Introduction

World over, road traffic injuries (RTI) are a major cause of misery, disability and death. ₁ In Sub-Saharan Africa, with increasing vehicular traffic, RTI has become an immense health problem even among children. RTI constitutes a burden on under-funded and oversubscribed health services. ₂, ₃ The WHO has estimated many more childhood deaths from road crashes than from HIV infection.₄ However, the prominence of communicable diseases in the region masks this relative epidemiologic significance. ₅

A number of scoring systems have been developed to facilitate consistent trauma triage, severity evaluation, management and prognostication. ₅, ₆ These include the Injury Severity Score (ISS) the Abbreviated Injury Score (AIS) and the Revised Trauma Score (RTS). ₅, ₆ Adesunkanmi and co-workers ₇ had earlier evaluated RTI among African children using the ISS. Unlike the ISS, the Pediatric Trauma Score (PTS) ₈, ₉ is exclusively used in children. It is reputably simple, consisting of six components (Table I). A score of +2, +1, or -1 is given to each variable and then added (range, -6 to 12). A PTS score of ≤ 8 indicates potentially major or severe trauma.

As roles in childhood emergency and ambulatory care continually escalate, it has become imperative that personnel in these departments understand and are able to assess the pattern and severity of RTI. Thus, this study was undertaken to assess severity of RTI using the PTS among children in the semi-urban Ijesa community of Southwest Nigeria. Hopefully, the information to be obtained will improve care of road crash victims and assist in formulating essential road traffic injury treatment strategy, particularly in this community. It was conducted at the Wesley Guild Hospital, Ilesa, a unit of the Obafemi Awolowo University Teaching Hospital and the main referral facility providing paediatric care for the semi-urban Ijesa community.₇

Methodology

All children aged below 16 years seen at the CHER with RTI between August 1, 2002 and July 31, 2003 prospectively studied. History was obtained from the parents or other accompanying guardians, referral notes and the Police as necessary. Data obtained included age and sex of each child, mode of involvement, types of vehicles involved and injury – presentation (IP) interval. The IP interval was recorded as either within one hour of the RTI (early) or after one hour (late). Unconsciousness, convulsion and or ongoing revealed bleeding at presentation were documented.

To obtain the severity of the trauma based on the PTS, ₈ the weight, airway patency, systolic blood pressure, central nervous system (CNS) status, presence or absence of open wounds and skeletal injury were documented as shown in Table I. A score of 8 or less (low PTS) was designated as major trauma and a score of 9 and above (high PTS) as minor trauma. The pattern of injuries was described based on anatomical regions: head, maxillo-facial, neck and spine, abdomen, chest, pelvis and limbs. The mechanism of the injuries was termed as either blunt or penetrating.₁₀,₁₁,₁₂ The eventual outcome of the patients was documented as discharged alive or died.

Data were analysed with the Student's‘t' test or the z test as applicable using the Computer program for epidemiologists (PEPI) Version 3.01. ₁₃ ‘p' values < 0.05 in two-tailed tests were accepted as statistically significant.

Results

The patients and the vehicles.

The clinical presentation, the types and mechanisms of injuries.

Outcome

The case fatality rate was 9.9% as 26 children (14 pedestrians and 12 passengers) died. This represents 17.6% of the 148 overall CHER deaths. The mean PTS (SD) was 2.65 (3.02) for children who died and 9.24 (1.93) for those who survived. Thus, the children who died had lower and statistically significant PTS (t = 15.49, p < 0.001). All those that died as against 70 (29.5%) of the 237 survivors had low PTS (z = 6.87, p < 0.001). From Table II, it can be seen that PTS ≤ 2, ≤ 6 and ≥ 7 were respectively associated with 100%, 36.0% and 3.8% mortality. Twenty (76.9%) of those that died were girls. Thus, significantly many more girls than boys had fatal outcome (z = 3.34, p = 0.001). Also, 23 (88.5%) of the deaths involved motorcycles.

All the children who died sustained multiple injuries and severe head injuries, 12 (46.2%) had severe bleeding with shock, 10 (38.5%) also sustained multiple limb fractures while 2 (7.7%) had intestinal protrusion from burst abdominal injuries. In all, 21 (80.8%), 4 (15.4%) and 1 (3.8%) deaths occurred respectively within 24 hours, between 24 and 48 hours and after 48 hours of the various road crashes. Within the first 24 hours, 3 (14.3%) deaths happened during the first hour, another 8 (38.1%) within 6 hours while 10 (47.6%) occurred between 6 and 24 hours. Late deaths were not recorded.

