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HEAD INJURY ADMISSIONS AT A REFERRAL HOSPITAL IN ETHIOPIA

Authors:
  • Mekele University
  • Genworth Financial

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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)
198
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)
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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)
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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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19. Bener A, Omar AO, Ahmad AE, Al-Mulla FH, Abdul Rahman YS. The pattern of traumatic brain injuries: a
country undergoing rapid development. Brain Inj. 2010;24(2):74-80.
... Skull fracture (51.0%) followed by brain contusion (43.0%), BSF (37.3%) were the common findings that are similar to the studies done in India, Tanzania, Ayder, Dilla university, and TASH (3,9,13,15,16,20). Around 31.6% of all the cases had other site injuries which are comparable to the study done in TASH, but lower than that of the study done in central India (50.6%) (9, 13). ...
... 134 (44%) patients stayed greater than 72 hours in the emergency department before disposition, which has a significant impact on the turnover of ED patients and causes ED overcrowding. The mortality rate in this study was higher than the Saudi Arabian (2.5%) and Nigerian (4.7%) studies, but lower than Ayder (8.3%) & TASH (10.3%) (9,14,15,20).This could be because of the availability of timely CT scans in the ED, early resuscitation in the ED, consultants' decisions, surgical interventions, and nursing care. We suggest having such comprehensive trauma centers in the regions of Ethiopia. ...
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BACKGROUND: Traumatic brain injury (TBI) is the leading cause of death and disability in young adults in the world. This study assessed clinical characteristics and in-hospital outcomes among traumatic brain injury patients presenting to Addis Ababa Burn, Emergency, and Trauma hospital. METHODS: A cross-sectional hospital-based survey was conducted at AaBET hospital from January 01/2020 to April 30/2020. Data were collected using structured questionnaires from the trauma registry and patient chart. The collected data were analyzed using statistical software SPSS v 25.0. RESULTS: Among the 304 traumatic brain injury patients, 75% were males with a mean age of 30.4 + 15.7, and 59.2% came from the Oromia region. Road traffic injury was responsible for 45% of the cases, of which pedestrian struck accounts for 52.2% of the cases. Only 50 (16.4%) patients arrived below 02 hours. 201 (66.1%) patients had mild traumatic brain injury the rest had moderate to severe traumatic brain injury. Skullbone fracture (linear, DSF, & BSF) was the most common (n=157, 63.1%) followed by intracerebral lesions (DAI, brain contusion, & ICH) (n=140, 56.5%). Forty-three (14.1%) patients were intubated. 45(14.8%) cases had a neurosurgical intervention. The mortality rate of severe, moderate, & mild TBI were 25%, 8.0% & 2.0% respectively with an overall mortality of 5.6%. CONCLUSION: This study showed road traffic injury was the commonest cause of traumatic brain injury which affected young age groups. There was a delayed presentation to AaBET hospital Emergency. The mortality rate was lower than other Ethiopian hospital studies
... At the end of follow -up, about 103 patients died and 235 patients were censored, thereby resulting in a cumulative incidence of death of 30.47% after 80 days of follow-up and a mortality rate of 25.3 per 1000 person-days. These findings are similar to the results obtained by a study conducted in Malawi (30.9%) and Qatar (27%) [24,27], but lower compared with a study conducted in Turkey University Hospital (50%) [28] and higher compared with other studies conducted in Ethiopia (2.11% to 21.2%) [21,29]. These differences may have been due to variations in the sampling size and study period. ...
