Gjergji Bizhga1,

Trauma University Hospital

Abstract

Background: Injuries are the fourth most common cause of death, after cardiovascular diseases, cancer, and respiratory diseases. Head trauma occur in 50% of cases in road injuries. Head and neck trauma results in a range of injuries, spanning minor lacerations to life-threatening airway compromise. The aim of the study was to give an the epidemiological overview of severe traumas in the head-neck region in Albania.

Material and methods: This cross-sectional study included patients with severe head and neck trauma and trauma  of ORL region who were hospitalized at Trauma University Hospital (TUH) in Tirana Albania over the year 2015.

Results: Overall, 1536 (10.5%) out of 14608 patients presented with head and neck injuries of whom 320 (20.8%) were hospitalized (320/1536).The mean age of 320 patients was 30.4 (19.4) years with a range 1-88 years. Median age is 35 years. Regarding the gender the vast majority of patients were males 232 (72.5%) and only 88 (27.5%) females (table 2). The most affected age group is ≤ 40 years with 64.7% of cases (p<0.01). Road injuries from automobile crashes rank first as the cause of traumas with 190 (59.4%) of cases (p<0.01), followed by cold weapons 31 (9.7%), gun-related injuries 6 (1.9%) and other causes 79 (24.7%).

Conclusion: These data have implications for head and neck injury surveillance and may be also used to risk-stratify patients who present with injuries in the acute care setting.

Key words: head and neck trauma, epidemiology

Introduction

A traffic collision, also known as a motor vehicle collision (MVC) among others, occurs when a vehicle collides with another vehicle, pedestrian, animal, road debris, or other stationary obstruction, such as a tree or utility pole. Traffic collisions may result in injury, death and property damage. A number of factors contribute to the risk of collision, including vehicle design, speed of operation, road design, road environment, and driver skill, impairment due to alcohol or drugs, and behavior, notably speeding and street racing. Worldwide, motor vehicle collisions lead to death and disability as well as financial costs to both society and the individuals involved.

Road injuries occurred in about 54 million people in 2013.[1] This resulted in 1.4 million deaths in 2013, up from 1.1 million deaths in 1990.[2] About 68,000 of these occurred in children less than five years old.[2] Almost all high-income countries have decreasing death rates, while the majority of low-income countries have increasing death rates due to traffic collisions. Middle-income countries have the highest rate with 20 deaths per 100,000 inhabitants, 80% of all road fatalities by only 52% of all vehicles. While the death rate in Africa is the highest (24.1 per 100,000 inhabitants), the lowest rate is to be found in Europe (10.3).[3]

Injuries are the fourth most common cause of death, after cardiovascular diseases, cancer, and respiratory diseases ne EU. Every two minutes one EU-citizen dies of an injury. For each fatal injury case, 25 people across the EU are admitted to hospital, 145 are treated as hospital outpatients and many more seek treatment elsewhere, e.g. by family doctors. Injuries due to accidents and violence are a major public health problem, killing more than 230 000 people in the EU-27 each year (annual average 2008-2010) and disabling many more. This means that each year a staggering 5.7 million people are admitted to hospital and 33.9 million people are treated as hospital outpatients as a result of an accident or violence related injury [ ]. Almost 55% of deaths occur in young people aged 15-44 and 75% of them occur in men rather than women. Road traffic trauma are the leading cause of death among young people aged 5-29 years. Trauma is the leading cause of deaths under the age of 45 years. Head trauma occur in 50% of cases in road injuries. Road Safety is a major societal issue. Although road fatalities represent a downward trend in 2014, more than 25000 people died on the roads of the European Union, i.e. the equivalent of a medium town. For every death on Europe’s roads there are an estimated 4 permanently disabling injuries such as damage to the brain or spinal cord, 8 serious injuries and 50 minor injuries. Accident –related trauma was almost unfamiliar to Albanians till 1990 when our country sought to escape its self-imposed isolation and started to open up to the world. The increased number of cars coupled with heavy traffic in the streets consequently brought an increase in road accidents, which in turn resulted in more seriously injured people and more traffic deaths. Even though there has been some improvement made in the road infrastructure, the level of accidents in our country is still very high and so is the number of deaths caused by these accidents. It is calculated that there have been  X (numri) accident-related deaths from 2006 to date. The aim of the study was to give an the epidemiological overview of severe traumas in the head-neck region in Albania.

