|Year : 2021 | Volume
| Issue : 2 | Page : 126-131
Adolescent trauma: Patterns and outcomes
Joanna Preritha Fernandes1, Darpanarayan Hazra1, Chinta Annie Jyothirmayi2, Kundavaram Paul Prabhakar Abhilash1
1 Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Pediatrics, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||18-Aug-2020|
|Date of Acceptance||26-Mar-2021|
|Date of Web Publication||29-Jun-2021|
Dr. Chinta Annie Jyothirmayi
Department of Pediatrics, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Adolescence is the transitional stage of physical and psychological changes that occur from puberty to adulthood, and disruption in growth at this stage can have long-lasting effects. Our main aim was to profile these injuries treated in the emergency department (ED) and describe the etiology, patterns, and outcomes in such patients.
Materials and Methods: We conducted a retrospective descriptive analysis of these victims who presented to us from January 2017 to December 2018. Among key factors studied were patient demographics, mechanism of trauma, injury severity, hospital admission status. In addition to descriptive statistics, we utilized univariate and multivariate analyses to help elucidate factors associated with severe injuries.
Results: The data for a total of 693 patients were analyzed. Among these, 84.5% were male. The mean age was 17.2 ± 1.33 years. Based on their hemodynamic stability, the majority were triaged as priority 2 (49.6%). The most common causes of trauma were road traffic accidents (RTAs) (63.3%), followed by sports related injury (13.7%). Two-wheeler-related incidents accounted for 82.5% of RTA-related injuries. Extremities, face, and head were injured in 51.3%, 25.8%, and 13.5%, respectively. New injury severity score of more than 14 was noted in 82 (13.2%) cases. Approximately half of the study population, 374 (54%), were discharged stable from the ED, whereas 254 (37%) were admitted with 194 (28%) requiring major surgical intervention.
Conclusions: Most of the traumas related to adolescents are RTAs, followed by sports-related injuries. Male gender and pedestrian-related injuries are independent predictors for high severity of injuries.
The following core competencies are addressed in this article: Patient care, Systems-based practice, Medical knowledge, Practice-based learning and improvement.
Keywords: Adolescent trauma, pedestrian injuries, road traffic accidents, trauma, two-wheeler-related injuries
|How to cite this article:|
Fernandes JP, Hazra D, Jyothirmayi CA, Abhilash KP. Adolescent trauma: Patterns and outcomes. Int J Acad Med 2021;7:126-31
| Introduction|| |
Adolescence is the critical stage of transition in human development in which individuals transform from children to adults and gain independence from parents. During this vulnerable period of life, individuals often experiment with intoxicating substances and attempt other risky behaviors. According to the World Health Organization (WHO) report on road safety, road traffic accidents (RTAs) will be the fifth leading cause of death worldwide by 2030. Worldwide, the leading cause of death among individuals younger than 19 years of age is trauma., Thus, this study has focused on the late adolescent age group (17–19), as they are more likely to have access to motorized vehicles. India is the second-most populous country in the world and as per the 2011 census with 253 million adolescents in India. The young population of India and other such rapidly developing countries have access to growing numbers of vehicles. This, in addition to the absence of proper road infrastructure, education, licensing, traffic laws, and law enforcement contribute to the frequency and severity of trauma. The WHO, therefore, organized the decade of road safety (2011–2020) focusing on improving and equalizing systems among developing countries. During recent years, the Indian government has been giving a lot of emphasis on the health and well-being of adolescents. At the Summit on the Call to Action for Child Survival, in February 2013, India launched a new zealous strategy for adolescent health, known as Reproductive, Maternal, New-born, Child, and Adolescent Health to decrease mortality among adolescents in India.
