Hospitalized injuries and deaths in a trauma unit in upper Egypt

Abstract

Context:

It is predicted that injuries will be among the top 20 leading causes of death worldwide by 2030. In Egypt, injuries burden is significant as it was the fifth leading cause of death in 2004. Also, it's considered as a hidden epidemic due to under-reporting.

Aims:

To identify the patterns of hospitalized injury cases at Trauma Unit in Assiut University Hospitals and to provide an indication about who are at increased risk of hospitalization or death due to injury.

Settings and Design:

A descriptive retrospective study.

Materials and Methods:

Registered data of all hospitalized injuries from January 2002 to December 2009 at Trauma Unit of Assiut University Hospitals in Upper Egypt were included.

Statistical Analysis:

Advanced statistical package for social sciences (SPSS) program version 16 (IBM Corporation - http://www.spss.com) was used for data analysis. Descriptive statistics and tests of significance were used. P value was considered statistically significant when it was less than 0.05 and highly significant when it was less than 0.001.

Results:

Admitted cases of attended injuries were (31.8%). Most admissions were below the age of 30 years (58.4%). Male to female ratio was 3:1. Falls were the most common injuries (43.6%), followed by transport accidents (31.1%). More than half of deaths (56.4%) were due to transport accidents. Transport accidents, falls, interpersonal violence and gunshot injuries had an early ranking throughout the study period.

Conclusion:

Road traffic injuries, falls and violence are areas of priority in preventive strategies. Paying special attention for young adults is recommended.

INTRODUCTION

Injury is among the top ten leading causes of death globally.[1,2]

Years of life lost due to injury deaths in Egypt accounted for 8%[3] and the fifth death leading cause in 2004.[4]

Injury in Egypt is several times higher due to under-reporting and misclassification.[4]

The present study was motivated by the lack of information about injuries in Upper Egypt.

The aim of this study is to identify the patterns of injury admissions and deaths in the Trauma Unit of Assiut University Hospitals in Upper Egypt and to provide an indicator about who are most at risk.

MATERIALS AND METHODS

A descriptive retrospective study of all patients with injuries admitted to the Trauma Unit-Assiut University Hospitals in Upper Egypt from January 2002 to December 2009 was carried out using patients’ medical records database.

Data of the admitted injury cases were obtained from the database office at the Trauma Unit of Assiut University Hospitals. Data registration was done by the resident doctors at the Trauma Unit and data entry was performed by well trained personnel. The data were obtained in Excel program. Coding of causes of injuries was carried out using the tenth revision of the international classification of diseases (ICD-10) codes. In the ICD-10, external causes are classified under a series of alphanumeric codes V01-Y98.

This Governorate is considered as one of the biggest in Upper Egypt. The Trauma Unit in the University Hospitals in Upper Egypt is considered as the central unit of trauma in Upper Egypt, to which injury cases are referred from all Upper Egypt and Red Sea Governorates.

The total population in Egypt increased from 70,712,345 in 2002[5] to 79,716,200.0 in 2009[6] and the percent of the population in Upper Egypt and Red Sea Governorates is about 25.8% from the total population in Egypt.[7]

The data abstracted included age, sex, cause of injury/death, parts of the body injured. Age was written by a completed years; e.g., all child less than 1 year (infant) his age was written as 1 year. Classification of age groups was carried out according to World Health Organization (WHO) and international studies. Data was analyzed by using the advanced statistical package for social sciences (SPSS) program version 16 (IBM Corporation - http://www.spss.com).

Data analysis was started by descriptive statistics (frequencies and percentages) then application of tests of significance as: Chi-square test and Chi-square for trend test for comparison of qualitative data (Chi-square for trend test was done by using the EPI info program). P value was considered statistically significant when it was less than 0.05 and highly significant when it was less than 0.001.

Calculation of years of potential life lost (YPLL) was carried out by using the following formula:

YPLL = (Life expectancy - midpoint in each age group) × (the number of injury in eachage group).[8]

Life expectancy for males at birth was 66 years and for females was 70 years.[9]

The study protocol was approved by the ethical committee, Faculty of Medicine, Egypt. Data obtained from the database office of Trauma Unit were unnamed. Privacy and confidentiality of all information were maintained.

RESULTS

Attended cases at Trauma Unit in the University Hospitals were 19,869 in 2002 and increased up to 32,699 in 2009. Out of the total cases in 8 years study duration, slightly more than two-thirds of the injured cases (68.2%) 145,817 were treated in the emergency department and discharged (treated only) while 68,018 of them were admitted, accounting for nearly one-third of injuries (31.8%) [Figure 1].

Figure 1.

Distribution of attended injured cases at Trauma Unit, University Hospital, 2002-2009

Injury pyramid at the Trauma Unit during the period 2002-2009 showed that the majority of injuries was treated in the emergency department and then discharged (68.2%) while 30.6% were hospitalized at the Trauma Unit and 1.2% (2.641) were deaths [Figure 2].

Figure 2.

Injury pyramid of injury cases at Trauma Unit, University Hospital, 2002-2009

The death rate decreased from 4.9 per 100 admitted cases in 2002 to3.7/100 admitted cases in 2009.

