PAKISTAN ARMED FORCES
MEDICAL JOURNAL (Category Y)

A Journal of Army Medical & Dental Corps

Being published since 1956

ISSN (online) 2411-8842
ISSN (print) 0030-9648

VOL 61, No. 2, JUNE 2011

PATTERNS OF FATAL HEAD INJURIES DUE TO ROAD TRAFFIC ACCIDENTS AUTOPSY FINDINGS AT AFIP RAWALPINDI, PAKISTAN

Muhammad Tahir Khadim, Usman Hassan, Sheeba Ishtiaq, Tariq Sarfraz

Abstract

Objective:  To analyze the antopsy findings in cases of fatal head injuries due to road traffic accidents.
Study Design: Descriptive Study.
Place and Duration of Study; Armed Forces Institute of Pathology Rawalpindi from 2004 to 2008.
Material and Methods: The present study was conducted to ascertain the patterns of fatal head injuries due to road traffic accidents as documented during autopsies performed at AFIP, Rawalpindi during the five years period (2004-2008). Data were analyzed using SPSS version 14. Mean, median and mode were calculated for quantitative variables like age and hospital stay. Frequencies and percentages were calculated for qualitative variables like time of accident, pattern of head injury, skull bones fractured, and other associated injuries, passenger status of deceased and duration of hospital stay.
Results: Out of 550 postmortem cases received during the study period, 57(10.4%) deaths were due to head injuries. The age ranged from 19 to 51 years with mean age of 35.6+ 7.9 years. Most (50%) of the deaths occurred in 4th decade and during daytime 34 (59.6%). Majority of subjects died on spot 40 (70.1%). Most of the deceased suffered from more than one compartment hemorrhage 30 (52.6%) and multiple skull bone fractures 24 (42.1%). November was the month in which most of the deaths occurred 13 (23.1%) followed by September 7 (17.5%). Majority 36 (63.1%) of subjects were travelling as passengers.
Conclusion: Head injury is one of the most frequent causes of death in road traffic accidents. Most of the deaths occur on spot before any life support can be give to these subjects. The pattern of skull fractures observed, was quite comparable to other studies. It indicates that road traffic accidents lead to similar kinds of fatal head injuries throughout the world. The frequencies of such injuries are more frequent in developing world due to the lack of traffic safety regulations.

Keywords : Head injuries, Road traffic accidents, skull fractures.

Article

INTRODUCTION
Road traffic accidents are one of the major causes of death in developed as well as developing countries1. Although this problem has been controlled very much in developed countries but in developing countries like Pakistan, condition is still worsening. Road traffic accidents still remain one of the leading causes of death in youth. The major reason is that it is one of the neglected health problems in Pakistan. About 1.2 million people are killed and 50 million people are injured due to road traffic accidents each year worldwide2. In 2002, road traffic accident ranked 9th amongst the leading causes of disease burden accounting for 2.6% of overall global disabilities. If increased motorization continues to follow the same trends, it is estimated that by 2020, road traffic accidents will rank as third leading cause of disease burden globally3. According to a report released by World Health Organization on April 7th, 2004, road traffic accidents kill at least 5000 and injure 12,000 persons in Pakistan every year4.
Although there are many causes of fatalities in road traffic accidents, head injury is one of the major cause. Head injury may lead to skull fractures, various extents of brain parenchymal injuries and traumatic vascular injuries5. The latter includes formation of epidural and subdural hematomas and intracerebral hemorrhages6. Death due to head injury depends upon various factors including intensity of impact on head, degree of deceleration, pattern of skull bones fractured, degree and sites of parenchymal and vascular injuries, time spent from the time of injury to the specialized health care at hospital and how efficiently life support measures were given7. Unless some safety and preventive measures are strictly implemented death toll will continue to increase and will cause significant loss of precious lives.
The present study was conducted to ascertain the patterns of fatal head injuries due to road traffic accidents in northern areas of Pakistan as documented during autopsies performed at AFIP, Rawalpindi.
MATERIAL AND METHODS
This descriptive study was carried out at AFIP Rawalpindi, Data of all postmortem examinations carried out during the years 2004-2008 were retrieved from the record. Out of 550 autopsies carried out during these 5 years, a total of 57 comprised deaths secondary to head injuries resulting from road traffic accidents. All cases received due to death secondary to causes other than head injuries were excluded. Since we perform autopsies on serving soldiers and male employees of defense forces only, all cases were male.
Variables were age of the deceased, time of accident, pattern of vascular injury (extradural, subdural, intracerebral or combination of these), skull bones fractured, single or multiple with description of anatomical sites, other associated injuries, status of the deceased (whether passenger or driver), duration of hospital stay, calendar month of accident. Data were analyzed using SPSS version 14. Mean, median and mode were calculated for quantitative variables like age and hospital stay. Frequencies and percentages were calculated for qualitative variables like time of accident, pattern of head injury, skull bones fractured, other associated injuries, passenger position, status of deceased and duration of hospital stay.
RESULTS
Out of 550 autopsies received during the study period, 57 (10.4%) deaths were due to head injuries. All cases were males. The age ranged from 19 to 51 years with a mean age of 35.6+ 7.9 years. The hospital stay ranged from 1 hour to 14 days with a mean of 2.7 + 3.8 hours.
Out of total of 57 cases, 34 (59.6%) deaths occurred during day time and 23 (40.4%) deaths occurred during evening. Most deaths occurred in 4th decade (50.9%), followed by third (26.3%) and fifth decades (21%) of life (Figure). There was only one (1.8%) person who died at the age of 19 yrs. A total of 40 (70.2%) injured persons died on spot. The remaining 17 (29.8%) were received alive in various nearby hospitals. Seven (12.3%) patients died within 5 hours, 2 (3.5%) between 5-10 hrs, 4 (7%) could stay alive for 21-24 hrs and 1 (1.8%) each for 2 days, 5 days, 10 days and 14 days respectively. According to history all these patients who were received alive were given full life support. Fifteen (26.3%) cases had no skull bone fractures at all, 10 (17.5%) patients sustained more than 2 skull bone fractures and rest 14 (24.6%) had two skull bone fractures (Table 1).

