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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 12
| Issue : 3 | Page : 191-195 |
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Clinical profile of pediatric head injury
Aashay S Nitnaware, Jayant Vagha, Revat Meshram
Department of Paediatrics, Jawaharlal Nehru Medical College, DMIMS (Deemed to be University), Sawangi (M), Wardha, Maharashtra, India
| Date of Web Publication | 2-Feb-2018 |
Correspondence Address:
Dr. Aashay S Nitnaware
C/o JNMC, Sawangi (Meghe), Wardha - 442 004, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_83_17
Introduction: Head injury in pediatrics is considered to be a major health problem that is a frequent cause of death and disability and makes considerable demands on health services. In developing countries accident rates in general and traumatic brain injury (TBI) in particular are increasing as traffic increases besides other factors such as industrialization, falls, and ballistic trauma. Aim: The aim is to study the clinical profile of children with head injury. Objectives: (I) Study the etiology of head injury in children >16 years admitted in our hospital. (II) Study the clinical course and management of patients during the hospital stay. Materials and Methods: Place of Study: AcharyaVinobaBhave Rural hospital, Sawangi, Wardha. Study Design: Prospective observational study. Study Duration: July 1, 2015–June 31, 2016. Sample Size: Fifty. Result: As per my survey, fall from height as the most common cause of pediatric head injury with male predominance, followed by road accidents various other. The most common lesion seen on computed tomography scan was an extradural hematoma, and frontal lobe being the most common site. Conclusion: TBI in rural areas is mostly among the young male population and is increasing every year with majority coming from nearby villages which is very alarming and highlights the need for taking urgent steps for establishing good prehospital care and provision of trauma services at site in India.
Keywords: Convulsion, Glasgow Coma Scale, head injury
How to cite this article:
Nitnaware AS, Vagha J, Meshram R. Clinical profile of pediatric head injury. J Datta Meghe Inst Med Sci Univ 2017;12:191-5 |
| Introduction | |  |
Head injury is considered as a major health problem that is a frequent cause of death and disability and makes considerable demands on health services. In developing countries, accident rates in general and traumatic brain injury (TBI) in particular are increasing as traffic increases besides other factors such as industrialization, falls, and ballistic trauma. Head injuries account for one quarter to one-third of all accidental deaths, and for two-thirds of trauma deaths in hospitals.[1]
TBI is commonly used as synonym for the head injury, acquired brain injury, and brain injury.[1] It is a common occurrence in the pediatric population and accounts for the largest cause of acquired disability in childhood.[2] The field of pediatric head injury is broad and versatile. Recommendations and opinions are deviating and proposed management regimes are not always optimal or easily applied.
The study focuses on understanding the etiology, clinical presentation, treatment options, and outcome of these patients and to strengthen these aspects further with preventive issues and imparting health education.
| Materials and Methods | | |
Place of study
AcharyaVinobaBhave Rural hospital, Sawangi, Wardha.
Study design
Prospective observational study.
Study duration
July 1, 2015–June 31, 2016.
Inclusion criteria
Children (under 16 years of age) presenting with head trauma between July 1, 2015 and June 31, 2016.
Sample size
Fifty.
Methodology
Study was started after obtaining the permission from ethical committee of the hospital. Informed consent was obtained from the parent/guardian/relative of the patient.
Clinical characteristics
A detailed clinical history will be obtained from the parents/guardian/relative admitted in the hospital with head injury.
A detailed clinical examination was performed on the patient and data acquired after taking the permission from the HOD of the concerned department, was entered in a predesigned validated pro forma.
The result of blood investigations and neuro-imaging studies was entered in the pro forma. Clinical course and immediate outcome (death or discharge) were noted.
Analysis
Statistical analysis was performed using the collected data on incidence and clinical– radiologic correlation.
Analyses included the age and gender distribution of the children, the cause and location of the injury, medical status, the part of the head injured and type of injury, and the treatment provided. A comparison of types of head injuries sustained by gender, age, and cause was also carried out.
| Observations and Results | | |
[Table 1] shows severity of head injury by physical examination (Glasgow Coma Scale [GCS]), total number of cases were 50 of which 41 (82%) had mild head injury (i.e., GCS more than 13), and remaining 9 (18%) (i.e., GCS between 9 and 12) had moderate head injury and none of them had severe head injury (i.e., between 3 and 8). Ratio of mild head injury to moderate head injury was 4.5:1.
[Table 2] shows sex-wise distribution of mild to moderate head injury. Out of 50 children, 35 (70%) were male and 15 were female (30%) at ratio of 2.33:1 (M:F), of which 41 children (82%) had mild head injury and 9 (18%) had moderate head injury, none of the children had severe head injury. In mild head injury, out of 41 children, 29 (70.7%) were male and 12 (29.3%) were female, at ratio of 2.4:1 (M: F). In moderate head injury, 6 (66.6%) were male and 3 (33.3%) were female at ratio of 2:1 (M: F).
