HEAD INJURY ADMISSIONS AT A REFERRAL HOSPITAL IN ETHIOPIA

Abstract

Background: Head Injury is one of the most common reasons for patient admission and death in a trauma setting. Trauma is one of the major burdens on our health system. Although there are some studies done on head injury patterns elsewhere in the country and in the world, there is no study done in Mekele. Anecdotal evidence shows that we are having a significant number of patients with head injury. Characterizing the pattern of head injury will help plan preventive measures. The objective of this study was to assess the burden of head injury admissions and operations in Ayder Referral Hospital. Methods: Record review was conducted on charts of patients admitted to the surgical ward with a diagnosis of head injury. The study was conducted in Ayder Referral Hospital Department of Surgery and included charts of patients who were seen from January, 2011 to December, 2014 using a structured questionnaire. The collected data were analyzed using SPSS version 16. Results: A total of 750 records were analyzed. The gender distribution is 598 males to 152 females, making the male to female ratio 4:1. The most commonly affected age group was from 6-25 years. A total of 422 (56.3 %) of the head injury patients came from the urban area. The causes of the head injury were fall down accident in 41.9%, interpersonal violence in 24.8%, and road traffic accident (RTA) in 24.9 %. Of the 187 RTA cases 102 were pedestrians and 84 were vehicle occupants. Conclusion: Head injury is causing significant morbidity and mortality. The young and male are commonly affected. Interpersonal violence is a neglected cause of head injury that needs to be addressed.

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Fasika Amdeslasie, Mizan Kidanu, Anteneh Tadesse, Wondwosen Lerebo. Ethiop Med J, 2017,Vol.55, No. 3
ORIGINAL ARTICLE
HEAD INJURY ADMISSIONS AT A REFERRAL HOSPITAL IN ETHIOPIA
Fasika Amdeslasie MD
1
, Mizan Kidanu MD
1
, Anteneh Tadesse MD
1
, Wondwosen Lerebo MD
1
ABSTRACT
Background: Head Injury is one of the most common reasons for patient admission and death in a trauma setting.
Trauma is one of the major burdens on our health system. Although there are some studies done on head injury
patterns elsewhere in the country and in the world, there is no study done in Mekele. Anecdotal evidence shows
that we are having a significant number of patients with head injury. Characterizing the pattern of head injury will
help plan preventive measures. The objective of this study was to assess the burden of head injury admissions and
operations in Ayder Referral Hospital.
Methods: Record review was conducted on charts of patients admitted to the surgical ward with a diagnosis of
head injury. The study was conducted in Ayder Referral Hospital Department of Surgery and included charts of
patients who were seen from January, 2011 to December, 2014 using a structured questionnaire. The collected
data were analyzed using SPSS version 16.
Results: A total of 750 records were analyzed. The gender distribution is 598 males to 152 females, making the
male to female ratio 4:1. The most commonly affected age group was from 6-25 years. A total of 422 (56.3 %) of
the head injury patients came from the urban area. The causes of the head injury were fall down accident in
41.9%, interpersonal violence in 24.8%, and road traffic accident (RTA) in 24.9 %. Of the 187 RTA cases 102
were pedestrians and 84 were vehicle occupants.
Conclusion: Head injury is causing significant morbidity and mortality. The young and male are commonly af-
fected. Interpersonal violence is a neglected cause of head injury that needs to be addressed.
Key words: head injury, road traffic accident, violence
1
Department of Surgery, College of health Sciences, Mekele University
* Corresponding author: fasikamdes@gmail.com
INTRODUCTION
Head injury and Traumatic Brain Injury (TBI) are
among the most common causes of morbidity and
mortality in the world (1). In USA, in 2010, about
2.5 million emergency department (ED) visits, hospi-
talizations, or deaths were associated with TBI-either
alone or in combination with other injuries, and it has
contributed to the death of more than 50,000 people
(2).
Traumatic brain injury, according to the World
Health Organization, will surpass many diseases as
the major cause of death and disability by the year
2020. Worldwide, it is estimated that 10 million peo-
ple are affected annually by TBI. TBI imposes a sig-
nificant burden of mortality and morbidity on soci-
ety. This makes TBI a pressing public health and
medical problem (2).
Even if the burden of TBI is found throughout the
world, it is especially prominent in Low and Middle
Income Countries. Countries in Sub-Saharan Africa
are one of the most commonly affected by traumatic
brain injury. These countries lack an adequately pre-
pared health system to address the health outcomes
associated with TBI. The global rate of TBI is esti-
mated as 106 per 100,000 and the incidence rate in
sub-Saharan Africa is estimated to be 150 to 170 per
100,000 (2).
Head injury is one of the most common reasons for
emergency outpatient (OPD) visits in Ethiopia too.
Previous research conducted in Ethiopia and other
countries of Africa has shown that trauma and spe-
cifically head injury is a major cause of death and
disability (3-5). In our experience in the last four
years, head injury is the commonest reason for emer-
gency OPD visit and it is the commonest cause of
death in our monthly mortality reporting sessions.
We also have the experience that the majority of sur-
gical patients admitted to intensive care unit (ICU)
are head injury patients.

