ARTICLE IN PRESS

Trauma care in India: A review

of the literature
Hadley K. H. Wesson, MD, MPH,a and Mimmie Kwong, MD,b Baltimore, MD, and Sacramento, CA

Background. We reviewed the published literature related to prehospital and hospital trauma care in
India to identify how trauma care is defined in the literature and what factors limit the delivery of
appropriate trauma care. In summarizing the evidence and recommendations regarding trauma care,
this review identifies essential research and development goals to address the burden of injury in India.
Methods. A review of the literature was conducted between August 2014 and September 2014. The
literature was sorted into 3 categories: prehospital care, hospital clinical care, and hospital
administrative care. The characteristics of trauma care were explored using the Essential Trauma Care
Project of the World Health Organization.
Results. A total of 38 studies were included. Prehospital care lacked care provided at the scene of the
injury, timely transport to a hospital, and transport via ambulance. With regard to hospital care, we
found a lack of capabilities of basic clinical care, such as airway management, insertion of chest tubes,
and efforts at resuscitation. There was a lack of administrative capabilities, including trauma data
systems, trauma-specific training, quality improvement, and development of designated trauma teams.
Conclusion. The high rate of injury-related deaths and disabilities in India could be in part due to the
absence of integrated and organized systems of trauma care. In the prehospital setting, a multisector
approach must be implemented to address the training of emergency medical service providers and
community members. Prehospital transport time can be decreased through improved communication and
transport modalities. The Indian trauma care system could also be strengthened through hospital-based
training programs and trauma response teams. (Surgery 2017;j:j-j.)

From the Department of Surgery,a Johns Hopkins University, Baltimore, MD; and the Department of Vascular
Surgery,b University of California, Davis, Sacramento, CA

THERE ARE MORE ROAD TRAFFIC INJURIES (RTIs) and
more RTI-related deaths in India than any other
country in the world.1 In India, an estimated 83
deaths per 100,000 deaths are due to injuries
each year, of which 16.7 per 100,000 deaths are
due to RTIs, which account for approximately
13% to 18% of all deaths in India.2 To address
this, the Indian government is investing in road
safety currently through, for example, the stricter
Road Safety and Transport Bill.3 No matter how
successful, legislation does not address fully the
spectrum of the burden of injury. Specifically, legis-
lation does not address the care provided to the
injured patient after the injury occurs or ways to
improve the role of trauma care systems in India.3,4
Accepted for publication January 20, 2017.
Reprint requests: Hadley K.H. Wesson, MD, MPH, Department
of Surgery, Johns Hopkins Medical Center, 11085 Little Patux-
ent Parkway, Suite 103, Baltimore, MD 21044. E-mail:
Hwesson1@jhu.edu.
0039-6060/$ - see front matter
Ó 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.surg.2017.01.027
Trauma care in India has been described as
“disorganized” and “inadequate.”4 At the national
level, India does not have a central government
agency, such as a division within the Ministry of
Health, that oversees trauma care.5 Data to
describe national, trauma-related outcomes and
trends are scarce.6 At the community level, there
are limited descriptions of trauma systems at the
prehospital and hospital levels.5
To begin to understand how Indian trauma
systems can improve, a descriptive account of the
extent to which formal and informal trauma
systems are present in India is required. We
conducted a review of the published literature
related to prehospital and hospital trauma care in
India to identify how the literature has defined
trauma care and has described gaps within the
current trauma care systems. We present our
findings and suggest future research and the
development of goals to address the burden of
injury in India.
METHODS
A review of the published literature on trauma
care in India was conducted between August 2014

