Trauma & Acute Care Open Access

Keywords

Epidemiology; Craniocerebral trauma; Resuscitation; Ivory Coast

Introduction

Craniocerebral trauma is defined as any direct or indirect mechanical aggression on the skull, immediately or subsequently responsible for disturbances of consciousness, resulting in diffuse or localized encephalic pain, ranging from obliteration to coma [1]. Craniocerebral trauma is a serious public health problem in the world and is responsible for significant morbidity and mortality [2]. Despite the many advances made in the knowledge of their pathophysiology and their management, the mortality attributable to them is still high even in developed countries where they are the leading cause of death in young adults [3]. In the United States, craniocerebral trauma accounts for 40-50% of traumatic deaths [4,5]. In Europe, they account for between 35% and 42% of all deaths among young people aged 15-25 years [6]. In Africa, management of craniocerebral trauma remains difficult and mortality is high by 70%, due to inadequate financial resources and weak technical facilities [7,8]. In Bouake, the second largest city in Côte d'Ivoire, craniocerebral traumaare a common reason for admission to surgical emergencies and pose an urgent problem of diagnosis and management. It is therefore essential to identify the epidemiological factors of craniocerebral trauma with a view to their prevention. The aim of this work was to describe the main epidemiological aspects of craniocerebral trauma in charge of identifying preventive measures with a view to reducing morbidity and mortality.

Patients and Methods

This was a retrospective descriptive study of hospitalized patients treated for craniocerebral trauma in the intensive care unit of the teaching hospital of Bouake over a one-year period from January 2013 to December 2014. The intensive care unit of the teaching hospital of Bouake, is the only intensive care unit in the country with a radius of coverage of 250 km². Included were all patients admitted for craniocerebral trauma with a Glasgow score below 14. Patients who died on arrival, those with a craniocerebral trauma with normal consciousness or unusable records did not include. The parameters studied were: age, sex, occupation, circumstances of occurrence, etiologies, risk factors, transport modalities of trauma, time to hospital admission and evolution. The data was processed using a Microsoft Excel 2011 file.

Results

Of a total of 1244 patients admitted to hospital during the study period, 92 patients were hospitalized for craniocerebral trauma, a hospital prevalence of 7.39%. Craniocerebral trauma was observed mainly in young (Table 1) male subjects in 93.4% with a sex ratio of 14.3 and an average age of 32.6 years (range: 2 and 76 years). The etiology of craniocerebral trauma was variable. Road accidents were the most frequent (87%) followed by falls (4.3%) and brawls (4.3%) (Table 2). Drivers of motorcycle taxi (49%) and students (24%) were the most concerned social groups (Table 3). Two-wheeled vehicles (motorcycles) were incriminated in the occurrence of 40% of traffic accidents and pedestrians accounted for 31.5% of craniocerebral trauma victims. None of the motorcycle drivers were wearing helmets when the accident occurred.

Table 1: Distribution of trauma patients by age (n=92).

Table 2: Distribution according to the etiologies of the trauma (n=92).

Table 3: Distribution of traumatized patients according to socioprofessional categories (n=92).

The risk factors associated with the occurrence of traffic accidents were speeding (92%) and drinking (8%). None of the patients had received pre-hospital care and medical transportation from the accident site to the hospital. In 48.9% of the cases, patients were evacuated by the military fire brigade and the majority of patients (61%) had been admitted before the 6^th h following the trauma. The average time of arrival of patients in surgical emergencies was 3 h (extremes: 1 and 72 h) and that of their admission in intensive care of 6.5 h.

The Glasgow score was less than 8 in 61% of patients and 18% were polytrauma patients. Cranio-encephalic computed tomography was only possible in 20% of the trauma patients and the most objectivized brain lesion was oedematous haemorrhagic contusion (42%). The mean duration of stay was 4.37 ± 4.23 days (range: 1 and 21 days) with a mortality of 66%.

