O r i g i n l A r t i c l e Singpore Med J 2005; 46(5) : 219 Accident nd Emergency Medicine School of Medicl Sciences Universiti Sins 16150 Kubng Kerin Kot Bhru H C Chn, MBBS, MMed Physicin W A W Asim, MBChB, MMed Hed Anesthesiology N M Abdullh, MD, Dip Eur Anesth Associte Professor nd Hed Biosttistic nd Reserch Methodology Unit N N Ning, MBBS, PhD Associte Professor nd Hed Neurosciences J M Abdullh, MD, PhD, FACS Professor nd Hed Neurosurgery Institute Kji srf dn Otk Tengku Abdul Rhmn Hospitl Kul Lumpur Jln Phng Kul Lumpur M H M Sffri, MD, Dip Neurosurg Hed Accident nd Emergency Medicine Hospitl Ipoh Jln Hospitl Ipoh, Perk A Osmn, MD, MMed Hed Correspondence to: Prof Jfri Mlin Abdullh Tel: (60) 9766 4240 Fx: (60) 9764 8613 Emil: deptneuro sciencesppspusm@ yhoo.com Chrcteristics nd clinicl predictors of minor hed injury in children presenting to two n ccident nd emergency deprtments H C Chn, W A W Asim, N M Abdullh, N N Ning, J M Abdullh, M H M Sffri, A Osmn ABSTRACT Introduction: Peditric minor hed injuries (MHI) re just s common in both bigger nd smller towns in. Urbn-bsed MHI re due more to motor vehiculr injuries compred to rurl-bsed MHI which re minly due to non-motor vehiculr injuries. The min objectives of this study were to compre incidence of dmitted ptients to ccident nd emergency deprtments of hospitls in two different settings in, nmely: Ipoh (urbn-bsed) nd Kot Bhru (rurl-bsed); nd to correlte to demogrphicl chrcteristics, types of ccident, clinicl signs nd symptoms, rdiologicl nd computed tomogrphy (CT) findings, mngement; nd finlly, to determine clinicl predictors of intrcrnil injury in MHI. Methods: A cross-sectionl study of 153 peditric ptients ged 2-18 yers who were dmitted to the Ipoh Hospitl, Perk nd 112 ptients of the sme ge group dmitted to Hospitl Universiti Sins, Kelntn were included in this study. The study period ws between 1 Jnury 1998 nd 31 December 2001. Dt collection ws done prospectively. Chi-squre nd independent t-tests were pplied to compre chrcteristics of ptients dmitted to these two hospitls. Bckwrd stepwise multiple logistic regression ws pplied to determine clinicl predictors of intrcrnil injury. Results: There were significnt differences of ge, rce, types of ccidents, clinicl signs nd symptoms, Glsgow com scle (GCS), skull frcture nd CT findings between two hospitls. Significnt clinicl predictors were hedche (OR 20.8, 95 percent CI 3.9-25.2, p-vlue is less thn 0.001), unequl pupils (OR 8.4, 95 percent CI 4.3-17.9, p-vlue is equl to 0.0413) nd GCS score of 13 (OR =3.8, 95 percent CI 1.9-6.8, p-vlue is equl to 0.005). Skull frctures nd intrcrnil injuries were more common in Kot Bhru due to children riding motorcycles without helmets thn in Ipoh (p-vlue is less thn 0.001). Conclusion: In the rurl n community, both the police nd physicins must be lerted to the fct tht unhelmeted children riding motorcycles re more likely to sustin morbidity thn those in urbn res. More ggressive trffic policing of the villge rods should be done by the relevnt uthorities. Keywords: childhood injury, crniocerebrl trum, emergency medicine, hed injury, minor hed injury Singpore Med J 2005; 46(5):219-223 INTRODUCTION The Americn Acdemy of Peditrics (AAP) defines children with minor hed injury (MHI) s those who hve norml mentl sttus t the initil exmintion, who hve no bnorml or focl findings on neurologicl exmintion, nd who hve no physicl evidence of skull frcture (1). MHI is usully tken s Glsgow com scle (GCS) of 13 to 15. Within this group, there is heterogeneous pthophysiology rnging from miniml intrcrnil pthology to n evolving intrcrnil bleed requiring neurosurgicl intervention. Approprite mngement of peditric MHI in developing countries includes prepredness to recognise nd to tret the neurologicl deteriortion nd potentil complictions. The objectives of this study were to compre chrcteristics of ptients with MHI presenting to two different ccident nd emergency deprtments in two different sttes of, nd to determine clinicl predictors tht ffect children who were dmitted with MHI defined by the AAP. METHODS A cross sectionl study ws conducted from 1 Jnury 1998 to 31 December 2001 on ll peditric ptients with MHI following the criteri set by the AAP. The Accident nd Emergency (A&E) of Ipoh Hospitl oversees nerly 100,000 cses per yer with brekdown of 70% medicl- nd 30% surgicl-bsed ptients, respectively. Of these, nerly 5% re neurotrum cses. The other A&E deprtment
