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ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 4  |  Page : 549-554  

Head and neck trauma: Profile and factors associated with severe head injury


1 Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Surgical Oncology, Cochin Cancer Research Center, Kochi, Kerala, India

Date of Submission01-Jan-2021
Date of Decision22-Apr-2021
Date of Acceptance22-Apr-2021
Date of Web Publication28-Jan-2022

Correspondence Address:
Kundavaram Paul Prabhakar Abhilash
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_3_21

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  Abstract 


Background: Head and neck trauma is an increasing cause of morbidity and mortality in India. The mode of trauma has varies with geographical progress and it is important to understand the factors associated with severe head injury among this cohort. Methods: This was a retrospective observational study of all adult trauma patients with head and neck trauma presenting to our emergency department (ED). Details of the incident, injuries and outcome were analyzed. Results: During the 3-month study, the ED attended to 16,169 patients with 2022 being trauma victims. Among them, 51.4 3% (n = 835) adults who sustained head, face or neck trauma and hence were included in the final analysis. Overall, RTA s were the predominant mode of injury (81.2% (n = 678), followed by fall on level ground (6.5%; n = 54), fall from height (5.1%; n = 43) and assault (3.7%; n = 31). A history of consuming alcohol prior to the incident was obtained in 16.2% (135) of the patients. Head, face, and neck injuries were seen in 74.9% (n = 626), 64.1% (n = 536), and 4.9% (n = 41) of patients respectively. Bivariate analysis showed male sex (90.3% vs. 76.8%; unadjusted odds ratio [OR]: 2.81, 95% confidence intervals [CI]: 1.19–6.64; P = 0.018) and pedestrian injuries (19.4% vs. 8.5%; unadjusted OR: 2.57, 95% CI: 1.30–5.07; P = 0.006) to have a statistically significant association with sustaining severe head injury. Conclusion: Head and neck trauma comprises a significant proportion of patients with trauma with RTA and falls being the most common causes. Among patients with head and neck trauma, males and pedestrians have an increased odds of sustaining severe head injury (Glasgow Coma Scale ≤8).

Keywords: Accidents, emergency department, head and neck, head injury, trauma


How to cite this article:
Prabhakar Abhilash KP, Abraham SL, Hazra D, Nekkanti AC. Head and neck trauma: Profile and factors associated with severe head injury. Med J DY Patil Vidyapeeth 2022;15:549-54

How to cite this URL:
Prabhakar Abhilash KP, Abraham SL, Hazra D, Nekkanti AC. Head and neck trauma: Profile and factors associated with severe head injury. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Jul 5];15:549-54. Available from: https://www.mjdrdypv.org/text.asp?2022/15/4/549/336710




  Introduction Top


Trauma is a significant cause of morbidity and mortality in both the developing and the developed countries. Road traffic accidents (RTA), fall from height or on level ground, occupational injuries, and assault are the usual causes of trauma with geographical variation. RTA s are projected to be the fifth leading cause of death worldwide by the year 2030, according to the World Health Organization (WHO).[1],[2] This is perhaps a result of urbanization across in many developing countries and rapid increase in the use of automobile for travel. In India, upgrading of national highways and increase in expressways across the length and breadth of our country also perhaps has contributed to the increasing in RTAs. Majority of trauma-deaths occur in the “golden hour” which refers to the prehospital care time, as a result of insufficient prehospital care where the first 60 min after trauma.[2],[3] Head and neck injuries are a major cause of concern as they are associated with significant morbidity and mortality.[4],[5],[6] Head and neck injuries range from innocuous abrasions/lacerations to severe airway compromise and traumatic brain injuries (TBI). This is more concerning as the mean age of trauma victims usually falls in the highly productive middle age group.[5],[7] This not only leaves long-lasting scars on the entire family of the victims but also cripples the economy of the nation. It is therefore important to understand the common modes of injury resulting in head and neck trauma and factors associated with the severity of head injury. We, therefore, conducted this study to determine the profile and severity of head, face, and neck injuries among trauma victims.


  Methodology Top


Study design

This was a subanalysis of a large retrospective study on trauma victims conducted by Abhilash et al. between October 2014 and December 2014.[7]

Study setting

The study was conducted in the emergency department (ED) of a large tertiary care hospital in South India. Our ED is a 50-bed department and usually tends to about 75,000 patients per year.

Participants

All trauma victims who presented during the study were screened.