SURGERY 1
 ARTICLE IN PRESS
2 Wesson and Kwong
and September 2014, supervised by a public health
and basic science informationist who specializes in
the design of literature reviews. We searched 11
databases: PubMed/Medline,7 Embase,8 the Co-
chrane Library,9 the System for Information on
Grey Literature in Europe,10 Eldis,11 Scopus,12
Web of Science,13 Proquest Digital Dissertations,11
Oaister,14 Global Health Ovid,15 and MedIndia.16
Articles were identified by keywords containing
“India” and at least one of the following key terms
to describe trauma care: trauma care, injury, inten-
tional injury, unintentional injury, trauma, preho-
spital care, surveillance, registry, alcohol, road
traffic injury, burns, firearms, assault, violence, or
falls. Search results were not limited by year or
language.
Study definitions. Because trauma care is a
complex and multifaceted topic, we defined a
“trauma care system” as a collection of compo-
nents essential to the care of the injured.5,17 Using
the guidelines of the World Health Organization
(WHO), we identified 3 categories essential to
any trauma care system: prehospital care, hospital
clinical care, and hospital administrative care.17
Prehospital care is the care provided to the injured
individual before they present to the health care
facility and includes the medical care given to
the individual at the scene of the injury (including
the type of care provided and by whom), the pre-
hospital time (ie, the time from the injury until
the patient arrives at the treating facility), mode
of transportation and evacuation, and paramedical
resources.18
Hospital clinical care is defined by the provision
of 9 clinical capabilities provided within a hospital
identified by the WHO: airway management,
placement of chest tubes, provision of supple-
mental oxygen, control of external hemorrhage,
intravenous access and appropriate fluids, capability
for blood transfusions, wound care, surgical man-
agement, and spinal immobilization (Table I).17 Hos-
pital administrative care includes 4 capabilities
identified by the WHO: documentation of trauma
cases, training for trauma care providers, quality
improvement for trauma care, and the provision of
a trauma team.20 Small hospitals are defined as hav-
ing bed sizes of 30 to 100 beds, while large hospitals
have bed sizes of 100 to 600 beds.
Inclusion criteria. For the purposes of this
review, we defined “included studies” as prospec-
tive or retrospective studies that reported original
data pertaining to either trauma patients or
trauma care systems in India. Studies that did not
include trauma patients or trauma care systems in
India or did not provide data describing one or
Surgery
j 2017
more aspect of trauma care (defined for the
purposes of our study) were excluded from further
analysis. Articles that addressed only the epidemi-
ology of injury were excluded, because they did
not describe the actual trauma care provided to
the patient. Review articles and commentaries were
excluded, because they did not provide original
research, but review articles and commentaries
were read as a part of a snowball analysis to identify
additional citations of relevant empiric literature.21
Study selection. In evaluating articles for initial
inclusion, all titles and abstracts were screened by 2
reviewers (H.W. and M.K.). If there was a disagree-
ment regarding inclusion of the article, it was
discussed among the reviewers; if an agreement
could not be reached, a third reviewer was con-
sulted. The full texts of the included articles were
obtained and reviewed in their entirety by 2
reviewers using the same inclusion and exclusion
criteria. Through this process, we then arrived at a
final set of included articles.
Data extraction. Data were extracted by 2
authors (H.W. and M.K.) into a standard Microsoft
Excel file developed by the Child Health Epidemi-
ology Reference Group to standardize literature
reviews.22 Data included population characteristics
and selection of the population, study design/
setting, age range, case definitions of injury, and
the provision of trauma care. We then categorized
findings into 4 categories that we developed for
the purpose of this review: patient demographics,
patient outcome, prehospital care, hospital care,
and clinical and operational capabilities.
Patient demographic variables included avail-
able information on the mean age of the study
population, sex distribution (reported as the per-
centage of male patients), and mean severity as
reported by each study. Severity included the
Glasgow Coma Scale, Injury Severity Score, or
Abbreviated Injury Score. Patient outcome
included the percentage of the study sample that
was admitted to the hospital and died. Mortality
rate as reported by each study included the overall
mortality rate. Data regarding prehospital and
hospital care were extracted based on the defini-
tions of each category as identified in Table I. If a
study discussed specific conclusions and/or recom-
mendations for the provision of trauma care as
defined by our study definitions, these topics
were extracted from the text.
Assessment of quality. Articles were evaluated
individually for limitations of study design and
generalizability to the population of interest to
determine the quality of the evidence and conclu-
sions presented.22,23 Assessment of study design
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Surgery Wesson and Kwong 3
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Table I. Hospital-based trauma care clinical and administrative capabilities defined by the World Health
Organization
Clinical capabilities
Airway management
Basic airway management including ability to detect airway obstruction and to treat with positioning maneuvers,
use of suction, and oral or nasal airway.
Advanced airway management including emergent endotracheal intubation and/or cricothyroidotomy and/or
tracheostomy.
Chest tubes
Including ability to perform insertion procedure safely and to maintain underwater seal drainage system safely
Oxygen
External hemorrhage control
Skills, as well as at least clean, preferably sterile, bandages
Resuscitation
Including intravenous access and appropriate fluids
Blood transfusion capabilities
Wound care
Emergent debridement and irrigation
Basic closed fracture management including external reduction and POP application
Splinting of fractures
Surgical management
Including external and internal fixation
Spinal immobilization
Including cervical collar; spine backboard or other method to immobilize thoraco-lumbar spinal injuries
Administrative capabilities
Documentation of trauma cases
Including ability to indicate number of trauma cases cared for or admitted to health care facility during a specified
period of time
Training: CME course certification in trauma care
For all first-line care providers (doctors, nurses, and other clinicians) who handle a substantial number of trauma
cases (defined on a local needs basis)
Trauma quality improvement program
Indicates ongoing quality improvement mechanism, as appropriate for the volume of trauma cases, such as a
trauma registry with risk adjustment, and identification of preventable deaths
Trauma team
Indicates clinicians with preassigned roles during major trauma resuscitations with appropriate training and/or
monitoring of the functioning of the preassigned roles
CME, Continuing medical education; POP, plaster of paris.
Source: Adapted from the World Health Organization.19