Material and methods

This cross-sectional study included patients with severe head and neck trauma and trauma  of
Otorhinolaryngology (ORL) region who were hospitalized at Trauma University Hospital (TUH) in Tirana Albania over the year 2015. Post-traumatic damages often are of primary importance, but in many cases they are treated as a matter of secondary importance, since it is essential to first deal with the head trauma which implies that of the central nervous system.

The causes of trauma have been divided into five groups:

In the “Trauma from Automobile Crashes” group   we have included all the cases where automobile crashes were the ones which caused the trauma including the trauma on the driver, passenger, and pedestrian – caused by all types of vehicles.

In the “Trauma from work-related accidents” we have included all the trauma cases that were caused by an accident during work.

In the “Trauma from Gun-related injuries” group we have included all the trauma cases that were caused from firearms injuries.

In the “Cold weapon-related trauma” group, we have included all injury cases which are caused by sharp or heavy weapons.

In the “Trauma from other sources” group , we have included sport-related traumas, domestic or daily-related traumas.

Patients’ general information includes age and gender.

Statistical analysis

Data were analyzed using SPSS statistical package. Descriptive analysis was performed to characterize patient demographics and causes of trauma. Differences in proportions were assessed using chi-square and Fisher’s exact test. A p value ≤ was considered statistically significant.

Results

Overall, 14608 patients presented with different type of traumas during the study period. Table 1 shows the total number of trauma cases presented at emergency department.

Table 1. Total number of trauma cases presented at emergency department

Type of trauma Hospitalized n (%) Outpatients n (%) Total
No head and neck injuries 2191 16.8 10881 83.2 13072
Head and neck injuries 320 20.8 1216 79.2 1536
Total 2511 17.2 12097 82.8 14608

Overall, 1536 (10.5%) out of 14608 patients presented with head and neck injuries of whom 320 (20.8%) (95%CI 9.06-12.13) were hospitalized (320/1536).

Table 2. Sociodemographic characteristics and causes of trauma

Variables N (%)
Gender
  Males 232 72.5
  Females 88 27.5
Age-group (yr)
    ≤10 39 12.2
  11-20 42 13.1
  21-30 65 20.3
  31-40 61 19.1
  41-50 46 14.4
  51-60 33 10.3
  > 60 34 10.6
Cause of trauma
  Automobile crashes 190 59.4
  Cold weapons 31 9.7
  Work-related accidents 14 4.4
  Gun-related injuries 6 1.9
  Other causes 79 24.7

The mean age of 320 patients was 30.4 (19.4) years with a range 1-88 years. Median age is 35 years.

Regarding the gender the vast majority of patients were males 232 (72.5%) and only 88 (27.5%) females (table 2). The most affected age group is ≤ 40 years with 64.7% of cases (p<0.01).

Road injuries from automobile crashes rank first as the cause of traumas with 190 (59.4%) of cases (p<0.01), followed by cold weapons 31 (9.7%), gun-related injuries 6 (1.9%) and other causes 79 (24.7%).

The distribution of causes of trauma by gender is shown in table 3.

Table 3. Distribution of causes of trauma by gender

 Cause of trauma Males n (%) Females  n (%) p
Automobile crashes 138 72.6 52 27.4 < 0.01
Cold weapons 52 65.8 27 34.2 < 0.01
Work-related accidents 26 83.9 5 16.1 < 0.01
Gun-related injuries 10 71.4 4 28.6 < 0.01
Other causes 6 100.0 0 0.0 < 0.01

As noticed from table 3, there is a statistically significant difference between males and females regarding the cause of trauma.    

Discussion

A total number of 1536 patients presented to emergency department due to multiple traumas and all showed signs of damage in the Otorhino-laringology (ORL) region. 320 patients out of them were hospitalized and involved in this study.

