‘Head injuries in Kashmir turning into epidemic’

Head injury is a global phenomenon and an unfortunate economic burden. About 5.5 million accidents/year occur worldwide with 1.2 million deaths annually and 3400 deaths per day. The incidence of head injury in low and middle-income countries is very high. In India, nearly 350 deaths occur due to motor vehicle accidents every day. In Indian sub-continent head injury leaves about 1 million survivors who require long-term rehabilitation. In Maharashtra, about 13 thousand people died of head injury in 2018 (HT,15-1-19) About 60 % of all head injuries are caused by motor vehicle accidents. Half of those who die due to head injury, do so within the first two hours of trauma caused by primary brain injury (brain injury at the time of the accident). Rest, die because of secondary brain injury attributed to progressive brain damage following the initial insult to the brain. 

Since SKIMS is a prime institution receiving a major chunk of head injury patients, we conducted a prospective study in the Dept. of Neurosurgery, Sheri – Kashmir Institute of Medical Sciences, to note the demographic and clinical pattern of patients with head injury who report to SKIMS. The period of study was from November 2017 to October 2018 (1-yr). We are reproducing some salient points from our study for the benefit of the community and are highlighting some deficiencies and omissions on part of the injured who would have had a better outcome had they adhered to protective measures.

A total of 1153 patients of head injury presented to SKIMS in this one year, and we classified them  as per the international scale [Glasgow Coma Scale (GCS)] as:

Mild: GCS 13-15, Patients are awake, and may be confused but can communicate and follow commands.

Moderate: GCS 9-12, Patients are generally drowsy to obtunded but not comatose. They can open their eyes and localize painful stimuli. They are at high risk of clinical deterioration and must be monitored carefully.

Severe: GCS 3-8, Patients are comatose, they do not follow commands. They have significant structural and metabolic brain dysfunction and are at high risk of secondary brain injury and deterioration.

As patients with mild head injury were not admitted and discharged with symptomatic treatment we included patients with moderate and severe head injury in our study. A total of 430 patients were enrolled which comprised 37% (430/1153) of total head injury patients.

Our observations included:

Road traffic accidents (RTAs) were a major cause of head trauma (52.32 %), followed by fall from height (27.44 %). Firearm injuries to head constituted 4.18 % of our cases (Table-1).

Males (73.3%) outnumbered females (27.7 %) by a ratio of 2.8:1. The maximum number of patients were in the age group 21-40 years (230, 53.48 %), while the least number of patients were in the extremes of age (0-10 years, (2.5 %); 61-80 years, (8.14 %). 

 Fall from walnut trees forms a special group of victims in the walnut season (October-November) owing to the slippery nature of the walnut trees and the lack of utilization of protective harnesses by the people involved.

Students  (37.9 %) formed the major chunk of the victims of traumatic brain injury. This is because the students, owing to their tendency for carelessness (not wearing helmets and seat belts, high-speed driving, lane-cutting, talking over mobile phones etc,) are more liable to get hurt. The laborers, due to unsafe working conditions (absence of protective harness, the absence of protective gear, unprotected heavy machinery etc.) also form a vulnerable group.

Two-wheeler riders (47.55 %) and pedestrians (33.34 %) were mostly hurt in RTAs. Pillion riders outnumbered the drivers, as the driver instinctively takes evasive action while the pillion is caught completely off the guard. The victims with protective helmets tend to have a less severe brain injury as compared to those not wearing helmets. The protective helmet is a major safety measure as was evident from our study (77.78 % cases of two-wheeler trauma without protective helmets). 

The maximum number of head injuries were from Srinagar 17.9% (77/430), followed by Anantnag 10.23% (44/430) and  Baramullah 9.53% (41/430). 

Majority of  RTAs occurred in the late afternoon and early night hours (12-18 hrs, 43.11 %; 18-24 hrs, 33.44 %); and towards the later part of the journey (76.39 %). This finding can be attributed to the fact that this time range corresponds to people returning towards homes with a corresponding increase in the fatigue level of drivers and the pedestrians, increased traffic, reduced attention and slowed reflexes of both drivers and the pedestrians. 

Among the four-wheeler victims, the majority were front seat occupants (66.66 %). The victims with protective seat-belts tend to have a less severe brain injury (GCS 9-12, 66.67 %) as compared to those not wearing safety seat-belts (GCS 3-8, 86.11 %).

Summer season showed a maximum incidence of head injuries with a peak in the month of July, 29.53% (127/430)

Firearm injuries form an important class of injuries in our valley. The morbidity and mortality associated are very high.

In our study, skull bone fracture (61.05 %) was the commonest head injury, followed by traumatic subarachnoid bleed (29.76 %), brain contusions ( 27.2 %), acute subdural hematomas (26.27 %) and extra-dural hematomas (22.27 %). Associated traumatic injuries were common and comprised mainly of fractures (46.5 %) of clavicle, spine, long bones and visceral injuries. 

A large proportion of patients (347/430, 80.70 %) presented to us after the golden hour, which is the first hour after receiving trauma. This depicts the poor pre-hospital management and slow transportation of these sick, potentially salvageable patients to the referral centers. 

We lost 112 patients, overall mortality of 26% (112/430).  It was 9.41% (24/255) for GCS 9-12 and 50.28% (88/175) for GCS 3-8. We had 78 patients with severe disability which prevented them from returning back to their pre-injury activities of daily lives. The total hospital stay (about 3-weeks), the intensive care unit stay and the total cost incurred on  patients with  head injury was much higher as compared to rest of the patients, a strain on our over-burdened health care system.

We concluded that:

1.    Road traffic accidents are the major cause of head trauma in Kashmir valley.

2.  Young, economically and socially valuable people are the major victims of traumatic brain injuries.

3.    Unsafe driving practices, especially among students and unsafe roads, are key-contributors of head injury.

4.  Helmets, seat belts, airbags play a major role in preventing and minimizing the damage caused during vehicular crashes.

5. Most patients do not reach  hospital within the golden hour.

6. Head injury is a drain on hospital resources and a major cause of prolonged bed occupancy.

7. Head injury is a PREVENTABLE cause of death.

We recommend:

To reduce the incidence of RTAs we have to convince people to use seat belts and crash helmets. Also raising the road safety standards, implementation of stricter traffic laws (in Goa about 7.7 lac people were fined for traffic violation in 2018, which constitutes about half the population of Goa, HT dated 15-1-19), road safety campaigns, as well as improvement in traffic signalization, will go a long way to lower the incidence of head injuries.  Trauma centers at district levels to tackle the patients of head injury in an effort so that golden hour losses do not occur. At the same time, protective grills at workplaces in factories and using protective harnesses and nets are vital for reducing falls.

Appropriately equipped and staffed ambulances should be kept available on key-points of the highways. Commercial vehicles and bus operators should be encouraged to carry first aid kit with them. 

Among the RTA group, 107 were two-wheeler riders, 45 were four-wheeler riders and 73 were pedestrian hits. 

The authors are working as Neurosurgeons in SKIMS, have a special interest in brain and spinal injuries, will be conducting Annual National Neurotrauma Conference and workshop in SKIMS in August 2019.

neurotraumaskims@gmail.com