Dynamics of lethal head injuries in Riga in 90-ties.

In forensic pathology Lethal Head Injuries (LHI) in Latvia has been met in 2/3 cases of all lethal mechanical injuries and among joungsters is even in the first place of all death reasons. In 1993-1995 LHI were in the third place after coronary and cancerous deseases. For the prophylaxis of LHI it is important to research its dynamics and ethiology. As a comparison there have been chosen data of the years 1993, 1995 where there was the highest mortality level of LHI and the stabilisation period at the end of 1999 - after the data of forensic medicine authopsies in Riga and Riga region (approximately on 1million inhabitant). Results: after the increase of LHI at the begginning of 90-ties, the fall of the number of cases at the begginning of 1999 has afflicted only men. In the age group of 41-60 there is the highest number of lethal cases with the largest difference between men and women: 4,75 : 1; in the age group above 60, the ratio is almost 1:1. In the ethiology of LHI there have maintained the proportions of 1993-1995, where prevails falls with the highest mortality (44,09% and 45,71% of all LHI). The largest risk group is men of the age of 41-60. In 1999 proportionally increased number of transport traumas, especially the amount of byke and moto traumas, mainly in the group of school children, as well as in the group of elderly women in pedestrian autotraumas. Great number of LHI occures in cases of uncertained circumstances (increased from 6,5% up to 10,12% cases), which can evidence on received unsatisfactory references (police investigations). In 1999 there has been noticed increase of shot criminal traumas which has reached 5% of all LHI. But there is fallen number of suicides which appears using shot weapons. Number of production traumas have increased more than twice. In morphology of LHI there have beeen observed increase of gravity of the traumas: fractures of the skull have been stated more often - 97,8% in 1999 against 58,8% in 1993; number of politraumas have increased up to 52,1% from 30,5%. The increase of the gravity of the traumas could evidence mortality during the first hours after hospitalisation. In ethiology of traumas great importance is to proportionally high alchocol intoxication (55,27%), marking new tendence - head injuries influenced by narcotic stuff. Dynamics of LHI is connected with the social changes: social stress during the renewal period of the country, rapid increase of the number of the cars and car accidents, unfavourable criminogen situation, alchocolism, increase of narcomania, social adaptation at the end of 90-ties, norms of legislation which limits the speed of the traffic, usage of mobile phones while driving, usage of winter tires, improvement of the technical control in transportation fleet, effective control of alchocol intoxication, fight with criminality, stabilisation of economical situation, improvement of the quality of medical assistance (CT, MRI, acceleration of the time of ambulance, and others)

Introduction

In clinical forensic medicine as well as in forensic pathology head injuries take the leading place among other mechanical traumas in all groups of mechanical traumas also in Latvia and it is the main reason of death. For example, from the statistical registration of Latvian forensic medical expertise centre in the period from 1983-1988 [1] (O. Teteris, dissertation) every year head injuries have been the direct reason of the death in 60,4-70,2% cases of car accidents, in 69,7-88,1% cases of moto traumas, in 55,3-80,3% cases of lethal railway traumas, in 66,5-79,5% cases of falls from the hight, in 59-66,3% cases of traumas from blunt object. Reason, morphology, patogeneses, tanathogeneses as well as clinical and forensic medicine diagnostics of LHI and sense of it research became actual at the begginning of 90-ties, especially in 1993-1995 when there was rapid increase of mechanical traumas and LHI, and it reached characteristics of epidemy. [2] (O. Teteris, Epidemic of lethal head injuries). In 1994 total amount of HI caused death were in the first place in Latvia ahead oncological as well as cardiovascular deseases [3] (V. Keris, J. Ozoliņš, H. Ozoliņš, H. Aide, and others. Improvement of treatment of heavy HI / Traumatism of head brain (Materials from scientific conference), Riga, 1994, p. 16-17). Common annual state medical statistics does not show the exact number of head injuries, because there are marked only the direct reasons of mortality, shock, anaemiae, coma, counting in the main diagnostics only one of the morphologic forms of head injuries or in cases of politraumas, or competitive reasons of mortality - not counting head injuries at all and not marking statistical data of cities or country regions where are different groups of the risk. [4, 5] (Annual Statistical Book of Health care in Latvia (1993, 1995)). That is the reason why "hidden head injuries" does not appear in the statistics of total amount of lethal cases. Incomplete count of head injuries appears also in cases of light head injuries, because part of the victims refuses from therapy and diagnostics due to the financial status, which later can cause problems in clinical forensic medicine evaluating bodily injuries of these persons. In 80-ties only in 1987 more detailed research of epidemiology of head injuries was done by doctors from neurosurgery and forensic medicine centres (on LHI), inspecting one of Riga district (population of 200 000 and one rural region with population of 50 000).