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Introduction Traumatic brain injury is a major global public health problem causing substantial mortality among the adult population. Hence, this study aimed to determine the predictors of mortality among adult traumatic brain injury patients in Felegehiwot Comprehensive Specialized Hospital in Northwest Ethiopia during 2020. Methods A retrospective cohort study was conducted at Felegehiwot Comprehensive Specialized Hospital using anonymized patient data obtained from chart review. Descriptive statistics were used to summarise the patient characteristics. The Kaplan–Meier survival curve and log-rank test were used to test for differences in survival status among groups. The Cox proportional hazards regression model was used at the 5% level of significance to determine the net effect of each explanatory variable on time to death. Results In total, 338 patients aged ≥15 years and diagnosed with traumatic brain injury were included in the analysis. Among these patients, 103 (30.45%) died, giving a crude death rate of 25.53 per 1000 (95% CI: 21.05–30.98) person-days of follow-up. The overall median survival time was 44 days. The independent predictors of mortality after diagnosis of traumatic brain injury were admission Glasgow coma scale score ≤ 8 (adjusted hazard ratio (AHR): 4.85; 95% confidence interval (CI): 1.73–13.62), bilateral non-reactive pupils at admission (AHR: 2.00 (95% CI: 1.10–3.71), elevated systolic blood pressure at admission (AHR: 0.31; 95% CI:0.11–0.86), elevated diastolic blood pressure at admission (AHR: 3.54; 95% CI: 1.33–9.43), and haematoma evacuation (AHR: 0.42; 95% CI: 0.16–0.90). Discussion The Survival status of traumatic brain injury patients was relatively low in this study. Glasgow coma scale score, bilateral non-reactive pupils, and elevated blood pressure were significant predictors of mortality. Further prospective follow-up studies that include residence and occupation are recommended.
... A study at Gondar University referral hospital also showed a prevalence of 40.5% for head injury; of these 46.7% occurred due to interpersonal fight (18). A study in Ayder referral hospital showed prevalence of head injury was 56.3% and the most common causes were fall accident (41.9%), road traffic accident (24.9%), and interpersonal violence (24.8%) (19). In Ethiopia, a national prevalence of head injury is lacking, and health planners and policymakers use demographic health surveys. ...
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Background: Traumatic brain injury (TBI) is a common cause of mortality and disability in young age populations, particularly in children and adolescents. The objective of this systematic review and meta-analysis was to assess the prevalence of TBI among trauma patients in Ethiopia. Methods: A three-stage search strategy was conducted on PubMed/Medline, Science Direct and African Journals Online, and a grey literature search was conducted on Google Scholar. Data were analyzed with R version 3.6.1. Results: The pooled prevalence of TBI in Ethiopia was 20% (95% confidence interval (CI), 11-32). Subgroup analysis revealed that road traffic accident was the commonest mechanism of injury in Ethiopia at 21% (95% IC, 15-30), next was assault at 18% (95% CI, 5-48). Conclusion: This review shows a high prevalence of TBI among trauma patients in Ethiopia when compared with continental and global reports. Policymakers and stakeholders should work on regulatory laws on transportation; pre-hospital emergency medical care system is also in high demand. Protocol registration: CRD42020146643.
... Among this 46.7 % occurred due to interpersonal fight (18). A Study done in Ayder referral hospital showed that the prevalence of head injury was 56.3% and the most common causes of head injury were fallen down accident (41.9%), road traffic accident (24.9%), and interpersonal violence (24.8%) (19). In Ethiopia, there no national prevalence of head injury and the health planners and policymakers utilized demographic health surveys. ...
