|Year : 2017 | Volume
| Issue : 1 | Page : 34-37
Grievous injuries in children due to tractor-related accidents
Kala Ebenezer1, Rimi Manners1, Sampath Karl2, Vrisha Madhuri3
1 Paediatric Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Paediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India
3 Paediatric Orthopaedic Unit, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||17-Feb-2017|
Paediatric Intensive Care Unit (PICU), Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Tractor-related accidents are common among the agricultural injuries. Children are prone to such incidents as farmers live in the vicinity of the farmland. Materials and Methods: From the Paediatric Intensive Care unit (PICU) database we extracted the details of children with unintentional injuries and poisonings during the period January 2008 to June 2009. Those with tractor-related injuries were further analyzed using outpatient and inpatient charts, computerized hospital records were accessed to obtain laboratory and radiological investigations details. The clinical characteristics, injuries, and outcome of these children are presented. Results: In the 18 months period, there were 107 children with trauma, envenomations and poisoning constituting 6.5% of all PICU admissions. Of the 31 (29%) with polytrauma, four (12.9%) children, three of them boys had sustained tractor-related injuries. The injuries included three with multiple limb fractures, two each of head, chest, musculoskeletal and perineal injury and one each of abdominal and major vascular injury. All had reached the hospital in life-threatening shock and were resuscitated. Multidisciplinary surgical intervention including craniectomy, liver resection and femoral vessels anastomosis were required along with blood transfusions, ventilatory support and inotropes. Three of them survived the injuries after a mean PICU stay of 34 days. Conclusion: Tractor-related incidents among rural children are associated with major injuries and fatalities in children. The findings call for interventions to prevent such injuries and education of the farming community involved with tractors and other agricultural machineries.
Keywords: Critically ill, farming machinery, tractor
|How to cite this article:|
Ebenezer K, Manners R, Karl S, Madhuri V. Grievous injuries in children due to tractor-related accidents. Paediatr Orthop Relat Sci 2017;3:34-7
|How to cite this URL:|
Ebenezer K, Manners R, Karl S, Madhuri V. Grievous injuries in children due to tractor-related accidents. Paediatr Orthop Relat Sci [serial online] 2017 [cited 2019 Mar 23];3:34-7. Available from: http://www.pors.co.in/text.asp?2017/3/1/34/200292
| Introduction|| |
The importance of agriculture in a country like India cannot be overemphasized. An estimated 222 million workforce cover 140 million hectares of total cultivated land in India. Although a large proportion of agriculture in India is dependent on traditional methods, mechanization is happening at a fast pace. Tractors are an integral part of mechanization and play a crucial role in enhancing agricultural productivity. The Indian tractor industry is the largest in the world, accounting for one third of the global production.
Injuries related to agricultural equipment cause significant mortality and morbidity among the rural poor farmers. Children get involved in such accidents, as farmers tend to live in the vicinity of the farming land. Children in the farming families are known to bear a disproportionately high risk of morbidity, disabilities, and mortality due to injury.,
Farm injuries have been well recognized and have led to the establishment of preventive strategies in industrialized countries.,,,, Such injuries are underreported from developing countries with few hospital-based reports available in the literature. No series involving children from India has been reported in the indexed literature.
| Materials and Methods|| |
The Paediatric Intensive Care Unit (PICU), Christian Medical College, Vellore, India, where children with polytrauma needing intensive care are admitted, is an 11-bed unit receiving about 1200 admissions per year. During the 18-month period from January 2008 to June 2009, 107 children who had sustained unintentional injuries and poisonings were admitted, contributing to 6.5% of all PICU admissions. Of the 107 children, 31 (29%) had polytrauma, 35 (32.7%) had poisonings, 16 (14.9%) had envenomation, 11 (10.2%) had sustained burns, and 12 (11.2%) had submersion injury; the remaining two (1.8%) were cases of accidental hanging. The overall mortality from childhood injuries was 9%. Of the 31 children with polytrauma, four (12.9%) had sustained tractor-related injuries. These four cases are presented to highlight the presentation, management, and residual disability in these cases. The clinical characteristics, injuries, and outcome of the children are presented and discussed further.
An 11-year-old boy was playing near a stationary tractor that was offloading sand. The tractor overturned and fell on him. The child lost consciousness for a few minutes. On regaining consciousness, he had breathing difficulty and complained of severe chest pain. He presented to the emergency room (ER) after 2 h of the accident. He was restless, agitated, and had severe respiratory distress. The left half of the chest was visibly swollen and had absent breath sounds. There was subcutaneous emphysema of his trunk extending into the neck, face, upper limb, and thighs. His pulse rate was 140/min, peripheries cold, and peripheral pulses absent. His blood pressure was not recordable. Pulse oxymetry showed an oxygen saturation of 78% in room air. He was immediately started on 100% oxygen and then intubated along with fluid resuscitation (40 ml/kg) and packed red cell transfusion (350 ml).