Inclusion criteria

We included patients who presented to our ED with head and neck trauma due to RTA, fall from height or fall on level ground, assault injures, workplace injuries, and other modes of trauma. Superficial lacerations, abrasions, and minor soft tissue injuries were considered superficial injuries while penetrating injuries, fractures, dislocations, TBIs were classified as deep injuries.

Exclusion criteria

Patients who were brought dead to the ED following trauma and charts with missing data were excluded.

Variables

We collected data of head and neck trauma patients from our hospital's electronic database. The following data were extracted: demographic data, mode of injury, triage priority level, and injuries sustained. Triaging of trauma victims was done at ED arrival and is summarized as follows:

  • Triage priority I: Trauma victims with compromised airway, breathing or circulation and/or with Glasgow Coma Scale (GCS) ≤8
  • Triage priority II: Trauma victims with a stable airway, breathing, and circulation. These included patients with extremity injuries, stable thoracoabdominal injuries, and mild-to-moderate head injury
  • Triage priority III: Trauma victims with minor injuries without any hemodynamic instability.


Bias

This was a retrospective study, and therefore, relied on the ED team for accurate record keeping.

Statistical analysis

Data were analyzed the data by Statistical Package for Social Sciences for Windows (SPSS Inc. Released 20013, version 21.0. Armonk, New York, USA). Continuous variables were expressed as mean with standard deviation while nominal variables were expressed as numbers and percentages. Dichotomous variables were compared using Chi-square test. The factors associated with severe head injury (GCS ≤8) among patients with head and neck trauma were determined by bivariate analysis and their 95% confidence intervals (CI) calculated. A two-sided P < 0.05 was considered to be statistically significant.

Ethical considerations

We obtained approval by the Institutional Review Board and Ethics Committee (IRB Min. No. 9102 dated 12.02.2015) prior to the commencement of this study. Patient confidentiality was maintained using unique identifiers and password-protected data entry software accessible only by the primary investigators.


  Results Top


During the 3-month study, the ED attended to 16,169 patients with 2022 being trauma victims including 1624 (80.3%) adults. Among them, 51.4 3% (n = 835) sustained head, face or neck trauma and hence were included in the final analysis [Figure 1].
Figure 1: STROBE diagram

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Baseline characteristics

The mean age of our cohort was 38.9 (16.69) years with three-fourths (77.8; n = 650) being males. Due to the tertiary nature of our ED, less than half of the patients (46.4%; n = 388) presented to our ED directly while 53.6% (447) were referred after being administered first aid at primary or secondary level hospitals. A history of consuming alcohol prior to the incident was obtained in 16.2% (135) of the patients. The baseline characteristics are shown in [Table 1].
Table 1: Baseline characteristics (n=835)

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Mode and severity of trauma

Overall, RTA s were the predominant mode of injury (81.2% (n = 678), followed by fall on level ground (6.5%; n = 54), fall from height (5.1%; n = 43) and assault (3.7%; n = 31) [Figure 1]. Head, face, and neck injuries were seen in 74.9% (n = 626), 64.1% (n = 536), and 4.9% (n = 41) of patients respectively. Other associated injuries among our cohort included extremity injuries (59.6%; n = 498), thoracic (19.2%; n = 160) and abdomino-pelvic injuries (10.3%; n = 86). Severe head injury (GCS ≤8) was sustained by 7.4% (n = 62) of our study cohort [Table 2]. Details of the mode of trauma of head, face and neck injuries is shown in [Table 3].
Table 2: Examination findings at presentation (n=835)

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Table 3: Mode of trauma of head, face and neck injuries

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Factors associated with severe head injury

We performed a bivariate analysis of factors associated with severe head injury (GCS ≤8) among our study cohort [Table 4]. Male sex (90.3% versus 76.8%; unadjusted odds ratio [OR]: 2.81, 95% CI: 1.19–6.64; P = 0.018) and pedestrian injuries (19.4% versus 8.5%; unadjusted OR: 2.57, 95% CI: 1.30–5.07; P = 0.006) were found to have a statistically significant chance of sustaining severe head injury. The ED mortality rate among our study cohort was 0.47% (n = 4).
Table 4: Bivariate analysis of predictors of severe head injury (Glasgow Coma Scale ≤8) among patients with head and neck trauma

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  Discussion Top


Our study of a cohort of head and neck trauma victims showed the profile, common modes of injury, and factors associated with the severity of TBI. The head and region is an extremely vital area that is includes the brain, sense organs, large vessels, and the airway. Hence, we focused our study on a broad epidemiological profile of trauma to this vital region of the body.

