Prehospital transport of spinal cord-injured patients in Nigeria.
Background. Well-organised and efficient prehospital transport is
associated with an improved outcome in trauma patients. In Nigeria there
is a paucity of information on prehospital transport of spinal
cord-injured patients and its relation to mortality.
Objective. To determine whether prehospital transportation is a predictor of mortality in spinal cord-injured patients in Nigeria.
Design. Prospective cohort study.
Methods. Prehospital transport-related conditions, injury-to-arrival intervals and persons who brought spinal cord-injured patients to the casualty departments at the University of Abuja Teaching Hospital, Gwagwalada, and the National Orthopaedic Hospital, Lagos, were noted. Data were analysed using descriptive statistics, the chi-square test and multiple logistic regressions.
Main outcome measures. Mortality within 6 weeks of admission.
Results. During the review period, 168 patients with spinal cord injury presented to the casualty departments. Most presented 24 hours or more after the injury (67.9%) and were brought to casualty by their relatives (58.3%). Saloon cars were the most common mode of transportation (54.2%), most patients (55.4%) lying on their back during transfer. The majority of the patients (75%) had been taken to at least one other hospital before arriving at our casualty departments. The mortality rate was 16.7%. Multivariate analysis after adjusting for age, gender and means of transportation revealed that age (odds ratio (OR) 63.41, 95% confidence interval (CI) 9.24 - 43.53), a crouched position during transfer (OR 23.52, 95% CI 7.26 - 74.53), presentation after 24 hours (OR 5.48, 95% CI 3.20 - 16.42) and multiple hospital presentations (OR 7.94, 95% CI 1.89 - 33.43) were associated with death within 6 weeks of admission.
Conclusion. Well-organised and efficient prehospital transport would reduce mortality in spinal cord-injured patients. Providing information on prehospital transport would also reduce mortality.
Transport of sick and wounded (Analysis)
Spinal cord injuries (Care and treatment)
Ahidjo, Kawu A.
Olayinka, Salami A.
Mustapha, Alimi F.
Sulaiman, Gbadegesin A.A.
Gbolahan, Adebule T.
|Publication:||Name: South African Journal of Surgery Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 South African Medical Association ISSN: 0038-2361|
|Issue:||Date: Feb, 2012 Source Volume: 50 Source Issue: 1|
|Geographic:||Geographic Scope: Nigeria Geographic Code: 6NIGR Nigeria|
Spinal cord injury in Nigeria is associated with significant
morbidity and mortality. (1-8) Socio-economic factors, poor care in
hospital and inadequate rehabilitation of the victims after discharge
may be responsible for this situation. Studies (9-10) have identified
many risk factors (11-21) for morbidity and mortality after spinal cord
injury, but none of these has been studied in the developing world.
Well-organised prehospital transport has contributed to reducing morbidity and mortality in victims of road traffic accidents. (22) Nigeria is a country without an organised prehospital transport system for trauma patients. (23-24) A study has showed that only 6% of injured victims were transported to hospitals in an ambulance, the remainder being taken in private cars and public vehicles. (23) Solagberu et al. (24) noted that victims of road traffic accidents were most commonly transported to the hospital by their relatives, and that the means of transport are generally not optimal for those with spinal cord injury.
The aim of the present study was therefore to highlight the importance of prehospital transport of spinal cord-injured patients and the contribution of these injuries to mortality in Nigeria.
Patients, materials and methods
The records of spinal cord-injured patients seen at the casualty departments of the University of Abuja Teaching Hospital, Gwagwalada, and the National Orthopaedic Hospital, Lagos, from 1 January 2009 to 31 December 2009 and admitted for at least 6 weeks were studied.
Prehospital transport and related factors were recorded using percentages, crude odds ratios (ORs), 95% confidence intervals (CIs) of the ORs, and p-values. Univariate analysis was performed using chi-square tests to identify categorical variables for the predictor of mortality. Multiple logistic regressions were used to estimate the adjusted ORs and their 95% CIs as measures of associations, including identification and adjustment for confounding variables. The data were analysed using Statistical Package for Social Sciences (SPSS) 17.0 (SPSS Inc. Chicago, Illinois, USA); a p-value [greater than or equal to] 0.05 was set as significant.
During the study period, 168 spinal cord-injured patients were admitted to the casualty departments (149 males and 19 females, male/female ratio 7.8:1; age range 14-68 years, mean age 36.4 (standard deviation 12.7) years). The mortality rate during the first 6 weeks in hospital was 16.7%.
Table 1 shows the mode of transportation of the victims to casualty. One hundred and fourteen patients (67.9%) presented more than 24 hours after injury. The distribution of groups involved in the prehospital transport of spinal cord-injured patients within the first 24 hours and afterwards are set out in Table 2. Ninety-three patients (55.4%) were transported lying flat on their back, and 60 (35.7%) in a crouched position; the remaining 15 patients (8.9%) were seated. Forty-two patients (25%) presented directly to casualty, while 126 (75%) were taken to more than one hospital.
