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JINJ-6473; No. of Pages 3 Injury, Int. J. Care Injured xxx (2015) xxx–xxx

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Injury journal homepage: www.elsevier.com/locate/injury

Pattern of emergency room mortality among road traffic crash victims Oladimeji Ranti Babalola a,*, Kehinde Oluwadiya b, Goran Vrgocˇ c, Ugochukwu Akpati a, ˇ oklo d, Marin Marinovic´ e, Bore Bakota f Josˇko Sindik d, Miran C a

Department of Orthopaedic and Trauma National Orthopaedic Hospital, Igbobi, Lagos, Nigeria Department of Surgery, Faculty of Clinical Sciences, Ekiti State University, Ekiti State, Nigeria c Department of Orthopaedic Surgery, University Hospital ‘‘Sveti Duh’’, Zagreb, Croatia d Institute for Anthropological Research, Zagreb, Croatia e Department of Surgery, University Hospital Rijeka, Rijeka, Croatia f Department of Surgery, General Hospital Karlovac, Karlovac, Croatia b

A R T I C L E I N F O

A B S T R A C T

Keywords: Emergency room Mortality Road traffic crash Victim

Road traffic injuries are a major cause of death in the emergency room. The goal of this study was to highlight the demographic pattern of road traffic-related deaths in the accident and emergency room of a regional trauma centre. This was a 5-year retrospective study in which road traffic-related cases of emergency room mortality between June 2009 and June 2014 were reviewed. A total of 33 road traffic crash-related deaths occurred during this period with a male-to-female ratio of 2.3:1. Most of these patients were pedestrians with severe injuries involving two or more Abbreviated Injury Scale (AIS) coded regions. The mean time between injury and presentation in the first trauma facility was 112.1 (55.4) min, and between presentation in the emergency room and death was 410 (645) min. Mangled lower extremity, bilateral long bone lower limb fractures, pelvic injuries, blunt injuries to the chest and abdomen, and cranial fossae fractures were the common injury pattern. Median ISS and NISS in these patients were 22 (interquartile range [IQR] = 11) and 25 (IQR = 17), respectively. Severe injuries, delayed presentation, multiple referrals and delayed resuscitative measures contribute to road traffic crash-related mortality. ß 2015 Published by Elsevier Ltd.

Introduction Road traffic injuries are a major cause of death in the emergency room [1–3]. They are also a major cause of death and disability globally, with a higher number occurring in developing countries [4]. The findings in other climes are not different from those seen locally [5]. Urbanisation and the rapid growth of motorised transport in most cities in developing countries explain the high incidence of road traffic accident-associated morbidity and mortality [6,7]. The low compliance rate with the use of seat belts and other passive safety devices has also contributed significantly to the incidence of road traffic injuries in developing countries [8,9]. Increasing population density has been associated with a proportionately greater number of traffic-related deaths in the

* Corresponding author at: Arthroscopy and Sports Medicine unit, Department of orthopaedics and trauma, National orthopaedic Hospital, Lagos, Nigeria. Tel.: +234 8023647181. E-mail address: [email protected] (O.R. Babalola).

young and the elderly. Middle-income countries appear to have, on average, the largest road-traffic mortality burden, and the poorest countries show the highest road traffic-related mortality rate after adjustment for vehicle numbers [9,10]. Various factors contribute to the observed mortality in road traffic crash victims after arrival at hospital, including low use of passive safety devices, high-risk behaviour, injury severity, nature of pre-hospital care and time between injury and arrival at the first trauma centre [11,12]. The goal of this study was to highlight the demographic pattern of road traffic-related deaths in the accident and emergency room of a regional trauma centre in a developing country, and recommend measures that might improve the standard of care offered to these patients. Materials and methods This was a 5-year retrospective study in which cases that presented in the emergency room between June 2009 and June 2014 were reviewed. The goal of this study was to highlight the demographic pattern of mortality in road traffic crash victims in our centre and to identify factors that contribute to this mortality.

http://dx.doi.org/10.1016/j.injury.2015.10.065 0020–1383/ß 2015 Published by Elsevier Ltd.

Please cite this article in press as: Babalola OR, et al. Pattern of emergency room mortality among road traffic crash victims. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.10.065

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2 Table 1 Aetiology of emergency room-related mortality.

Table 3 Road user category and recorded number of emergency room deaths.

Aetiology

Frequency (percentage)

Birth trauma Gun-shot injury to the lower limb Fall from height + quadriplegia Trauma wound sepsis Pott’s disease + DVT Traditional bone setter’s gangrene + sepsis Brought-in-dead Industrial accident Physical assault Lower limb cellulitis Diabetic foot gangrene Major flame burns Hyperosmolar non-ketotic coma Road traffic crash Total

1 4 5 1 1 2 11 1 1 1 4 9 1 33 75

(1.3%) (5.3%) (6.7%) (1.3%) (1.3%) (2.7%) (14.7%) (1.3%) (1.3%) (1.3%) (5.4%) (12.0%) (1.3%) (44.0%) (100%)

