Childhood trauma fatality and resource allocation in injury control programs in a developing country

Background

Traditionally infectious diseases have been the leading cause of death especially among children [1]. However with the efforts of local health departments and international organizations such as World Health Organization, infectious diseases have been substantially controlled and injuries have become the number one cause of death in children and young adults in many high income countries [2]. Similar transition has been started in many lesser-developed countries [2]. It is predicted that by 2020 trauma will be the first or second leading cause of death for both developed and developing nations [3]. The high proportion of children and young adults and the substantial socio-economic consequences of childhood injuries in lesser developed countries [4] require prudent attention to the issue of injury control.

Figure 1 shows that trauma fatality follows a trimodal distribution [5,6]. In Phase I, death occurs immediately or quickly as a result of overwhelming injury [5]. Due to the severity of injury and short time interval between injury and death, patients often do not have the opportunity for benefiting from medical interventions. Therefore, improvements in quality of care does not significantly influence patients' outcome [5,6]. Phase II includes fatalities that occur within several hours of the event [5]. These injuries are often less severe and leave more time for prehospital and hospital care providers to intervene and improve patients' outcome. Under these circumstances, improvements in the quality of prehospital, and ED care can alleviate the magnitude of trauma fatality [5,6]. Deaths in Phase III, occur days or weeks after injury. These fatalities often occur in a hospital. Therefore patients' outcome is highly correlated with the quality of care that they receive in hospitals or Intensive Care Units (ICUs).

Identification of the relative importance of each phase of trauma fatality for any particular mechanism of injury has a substantial value for injury control programs. Based on this information, public health advocates and policy makers can allocate the limited injury control resources among prevention activities and prehospital and hospital care improvement programs more efficiently.

Currently very limited injury prevention activities have targeted children in Tehran. As the first step in controlling childhood injuries in our community, we evaluated the demographic and injury related characteristics of different mechanism of injury among hospitalized children [7]. However significant proportion of fatal injuries in developing countries occur in prehospital settings [1] which are not captured in hospital databases. We conducted this study in order to identify the trimodal distribution of trauma fatality for each mechanism of injury. We are hopeful that the results of this study help us prioritize our future injury control programs.

Methods

Results

A total of 4233 trauma deaths were reported to LMO during one year of data gathering period. Children 15 years old or younger comprised approximately 10% (419 cases) of the cases. Unintentional injuries accounted for 94% (394 cases) of the fatal childhood injuries. Twenty five cases were attributed to homicide (16 cases) or suicide (9 cases). Sixty two percent of the children were male. The highest and the lowest proportion of male victims were observed in falls (78%) and poisoning (44%) -related fatalities. The mean (± SD) age of the victims was 8 (± 5) years. Children 10–15 years old comprised 42% of the injuries, followed by children 5 to 9 years old (26%) and 1 to 4 years old (25%).

Motor vehicle crashes (MVCs) (50%), burns (18%), falls (6%) and poisonings (6%) were the most common mechanism of fatal injuries. Seventy-one percent of MVC victims were pedestrians (149 cases), followed by car occupants (20%), motorcyclists (drivers and passengers) (6%) and bicyclists (3%). Table 1 summarizes the distribution of the mechanism of injury for each age group.

Evaluation of the trimodal distribution of trauma fatalities showed that in general 43% of the deaths occurred in Phase I, 20% in Phase II and 37% in Phase III. As presented in Figure 2, there was a substantial difference in this distribution among different mechanisms of injury. For example, while more than 80% of fatalities due to poisoning or drowning happened in Phase I, 92% of burn-related deaths occurred in Phase III (Figure 2).

Discussion

Several studies have discussed the issue of fatal childhood injuries [2,10-19]. However in spite of the importance of the issue, evaluation of the trimodal distribution of fatal injuries has rarely been a topic of research in lesser developed countries [1].

Before discussing the major findings of the study, it is worth reviewing the limitations of the study. First, although LMO database is the single most complete data registry for trauma fatalities in Tehran, it does not capture all the incidents. Thus, we were not able to estimate the trauma mortality rate. Second, the time of death since injury is often not recorded in most administrative databases. Therefore, we had to use the place of death as the surrogate measurement for the time of death since injury. This issue might have led to misclassification of phase of death especially for Phase II trauma fatalities with extraordinary long prehospital times. However, Zargar et. al showed that the mean prehospital time for trauma patients in Tehran was 2 hours (SD: 2 hours) [9]. Therefore, we do not expect that such a misclassification has significantly influenced the distribution of the three phases of trauma fatality in this study [9].

