AgrawalA_Admission 252 | Agrawal et al - Admission characteristics and outcome in traumatic brain injury patients Admission characteristics and outcome in traumatic brain injury patients: a preliminary report from a tertiary care hospital Amit Agrawal1, Ashok Munivenkatappa2, B.V. Subrahmanyam3, S. Satish Kumar4, P. Ramamohan5 1Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh (India) 2National Institute of Epidemiology (ICMR), Chennai 3Department of Forensic Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh (India) 4Department of Emergency Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh (India) 5Pharmacology, Narayana medical college & hospitals, Nellore; Andhra Pradesh, INDIA Abstract: Introduction. Traumatic brain injury (TBI) is affected by multiple factors. Patient’s education, manifesting symptoms and surgical management play a significant role on discharge outcome. The literature of same from developing country is limited. The present pilot study aims to describe patient characteristics, presenting symptom and management aspects of TBI patients from a tertiary hospital. Methods. The present study is a prospective study, where TBI patients were selected and data of injury was entered on standard proforma on electronic data base. The study was approved by institute ethical board. The data was analyzed using Stats Direct version 3.0.150 software. Results. Three hundred and thirty three patients were evaluated. Eighty percent of patients were from rural areas. About 75% of patients were illiterates and married. Patient employment was significant with discharge outcome. All the patients manifested with symptoms loss of consciousness (LOC) was higher (73%) followed by vomiting (44%). LOC and oral bleed was significant with outcome. Associated injuries was higher in extremities (22.5%) followed by chest (4.4%). About 15% of patients require intracranial surgery that was significant with discharge outcome. Conclusion. The present pilot study finding is similar to available literature data and adds knowledge to TBI data of a developing country like India. Key words: illiterate, loss of consciousness, oral bleed, intracranial surgery, TBI, outcome Romanian Neurosurgery (2016) XXX 2: 252-257 | 253 Introduction The injury characteristics for traumatic brain injuries (TBIs) differ in important ways that has significant effect on outcome. (1, 2) The details of distribution of injured patient’s occupation and their marital status may be essential for outcome. (3, 4) Outcome has significant association with manifesting symptoms like duration of loss of consciousness and oral bleed. (5) The management of TBI patient especially intra cranial surgery is very crucial for patient outcome. (6) The details of published data of above mentioned variables of TBI from our local environment are limited. The aim of the present pilot study is to describe the injured patients educational, presenting symptoms and treatment characteristics of traumatic brain injuries from our setting. Methods The present study is a prospective study. The head injury patients attending emergency center of Narayana Medical College and Hospital, Nellore, Andhra Pradesh (India) was randomly selected. The study was approved by institute ethical committee and consent was taken by patient or by stander. The patient’s data was entered on standard head injury proforma which was comparable with Computerized Patient Management System. Patient’s data was mainly focused on education, employment, marital status, presenting symptoms and management aspects. The mentioned variable was checked for any significance with discharge outcome. The details of all variables was entered in simultaneous electronic data entry interface developed by FileMaker Pro Advanced 13 (Copyright © 1994-2015, FileMaker, Inc) and web data entry interface Drupal CMS. Statistical analysis The study data was analyzed using StatsDirect version 3.0.150 (StatsDirect Ltd. StatsDirect statistical software. http://www.statsdirect.com. England: StatsDirect Ltd. 2015). Frequencies and percentages were reported for categorical variables. Mean and standard deviation was reported for continuous variables. The significance between discharge outcome (alive or dead) and mentioned variables was analyzed using chi square test. The significant level was <0.05. Results Totally 337 head injury patients were evaluated during the study period. Twenty four (7.12%) patients expired during study period. The mean age was 36.26±15.86 years. Males were four times more than females. Fifty percent of patients had moderate to severe head injury. The details of patient’s education, employment and marital status with outcome are detailed in table 1. Only employment status was significantly associated with patient outcome. Table 2 highlights manifesting symptoms, other injuries, duration of LOC, pulse rate and systolic blood pressure with outcome. The medical and surgical management of head injury patients and their discharge outcome is shown in Table 3. 