196
It has been shown many times that head injury pa-
tients in low income countries suffer for many
reasons (3, 4, 6). The pre-hospital care is poor, liter-
ally nonexistent. The Ethiopian situation of head
injury is almost the same as that of any of the low
income countries in the world. Anecdotal evidence
has shown that most of the patients with severe head
injury have often already aspirated by the time they
reach the hospital and respiratory failure seems to be
the common cause of death in these patients. The
other factor is the lack of a well prepared setup for
neurosurgical intervention. In Ethiopia, there are
only two centers, both located in the capital city, that
provide neurosurgical care and have neurosurgeons
(7). So, the majority of head injury patients are first
seen by nurses or if they are lucky by General Practi-
tioners; and if at all they are managed, they are man-
aged mostly by General Surgeons after referral to
centers where there is General Surgery care. This can
make the outcome of head injuries worse. Few stud-
ies have been conducted to show the burden of head
injury in terms of epidemiology, management and
outcome.
Head injury usually affects males more than females
and young adults are usually affected. This is true in
both developed countries (8-11) and resource limited
countries like ours. Some studies done in the West
have found out that TBI are associated with low
socio economic status (9).
Even though there is some research done in Ethiopia
on head injury, no such study has ever been done in
this part of the country. Ayder referral hospital is a
university hospital with 400 beds. The surgical de-
partment has 70 beds. At the time of the study there
were 10 General surgeons who also operated on head
injuries. This study was conducted to determine the
pattern of head injuries (traumatic brain injuries) in
patients admitted to surgical wards.
PATIENTS AND METHODS
A record review was conducted on patients who were
admitted to the surgical wards and ICU of Ayder
referral Hospital during the study period, which is
from January1, 2011 up to December 31, 2014. A
structured questionnaire containing parts for demo-
graphic data (age, ethnic background, education) and
data pertinent to head injury (duration, cause, diagno-
sis, Severity, type of intervention done, length of
hospital stay, and outcome of treatment: death or
survival) was used to gather the data from medical
records. All patients who were listed in the admission
log book with a diagnosis of head injury were in-
cluded in the study and patients with incomplete
medical record lacking information about the cause
and type of trauma and management plan and pa-
tients who consulted more than once for the same
complaint were excluded.
All research instruments were pre-tested in non-study
area (Mekele Hospital). Based on the results of the
pretest, the materials were revised. Data collectors
received training on data collection techniques and
information gathering from medical records. Data
were collected under the supervision of the investiga-
tors. Prior to analysis, accuracy of data was verified
by entering data twice. Some outliers and missing
values were cross checked and data were cleaned.
Data were entered using Epi-info 2008 version 3.5
and data cleaning, recoding and analysis were done
using SPSS (version 16.0).
Ethical Considerations: Ethical clearance to conduct
the study was obtained from the Research and Com-
munity Service Council Ethical review board, Col-
lege of Health Sciences, Mekele University. Permis-
sion was secured from the hospital where study sub-
jects were recruited. The hospital administration was
informed about the purpose of the study, anticipated
benefits, selection criteria, and data collection proce-
dures.
The information from the medical record was kept
confidential, only the data collectors had access to
patient information pertaining to the topic of interest.
When labeling information exists within the data
collected, it was made anonymous by removing the
labels and coding during transcribing the data.
RESULTS
A total of 750 records were analyzed. The gender
distribution is 598 male to 152 female, making the
male to female ratio 4:1. The most commonly af-
fected age group was from 6-25 years (43.2 %)
(Figure 1). A total of 422/750 (56.3 %) of the head
injury patients came from the urban area. Among
these, 26.2% (196/750) were from Mekelle, the city
where the referral hospital is found; 22.4% (168/750)
were from the eastern zone). (Table 1) There was no
significant association between place of residence
and head injury. On presentation, 62.1% of the pa-
tients had mild head injury, 24.3% moderate and
13.6% had severe head injury. The mean time taken
for the patient to arrive for intervention was found to
be 96 hours, and the median was 24 hours. But the
mean time taken for the patient to arrive to the hospi-
tal in severe head injury was 54.7 hours, and the me-
dian was 10 hours.

