An epidemiological study on pattern of thoraco-abdominal injuries sustained in fatal road traffic accidents of Bangalore: Autopsy-based study.

BACKGROUND: The statistical profile reflects a global estimate of 5.1 million deaths in 2000, which was due to injuries that accounted for 10% of deaths due to all causes. Out of this, a quarter of injury-related deaths occurred in the South-East Asian region. Road Traffic Accident (RTA) is one among the top 5 causes of morbidity and mortality in South-East Asian countries. Most common cause of blunt abdominal trauma in India is road traffic accident followed by pedestrian accidents, abdominal blows, and fall from heights. AIMS: To analyze the epidemiology and pattern of fatal thoraco-abdominal injuries in road traffic accidents.
MATERIALS AND METHODS: An autopsy-based cross-sectional study conducted. A purposive sampling technique was applied to select the study sample of 100 post-mortems of road traffic accident between November 2008 and May 2010 subjected to medico-legal autopsy at the department of Forensic Medicine, KIMS Hospital Bangalore.
RESULTS: The majority of the victims were aged 21 to 40 years, 50 (50.0%), most of the victims were male 92 (92.0%); and male/female ratio was 11.5:1. Commonest offending agents in heavy motor vehicles were 54 (54.0%). Bony cage sustained injuries were observed in 71; out of this, fractures of ribs were observed in 45 (63.3%) victims, clavicle in 14 (19.7%), sternum was 6 (8.4%), and vertebrae 6 (8.4%) of fatal road traffic accidents. Internal thoracic injuries were observed in 26 cases. Among internal thoracic injuries, lungs were the most commonly involved organ 24 (92.3%) followed by the heart 2 (7.6%). Lung sustained more lacerations 19 (79.1%) than contusions 5 (20.8%). Internal abdominal injuries were observed in 49 cases. In road traffic accidents, the most commonly injured abdominal organs were solid organs such as liver 16 (32.6%) followed by spleen 9 (18.3%).
CONCLUSIONS: Majority of the times in road traffic accidents, young and productive males were injured or lost their life. This study may help the planners to take safety measures, to implement strict traffic rules, to risk stratification in the susceptible population to educate the people, and the study of nature of offending agent in RTA can help the authorities to plan better availability of health care on roads.

INTRODUCTION

Accidents are a counter product of modernization and hasty life and are considered as a modern day epidemic. The statistical profile reflects a global estimate of 5.1 million deaths in 2000, which was due to injuries that accounted for 10% of deaths due to all causes. Out of this, a quarter of injury-related deaths occurred in the South-East Asian region.[1] Road Traffic Accident (RTA) is one among the top 5 causes of morbidity and mortality in South-East Asian countries.[2] RTA cause mechanical trauma, resulting in morbidity, disability, and even mortality. The fatality rate in road traffic accident in India is one of the highest in the world and reported to be 20 times more than that reported in developed countries.[3] Narrow and defective roads were the major cause for RTA. The World Health Organization (WHO) in its international conference on RTA noted the importance of adequate data on traffic injuries. The abdomen is the third common region of the body that is injured in civilian trauma.[4] Blunt abdominal trauma (BAT) is one of the leading causes of mortality among trauma victims. It is the main cause of death in people under 35 years of age in worldwide.[5] Most common cause of blunt abdominal trauma in India is road traffic accident followed by pedestrian accidents, abdominal blows, and fall from heights. This ever-expanding epidemic targeting the young and productive generations is likely to take a heavy burden on the quality of life and socio-economic growth of the region.[6]

MATERIALS AND METHODS

An autopsy-based, cross-sectional study conducted in correlation with the relevant clinical records and the reports from investigating agencies. A purposive sampling technique was applied to select the study sample of 100 post-mortems autopsies between November 2008 and May 2010 of road traffic accident subjected to medico-legal autopsy at the department of Forensic Medicine, KIMS Hospital Bangalore, India - a tertiary care center. RTA was defined as an accident, which took place on the road between two or more objects, one of which must be any kind of a moving vehicle. The data were compiled with a focus on the analysis of injuries in the thoraco-abdominal region with special reference to the nature of the wound and organs most commonly affected in road traffic accidents and epidemiological factors in relation to victims, vehicles, and sites of impacts, etc. Besides, features pertaining to hosts (road users), the agents (vehicles) and the environmental condition (road, seasons, time etc.), and their period of survival will be studied.