Figure 1

Table I: The Paediatric Trauma Score (PTS).

Figure 2

Table II: The PTS compared with the outcome.

Figure 3

Table III: Comparative analysis of the PTS with some RTI outcome variables.

Figure 4

Table IV: Comparative analysis of the Means PTS by the body regions injured.

Discussion

A higher rate of road traffic injuries (RTI) was observed in this study than previously documented from this same centre about a decade earlier.₇ Noteworthy sex differences were observed. Fewer girls than boys had RTI although girls suffered more severe and fatal injuries. Boys are generally more active and injury prone. However, plausibly boys are also more agile to such extents of being able to react more promptly to potential accident situations thereby lessening the impact, injury severity and outcome.

In the present study, most injuries seen were minor with a Pediatric Trauma Score (PTS) above 8. This is similar to the findings of Adesunkanmi and co. ₇ Moore et al ₁₄ had earlier reported similar observations by the Injury Severity Scale (ISS). The low PTS documented among pedestrians in this study is consistent with previous observations.₇, ₁₀, ₁₅However, all the children who died had PTS scores less or equal to 8. PTS of less than 2 in this study was associated with 100 percent mortality. Tepas and co had reported that a PTS of less than 1 predicted more than 98 percent mortality. ₈ In our study, 36 percent of children with a score of 6 or less died as against 28 percent in another study. ₁₆

Majority of the fatalities in the present study were severely head-injured. Many studies have shown head injury as a leading cause of death following road crashes in children.₇, ₁₀, ₁₅In view of our results, children who convulsed or were unconscious, mainly if prolonged had low PTS with more fatal outcome. Head injury is thus common to many trauma scoring systems.₁₆, ₁₇

The fact that most of the deaths occurred within the first 24 hours of presentation reflects in part, the poor state of life support and resuscitation available in the present health system. It may also explain the absence of such complications as septicaemia and multiple organ failure. Many crash victims were brought into the hospital late, such that upon arrival 4.9 percent required blood transfusions. However, only 1 of the blood transfused victims survived. No victim was brought to the hospital by ambulances. In an ideal setting with good ambulatory care, blood and intravenous fluid transfusions would have commenced at the trauma site or while in transit.₁₈

The high fatality rate in this study is an indication of indication of the enormity of the problem of childhood RTI in this community. Although the overall mortality in the present study is comparable with those seen in studies from other African countries,₁₉ it is much higher compared with studies from developed countries.₇, ₁₉ There is no doubt that the hospital facilities, as they currently exist in many developing countries, are not adequate in quality and quantity, to improve the outcome of childhood RTI. The facilities and interventions necessary to improve survival for these children are very expensive and often unavailable.₇ The high hospital mortality mainly from head injuries, blood loss and penetrating injuries emphasises the need for co-ordinated pre-hospital resuscitation and evacuation services, together with an integrated in-hospital trauma team approach to management.₁₅There is a need to establish an intensive care unit (ICU) in all hospitals. In view of our results, it is suggested that outcome in injuries should be improved by rapidly categorising all RTI by PTS and referring the low scorers to the ICU so that they can be targeted for better care and monitoring. At present in most systems, RTI victims are managed along with other patients in open ward, emergency or other in-patient wards.

Trauma triage ensures prompt patient categorisation and referral to better prepared centres which ultimately improves survival rates. ₅, ₆ Also, it will ultimately facilitate comparison of data and assessment of quality of care. This result did not just support the views of Kaufmann and co ₉ that the PTS is a reliable index of trauma severity assessment in children, it also demonstrated its universal applicability. The rationale for a child-specific trauma scoring system is predicated on the fact that childhood response to physiologic derangement differs from adults. Hence, the application of adult physiologic measure to children often results in considerable inaccuracy.₆,₈ Thus, in view of the consistency and simplicity of the PTS, we recommend it for all personnel involved in childhood ambulatory and emergency care.

Acknowledgement

Correspondence to

Dr. JAO Okeniyi. Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife. e-mail: akinyemiokes2@yahoo.com Telephone: +234 (0) 8034014280