254 | Agrawal et al - Admission characteristics and outcome in traumatic brain injury patients TABLE 1 Patients’ educational, occupational and marital status with outcome Sl No. Variables Outcome P value Alive Dead 1 Education 0.732 Illiterate 225 19 Primary 41 3 Secondary 8 1 Graduate 19 0 Unknown 8 1 2 Employment 0.007* Farmer 132 9 Student 19 1 Laborer 16 0 Employee in service 4 0 Unemployed 2 2 Housewife 10 3 Unknown 5 0 3 Marital status 0.867 Married 262 21 Unmarried 50 3 Widow 1 0 *p value <0.05 TABLE 2 Symptoms and sigs presentation with outcome Sl No. Variables Outcome P value Alive Dead 1 Symptoms (present) LOC 228 21 0.115 Vomiting 138 11 0.868 Ear bleed 125 13 0.172 Nasal bleed 108 11 0.263 Oral bleed 43 7 0.040* Headache 52 2 0.287 Seizures 22 3 0.324 Post Traumatic Amnesia 14 2 0.391 2 Duration of LOC 1-29 minutes 176 4 30-59 minutes 60 11 0.021* 1-7 days 4 0 None 73 4 3 Other injuries (present) Neck 10 1 0.769 Thorax 4 1 0.259 Chest 13 2 0.339 Abdomen 1 0 0.782 Extremities 55 21 0.526 Cervical spine 1 1 0.018* Thorcaic spine 2 0 0.694 Lumbar spine 1 0 0.782 4 Pulse rate 0.016* <60 beats per minute 13 4 61-100 beats per minute 211 13 >100 beats per minute 43 6 5 Systolic Blood Pressure 0.834 <90 14 1 >90 258 23 LOC - Loss of consciousness; *p value <0.05 TABLE 3 Treatment with outcome Sl No. Variables Outcome P value Alive Dead 1 Medical treatment Urinary catheter 180 22 0.001* Nasogastric tube 58 12 0.001* Tetanus toxoid 215 20 0.132 Crystalloids 108 10 0.478 Colloids 179 15 0.612 Blood transfusion 1 0 0.782 Cervical collar 12 3 0.047* Cervical traction 1 0 0.782 Bed rest 246 18 0.68 Steroids 2 0 0.076 Ventilation 39 7 0.022* 2 Surgery Intra cranial 40 9 0.003* Extra cranial 17 2 0.576 *p value <0.05 Romanian Neurosurgery (2016) XXX 2: 252-257 | 255 Discussion The study results report that majority of evaluated patients were illiterates (72.4%). Farmers were about 37.4%. Three fourth (75%) of patients were married. All the patients manifested with symptoms among them loss of consciousness (LOC) was majorly reported (73.8%), followed by vomiting (44.2%), ear nose bleed (41%) and oral bleed (14.8%). Post traumatic amnesia was reported in 4.7%. Duration of LOC and oral bleed was significant with discharge outcome (p<0.05). Other than head extremities, chest and neck reported among 22.5%, 4.4% and 3.2% respectively. Pulse rate was significant with discharge outcome. Intracranial surgery was significant with discharge outcome. The study was conducted from a tertiary care hospital located in heart of the city. The hospital receives patients from local and surrounding areas. Majority of patients were from rural areas (81%). Our study reports that nearly three fourth of patients were not educated and there was no significance with outcome at discharge. A cross sectional study among moderate to severe TBI patients revel that higher education reduces the negative effect of TBI on cognitive outcome. Patients with higher intellectual enrichment had positive on outcome. (7) About eighty five percent of patient’s age was above twenty years, so it’s obvious that 75% were married. TBI literature from both developed and developing countries reports that productive age group is commonly affected. The occupation of majority of patients were agriculture (37.4%) followed by 6% of students and 5% of labor class. As majority of patients are from rural set up where agriculture is main mode of occupation. A district level study of traumatic brain injury patients reported that students were higher (29%) followed by civil servants (16%) and casual labors (13%). (3) Patients with TBI manifest with spectrum of symptoms. (8) TBI studies from India reports that brain injury patients manifest about 63% of LOC, 48 to 40% of vomiting, 36% of ear, nose and throat bleed and 24% of traumatic amnesia. (8) The present study result reflects the literature results, but the post traumatic amnesia is less in our study as compared to above study. The post traumatic amnesia manifests for varying duration. (9) It may be due to the fact that the patients with low education might not have understood or have failed to understand. LOC and its duration have significant association with outcome, longer the LOC duration worse the outcome. (10) Our