197
Figure 1. Distribution of admissions due to head injury by age and cause, Ayder Hospital (2011-2014)
Table 1a: Characteristics of the patients admitted to Ayder Hospital due to head injury (2011-2014)
Variable Number (%)
Residence
Rural 328(43.7)
Urban 422(56.3)
Sex
Female 152(20.3)
Male 598(79.7)
Age group
≤5 yrs 70(9.4)
6-15 yrs 160(21.4)
16-25 yrs 163(21.8)
26-39 yrs 117(15.7)
40-59 yrs 100(13.4)
>60 yrs 137(18.3)
Diagnosis at the time of admission
Concussion 17(2.3)
Cerebral laceration and contusion 210(28.0)
Subdural Hematoma 159(21.2)
Epidural Hematoma 69(9.2)
Intracerebral Bleeding 11(1.5)
fracture of vault of skull 81(10.8)
Depressed Skull Fracture 149(19.9)
Basal skull Fracture 91(12.1)
Compound skull fracture 31(4.1)
Glasgow Coma Scale (GCS) on admission
Mild 466 (62.1)
Moderate 182 (24.3)
Severe 102 (13.6)

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A total of 12.5% patients were admitted to the ICU,
and the average length of ICU stay was 6 days. The
rest 87.5% were admitted to the wards, and the aver-
age length of stay in the wards was 7 days. The
causes of the head injury could be fall down accident
41.9%, Interpersonal violence 24.8%, road traffic
accident (RTA) 24.9%, and the other causes of injury
which include firearm, object falling on the head, and
those with no history of trauma comprises 4.9%.
(Table 2; Figure 2). Of the 187 RTA cases 102 were
pedestrians and 84 were vehicle occupants.
Depressed skull fracture was observed to occur more
in interpersonal violence (72 of 186 which is 48%)
than RTA (10.7%) and Fall down accident (36.2%).
Fracture of the vault of the skull was found more in
fall down accidents (56.8%) than in interpersonal
violence (27.2%) and RTA (16%). Epidural hema-
toma was found in fall down accident, RTA and in-
terpersonal violence in 36.2%, 24.6% and 34.8%,
respectively. The majority of the subdural hematoma
were caused by fall down accident (48.4 %) than in
Interpersonal violence (15.1 %) or RTA (16.4 %)
(Table 2).
Skull X-ray was used for 33.2% (249) patients; while
CT scan was done for 60.5% (453) patients. Skull
vault fracture was found in 10.8% of patients (81),
19.9 % (149) of patients had depressed skull fracture,
12.1% (91) had basal skull fracture, 28% (210) had
cerebral laceration and contusion. The median time
of arrival to the hospital for all injuries was 24 hours.
In 21.8% (164) of patients, no imaging result was
found. In 44.9% (337) of patients, only CT scan was
done, and for 15.5% (116) both X-ray and CT scan
was done.
Trauma incidence was found to have no association
with seasons and months. Out of the 102 severe head
injury patients, 39 were diagnosed to have aspiration
pneumonia. In addition, 33.1% (248) of patients had
an associated injury and 12.8% (96) had fracture of
the limbs; 29.1% (223) of patients had focal neuro-
logical deficit, out of whom 13.3 %(100) had hemi-
paresis, 7.5%(56) speech disorder, and 5.9%(44)
seizure disorder.
No significant relationship was observed between
GCS level and occurrence of focal neurological defi-
cits. Time of intervention was tried to be docu-
mented, but 505 (67.3%) of the records did not docu-
ment the time of intervention. Two hundred fifty-one
patients (33.5%) had undergone surgery; no surgical
intervention was done on the remaining 66.5% (499)
of patients. Burr hole was done in 18.4% (138), DSF
elevation in 10.4% (78), Craniotomy in 3.2% (24).
Table 1b
Variable Number (%)
Causes of the Head injury
Fall down Accident 313(41.7)
Interpersonal violence 186(24.8)
No history of trauma 27(3.6)
Other 37(4.9)
Road Traffic Accident 187(24.9)
Road traffic accident
Pedestrian 102(54.5)
Vehicle occupant 85(45.5)
Skull X-ray was done
Yes 500(66.8)
No 249(33.2)
CT scan done
No 296(39.5)
Yes 453(60.5)
Where was the patient first admitted
ICU 94(12.5)
Ward 656(87.5)
Type of surgery
Burr Hole 138(18.4)
Craniotomy 24(3.2)
DSF Elevation 77(10.3)
Not Done 499(66.5)
Other 12(1.6)
Outcome
Died 62(8.3)
Discharged 605(80.7)
Left against medical advice 62(8.3)
Absconded (left without signing on chart) 21(2.8)