was based on the type of study, whether the study
was prospective or retrospective, and the duration
of the study period. Study limitations were based
on the site, population, and population represen-
tativeness of the study. Study site was categorized
as either a single or multicenter study. Generaliz-
ability was defined as the ability of each category
to be applied to the population of interest in a ho-
mogenous way.
The study population was defined according to
the inclusion criteria of each study to enroll
participants. The representativeness of the study
was defined as either facility or population based
with minimal or moderate bias. If studies
described sample populations with a specific type
of injury or outcome (such as fatalities only), the
inherent bias was taken into account and subse-
quently was considered to have moderate bias.
Summary measures and data synthesis. Given
the heterogeneity of the studies, the findings could
not be pooled to conduct a meta-analysis; however,
we tabulated ways in which prehospital and hospi-
tal care were described in the literature and we
calculated medians of reported averages when
applicable.
RESULTS
Study demographics. Thirty-eight articles were
included in our final analysis (Fig). The year of
publication of the studies ranged from 1989 to
2014. The majority of studies were conducted in
urban settings (95%, n = 36) in over 12 Indian
 ARTICLE IN PRESS
4 Wesson and Kwong
Fig. Literature review flowchart.
states, were single center (82%, n = 31), and were
cross-sectional in design (82%, n = 31). Twenty-
six studies described prehospital care, 8 described
hospital care as clinical capabilities, and 8
described hospital care as administrative capabil-
ities (Tables II and III). Regarding quality assess-
ment, the majority of studies were facility based
with moderate bias (Table II). Two studies were
population based.
Of the 113,923 injured patients included in the
reviewed studies, the median age was 25 years and
77% were men (Table IV). Eighteen studies,
including both prehospital and hospital studies, re-
ported a median mortality rate, of which the me-
dian of medians mortality rate was 17%. Few
studies reported the severity of the injury: one
study reported the mean Glasgow Coma Scale, 6
reported total burn surface area, and 4 reported
mean Injury Severity Score.
Prehospital care. Twenty-six studies described
prehospital care provided to 53,750 patients,
including patients who received medical care
prior to arriving at the receiving health care
center, were transported by ambulance, died in
the prehospital setting, or had their prehospital
Surgery
j 2017
time documented and published (Table V). The
median prehospital time defined as the time
from the injury to arrival at the hospital was
3 hours, as reported by 14 urban-based studies.
Six studies, all conducted in urban areas, reported
a median of only 4% of patients transported to a
hospital by ambulance and a median of only
15% who received prehospital care. Prehospital
mortality reported by 5 studies ranged from 5%
to 40%.
Hospital care. Eight studies described hospital
clinical capabilities in terms of airway management
(n = 6); chest tube capabilities (n = 2); capability of
provision of oxygen (n = 1), resuscitation (n = 4),
or blood transfusions (n = 4); surgical manage-
ment (n = 9); and spine immobilization (n = 2;
Tables IV and V). No study described clinical capa-
bilities with regard to control of hemorrhage.17
Five studies reported that 4% to 43% of patients
required intubation. One study found mechanical
ventilation was absent at small hospitals and inade-
quate at large hospitals. Of note, the 3 studies that
described the quality of airway management found
the capabilities of endotracheal intubation to be
inadequate.
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Surgery
Table II. Summary of the quality of the studies included in the literature review (n = 38)
Quality assessment: number of studies
Design Generalizability
Study population
Type of study Design of study Study location Study site Study population Summary of findings representativeness
Prehospital (26 studies)
Cross-sectional: 25 Prospective: 11 Urban: 24 Single center: 21 All Injuries: 10 Injured patients: 32,188 Facility based with
minimal bias: 4
Before and after: 1 Retrospective: 15 Rural: 1 Multicenter: 5 Injury by type: 13 RTIs: 12,520 Facility based with
moderate bias: 20