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Abstract Background: Traumatic Brain Injury is the common cause of mortality and disability in the young age populations particularly in children and adolescents. The objective of this systematic review and meta-analysis was to assess the prevalence of Traumatic Brain Injury among trauma patients in Ethiopia. Methods: A three-stage search strategy was conducted on PubMed/Medline, Science direct and African Online Journal and a grey literature search were conducted on Google scholars. The data analysis was conducted with R software version 3.6.1. Results: The pooled prevalence of Traumatic Brain Injury in Ethiopia was 20% (95% confidence interval, 11 to 32). Subgroup analysis revealed that Road Traffic Accident was the commonest mechanism of injury in Ethiopia 21% (95% confidence Interval (IC), 15 to 30 followed by Assault 18% (95% confidence interval, 5 to 48). Conclusion: The review revealed that the prevalence of Traumatic Brain Injury among trauma patients in Ethiopia is high as compared to continental and global reports. The policymakers and stakeholders should work on regulatory laws on transportation and pre-hospital emergency medical care system is also highly in demand. Registration: This review was registered in Prospero international prospective register of systematic reviews (CRD42020146643). Keywords: Head injury, Road Traffic Accident, Assault, Ethiopia
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Globally, head injury is a substantial cause of mortality and morbidity. A disproportionately greater burden is borne by low- and middle-income countries. The incidence and characteristics of fatal and hospitalised head injuries in Fiji are unknown. Using prospective data from the Fiji Injury Surveillance in Hospital system, the epidemiology of fatal and hospitalised head injuries was investigated (2004-2005). In total, 226 hospital admissions and 50 fatalities (66% died prior to admission) with a principal diagnosis of head injury were identified (crude annual rates of 34.7 and 7.7/100,000, respectively). Males were more likely to die and be hospitalised as a result of head injury than females. The highest fatality rate was among those in the 30-44-year age group. Road traffic crashes were the leading causes of injuries resulting in death (70%), followed by 'hit by person or object' and falls (14% each). Among people admitted to hospital, road traffic crashes (34.5%) and falls (33.2%) were the leading causes of injury. The leading cause of head injuries in children was falls, in 15-29-year-olds road traffic crashes, and in adults aged 30-44 years or 45 years and older 'hit by person or object'. Among the two major ethnic groups, Fijians had higher rates of falls and 'hit by person or object' and Indians higher rates for road traffic crashes. There were no statistically significant differences between the overall rates of head injuries or the fatal and non-fatal rates among Fijians or Indians by gender following age standardisation to the total Fijian national population. Despite underestimating the overall burden, this study identified head injury to be a major cause of death and hospitalisation in Fiji. The predominance of males and road traffic-related injuries is consistent with studies on head injuries conducted in other low- and middle-income countries. The high fatality rate among those aged 30-44 years in this study has not been noted previously. The high case fatality rate prior to admission to the hospital requires urgent attention.
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Injury statistics in Ethiopia provides little knowledge about its magnitude and related information needed for prevention. This study, therefore, aims to determine the magnitude and pattern of injury in Jimma University Specialized Hospital (JUSH). A retrospective review of records of all injured patients seen at surgical outpatient department from April 09, 2010 to January 07, 2011; was conducted in January 2011. Data were collected using a structured checklist that was developed by adapting the World Health Organization instrument. Five degree holder nurses collected the data while investigators closely supervised. Socio demographic characteristics of the patients and injury related information were collected. Data were analyzed using SPSS for windows version 16.0. Of 13500 patients who visited surgical outpatient department of JUSH during the study period, 1102(8.2%) were injury cases. The commonest mechanism of injury was blunt assault, 341(30.9%), followed by road traffic accident, 334(30.3). Fracture was the leading outcome of injury, 454(41.2%), followed by bruise or skin laceration, 404(36.7%). Significantly more males had cut, (AOR=2.0; 95% CI=1.2, 3.3) and stab, (AOR=3.0; 95% CI=1.6, 5.7), injuries compared to females. Conversely, significantly fewer males had burn, (AOR=0.4, 95% CI=0.2, 0.8) and road traffic accident, (AOR=0.7, 95% CI=0.5, 0.9), than females. Most, 715(95.8%), patients were presented to the hospital within one week. The commonest functional limitations were; difficulty to use hands, 312(28.3%) and difficulty to use legs, 217(19.7%). Eighty three, (7.5%) of the patients died and road traffic accident alone accounted for almost half, 179 (49.7%), of the severe injuries. The magnitude of injury in the hospital was considerably high. Age and sex were predictors of injury. Appropriate prevention strategies should be designed and implemented against assault, road traffic accident and cut by sharp tool.