Singpore Med J 2005; 46(5) : 220 Tble I. A comprison of chrcteristics of ptients with minor hed injury between those who were dmitted to two different hospitls. Chrcteristics Hospitl Test sttistics p-vlue Ipoh (n=153) HUSM (n=112) Age b 6.1 ± 3.4 15.7 ± 1.7 27.50 <0.001 c Sex d Mle 54 (35.3) 32 (28.6) 1.33 0.248 Femle 99 (64.7) 80 (71.4) Rce e Mly 84 (54.9) 108 (96.4) 58.21 <0.001 Chinese 28 (18.3) 3 (2.7) Indin 40 (26.1) 0 (0.0) Others 1 (0.7) 1 (0.9) Type of ccident e Fll 71 (46.4) 4 (3.6) 131.01 <0.001 Hit/ssult 17 (11.1) 8 (7.1) Pedestrin 28 (18.3) 9 (8.0) Pssenger 10 (6.5) 5 (4.5) Bicycle 17 (11.1) 6 (5.9) Motorcycle 10 (6.5) 80 (71.4) level of significnce _ = 0.05; b men ± SD; c t-test for two independent smples; d frequency nd percentge (in prenthesis); e chi-squre test. bsed in Hospitl Universiti Sins (HUSM) oversees 30,000 ptients of which 89% re mediclnd 11% surgicl-bsed, respectively. 2.5% of these re neurotrum ptients. Inclusion criteri included isolted closed peditric hed injury, mechnism of injury witnessed by second or third prty nd leglly reported to the police, symptoms of hed injury, initil GCS of 13 or higher on ccident site which improved to 15 on dmission t the A&E deprtment or ny helthcre professionl fcilities, norml mentl sttus before incident, nd no bnorml or focl finding on neurologicl exmintion seen cutely within 24 hours of injury in the A&E deprtment by n ccident nd emergency physicin or neurosurgeon. The exclusion criteri included ptients ged younger thn two yers nd older thn 18 yers, history of bleeding ditheses or neurologicl disorders potentilly ggrvted by trum, multiple trum, intentionl hed trum, nd speech disturbnces. Clinicl prmeters studied include progressive loss of consciousness nd new neurologicl deficits fter dmission, seizures nd hedche. Rdiologicl fetures ssessed on computed tomogrphy (CT) were: evidence of skull vult nd bse frctures s well s intrcrnil injury. Both clinicl nd rdiologicl prmeters were correlted to neurosurgicl intervention. All peditric MHI ptients ged 2-18 yers dmitted to the A&E deprtments in Hospitl Ipoh, Perk (n=153) nd Hospitl Universiti Sins (HUSM), Kelntn (n=112) were selected for this study fter prentl consent nd, for the ltter group, pprovl of the Universiti Sins ethicl committee. Chi-squre test ws pplied to identify difference of proportions of prmeters between two hospitls. The level of significnce ws set t 0.05. Bckwrd stepwise multiple logistic regression ws pplied to determine clinicl predictors of intrcrnil injury. Sttisticl Pckge for the Socil Sciences (SPSS) softwre version 11.0 (Chicgo. IL, USA) ws used in the dt nlysis. RESULTS In the Ipoh study, there were 54 boys (35.3%) nd 99 girls (64.7%) mong the peditric hed injury ptients. The mjority of ptients in this study were Mlys (84; 54.9%), followed by Indins (40; 26.1%), nd Chinese (28; 18.3%). The ptients in HUSM hospitl consisted of more Mlys (p<0.001). The men ges of ptients dmitted were 6.1 (± 3.4) yers for Ipoh Hospitl nd 15.7 (± 1.7) yers for HUSM (p <0.001). Sex distribution ws similr for both hospitls (p=0.248). Motor vehicle ccident ws the most common cuse of MHI for both hospitls,