All available records of all patients who presented in the emergency room within the study period were reviewed. These records included case files, attendance records in the emergency room, nurses’ reports and death certificates for bio-demographic characteristics, road user category, cause of road traffic crash, time of road traffic crash, interval between crash and presentation in the first trauma centre, pattern of injury and injury severity score at time of presentation. Death certificates and autopsy reports, when available, were also used as an aid to ascertain cause of death. Data were analysed using SPSS version 16. Descriptive statistics were used to determine frequency and percentage for biodemographic variables. The median ISS and NISS were used as the measure of injury severity (between the first and third quartile). Results There were 5217 cases of trauma presented in the emergency room during the study period. Of these, there were 75 emergency room deaths. The aetiology of these deaths is detailed in Table 1. There were a total of 33 cases of road traffic crash-related deaths of which 29 (71%) were males and four (29%) were females with a ratio of 7:3. The age range of the road traffic-related mortality cases was 14 to 75 years. The age group with the highest rate of mortality was the 21–35 year age group, which constituted 17 (49%) of the total mortality figure. Review of the distribution of injury pattern revealed 10 cases of blunt chest and abdominal injuries with visceral injury, seven cases of cranial fossa fracture, five cases each of mangled leg and bilateral femoral fracture, four cases of closed femoral fracture and three cases each of humeral and forearm fractures. There were five cases of traumatic quadriplegia. Twenty-six (78%) of these patients had involvement of more than one Abbreviated Injury Scale (AIS) coded region. Most deaths occurred during the weekends and on Thursdays (Table 2), with pedestrians constituting the largest road user category (Table 3) involved in the road traffic crash. The mean time Table 2 Day of the week and recorded number of emergency room deaths. Day of the week Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total

Frequency (N)

Percentage (%)

7 2 4 3 6 2 9 33

21.2 6.1 12.1 9.1 18.2 6.1 27.2 100.0

Pedestrian Motorised cyclist Driver of a car, bus, truck Passenger on a motorised cycle Passenger in a car, bus, truck Total

Frequency

Percent

20 4 1 3 5 33

60.6 12.1 3.0 9.1 15.2 100.0

between injury and presentation in the first trauma facility was 112.1 (55.4) min, and between presentation in the emergency room and death was 410 (645) min. The most common physiological derangement at presentation was haemorrhagic shock. The median ISS and NISS for these patients were 22 (interquartile range [IQR] = 11) and 25 (IQR = 17), respectively. Discussion The common causes of trauma-related death in our study were road traffic injury, flame burn and fall from a height. Road traffic injury was the most common reason for trauma-related emergency room death, a finding similar to that of Solagberu et al. [3], More males than females were affected, most of whom were young adults. This is understandable considering that young males are usually the more economically active and the more likely to be exposed to the dangers of daily activity [13]. No form of pre-hospital care was given to any of these patients prior to presentation in the first trauma facility as they were simply scooped from the scene of the crash by untrained sympathisers and transported to the nearest health facility. The common modes of transportation from the crash scene to the first trauma facility were taxi cabs (with the patients sitting up) and private pick-up vehicles. Only a few patients were brought in by police officers or members of the federal road safety commission, which is the body responsible for road traffic management in Nigeria. This scenario reflects the poor state of pre-hospital trauma care in the country, a factor that adversely affects the outcome of trauma care [14,15]. Most of the patients in this study presented with haemorrhagic shock, which is largely explained by the common patterns of injuries in these patients coupled with the involvement of more than one AIS coded region. This is further compounded by delayed presentation at the first trauma facility and multiple referrals before arrival at the final trauma facility. The provision of continuous resuscitation to these patients is difficult as they travel between trauma centres around the country, and some of the centres eventually refuse to accept the trauma patients because of insufficient bed space. This is common because there is poor communication between trauma centres prior to referral. The median NISS was slightly higher than the ISS. A study by Thomas Sullivan et al. [16], compared the ability of the ISS and the NISS to discriminate between survivors and non-survivors and showed that the NISS performed slightly better than the ISS. They also observed that the NISS was superior for predicting locomotion because it better accounts for patients with multiple extremity injuries. This may be the case in our study as the worst injuries were multiple and were situated in the extremities of these patients. Increasing ISS has been associated with rise in mortality rate in trauma patients [17]. ISS and NISS indicate that that these patients were in the category of severely injured patients and this may also contribute to the adverse outcome. Crude mortality rate was 1.44%, which is much lower than in other published studies in the country [18,19]. Mortality was highest over weekends and on Thursdays. This may be related to the fact that clinical activities and clinicians are fewer over the

Please cite this article in press as: Babalola OR, et al. Pattern of emergency room mortality among road traffic crash victims. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.10.065

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weekends. There is clearly a role for experienced trauma personnel in the initial care of patients with road traffic injuries. Conclusion Road traffic crash is the leading cause of emergency room mortality in our study location, with most fatalities occurring in the young adult age group. Severe injuries, delayed presentation, multiple referrals and inadequate resuscitative measures contribute to this mortality. Availability of land ambulance services to aid early arrival of victims, better communication between trauma centres and availability of trained and experienced trauma personnel will help further reduce these mortality figures. Limitations Our centre is largely a mono-subspecialty centre and hence we tend not to see the full spectrum of patients with road traffic injuries. Also, the study was conducted at a single trauma centre; involvement of multiple centres would add further credibility to the present study. Conflict of interest The authors declare no conflict of interest. References [1] Ekere AU, Yellowe BE, Umune S. Mortality patterns in the accident and emergency department of an urban hospital in Nigeria. Niger J Clin Pract 2005;8(1):14–8. [2] Osime OC, Ighedosa SU, Oludiran OO, Iribhogbe PE. Patterns of trauma deaths in an accident and emergency unit. Prehosp Disaster Med 2007;22(1):75–8. [3] Solagberu BA, Adekanye AO, Ofoegbu CPK, Kuranga SA, Udoffa US, AbdurRahman LO, et al. Clinical spectrum of trauma at a university hospital in Nigeria. Eur J Trauma 2002;28:365–9.

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Please cite this article in press as: Babalola OR, et al. Pattern of emergency room mortality among road traffic crash victims. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.10.065

Pattern of emergency room mortality among road traffic crash victims.

Road traffic injuries are a major cause of death in the emergency room. The goal of this study was to highlight the demographic pattern of road traffi...
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