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Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Approximately 53,000 persons die from TBI-related injuries annually. During 1989-1998, TBI-related death rates decreased 11.4%, from 21.9 to 19.4 per 100,000 population. This report describes the epidemiology and annual rates of TBI-related deaths during 1997-2007. January 1, 1997-December 31, 2007. Data were analyzed from the CDC multiple-cause-of-death public-use data files, which contain death certificate data from all 50 states and the District of Columbia. During 1997-2007, an annual average of 53,014 deaths (18.4 per 100,000 population; range: 17.8-19.3) among U.S. residents were associated with TBIs. During this period, death rates decreased 8.2%, from 19.3 to 17.8 per 100,000 population (p = 0.001). TBI-related death rates decreased significantly among persons aged 0-44 years and increased significantly among those aged ≥75 years. The rate of TBI deaths was three times higher among males (28.8 per 100,000 population) than among females (9.1). Among males, rates were highest among non-Hispanic American Indian/Alaska Natives (41.3 per 100,000 population) and lowest among Hispanics (22.7). Firearm- (34.8%), motor-vehicle- (31.4%), and fall-related TBIs (16.7%) were the leading causes of TBI-related death. Firearm-related death rates were highest among persons aged 15-34 years (8.5 per 100,000 population) and ≥75 years (10.5). Motor vehicle-related death rates were highest among those aged 15-24 years (11.9 per 100,000 population). Fall-related death rates were highest among adults aged ≥75 years (29.8 per 100,000 population). Overall, the rates for all causes except falls decreased. Although the overall rate of TBI-related deaths decreased during 1997-2007, TBI remains a public health problem; approximately 580,000 persons died with TBI-related diagnoses during this reporting period in the United States. Rates of TBI-related deaths were higher among young and older adults and certain minority populations. The leading external causes of this condition were incidents related to firearms, motor vehicle traffic, and falls. Accurate, timely, and comprehensive surveillance data are necessary to better understand and prevent TBI-related deaths in the United States. CDC multiple-cause-of-death public-use data files can be used to monitor the incidence of TBI-related deaths and assist public health practitioners and partners in the development, implementation, and evaluation of programs and policies to reduce and prevent TBI-related deaths in the United States. Rates of TBI-related deaths are higher in certain population groups and are primarily related to specific external causes. Better enforcement of existing seat belt laws, implementation and increased coverage of more stringent helmet laws, and the implementation of existing evidence-based fall-related prevention interventions are examples of interventions that can reduce the incidence of TBI in the United States.
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Traumatic brain injuries (TBIs) remain an important public health problem in most industrial developed and especially in developing countries. This may also result in temporary or permanent disability. The aim of this study was to examine the trends in the distribution of traumatic brain injuries by gender, age, severity of injury and outcome and describe the incidence in the injury patterns. This is a retrospective, descriptive, hospital-based study that included all cases of TBI during the period from January 2003 to December 2007. This study is a retrospective analysis of 1919 patients with traumatic brain injury attended and treated at the Accident and Emergency Department of the Hamad General Hospital and other Trauma Centers of the Hamad Medical Corporation. Details of all TBI cases were extracted from the database of the Emergency Medical Services (EMS). Severity of TBI was assessed by Glasgow Coma Scale (GCS). This study was based on 1919 patients suffering from traumatic brain injury, where 154 died and 97 (5.1%) of them died in the intensive care unit. The number of TBI cases increased remarkably in 2007 by 69.7%. However, the incidence rate was nearly stable across the years (4.2-4.9/10 000 population). Of the total TBI cases, the majority of them were non-Qataris (72.7%) and men (88.6%). There was a significant increase in number of TBI cases between 2003 and 2007 in terms of age group (p = 0.003), nationality (p = 0.004) and severity of injuries (p = 0.05). The highest peak rate of TBI cases was observed among the population over 65 years old, followed by 15-24 year olds. Falls caused most TBIs in the 1-14 years age group, road traffic accidents in the age group 15-24 years and sports and recreation in the age group 25-34 years. The present study findings revealed that traumatic brain injury is a major public health problem, especially among young adults and older people. Although there was a sharp increase found in the number of TBI cases, the incidence rate of TBI took a stable trend during the study period.