The mean age of trauma victims in our study was 38.9 years, 9 years higher than a similar but large cohort of patients studied in the United States in 2011.[8] We noticed a male preponderance in our study, a consistent factor in all trauma profiles.[7],[9],[10] This is due to the fact that in most developing countries like India, males are predominantly engaged in outdoor activities and travel in automobiles and hence are more prone to injuries.

RTAs was the predominant mode of trauma resulting in head and neck injuries. This finding of ours is consistent with other studies from India and abroad on the mode of trauma.[8],[9],[10],[11] According to the WHO report on road safety, more than 1.2 million people die on the roads every year with a further 50 million being injured.[1] These figures are alarming and calls for the authorities in both the developing and the developed Worlds to wake up and take cognizance of the impact of RTAs. Beyond the enormous physical damage, they cause, RTA s, especially if it involves breadwinners, can drive families into poverty as crash survivors and their family often struggle to deal with long term morbidity and consequences of loss of livelihood. RTAs also place an enormous burden on the country's health system, with many of them ill-equipped to handle the load.

The mode of trauma is an important factor in predicting the severity of injuries. In our study, 2-wheeler incidents comprised two-thirds of RTA s causing head and neck trauma. Poor compliance to helmet use and to road regulations in India are worrying factors. We urge law makers, police, and other government authorities to strictly enforce the use of helmets on the road to decrease the incidence of TBI. Unsafe and poorly maintained roads are other grave concerns that contribute to increased incidents of RTA and hence need to be addressed on a priority basis by the concerned authorities. Unlike 2 wheelers, 4-wheel vehicles offer reasonable protection to its occupants from mild to moderate impacts on the road. In contrast, pedestrians are directly exposed to the elements with little protective gear and hence more prone for severe injuries.[12],[13],[14] In our study, we found pedestrians to have 2.57 times increased risk of sustaining severe head injury compared to other modes of trauma. Brainard et al. reported increased likelihood of mortality with increasing age of pedestrians.[12]

Falls on level ground and from height comprised a tenth of the mode of injuries in our cohort, which is similar to findings of other studies related to trauma.[9],[11] Teo et al. described the characteristics of falls-related TBI in the elderly and it to be associated with significant functional decline, requiring recurrent admissions, thus increasing the burden on already stretched health care systems.[15] Similar revisit rates for TBIs were described by Hsia et al. and Taylor et al., thus highlighting the gravity of the long-term consequences of head and neck trauma.[16],[17]

Alcohol is a perennial evil that significantly impacts vigilance and concentration of motorists and is known to be a significant factor in 15%–30% of RTA s.[18],[19] In our study too, a significant percentage of people (16.2%) gave a history of consumption of alcohol prior to the incident and hence contributed not only to their injuries but also perhaps caused significant harm to other vehicular passengers and pedestrians. This again calls for strict law enforcement to decrease the incidence of alcohol-related trauma incidents.

Our study highlights the burden of head and neck trauma in the ED. More than half of our patients were referred after receiving first aid from local physicians and primary/secondary health centers. This fact emphasizes the importance of all primary and secondary level care physicians being trained in the acute management of trauma and have well-equipped medical centres to provide optimal care to trauma victims, as their early intervention could potentially save many lives.

Strengths and limitations

A strength of our study is the large sample size, thus adding substantial weightage to existing literature on head and neck trauma. However, our study has certain limitations. Being a single tertiary care hospital study, there may have been a referral pattern and patient selection bias. Although a positive history of alcohol consumption was obtained in a significant proportion of patients, it could not be corroborated with blood alcohol levels as the test was not available in our ED in 2014. Nonetheless, our study provides an insight into the profile, mode, and factors associated with severe head injury among a cohort of patients with head and neck trauma.