The chest X-ray showed bilateral hemopneumothorax. Intercostal chest drains were inserted in the fifth space on both the sides. His hematocrit was 25.2%. Arterial blood gas analysis showed pH 6.980, PCO2 81 mmHg, PO2 85.6 mmHg, HCO3− 18.1 mmol/l, and ABE 16.2. Serum electrolytes and liver function tests were normal. Cervical spine lateral radiographs were normal. Focused screening ultrasound examination of abdomen was a negative study.
He was shifted to the PICU, placed on a ventilator, and started on inotropic infusion. On the third day, he developed tonic posturing. A computerized axial tomography (CAT) scan of the brain excluded any intracranial bleed. With anticonvulsants, mannitol, and supportive treatment, he gradually improved and was weaned off the ventilator and extubated after 8 days. Subsequently, he was transferred to the rehabilitation unit after 12 days where he underwent treatment for 11 weeks and was discharged. At 1 year after injury, he started walking without support but had speech difficulty along with behavioral changes and was not able to restart schooling.
The second patient was a 14-year-old boy who was playing on the tractor with his school friends. He had jumped off the tractor when the driver started the engine and moved the vehicle. He presented to the ER, 8 h later with rectal bleeding and two episodes of vomiting. He was drowsy and responding only to pain. His heart rate and respiratory rate was 100/min and 34/min, respectively. Blood pressure was 100/60 mmHg. Secondary assessment revealed a diffuse swelling of the scalp with left periorbital ecchymosis. There was a laceration in the perineum extending up to the anal canal. Other soft tissue injuries were an abrasion with swelling over the left iliac fossa and a tender swelling of the left arm.
On investigation, his hematocrit was 17.9%. Serum electrolytes and bleeding parameters were normal. CAT scan of brain showed a bifrontal extradural hematoma of 5 mm and a subgaleal hematoma. Radiographs showed a midshaft spiral fracture of the left humerus and right superior and inferior pubic rami fractures of the pelvis.
He was admitted to the PICU for observation. Twenty-four hours later, his sensorium had deteriorated and he underwent craniotomy and evacuation of the hematoma. His perineal wound was repaired. The humerus fracture was managed with application of plaster of Paris cast. No surgical intervention was required for the pelvic fracture. He was given ventilatory support for 24 h, transferred to the ward, and discharged after 11 days. At follow-up, he was found to have a urethral stricture of 1.5 cm and left arm shortening. He had made good neurologic recovery.
The third patient was a 12-year-old boy who was returning from his school traveling on a tractor. He fell off the tractor and then was run over by the moving tractor. When he was brought to the ER, he was pale and tachycardic with a heart rate of 175/min and a respiratory rate of 38/minute. Oxyhemoglobin saturation was 80% in room air. His peripheral pulses were not palpable and there was no recordable blood pressure. His Glasgow coma scale (GCS) was 11/15 (E2M5V4). Secondary survey revealed a 20 cm × 15 cm laceration over the anterior and anterolateral aspect of the lower third of the right thigh down to the knee and leg with degloving of the skin. The skin tag was avascular and the muscles over the peroneal and lateral compartment of leg were contused. The patellar tendon, lateral collateral ligament, and cruciate ligaments were torn and exposed. His abdomen was distended and tender.
He was resuscitated with fluids and multiple packed cell transfusions. Urgent ultrasound examination of abdomen showed a liver laceration with hemoperitoneum. An emergency exploratory laparotomy was performed. At laparotomy, the devitalized right lobe of liver was excised, hemostatic sutures were placed, and cholecystostomy was performed along with wound debridement and external fixation of the right leg.
His initial hematocrit was 14.3%. Serum electrolytes were normal but serum amylase (1870 U/l) and liver enzymes [serum alanine amino transferase (SGPT): 1320 U/l, serum aspartate amino transferase (SGOT): 486 U/l] were elevated. Serum total and direct bilirubins were 1 and 0.2 mg/dl, respectively, and within the normal range for our laboratory. Serum albumin was 2.7 g/dl. Prothrombin time was 19.7 s (patient and control) with an international normalized ratio of 1.57. Partial thromboplastin time was 43.3 s (normal range).
Postoperatively, he was shifted to PICU and was on ventilatory and inotropic support. Chest X-ray showed hemopneumothorax with a contusion of the right lung for which an intercostal chest drainage tube was placed on the right side and 500 ml of blood was drained. His intensive care stay was complicated by obstructive jaundice and wound infection that necessitated prolonged ventilatory support. He was extubated on day 18 of hospital stay, but was readmitted and reintubated in PICU following a seizure and findings of depressed sensorium and hypertension with anisocoria. CT scan of brain showed an intracranial bleed with moderate hydrocephalus for which conservative management was advised by the neurosurgeons. Subsequently, his stay in ICU was complicated by poor neurological recovery, wound infection and sepsis, multiorgan dysfunction, and ventilator dependency; he was discharged on parental request on day 31 of hospital stay and taken home.
An 8-year-old girl was hit and run over by a tractor as she was walking along the road. She reached the ER conscious but very pale. Her heart rate was 160/min, respiratory rate 40/min, and blood pressure 100/50 mmHg. There was a deep laceration in the perineum extending from the pubic symphysis anteriorly through the vulva and the vagina to the anus posteriorly, with tear of the muscles attached to the pubic symphysis. Another large laceration was seen over the anterolateral aspect of the left femoral triangle with a tear in the femoral vessels and active arterial bleeding. The hemoglobin on arrival was 6.4 g%. X-ray of the pelvis showed pelvic diastasis with fracture of the body of left hemipelvis.