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Urban and rural: 1 RTI: 6 Falls: 3,020 Population based with
minimal bias: 1
Fall: 2 Burns: 1,060 Population based with
moderate bias: 1
Burn: 5 Pediatric 1; Assault: 7,380
Poly-trauma 1
Anatomic location: 3
Head injury: 4
Chest injury: 1
Hospital care: clinical capabilities (8 studies)
Cross-sectional: 8 Prospective: 3 Urban: 7 Single center: 7 All injuries: 2 Injured patients: 3,870 Facility based with
minimal bias: 2
Retrospective: 5 Urban and rural: 1 Multicenter: 1 Injury by type: 5 RTIs: 462 Facility based with
moderate bias: 6
Burn: 5 Falls: 328
Anatomic location: 1 Burns: 2,691
Chest: 1 Assault: 110
Hospital care: administrative capabilities (8 studies)
Cross-sectional: 2 Prospective: 6 Urban: 7 Single center: 7 Health care providers: 5 Health care providers: 186 Facility based with

Wesson and Kwong 5

minimal bias: 5
Before and after: 6 Retrospective: 2 Urban and rural: 1 Multicenter: 1 Health care facilities: 4 Facility based with
moderate bias: 5
Table III. Characteristics and quality of the studies included in the literature review (n = 38)

6 Wesson and Kwong

Limitations Consistency Population generalizability
Consistency of
Study Study population Study population definitions and Population Number of study
Author, y study design period representativeness Study site patients with description of care of interest subjects (%)
Colohan, 198924 Prospective 20 mo Facility based with Single-center Head injuries Prehospital care: Urban Injuries: 551
Cohort moderate bias study received care, RTIs: 334 (60)
transport by Fall: 102 (19)
ambulance, Assault: 47 (9)
transport time
Hospital care:
Clinical:
resuscitation,
surgical

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management
Maheshwari, Retrospective 16 mo Facility based with Single-center RTIs Prehospital care: Urban RTIs: 807
198925 Cross-sectional moderate bias study received care,
transport by
ambulance,
transport time
Sharma, 199326 Retrospective 36 mo Facility based with Single-center Burn injuries Hospital care: Urban Burns: 2,100
Cross-sectional moderate bias study Clinical: airway
management,
surgical
management
Gupta, 199327 Retrospective 20 mo Facility based with Single-center Burn injuries Prehospital care: Urban Burns: 629
Cross-sectional moderate bias study prehospital
time
Jayaraman, 199328 Prospective 12 mo Facility based with Single-center Burn injuries Prehospital care: Urban Burns: 1,368
Cross-sectional moderate bias study prehospital
time
Hospital care:
Clinical:
resuscitation,
surgical
management
Sarma, 199429 Retrospective 10 y Facility based with Single- center Burn injuries Hospital care: Urban Burns: 348
Cross-sectional moderate bias study Clinical:
surgical

