INTRODUCTION

The increasing role of head injury as a leading cause of morbidity and mortality in young males in the Arabian Gulf countries demands more attention than it is currently receiving. The problem should indeed have been anticipated given the marked increase in automobile use over a relatively short time and the expansion of road networks contingent on the very rapid economic and social development in these countries. Yet the trauma epidemic as it were, is sweeping over the sub-region without any coherent strategy to limit the incidence or contain the consequences of at least motor vehicle accidents which are the major cause of mortality. In addition the population in most countries in the peninsula is essentially a young one, consisting of a large proportion of actively working expatriates and immigrants with young families and an indigenous population typical of developing countries. Indeed in the 1986 census, only 2 % of the population of Qatar were found to be above 60 years of age [1]. It is precisely such a young population that is at most risk for traumatic brain injury (TBI). Any programme for limiting and managing such injuries will require a clear understanding of not only the extent of the problem but the patterns of injury and any peculiar local factors that modify it.

The studies available from Saudi Arabia [2-4], Kuwait [5,6] and United Arab Emirates [7] mainly addressed the general. aspects of trauma. This retrospective study examines the epidemiological and other features of TBI in the State of Qatar. To our knowledge no study in the Gulf has specifically addressed these features of head injuries.

The Hamad General Hospital where this work was done is a well equipped centre serving as the only Hospital in the country receiving trauma patients and so is uniquely placed to provide both epidemiological and Hospital based data for such a study.

MATERIAL AND METHODS

All patients who attended the Hamad General Hospital's Accident and Emergency department for trauma between January 1991 and December 1995 were identified from the Hospital Computer Data Base and analyzed to determine the general incidence and early mortality pattern.

The case files of all patients who were admitted with head injuries coded as (ICD) 800,801, 803,804, 850 - 854 were then further studied for injury mechanism, severity of injury using the Glasgow coma scale (GCS) score and outcome in terms of morbidity and mortality using the Glasgow outcome scale (GOS). Patients who had no clear evidence of traumatic brain injury (with or without CT-scan) and who were observed for less than 24 hours in the Accident and Emergency department before being allowed home were excluded. Also excluded were patients without adequate documentation in the case files.

RESULTS

General Incidence
During the period of study, 12042 patients attended the Hospital with head injuries. About 43.1% of these were from road traffic accidents while 33.6% were due to falls from heights at home, at play or at work. Sports injuries including falls from Camels and Horses, objects falling on patient's head, assaults and other sources of trauma accounted for the remaining 23.3%.

Early Mortality
There were 318 deaths from trauma occurring in the Accident and Emergency department in the study period. All had associated head injuries. This constituted about a third of deaths recorded in the Accident and Emergency department and in males over the age of 13 years, accounted for almost 40% of emergency deaths (table 1). All emergency trauma deaths in children occurred on or before arrival in hospital.

	All Deaths Trauma Deaths    Before Arrival In A & E Before Arrival In A & E Males 649 14 247 11 Females 235 11 33 1 Children (<13 years) 62 0 26 0    946 25 306 12
	Table 1 — Mortality pattern in the Accident & Emergency Department. of Hamad General Hospital (1991-1995)

ADMITTED CASES

 

3901 admitted patients met the criteria for inclusion into the study and of these 661 (17%) were admitted into the intensive care unit. Majority (38.9%) were children under 10 years and the male-female ratio was 3.3:1 (Table 2).

	Age (yrs) Males Females Total % under 10 940 579 1519 38.9 11 to 20 608 76 648 17.5 21 to 30 621 103 724 18.6 31 to 40 458 75 533 13.7 41 to 50 188 34 222 5.7 51 to 60 107 24 131 3.4 Over 60 70 18 88 2.3
	Table 2 — Age and sex distribution of admitted head Injuries

	Figure 1 — Distribution of traumatic brain injury by cause		Figure 2 — Causes of injury by age.
	Figure 3 — Nationality of patients with traumatic brain injury.		Figure 4 — Causes of injury by week days..

While road traffic accidents were the most common cause of traumatic brain injury requiring admission (Fig 1), fall related injuries came a close second, although they resulted in less severe injuries as measured by the GCS (Table 3).

