Trauma at a Nigerian teaching hospital: pattern and docu-mentation of presentation.

This study is aimed at identifying the characteristics of injuries and determining the efficiency of documentation of patients’ records in a tertiary hospital where there is no trauma registry. A retrospective case record analysis was conducted of injured patients seen at the Accident and Emergency unit over a 12 month period from January to December 2003.A total of 1078 records of injured patients that attended the A&E were analysed. Their mean age was 31 years (range 3 months to 85 years). Laceration (n = 408) and fractures (n = 266) representing 62.5% of injuries were seen. Injuries to the lower limb occurred in 239 patients, multiple anatomical sites 224, head 224, upper limb 203, the neck 20, and the abdomen 11 patients. Trauma was due to road traffic accident in 977 patients, fall in 39, assault in 14 while burns and firearm injuries occurred in 5 and 7 patients respectively. The mean injury severity score (ISS) was 4. Severe injuries, ISS > 15 occurred in 54 patients with mean ISS of 21, and resulted from RTA in 92.6% of cases. Mortality from severe injuries occurred in 31.5% of cases while overall mortality was 2%. Most deaths were associated with multiple injuries (60.9%) and head injury (30.4%). Incomplete documentation of accident and injury data occurred frequently, from 2% of some data to 100% of others.Lacerations and fractures were the most common injuries. Mortality is due usually to head and multiple injuries. Research into appropriate strategies for prevention of injuries, especially RTA, is required but this must start with the establishment of institutional and regional trauma registries for complete documentation of relevant data.