199
Table 2: Cause of head injury versus background characteristics, Ayder Hospital (2011-2014)
Cause of head injury-N (%)
Fall down Interpersonal RTA Other p-value
Residence
Rural 143(43.6) 93(28.4) 67(20.4) 25(7.6) 0.036
Urban 171(40.5) 93(22.0) 120(28.4) 38(9.0)
Sex
Female 89(58.6) 17(11.2) 33(21.7) 13(8.5) 0.000
Male 225(37.6) 169(28.3) 154(25.8) 50(8.4)
Age group
<=5 yrs 48(68.6) 3(4.3) 11(15.7) 8(11.4) 0.000
6-15 yrs 94(58.8) 36(22.5) 21(13.1) 9(5.6)
16-25 yrs 46(28.2) 56(34.4) 56(34.4) 5(3.1)
26-39 yrs 24(20.5) 42(35.9) 43(36.8) 8(6.8)
40-59 yrs 23(23.0) 34(34.0) 34(34.0) 9(9.0)
>=60 yrs 79(57.7) 15(10.9) 22(16.1) 21(15.3)
Diagnosis
Skull Vault Fracture 46 (56.8) 22 (27.2) 13 (16) 0 0.003
Depressed skull fracture 54 (36.2) 73 (49.1) 16 (10.7) 6 (4) 0.000
Basal Skull fracture 41 (45.1) 12 (13.2) 34 (37.4) 4 (4.4) 0.003
Compound skull fracture 8 (25.8) 20 (64.5) 2 (6.5) 1 (3.2) 0.000
Cerebral Contusion 75 (35.7) 68 (32.4) 59 (28.1) 8 (3.8) 0.001
Subdural hematoma 77 (48.4) 24 (15.1) 16 (16.4) 32(20.1) 0.000
Epidural hematoma 25 (36.2) 24 (34.8) 17 (24.6) 3 (4.3) 0.233
Where was the patient admitted to
ICU 38(40.4) 16(17.0) 33(35.1) 7(7.4) 0.064
Ward 276(42.1) 170(25.9) 154(23.5) 56(8,5)
Type of surgery done
Burr Hole 71(51.4) 22(15.9) 16(11.6) 29(21.0) 0.000
Craniotomy 12(50.0) 6(25.0) 5(20.8) 1(4.2)
DSF Elevation 36(46.2) 36(46.2) 5(6.4) 1(1.3)
Not Done 190(38.1) 122(24.4) 158(31.7) 29(5.8)
Other 4(44.4) 0(0.0) 2(24.9) 3(33.3)
Outcome
Died 15(24.2) 7(11.3) 37(59.7) 3(4.8) 0.000
Discharged 254(42.0) 162(26.8) 137(22.6) 52(8.6)
Left against advice 33(53.2) 14(22.6) 7(11.3) 8(12.9)
Absconded 12(57.1) 3(14.3) 6(28.6) 0(0.0)
Severity (GCS)
Severe 35 (34.3) 19 (18.6%) 42(41.2%) 6 (5.8)
Moderate 93 (51.1) 28 (15.4) 42 (23.1) 19 (10.4)
Mild 185 (39.7) 139 (29.8) 103 (22.1) 39 (8.3)

200
Figure 2: Causes of trauma
When we see the outcomes of injury and treatment,
80.7% (605) were discharged improved, 8.3% (62)
left against medical advice, and 8.3%(62) died. Of
the 62 who died 90% (56) were males. With regard
to the specific causes; 37(19.8%) out of the 187 RTA
had died, 15 of the 313 (4.8%) who sustained fall
down accidents had died, and 7 of the 186 (3.8%)
interpersonal violence died. (Table 3 & 4) RTA con-
tributed to 60% of the total deaths. Of all the 62 who
died, 2(<1%) had mild head injury, 12(6.6%) had
moderate head injury and 42 (47%) had severe head
injury. Aspiration pneumonia was diagnosed in 31 of
the 62 (50%) patients who died of head injury.
Table 3. Cause and severity of the injury
Pearson chi
2
(6) = 32.6282 Pr = 0.000 GCS = Glasgow Coma Scale, RTA = road traffic accident.
Table 4. Outcome versus severity of injury
Pearson chi
2
(6) = 245.3649 Pr = 0.000 Left AMA = Left against medical advice
GCS Fall down Interpersonal RTA Other Total
14 & 15 185 39.70 % 139 29.83% 103 22.10% 39 8.37% 466 100.00
9-13 93 51.10% 28 15.38 % 42 23.08% 19 10.44% 182 100.00
<=8 35 34.31 % 19 18.63% 42 41.18 % 6 5.88 % 102 100.00
Total 313 41.73 % 186 24.80 % 187 24.93 % 64 8.53% 750 100.00
Outcome (number and %)
GCS Died Discharged Left AMA absconded Total
14 & 15 (N) 2 410 37 17 466
(%) 0.43 87.98 7.94 3.65 100.00
9-13 (N) 12 151 16 3 182
(%) 6.59 82.97 8.79 1.65 100.00
<=8 (N) 48 44 9 1 102
(%) 47.06 43.14 8.82 0.98 | 100.00
Total (N) 62 605 62 21 | 750
(%) 8.27 80.67 8.27 2.80 | 100.00