Out of the total of 18 (31.6%) subjects which received single skull bone fracture, the most frequent bone fractured was temporal (44.4%), followed by occipital (27.8%), frontal (16.7%) and parietal and sphenoid (5.6%) each.
Out of these 57 cases, more than half 30 (52.6%) subjects presented with hemorrhage in more than one vascular compartment. The most frequent pattern was a combination of extradural and intracerebral hematomas i.e: 18 (60%). This was followed by extradural and subdural 6(20%), extradural and subarachnoid 3 (10%) and subdural and intracerebral 3 (10%). (Table 2).

Out of 27 (47.4%) single compartment hemorrhage, the most frequent was extradural 15 (55.6%), followed by subdural 7 (25.9%), subarachnoid 3 (11.1%) and intracerebral 2 (7.4%).
There were no injuries to other body parts in 14 (24.6%) cases. Out of the remaining 43 (75.4%) cases, there were 12 (28%) with rib fractures, 5 (12%) cases with lung lacerations, 4 (9%) with facial bone fractures, 5 (12%) with spinal injuries and 1 (2%) each for pelvic, lower limb, liver and tracheal injuries. A total of 13 (30%) cases received more than two injuries other than head injuries. About 36 (63.2%) subjects were travelling as passengers and 19 (33.3%) as drivers. Two (13.5%) subjects were pedestrians when they encountered accidents. Most deaths occurred in November 13 (23%) and September 7 (12%), followed by October 5 (9%). Other calendar months did not show significance regarding accident frequency. Out of total of 8 subjects encountering temporal bone fractures, 4 died on spot and 4 were received alive in hospitals. Of the later, 2 stayed alive for 24 hrs, 1 for 5 days and 1 for 14 days. All of the 5 subjects with occipital bone fractures died on spot. Out of 24 subjects receiving multiple skull fractures, 20 died on spot. Of the remaining four, 2 could stay alive for less than 5 hrs and other two for 24 hrs. There were 15 cases which did not encounter any fracture but yet 7 died on spot. Out of the remaining 8 which were received alive, 4 could stay alive for less than 5 hrs, 2 for 1 day, 1 for 2 days and 1 for 10 days. Out of 19 subjects which were drivers, most frequent hemorrhage was extradural followed by multiple hematomata. Of 36 subjects travelling as passengers, most had more than one vascular injury on post- mortem examination.
DISCUSSION
In this study, fatalities due to head injury comprised 10.4% of all deaths. All the deceased were males as we autopsy male soldiers only. In studies based on general population, most of the patients are males because that is the gender exposed more to traffic hazards on urban streets7,8. Hence although our study had a strong gender bias our results are still consistent with available data7,8.
The most common age group affected in this study was the fourth decade followed by the third. These results were compatible with studies from other countries9,10. This age group comprising breadwinners for their families, travel more. This study was carried out on army soldiers but most of the accidents occurred when they were travelling in public or private vehicles on their way to homes to visit their families or retuning to their units after holidays. As most of the deaths occurred while travelling in public transport, they were exposed to the usual traffic conditions just as applied to the general population.
Most of the deceased suffered from multiple skull bone fractures (n=24, 42.1%).  There was no skull bone fracture in 26.4% of cases. Out of the cases which suffered from single bone fractures, the most frequent bone fractured was temporal bone (n=8, 44.4%), followed by occipital bone (n=5, 27.8%). The results were identical to an Indian study11. The probable reason of multiple skull bone fractures is very high speed at which vehicles move on highways. So accidents which occur at high speeds cause a great impact on head when it strikes by forcible contact with a broad resisting surface.
In our study, multiple compartment hemorrhages were more frequent as compared to single compartment hemorrhages. Most of the deceased (n=30, 52.6%) suffered from combinations of vascular hemorrhages. The most frequent combination was of extradural and intracerebral hemorrhage. Out of the remaining cases with single compartment hemorrhages, the most frequent was extradural hemorrhage followed by subdural hemorrhage. In other studies, combination of hemorrhages was less frequent12. When frequencies of single compartment hemorrhages were compared, a large number of studies revealed subdural hemorrhage as the frequent group which was not consistent with our study where the frequent single compartment hemorrhage was extradural followed by subdural13, 14.
Most of the subjects (n=40, 70.1%) died on spot. The remaining 17 (29.9%) cases were received alive in various nearby hospitals and remained alive for a minimum of 1 hour to a maximum of 14 days as mentioned in results. These results were matched with a few international studies12-13. In our study, as in other full life support was available at the hospitals in which these subjects were received alive. Majority of these subjects were travelling as passengers. Most (n=34, 59.5%) of the accidents occurred during the day time in our study, in the months of October (9%) and November (23%). These results were comparable with a few studies and were different from other studies published. Maximum number of fatal accidents took place during the month of November in one Indian report11. In Nepal, maximum numbers of cases were reported in the month of July followed by January. In other studies conducted in India the results indicated maximum numbers of victims during the month of January with the peak time of road traffic accidents between 3 PM to 6 PM15,16. The studies conducted in Mangalore and Kathmandu (Nepal) indicated that most of the accidents happened during the afternoon and evening hours17,18.
CONCLUSION
Head injury is one of the important causes of death in road traffic accidents. Most of the deaths occur on spot before any life support can be give to these subjects. It is important to improve pre-hospital as well as hospital facilities to deal with fatal head injuries. The pattern of skull fractures observed in our study was quite comparable to other studies. It indicates that road traffic accidents lead to similar kinds of fatal head injuries throughout the world. The frequencies of such injuries are more frequent in developing world due to the lack of traffic safety regulations. Large scale studies are required to make recommendations for improving the vehicle designs, road safety measures and focusing on implementations of traffic legislations covering all the aspects of road traffic accidents. These studies will also provide guidelines for establishing possible emergency first aid providing medical and rescue facilities.