The majority of deaths related to trauma occur in the prehospital period due to insufficient prehospital care. The first 60 min after the trauma has been considered as the “;golden hour” of trauma. It is, therefore, important to quickly assess the severity of the injury accurately and quickly. This study was done to improve the understanding of the mode of trauma, severity of injuries, and outcome in adolescent patients presenting to our hospital, so that effective prevention and comprehensive management strategies could be made.
| Methodology|| |
This retrospective study was done in the emergency department (ED), which is a 49-bedded department and tends to about 300 patients per day including trauma and non-trauma patients. We recruited all patients in the age group of 17–19 years (late adolescence) who presented with trauma, during the study period of 24 months (January 2017 to December 2018). The study was approved by the Institutional Review Board (IRB Min no: 12222 dated August 22, 2019) before the commencement of the study. The study strictly adheres to the STROBE guidelines.
Our study aimed to describe the profile and outcome of adolescent patients with trauma presenting to our ED during the study period of 2 years. The objectives of the study were to determine the monthly variation of trauma, mode of trauma, proportion of patients under the influence of alcohol during the incident, severity based on anatomical scoring system, statistical analysis to determine the predictors of such injuries, and ED outcomes of these patients.
All patients had relevant radiological tests and routine blood investigations based on the initial primary and secondary surveys. The charts were reviewed, and the relevant history, clinical examination, laboratory, and radiological investigations were documented in a standard data abstraction sheet. Further, the severity of injury in terms of new injury severity score (NISS) and the outcome of each patient was noted from immediate resuscitation to conservative/surgical management. The NISS is an anatomical scoring system of the severity of trauma and is calculated by the sum of the squares of the abbreviated injury scale scores of three of the patient's most severe injuries irrespective of the body region in which they occur. Outcomes of the patients from the ED with regard to admission, discharge, leave against medical advice, and death were documented.
The data were analyzed using Statistical Package for the Social Sciences (SPSS) for Windows software released 2015, version 23.0, Armonk, New York, USA. The data were summarized using mean along with standard deviation for continuous variables and frequencies along with percentages for nominal variables. A bivariate analysis was done to identify the relationship between these variables and the potential determinants. All possible determinants with P ≤ 0.05 in the bivariate analysis were used as candidates for multivariate logistic regression analysis to determine their significant association.
| Results|| |
The ED attended to a total of 143,621 patients during the 2-year study period. The prevalence of trauma was 9.47% (13,604) with adolescents comprising 5.2% (693/13604) [Figure 1].
The mean age was 17.2 ± 1.33 years, with a male preponderance (84.5%). Based on their physiological status at arrival, half of the patients, 49.6% (344/693), were triaged as Priority 2, 37.2% (258/692) were triaged as Priority 3, and 13% (91/693) as Priority 1. Vital signs at presentation to ED are given in [Table 1].
|Table 1: Baseline characteristics, vital signs at presentation, and modes of injury|
Click here to view
Injury profile included fractures (53.1%; 368/693), lacerations (50.4%; 349/693), abrasions (47.2%; 327/693), hematomas (4.7%; 33/693), sprains (4.1%; 28/693), and dislocations (1.5%;11/693). Injuries were distributed over the body as follows: extremities (51.3%; 356/693), face (25.8%;179/693), head (13.5%; 94/693), scalp (10.5%; 73/693), thorax (5.6%; 39/693), and abdomen (4.5%; 31/693). Injuries to the back, neck, and spine were comparatively less [Figure 2].
Modes and types of injuries
The most common cause of trauma was RTA (63.3%), followed by sports-related injuries (13.7%). Fall from height (FFH) accounted for 7.5% of injuries and assaults accounted for 2%. Among RTA-related injuries, the largest proportion of injuries were two-wheeler-related 82.5%, followed by pedestrian-related injuries (6.2%). Other modes of RTA-related injuries are shown in [Table 1]. The highest number of trauma-related incidents were seen between July and December. RTA was highest in August (48/439; 10.9%), followed by September (46/439; 10.4%) [Figure 3].