Similar to some other lesser developed countries, we found that boys were more commonly affected and MVCs were the predominant mechanism of fatal childhood injuries [12-19]. Pedestrians comprised more than 70% of MVC-related fatalities which is similarly reported in other studies [20-24].

Mock et al. compared patients' outcome among three cities with different development status [1]. Table 2 summarizes the distribution of the place of death in that study. As presented, in all settings, prehospital was the predominant place of death occurrence. However, this predominance was inversely correlated with the EMS development and prehospital time in these cities. In other words, Seattle with the most advanced EMS system and the shortest prehospital time had the lowest proportion of prehospital fatalities[1]. At the same time, prehospital deaths were more common in Kumasi with no organized EMS system and the longest prehospital time. Comparison of these results with the findings form our study showed that the distribution of trauma fatalities in Tehran was more similar to such a distribution in Seattle rather than Monterrey. Differences in research methodology are the most plausible explanations for this observation.

Mock et al. excluded all fatalities that were referral from other medical care facilities [1], while these subjects were included in our analysis. Referral patients are in general sicker and at higher risk of death. Therefore, hospital trauma fatality in our study was inflated by the number of referral subjects. Unfortunately, our data does not allow us to evaluate the proportion of the patients who died in a referral hospital. However, our previous study showed that significant proportion of fatalities from MVCs or burns occurred in a few university hospitals and two burn referral hospitals that often take care of severely injured patients [9]. Second, Mock and his colleagues excluded children younger than 15 years old, which comprised the study population in our analysis. Children often play around their homes and under supervision of other adults. Therefore in the case of emergencies, they often receive a quicker response compared to adults. Furthermore, their smaller body stature makes their transportation via private vehicles easier and faster. This can explain why in our previous study children were less frequently transported to a hospital by EMS ambulances compared with adults [7]. Even among pediatric population, younger children were less probable to use EMS services relative to older children [7].

Third, Mock et al. excluded death due to burns, strangulations, hangings, or suicide by poisoning. Burns alone comprised 18% of the fatal injuries in our study, 92% of them died in a hospital.

As mentioned before, the trimodal distribution of fatal injuries has a substantial importance in resource allocation in injury control programs. For poisoning and drowning with significant proportion of trauma fatalities in Phase I, prevention is the single most important strategy for controlling the magnitude of the problem. Improvements in the quality of care often do not influence patients' outcome, since the majority of these fatalities occur before any medical care is provided to trauma victims. Injuries due to MVCs and falls often occur in Phases II and III. Under these circumstances, improvements in prehospital and ED care might significantly improve patients' outcome. For deaths that happen days or weeks after injury, improvements in hospital and ICU care might be the most important strategy in alleviating the magnitude of the problem. Burns with more than 90% hospital death in our study is the best example of this group.

We discussed the importance of prehospital and hospital care in reducing the burden of fatal injuries in Phase II and Phase III. However, we would like to emphasize that the detrimental consequences of injuries is not limited to hospital admissions and fatalities. Other physical and psychosocial consequences of injuries such as long and short term disabilities and post traumatic stress disorders might be alleviated if improvements in health care programs are associated with effective injury prevention endeavors.

Describing the different injury control strategies that could be adopted in a large city such as Tehran is beyond the scope of this paper and can be found in references [23,25-30]. However, the results of this study and previous researches in regards to the identification of the risk factors, mechanisms and severity of injuries and trauma fatality among Tehran's children [7,9] have paved the way for future interventions.

Conclusion

Our study showed that injury prevention is the single most important solution for controlling trauma fatalities due to poisoning and drowning. Improvements in the quality of care in hospitals and intensive care units might substantially alleviate the magnitude of the problem due to burns. Improvements in prehospital and ED care might significantly decrease MVC and falls-related fatalities.

Competing interests

The author(s) declare that they have no competing interests.

Authors' contributions

BR and MG participated in study design and obtaining the required funding for the project; MS supervised data collection process, BR and MS conducted data analysis and prepared the first draft of the paper. BR, MS and MG have read the paper and commented on the final draft.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2458/6/117/prepub