[Table 3] shows age-wise distribution according to the severity of head injury. Age-wise distribution was done into 3 groups. First group (n = 29) comprises of children up to 5 years of age in which 25 (86.2%) children had mild head injury and remaining 4 (13.8%) children had moderate head injury. Second group (n = 16) comprises of children from 6 to 10 years of age in which 13 (81.25%) had mild head injury and 3 (18.75%) had moderate head injury. third group (n = 5) comprises of children from 11 to 16 years of age in which 3 (60%) had mild head injury and 2 (40%) had moderate head injury.
[Table 4] shows incidence of location according to the severity of head injury. Out of 50 children, 28 (56%) children had head injury at home from which 23 (82%) had mild head injury and 5 (18%) had moderate head injury. Remaining 22 children had head injury outside their home in which 18 (81.81%) children had mild head injury and 4 (18.18%) children had moderate head injury. Ratio of head injury home to outside home was 1.27:1.
[Table 5] shows mode of head injury and their severity. Maximum number of cases (n = 28) (56%) of head injury were due to fall from height, of which 23 (82.14%) had mild head injury and 5 (17.86%) had moderate head injury followed by head injury due to road traffic accident (RTA) (n = 17) (34%) in which 13 (76.47%) had mild head injury and 4 (23.53%) had moderate head injury and remaining 5 (10%) children had head injury due to hit by some object and all of them had mild head injury. Ratio of fall from height to RTA to hit by some object was 5.6:3.4:1.
[Table 6] shows different sites of head injury in which most common site is frontal region (n = 23) (46%) with 19 (82.6%) children had mild head injury and 4 (17.4%) children had moderate head injury, followed by face (n = 11) (22%) with 9 (81.8%) had mild head injury and 2 (18.2%) children had moderate head injury, followed by temporal site (n = 9) (18%) with 7 (77.8%) children had mild head injury and 2 (22.2%) children had moderate head injury, followed by occipital (n = 6) (12%) had mild head injury, remaining 1 child had head injury in the parietal region which was mild.
[Table 7] shows different symptoms in head injury in which 22 (44%) children had convulsion of which 14 (63.6%) had mild head injury and 8 (36.4%) children had moderate head injury. 9 (18%) children had vomiting of which 7 (77.8%) children had mild head injury and 2 (22.2%) children had moderate head injury. Children with ENT bleed were 7 (14%) of which 3 (428%) children had mild head injury and 4 (57.2%) children had moderate head injury.
[Table 8] shows abnormal findings of computed tomography (CT) scan in which 4 (50%) children were found to have skull fracture in which 3 (75%) children were found to have moderate head injury and 1 (25%) children found to have mild head injury. 3 (37.5%) children found to have extradural hematoma, all were having moderate head injury, and 1 child found to have intraventricular bleeding with moderate head injury. Out of 22 normal CT study, 2 found to have moderate head injury. These values are statistically significant (P = 0.0005).
[Table 9] shows duration of hospital stay after head injury which were divided into 3 groups. First group comprises of stay up to 3 days (n = 29) (58%) in which 27 (93.1%) children found to have mild head injury and 2 (6.9%) children found to have moderate head injury. Second group comprises of stay from 4 to 7 days (n = 14) (28%) in which 12 (85.7%) children found to have mild head injury and 2 (14.3%) children found to have moderate head injury. Third group comprises of stay more than 7 days (n = 7) (14%) in which 5 (71.4%) children found to have mild head injury and 2 (28.6%) children found to have moderate head injury. These values are also found to be statistically significant (P = 0.0003).
[Figure 1] shows graphical presentation of incidence of head injury monthly wise, In which maximum number of cases were found in the month of May followed by July.
| Discussion | | |
In India, children between 1 and 16 years form about 35% of the total population.[3] Head Injury in infancy and childhood has been documented as the single most common cause of death.[4] Moreover, the modes of injury, the mechanisms of damage, and the management of specific problems differ significantly between the adult and pediatric populations.
Various studies on pediatric head injury have confirmed a male preponderance (70% of cases).[5],[6],[7],[8] However, Sambasivan [6] has reported an equal number of males and females in his series on pediatric head injury. Fall from height has been cited by most studies as the most common cause of pediatric head injury.[5],[6],[7],[8],[9],[10] This is followed by road accidents, assaults, sports injuries, and various other mechanisms like coconut injury.[6]
This study was carried out to analyze the clinical profile of pediatric head injury in relation to age distribution, sex, mode of injury, and types of injuries.