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Using the method described in Part I (p. 283), data on the epidemiology of traumatic brain injury (TBI) in Johannesburg are presented. The overall annual incidence of TBI is 316 per 100,000. Data for Africans and Whites show marked contrasts. Among Africans, incidence is 355/100,000, with a male-female ratio of 4.4, and 763/100,000 for males aged 25-44; for Whites, it is 109/100,000 overall, with a male-female ratio of 40.1, and 419/100,000 for men aged 15-24. The overall incidence of fatal TBI is 80/100,000, with a case fatality ratio of 0.20. Interpersonal violence accounts for 51% of nonfatal TBI among Africans, as against 10% for Whites, while motor vehicle accidents cause 27% of African nonfatal TBI and 63% among Whites. Some explanatory hypotheses for this race- and sex-specific skewing of the incidence and causes of TBI are developed.
Article
Trauma, especially head trauma, is an expanding major public health problem and the leading cause of death of the young and productive part of the world's population. Research is mainly done in high-income countries where only a small proportion of the worldwide fatalities occur. The intention of this study was to analyze head injury in a setting where most patients in low- and middle-income countries receive treatment, a referral hospital with general but no neurosurgical service like Jimma University Specialized Hospital. The study aims to provide surgeons, hospital managers and health planners working in similar set-ups with baseline information for further investigation and prevention programs intending to reduce the burden of head injury. All head injury patients presented to Jimma University Specialized Hospital between March and June 2010 were included in this prospective research. Epidemiological, clinical and management data were collected for the study. Out of 52 patients, 47 were males. The median age was 20.0 years (SD=13.3). Fights (n=20, 38.5%) and road traffic accidents (n=19, 36.5%) were the most common causes of head injury. Half of the patients sustained mild and 36.5% sustained severe head injury. The initial GCS had a significant correlation with the outcome. The mortality rate was 21.2%. Of all patients 76.9% were managed conservatively. Prevention of road traffic accidents and improvement of conservative care were identified as major methods to reduce the burden of head injury in a set-up similar to Jimma. Further studies on head injury patients in low-income countries should be done.
Article
Background: The aim of this prospective study was to estimate annual incidences of hospitalization for severe traumatic brain injury (TBI) (maximum Abbreviated Injury Score in the head region [HAIS] 4 or 5) in a defined population of 2.8 million. Methods: Severe TBI patients were included in the emergency departments in the 19 hospitals of the region. A prospective data form was completed with initial neurologic state, computed tomographic scan lesions, associated injuries, length of unconsciousness, and length of stay in acute care centers. Outcome at the time the patient left acute hospitalization was retrospectively assessed from medical notes. Results: During the 1-year period (1996), 497 residents fulfilled the inclusion criteria, leading to an annual incidence rate of 17.3 per 100,000 population; 58.1% were HAIS5. Mortality rate was 5.2 per 100,000. Men accounted for 71.4% of cases. Median age was 44 years, with a quarter of patients more than 70 years old. Traffic accidents were the most frequent causes (48.3%), but falls accounted for 41.8% of all patients. Age and severity were different according to the major categories of external causes. In HAIS5 patients, 86.5% were considered as comatose (coma lasting more than 24 hours or leading to immediate death) but only 60.9% had an initial Glasgow Coma Scale score < 9. In the HAIS4 group, 7.2% had an initial Glasgow Coma Scale score < 9. Fatality rates were 30.0% in the whole study group, 7.7% in HAIS4, 12.8% in HAIS5 without coma, and 51.2% in HAIS5 with coma. Conclusion: This study shows a decrease in severe TBI incidence when results are compared with another study conducted 10 years earlier in the same region. This is because of a decrease in traffic accidents. However, this results in an increase in the proportion of falls in elderly patients and an increase in the median age in our patients. This increased age influences the mortality rate.
