Background
Major or severe trauma constitutes a global public health problem and poses diagnostic and therapeutic challenges to trauma, orthopaedic and general surgeons practicing in developing countries [
1]. Major trauma contributes significantly to high morbidity, mortality and long-term disabilities worldwide [
1,
2]. In developing countries including Tanzania, injuries in general are increasing due to increase in urbanization, motorization, civil violence, wars and criminal activities [
3]. In these countries, major trauma remains a major cause of hospitalization and intensive care utilization and consumes a significant amount of the health care budget [
4]. In Bugando Medical Centre, major trauma is the single most common reason for admission to the Intensive Care Unit (ICU) and is it associated with substantial emotional, physical and financial burden on community and hospital resources.
Major trauma is often life threatening and usually presents as an emergency, requiring either immediate surgical intervention or intensive care or both [
4,
5]. The Intensive Care Unit is a specialized area where facilities for the critically ill or severely injured patients are concentrated and where the level of care and supervision is considerably more sophisticated than in the ordinary ward [
4‐
6]. Worldwide, intensive care unit requires a vast use of up to date resources such as advanced monitors, organ support equipments and highly skilled staff. This however, often taxes the most buoyant health systems even of the developed nations [
4,
6]. In most developing nations where there are several financial constraints resulting from poor funding of the health care generally and the ICU specifically, there is often a limit to the availability and specialization of this form of care [
6]. Besides allocation of resources, intensive care also demands a tremendous amount of time and effort on behalf of the medical and nursing staff to treat and improve survival of the critically ill patients. It therefore follows that the role of the ICU must be justified wherever it exists [
5,
6]. The allocation of ICU facilities when financial resources are limited is determined by cost/benefit and patient outcome [
6,
7]. Admission of patients with poor prognosis and/or prolonged use of the ICU facility results in other patients with a better prognosis being denied care; many of these die as a result [
7].
Despite continued advances in intensive care unit technology and the availability of sophisticated interventions for the treatment of critically ill or severely injured patients, major trauma patients continue to die in the ICU [
6,
7]. Identification of factors responsible for this state of affairs is of paramount in order to improve the outcome these patients. Understanding the magnitude of the problem and characterizing the patterns of injury in these patients is important in planning programmes targeted at preventing their occurrence and subsequently reduce ICU admissions. There is paucity of published data on ICU trauma admissions in our environment despite large number of trauma admissions to our ICU. This study was conducted to describe the characteristics and treatment outcome of major trauma patients admitted into our ICU and to identify predictors of outcome.
Methods
Study design and setting
Between January 2008 and December 2010, a descriptive prospective study was conducted in the ICU of Bugando Medical Centre (BMC). BMC is found in Mwanza city in the Northwestern Tanzania along the shore of Lake Victoria. It is one of the four tertiary referral hospitals in the country and serves as a teaching hospital for Weill- Bugando University College of Health Sciences (WBUCHS) and other paramedics. It has a bed capacity of 1000 and provides services to approximately 13 million people from six regions namely Mwanza, Kagera, Mara, Shinyanga, Kigoma and Tabora. The hospital has a 12-bed adult and 10-bed paediatric multi-disciplinary Intensive Care Unit (ICU) which is headed by a consultant anesthesiologist and run by trained ICU nurses. The ICU provides services to all patients (trauma and non-trauma, medical and surgical) requiring advanced airway support, mechanical ventilation, hemodynamic support, and electronic monitoring which are usually not available in the open wards in our hospital. The majority of trauma patients admitted in the ICU come from the Accident and Emergency (A & E) department, operating theatre, wards and others come from other peripheral hospitals.
Study subjects
The study subjects included all patients with traumatic injuries severe enough to warrant ICU admission and who consented for the study. Patients who were readmitted to the ICU during the same hospital stay were excluded from the study. A total of 334 patients were recruited for the study and screened for inclusion criteria. Of these, 314 patients met the inclusion criteria and the remaining 20 patients did not. Patients who met the inclusion criteria were requested to consent for the study before being enrolled in the study. Two patients refused to consent for the study. Thus, 312 patients were enrolled in the study.