Predictors of mortality
Univariate analysis showed the following prehospital transport and related factors to be significantly associated with mortality within 6 weeks of admission (Table 3): age, gender, transfer by bystanders, commercial bus transport, a crouched position during transfer, presentation after 24 hours, and attending more than one hospital (p<0.05). Multivariate analysis after adjusting for age, gender and means of transportation revealed that a crouched position during transfer (OR 23.52, 95% CI 7.26-74.53), presentation after 24 hours (OR 5.48, 95% CI 3.20-16.42) and being taken to more than one hospital (OR 7.94, 95% CI 1.89-33.43) were associated with mortality.
The majority of the spinal cord-injured patients treated in our casualty departments were young men. This has been noted in many reports (2-11) reviewed. These are economically active people whose disability and death causes socio-economic problems in a developing country like Nigeria.
Nigeria is a country without an organised prehospital transport system for trauma patients. (23-24) This is reflected in our finding that only 5.4% of spinal cord-injured patients were transported to the hospital in an ambulance, a figure similar to the 6% reported by Adeyemi-Doro et al. (23) The majority of our patients were transported to casualty in a saloon car. This differs from the findings in Ghana (25) and Kenya, (26) where commercial vehicles were reported to be the most common mode of transport of trauma patients, perhaps because in our study relatives represented the largest category of people who conveyed spinal cord-injured patients to hospital, usually using their own vehicles (mostly saloon cars).
We found that bystanders were the largest category that conveyed spinal cord-injured patients to hospital within the first 24 hours, probably because they are the first contact with the patient. Relatives represent the largest category that conveyed patients to hospital after 24 hours. Solagberu et al. (24) noted a similar finding. This may be because they are contacted later, when they would arrange transfer of the patients to the hospital of their choice. Relatives form the largest category that conveys spinal cord-injured patients to hospital in overall, probably because they are usually responsible for the hospital bills during the first few weeks after an accident, and the communal nature of Nigerian society means that family plays a fundamental role in the lives of individuals.
The present study shows that prehospital transport-related variables such as age, a crouched position during transfer, presentation after 24 hours and attendance at more than one hospital were associated with mortality within 6 weeks of admission in spinal cord-injured patients. Age is known to predict poor prognosis in these patients, (20-21) but a crouched position during transfer, presentation after 24 hours and multiple hospital presentation have not previously been described as significant risk factors.
Patients going from hospital to hospital and presenting after 24 hours can indicate poor trauma care in a country. In Nigeria many hospitals do not have trauma centres, and where centres do exist they often have obsolete facilities, inexperienced and overworked staff, and no dedicated trauma team. Patients may go from one health care centre to another because they do not receive adequate care. In addition, no organised prehospital transport system exists in Nigeria, so patients often present to a trauma centre late and therefore with a poor prognosis. (23) This factor may account for the high mortality rate in our study.
Our mortality rate was 16.7%. An acceptable rate in patients with spinal trauma is 5-10%, (17) so our rate is unnecessarily high and indicates the poor state of our trauma centres and care in Nigeria.
Transferring patients in a crouched position may further compromise the damaged neurons in the spinal cord. In an injury above the third cervical vertebra, this could cause paralysis of the diaphragm with resultant respiratory distress that could lead to death.
Well-organised and efficient prehospital transport would reduce mortality in spinal cord-injured patients. Disseminating information on prehospital transport would also reduce mortality.
Authorship. All the authors contributed equally to this work.
(1.) Odeku EL Richard RD. Peculiarities of spinal trauma in Nigeria. West Afr J Med 1971;20:211-225.
(2.) Solagberu BA. Spinal cord injuries in Ilorin, Nigeria. West Afr J Med 2002;21:230-232.
(3.) Obalum DC, Giwa SO, Adekoya-Cole TO, Enweluzo GO. Profile of spinal injuries in Lagos, Nigeria. Spinal Cord 2008, Aug. http://www.ncbi.nlm.nih.gov/sites/entrez (accessed 6 September 2008).
(4.) Olasode BJ, Komolafe IE, Komolafe M, Olasode OA. Traumatic spinal cord injuries in Ile-Ife, Nigeria, and its environs. Trop Doct 2006;36:181-182.
(5.) Umaru H, Ahidjo A. Pattern of spinal cord injury in Maiduguri, North Eastern Nigeria. Niger J Med 2005;14:276-278.
(6.) Nwadinigwe CU, Iloabuchi TC, Nwabude IA. Traumatic spinal cord injuries (SCI): a study of 104 cases. Niger J Med 2004;13:161-165.
(7.) Igun GO, Obekpa OP, Ugwu BT, Nwadiaro HC. Spinal injuries in Plateau State, Nigeria. East Afr Med 11999;76:75-79.