In our epidemiologic research of LHI in 1993 there were covered all 735 cases of LHI in the capital of Latvia Riga and there was made inquery in all regions of Latvia - total amount of heavy head injuries which caused death in 1993 was in 15?050 cases in the whole territory of Latvia. Taking in consideration the great number of LHI, in 1995 cases of LHI in Riga (including Riga district) were counted repeatedly, where there were determinated the highest result in 1993 and the gained epidemiologic results were almost analogous as in 1993. At the end of 90-ties decreased and stabilised the total amount of lethal cases caused by mechanical traumas in Riga [6] (G. Grauss, Z.?Ganulevičs. The analysis of homicides and accidents caused by mechanical factors in the city and district of Riga during the period from 1993 to 1997. Medicina Legalis Baltica, V 10, 1999, p. 32-39) but still there remained large number of cases of LHI. In 2000 Centre of Neurosurgery stressed the necessity to analyse the risk factors of head injuries and to determine groups for the most succesful prophylaxis of head injuries once more. That is why there was made repeated reasearch of epidemiologic data on cases of LHI in Riga city in 1999.

Results

Research of the structure of violant death in the Baltic countries [5,7] (Statistical book of Medicine 1995, 1999) allows to conclude that equal rates of violant death (half of them are from mechanical traumas (2/3 are LHI) appear in all of the Baltic countries and its dynamics gaining independance in 90-ties was almost similar, when violant mortality increased at the begginning of 90-ties and decreased at the end of 90-ties, staying 3 to 5 times greater than in Scandinavian countries or Germany. [7] (Statistical book of 1999). In 1995 the amount of violant death in Latvia was 235,9 cases on 100 000 inhabitants, in Lithuania 185,9/100 000 and in Estonia 233,2 / 100 000.

In the Baltic countries in medical statistics LHI are not analysed like separate cases which makes necessity to research them separately. In the research of LHI in 1993, 1995, 1999 in the group of mechanical traumas there were counted all cases of mortality connected with the morphologically heavy head brain injuries (HBI) in authopsies, including mortality with heavy BI combining with other associated injuries, in cases of politrauma registering cases of damage of skeleton bones and internal organs. Light head injuries were not included in the research - clinically set diagnosis as brain concussion. Comparing with the epidemiologic researches of LHI in the world mentioned in the scientific literature [8] (G. M. Teasdale Head injury, J. Neurol Neurosurg-psychiatry, 1995, v.?58, n 5, p.?526) number of cases of LHI in Latvia and specially in its capital Riga in the middle of 90-ties was the highest, which decreased a little bit only at the end of 90-ties.

Table. Epidemiology Of LHI in the world

State	years	Addmission/	Death/	Lathality
(city)		100000	100000	in (%)
USA	1970-74	200	25	12,5??
Olmsted Co	1935-74	193	22	11,3??
Bronx	1981	249	28	10,8??
Sand-Diego	1978	295	22	7,5
Chicago	?	?	?	?
City black	?	403	32	7,9
Suburban black	?	394	19	4,8
Suburban white	?	196	11	5,5
Australia	1977	392	25	6,3
Australia	1977	180-200	25	14-15,6
England	1972	270	10	3,7
England	1993	?	9	?
Scotland	1974-76	313	10	3,2
Johannesburg	1986	316	81	25,6??
France	1986	281	22	7,8
Spain	1988	91	20	21,9??
Cantabria	1992	?	19,7??	?
Sweden	1984	249	17	6,8
Estonia	1993	?	20	?
Latvia (1 region)	1984	?	29	?
Latvia	1993	411	54	13,1??
Riga	1993	?	73	?
Riga	1995	?	61	?
Riga	1999	?	~50??	?

Detailed analyses of LHI on different kinds of transport, fall and criminal traumas and its proportions in Riga in 1993 and in 1999 in comparison of other regions of Latvia are given in the table.

The data from the table shows that due to the decrease of the number of LHI the proportions have changed - there is increase of transport trauma, identic number of mortality cases from fall and twice times decreasing number of criminal traumas, at the same time in absolute numbers (twice) and structurally (three times) increasing number of murders of shot weapons. There is also increase of work-related traumas. The absolute numbers and proportional changes somehow show the processes in society in 90-ties: increase of transport intensity on the roads, decreasing traffic on the railways, relative decrease of crimes upon person's life which is connected with the stabilisation of economy, increase of spread of the weapons in society, extension of industry at the end of 90-ties. At the same time there should be taken into consideration the prophylaxis of traumas (speed limits, usage of near lights, obligatory usage of winter tires, more careful technical car control, usage of alcometers to determine degree of intoxication of the drivers, usage of hand-free system in cars while talking on the mobile phones, etc.) which has changed lethality and rareness of auto traumas.

Tabel. Causes of head trauma in Riga 1993, 1999 and in regions of Latvia

Kind of trauma	1993	1999	regions
TRANSPORT TRAUMA	221 (30,06%)	39,87%	45,11%
auto-pedestrian	114 (15.51%)	93 (19,21%)	11,14%
car drivers and passangers	66 (8.98%)	59 (12,19%)	18,01%
motor cycle	3 (0.41%)	20 (4,13%)	8,57%
tram, trolley, bus	7 (0.95%)	?	?
railway	31 (4.22%)	13 (2,68%)	5,49%
FALL	336 (45,71%)	209 (43,18%)	27,26%
Fall at uncertain condicion	47 (6,5%)	48 (9,91%)	?
simple fall	202 (27.48%)	125 (25,82%)	14,58%
on stairs	61 (8.30%)	24 (4,95%)	6,52%
from structures	71 (9.65%)	59 (12,19%)	5,15%
falling objects	2 (0.27%)	3 (0,61%)	1,03%
CRIMINAL TRAUMA	158 (21.50%)	82 (16,94%)	22,8%
punch, kick	87 (11.84%)	39 (8,85%)	12,18%
weapons	58 (7.89%)	8 (1,65%)	8,91%
shot injuries	13 (1.77%)	24 (4,95%)	1,71%
suicide-related	16 (2.18%)	2 (0,41%)	3,43%
Work-related	4 (0.54%)	13 (2,68%)	0,68%

At the end of 90-ties in the structure of LHI the relation of traumas have changed among women and men, remaining almost the same among women and rapidly decreasing among men in 1999, which can testify that in the periods of social changes men are related to the traumas more often.

Table. LHI related to the age and sex in 1993, 1999

The mentioned table shows the largest risk group of LHI among men in the age group of 41-60, where the proportion of men/women is 4,75:1, but in the age group above 60 the proportion is almost 1:1 (there should be considered the prevalence of women in the population at this group of age)

To evaluate the highest group of risk there have been analysed the main ethiological groups of LHI: transport traumas, falls, criminal traumas and it separate kinds depending on the age and sex.

Table. Structure of the transport traumas depending on age and sex

The table No. demonstrates the highest group of risk of LHI among auto - pedestrian and railway traumas in the group of elderly women which is connected with the reaction and speed limit at this age; the high risk of drivers in the group of young men. In comparison with the year of 1993 there is increase of number of mototraumas.

Table. Falls depending ex, kind of fall

The fall table demonstrates the high risk among the group of common falls on plane (hard surface) which is the largest group of all kinds of traumas in the group of middle aged men of 41-60, analogic to 1993; the main reason of these traumas is intoxication with alchocol. The attention should be made on adult - on the morphology of trauma characteristic to the number of falls and the unclear circumstances of them which can justify the unsatisfactory work of examination service.

Table. Criminal traumas

In comparison of 1993 in 1999 number of criminal traumas has decreased, but there is a danger tendence to do a crime with guns - number of victims in 1999 has increased twice. These numbers mirror the inconsiderated politics of free usage and purchase of guns, which, for an example, has become a national disaster in several states of USA.

In comparison of LHI structural rates in the world, there should be marked the high number of LHI in group of falls in 90-ties in Latvia, which considerably exceeds rates in other countries.

Table. Distribution (%) of LHI causes in different states and cities

Place and Reference

Road traffic

accidents

Falls

Assault

USA	49	28	-
Olmsed Co	47	29	4
Bronx	31	29	33
Sand Diego	48	21	12
Chicago	?	?	?
City black	31	29	40
Suburban black 32	21	?	?
Suburban white 39	31	10	?
Maryland	49	26	11
Australia	53	28	-
Scotland	24	39	20
France	60	32	1
Spain	60	24	-
Taiwan	90	5	-
Johannesburg	M 35	4	45
?	F 39	3	38
Riga (1993)	30	46	21,5
Latvia (1993)	38	36,5	22
Latvia,s country-side	45	27	23
Riga (1999)	40	43	17

Considering that epidemiologic rates in 1995 structurally were almost identic to the rates in 1993, for comparison we give evaluation of LHI in Riga of years 1993 and 1999 and in the regions of Latvia of year 1993.

Comparison researches of LHI in Riga, as one of the cities of the world (more than 1 million inhabitant), and in other regions of Latvia (in the research of year 1993) showed great difference in the epidemiology of LHI which depends on social life, transport and other circumstances in cities and country-side. The table shows the great prevalance of transport traumas in the country-side, especially LHI in the saloons of the car (driver, passengers), great risk of byke, moto traumas, but at the same time number of LHI decrease twice in case of falls in the middle of almost similar rates of criminal traumas.

As mentioned in the epidemiology of head injuries one of the main reasons is intoxication with alchocol which is separate problem in the Baltic countries and it is one of the leading reasons of the high rates of violent mortality. In the group of LHI there are summarised rates of dead persons comparing years 1983, 1986 (after anti-alchocol campagne of Mr. Gorbachov), 1993 and 1999.

Table. Intoxication with alchocol in the group of LHI 1983-1999

?	1983	1986	1988	1993	1999
					Men	Women
Falls from the hight	58%	43,7%	47,1%	-	55%	22%
Traumas with dull weapons	51,8%	40%	46,9%	-	-	-
Auto trauma	49,1%	34,4%	41,3%	-	51%	31%
Railway trauma	68,9%	31,8	61,4%	-	75%	56%
Total used alchocol	57%	37,5%	49%	56%	55,27%

The mentioned numbers in the table show the high proportion of intoxicated persons in the different groups of LHI, even women, especially in the group of railway traumas. The identic usage of alchocol can be observed in the pre-campagne period of Mr. Gorbachov in 1983, high decrease after anti-alchocol campagne in 1986 and return back to the previous high rates in 90-ties. As it is showed in statistics of lethal and violant traumas of 1985-1987, decrease of death cases in Latvia during this period is a positive result of governmental administrative decisions, which is also observed in the countries with low usage of alchocol and low number of cases of violant death from intoxication (for example in Sweden, etc.). At the same time unfavourable situation in the usage of achocol in Latvia there should be marked the new tendency of 90-ties - traumatism using narcotic stuff.

Inspecting morphology and characteristics of LHI and neurotraumas comparing years 1993 and 1999 there can be observed unfavourable dynamics?- increase of heavy traumas and politraumas, which is testified by more often skull fructures.

Table. Characteristics of lethal neurotraumas in riga in 1999

Characteristics of trauma	1999			1993
	Women	Men	Total	Women	Men
head injuries skull fructures	135	339	484 76,8%	142 together	593 58,8%
backbone injuries	20	39	59	-	-
politraumas	87	160	247 (51%)	30,5%
politraumas dead at the place of an accident	51	90	141 53,8%	40%
politraumas dead in the hospital	36	70	106 50%	19,8%
dead in the hospital	?	43,2%		46,6%

Increase of heaviness of LHI can be explained with the changes of epidemiologic rates of LHI - there is rapid increase of proportion of heavy traumas (%): transport traumas, falls from hight, production traumas characterised by great number of politraumas and skull fructures in these groups. At the same time not considering the prophylaxis of auto traumas there is increase of powerful number of cars, great speed, weak discipline of drivers violating speed limit as well as bad equipment in old cars (no air bags, etc.)

Considering heaviness of head injuries and lethality attention is paid on number of dead in hospitals from all LHI and on treatment time before death, which can also show the effectivness of medical care. Establishing CTM and MR examinations in 90-ties the early diagnostics of head injuries improved, especially in cases of intracranial haematoma an number of skull operations. However comparing rates in 1993 number of dead at the place of an accident in 1999 has increased proportionally, although ambulance has arrived in 15 minutes, which testifies increase of heaviness of head injuries.

Table. Time of treatment at the hospital before death

Time of hospitalisation	1993	1999
Up to 1 h Up to 6 h Up to 12 h Up to 24 h More than 24 h More than week	4,08% 16,03% 24,4% 32,4% 67,6% 20%????	7,65% 19,8% 21,6% 35,6% 64,4% 18,9%

Increase of lethality during the first 6 hours after hospitalisation in 1999, not considering the improvement of diagnostics, can show the increase of heaviness of traumas where there is sense of great number of politraumas and connected complications.

It could also be connected with more faster hospitalisation after traumas in 1999 comparing with the situation in 1993.

Conclusions

The following dynamics of epidemiologic rates of LHI are observed in Latvia and Riga in 90-ties:

• decrease of LHI at the end of 90-ties comparing with increase of LHI in 1993-1995, but still taking high place among other cities and countries - frequently, structurally; remaining high lethality in group of falls, increasing number of auto traumas and decreasing number of criminal traumas;

• Important changes in LHI among women and men, increasing number of women at the end of 90-ties

• mark of high risk groups in separate epidemiologic groups in Riga - young men and in 1999 also young women (19-40 years) among drivers; elderly women (above 60 years) in the group of pedestrians, autotraumas, railway traumas; middle-aged men (40-60 years) in the group of falls; in the group of young men - criminal traumas, increase of usage of guns;

• in the ethiology of LHI there can be observed difference in the structural rates in the capital Riga and in the country-side; in the country-side there prevails auto traumas, especially in saloons, but in the capital - death of falls;

• increase of heaviness of LHI at the end of 90-ties, testified by increase of politraumas, great number of skull fructures, larger number of mortality in the place of an accident or during the first hours of hospitalisation not considering the improvement of medical care;

• contributing factor of LHI can be observed intoxication, ½ of all victims; new tendency at the end of 90-ties - LHI of narcotic stuff.