The young adults aged 20-29 years have the majority of injury admissions 11,614 (17.1%), followed by age group 5-9 years 8,893 (13.1%) and 30-39 years 7,976 (11.7%) [Figure 3].

Figure 3.

Distribution of hospitalized injured cases by age group at Trauma Unit, University Hospital, 2002-2009

The hospitalized injured males were 50,733 representing 74.6% of admissions while 17,271 (25.4%) were females.

Falls were the most common injuries 43.6% (29.650), followed by transport accidents 31.1% (21.142) and exposure to inanimate mechanical forces 12.9% (8.803) [Figure 4].

Figure 4.

Distribution of registered hospitalized injuries by cause of injury at Trauma Unit, University Hospital, 2002-2009

Regarding causes of admission among different age groups, falls was the first among the age group under 15 and above 49 years old. From 15 to 49 years old transport accidents was ranked as the first cause of admissions.

The highest rate among hospitalized injury deaths were 42.6/100 admitted cases among those aged 15 up to 50 years. Death rates comprised 14/100 admitted cases among ages 50-59 years (370 deaths) followed by ages 20-29 years (13.1) as 346 deaths and ages 70 years and older (12/100) as 317 deaths. The majority of deaths (76.4%) comprised 2,018 among hospitalized injuries were males and 23.6% (623) were females.

The majority of deaths (56.4%) were due to transport accident accounting for more than half of deaths as 1,490 followed by falls (29.5%) as 779 and 151 for interpersonal violence (5.7%) [Figure 5].

Figure 5.

Distribution of registered deaths by cause of injury at Trauma Unit, University Hospital, 2002-2009

The most body regions affected by injuries among deaths were the head (34.6%) accounting for 1,638, followed by the chest among 839 deaths (17.7%) [Table 1].

Table 1.

Distribution of injuries among registered deaths by affected body region at Trauma unit, university hospital, 2002-2009

Estimated total YPLL was 78,499 years during the whole study period from 2002 to 2009. The highest portion of YPLL was 14,507 among the age group 20-29 years and 14,160 YPLL among ages 0-4 years.

The transport accident was the first leading cause of deaths among all age groups except ages 0-4 years and 70+ and over, which was the second cause. Fall was the second leading cause of deaths among all age groups except ages 0-4 years and 70 years old and over which was the first cause. Gunshot injuries were the third cause of death among those aged 15-29 years and the fourth cause among aged 30-50 years.

Transport accidents were ranked as the first leading cause of deaths throughout the whole period from 2002 to 2009, followed by falls as the second cause throughout the whole period from 2002 to 2009.

Gunshot injuries were the third cause of deaths in 2002-2003, then became the fourth cause in 2004, in 2005-2006 occupied the fifth cause, then became the fourth cause together (with interpersonal violence) in 2007-2009. Interpersonal violence was the fifth leading cause in 2002-2003 and became the third cause in 2004-2007 [Table 2].

Table 2.

Ranking the leading cause of death among hospitalized injuries at Trauma unit, university hospital, 2002-2009

DISCUSSION

Injury and violence are one of the major public health problems, which are highly prevalent world-wide. Around 9% of the global mortality are attributed to injury and violence.[10]

The increase in the number of injury hospitalization in the Trauma Unit- Assiut University Hospitals in Upper Egypt throughout the period from 2002 to 2009 with 1.2/100 cases death rate is indicative that injury problem is a rising public health problem in Upper Egypt, which may represent a national situation.

The current study highlights some areas of priorities that need more attention in injury problem. These areas included falls which represent the most common injuries followed by transport accidents and more than half of deaths were due to transport accidents. Most common cause of admissions in extremes of age less than 15 years and more than 49 years were due to falls and the age group in between were due to transport accidents. The most body regions affected by injuries among deaths were the head and chest. This is important in fashioning effective preventive programs.

Young adults aged 20-29 years have the majority of injury admissions, followed by age group 5-9 years. The age distribution indicates that most admissions were below the age of 30 years (58.4%). This is similar to other studies conducted in Egyptian injury surveillance 2009 report and other studies in South Africa and in Nigeria.[4,10,11] This provides the evidence that age 20-29 years is an important group at risk for injuries, as they are usually very active and mobile and often constitutes a great percentage of the economic force.

In this study, the hospitalized injuries of the group aged more than 50 years represent 20.3% of total admission, which was more than the reports of other studies.[11,12,13]

Hospitalization rate of patients aged more than 70 years was the lowest among total admissions. This finding was not in concordance with USA study where older adults had much higher rates of hospitalization for injury than persons in other age groups throughout the 1988-2005 periods.[14] This may be due to the different population age structure in developing countries.

