of ambulances. Data from these surveillance systems can be used to understand the problem and monitor the impact of prevention interventions. This study also suggests the need to establish appropriate EMRS in rural areas, especially in areas with high levels of injury. There is the need to continuously assess the burden of trauma, the adequacy of prehospital and in-hospital care, and whether cost-effective resources are available to provide adequate acute and long-term care, including rehabilitation services. Studies on the acute and long-term human and socioeconomic consequences of injury, including TBI, are also needed for the proper allocation of resources to address the long-term consequences of this preventable public health problem. Most importantly, healthcare professionals can help to reduce the burden of injuries, including road traffic-related injuries in India by, for example, by educating patients about the use of seat belts  and identifying and referring to counseling those who consume unhealthy levels of alcohol.  As road traffic injuries were the main mechanism of injury in this study, preventing them in rural areas of Maharashtra, India, may require implementing the World Health Organization's recommendations on road traffic injury prevention.  These recommendations include: Identifying an agency to guide the road traffic safety effort, assessing the problem, policies and institutional settings relating to road traffic injury, and the capacity for road traffic injury prevention; preparing a national road safety strategy and plan of action; allocating financial and human resources to address the problem; implementing specifications to prevent road traffic crashes, minimizing injuries, and their consequences; evaluating the impact of these actions; and supporting the development of national capacity and international cooperation.  Results from this study can be used by public health and healthcare practitioners to promote the design and implementation of injury surveillance and prevention initiatives and to improve emergency medical services , in rural India.
The findings and conclusions of this research are those of the authors and do not represent the official views or policies of the U.S. Department of Health and Human Services (DHHS) or the Centers for Disease Control and Prevention (CDC). The inclusion of individuals, programs, or organizations in this manuscript does not constitute endorsement by the U.S. Federal Government, DHHS, or CDC.
| References|| |
Bajracharya A, Agrawal A, Yam B, Agrawal C, Lewis O. Spectrum of surgical trauma and associated head injuries at a university hospital in eastern Nepal. J Neurosci Rural Pract 2010;1:2-8.
Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD. Epidemiology of trauma deaths. Am J Surg 1980;140:144-50.
Raftery KA. Emergency medicine in southern Pakistan. Ann Emerg Med 1996;27:79-83.
Coronado VG. Epidemiology. In: Jallo J, Loftus CM, editors. Neurotrauma and Critical Care: Brain. New York: Thieme; 2009. p. 3-19.
Ghaffar A, Hyder AA, Mastoor MI, Shaikh I. Injuries in Pakistan: Directions for future health policy. Health Policy Plan 1999;14:11-7.
Agrawal A, Galwankar S, Kapil V, Coronado V, Basavaraju SV, McGuire LC, et al
. Epidemiology and clinical characteristics of traumatic brain injuries in a rural setting in Maharashtra, India. 2007-2009. Int J Crit Illn Inj Sci 2012;2:167-71.
Agrawal A, Kakani A, Baisakhiya N, Galwankar S, Dwivedi S, Pal R. Developing traumatic brain injury data bank: Prospective study to understand the pattern of documentation and presentation. Indian J Neurotrauma 2012;9:87-92.
Gururaj G. An epidemiological approach to prevention-Prehospital care and rehabilitation in neurotrauma. Neurol India 1995;43:95-105.
Gururaj G. Epidemiology of traumatic brain injuries: Indian scenario. Neurol Res 2002;24:24-8.
Jat AA, Khan MR, Zafar H, Raja AJ, Hoda Q, Rehmani R, et al
. Peer review audit of trauma deaths in a developing country. Asian J Surg 2004;27:58-64.
Minayo MC. Implementation of the national policy to reduce accidents and violence. Cad Saude Publica 2007;23:4-5.
Rajendra PB, Mathew TP, Agrawal A, Sabharawal G. Characteristics of associated craniofacial trauma in patients with head injuries: An experience with 100 cases. J Emerg Trauma Shock 2009;2:89-94.
Baisakhiya N, Agrawal A, Kakani A, Galwankar S, Dwivedi S. (P2-79) Retrospective review of mortality in patients with traumatic brain injury from rural India. Prehosp Disaster Med 2011;26 (Supplement S1):s162.
Moylan JA, Fitzpatrick KT, Beyer AJ 3 rd
, Georgiade GS. Factors improving survival in multisystem trauma patients. Ann Surg 1988;207:679-85.
Coronado VG, Xu L, Basavaraju SV, McGuire LC, Wald MM, Faul MD, et al
. Centers for Disease Control and Prevention (CDC). Surveillance for traumatic brain injury-related deaths--United States, 1997-2007. MMWR Surveill Summ 2011;60:1-32.