RESULTS

The majority of the victims were aged 21 to 40 years 50 (50.0%); most of the victims were male 92 (92.0%); and male/female ratio was 11.5:1. More crashes 37 (37.0%) took place between 6:00 PM to 12:00 PM. Majority of the RTA took place on weekends 55 (55.0%) at city roads 70 (70.0%). Details of RTA victims and their epidemiology have been provided in Table 1. Two-wheeler occupants were the most common victims of road traffic accidents 52 (52.0%), followed by pedestrians/bicycle 38 (38.0%), and light motor vehicle (LMV) 8 (8.0%). Most common injuries in RTA were external thoracic injuries observed in 73 (73%) of victims, followed by abdominal injuries observed in 49 (49%), head injuries in 47 (47%) of cases, extremities in 46 (Upper limb 33 and Lower limb 13) (46%) of victims, vertebra in 7 (7%), pelvis in 5 (5%), and spinal card in 4 (4%) of the victims.

Table 1

Distribution of RTA victims based on Epidemiology and sex n=100

External abdominal injuries were involved in 44 cases. Most common type of injury was contusion 21 (47.7%), followed by abrasion 16 (36.3%), laceration 5 (11.3%), and incised wounds 2 (4.5%). Internal abdominal injuries were observed in 49 cases. In road traffic accidents, the most commonly injured abdominal solid organs were liver 16 (32.6%) followed by spleen 9 (18.3%). Details of abdomino-pelvic injuries have been given in Table 2. Among the abdominal injuries sustained in road traffic accidents, the liver and spleen injured more lacerations than contusions, whereas in the kidney, contusion was the common.

Table 2

Distribution of RTA victims based on type of abdomino-pelvic injury

External injuries to the thorax were more frequent than internal injuries while in the abdomen, internal injuries were more frequently observed than external injuries. External thoracic injuries were observed in 73 cases; commonest was contusion 39 (53.4%) followed by abrasions 28 (38.3%), lacerations 7 (9.5%), and incised wounds 1 (1.3%). Bony cage sustained injuries were observed in 71; out of this, fractures of ribs were observed in 45 (63.3%) victims, clavicle in 14 (19.7%), sternum was 6 (8.4%), and vertebrae 6 (8.4%) of fatal road traffic accidents. Internal thoracic injuries were observed in 26 cases. Among internal thoracic injuries, lungs were the most commonly involved organ 24 (92.3%), followed by the heart 2 (7.6%). Lung sustained more lacerations 19 (79.1%) than contusions 5 (20.8%).

The most common cause of death in RTA was head injury 47 (47.0%); second common cause of death was persistent irreversible shock in 42 deaths (42.0%), and considerable amount of cause of death was septicemia 11 (11.0%). Survival time in detail has shown in Table 3. Commonest offending agents were heavy motor vehicles 54 (54.0%). In 24 (24%) cases, the offending vehicles would be LMV and in remained 12 (12.0%) were with two-wheeler, and 10 (10%) unknown indicating the incidence of ‘hit and run’ cases. Fracture extremities details have been provided in Table 4.

Table 3

Showing period of survival following accident and site of initial impact of the responsible vehicle

Table 4

Type of Fracture extremities among RTA

DISCUSSION

This study has found that majority of the Road Traffic Accidents (RTA) victims were aged 21 to 40 years (50.0%). Other similar studies conducted by Chaudhary et al.[7] and Suresh Kumar[8] founds the similar findings (51.2%) and (83%), respectively. Most of the victims were males (92.0%). Agnihotri et al.[9] and Khajuria et al.[10] studies observed the same result, (80.58%) and (85.14%), respectively. Present study found 37.0% of the RTA occurred in between 6:00 PM to 12:00 PM, and 55.0% took place on weekends. Kimberly et al. also argued the same,[11] but Khajuria et al. reported that 54.22% RTAs occurred during the daytime, between 9 AM to 8 PM.[10] Nearly 3 quarter of the RTA occurred at city cross roads (70.0%).

Research has shown that the two-wheeler occupants are among the majority to be affected in RTA.[12] In our study, most of the victims who sustained thoraco-abdominal injuries in the road traffic crashes (52% (riders 38% and Pillion riders 14%)) were two-wheeler occupants, followed by pedestrians (38%) and LMVs (8%). Our findings in this regard correlate well with the earlier studies. Chaudhary et al.[7] and Suresh Kumar et al.[8] study also found that most of the victims were (34.5%) two-wheeler riders and 23% were of pedestrians, and the common region of injury was the chest. But, Archana et al. study contradicted with our findings; they observed that pedestrians were maximum number of fatalities (35.79%), followed by motorized two-wheelers (motor cyclist scooterist etc.) (30.5%), and lowest incidence have been noted among pedal cyclists (5.47%).[13] Motor cyclist/scooterists comprise of most commonly involved group in fatal RTA reason being careless speed driving, thrill seeking, overtaking, and less stability of the vehicle. Besides, these vehicles are mostly used by 15-50 years age group.

