Pediatric head injury in last 7 years: a hospital based epidemiological analysis from Andhra Pradesh

Dr. Shailendra Deepak Anjankar

Title: Pediatric head injury in last 7 years: a hospital based epidemiological analysis from Andhra Pradesh

Author : Dr. Shailendra Anjankar,

Guides: Dr. Subodh Raju, Dr. M. A. Jaleel,

Dr. Dilnavaz B.

Department of Neurosurgery, Kamineni Hospital, L. B. Nagar, Hyderabad, A.P., India.

Outline

IntroductionAim Material and MethodsResultsDiscussionConclusion

Which is a safer place?

THE WORLD IS FULL OF IDIOTS ! THINK FIRST AND FAST

Introduction Population of India

(as on July 2011) : 1,205,073,612

In India, children between 1 to 14 years forms 29.7% of total population

Reference: CIA world factbook.(Government organisation)

Reference: Thomas M.McDevitt and Patricia M. Rowe, The United States in International Context: 2000, Census 2000 Brief, C2KBR/01-11. U.S. Census Bureau, Washington, DC. (2002), p. 9.

The statistics from India are chilling!

At least 14 deaths per hour in 2008. The total annual deaths due to road accidents has crossed 1.18 lakhOf total road accident deaths in the country maximum are from Andhra Pradesh (12%), Maharashtra (11%) and Tamil Nadu (10.8%). The death rate per 10,000 vehicles in India is 45 while it is only 3 in developed countries.

Reference : National Crime Records Bureau (NCRB), 2008 report.

Leading causes of death, WHO 2004

Rank Disease or Injury

1 Ischaemic heart disease

2 Cerebrovascular disease

3 Lower respiratory infections

4 COPD

5 Diarrhoeal diseases

6 HIV/AIDS

7 Tuberculosis

8 Trachea, bronchus, lung cancer

9 Road traffic injuries

10 Prematurity & low-birth weight

Rank Disease or Injury

1 Ischaemic heart disease

2 Cerebrovascular disease

3 COPD

4 Lower respiratory infections

5 Road traffic injuries

6 Trachea, bronchus, lung cancer

7 Diabetes mellitus

8 Hypertensive heart disease

9 Stomach cancer

10 HIV/AIDS

2004 2030

Reference : Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

Reference : Luerssen TG, Klauber MR, Marshall LF. Outcome from head injury related to patient's age.A longitudinal prospective study of adult and pediatric head injury. J Neurosurg. 1988;68:409–16.

Children are not little adult!Children have greater disposition to head trauma:

o Greater head mass relative to body weight ratio making them top-heavy

Neck musculature has not been developed to handle relatively heavier structure

Increased head weight results in increased momentum during falls or injuries

o Brain area has more fluid: more susceptible to wave-like forces

o Less myelination

o Thinner cranial bones more easily shattered

The Aim of this study:

is to analyze epidemiology of Pediatric head injury with respect to Mode of accident, Pediatric Trauma Score, GCS, Radiological and laboratory analysis and its correlation with GOS.

Material and methods

In this retrospective study, we included all patients with TBI aged less than 12 years admitted in our hospital, during last 7 year. Our hospital is 350 bedded Tertiary care centre on National Highway (NH-9).Patients admitted were examined and scored according to Glasgow coma scale(GCS) score on arrival and underwent computed cerebral tomography (CT) scan, X-ray Cervical-spine as routine protocol, as soon as feasible.

The patients medical files were retrospectively reviewed, and the data was collected and was recorded in Proforma.

Age, gender, vital signs, socioeconomic status, mode of injury, GCS score, pupil response, motor deficit, presence of LOC, vomiting, convulsion, ENT bleed, Peadiatric Trauma Score, Brain CT-scan and X-ray C-spine findings, Lab investigations, use of mechanical ventilation, number of ICU stay, need for surgery, and outcome analysed at discharge and follow-up.

Collected data were analyzed using Microsoft Assess software and results were tabulated and compared.Statistical tools – averages and percentages.

ResultsDuring the study period, 209 children were admitted with TBI in our hospital were included in the study.There were only 4 (1.91%) infants,86 (41.15%) were belonging to age group of 1-5 Yrs and 119 (56.94%) were of 6-12 Yrs. Majority 142 (67.94%)were boys and 67 (32.06%) were girls.

The major cause of head trauma was Road Traffic Accident (59.81%) which included

26.32% (55) RTA while Crossing the Road, 15.79 % (33) while traveling on 2 wheeler as pillion rider 7.66 % (16) while driving 2 wheeler, 10.05 % (21) while traveling in 4 wheeler.

Second most common cause of head injury was fall from height (21.53%), whereas 4.78% had injury due to fall of TV set on head.

Mean Glasgow Coma Scale was 12+/- 3, 116 (63%) had mild head injury, 68 (25%) had moderate head injury and 25 children (12%) had severe head injury.

15.78% (33 children) presented with seizuresMost common was Loss of consciousness in 74.64 % (156 children) whereas Vomiting was present in 47.84% ( 100 children)

The median pediatric trauma score was 7. Uni-variate analysis showed showed poor outcome (GOS 1,2 and 3) in 80% (N=8) with PTS of < 0.

PTS of < 0

GOS

Bad outcome (GOS 1,2,3) in 8/10 Good outcome

(GOS 4,5) in 2/10

Most common CT scan brain finding was fractures seen in 86 (40.67%) children. 63 (29.67%) children had normal CT brain finding.