	GCS RTA FALLS OTHER 3 - 8 422 95 19 9 - 12 123 78 41 13 - 15 1225 1547 351 P<0.001
	Table 3 — Admission Glasgow Comma Scale by Cause of Injury

Figure 2 shows the cause of injury by age. In the road traffic accident subgroup, injury 22 severity was more in pedestrians than in car occupants (table 4). The indigenous population was involved in 45.8% of cases (fig 3). Most of the admissions were on Thursday or Friday (fig. 4) but no real seasonal variation was demonstrated. There were 126 inpatient trauma deaths, 96% of which were from road traffic accidents. 102 patients required continuing care either in the National Rehabilitation centre or had to travel abroad for further care. Table 5 shows the outcome at 3 months. There was an overall mortality of 3.7% (444 patients) of which 88.1% were males.

	Motor Vehicle Occupants GCS Pedestrian(%) Driver(%) Passenger(%) 3 - 8 162 (32.7) 92 (21.5) 155 (25.9) 9 - 12 76 (15.4) 51 (11.9) 79 (13.2) 13 - 15 257 (51.9) 285 (66.6) 365 (60.9)
	Table 4 — Injury severity in motor vehicle accidents

	GCS Good Moderate Disability Severe Disability Vegetable Death Uncertain 3 - 8 95 207 40 5 113 76 9 - 12 146 19 22 1 11 43 13 - 15 2651 98 2 - 2 370 Total (%) 74.1 8.3 1.6 0.3 3.2 12.5
	Table 5 — Outcome at 3 months in admitted patients

DISCUSSION

The incidence of traumatic head injuries in Qatar is high. With a population of around 526,647 [8] for the country the incidence is 457 / 100,000 / year, which is much higher than the incidence in the United States [9] or United Kingdom [10], but similar to that reported from South Africa [11]. Reports from other Arabian Gulf countries indicate a similar trend. As is the case in most reports, road traffic accidents are the most common cause of head injury but majority of the patients sustain minor injuries that do not require admission f12]. In our series, only 27.9% of patients who sustained head injury were admitted and amongst these 80.1% were categorized as minor (GCS >13). Khoweiled et al [3] however, found that in some districts of Saudi Arabia, both the accident / injury ratio (3:2) and the case / fatality ratio (1:10) for road traffic accidents were considerably higher than comparable data from the United Kingdom.

Trauma involving the head accounts for 32.8% of emergency deaths in the State of Qatar. Over 80% of these occur in young males aged between 15 and 40 years (table 1). Trauma in general is the leading cause of emergency deaths in the country Similar high mortality from trauma has been described in other Gulf countries. In Kuwait, traffic accidents were the second leading cause of death after cardiac disease [6] and Al-Tukhi [4] analyzing reports from the Gulf area concluded that road traffic accident related deaths on the whole were second only to infectious causes. About 71.6% of deaths from trauma occurred at the scene or on arrival to the Hospital before any meaningful treatment could be instituted. Children were more likely to die before arrival in hospital than adults and this must be considered in all aspects of Emergency Medical Services(EMS) planning.

Fall related head injuries accounted for 33.6% of attendance to Hospital. Amongst admitted cases however, falls accounted for 44.1% of patients with head injury but this is not necessarily a reflection of increased severity. Since the majority of falls occurred in females and children under 10 years (fig 2), the high proportion of admissions for falls may in fact be more related to a lower threshold for admission of children. Indeed, as shown from Table 2, only 10% of patients admitted with falls had moderate to severe injuries while injuries of the same severity occurred in 30.8% of road traffic accident patients.

In the road traffic accident subgroup of patients, pedestrians sustained more severe injuries than motor vehicle occupants (P<0.001) and this is consistent with findings in Australia [14] suggesting that pedestrians are more likely to develop head injuries while motor vehicle occupants are more prone to chest and limb injuries. Road traffic accident was the commonest cause of admissions for trauma in young adults between the ages of 15 and 40 years with a peak in the third decade (fig2). Recent studies on drivers in Qatar and United Arab Emirates showed that seat belt utilization, which is closely related to the severity of injury, increased with increasing age and driving experience. Female gender and high educational background were also found to increase seat belt utilization and to result in a lower accident rate [13].

Overall the patients ages ranged from 2 weeks to 93 years with a median age of 17 years and a mean of 19.59. In spite of the diffuse mix of nationalities in Qatar, there is a relatively high incidence of TBI among the indigenes. With an estimated proportion of Qataris of about 38% of the population, the head injury incidence of 45.8% in Qataris is significantly high. This study confirms the previous findings here [15] that more injuries occur on Thursdays and Fridays. Since these days are observed as weekend days, this corresponds to the weekend pattern for trauma noted elsewhere. It does not seem to matter where the so-called rest days are placed.

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