Sasser S, Hunt R, Sullivent E, Wald M, Mitchko J, Jurkovich G, et al
. National Expert Panel on Field Triage, Centers for Disease Control and Prevention (CDC). Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep 2009;58(RR-1):1-35.
Bazzoli GJ, Madura KJ, Cooper GF, MacKenzie EJ, Maier RV. Progress in the development of trauma systems in the United States. Results of a national survey. JAMA 1995;273:395-401.
Cales RH, Trunkey DD. Preventable trauma deaths. A review of trauma care systems development. JAMA 1985;254:1059-63.
Boyd CR, Corse KM, Campbell RC. Emergency interhospital transport of the major trauma patient: Air versus ground. J Trauma 1989;29:789-93.
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81-4.
Molyneux E, Ahmad S, Robertson A. Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting. Bull World Health Organ 2006;84:314-9.
Razzak JA, Hyder AA, Akhtar T, Khan M, Khan UR. Assessing emergency medical care in low income countries: A pilot study from Pakistan. BMC Emerg Med 2008;8:8.
Ali J, Naraynsingh V. Potential impact of the advanced trauma life support (ATLS). Program in a Third World country. Int Surg 1987;72:179-84.
Gerardo CJ, Glickman SW, Vaslef SN, Chandra A, Pietrobon R, Cairns CB. The rapid impact on mortality rates of a dedicated care team including trauma and emergency physicians at an academic medical center. J Emerg Med 2011;40:586-91.
In: Jha N, Agrawal CS, editors. Epidemiological Study of Road Traffic Accident Cases: A Study from Eastern Nepal. WHO Reg Health Forum 2004;8:15-22.
Baker SP. The Injury Fact Book. 2 nd
ed. New York: Oxford University Press; 1992.
Davis JW, Hoyt DB, McArdle MS, Mackersie RC, Eastman AB, Virgilio RW, et al
. An analysis of errors causing morbidity and mortality in a trauma system: A guide for quality improvement. J Trauma 1992;32:660-5.
Haddon W Jr. Options for the prevention of motor vehicle crash injury. Isr J Med Sci 1980;16:45-65.
New approaches to improve road safety. Report of a WHO Study Group. World Health Organ Tech Rep Ser 1989;781:1-62.
Cummings P, McKnight B, Rivara FP, Grossman DC. Association of driver air bags with driver fatality: A matched cohort study. BMJ 2002;324:1119-22.
Higgins-Biddle J, Hungerford D, Cates-Wessel K. Screening and Brief Interventions (SBI) for unhealthy alcohol use: A step-by-step implementation guide for trauma centers. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2009.
Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, editors. World Report on Road Traffic Injury Prevention. Geneva: World Health Organization; 2004.
Older Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O, editors. Injury Surveillance Guidelines. Geneva: World Health Organization; 2001.
Mock C, Lormand JD, Goosen J, Joshipura M, Peden M. Guidelines for essential trauma care. Geneva: World Health Organization; 2004.
[Table 1], [Table 2]
|This article has been cited by|
||Bystander Assistance for Trauma Victims in Low- and Middle-Income Countries: A Systematic Review of Prevalence and Training Interventions
| ||Kamna S. Balhara,Nirma D. Bustamante,Anand Selvam,W. Tyler Winders,Amin Coker,Indi Trehan,Torben K. Becker,Adam C. Levine |
| ||Prehospital Emergency Care. 2018; : 1 |
|[Pubmed] | [DOI]|
||ICP management in patients suffering from traumatic brain injury: a systematic review of randomized controlled trials
| ||Peter Abraham,Robert C. Rennert,Brandon C. Gabel,Jayson A. Sack,Navaz Karanjia,Peter Warnke,Clark C. Chen |
| ||Acta Neurochirurgica. 2017; |
|[Pubmed] | [DOI]|
||Guideline Adherence and Outcomes in Severe Adult Traumatic Brain Injury for the CHIRAG (Collaborative Head Injury and Guidelines) Study
| ||Deepak Gupta,Deepak Sharma,Nithya Kannan,Suchada Prapruettham,Charles Mock,Jin Wang,Qian Qiu,Ravindra M. Pandey,Ashok Mahapatra,Hari Har Dash,James G. Hecker,Frederick P. Rivara,Ali Rowhani-Rahbar,Monica S. Vavilala |
| ||World Neurosurgery. 2016; 89: 169 |
|[Pubmed] | [DOI]|