The data at table 1 indicates that a total of 14608 patients showed up at the emergency department of TUH during the study period. 13072 or 90.5% of them had no head and neck injuries whereas 1536  patients revealed signs of damage in the ORL region and this number corresponds to a prevalence of 10.5% of all patients with trauma in general, whereas 320 patients were hospitalized, which in turn corresponds to a rate of 12.7% of all hospitalized patients. 320 (20.8%) patients with severe had and neck trauma were hospitalized, representing 12.7% of all patient hospitalized with trauma.

 The head to neck trauma was studied according to sociodemographic characteristics of patients andd patients. Table 3 indicates that male gender is dominant in comparison to the females for all causes of trauma. This indication is clearly observed in all trauma reports. All the data related to trauma in Albania is comparable to the data of other developed countries and especially U.S.A  regarding hospitalization, with about 16% of the total number of traumas, whereas the prevalence of injuries in ORL area is lower, 6.6%-7.8% of the total trauma cases [  ].

There were 320 hospitalized patients in total during a year, who have suffered from severe trauma due to different causes. The trauma in the head to neck area derived from automobile accidents ranks amongst the first in relation to all the other traumas in general and separately. Median age is 35 years old and this is an important indicator. It is observed that the young age of traumatized patients corresponds to all the statistical data on an international scale in regards to the trauma, Nowadays, trauma is ranked in the first place for all the hospitalized patients under 40 years old and all deaths that occur to patients under 45 years old. As far as gender is concerned 72.5% patients are males and 27.5% patients are females, with a significant statistical difference between them. This indicates that in general males are more affected from trauma and this is comparable to other international data. Trauma from automobile crashes is very important worldwide when seen from the social, economic and medical viewpoint. It is among the new problematic issues in Albania that has gradually increased with our country featuring a transition from isolation to integration. In the times before transition Albania was characterized by very little traffic and use of any vehicles was prohibited. We did inherit an infrastructure backwardness from the past and also we lacked in knowledge in the road and traffic signs. Due to this consequences have been catastrophic in relation to the automobile accidents, on one hand the number of accidents is increasing and on the other hand we lack in experienced medical staff on how to handle the trauma. All these specifications are not taken into consideration in our study. There are 190 cases or 59.4% cases of Traumas (in comparison to the total cases) from automobile accidents that are involved in this study. Based on the published data from the Ministry of Internal Affairs (General Directorate of Police), it is proven that the general number of the seriously injured people from automobile crashes is 392 people, out of who 314 or 80.1% are males and 78 or 19.9% are females [ ]. In our country, as opposed to other ex-communist countries and especially those of European Union, the trend of road traffic accidents has steadily increased since 2007- 2015 even though there are significant improvements made in the road infrastructure. According to the World Bank, Albania ranks as one of the countries with high incomes, but in relation to the accidents this indicator belongs to the countries with low or medium income. There have been 190 trauma cases treated at National Trauma Center (all of these in the head to neck area), or 48.4% of all seriously injured people from automobile accidents for the chosen year for the study purpose. This data matches with other international data where head and neck injury is regarded as the cause of about 50% of automobile crashes. Since heavy traumas in the head to neck area areas are only treated at TUC, it is proven that from 392 seriously injured patients (as per police records), 190 patients are treated at TUC or just 48.8% of the total cases. Even this study indicates that the head to neck traumas count for more than 50% of the injuries from road accidents. Median age of patients in this category is 36 years old. It is observed that 25% of the patients are younger than 22 years old, whereas 75% of them are younger than 50 years old. The most common age group is that of 20 years old. Based on the statistical data of the successive years, it is clearly seen that the number of accidents has steadily increased resulting in serious injuries or deaths, even though there have been major improvements in the infrastructure. The cause is believed to be a tendency in not following traffic rules from the drivers, passengers and pedestrians. As far as gender is concerned 138 people (72.6%) are males and 52 people (27.4%) are females, with a significant difference by gender. This data corresponds with other epidemiological data published in the USA and Europe where it is reported that male gender is the one