Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 141 Emergency (2015); 3 (4): 141-145 ORIGINAL RESEARCH An Epidemiologic Study of Traumatic Brain Injuries in Emergency Department Vahid Monsef Kasmaei, Payman Asadi*, Behzad Zohrevandi, Mohammad Taghi Raouf Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran. *Corresponding Author: Payman Asadi; Road trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran. Tel: +989113344071. Fax: +981313238373; Email: payman.asadi@yahoo.com Received: December 2014; Accepted: January 2015 Abstract Introduction: Traumatic brain injuries (TBI) are one of the most important causes of death in patients under the age of 25 years and is responsible for one third of total deaths caused by trauma. Therefore, knowing its epidemi- ologic pattern in different populations seems vital. Therefore, this study aims to examine the epidemiologic pattern of TBI in emergency department. Methods: In this cross-sectional study, the profiles of 1000 patients affected by TBI were selected using simple random sampling. The examined variables in this study included demographic, sea- son, mechanism of injury, accompanying injuries, level of consciousness, hospitalization duration, computed to- mography (CT) scan results, needing surgery, admission to intensive care unit, and outcome of the patient. In the end, independent risk factors for the death of patients were determined. Results: 1000 patients suffering from were studied (81.8% male; mean age 38.5±21.7 years). The frequency of their referral to hospital in spring (31.4%) was more (p<0.01). 45.9% of the patients had a level of consciousness less than 9 based on the Glasgow Coma Scale (GCS). Subdural (45.9%) and epidural bleeding (23.7%) were the most common findings in CT scans in this study (p<0.001). Finally, 233 (23.3%) of the patients were dead. Over 60 years of age, falling and motorcycle accidents, intracranial hemorrhage accompanied by brain contusion, subdural bleeding, a GCS of less than 9, and the need to be admitted to intensive care unit were independent risk factors of death in TBI. Conclusion: Age Over 60 years, falling and motorcycle accidents, intracranial hemorrhage accompanied by brain contusion, subdural bleeding, a GCS of less than 9, and need to be admitted to intensive care unit were independent risk factors for the death in TBI patients. Key words: Brain injuries; head injuries; epidemiology; mortality; risk factors Cite this article as: Monsef Kasmaie V, Asadi P, Zohrevandi B, Raouf MT. An epidemiologic study of traumatic brain injuries in emergency department. Emergency. 2015;3(4):141-5. Introduction: rauma, as 1 of the 5 major causes of death and dis- ability in the world, leads to about 5 million deaths per year or 16 thousand deaths daily (1). In Iran, accidents are the leading cause of death in the youth and the major reason for years of potential life lost (2). Traumatic brain injuries (TBI) are among the worst consequences of these accidents and are the major causes of death in patients under the age of 25 years (3). It is also the leading cause of trauma related coma and disabilities (4). In developed countries the rate of deaths induced by head injury has been about 21% (in the first month) and this rate goes up to 50% in developing coun- tries (5, 6). TBI occurrence is increasing as motor vehi- cles are being more widely used in the developing coun- tries (7). In its last report, the world health organization (WHO) has stated the need for more research on the ep- idemiologic pattern of accidents in low and middle-in- come countries to determine the dimensions of the prob- lem and identify susceptible people. Despite the valuable efforts made in the past few years to determine the epi- demiology pattern of trauma and their outcomes in Iran, available data still seems insufficient (8). As TBI are one of the most common and dangerous outcomes of acci- dents, the present study aims to determine the epidemi- ologic pattern of TBI in emergency department. The re- sults from this study will be of help to identify the pat- tern of accident type, age, and sex distribution and the prevalence of other clinical and practical factors in trau- matic brain injuries. Methods: Study design and setting This cross-sectional, retrospective study was aimed to determine the epidemiologic pattern of TBI in the emer- gency patients admitted to Poorsina Hospital, Rasht, Iran T This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Monsef Kasmaei et al 142 from 2012 to 2013. Poorsina Hospital is one of the most important trauma center of Northern Iran, admitting about 18 thousand patients annually (9). This study has been approved by the ethics committee of Gilan Univer- sity of Medical Sciences and the researchers have ad- hered to the principles of the Helsinki declaration. Participants The sample population consisted of all of the patients ad- mitted to emergency department of Poorsina Hospital, who were diagnosed as TBI. Simple random sampling was used. In the beginning, all of the TBI patients’ pro- files were sorted alphabetically. Then, using a web based random number table, 1000 profiles were chosen ran- domly and were studied. Exclusion criteria included in- complete profile, no final decision recorded, no recorded CT scan result and making a final decision using tests other than CT scan. To reach the minimum number of samples required considering the 21% death rate in TBI (5), 95% confidence interval (α=0.05), 90% statistical power (β=0.1) and 1% accuracy (d=0.01), 865 samples were sufficient. Studied variables The studied variables in this study included demo- graphic (age, sex, marital status, level of education, occu- pation, place of residence), season, mechanism of trauma, presence of accompanying injuries, level of con- sciousness based on the Glasgow Coma Scale (GCS), hos- pitalization duration, CT scan results, needing surgery, needing admission to intensive care unit and the final outcome of patient. Patient outcome was divided into 3 groups: discharged or returned to baseline health char- acteristics, death, or referred to another hospital. The data were recorded by a trained physician in a checklist designed for this study. Statistical analysis The data set was analyzed using the SPSS version 21. The qualitative variables were stated in percentage and quantitative variables were input as mean ± standard de- viation. To evaluate the statistical difference of the stud- ied factors between subgroups of each variable multino- mial logistic regression was used. To determine the fac- tors playing a role in patients’ death, after defining prob- able risk factors based on chi square, Fisher's exact (for verbal qualitative variables) and Kruskal–Wallis test (for qualitative numerical variables), multivariable regres- sion model was used. In all analyses p<0.05 was consid- ered as significance level. Results: 1000 patients suffering from TBI were evaluated (81.8% male; mean age 38.5 ± 21.7 years). Frequency of individuals affected by head trauma in people aged 20- 60 (p < 0.001) and in spring (31.4%) was higher (p < 0.01). Motorcycle accidents were the most common trauma mechanism in this study with 48.5% prevalence (p<0.001) and the least common mechanism was inten- tional damage (1.5%) (Table 1). The mean GCS of patients was 9.94 ± 3.78 and 45.9% of them had a GCS of less than 9 (p<0.001). Subdural hem- orrhage (45.9%) epidural hemorrhage (23.7%) and in- tracranial hemorrhage accompanied by brain contusion (17.1%) were the most common findings of brain CT scans (p<0.001). The mean hospitalization duration was 7.52 ± 6.62 days. 721 (72.1%) patients were hospitalized for between 1 and 10 days, 194 patients between 11 and 20 days and 3 patients between 31 to 40 days. finally, Table 1: Demographic and basic variables of the patients in study Variable Frequency (%) p Age 0-20 211 (21.1) <0.001 21-40 312 (31.2) ref 41-60 286 (28.6) 0.29 61-80 162 (16.2) <0.001 Over 80 29 (2.9) <0.001 Sex Male 818 (81.8) ref Female 182 (18.2) <0.001 Place of residence The county 522 (52.2) ref The city 478 (47.8) 0.02 Level of education Uneducated 147 (14.7) <0.001 Less than high school 258 (25.8) <0.001 High school diploma 465 (46.5) ref University degree 130 (13.0) <0.001 Marital status Single 435 (43.5) ref Married 547 (54.7) <0.001 Occupation Self-employed 389 (38.9) ref Unemployed 266 (26.6) <0.001 Employee 207 (20.7) <0.001 Housekeeper 86 (8.6) <0.001 Other 52 (5.2) <0.001 Reference season Spring 314 (31.4) ref Summer 250 (25.0) 0.007 Fall 225 (22.5) <0.001 Winter 211 (21.1) <0.001 Mechanism of damage Motorbike rider 485 (48.5) ref Car accident 99 (9.9) <0.001 Bike accident 21 (2.1) <0.001 Falling 268 (26.8) <0.001 Same level falling 112 (11.2) <0.001 Intentional damage 15 (1.5) <0.001 Accompanying injuries Negative 591 (59.1) ref Positive 409 (40.9) <0.001 This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 143 Emergency (2015); 3 (4): 141-145 233 patients (23.3%) died while 745 (74.5%) recovered completely and were discharged. Univariate analyses showed that over 60 years of age (36.4% vs. 20.9%), ed- ucation less than high school diploma (32.1% vs. 24.4), being married (92.4% vs. 46.2%) and residing in rural areas (79.9% vs. 46.0%) had more prevalence in the dead patients