All study patients were initially resuscitated according to ATLS and treated according to ICU protocols. The severity of injury was assessed by the injury severity score (ISS) and the Glasgow coma score (GCS). An initial systolic blood pressure (SBP) on each patient was also recorded on admission. Data were collected used a questionnaire. Data administered in the questionnaire included details of demographic profile, causes of injury, injury characteristics, injury severity using Glasgow Coma scale (GCS) and injury severity score (ISS), treatment offered, complications, ICU length of stay (LOS), mortality and patient disposal. ICU length of stay. Patients were followed up till death or discharge from the ICU.
Statistical data analysis
Data collected was analyzed using SPSS software version 15.0. Data was summarized in form of proportions and frequent tables for categorical variables. Continuous variables were summarized using means, median, mode and standard deviation. χ2-test was used to test for significance of associations between the predictor and outcome variables in the categorical variables. Student t-test was used to test for significance of associations between the predictor and outcome variables in the continuous variables.. Significance was defined as a p-value of < 0.05. Multivariate logistic regression analysis was used to determine predictor variables that are associated with outcome.
Variable definitions
Road traffic crash was defined as accident which took place on the road between two or more objects one of which must be any kind of a moving vehicle.
Patients were divided into two groups according to the timing of ICU admission on arrival. Patients who were admitted to the ICU immediately on arrival were classified as "immediate admission group" and patients who had to wait for ICU admission due to bed unavailability or any other reason were classified as "delayed admission group". The nature of injury was classified as "intentional injuries" defined as injuries that occur as a result of interpersonal or self-inflicted violence and "unintentional injuries" defined as injuries that occur accidentally. ICU length of stay was arbitrary dichotomized into two groups' i. e. ≤ 14 days and > 14 days respectively. An ICU length of stay of > 14 days was considered as prolonged hospital stay.
Ethical consideration
Ethical approval to conduct the study was obtained from the WBUCHS/BMC joint institutional ethic review committee before the commencement of the study. Patients who met the inclusion criteria or their relative were requested to sign a written informed consent before being enrolled into the study.
Results
There were a total of 312 trauma admissions to the ICU during the period under study, representing 37.1% (312/841) of the total ICU admissions. There were 264 (84.6%) males and females were 48 (15.4%) with a males to female ratio of 5.5:1 compared with 1.2:1 for the total ICU admissions. Their ages ranged from 4 years to 71 years (median 27 years). Trauma admissions were almost exclusively emergencies (95.2%) and came mainly from the Accident and Emergency (60.6%) and Operating Room/Post Anaesthesia Care Unit (23.4%). (Table
1)
Table 1
Demographic and clinical characteristics of the ICU trauma admissions
Number (N/%)
| 312 (37.1) | 841 (100) |
Sex (Male: Female ratio)
| 5.5: 1 | 1.2:1 |
Median age (in years)
| 27 | 30 |
Modal age group (years)
| 21-30 | 31-40 |
Source of admission (N/%)
| | |
° A & E department | 189 (60.6) | 301 (35.8) |
° OR/PACU | 73 (23.4) | 385 (45.8) |
° Wards | 33 (10.3) | 132 (15.7) |
° Other hospital s | 17 (5.7) | 22 (2.6) |
° Unspecified | - | 1 (0.1) |
Timing of admission
| | |
° Immediately | 111 (35.6) | 365 (43.4) |
° Delayed | 201 (64.4) | 476 (56.6) |
Type of admission (N/%)
| | |
° Emergency | 297 (95.2) | 573 (68.1) |
° Elective | 15 (4.8) | 268 (31.9) |
Length of hospital stay (N/%)
| | |
° < 3 days | 110 (35.1) | 370 (44.0) |
° ≥ 3 days | 202 (64.9) | 471 (56.0) |
Mortality rate (%)
| 102 (32.7) | 158 (18.8) |
The majority of the injuries were unintentional in 232 (74.4%) patients. Intentional injuries were recorded in sixty (19.2%) of cases and the remaining twenty (6.4%) patients were cases of indeterminate intent. Road traffic crush was the most common cause of injuries affecting 70.8% of patients (Table
2).