to be mostly involved in traffic accidents in 75-77% of cases. [ ]. Male gender is much more exposed to these risks and perhaps in our country it has its own peculiarities, but this indicator is more or less the same one worldwide. One of the main results that these data present is that the traffic accidents are ranked among the first causes to be associated with traumatic injuries in the ORL area. Comparing our research to a similar one carried out in the USA [  ] which involved 1042 patients with trauma in the facial area which implies the area under study, it was found that in 54% of these patients the trauma was caused due to traffic accidents. In Europe as well, road traffic accidents are the leading cause for 47-58% of trauma cases in the head to neck area, with males being affected twice as much as females. These data correspond with the findings in our study as well [ ]. In the case of road traffic accidents, injuries in the head to neck area make up 50% of the total cases and in 11% of road traffic accidents there are bone fractures in the ORL area. Nowadays this trauma is predominant worldwide and it is ranked in the first place in relation to serious injuries, disabilities or deaths caused by traffic accidents (except in the war countries). Accident-related injuries depend on different type of mechanisms that are active during the accident, in which even though a patient does not have open injuries or fractures, that does not exclude the fact that there might be damage done to the endocrinal system or the cavitary organs in the ORL section. Or a patient that survives the accident, without any observed injury at first sight, can suffer a massive haemorrhage which can be threatening to his life or can lead to disability. Features of the  accident-related injuries result from a special mechanism where the final damages caused by the pressure of external forces are in correlation with the intensity of the force. Having a knowledge about all the physical factors involved in the damage, it is possible to understand the causation process, intensity and importance of the injury, and also prevent the consequences related to the acute phase response or during the healing process. The physical elements in the head to neck injuries imply a moving object that hits the patient while not moving or the opposite. It has been proven that when the head is in a loose position it suffers more injuries than when the head is in a fixed positionfor the same applied force. This fact is a main indicator of the major importance of putting on safety belts and also shows that headrest is one of the important tools to prevent road accidents. Following  car collision, the kinetic energy of the system spreads up from the distortion and friction of the object. Human body tissues are weaker than the object which causes the injury and as a result they suffer a much bigger damage. During the crash, the tissues that suffer the injury have a critical stress limit, but in case the applied force exceeds this limit, then tissue deconstruction is observed. The impact and the internsity of the injury depends on: 1. The direction of traveling. 2. Magnitude of the force, 3. Tissue tolerance, 4. Spread up of the force. As above mentioned the median age is 36 years old, a very clear indicator that the road accident-related trauma affects young ages, and as it is detailed above the patients’ age mainly affected from these traumas is 20 years old. These data is comparable with those of developed countries in which the most affected age is < 35 years old. [  ]. This is mainly caused from not respecting traffic rules or from alcohool impairment.

Trauma in general and especially the trauma caused by road accidents are ranked among the first causes of illnesses for people under 40 years old, illnesses that start in an acute form and continue for a long time perhaps with detrimental health effects. It is vital for the trauma to be studied in comparison with age, since it takes the first place for age-related illnesses in the world’s literature. It has a bad impact on the personal aspect and social one, since it is very costly to be cured. In Albania part of the cure is paid for by the state and the remaining part from the individual himself or his family. What we mean by social impact is that trauma often requires a long rehabilitation or causes diability in the patient and this cost must also be paif from the society at large.

Conclusion

This study provides a landscape analysis of head and neck injuries in Albania. In 2015, there were over 14000 head and neck trauma that ranged in severity from minor lacerations to penetrating wounds. These injuries infrequently result in admission to a hospital and require intensive care treatment. These data have implications for head and neck injury surveillance and may be also used to risk-stratify patients who present with injuries in the acute care setting.

References

  1. Global Burden of Disease Study 2013, Collaborators (22 August 2015). “Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.”. Lancet (London, England). 386 (9995): 743– 800. doi:10.1016/s0140-6736(15)60692-4. PMC 4561509. PMID 26063472.
Freely accessible

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