Triage priority level and severity of injuries
The breakdown of triage priority level versus NISS is as follows. Among the Priority I patients, NISS of more than 14 was seen in 43.9% (40/91) of cases, NISS 8–14 in 27.3% (23/91) of cases, and <8 in 30.8% (28/91) of cases. In Priority 2 patients, majority, i.e., 59.9% (206/344), had NISS of less than 8, followed by 27.9% (96/344) with NISS ranging from 8 to 14. Similarly, in patients triaged as Priority 3, majority, i.e., 89.5% (231/258) of cases had NISS of <8, followed by 9.7% (25/258) of cases with NISS ranging from 8 to 14. Multivariate logistic regression analysis revealed male gender (Odds Ratio [OR]: 0.57; 95% confidence interval [CI]: 0.35–0.95; P = 0.03) and pedestrian injuries (OR: 0.41; 95% CI: 0.18–0.94; P = 0.035) to be independent risk factors of sustaining severe injury [Table 2].
|Table 2: Bivariate and multivariate logistic regression analysis for predictors of severity of injuries in adolescents suffering from trauma|
Click here to view
Hospital course and outcome
The departments involved in patient care in the ED were orthopedics 31.7% (220/693), neurotrauma 23.8% (165/693), plastic surgery 16.1% (111/693), pediatric surgery 11.1% (77/693), trauma surgery 9.7% (67/693), and pediatric orthopedics 8.9% (62/693) [Figure 4]. ED disposition was as follows: 54% (374/693) of patients were discharged stable from the ED, whereas 37% (254/693) were admitted with 28 (194/693) requiring major surgical intervention. Minor surgical intervention was sufficed in 22.6% (157/693) of patients, whereas 49.4% (342/693) were treated conservatively.
|Figure 4: Departments involved in the management of patient in the ED and subsequent admission|
Click here to view
| Discussion|| |
Our study clearly showed the severity and pattern of trauma among the adolescent population. We noted RTAs secondary to two-wheeler-related incidents as a dominant risk factor for sustaining injuries in adolescents. Studies in the past have used different scoring systems such as acute physiology and chronic health evaluation, injury severity score, and simple scores like that of revised trauma score to predict early mortality. However, among these, the new standard scoring system is the NISS which is the score used in this study to predict the severity of injury and mortality. Our study shows that male gender and pedestrian injuries were independent risk factors for a high NISS, which is an indicator of severe injury. This combination of factors can lead to traumatic injuries of different kinds, some of which required life-saving emergency treatment. Similar findings were also observed by Boyle et al. and Abhilash et al. in 2008 and 2016, respectively., Previous studies on RTA revealed that more than one-third of the adolescents are at risky behavior and disobey traffic rules, leading to such incidents and even death.,, This is explained by the fact that young men are more inclined to outdoor activities and hence more vulnerable to injuries. Nearly 13.5% of patients in our study had traumatic brain injury, almost always associated with other major injuries. Falls comprised 7.5% all trauma cases in our study and this proportion is similar to that of other studies., Four-wheeler vehicles offer more protection to those sitting inside them, unlike two-wheeler passengers and pedestrians. This could be the reason for an overwhelming majority of accidents involving two-wheelers and pedestrians, consistent with other Indian studies., A comparison between overall trauma, RTA-related, and two-wheeler-related injuries in regard to monthly distribution showed that there was an increasing trend during July through December. This coincides with the local monsoon season. A similar trend seen among two-wheeler injuries as shown in [Figure 3] is due to the fact that the two-wheeler-related injuries are a substantial part of the RTA and overall trauma, which was also seen in a previous study done by Abhilash et al. Being an advanced tertiary care center, the trauma teams operating in our ED are highly specialized, and after initial resuscitation by the ED team, these cases are managed by higher specialty trauma departments such as trauma surgery, orthopedic surgery, neurosurgery, plastic surgery, hand surgery, vascular surgery, cardiothoracic surgery, and spine surgery.