Discussion

The study found that craniocerebral trauma accounted for 7.39% of intensive care admissions, most often involving young people, motorcycle taxi drivers (49%) and students (22%). In 87% of the cases, they were the result of traffic accidents involving a two-wheel motorized machine in 40% of the cases. Pedestrians accounted for 31.5% of craniocerebral trauma victims per traffic accidents. Medical transport was non-existent and patient evacuation was provided by the military fire brigade in 48.9% of cases with an admission delay of less than 6 h in 61% of patients. The average length of stay was 4.37 days with a mortality of 66%. These main results should be qualified due to the retrospective nature of this study and the presence of bias. However, this work provides, for the first time in Bouake, epidemiological data on craniocerebral trauma and gives rise to many points of discussion. The prevalence of craniocerebral trauma in our series (7.39%) was higher than that reported by Coulibaly et al. [9] in Mali 5.9%; but lower than that reported by Bahloul et al. [10] 14.2% in Tunisia. This prevalence of craniocerebral trauma underestimates the reality since it did not take into account patients who died before admission and those with a normal level of consciousness and cared for in surgical emergencies. A clear male predominance was observed in our series (93.4%) and the sex ratio H/F was 14.3. This masculine predominance is reported by several authors; Coulibaly et al. in Mali [9] 75%, Bahloul et al. in Tunisia [10] 90%, Wu et al in China [11] 76.6%, Privat et al. [12] and Rougier et al. [13] in France, with respectively 83.3% and 88%. It could be explained by the fact that men are an active population and engage in hazardous occupations such as those of taxi drivers or motorcycle taxi drivers who expose them to the risk of a traffic accident. Traffic accident was the main etiologies of craniocerebral trauma  (87%). These results were superimposed on those of Sidibe et al. [14] in Mali, which reported thattraffic accident were incriminated in the occurrence of 82.8% ofcraniocerebral traumain Mali and different from those of Norman et al. [15] who found that physical violence was the main cause ofcraniocerebral trauma in South Africa. The increase in the number of traffic accident would be linked to the combination of several factors, such as a considerable increase in the number of motor vehicles and especially motorized two-wheeled vehicles, the presence of unskilled drivers, speeding, alcoholism and the ignorance of the Highway Code. Motor vehicles with two wheels were the most incriminated in the occurrence of traffic accident (40%). This frequency was superimposable to that reported by Sidibe et al. [14] 41.6% in Mali, Wu et al. [11] 33.4% in China and Chiu et al. [16] 64.5% in Taiwan. The high number of motorized two-wheeled vehicles (34.7%) among the agents responsible for traffic accident can be explained by their large use as the main means of displacement of populations and by the explosion of the phenomenon of motorcycles in Bouake. Also, the users of these two-wheeled motorized vehicles with a very varied socio-professional profile are not always respectful of the rules of the traffic and are without wearing protective helmet while driving. According to the WHO, helmet use in developing countries would help reduce mortality by 40% and craniocerebral trauma morbidity by 70% [17]. The high proportion of pedestrians (31.5%) among victims of craniocerebral trauma by traffic accident was due to their frequent presence on roadways and to the absence of pedestrian walkways in Bouake. None of our patients had been provided with medical transport, and the evacuation of traumatized persons from the accident site to the hospital was most often carried out by the non-medicalized ambulances of the military fire brigade (48.9%). These results were consistent with those of Ouedraogo N. et al. [18] in Ouagadougou, which found a predominance of the evacuation of traumatized people in Ouagadougou by non-medical ambulances (54.9%). On the other hand, they differed from those of Rouxel JPM, who in his study carried out at the hospital in Bicêtre (France) reported that all cranial traumatized patients (100%) benefited from pre-hospital care and medical transport [19]. In our series, the average wait time was 3 h (extremes: 1 h and 72 h) and 61% of our patients were admitted before the 6^th h following the trauma. All authors agree that craniocerebral trauma should be taken care of in the very early hour to prevent life-threatening systemic secondary brain stress factors [20]. Our results were superior to those of Motah M. et al. [21] in whom 27.09% of the traumatized were admitted less than 6 h after their accident. This short period of admission could be explained on the one hand by the occurrence of most accidents in the town of Bouake and on the other by the high availability of the military fire brigade. Craniocerebral trauma is the leading cause of mortality and disability worldwide [22]. Hospital mortality in our study was 66%. This mortality was higher than that reported by Emejulu et al. [23], Coulibaly et al. [9], and Bahloul et al. [10], which reported mortality rates of 19.1%, 30% and 38%, respectively. This significant lethality in our series is related to the initial severity of trauma (61% severely traumatized with a Glasgow score of 8), lack of prehospital care, lack of medical transportation, Insufficiency of the technical platform of the resuscitation department of the teaching hospital of Bouake.

Conclusion

Craniocerebral trauma are common in Bouake, they are secondary to traffic accidentinvolving motorized two-wheeled vehicles and are responsible for heavy mortality among the young working population. The improvement of their prognosis requires on the one hand the implementation of a prevention policy through awareness campaigns on compliance with the Highway Code.

State of current knowledge on the subject

• Craniocerebral trauma is a major source of morbidity and mortality in young adults, mostly male.

• The etiologies are dominated by traffic accident, most often involving cars.

• Contribution of our study to knowledge.

• Epidemiological profile of patients suffering from craniocerebral trauma in Bouake.

• Etiologies of craniocerebral trauma are dominated by traffic accidents, most often involving two-wheeled motorized vehicles.

• The need for public awareness campaigns on compliance with the Highway Code and the creation of an urgent medical assistance service in Bouake.

Conflicts of Interest

The authors declare no conflicts of interest.

Author Contributions

All authors have read and approved the final version of the manuscript.

Acknowledgement

I acknowledge my master, Professor Brouh Yapo, who has agreed to instruct my manuscript, the students who helped us with the counting of the files and all those who participated from afar or close to the writing of this article.