study reports duration of LOC has significance with outcome at discharge. The study reports that oral bleed has significance with discharge outcome. Forty three percent of severe patients, 19% of moderate patients and 9% of mild group patients had oral group that was significant (p<0.001). A retrospective study from Taiwan reports that severe the head injury patients with oronasal bleed had worse outcome. (11) Associated injuries like involvement of neck, thoraco-abdominal, extremities and spine are common in TBI patients. Our study reports associated injuries was higher in extremities (22.5%) followed by chest and neck. A TBI study from tertiary care center 256 | Agrawal et al - Admission characteristics and outcome in traumatic brain injury patients reports higher neck injuries (95%), extremities on average of 32% and chest of 4.5%. (12) The management of patients with head injury is complex and requires a prompt, coordinated, comprehensive and multidisciplinary approach. Early recognition and immediate treatment of surgically correctable intracranial lesion is essential for optimal patient outcome. (3, 14) The present study reports that intracranial surgical management of TBI patient was significant with discharge outcome. Limitation The present study sample size is small with lack of data on long-term outcome. The statistics used are simple one, higher statistics like logistics to find detail association and risk factor that has significance with discharge outcome was note done. Conclusion The pilot study reports that majority of patients were illiterates and married. LOC was present among majority of patients and was significant with discharge outcome. Associated injuries were present in majority of patients. Intracranial surgery was significant with discharge outcome. Studies with larger sample size and higher statistics should be considered to establish better prevention strategies and treatment protocols. Correspondence Dr. Amit Agrawal Professor of Neurosurgery Department of Neurosurgery Narayana Medical College Hospital Chinthareddypalem Nellore-524003 Andhra Pradesh (India) Email- dramitagrawal@gmail.com dramit_in@yahoo.com Mobile- +91-8096410032 References 1.Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ (Clinical research ed) 2002;324:1139-1141. 2.Masiira-Mukasa N, Ombito BR. Surgical admissions to the Rift Valley Provincial General Hospital, Kenya. East African Medical Journal 2002;79:373-378. 3.Kobusingye OC, Guwatudde D, Owor G, Lett RR. Citywide trauma experience in Kampala, Uganda: a call for intervention. Inj Prev 2002;8:133-136. 4.Chalya PL, Mabula JB, Dass RM, et al. Injury characteristics and outcome of road traffic crash victims at Bugando Medical Centre in Northwestern Tanzania. Journal of trauma management & outcomes 2012;6:1. 5.Pruthi N, Ashok M, Kumar VS, Jhavar K, Sampath S, Devi BI. Magnitude of pedestrian head injuries & fatalities in Bangalore, south India: a retrospective study from an apex neurotrauma center. Indian J Med Res 2012;136:1039-1043. 6.Horn SD, Corrigan JD, Beaulieu CL, et al. Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge. Archives of physical medicine and rehabilitation 2015;96:S304-329. 7.Sumowski JF, Chiaravalloti N, Krch D, Paxton J, Deluca J. Education attenuates the negative impact of traumatic brain injury on cognitive status. Archives of physical medicine and rehabilitation 2013;94:2562-2564. 8.Munivenkatappa A, Shukla DP, Devi BI, Kumarsamy AD, Bhat DI, Somanna S. Domestic animal-related neuro-trauma: An account, from a tertiary institute. Journal of neurosciences in rural practice 2013;4:19. 9.Ponsford JL, Spitz G, McKenzie D. Using Post- Traumatic Amnesia To Predict Outcome after Traumatic Brain Injury. Journal of neurotrauma 2015. 10.Shaklai S, Peretz R, Spasser R, Simantov M, Groswasser Z. Long-term functional outcome after Romanian Neurosurgery (2016) XXX 2: 252-257 | 257 moderate-to-severe paediatric traumatic brain injury. Brain injury 2014;28:915-921. 11.Liao C-C, Tseng Y-Y, Chen C-T. Transarterial embolisation for intractable post-traumatic oronasal haemorrhage following traumatic brain injury: Evaluation of prognostic factors. Injury 2008;39:507-511. 12.Munivenkatappa A, Pruthi N, Philip M, Devi BI, Somanna S. Elderly pedestrian neurotrauma: A descriptive study from a premier neurotrauma center in India. Journal of neurosciences in rural practice 2013;4:29. 13.Marik PE, Varon J, Trask T. Management of head trauma. CHEST Journal 2002;122:699-711. 14.Yattoo G, Tabish S, Rangrez R, Afzal M, Bukhari I, Kirmani M. Injuries Profile of Head Trauma Patients at a Teaching Hospital. JK-Practitioner 2008;15:S31-S32.