Our results are in accordance showing fall from height as the most common cause of pediatric head injury. This peculiarly occurs from unguarded rooftops while the child is playing. However, Osmond et al.[6] from Canada cites motor accidents as the most common cause. The most common lesion seen on CT scan was an extradural hematoma (EDH) and Fracture, whereas Mahapatra reports contusion as the most common. Seizure was seen in 28% of our children; a similar incidence has been reported by others also.[6]
This study found that in rural Vidarbha head injury mostly affects young boys, due to RTA. These injuries resulted in a spectrum of imaging features and expected pathology. Low Glasgow coma score at admission was significantly associated with mortality as an outcome. This report is similar to many other reports from urban India, and other parts of the world, as there is disproportionate burden of motor vehicle-related injury morbidity and mortality.[7]
It is important to understand the dynamics of RTA in rural India. Most vehicle ownership is in the urban areas, and those vehicles which are owned by rural population are typically low-speed such as tractors, two-wheelers, and cycles. However, a vast number of highways pass through rural and remote areas with extensive use of heavy motor vehicles travelling at high speed. Residential areas and highways are not segregated, and safety laws are not universally applied.
Many interventions (e.g., road lighting, traffic signals, guard railing, seatbelts, helmets, airbags, and antilock brakes) have also demonstrated success in more industrialized setting and are likely to be valuable in resource-constrained setting such as India.[8] For example, in the United States, the rate of motor vehicle-related TBI fatalities decreased substantially from 11.4/100,000 in 1979–6.6/100,000 in 1992.[8]
This decrease was largely attributed to an increase in seat belt and child safety seat use, standardized implementation of air bags, infrastructure investments, and improved safety engineering.[9] In India, vehicles, especially those designed locally; do not conform to international safety standards in materials or design (e.g., roll-over prevention or passenger ejection).[10]
There is a need to improve prehospital care to reduce morbidity and mortality.[11] Apart from safety laws, prompt transport to a hospital after an accident is another important measure to reduce mortality.[12]
The majority of patients in India are brought to the emergency department by relatives or bystanders in private vehicles, and prehospital emergency medical services remain under-organized. Field triage often relies on bystanders who transport injured victims to the nearest clinic, which is often unable to provide appropriate treatment.[13]
Major urban areas also have a loosely networked trauma system, untrained emergency medical services personnel, and unequipped ambulances.[14] Our observation of family and bystander transport supports the notion that prehospital care in rural India requires much improvement.
In addition, during each year of the study, TBI admissions experienced a bimodal peak, during the months of March to June and from October to November. These months coincide with the Vacation. However, there is further need to confirm this pattern as it would be useful to plan preventive strategies.
Children play in the streets, have less supervision of the parents and above all there is lack of safety measures in place where they play. Males predominate was also seen in our study also. The male:female ratio being 3:1. Most of the USA reports show an incidence ratio of 2.0 or more for males compared to females.[15]
One of the series of 672 patient had 533 male and 139 female patients.[16] Our observation corresponds with the observations made by other authors. The reason is that male child move out more frequently than female child.
Our results are in accordance showing age group 0–5 had most cases n = 29 (58%) cases, followed by 6–10 age group (n = 16) (32%) and in age group of 11–16, i.e., 5 cases (10%), similarly, in a recent study, Knudson et al. from India investigated TBI in children, found that most (55.5%) of these injuries were recorded in the youngest, 0–5 age group.[17] This is consistent with data reported from other studies, where the highest incidence of head trauma was found in the 6–10 age group.[17]
According to the Accident and Emergency Department data, the maximum is observed at age 10–16 age group.[18] Similar data have been reported by Bernat et al. from their study including 192 injured patients, of which the majority (90%) were in the 10–16 age group.[19]
Severe injuries of neurocranium are still less common in childhood heavy bleeding with hematoma (epidural bleeding, subdural bleeding, intracerebral bleeding, traumatic [subarachnoid hemorrhage]). According to Case's results, epidural bleeding is generally found in around 6% of all head injuries. Such bleeding is not common in the first 2 years of age because the dura is tightly connected to the inner side of the skull.[20] On the other hand, Hann et al.[10] analyzed found a history of epidural bleeding in 44% of intracranial bleeding cases.[21]
| Conclusion | | |
The study results are in accordance showing fall from height as the most common cause of pediatric head injury with male preponderance, followed by road accidents, assaults, sports injuries, and various other mechanisms, this peculiarly occurs from unguarded rooftops while the child is playing or rolled off bed.
The most common lesion seen on CT scan was an EDH and fracture, and frontal lobe being the most common site as children. May month have more cases of head injury, seizure was seen in 28% of our patients and limited to patients of mod head injury.
Falls form the most important cause of pediatric head injury and slight carefulness on the part of parents can help avoid disastrous consequences for the children.
TBI in rural areas is mostly among the young male population and is increasing every year with majority coming from nearby villages which is very alarming and highlights the need for taking urgent steps for establishing good prehospital care and provision of trauma services at site in India.
Recovery with minimal disability was observed in only approximately all of cases in this sample. Availability of good neurosurgical care is essential for these patients. A computerized trauma registry is urgent required to bring out the risk factors, circumstances, chain of events leading to the accidents and will be extremely helpful in policy making and health management at the national level in India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]
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