Singpore Med J 2005; 46(5) : 221 Tble II. A comprison of clinicl new signs nd symptoms occurring fter dmission, CT findings nd mngement between children with minor hed injury dmitted to two different hospitls. Chrcteristics Hospitl Test sttistics b p-vlue c Ipoh HUSM New episode of Loss of consciousness 92 (60.1) 107 (95.5) 35.44 <0.001 Vomiting 63 (41.2) 28 (25.0) Hedche 10 (6.5) 34 (30.4) Seizures 5 (33.3) 2 (1.8) Neurologicl deficits 1 (0.7) 8 (7.1) Unequl pupil 2 (1.3) 4 (3.6) ENT bleeding 11 (7.2) 8 (7.1) GCS fter dmission with MHI 15 35 (22.9) 73 (65.2) 52.51 <0.001 14 49 (32.0) 25 (22.3) 13 69 (45.1) 14 (12.5) Skull frcture seen on CT Norml 58 (37.9) 96 (85.7) 78.26 <0.001 Liner 78 (51.0) 5 (4.5) Depressed 15 (9.8) 4 (3.6) Bse of skull 2 (1.3) 7 (6.3) Intrprenchyml CT findings d Intrcrnil injury 31 (20.3) 22 (62.9) 25.53 <0.001 No intrcrnil injury 122 (79.7) 13 (37.1) Mngement Observtion 145 (94.8) 104 (92.9) 0.42 0.518 Neurosurgicl intervention 8 (5.2) 8 (7.1) frequency nd percentge (in prenthesis); b chi-squre test pplied; d ptients who were not done for CT in HUSM were excluded from the nlysis (n=77); d level of significnce α=0.05 with flls nd hit/ssult producing MHI in some ptients (p<0.001) (Tble I). Progressive loss of consciousness fter dmission ws the mjor clinicl symptom in ptients dmitted to HUSM, followed by hedche, vomiting nd seizures (p<0.001). More ptients with MHI t HUSM hd GCS of 15 tht did not deteriorte, compred to the hospitl in Ipoh (p<0.001). More rdiologicl skull frctures seen on CT were reported mong ptients in HUSM. More intrcrnil injuries were reported in these HUSM ptients who proceeded to progressive decrese in GCS (p<0.001). These ptients hd more intrcrnil contusions (80%), intrventriculr bleeds (10%), subrchnoid bleeds (5%) nd extrdurl hemtoms (5%). Mngement ws similr in the two hospitls (p=0.518) (Tble II). No clinicl predictors could be determined for ptients with MHI t HUSM, while hedche, unequl pupils nd decresing GCS score were significnt predictors of more serious MHI mong ptients dmitted to Ipoh hospitl. Ptients who hd more serious MHI in the Ipoh hospitl hd lmost 21 times higher probbility of hving hedche (OR=20.8, 95% CI 3.9-25.2) (p<0.001). Ptients with MHI nd intrcrnil bleeds hd 8 times higher probbility of hving unequl pupils thn those who hd norml CT findings (OR=8.4, 95% CI 4.3-12.9, p=0.043). Those with MHI nd intrcrnil bleed hd nerly 4 times higher probbility of hving GCS score of 13 fter dmission rther thn 15, thn those who hd norml CT findings ( OR=3.8, 95% CI 1.9-6.8, p=0.005) (Tble III). There were no significnt ssocition between motorcycle ccidents nd skull frcture (OR=0.29, 95% CI 0.1-1.1, p=0.075) shown by Fisher s exct test. There ws lso
Singpore Med J 2005 Vol 46(5) : 222 Tble III. A comprison of new clinicl predictors between children fter dmission with minor hed injury dmitted to two different hospitls. Clinicl predictors Ipoh HUSM Progressive loss of consciousness Vomiting Adjusted p-vlue b Adjusted OR p-vlue b OR (95% CI) (95% CI) Conscious 1 c 0.576 1 0.949 Not conscious 1.3 (0.8-2.1) 1.9 (0.6-4.5) No 1 0.361 1 0.613 Yes 1.4 (0.5-7.0) 0.58 (0.07-4.85) Hedche Seizures No 1 <0.001 1 0.072 Yes 20.8 0.74 (0.09-5.69) (3.9-25.2) No 1 0.988 1 0.952 Yes 0.9 (0.6-3.8) 0.1 (0.0-32.5) Focl neurologicl deficit No 1 0.056 1 0.213 Yes 2.5 (1.0-5.2) 0.1 (0.0-4.0) Unequl pupil Equl 1 0.043 1 0.967 Unequl 8.4 (4.3-12.9) 0.9 (0.0-22.9) ENT bleeding GCS No 1 0.167 1 0.861 Yes 2.4 (0.6-5.6) 3.6 (0.8-18.2) 13 3.8 (1.9-6.8) 0.005 0.8 (0.1-7.7) 0.833 14 1.9 (0.8-5.1) 0.24 5.6 (0.3-21.2) 0.229 15 1 Multiple logistic regression (bckwrd stepwise); b Wld s test; c Reference ctegory no significnt ssocition between motorcycle ccidents nd CT findings (OR=1.1, 95% CI 0.3-4.5, p=0.886). DISCUSSION Hed trum is one of the most common childhood injuries. Annully, they ccount for more thn 500,000 emergency visits, 95,000 hospitl dmissions, 7,000 deths nd 29,000 permnent disbilities. Hospitl cre costs lone exceed $1 billion nnully (5). Most ptients hve minor trum (5,6), nd while most of these injuries re significnt, MHI peditric ptients cn hve underlying intrcrnil injuries (7-11). The vilble reserch literture indictes tht few peditric ptients with minor hed trum require surgicl intervention. There re very few studies of MHI mong children in Asin developing countries (12-18). A study from Pkistn indicted tht there were 52% ptients out of totl of 260,000 who hd MHI over period of four yers. Of these, 57.2% were children (12). Other studies in developed North Asi reveled high incidence of MHI ssocited with motorcyclists in dults (13) nd children (14). Most children were in the 15-17 yers old ge group, with lrger mle rtio. Those in the younger ge group (younger thn 9 yers) were pedestrins, nd those older thn 14 yers were motorcyclists. Those between 10 nd 14 yers of ge hd MHI for
Singpore Med J 2005; 46(5) : 223 flls during sports, ply, or from their bicycles. About 76% (n=624) of these ptients hd MHI. Another detiled study of injuries in Tiwn reveled tht unhelmeted riders of motorbikes contributed to MHI, especilly mong children, compred to bicyclists or pedestrins (15). One study found tht MHI nd their predictors were nonrndom nd more likely to occur in certin types of younger individuls under certin circumstnces (17). Differences between city study nd country study on hed injuries reveled tht more dolescents hd motorcycle ccidents in the country res, wheres pedestrins were minly children who fell victims to MHI in the city (16,18). Even in the United Sttes of Americ in 1996, only 18% of motorcyclists in generl were helmeted, nd more unhelmeted victims sustined hed nd spine injuries (19). Our study ws done to compre the type of ccidents involving children in two cities, one in the mid-west (Ipoh) nd the other in the north est (Kot Bhru) of Peninsulr. Ipoh, more developed city with better rods nd highwys, ws presumed to hve more children involved in motor vehicle nd pedestrin collisions on these rods. The Kot Bhru group ws expected to hve more ccidents involving ungzetted rods in villges becuse of the poor development of lrger highwys nd bigger trunk rods in this stte. We lso presumed tht the more finncilly better-off Ipoh popultion would be driving their children to school in their own crs or using school buses. The less developed stte of Kelntn nd its cpitl city, Kot Bhru, with lrger low income popultion, would be using motorcycles insted of crs or school buses to trnsport their children to school or to trvel. Interestingly, lrge number of children of erly dolescence were illeglly driving these motorcycles themselves, since the ge llowed for obtining motorcycle or cr license is 16 yers nd 17 yers of ge, respectively, in. In our study, greter numbers of younger dolescents were involved in the HUSM group compred to the Ipoh group. Motorcycle ccidents resulting in MHI mong children ged 2-18 yers comprised 13 out of 167 MHI (7.8%) in Ipoh Hospitl, compred to 131 out of 215 MHI (60.9%) in HUSM (p<0.001). In conclusion, our study dt indictes tht in rurl res of, the rod trffic council of tht respective town or stte my need to concentrte on villge rods where ccidents occur. Young dolescent children need specific eduction both in schools nd colleges in order to prevent motorcycle ccidents. Techers nd rod trffic uthorities ply big role to educte young dolescents in the right ttitude of not riding motorcycles unless they hve pssed their licence. Control of rod trffic ccidents in both urbn nd rurl towns re different, nd it is thus the responsibility of ll governmentl nd non-governmentl orgnistions to prevent further ccidents from occurring. Specific mesures to educte the public t lrge nd relevnt institutions must be mde priority so s to decrese the rtes of MHI ssocited with motorcycle ccidents. REFERENCES 1. 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