She was given fluid resuscitation (60 ml/kg) and packed cell transfusions and taken to the operating room where the torn femoral vessels were repaired and the wounds debrided. Suprapubic cystostomy was done and she was shifted to the PICU for postoperative monitoring. Her pelvic fracture did not require any intervention and was conservatively managed. She was discharged in a stable condition after 18 days. She was followed up at regular intervals and had one episode of urinary tract infection. Suprapubic cystostomy was closed after 2 months. There was a residual mild abduction and flexion deformity of the left lower limb not requiring any intervention.
Clinical findings, injuries, and outcomes in these children are summarized in [Table 1].
| Discussion|| |
The four children with tractor-related injuries, three boys and a girl, of schoolgoing age, who are presented here, constituted 12.9% of all children with polytrauma admitted to our intensive care unit (ICU) during an 18-month period. Their injuries were of a grievous and life-threatening nature [Table 1].
Children less than 15 years made up to 20% of all unintentional farm-related fatalities in Australia, whereas Indian data indicated that the children sustained 2–5% of such injuries (southern, northern, and central India), with 10% injuries reported from the villages in eastern India. Among the agricultural injuries, tractor incidents were the most common (27.7%) and associated with major injuries and fatalities in children.
The injuries that were seen in our patients were three multiple limb fractures (75%), two head injury (50%), two chest injury (50%), two extensive musculoskeletal injury (50%), two perineal injury (50%), one abdominal injury (25%), and one major vascular injury (25%). The victims were neither the operators nor engaged in labor; the accidents had occurred while playing in the vicinity of the tractor in two children, the third was hit while walking on the rural road, and the fourth was a passenger who fell off the moving tractor. This pattern of mode of injuries from a tractor has been previously reported;,, 54% of tractor injuries reported from North India were because of nonfarming activities. The leading mechanism of injury among paediatric farm injuries in the United States was bystander and passenger runovers in 22.5 and 21.7% of fatalities, respectively. From this it is clear that injuries can be prevented by having clear enforceable guidelines on safety protocols for heavy farm machinery use and a ban on the use of tractors for human transport.
The commonly reported causes of tractor injuries are overturns, falls, collisions, power take-off injuries, and injuries sustained while mounting and dismounting. Increased mobility, aggression, risk-taking behavior, and inexperience commonly seen in this age group may also contribute to these accidents. Curiosity and the perceived safety of this slow-moving vehicle are other factors that are contributory. Apart from these, in our country, tractors are also used for transportation in rural areas and the lack of proper guard around the seating leads to accidental fall of the passengers. Inadequate tractor–trailer stability and lack of maneuvering skills by the operators have also been reported as major reasons of accidents. The tractor operation often requires a large braking force (600 N or more) to be exerted by an average operator weighing 50–60 kg. Also, the location of the seat and controls on the tractor makes it difficult for one to operate the controls in emergencies and/or egress from the tractor. In spite of regular maintenance of battery, the self-starter is an inherent problem with the tractors.Tractor injuries have also been found to be more severe than vehicular injuries. In England, like ours, one in four tractor injuries was fatal as compared with one in 22 of traffic injuries. In Madhya Pradesh, nearly half of the fatal agricultural incidents were because of tractors (42.9%). All our patients reached the hospital in life-threatening shock because of severe blood loss after a mean of 9.75 h (range 2–17 h) after the incident. Emergency chest tube insertion was performed in two of them. Primary care treatments such as fluid boluses and pain relief, if available to these victims before reaching a tertiary center, have shown to be life saving and need to be incorporated in our primary and ambulance care protocols.
Once these children were tided over their acute phase, they needed major surgical procedures such as craniectomy (1), laparotomy and resection of liver segments (1) and repair of torn femoral vessels (1), and suprapubic cystotomy (1) apart from the routine sutures and treatment of soft tissue injuries. The mean duration of ICU stay was 34 (range 18-77) days. Ventilatory support, blood product transfusion and inotropic infusion were other modalities of treatment given. Thus, survival was possible only because Paediatric Surgical, Paediatric Orthopaedic and Neurosurgical expertise along with emergency and intensive care support was available to these patients, not withstanding the prolonged hospitalization and treatment costs.
| Conclusions|| |
Multiple interventions involving public health, political, legal, agricultural sector, manufacturing industries, and media need to combine to effectively prevent such injuries and improve outcomes. Along with encouraging research to develop new technologies to increase safety and decrease the number of such agricultural injuries, the farming community needs to be educated about the injuries and risks involved with tractors and other agricultural machineries. Children should be restricted from playing around or riding on machinery or motor vehicles not approved for passengers. Adequate technical and human resources at all levels of healthcare delivery system should be provided and skills of professionals in trauma care should be enhanced to avoid time delay and provide the best medical care.
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Conflicts of interest
There are no conflicts of interest.
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