Reference

1. Ganveer GB, Twiari RR. Injury pattern among nonfatal road traffic accident cases: A cross-sectional study in Central India. Indian J Med Sci 2006: 6; 59: 9-12.
2. Rehman HA, Zulkifli NAH, Subramaniam K et al. Car occupants accidents and injuries among adolescents in a state in Malaysia. Proceedings of Eastern Asia Society for Transportation Study 2005;5:1867-1874
3. M Peden, L Sminkey. World Health Organization dedicates World Health Day to road safety. Inj Prev 2004; 10:67.
4. World Health Organization. World report on road tra ffic injury Prevention. Geneva : WHO; 2004.P.3-29.
5. Bazarian JJ, McClung J., and Shah MN. Mild traumatic brain injury in United State, 1998 – 2000. Brain injury 2005; 19(2):85-91.
6. Shepard S. Head trauma. American Association of Neurological Surgeon, Joint a and
7. Marcus M.L. (2003): Incidence, external causes, and outcomes of work-related brain injuries in male. J Occup Med. 2003; 27: 757- 760.
8. Kiran E R. Road safety at cross roads. JIndian Acad Forensic Med. 2004; 26(4): 147- 152.
9. Kochar A. Road Traffic Accidents & Alcohol. Int J Med Toxicol Leg Med.. 2002;5(1): 22-24
10. Jha N, Agrawal CS. Epidemiological study of Road Traffic Accident Cases: A Study from Eastern Nepal. Regional Health Forum WHO South-East Asia Region 2004; 8 (1).
11. Vorko-Jovic A, Kern J, Biloglav Z. Risk factors in urban road traffic accidents. J Safety Res 2006; 37(1): 93-8.
12. Kumar A, Lalwani S, Agrawal D, Rautji R, Dogra TD. Fatal road traffic accidents and their relationship with head injuries: An epidemiological survey of five years. Indian Journal of Neurotrauma. 2008, Vol. 5, No. 2, pp. 63-7.
13. Akang EE, Kuti MA, Osunkoya AO, Komolafe EO, Malomo AO, Shokunbi MT, Amutta SB. Pattern of fatal head injuries in Ibadan—a 10 year review. Med Sci Law 2002; 42: 160-6.
14. Elesha SO, and Daramola AO. Fatal head injuries: the Lagos University Teaching Hospital experience (1993-1997). Niger Postgrad Med J 2002; 9:38-42.
15. Menon A, Pai VK, Rajeev A. Pattern of fatal head injuries due to vehicular accidents in Mangalore. J Forensic Leg Med 2008; 15: 75-7.
16. Mehta SP. An epidemiological study of road traffic accident cases admitted in Safdarjang Hospital, New Delhi. Ind J Med Res 1968; 56:456-66.
17. Ghosh PK. Epidemiological study of the victims of vehicular accidents in Delhi. J Ind Med Assoc 1992; 90: 309-12.
18. Banthia P, Koirala B, Rauniyar A, Chaudhary D, Kharel T, Khadka SB. An epidemiological study of road traffic accident cases attending emergency department of teaching hospital. J Nepal Med Assoc 2006; 45: 238-43.



Creative Commons License
This is an Open Access article distributed under the terms of the Creative Commons Attribution License Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.