Article
To describe the most recent estimates of the incidence and prevalence of traumatic brain injury (TBI) and review current issues related to measurement and use of these data. State of the science literature for the United States and abroad was analyzed and issues were identified for (1) incidence of TBI, (2) prevalence of lifetime history of TBI, and (3) incidence and prevalence of disability associated with TBI. The most recent estimates indicate that each year 235 000 Americans are hospitalized for nonfatal TBI, 1.1 million are treated in emergency departments, and 50 000 die. The northern Finland birth cohort found that 3.8% of the population had experienced at least 1 hospitalization due to TBI by 35 years of age. The Christchurch New Zealand birth cohort found that by 25 years of age 31.6% of the population had experienced at least 1 TBI, requiring medical attention (hospitalization, emergency department, or physician office). An estimated 43.3% of Americans have residual disability 1 year after hospitalization with TBI. [corrected] The most recent estimate of the prevalence of US civilian residents living with disability following hospitalization with TBI is 3.2 million. Estimates of the incidence and prevalence of TBI are based on varying sources of data, methods of calculation, and assumptions. Informed users should be cognizant of the limitations of these estimates when determining their applicability.
Article
A three-year retrospective analysis was undertaken of all surgical admissions to Tikur Anbessa Hospital (TAH) between September 1994 and August 1997. There was a total of 5,353 surgical admissions of which 3,968 (74.1%) were elective cases. The overall male to female ratio was 1.7:l. Gastrointestinal and genitourinary conditions accounted for 62% of elective cases, while for emergencies, gastrointestinal and neuro-surgical patients constituted 75.8% of admissions. The overall mortality was 8%, being higher for emergencies (21.1%) than for elective surgery (3.4%) Gastrointestinal (GI) and neurosurgical conditions accounted for 71.2% of all deaths. Neurosurgical emergencies had the highest mortality rate (36.8%). The admission pattern revealed that many of the patients had conditions that could have been treated at the secondary level hospitals and that some causes death were preventable.
Article
Head and neck injuries following the road traffic crashes (RTCs) are the most common cause of morbidity and mortality in most developed and developing countries and may also result in temporary or permanent disability. The aim of this study was to determine the incidence pattern of head and neck injuries, investigate its trend and identify the severity of injuries involved with road traffic crashes (RTCs) during the period 2001-2006. This is a retrospective descriptive hospital based study. The patients with head and neck injuries were seen and treated in the Accident and Emergency Department of the Hamad General Hospital and other Trauma Centers of the Hamad Medical Corporation following the road traffic crashes during the period 2001-2006. This study is a retrospective analysis of 6709 patients attended and treated at the Accident and Emergency and Trauma centers for head and neck injuries over a 6 year period. Head and neck injuries were determined according to the ICD 10 criteria. Of these, 3013 drivers, 2502 passengers, 704 pedestrians and 490 two wheel riders (motor bike and cyclists). Details of all the road traffic crash patients were compiled in the database of the Emergency Medical Services (EMS), and the data of patients with head and neck injuries were extracted from this database. A total of 6709 patients with head and neck injuries was reported during the study period. Majority of the victims were non-Qataris (68.7%), men (85.9%) and in the age group 20-44 years (68.5%). There were statistical significant differences in relation to age, nationality, gender, and accident during week ends for head and neck injuries (p<0.001). The male to female ratio for head and neck injury was 6.1:1. There was a disproportionately higher incidence of accidents during weekends (27.8%). Majority of the patients had mild injury (87.2%), followed by moderate (7.3%) and severe (5.5%). The highest frequency of head injury was among the young adults 20-44 years (68.5%). There was a remarkable increase in the incidence rate of head and neck injuries per 10,000 population in the year 2005 (18.2) compared to previous years and declined slightly in the year 2006 (17.1). Overall, the incidence of head and neck injuries from road traffic crashes are increasing. The present study findings provided an overview of head and neck injuries in Qatar from road traffic crashes. The incidence of head and neck injuries is still very high in Qatar, but the severity of injury was mild in most of the victims. The findings of the study highlighted the need for taking urgent steps for safety of people especially drivers and passengers.