  Conclusion Top


Head and neck trauma comprises a significant proportion of patients with trauma with RTA and falls being the most common causes. Among patients with head and neck trauma, males and pedestrians have an increased odds of sustaining severe head injury (GCS ≤8).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Global Status Report on Road Safety, Time for Action; 2020. Available from: https://www.who.int/violence_injury_prevention/road_safety_status/report/en/. [Last accessed on 2020 Dec 23].  Back to cited text no. 1
    
2.
Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-Based Injury Statistics Query and Reporting System (WISQARS); 2015. Available from: http://www.cdc.gov/injury/wisqars. [Last accessed on 2021 April 2].  Back to cited text no. 2
    
3.
Abhilash KP, Sivanandan A. Early management of trauma: The golden hour. Curr Med Issues 2020;18:36-9.  Back to cited text no. 3
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4.
Agrawal D, Ahmed S, Khan S, Gupta D, Sinha S, Satyarthee GD. Outcome in 2068 patients of head injury: Experience at a level 1 trauma centre in India. Asian J Neurosurg 2016;11:143-5.  Back to cited text no. 4
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5.
Gururaj G. Epidemiology of traumatic brain injuries: Indian scenario. Neurol Res 2002;24:24-8.  Back to cited text no. 5
    
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Wade AL, Dye JL, Mohrle CR, Galarneau MR. Head, face, and neck injuries during operation Iraqi freedom II: Results from the US Navy-Marine corps combat trauma registry. J Trauma 2007;63:836-40.  Back to cited text no. 6
    
7.
Abhilash KP, Chakraborthy N, Pandian GR, Dhanawade VS, Bhanu TK, Priya K. Profile of trauma patients in the emergency department of a tertiary care hospital in South India. J Family Med Prim Care 2016;5:558-63.  Back to cited text no. 7
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8.
Sethi RK, Kozin ED, Fagenholz PJ, Lee DJ, Shrime MG, Gray ST. Epidemiological survey of head and neck injuries and trauma in the United States. Otolaryngol Head Neck Surg 2014;151:776-84.  Back to cited text no. 8
    
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Boyle MJ, Smith EC, Archer FL. Trauma incidents attended by emergency medical services in Victoria, Australia. Prehosp Disaster Med 2008;23:20-8.  Back to cited text no. 9
    
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Yattoo G, Tabish A. The profile of head injuries and traumatic brain injury deaths in Kashmir. J Trauma Manag Outcomes 2008;2:5.  Back to cited text no. 10
    
11.
Rastogi D, Meena S, Sharma V, Singh GK. Epidemiology of patients admitted to a major trauma centre in northern India. Chin J Traumatol 2014;17:103-7.  Back to cited text no. 11
    
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Brainard BJ, Slauterbeck J, Benjamin JB, Hagaman RM, Higie S. Injury profiles in pedestrian motor vehicle trauma. Ann Emerg Med 1989;18:881-3.  Back to cited text no. 12
    
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Demetriades D, Murray J, Martin M, Velmahos G, Salim A, Alo K, et al. Pedestrians injured by automobiles: Relationship of age to injury type and severity. J Am Coll Surg 2004;199:382-7.  Back to cited text no. 13
    
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Li G, Wang F, Otte D, Simms C. Characteristics of pedestrian head injuries observed from real world collision data. Accid Anal Prev 2019;129:362-6.  Back to cited text no. 14
    
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Teo DB, Wong HC, Yeo AW, Lai YW, Choo EL, Merchant RA. Characteristics of fall-related traumatic brain injury in older adults. Intern Med J 2018;48:1048-55.  Back to cited text no. 15
    
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Hsia RY, Markowitz AJ, Lin F, Guo J, Madhok DY, Manley GT. Ten-year trends in traumatic brain injury: A retrospective cohort study of California emergency department and hospital revisits and readmissions. BMJ Open 2018;8:e022297.  Back to cited text no. 16
    
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Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths-United States, 2007 and 2013. MMWR Surveill Summ 2017;66:1-16.  Back to cited text no. 17
    
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Prabhakar Abhilash KP, Lath D, Kowshik J, Jose A, Chandy GM. Blood alcohol levels in road traffic accidents: Factors associated and the relationship between history of alcohol consumption and blood alcohol level detection. Int J Crit Illn Inj Sci 2019;9:132-7.  Back to cited text no. 18
    
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Papalimperi AH, Athanaselis SA, Mina AD, Papoutsis II, Spiliopoulou CA, Papadodima SA. Incidence of fatalities of road traffic accidents associated with alcohol consumption and the use of psychoactive drugs: A 7-year survey (2011-2017). Exp Ther Med 2019;18:2299-306.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 1], [Table 2], [Table 3], [Table 4]



 

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