In the present study, the hospitalized males to females’ ratio were 3:1. Males are more likely than females to be involved in violent activities and motor vehicle crashes and often sustain more severe injuries compared to females. Consequently, mortality sex ratio among admissions in this study was the same ratio. Similar findings have been noted in other studies.[15,16,17]

This study showed that falls were the most common injury admissions, followed by transport accidents and exposure to inanimate mechanical forces. This agrees with the Egyptian injury surveillance report 2009 at which falls were ranked as the first leading cause of injuries in 2009.[4]

This finding varies with a study in Nepal which concluded that road traffic accident was the first cause of injury followed by falls.[15]

In the present study, exposure to inanimate mechanical forces was the third cause of hospitalization. This agrees with studies in India and Canada.[18,19] They show that it was the third most common cause of injury admissions while in Maryland study in USA, exposure to inanimate mechanical force was the fourth cause of hospitalization.[20]

In this study, interpersonal violence was the fourth cause of injury admissions. This agrees to some extent with a study in Nepal showed that interpersonal violence was one of the major causes of morbidity.[15] In addition, gunshot injuries comprise 3% of hospitalized injuries, which was much lower than what was found in Nigeria (15.8%).[8] This in turn indicates the need for promoting violence reduction programs in the community by greater awareness at the family and interpersonal levels.

Exposure to animate mechanical forces was the sixth cause of admissions in this study, while in the Egyptian injury surveillance 2009 report and other study in Indiana State in USA revealed that animal bite was the fifth cause of injuries.[4,21]

In this study, only three self-inflected injuries were hospitalized in Trauma Unit, two cases in 2002 and one case in 2007. This is due to cultural and social pressures to keep violence behind closed doors. Due to the medico legal aspect and social stigma, suicide has always been concealed in western societies. So underreporting and misclassification in official reports are expected consequences. This very low number is not in concordance with what was shown in India and Nepal.[12,15]

Among hospitalized injury cases, death rate was 3.9 deaths/100 admitted cases; the decrease in hospital mortality rate from 2002 to 2009 may indicate an improvement in the health care level. With mortality more than 50/100 admitted cases due to transport accidents; this is an indicative of a rising problem with high severity injuries.

Deaths among hospitalized injury cases aged 15-40 years comprised a rate of 42.6/100 hospitalized cases, (13.1) among those aged 20-29 years. This age group constitutes a greater percentage of the nation's economic work force, which requires special attention. This evident finding is in concordance with the Egyptian injury surveillance 2009 report and WHO 2002 report[4,22] the same was found in other studies.[11,23,24]

Transport accidents were the first cause of deaths among the hospitalized cases with more than 50% in our study; same finding was shown in other studies.[11,23,24]

In 2004, road traffic injury was the sixth leading cause of death in the Eastern Mediterranean Region. Egypt has the highest road traffic injuries fatality rate in the Eastern Mediterranean Region.[25] Globally road traffic injuries are predicted to become the fifth leading cause of death by 2030.[26]

Falls as a cause of deaths occupied the second cause of death throughout the study period. This may be referred to that falls was the first cause of admissions in extremes of age less than 15 years old and more than 49 years old. In USA, death rates from falls have also started to increase rapidly. However, motor vehicle traffic death rates declined from the mid-1980s to the mid-1990s before stabilizing.[14] This is due to the injury preventive measures taken in developed countries and not well-practiced in developing ones to prevent falls. This is not in concordance with the Egyptian injury surveillance report 2009; falls was the fourth cause of injury deaths.[4] In other study in Indiana State, falls were the third leading cause of unintentional injury deaths for Indiana residents.[21]

In the present study interpersonal violence was the third cause of deaths, this agrees with two study results, in USA and in Nepal.[14,15] Gunshot injuries was the third leading cause of death then became the fourth with interpersonal violence in 2007-2009 while reports from Nigeria and other studies have shown that gunshot injuries were the second cause of trauma deaths.[11,27] This can be explained by that Egypt was the lowest in the proportion of injury deaths attributed to intentional injuries (violence) among low and middle income countries in the african region.[28]

In the present study, exposure to inanimate mechanical forces was the fourth cause of death, which is earlier than its ranking as the seventh cause in Maryland study in USA.[20] This may be due to the presence of well-practiced preventive measures and good medical care in USA than in Egypt.

In the present study, the most body region affected by injuries among deaths was the head as shown in Nigeria and in USA.[11,14]

The chest was the second most common traumatized part of the body among deaths, followed by the lower limb and abdomen. This pattern also has been reported in other studies.[11,16,17]

Trauma to the head and chest region often are very severe and tend to cause death more than injuries to other body regions. Prehospital, early presentation and prompt management of head, chest and abdominal injuries could minimize the mortality associated with such injuries.

Aggregation of data for 8 years had given a clear and actual data about the admitted injury cases and deaths as a public health problem at this big Trauma center in Upper Egypt.

Furthermore, the aggregation of the 8 years data in this big trauma care center had given a reliable prediction about the real pattern and areas of priorities for attention. Our study had some limitations. First in the current study admitted poisoning, drowning and burn injuries were not included in the study, because they are not admitted in the Trauma Unit, but in the emergency room of internal medicine and burn casualty center.

CONCLUSION

Road traffic injuries, falls and violence are areas of priority in policy making of preventive integrated activity strategies by intersectoral approach according to this realistic situation. This is a national priority for reduction of injury morbidity and mortality. Paying special attention for young adults as a group at risk for injuries and related deaths is recommended.