(8.) Okonkwo CA. Spinal cord injuries in Enugu, Nigeria -preventable accidents. Paraplegia 1988;26:12-18
(9.) Bouamra O, Wrotchford A, Hollis S, Vail A, Woodford M, Lecky F. Outcome prediction in trauma. Injury 2006;37:1092-1097.
(10.) Furlan JC, Krassioukov AV, Fehlings MG. The effects of gender on clinical and neurological outcomes after acute cervical spinal cord injury. J Neurotrauma 2005;22:368-381.
(11.) Bakers SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187-196.
(12.) Coelho DG, Brasil AV, Ferreira NP. Risk factors of neurological lesions in low cervical spine fractures and dislocations. Arq Neuropsiquiatr 2000;58:1030-1034.
(13.) Gabbe BJ, Cameron PA, Wolfe R. TRISS: does it get better than this? Acad Emerg Med 2004;11:181-186.
(14.) Gabbe BJ, Cameron PA, Wolfe R, Williamson OD, Cameron PA. Predictors of mortality, length of stay and discharge destination in blunt trauma. Aust N Z J Surg 2005;75:650-656.
(15.) George RL, McGwin Jr G, Metzger J, Chaudry IH, Rue III LW The association between gender and mortality among trauma patients as modified by age. J Trauma 2003;54:464-471.
(16.) Liang H W, Wang YH, Lin YN, Wang JD, Jang Y. Impact of age on the injury pattern and survival of people with cervical cord injuries. Spinal Cord 2001;39:375-380.
(17.) Neumann CR, Brasil AV, Albers F. Risk factors for mortality in traumatic cervical spinal cord injury: Brazillian data. J Trauma 2009;67:67-70.
(18.) Claxton AR, Wong DT, Chug F, Fehlings MG. Predictors of hospital mortality and mechanical ventilation in patients with cervical spinal cord injury. Can J Anaesth 1998;45:144-149.
(19.) Pull ter Gunne AF, Aquarius AE, Roukema JA. Risk factors predicting mortality after blunt traumatic cervical fractures. Injury 2008;39:1437-1441.
(20.) Cusick IF, Yoganandan N. Biomechanics of the cervical spine 4: major injuries. Clin Biomech (Bristol, Avon) 2002;17(1):1-20.
(21.) Goldberg W Mueller C, Panacek E, Tigges S, Hoffman JR, Mover WR. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med 2001;38:1721.
(22.) Mock CN, Jurkovich GJ, nii-Amon-Kotei D, Arreola-Risa C, Maier RV Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. J Trauma 1988;44:804-812.
(23.) Adeyemi-Doro HO, Sowemimo GOA. Optimal care for trauma victims in Nigeria. Trauma Quarterly 1999;14:295-300.
(24.) Solagberu BA, Ofoegbu CKP, Abdur-Rahman LO, Adekanye AO, Udoffa US, Taiwo J. Pre-hospital care in Nigeria: a country without emergency medical services. Nig J Clin Pract 2009;12:29-33.
(25.) Forjouh S. Transport of the injured to the hospitals in Ghana: the need to strengthen the practice of trauma care. Pre-hospital Immediate Care 1999;3:66-70.
(26.) Nantulya VM, Reich MR. The neglected epidemic: road traffic injuries in developing countries. BMJ 2002,324:1139-1141.
Kawu A. Ahidjo
University of Abuja Teaching Hospital, Gwagwalada, Federal Capital Territory, Nigeria
Salami A. Olayinka
National Orthopaedic Hospital, Yaba, Lagos, Nigeria
Department of Anatomy, University of florin, florin, Nigeria
Alimi F. Mustapha
Gbadegesin A. A. Sulaiman
Adebule T. Gbolahan
National Orthopaedic Hospital, Yaba
TABLE 1. MODE OF TRANSPORT Mode of transport (N (%)) Saloon car 91 (54.2) Commercial bus 41 (24.4) Open truck 23 (13.7) Ambulance 9 (5.4) Motorcycle 4 (2.4) Total 72(100) TABLE 2. GROUP OF PERSONS INVOLVED IN PREHOSPITAL TRANSPORT Group of person Within 24 hours After 24 hours Total (N (%)) (N (%)) Relative 9 (5.3) 89 (52.9) 98 (58.3) Police/FRSC staff 16 (9.5) Nil 16(9.5) Bystander 29 (17.3) 25 (14.9) 54 (32.2) Total 54 (32.1) 114 (67.9) 168 (100) TABLE 3. MULTIVARIATE ANALYSIS OF PREDICTOR OF MORTALITY Variables n/N (%) RR 95% CI p-value Crouched position 16/60 (26.7) 23.52 7.26-74.53 0.001 Presentation after 24 19/114 (16.7) 5.48 3.30- 16.42 0.001 hours Multiple hospital 21/126 (16.7) 7.94 1.89-33.43 0.001 presentation RR = relative risk; CI = confidence interval.
|Gale Copyright:||Copyright 2012 Gale, Cengage Learning. All rights reserved.|