Profile of patients with head injury among vehicular accidents: An experience from a tertiary care centre of India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.149382
Source of Support: None, Conflict of Interest: None
Background: Pattern of injuries among drivers, pillion riders and co-passengers of two and four-wheeler vehicles need to be separately evaluated and addressed. Materials and Methods: A prospective study was conducted on 1545 patients (1314 males and 231 females) between 01 April, 2011 to 31 December, 2011, to evaluate the profile of head injury patients due to road traffic accidents, admitted in Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. Proper subset of cases and controls with or without helmet, seat belt and history of alcohol intake were compared. Data was analyzed to evaluate the incidence, severity, pattern of head injury and outcome of the patients. Results: Male drivers of two-wheeler vehicular accidents (71.4%) were most commonly injured. Among helmeted patients, only 4.8% sustained severe head injuries compared to 23.7% of un-helmeted patients. Only full coverage helmets were effective in preventing head injury. Among helmeted patients with a proper chinstrap, 2.6% suffered critical injuries compared to 14% of non-strapped ones. In 142 patients, helmet was at position after the crash and only 0.7% of these sustained severe head injuries. Drunk driving was noticed among 19% and 6% of two- and four-wheeler vehicular occupants, respectively. Only 7.5% of the four-wheel vehicular occupants were wearing seat belt at the time of accident. Conclusions: Injury profile of two- and four-wheeler vehicular accident victims is entirely different. A ready supply of affordable helmets of appropriate quality and strict legislation for safety constraints is the need of the hour for road safety.
Keywords: Alcohol, driver, head injury, helmet, pillion-rider, seat belt, two-wheeler
Road traffic accidents (RTAs) have been the bane of the modern civilization accounting for considerable loss to the nation. General callous attitude for safety measures, poor law enforcement and uncontrolled motorization have caused significant increase in incidence of RTAs. World Health Organization (WHO) puts RTAs as the sixth leading cause of deaths in India, with a greater share of hospitalizations, deaths, disabilities and socioeconomic losses in young and middle aged population. 
Lack of reliable and good quality national or regional data has thwarted its actual magnitude. The pattern of injury between two-wheeler and four-wheeler vehicular accidents is entirely different and needs to be evaluated accordingly. The aim of present study was to evaluate the profile of patients of two and four wheeler vehicular accidents in terms of their demographic profile, injury pattern, injury severity, usage of safety constraints, incidence of drunk driving and outcome.
This prospective study was conducted at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, from 01 April, 2011 to 31 December, 2011. All the cases of traumatic head injury (THI) that is, drivers and the pillion riders of motorized two-wheeled vehicles (TWVPs) and driver and co-passenger of motorized four-wheeled vehicles (FWVPs) were enrolled. Proper subset of cases and controls with or without helmet, seat belt and history of alcohol intake were compared. Injury severity was assessed by Glasgow coma scale (GCS). Patients were re-assessed after 3-month interval with Glasgow Outcome Score (GOS). Data was analyzed to evaluate the incidence, severity, and pattern of head injury and outcome of THI patients. Spearman ranked sum analysis and multivariate analysis were used to evaluate correlation and statistical significance among various factors.
Total 1545 patients of RTAs were admitted during the nine-month period. Of these, 1346 patients belonged to two-wheeler vehicles (TWVP) while 199 to four-wheeler vehicles (FWVP).
Among 1346 TWVPs, drivers significantly outnumbered pillion riders (5.76:1) [Figure 1]a and b. The median age of the drivers and pillion riders was 30 and 36 years, respectively. Of 199 FWVPs, maximum were co-passengers that is, 1.34:1. Overall, the most commonly affected age group was 18-29 years comprising 45.43% and 46.43%, respectively in TWVP and FWVP patients. The overall male:female patient ratio was 10.8:1 [Table 1] and [Table 2].
Helmet usage rate
Despite legislation and many public awareness programs, only 13.4% of all TWVPs (16.5% drivers and 3.7% pillion riders) were wearing helmet at the time of accident (P < 0.001) [Figure 2]a. There was no statistically significant difference in helmet usage among different age group patients [Figure 2]b and c. Only 14.7% males and 5.6% females were wearing helmet; 72.7% patients were wearing a full coverage helmet and only 44.4% helmets were Indian Standards Institute (ISI) certified that is, standard helmets [Figure 3].
Seat Belt usage rate
Similarly, only 7.5% of all FWVPs (12.9% drivers and 3.5% co-passengers) were wearing seat belt [Figure 2]d. Only 2% of rear seat co-passengers of the car were wearing seat belt. There was no statistically significant difference in seat belt usage among different age groups, drivers and co-passengers, suggestive of a general attitude of negligence [Figure 2]e and f.