Most common injuries in RTA were external thoracic (73%) of RTA victims, followed by abdominal injuries observed in 49%, head injuries in 47% of cases, upper limb in 33 and lower limb in 13 of victims, vertebra in 7%, pelvis in 5%, and spinal card in 4% of the victims. Our observations were contradicted by Jha N et al,; his study found that head injuries was the commonest (34.1%), followed by lower limbs (13.7%) and face (10.7%).[14] Khajuria et al. reported that limb injuries (31%) were commonest, followed by head (28%), thorax (18%), abdomen (17%), pelvis (3%), and spine (0.8%).[10]

External thoracic injuries were observed in 73% cases. Contusion was 53.4%, followed by abrasions (38.3%) and lacerations (9.5%). External abdominal injuries were involved in 44% cases. Most common type of injury was contusion 21 (47.7%), followed by abrasion 16 (36.3%) and laceration 5 (11.3%). Similar findings were observed by Jha N et al.[14] and Suresh Kumar et al.[8] Bony cage sustained injuries were observed in 71% of the victims; fractures ribs were observed in 63.3% victims, 19.7% of the cases were clavicle fractures, and 8.4% cases of each had sternal and vertebrae fractures. Suresh Kumar et al. also argued the same.[8]

In current study, most common abdominal solid organs injured were liver (32.6%), spleen (18.3%), and kidney (12.24%). But, Suresh Kumar et al.[8] and Bakkannavar et al.[15] argued that most common solid abdominal organ involved was kidney, (48%) and (23%), respectively, followed by the liver (39.7%). Ravindra et al.[16] and Maurice et al.[17] contradicted the above both statements; they found that the most commonly injured organ was spleen in both the studies (52.9%) and (50%), respectively. In this study, liver and spleen injured more lacerations than contusions, whereas in the kidney, contusion was the common. Suresh Kumar et al. also supported our findings.[8] The abdomen is vulnerable to injury since there is minimal bony protection for underlying organs. Lungs were the most commonly involved organs (92.3%) in the thoracic region followed by the heart (7.6%). Suresh Kumar et al.[8] and Bakkannavar et al.[15] studies also confirmed our study findings that lungs were the most common organ injured, 61.3% and 61% in thoracic region, respectively. The lungs occupy most of the rib cage, and thus are probably more vulnerable to injury when compared to the heart. Lungs sustained more lacerations (79.1%) than contusions (20.8%).

The period of survival after meet with accident: In this study, 20% of the victims died on the spot and 39% were survived up to 24 hours, and majority of the victims survived more than 24 hours (41%), but these too died within 21 days. Archana et al. study also supported our findings,[13] whereas in Meera et al. study, the results was quite contradictory; the 47% of them were died on the spot, and 44% were died within 24 hours.[18] Most common cause of death in RTA was head injury 47 (47.0%), second common cause of death was irreversible shock in 42 (42.0%), and in remained, septicemia 11 (11.0%) was the cause of deaths. Khajuria et al. study also confirmed our findings.[10] But, this observations has been opposed by Ravindra et al.[16] study and Meera et al.[18] study; shock was the major culprit (62.7%) and (44%), respectively.

Offending agent cause for the accident: Heavy vehicles (trucks, oil tanker, lorries, bus etc.) have been found to be mostly responsible for 54.0% of cases, followed by light vehicles (car, jeep, van, taxies) 24.0%, and 12% by two-wheeler of fatal RTA. Similar studies from India also observed same findings.[913] The involvement of the heavy vehicles is due to rash driving, poor condition of the roads and vehicle, and lack of discipline among the drivers.

CONCLUSION

Majority of the times in road traffic accidents, young and productive males were injured or lost their life. More than 50% of the accidents were found to occur during the weekends. Since road users are not uniform population, these are exposed to different kinds of hazards depending upon conditions prevailing in that region, hence present different epidemiological findings. This study may help the planners to take safety measures, to implement strict traffic rules, to risk stratification in the susceptible population to educate the people, and the study of nature of offending agent in RTA can help the authorities to plan better availability of health care on roads.