201
DISCUSSION
The study has revealed that there is significant bur-
den of head injury in the study area. Young males
were found to be affected more often. A similar find-
ing has been reported in many previous studies (2, 3,
6, 12). This might be attributed to the existing culture
that males are mainly engaged in outdoor activities
including work and social gathering while the
women spend most of their time indoors, and may
have limited outdoor activity. Males may travel
more and show more aggressive behavior which
leads them to be involved in fighting and road traf-
fic accidents. The commonest cause for head injury
was found to be fall down accident. Previous studies
in other countries had shown similar observations
(13). Fall down has been identified as the main cause
of head injury in children under 15 and above 60
years of age. Other studies also showed that fall
down accidents are associated with the extreme age
groups (less than 4 and more than 65 years) most of
which are domestic accidents (14, 15,16). Fall down
accident can also be work related. Though much fo-
cus is given to Road Traffic accident, as interper-
sonal violence and fall down accidents have also
been found to be the causes for head injury attention
should be given to them by the government.
The second most common cause for head injury in
this study was found to be interpersonal violence.
Violence has been related to poverty and substance
abuse including alcohol. This needs further study as
it turns out to be another important cause of injury. In
the study done in Jimma, the two most common
causes of injury were fighting (38.5%) and RTA
(36.5%) (4). A study in South Africa showed that
interpersonal violence was a more common cause of
injury in blacks than among whites (6). Even if RTA
has been identified as an important cause of injury,
interpersonal violence is seemingly neglected al-
though it is contributing to a significant amount of
head injury in Africa, and also in Ethiopia.
The time required for a trauma patient to arrive to the
health facility for intervention was very long. The
mean cannot be taken as a good indicator since the
graph of distribution is negatively skewed with 3 or 4
outliers. But still, the median which is 24 hours for a
trauma patient to arrive to the hospital is too long to
intervene. Even the patients with severe head trauma
took 10 hours to arrive to the hospital. That is proba-
bly why aspiration pneumonia was found to be sig-
nificantly high in patients with severe head injury.
With nonexistent pre-hospital care, this can tell us
that many preventable deaths from head injury are
occurring in the field. This delay can be explained by
the distance to the health care facility, as there is only
one such facility in 500 km diameter, the other can
be because of the limited availability of transport.
The severity of the head injury in the admitted pa-
tients was 62.1%, 24.3% and 13.6% ( in the ratio of
4.6: 1.8:1). In Europe, the ratio is found to be 22: 1.5:
1 for mild vs. moderate vs. severe cases, respectively
(8). This shows that we are having a significantly
high proportion of severe head injury patients among
our admissions. The proportion of incidence of se-
vere head injury can be higher than this as many
more may have died before coming to this hospital
given the nonexistent pre-hospital care, and this
study reported only those who arrived at this hospi-
tal alive and were admitted. Road traffic accident
was found to cause the majority of the severe head
injuries, followed by fall accident.
Mortality is associated with the severity of the head
injury. Road traffic accident is also found to contrib-
ute to most of the deaths. This is also the case in
other studies conducted previously (13). Overall
mortality was found to be 21.2% and mortality in
severe head injury was 57.9% in a study done in
Jimma (5), and this is comparable with reports from
different countries (12, 17, 18, 19).
Conclusions: Head injury is one of the most com-
mon preventable ailments affecting our society. It is
causing significant mortality and morbidity, mostly
to the young and productive members of the society.
Due attention should be paid by all responsible bod-
ies including physicians, and the government at
large. Establishing a trauma registry would help us
have a better summary of events for best decisions
and judgment. Solving the documentation problem is
a priority considering the increasing incidence of
trauma and despite the overwhelming load of work
on the few surgeons we have. Future studies should
explore the neglected causes of head injury such as
interpersonal violence and fall accident.

202
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