Total 17.6% of the injured patients (19% of TWVPs and 6% of FWVPs) had consumed alcohol before driving [Figure 4]. Among TWVPs, 22.5% of drivers [Figure 4]a and 8.3% of pillion riders [Figure 4]b had historically consumed alcohol. Alcohol consumption was equally prevalent in different age groups. In India, 'drunk driving' is still a male-dominated behavior as observed in our study. Only 4/231 female patients (i.e. 1.7%) had a history of alcohol intake. The maximum alcohol consumption was noticed on Fridays and the least on Tuesdays.
Grade of Injury
Among TWVPs, 14.3% and 6.2% patients suffered from severe and critical head injury, respectively. In every category, drivers outnumbered pillion riders but the grade of injury was nearly the same. Total 17.8% of helmeted patients suffered from moderate to severe THI in comparison to 43% of non-helmeted patients (P < 0.001). Injury grade was same among helmeted and non-helmeted drivers and pillion riders [Figure 5]a and b. We observed that among full coverage helmeted patients, only 12% suffered from moderate to severe head injury in comparison to 29.7% of partial coverage helmeted patients (P < 0.001) [Figure 5]c. Similarly, only 3.8% ISI-marked helmeted patients suffered moderate to severe head injury in comparison to 29% non-ISI-marked helmeted patients [Figure 5]d. Injury severity was statistically less in patients wearing helmet with proper chinstrap in comparison to patients not wearing it (P < 0.001) [Figure 5]e. Injury grade was significantly less in patients having helmet in situ after RTA (78.8%) in comparison to those, whose helmet got detached (P < 0.001) [Figure 5]f.
Surprisingly, among FWVPs, no statistically significant correlation could be found between injury severity and seat belt usage among drivers and co-passengers (P < 0.05) Nearly 27.3% seat belt users suffered from moderate to severe head injury in comparison to 25.7% non-seat belt users [Figure 6]a and b. No significant difference was observed in FWVP drivers and co-passengers in the injury grade at the time of admission in relation to those with alcohol intake.
GOS at follow up
There was a significant consistent relationship observed between GCS at admission with GOS at three-month follow up. The patients presenting in a better GCS score fared well in their follow up, while patients presenting in a poor GCS either remained in the same status or deteriorated at follow up. Total 478/660 that is, 89.7% patients admitted with mild head injury had good outcome at follow up and only 1.7% of critically injured patients fared well [Figure 7] a and b. It is suggestive of a significantly higher prognostic value of grade of injury at the time of admission. Total 297 (19.22%) patients were lost to follow up.
Exploding population, increasing registration of automobiles every month, rampant encroachment of roads, habitual tendency of violating rules and chaotic traffic systems have greatly contributed to rapid strides in RTAs. 
Young commuters (18-29 years age group) are at the maximum risk [Table 1], attributable to a high incidence of alcohol and drug consumption, poor overall sense of judgment and decision-making ability. Risk-taking behavior of adolescents, peer pressure, inexperience of young drivers and a false sense of invulnerability also contribute to unsafe driving. The higher involvement of young and male drivers seems related to how they choose to drive, particularly their propensity to take driving risks, than to their abilities at the driving task.
Only a few cities of India are actually following mandatory helmet law for drivers and pillion riders.  Pathak et al in a similar study in Jaipur found that among TWVPs most of the victims (87.2%) were not wearing any protective helmet at the time of incidence.  In our study, only 5.6% females were wearing helmet at the time of accident against 14.7% of males. The reason may be exemption from wearing helmet for Sikhs and females, who comprise 16.1% and 48.7% of the population, respectively.
A helmet aims at reducing the risk of serious head injury by minimizing the impact of force, by reducing the deceleration of the skull, spreading the forces over a greater surface area and preventing direct contact between skull and the impacting object. , When motorcyclists crash at lower speeds, helmets significantly decrease the risk of death but at speeds greater than 50 km/h, there is no added benefit from a helmet.  This finding is plausible given that motorcycles crashing at higher speeds may result in overall body injuries not compatible with life regardless of how well the head is protected, or that the energy transfer on crashing above a certain speed overcomes any protective effect of a helmet.
The incidence of full head coverage helmet was better (72.7%) in our study as compared to other studies [Figure 3].  The possible reason for this may be better availability of full head coverage helmets in the market. Full head coverage also provides an extra advantage in reducing the injuries to cervical spine and facial structures. ,,
Standard helmets (ISI marked) provide full head coverage and a thick energy-absorbing lining, while non-standard helmets cover only a small surface area of the head and have a thinner internal lining made upon less absorbent material. ,, Chin and neck straps, which are specifically designed to keep the helmet on head during an impact, must be correctly used for the helmet to function as it is designed for. ,, Individuals wearing helmet without chinstrap suffered twice the more severe injuries as compared to individuals wearing strapped helmets [Figure 5]c. ,,
The above observation demands the need for a compulsory helmet law irrespective of sex and religion. In Texas, helmet-wearing tendency fell back to less than 60% from earlier 90% when mandatory helmet laws were repealed , , which translated to increase in fatality rates by about 20.5%. , It is therefore important that when helmet-wearing legislation is introduced in low- and middle-economic countries, there should be effective enforcement along with a ready supply of affordable helmets of appropriate quality and widespread education campaigns for both community and police.