Table 2
Causes of injuries among ICU trauma victims
Road traffic crush | 221 | 70.8 |
Assaults | 36 | 11.5 |
Falls | 12 | 3.8 |
Burns | 9 | 2.9 |
Other causes | 14 | 4.5 |
Unknown | 20 | 6.4 |
Total
|
312
|
100
|
One hundred and fifty-two (68.8%) of RTCs were related to motorcycle injuries affecting motorcyclists (93, 61.2%), passengers (40, 26.3%) and pedestrian (19, 12.5%).
The head/neck and musculoskeletal (extremities) regions were commonly affected accounting for 95.5% and 34.6% of cases respectively (Table
3). Isolated injuries occurred in 208 (66.7%) patients while 104 (33.3%) patients had multiple injuries. Soft tissue injuries (i.e. bruises, laceration, abrasion and contusions) and fractures (long bones, spines, pelvis, ribs, and skull) were the most common type of injuries accounting for 97.8% and 32.4% respectively
( Table
4).
Table 3
Site of injury among ICU trauma victims
Head/neck | 298 | 95.5 |
Musculoskeletal (extremities) | 108 | 34.6 |
Chest | 82 | 26.3 |
Abdomen | 62 | 19.9 |
Pelvis | 14 | 4.5 |
Spines | 8 | 2.6 |
Genitalia | 4 | 1.3 |
Table 4
Type of injuries among ICU trauma victims
Soft tissue injuries (wounds) | 305 | 97.8 |
Fractures | 101 | 32.4 |
Craniocerebral injury | 67 | 21.5 |
Visceral injury | 41 | 13.1 |
Burns | 9 | 2.9 |
Other injuries | 12 | 3.8 |
The ISS ranged from 16-56 with the mean of 19.74 ± 9.81. The median was 17.00. The mean GCS for patients with head injuries was 9.65 ± 12.43 (range 3-15). The median GCS was 9. The majority of patients (172, 55.1%) had admission SBP < 90 mmHg.
Of the 312 patients admitted to the ICU, 169 (54.2%) patients were intubated and ventilated for a median of 7 days (range 1-32 days). Two hundred fourteen patients (68.6%) required surgical intervention. Wound debridement, treatment of fractures and craniotomies were the commonest surgical procedures performed in 95.3%, 43.5% and 14.5% of patients respectively (Table
5).
Table 5
Type of surgical procedure performed (N = 214)
Wound debridement | 204 | 95.3 |
Treatment of fractures | 93 | 43.5 |
Craniotomy (including elevation of skull fracture) | 31 | 14.5 |
Underwater seal drainage | 23 | 10.7 |
Exploratory laparotomy | 17 | 7.9 |
Tracheostomy | 12 | 5.6 |
Eye surgery | 9 | 4.2 |
Thoracotomy | 2 | 0.9 |
The overall ICU length of stay (LOS) for all trauma patients ranged from 1 to 59 days (median = 8 days). The median ICU length of hospital stay (LOS) for survivors and non-survivors were 8 and 5 days respectively. These differences were statistically significant (P = 0.002).
Of the non-survivors, ten (9.8%) died within 24 hours of ICU admission while twenty-four (23.5%) died within 72 hours and six-eighty (66.7%) died by the seventh ICU day. Of the survivors, thirty-two (15.2%) were discharged to the wards within 72 hours, fifty-four (25.7%) on the seventh day and one hundred and twenty-four (59.0%) were discharged by the fourteenth day of ICU admission.
Analysis of outcome showed that 201(64.4%) patients were transferred to the ward and 4 (1.3%) patients were discharged home direct from the ICU. 3 patients (1.0%) were referred to another tertiary institution and 1 (0.3%) patient each absconded and left against medical advice respectively. A total of 102 patients died giving a mortality rate of 32.7%. Mortality rate of trauma patients was significantly higher than that of all ICU admissions (32.7% vs. 18.8%, P = 0.0012). According to multivariate logistic regression analysis, multiple injuries (O.R.= 2.34, 95% C.I.( 2.11-4.78), P = 0.012), severe head injuries [GCS = 3-8] (O.R.= 0.54, 95% C.I.(0.13-0.69), P = 0.036) and burns (O.R.= 4.92, 95%C.I. (2.43-8.15), P = 0.017) were responsible for a longer (> 14 days) ICU stay. Table
6 shows predictors of mortality according to univariate and multivariate analysis
Table 6
Predictors of mortality according to univariate and multivariate analysis
Age
| | | | | |
≤40 | 202(64.7) | 1 | | 1 | |
> 40 | 110(35.3) | 1.41 (0.45-1.82) | 0.098 | 2.5 (0.56-6.67) | 0.765 |
Sex
| | | | | |
Male | 264(84.6) | 1 | | 1 | |
Female | 48 (15.4) | 4.52 (0.95-5.83) | 0.678 | 3.12(0.97-5.78) | |
Type of admission
| | | | | |
Emergency | 297(95.2) | 1 | | 1 | |
Elective | 15 (4.8) | 2.71 (1.2-3.7) | 0.024 | 3.83 (0.93-5.98) | 0.934 |
Timing of admission
| | | | | |
Immediately | 111 (35.6) | 1 | | 1 | |
Delayed | 201 (64.4) | 2.93 (2.22-8.45) | 0.003 | 3.43(2.26-7.91) |
0.028
|
Duration of LOC (N = 214)
| | | | | |
≤ 2 hours | 72(33.6) | 1 | | 1 | |
> hours | 146(68.2) | 2.23 (1.89-7.98) | 0.000 | 0.34(0.12-0.78) |
0.004
|
ISS
| | | | | |
≤ 15 | 2(0.6) | 1 | | 1 | |
>15 | 310 (99.4) | 6.83(3.56-8.91) | 0.012 | 7.21 (2.65-10.96) |
0.000
|
GCS
| | | | | |
<9 | 192(61.5) | 1 | | | |
≥9 | 120(38.5) | 2.64( 1.32-6.76) | 0.034 | 4.72 (3.16-9.23) |
0.003
|
Admission SBP(mmHg)
| | | | | |
< 90 | 172(55.1) | 1 | | 1 | |
≥90 | 140(44.9) | 1.76(0.56-4.35) | 0.042 | 8.34 (4.61-9.98) |
0.016
|
Need for ventilatory support
| | | | | |
Yes | 169(54.2) | 1 | | 1 | |
No | 143 (45.8) | 2.45(1.24-5.89) | 0.038 | 0.65 (0.28-0.86) |
0.018
|
CT scan brain findings of SOL (N = 122)
| | | | | |
Yes | 98(80.3) | 1 | | 1 | |
No | 24(19.7) | 0.77 (0.23-0.98) | 0.000 | 3.53(2.23-6.97) |
0.015
|
Conclusion
Major trauma resulting from road traffic crashes is a leading cause of intensive care utilization in our hospital. Urgent preventive measures targeting at reducing the occurrence of RTCs is necessary to reduce the incidence of major trauma in this region and subsequently reduce ICU trauma admissions. These preventive measures include increased public education, enforcement of road safety rules, improvement in socioeconomic situation and employment opportunities in our country. Improved pre- and in-hospital care of trauma victims will improve the outcome of major trauma patients admitted to our ICU.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
PLC contributed in study design, literature search, data analysis, manuscript writing & editing. JMG and RMD participated in study design, data analysis, manuscript writing & editing. MDM participated in data analysis, manuscript writing & editing. MM and JBM participated in data analysis and manuscript writing. WM supervised the study and contributed in data analysis, manuscript writing & editing. All the authors read and approved the final manuscript.