Studies have shown that there are two important factors contributing to trauma in the adolescent-underdeveloped skills due to inexperience which has been termed as “the young driver problem” or intentional risk-taking associated with adolescence termed as “the problem young driver.”, Some practical solutions that have been shown to be effective are communication campaigns highlighting the dangers of unsafe behavior particularly targeting young males and pre-driving teens, which particularly emphasizes on issues such as speed, drunk driving, and mobile phone uses. In addition, laws need enforcement to be effective, especially when it comes to the issue of drivers' licenses, use of helmets, seatbelts and distribution, and consumption of alcohol. In addition, modern technology such as smart cards that avoid unauthorized drivers and alcolock which prevents drink and drive can be implemented. A combination of more than one approach is required for maximum effectiveness.
Research in the realm of adolescent health is surprisingly poor in India and major findings regarding the adolescent health problems are from the national level surveys such as the national family health survey; hence, there is a large void in data and therefore this study is relevant in the present scenario.
Our study is a retrospective study; thus, we had to rely on documentation done by other doctors and charts from our online patient information. Our study only included trauma victims in the late adolescent age group (17–19). Missing charts and incomplete documentation were the roadblocks encountered during data collection. As our hospital is a tertiary care center and is influenced by referral bias, these data might not be a true reflection of the community.
| Conclusions|| |
RTA secondary to two-wheeler-related injuries is the most common mode of injury. Male gender and pedestrian-related injuries are independent predictors for high severity of injuries. The fact that more than a quarter of trauma victims in this budding age group required major surgical intervention is quite perturbing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Research quality and ethics statement
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is IRB Min no: 12222 dated August 22, 2019. We also certify that we have not plagiarized the contents in this submission and have done a plagiarism check.
| References|| |
Denning GM, Jennissen CA. Pediatric and adolescent injury in all-terrain vehicles. Res Sports Med 2018;26:38-56.
Samal J, Dehury RK. Salient features of a proposed adolescent health policy draft for India. J Clin Diagn Res 2017;11:LI01-5.
Abhilash KP, Chakraborthy N, Pandian GR, Dhanawade VS, Bhanu TK, Priya K. Profile of trauma patients in the emergency department of a tertiary care hospital in South India. J Family Med Prim Care 2016;5:558-63.
] [Full text]
Doud AN, Moro R, Wallace SG, Smith MD, McCall M, Veach LJ, et al
. All-terrain vehicle injury in children and youth: Examining current knowledge and future needs. J Emerg Med 2017;53:222-31.
Boyle MJ, Smith EC, Archer FL. Trauma incidents attended by emergency medical services in Victoria, Australia. Prehosp Disaster Med 2008;23:20-8.
Kenefake ME, Swarm M, Walthall J. Nuances in pediatric trauma. Emerg Med Clin North Am 2013;31:627-52.
Sunitha S, Gururaj G. Health behaviours & problems among young people in India: Cause for concern & call for action. Indian J Med Res 2014;140:185-208.
] [Full text]
Cutler GJ, Kharbanda AB, Nowak J, Ortega HW. Injury region and risk of hospital-acquired pneumonia among pediatric trauma patients. Hosp Pediatr 2017;7:164-70.
Klaitman SS, Solomonov E, Yaloz A, Biswas S. The Incidence of road traffic crashes among young people aged 15-20 years: Differences in behavior, lifestyle and sociodemographic indices in the galilee and the Golan. Front Public Health 2018;6:202.
Araki T, Yokota H, Morita A. Pediatric traumatic brain injury: Characteristic features, diagnosis, and management. Neurol Med Chir (Tokyo) 2017;57:82-93.
Roy N, Kizhakke Veetil D, Khajanchi MU, Kumar V, Solomon H, Kamble J, et al
. Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths. BMC Health Serv Res 2017;17:142.
Sivagurunathan C, Umadevi R, Rama R, Gopalakrishnan S. Adolescent health: Present status and its related programmes in India. Are we in the right direction? J Clin Diagn Res 2015;9:LE01-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]