Alcohol consumption has ured itself in human affairs since time immemorial. The higher incidence of alcohol consumption on Fridays and Saturdays is attributable to weekend holidays, social gatherings and social acceptance. In contrast to western countries,  the least consumption was seen on Tuesdays. In Indian context, this may be because of the religious importance of Tuesday.
In India, intake of alcohol/drugs by drivers resulted in 27,152 RTA in 2009. Percentage share of total RTA and deaths due to the driver's fault and intake of alcohol/drugs accounted for 7.1% and 10.3%, respectively.  Drivers who consumed liquor suffered more serious injuries as compared to those who were sober.
Though we could not find a statistical significance for injury severity among seat belt wearers and non-wearers, studies do support the effectiveness of seat belts in preventing severe head injury. In our study, this paradox may be attributable to the less number of the patients. There is copious evidence that belt wearers are more careful drivers than non-wearers.  When belted drivers have crashes, they are of lower severity than crashes of unbelted drivers.  Thus, the simple calculation incorrectly attributes to the reduction in injury due to seat belt, that are in fact caused by belted drivers being in fewer, and less severe crashes. What other things are different between persons who wear restraints and those who do not is 'Nearly everything'. 
Prevention and care of injury is a multidisciplinary area and requires inter-sectoral coordination for planning. Lack of efficient surveillance system results in biased reporting of injury by different agencies, for example, RTAs constitute 95.7% of all injuries according to police department in Delhi; however, only 31% were found to be due to traffic injuries in an independent study.  The road safety problem in developing countries may be much worse than the official statistics suggest because of widespread underreporting of RTA deaths and an over-estimate of licensed vehicles.
Key determinants of RTAs in developing countries
A primary reason for rising RTAs in developing countries is increasing number of vehicles, their poor maintenance and poor laws controlling them. In India, four-wheeled motor vehicles have increased by 23% in only three years and could increase to 267 million by 2050. ,,
As a general rule, the greater the speed, the more likely a crash will occur and the more likely severe injuries will be sustained.  Accidents caused due to "Exceeding lawful speed" (driver's fault) accounted for a high share of 57.5% (219,305 out of 381,648 accidents). Similarly, persons killed due to excessive speed by drivers were to the tune of 5.9%. 
Alcohol is a prominent cause for RTAs but the reliable data of drinking under influence of alcohol is sparse. In India, the permissible "Blood Alcohol Concentration" (BAC) limit for drivers is 0.03% or 35 ml of alcohol in 100 ml of blood. In the year 2009, intake of alcohol/drugs by drivers resulted in 27,152 road accidents and 9,307 fatalities. 
Danger arises from the mixture of slow-moving non-motorized users and fast-moving motorized users sharing the same road space. A large number of road users in India are pedestrians, two-wheeler riders, bicyclists-vulnerable road users (VRUs) and even stray animals. Unlike occupants in cars and other heavy vehicles, these road users are directly exposed to traffic environments and are thus unprotected. In the event of a crash, they come in direct contact with the impacting vehicle and energy transfer is high (even in low velocity crashes) resulting in serious injuries and deaths.
Apart from the normal chaos on the roads, additional factors prevail leading to increased incidence of RTAs. To name a few, use of mobile phones while driving, listening to music, putting small children in front of the driver on the two wheelers or on the co-passenger seat of the car are some of the examples.
Inadequate public health infrastructures mean that many victims of traumatic head injury die or get disabled as they do not receive prompt trauma care. Instead of trained paramedical staff, usually bystanders, relatives, commercial vehicles or the police often transport the surviving traffic crash victims to a hospital. , Chandigarh has a higher rate of severity of RTAs with an average of 40.3 persons killed per 100 accidents against the national average of 25.8. 
RTAs (both crashes and injuries) are amenable to remedial action. Many developed countries have witnessed drop in RTA and casualties by adopting multi-pronged approach to road safety that encompasses traffic management, appropriate infrastructure, road designs, safer vehicles, law enforcement and provision of accident care, etc. The challenge for us is to adapt and evaluate these approaches to suit our needs. The time for reforms is only now. Road safety laws should be properly implemented with emphasis on general awareness about safety constraints and safe driving as primary preventive measures. This report may strengthen the database of policy makers.
My sincere thanks to Dr. Soumyata Tripathi (DNB) Dr. Amey Savardekar (MCh), Prof. M M Tondon (MA), and Mrs. Kusum Chopra (MSc) for their untiring efforts and guidance in compiling the data and statistical analysis.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]