while the prevalence of self-employed (14.1% vs. 34.7%) in this population was less than those who survived (Table 4). In evaluating clinical factors, it was determined that motorcycle accidents and falling, a GCS of less than 9 (53.6% vs. 39.9%), needing surgery (54.9% vs.43.3%), subdural hemorrhage (54.5% vs. 44.6%) and intracranial hemorrhage accompanied by brain contusion (24.5% vs. 14.2%) were more common in the dead patients (Table 5). The results of multiple variable regression analysis showed that, more than 60 years of age, trauma due to falling and motorcycle accidents, presence of intracranial hemorrhage accom- panied by brain contusion, presence of subdural hemor- rhage, GCS of less than 9 and the need to be admitted to intensive care unit were independent factors affecting the patients’ death (Table 6). Discussion: The results from this study showed the significant higher frequency of TBI in male, patients 20-60 years old, spring and motorcycle riders. It was seen that most patients had a decreased level of consciousness (GCS<9) and subdural and epidural hemorrhage were the most common find- ings of brain CT scan. Prevalence of death was 23.3% in the present study. More than 60 years of age, trauma due to falling and motorcycle accidents, presence of intracra- nial hemorrhage accompanied by brain contusion, pres- ence of subdural hemorrhage and GCS of less than 9 were independent risk factors of death. Men’s employment in places outside home, justifies the greater extent of TBI in this sex. This finding is in accordance with other studies that have reported the ratio of head injuries in men to women to be 3 to 1 (10). In addition, in various inter- national and regional studies TBI in men were re- ported more than women. Although this ratio is changing in more recent studies and the percentage of women affected by TBI is rising. The reason is that women are using motor vehicles more than before and are participating in activities outside the house more Table 2: Level of consciousness and CT scan findings in the studied patients Variable Frequency (%) P Level of consciousness (GCS score) 3-8 459 (45.9) ref 9-12 244 (24.4) <0.001 13-15 297 (29.7) <0.001 CT scan findings SDH 459 (45.9) ref EDH 237 (23.7) <0.001 Diffuse axonal injury 114 (11.4) <0.001 ICH and brain contusion 171 (17.1) <0.001 Simultaneous SDH and EDH 19 (1.9) <0.001 SDH: Subdural hemorrhage; EDH: Epidural hemorrhage ICH: Intracranial hemorrhage Table 3: Final outcome of the patients Variable Frequency (%) Final outcome Improved health 745 (74.5) Deceased 233 (23.3) Referral to another hospital 22 (2.2) Need for surgery Yes 454 (45.4) No 546 (54.6) Hospitalization duration (days) 1-10 721 (72.1) 11-20 194 (19.4) 21-30 82 (8.2) 31-40 3 (0.3) Admitting to intensive care unit Yes 372 (37.2) No 628 (62.8) Table 4: The relationship of demographic factors with patient outcome Factor Survived Deceased P Age Under 60 628(79.1) 117 (63.6) <0.001 60 and over 166 (20.9) 67 (36.4) Sex Male 666 (81.6) (82.6) 0.75 Female 150 (18.4) 32 (17.4) Level of education Uneducated 116 (14.2) 31 (16.8) <0.009 Less than high school 199 (24.4) 59 (32.1) High school diploma 400 (49.0) 65 (35.3) University degree 101 (12.4) 29 (15.8) Marital status Single 439 (53.8) 14 (7.6) <0.001 Married 377 (46.2) 170 (92.4) Place of residence The county 375 (46.0) 147 (79.9) <0.001 The city 441 (54.0) 37 (21.1) Occupation Employee 230 (28.2) 57 (31.0) <0.001 Self-employed 283 (37.4) 26 (14.1) Housekeeper 55 (6.7) 31 (16.8) Unemployed 248 (30.4) 18 (9.9) Other 0 (0.0) 52 (28.3) This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Monsef Kasmaei et al 144 than before (11-14). Plus, as stated before prevalence of TBI is more in the youth. This, is in agreement with the fact that generally, trauma and accidents in this group of age is more than other ages (2, 15). Though the statistics in this study is not similar to the devel- oping countries, it shows the same pattern. While a study in Norway, showed that, the prevalence of TBI was more in people aged 0-4 years old and people older than 75 compared to other groups (13). This dif- ference is due to the age distribution differenc e in the 2 countries, as average age in most developing coun- tries is much less than that in developed countries and this can affect the pattern of epidemiologic character- istics of TBI. The pattern of trauma mechanism was also different in Norway. In the afore-mentioned study, the most important cause of trauma was re- ported as falling but the most important cause in Iran is road accidents. Not using helmets is the main reason for the high prevalence of TBI in