References

1. Rambeau M, Crevetton R, Duveaufferier  MR, Treguier  C (1998) Sémiologie du crâne et de l’encéphale du nouveau-né et de l’enfant en scanner et IRM. Aspects normaux et pièges. Encyclopédie Méd Chir Radiodiagnostic-Neurologie 620: 10.
2. Raggueneau JL, Jarrigue B (1988) Épidémiologie: pronostic et devenir de 921 traumatisés crâniens graves. Agressologie 29: 433-438.
3. Meyer AA (1998) Death and disability from injury: a global challenge. J Trauma 44: 1-12.
4. Shackford SR, Mackersie RC, Holbrook TL, Davis JW, Hollingsworth-Fridlund P, et al. (1993) The epidemiology  of traumatic death-A population-based analysis. Arch Surg 128: 571-575.
5. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, et al. (1995) Epidemiology of trauma deaths: a reassessment. J Trauma 38: 185-193.
6. Engberg A (1995) Severe traumatic brain injury - Epidemiology, external causes, prevention, and rehabilitation of mental and physical sequelae. Acta Neurol Scand 92: 1-151.
7. Odimba E (2007) Aspects particuliers des traumatismes dans les pays peu nantis d’Afrique. Un vécu chirurgical de 20 ans. E-mémoires de l’Académie Nationale de chirurgie 6: 44-56.
8. Ouédraogo N, Niakara A, Simporé A, Barro S, Ouédraogo H, et al. (2002) Soins intensifs en Afrique : expérience des deux premières années d’activités du service de réanimation du centre hospitalier national de Ouagadougou (Burkina Faso). Santé 12: 375-381.
9. Coulibaly Y, MP E, Diallo A, Doumbia D, Keita M, et al. (2004) Le traumatisme crânien à l’hôpital du point G : à propos de 80 cas. Mali médical 2004, T  XIX  N° 3-4: 28-31.
10. Bahloul M, Chelly H, Ben Hmida  M, Ben Hamida C, Ksibi H, et al. (2004)  Prognosis of traumatic head injury in South Tunisia: a multivariate analysis of 437 cases. J Trauma 57: 255-261.
11. Wu  X, Hu J, Zhuo L, Fu C, Hui  G, et al. (2008)  Epidemiology of traumatic brain injury in eastern China, 2004: a prospective large case study. J Trauma 64: 1313-1319.
12. Privat JM, Privat JM, Double CM, Frerebeau P (1979) Aiguesvives. Etude anatomo-clinique du syndrome du traumatisme crânien grave. Rev Electroencephalogr Neurophysiol Clin 9: 109-15.
13. Rougier A, Bonnaud E, Castel JP, Richer E, Vital C, et al. (1979). Contrôle anatomique de 30 cas de comas traumatiques graves d’emblée. Rev Electroencephalogr Neurophysiol Clin 9: 101-108.
14. Sidibe S, Diallo A, Toure M, Tchamko-djeutcheu FR, Traore I (2005) Apport de la tomodensitométrie dans la prise en charge des traumatismes crânio-encéphaliques à Bamako. Mali Médical T XX, N° 1-2.
15. Norman R, Matzopoulos R, Groenewald P, Bradshaw D (2007) The high burden of injuries in South Africa. Bull World Health Organ 85 :695-702.
16. Chiu WT, Yeh KH, Li YC, Gan YH, Chen HY, Hung CC. Traumatic brain injury registry in Taiwan. Neurol Res. 1997 ; 19(3):261-4.
17. OMS-World Health organisation. Global status report on road safety: time for action. WHO press 2009.
18. Ouédraogo N, Ouédraogo S, Kaboré RAF, Rouamba A (2010) Traumatismes crâniens graves au centre hospitalier universitaire Souro Sanou de Bobo-Dioulasso Reanoxyo 26: 58-61.
19. Rouxel JMP, Tazarourte K, Le Moigno S, Ract C, Vigué B (2004) Prise en charge préhospitalière des traumatisés crâniens. Ann Fr Anesth Réanim 23: 6-14.
20. Quelles sont les modalités de prise en charge des traumatismes crâniens graves en phase préhospitalière (1999) Ann. Fr  Anesth Réanim 18: 36-46.
21. Motah M, Sende N.C, Beyiha G, Belley PE, Nguemgne M.C, et al. (2011) Prise en charge des traumatismes crâniens isolés à l’hôpital général de Douala Heath Sci Dis 12: 26-29.
22. Roozenbeek B, Lingsma HF, Lecky FE, Lu J, Weir J, et al. (2012) Prediction of outcome after moderate and severe traumatic brain injury: external validation of the International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) prognostic models : Crit Care Med 40: 1609-1617.
23. Emejulu JKC, Malomo O (2008) Head Trauma  in a Newly Established  Neurosurgical     Centre in Nigeria. East and Central African Journal of Surgery 13: 383-388.