None of the children were found to have associated cervical spine injury in our study11% (23 children) required surgery for traumatic brain injury in our study.

Mean serum sodium was 137 +/-5, potassium 4.1 +/-0.6, hemoglobin was 10.4 +/- 1.7.

Laboratory parameters

Mean value +/- 2 SD

Blood Glucose ( mg/dl) 128 --

Serum Sodium (mEq/ L) 137 5

Serum Potassium (mEq/L)

4.1 0.6

Hemoglobin (%) 10.4 1.7

Mean blood sugar level was 128.37 and high blood sugar level was found to be associated with poor GCS at the time of admission

Glasgow outcome scale was performed at discharge showed good outcome (GOS=5) for (87.08% ) 182 children. There were only 6 (2.87%) mortalities observed in our study.

DiscussionOur study showed RTA as major cause of pediatric TBI, whereas other studies from India showed Fall as the most common cause.1-6

Majority of study including ours shows male predominance.1-4

Reference:1. Mahapatra AK. Head injury in children. In: Mahapatra AK, Kamal R, editors. A Text Book of head Injury. Delhi: Modern Publ; 2004. pp. 156–702. Osmond MH, Brennan-Barnes M, Shephard AL. A 4- year review of severe pediatric trauma in eastern Ontario: a descriptive analysis. J Trauma. 2002;52:8–12. 3. Lalloo R, vanAs AB. Profile of children with head injuries treated at the trauma unit of red cross. S Afr Med J. 2004;94:544–6. 4. . Crankson SJ. Motor vehicle injuries in childhood: A hospital based study in Saudi Arabia. Pediatr Surg Int. 2006;22:641–5.5. Sambasivan M. Epidemeology-Pediatric head injuries. Neurol India. 1995;43:57–8.6. Jennet B. Epidemeology of head injury. Arch Dis Child. 1998;78:403–6.

Fall of TV on head still remains the cause of Pediatric TBI, as also reported by Samson et al.7

Younger age group/ Children fare better as also found in our study.8-11

Reference:7. Samson SK, Nair PR, Baldia M, Joseph M. Television tip-over head injuries in children. Neurol India 2010 Sep-Oct;58(5):752-5.8. Alberico AM, Ward JD, Choi SC, et al.:Outcome after severe headi njury. Relationship to mass lesions, diffuse injury, and ICP course in pediatric and adult patients. J Neurosurg 67:648-656, 1987. 9. Andrews B, Pitts LH: Functional recovery after traumatic transtentorial herniation. Neurosurg 2:227-231, 1991. 10. Berger MS, Pitts LH, Lovely M, et al.: Outcome from a severe head injury in children and adolescents. J Neurosurg 62:194-199, 1985. 11. Bruce DA, Schut L, Bruno LA, et al.: Outcome following severe head injuries in children. J Neurosurg 48:679-688, 1978.

Factors associated with poor outcome include low GCS at admission and prolonged impairment of consciousness.12

Hyperglycemia, and especially its persistance over time, appears to be an important negative prognostic factor. 13

References : 12. Luerssen TG. Acute traumatic cerebral injuries. In: Cheek WR eds.Pediatric Neurosurgery. Philadelphia: W.B. Saunders, 1994;266–278.13. Chiaretti A, DeBenedictis R, Polidori G. Early post-traumatic seizures in children with head injury. Childs Nerv Syst 2000 Dec; 16(12): 862-6.

Persistence of hypoxia on admission and CT scan finding of SAH, DAI, Brain edema are factors associated with poor outcome.14

Pediatric trauma score of <0 have poor outcome as also seen in our study.15

Reference:14. Munch E C, Bauhuf C, Horn P. et al Therapy of malignant intracranial hypertension by controlled lumbar cerebrospinal fluid drainage. Crit Care Med 2001. 29976–981.981.15. Campbell, John Creighton (2000). Basic trauma life support for paramedics and other advanced providers. Upper Saddle River, N.J: Brady/Prentice Hall Health

Conclusion

Road traffic Accident is the major cause of Pediatric mortality and morbidity in our country, followed by Falls.Need to follow “Start early, reach safely” axiom.India need to have “ThinkFirst For Kids program” . And also support United Nations “Decade of Action for Road Safety- 2011-2020” theme.

The ThinkFirst For Kids program represents a collaborative effort of educators, the ThinkFirst National Injury Prevention Foundation, the National Highway Traffic Safety Administration (NHTSA), the American Academy of Pediatrics, the Peace Education Foundation and professionals from the fields of psychology and psychiatry. The goal of the program is to increase knowledge and awareness among children in grades 1-3 of the causes and risk factors of brain and spinal cord injury, injury prevention measures, and the use of safety habits.

The United Nations General Assembly has proclaimed the period 2011-2020 as the Decade of Action for Road Safety, “with a goal to stabilize and then reduce the forecast level of road traffic fatalities around the world by increasing activities conducted at the national, regional and global levels”.

Acknowledgement Thankful to my Guides- Dr. Subodh Raju, Dr. M. A. JaleelTo our Dean DNB- Dr. Q. Hassan To Managing Director - Dr. Shashidhar Kamineni Sir and KHL, LB Nagar staff.

To my colleagues – Dr. Renuka Sharma, Dr. S. Ramesh. Dr. Harikishor ReddyTo Medical Records Section – Mr. Kishor,

To Pediatric and Neurosurgery department staff

To my wife – Dr. Sumedha Anjankar and my parents Dr. Deepak and Vidhya Anjankar