motorbike riders. So more preventive laws are needed in this regard. The results from Wu et al. (11) and Masson et al. (16) also show that motorcycle accident has the most preva- lence in TBI and intentional damages were the least common. Death prevalence in the studied patients was 23.3%. The statistics in other similar studies vary be- tween 30-38% (17-19). Although, Roozenbeek et al. have reported that the prevalence of death in the pa- tients with traumatic brain injury is between 31% and 51% in their review study. The researchers believe that this is due to differences in habits, lifestyle and health care in the populations. Like death prevalence, death risk factors are also vastly different in the avail- able reports (3). For instance, Ducrocq et al. report that the existence of hypotension in the time of admis- sion to the hospital, decreased GCS and higher injury severity score are independent risk factors for death in TBI (20). While Hukkelhoven et al. demonstrate that aging is an independent risk fact or for death in these patients (21). In addition, Tohme et al. introduce a fall in blood pressure and pre-hospital hypoxia as in- dependent risk factors of death (22). The reason for these differences is that each study has paid attention to a different aspect. For example, Tohme et al. have Table 5: The relationship of clinical factors with patient outcome Factor Survived Deceased P Presence of accompanying injuries Yes 331 (40.6) 78 (42.4) 0.65 No 485 (59.4) 106 (57.6) GCS level 3-8 221 (39.9) 238 (53.6) <0.001 9-12 152 (27.4) 92 (20.6) 13-15 181 (32.7) 116 (26.0) Need for surgery Yes 353 (43.3) 101 (54.9) 0.004 No 463 (56.7) 83 (45.1) CT scan findings Epidural hemorrhage 195 (26.2) 28 (12.0) <0.001 Subdural hemorrhage 332 (44.6) 127 (54.5) Diffuse axonal injury 98 (13.2) 16 (6.9) Simultaneous epidural and subdural hemorrhage 14 (1.9) 5 (2.2) Intracranial hemorrhage and brain contusion 106 (14.2) 57 (24.5) The need to be admitted to intensive care unit Yes 283(38.0) 89 (38.2) 0.95 No 462 (62.0) 144 (61.8) Table 6: Independent risk factors for the death of patients Factor Odds ratio 95% confidence interval P Over 60 years of age 3.5 1.4-8.9 0.008 Falling 5.0 1.8-14.3 0.002 Motorcycle accident 9.4 5.4-17.5 <0.001 Presence of subdural hemorrhage 12.1 5.0-29.4 <0.001 Intracranial hemorrhage and brain contusion 6.1 2.2-16.7 <0.001 GCS of less than 9 2.5 1.2-5.3 0.02 This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 145 Emergency (2015); 3 (4): 141-145 concentrated on pre-hospital factors, while Hukkelho- ven et al. have paid more attention to the hospital and clinical aspects. Therefore, each of the afore -men- tioned studies (including this study) have missed some of the probable risk factors and more careful ex- amination is needed in this field. A shortcoming re- garding this study is that it was a retrospective study. Studies on patients’ profiles is always accompanied by missed data due to a lack of records or careless re- cording of data. That is the reason why, many proba- ble risk factors of death mentioned in the aforemen- tioned studies like blood pressure level at the time of admission to hospital were not studied. But the simple random sampling used in this study makes it possible to generalize the findings to the whole popula tion. Conclusion: This study’s findings demonstrated that TBI are more prevalent in people aged 20-60, male, spring and mo- torbike riders. It was also shown that the injury has been severe in most of them and subdural and epi- dural hemorrhage have been the most common find- ings of brain CT scans. The prevalence of death was 23.3% in this study. Over 60 years of age, trauma due to falling and motorcycle accidents, presence of intra- cranial hemorrhage accompanied by brain contusion, presence of subdural hemorrhage and a GCS of less than 9 were independent risk factors for the death in these patients. Acknowledgments: This article is derived from thesis of Nastaran Aziz zadeh roudpishi to give the doctorate degree of medicine from Gilan University of Medical Sciences. We would like to say thanks to vice chancellor for research of medical faculty and those helped us to perform this project. 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Prehospital risk factors of mortality and impaired consciousness after severe traumatic brain injury: an epidemiological study. Scand J Trauma Resusc Emerg Med. 2014;22(1):1-10. Introduction: Methods: Study design and setting Participants Studied variables Statistical analysis Results: Discussion: Conclusion: Acknowledgments: Conflict of interest: Funding support: Authors’ contributions: References: