AN EPIDEMIOLOGICAL ASSESSMENT OF CHILD INJURIES IN ZAGAZIG UNIVERSITY HOSPITALS; PATTERNS AND MANAGEMENT MODALITIES.

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William Haddon developed a scheme (known as the "Haddon Matrix") in the 1960s to apply the principles of public health to the problem of road traffic safety (Runyan, 1998). It has since been used as a means of developing ideas to prevent injury of all types. The matrix consists of 12 cells. These are arranged in a table of four columns relating to the host, agent/vehicle, physical environment and social environment, and of three rows relating to the periods before, during and after the injury. The resulting matrix provides a means to identify, cell by cell: strategies and priorities for injury prevention, in terms of their costs and effects; existing research and research that needs to be undertaken; the allocation of resources in the past and the future, and the effectiveness of such allocation. Haddon went on to describe 10 strategies to accompany the matrix, which describe the ways in which the harmful transfer of energy can be prevented or controlled in some way. The significance of the Haddon Matrix and Haddon's 10 injury prevention countermeasures is that they highlight the fact that not only can society intervene to reduce injury, but that such interventions can occur at different stages (Christoff and Gallagher 1999).
Aim:-To evaluate child injury in Zagazig University Hospitals in the light of agent-host-environment triangle.
Objectives:-To study the types and pattern of child injury received in the hospital, to study the outcome of child injury (death, temporary disability or permanent disability) and to formulate suggested preventive measures according to Haddon's matrix.

Patients and Methods:-
This observational cross sectional study was conducted in Zagazig University Hospitals and included children who suffered injuries during the period from April 2013 to April 2015.    3. Developmental level: injuries were most common among young school children. When mechanisms of trauma were related to age groups in this study, we found that road traffic accidents were significantly more common among children aged from 10 to 14 years, whereas falls were significantly more common among children aged from 1 to 5years (table7,8 ). 4. According to injured areas of trauma in the body, the abdomen was` the most common area (168 patients), head and neck (48 patients), chest (9 patients), pelvis (13 patients), multiple organs (43 patients), upper limb (143 patients) and lower limb (45 patients) (table8).      (9 patients). 3. According to seasonal variation of injures, the summer was the highest prevalence (50.6%) and no statistically significant relationship with mortality (P value=0.627) but statistically significant relationship with disability (P value=0.002) (table10, 11).
Psychosocial environment:-According to this study, pediatric trauma is more common among children living in low socioeconomic states (61%) but there was no statistically significant relationship with mortality (P value=0.804) (table12).   Mortality:-1. Out of 469 children admitted to emergency ward of general surgery department; 21 patients died with mortality rate of (4.47%). 2. Children of 10-14 years had the highest mortality (38%), followed by 1-5 years old children (23.8%). 3. This study revealed RTA as the major cause of injury, causing the highest mortality (71.4%). 4. Eight died patients received pre-hospital care while 13 did not receive it. Seven deaths were attended by ambulance while fourteen deaths came without. There was no safety facility in 17 deaths. 5. One hundred and eight patients were managed during golden hour, five patients died out of them and one hundred and twenty three patients were managed after the golden hour, sixteen patients died out of them table (15'16'17'18).     ., 2004). This was probably due to delayed presentation to tertiary institute (either via referrals or direct admission), or probably due to the lack of knowledge and low literacy levels among the parents of these children (Sharma et al, 2011).
Waly et al mentioned in their study, and in reference to agent-host-environment model; that the most critical host factor that carries the risk for BAT (blunt abdominal trauma) was boys aged 5 to 9 years (Waly et al, 2011). In the study conducted by Sharma et al; the mean age of presentation was 6.3 years and boys were more commonly hospitalized than girls. Sharma et al attributed that to the more freedom given to the boys as well as free hand to work or play outside their homes. Boys to girls ratio was (1.9:1); School age children (6-12 years) were the most commonly affected agent group in Sharma et al study ( Sharma et al, 2011). Similarly; in the present study the researchers found that the mean age of presentation was 6.5 years and boys were injured more than girls with a male-to-female ratio of approximately (2.1: 1). This comparability of results can be explained by the similar social habits of giving boys more space of freedom.
In this study orthopedic injuries were the highest prevalence followed by head and abdominal injuries. These findings are matched with those of Sharma et al (2011). They described that children mostly suffered from orthopedic injuries while among the non-orthopedic injuries; head and abdominal injuries were the most commonly seen in the children (Sharma et al, 2011).
The most common form of energy causing injuries in this study was mechanical energy (93.1%) by RTS (47.1%) followed by home accidents (29.8%). Also Waly et al found that mechanical energy that was most commonly transmitted through RTAs (55.8%), (Waly et al, 2011).
In the present study the physical abuse and gun shots were small numbers (4 patients) and (2 patients In our study the teenagers (10-14 years) were the most liable to RTA. Falls were more common in 1-5 years age group, followed by injury by sharp objects, animal kicks and fist. These findings correlate with what is reported by Constan et al., in 1995. They found that in pre-school age (1)(2)(3)(4)(5) years the prevalence of falls increased to be less than RTAs by few percentage and followed by sharp objects that was the commonest vector in children less than 1 year old, (Constan et al., 1995). In the present study, most of the victims of RTAs were pedestrians and this finding is similar to that derived from the study done at Maput and Tehran (Petersburgo et al, 2010).

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As regards the injured site, this study found that the abdomen was the most common site of injury 35

Conclusion:-
In this study children admitted at surgery department ward were (469 patients) out of 2636 children had different types of injuries and in the light of (agent-host-environment) model this study revealed that:-Host:-School age children were the most commonly injured with the mean age of presentation 6.5 years. Boys to girls' ratio were 2.1: 1and abdominal injuries were the commonest. Mortality rate was (4.47%).

Agent:-
Mechanical energy was the most common energy. Road traffic accident was the commonest vector.
Environment:-Roads were the most common site for child injury and more common among children living in low socioeconomic states.
There was significant association between pre-hospital care, the presence of near ambulance, safety facility and management during golden hour with survival and no significant association between the place of trauma and the social level with survival.