Received Date: March 27, 2012; Accepted Date: April 17, 2012; Published Date: April 19, 2012
Citation: Kumar D, Bains V, Sharma BR, Harish D (2012) Descriptive Study of Head Injury and its Associated Factors at Tertiary Hospital, Northern India. J Community Med Health Educ 2:141. doi: 10.4172/jcmhe.1000141
Copyright: © 2012 Kumar D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Skull fracture; Hemorrhage; India
Head Injury is defined by the National Advisory Neurological Diseases and Stroke Council (NANDSC) as a morbid state, resulting from gross or subtle structural changes in the scalp, skull and/or the contents of the skull, produced by mechanical forces. Majority of fatalities in trauma cases occurs due to head injury . Unintentional injuries contribute 66.0% of all injury deaths and 70.0% of injury Disability Adjusted Life Years (DALYs). Road Traffic Injuries (RTI) contribute a large among unintentional injuries in low middle income countries. Young people from 15-29 year accounted highest portion of RTI. It is a modern epidemic with rising vehicles density, high velocity technology, along with congestion of roads and traffic rules violation. India has just 1% of the total vehicles in the world but it contributes to 6% of the global Road Traffic Cases . Estimates suggest that New Delhi has the highest number of road side accidents in India .
Unintentional head injury varies with extremes of outcome from good recovery to death. The lethality of injury depends on amount of strike force, skull properties at the point of the contact, thickness of scalp, amount of hair and thickness and elasticity of individual skull, etc. . It is observed that the victim is more vulnerable in frontal collision, side collision and if hit by heavy motor vehicle. Head injury is also caused by the assault as a common reason and pattern of injuries depends upon type of weapon . Clinical features of head injury are: Loss of consciousness or headache, nausea and vomiting, ear bleed, vertigo and papilloedema. Likelihood of skull fracture is directly associated with severity of injury and vault is involved three times more often than the base. Sub dural hematoma (SDH) was the most common intracranial lesion resulting from head injury. Contusions and lacerations of the brain often seen in vehicular accidents and fall from height cases. These may occur with or without external injury to the scalp and fracture of the skull .
Preoccupation with knowledge of skull area involvement followed by type of injury helps in triage and patient care management. Present study rationalizes the institute injury surveillance towards facility preparedness in managing the patients with injury with the objective to analyze the pattern of skull fractures among all patients with head injury reported to tertiary care hospital of North India, June 2007 to May 2008.
This study was undertaken in the Government Medical College and Hospital (GMCH) and Government Multispecialty Hospital (GMSH) Chandigarh with prior ethical approval from Institution Ethics Committee (IEC), from both the institutes. Information was collected on pretested structured questionnaire from the police and accompanying relatives/friends to gather information regarding the age, sex, socioeconomic status, pucca (Hard with gravel and charcoal tar) or kuccha (Loose ground without gravel and charcoal tar) road, the type of weapon in case of assault and height from where the person fell. The pattern of skull fracture i.e. type of skull fracture, region and bones of skull involved, any accompanying underlying brain injuries, was noted along with injuries to other parts of the body. The clinical records of the deceased were collected before and compare after the autopsy findings of those cases that received treatment at study hospitals but eventually succumbed to their injuries/complication.
Total of 84 deceased including 7 crush injuries with skull fracture were studied. All the deceased had more than one type of fracture and associated finding. Quarter of victims died before reaching the hospital. Head injury with skull fracture found to be associated with road traffic accident (78; 92.8%), fall from height (3; 3.6%), assault (2; 2.4%) and railway accident (1; 1.2%). Age of the victims varied from 2-75 years with large number (27.9%) from age group 21-30 years and 31-40 years (23.8%). Males were involved more (81.0%) with male to female ratio being 4.2:1. Total 60 victims were able to be studied for socio-economic status; more belonged to middle (53.4%) than lower (28.3%) and higher (18.3%) status. Rest could not be studied as victims were unknown. Significantly (p < 0.05) majority of victims belonged to urban area (64; 76.20%) than rural area.
Based upon clinical investigation and autopsy, the base skull fracture alone was common (44.0%), followed by base with vault (31.0%). Vault alone was involved in 25.0% cases. In all type of victims the most common type of fracture present was linear fracture. Temporal region was the commonest (35.9%) region involved in fracture followed by parietal (29.5%) and frontal (34.6%) region. Skull fracture unilaterally present among maximum (70.6%) victims. The ratio of unilateral to bilateral involvement of skull vault in fracture was 2.40:1. The middle cranial fossa was the commonest region involved (52.2%) followed by posterior cranial (25.4%) and anterior cranial fossa (22.4%). Subdural (43.1%), subarachnoid (31.9%) and extradural (19.4%) haemorrhage was associated with skull fracture. Edema (11), laceration (7), midline shift (6) and necrosis (5) were other intracranial observations.
Of the 78 cases of road traffic accidents (RTA), half (51.3%) were two wheeler occupants and 82.5% of whom were the drivers. The next major group of victims were the pedestrian (37.2%) followed by the bicycle riders (6.6%). Only 3 (7.5%) were reported to be wearing helmet among motorized two wheeler riders. Car was the most common offending vehicle (43.4%) followed by bus (21.1%) and trucks (11.8%). Information regarding the offending vehicle was not available in 15.4% cases. Majority of RTA victims were reported to have been hit either from side (33.3%) or from behind (33.1%). Head on collision was reported in 15.4% cases, while 7.7% cases of vehicular accident occurred due to skidding of motorcycle.
Accident on pucca (94.9%) found to be significantly higher (p < 0.05) than kuccha road (5.1%). Maximum number of RTA occurred between 15:00-18:00 (23.8%), 09:00-12:00 (22.5%), 12:00-15:00 (13.7%) and 24:00-03:00 (11.3%) hours. Thirty five victims (41.7%) died within 6 hours of the incident, of which 25 (71.4%) died within 1 hour of the incident. Forty seven (56%) victims died within 24 hours of the incident.
As a part of body, head is one of the most accessible and vulnerable to injury. Continued and facility based injury surveillance helps in understanding the effects of trauma to the head and facility preparedness in trauma care. Vehicle usage is related with age and gender of the population. The present study observed peak injury incidence at the age group of 21-40 years (51.2%) as reported in other studies . Male involvement found to higher (81%) as predisposed to vehicular mobility and reported from other evidences [8,9]. Work timings associated with high traffic congestion on the road found to be associated as in present study, majority of the incidents occur morning and evening hours as reported earlier in India [7,9]. Almost all (94.9%) of the accidents were reported to be occurred on the metallic road.
Severity of injury and transportation mechanism to health facility is important for the patient management and survival. In present study, about half (47.1%) of the victims died on the spot within 6 hours and out of them 71.4% died within 1 hour of accident. Laceration alone (21.4%) and laceration with contusion (21.4%) was found to be common scalp injury as reported from other study [8,10]. However, contusion and scalp hematoma was observed as common scalp injury . Present and other evidences observed fracture base of skull a commonest (44.0%), vault alone (25.0%) and involvement of both vault and base of skull was found in 30.95% cases . In our study, temporal bone was involved the most as reported in another studies [4,13].
Linear fractures were the most commonly observed fractures in the present study. It was observed among 30.4% in other study . Fissure fracture was also found common . Followed with fracture, subdural haemorrhage was found in 43.1% of cases in the present study hence it was observed as 22.7% and 52.63% in another studies [7,10]. A study found subarachnoid haemorrhage as high as 66.9%, whereas present study found only in 31.9% of victims and by extradural haemorrhage (31, 19.4%) . Laceration was present in 7 cases. Intracerebral haemorrhage was seen in 9 cases.
Present study found 51.3% and other 48.0% reported two wheeler riders and 92.5% were not had helmets while driving. Car was the most common (43.4%) offending vehicle followed by bus (21.1%) in the present study . Majority got hit from side (33.3%) and behind (33.1%) at the time of accident.
As the maximum number of cases of head injury is due to vehicular accidents and proved to be fatal for life, the safety measures, for both the drivers and the passengers of the respective vehicles should be addressed. Awareness of safety rules should spread through the society by judicious use of multimedia facilities available to us in the modern era. Speed limit for different type of vehicles should be implemented strictly. Helmet use for two wheeler motorized vehicle should be made mandatory. Special emphasis is given to peak timing of road congestion. Local hospital based injury surveillance system is to be established to understand the type of fatal injury for patient triage and management.
We acknowledge the Government Multi-specialty hospital, Chandigarh for participating in this study.