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management
(continued)
Table III. (continued)

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Surgery
Limitations Consistency Population generalizability
Consistency of
Study Study population Study population definitions and Population Number of study
Author, y study design period representativeness Study site patients with description of care of interest subjects (%)
Subrahmanyam, Prospective 9 mo Facility based with Single- center Burn injuries Prehospital care: Urban Burns: 175
199630 Cross-sectional moderate bias study prehospital
time
Ahuja, 200231 Retrospective 7y Facility based with Single- center Burn injuries Prehospital care: Urban Burns: 11,196
Cross-sectional moderate bias study prehospital
time
Goal, 200432 Prospective 1.5 mo Facility based with Single- center Injuries Prehospital care: Urban Injuries: 180
Cross-sectional minimal bias study prehospital RTIs: 42 (23)
time Falls: 62 (34)

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Burns: 39 (22)
Murlidhar, 200433 Prospective 10 mo Facility based with Single- center Injuries Prehospital care: Urban Injuries: 1,074
Cross-sectional minimal bias study received care, RTIs: 421 (39)
prehospital Falls: 287 (27)
time Assault: 89 (8)
Hospital care:
Clinical:
surgical
management
Mock, 200634 Prospective NS Facility based with Health care Health care Hospital care: Urban 28 clinics, 14
Cross-sectional very minimal facilities facilities Clinical: airway and hospitals, 1
bias management, rural large hospital
chest tube,
resuscitation,
blood
transfusion
capabilities,
surgical
management

Wesson and Kwong 7

Hospital care:
Administrative:
documentation,
training, quality
improvement,
trauma team
(continued)
Table III. (continued)

8 Wesson and Kwong

Limitations Consistency Population generalizability
Consistency of
Study Study population Study population definitions and Population Number of study
Author, y study design period representativeness Study site patients with description of care of interest subjects (%)
Mohta, 200635 Retrospective 12 mo Facility based with Single- center Chest injuries Prehospital care: Urban Injuries: 105
Cross-sectional moderate bias study prehospital RTIs: 41 (39)
time Falls: 26 (25)
Hospital care: Assault: 21 (20)
Clinical: airway
management,
resuscitation
Rautji, 200636 Prospective 24 mo Facility based with Single- center RTI deaths Prehospital care: Urban RTIs: 400
Cross-sectional moderate bias study received care,

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prehospital
time
Pandey, 200737 Prospective 10 mo Facility based with Single- center Traumatic spinal Prehospital care: Urban SCIs: 60
Before and after moderate bias study cord injuries time to RTIs: 29 (48)
rehabilitation, Fall: 26 (43)
transport
Ramanujam, Retrospective 1 mo Facility based with Multi-center study Injuries Prehospital care: Urban NS
200738 Cross-sectional minimal bias received care
Hospital care:
Clinical: airway
management,
resuscitation,
spinal
immobilization
Tchorz, 200739 Prospective 2 days Facility based with Single- center Physicians Hospital care: Urban 32 physicians
Before and after moderate bias study Administrative:
training
Kumar, 200840 Retrospective 4y Facility based with Single- center RTI deaths Prehospital care: Urban RTIs: 2,472
Cross-sectional moderate bias study Mortality rate
Singh, 200841 Retrospective 2y Facility based with Single- center Injury-related Prehospital care: Urban Injuries: 470
Cross-sectional moderate bias study deaths Mortality rate RTIs: 178 (52)
Falls: 42 (12)
Burns: 81 (24)
Assault: 15 (4)

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Table III. (continued)

Volume j, Number j
Surgery
Limitations Consistency Population generalizability
Consistency of
Study Study population Study population definitions and Population Number of study
Author, y study design period representativeness Study site patients with description of care of interest subjects (%)
Fitzharris, 200942 Retrospective 8 mo Facility based with Three-center RTI injuries Prehospital: Urban RTIs: 378
Cross-sectional moderate bias study Mortality rate
Kumar, 200943 Prospective NS Facility based with 4-center study Tertiary hospitals Hospital care: Urban 4 tertiary hospitals
Cross-sectional minimal bias Clinical: trauma
care training,
infrastructure
and resource
availability
Hospital care:

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Administrative:
training
Saini, 200944 Prospective NS Facility based with Single- center Hospital-based Hospital care: Urban 50 nurses
Before and After moderate bias study nurses Administrative:
training
Verma, 200945 Prospective 12 mo Facility based with Single- center Pediatric injuries Prehospital care: Urban Injuries: 225
Cross-sectional moderate bias study Mortality rate RTIs: 37 (16)
Hospital care: Falls: 144 (64)
Clinical: Burns: 7 (3)
resuscitation
Dandona, 201046 Retrospective 8 mo Population based Multiple village Non-fatal falls Prehospital care: Rural Falls: 126
Cross-sectional with moderate based Prehospital
bias time
Ganesamoni, Retrospective 13 mo Facility based with Single- center Burn injuries Prehospital care: Urban Burns: 222
201047 Cross-sectional moderate bias study Prehospital
time
Chakraborty, Retrospective 2 mo Facility based with Single- center Burn injuries Hospital care: Urban Burns: 83
201048 Cross-sectional moderate bias study Clinical: Blood
transfusion

Wesson and Kwong 9

capabilities
Douglas, 201049 Prospective 1 mo Facility based with Single center ED physicians Hospital care: Urban 77 physicians
Before and After moderate bias study Administrative:
training
(continued)
Table III. (continued)

10 Wesson and Kwong

Limitations Consistency Population generalizability
Consistency of
Study Study population Study population definitions and Population Number of study
Author, y study design period representativeness Study site patients with description of care of interest subjects (%)
Gupta, 201050 Prospective 4 days Facility based with Single- center ED physicians Hospital care: Urban 42 physicians
Before and After moderate bias study Administrative:
training
Menon, 201051 Prospective 6 mo Facility based with Health care Health care Hospital care: Urban NS
Cross-sectional minimal bias facilities facilities Administrative:
Data collection
Roy, 201052 Prospective 2 mo Facility based with Single- center Injuries Prehospital care: Urban Injuries: 170
Cross-sectional minimal bias study received care, RTIs: 74 (46)
transport time, Fall: 27 (17)
mode of Assault: 6 (4)

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transport
Bajwa, 201153 Retrospective 3.5 y Facility based with Single- center Multiple injuries Prehospital care: Urban Injuries: 531
Cross Sectional moderate bias study Prehospital RTIs: 473 (89)
time Falls: 26 (5)
Hospital care: Other: 32 (6)
Clinical: airway
management,
chest tube,
resuscitation,
blood
transfusion
capabilities,
surgical
management
Gupta, 201154 Prospectively 6y Facility based with Single- center Burn injuries Hospital care: Urban Burns: 892
Cross Sectional moderate bias study Clinical:
surgical
management
Kavita, 201155 Retrospective 12 mo Population based 23-center study Injuries Prehospital care: Urban Injuries: 13,231
Cross sectional with minimal received care RTIs: 5,459 (41)
bias
O’Reilly, 201156 Prospective 3 wk Facility based with Single- center Physicians Hospital care: Urban 22 physicians
Before and After moderate bias study Administrative:
training
Tandle, 201157 Retrospective NS Facility based with Single- center RTI fatalities Prehospital care: Urban RTIs: 138

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Cross-sectional moderate bias study prehospital
mortality
(continued)
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Surgery Wesson and Kwong 11
Volume j, Number j

Chest tubes were placed in 12% of patients in

Number of study
one study. One study found chest tubes to be absent

subjects (%)
Population generalizability

Injuries: 241
in small hospitals and only partially adequate at

5 physicians
Falls: 1,407

RTIs: 182
large hospitals. One study described the capability
to provide oxygen as placing 1% of patients on
oxygen. Five studies reported 8% to 81% of patients
required resuscitation and subsequent intensive
Population

care unit care. Capabilities of providing blood

of interest

transfusion were adequate at large hospitals: of

Urban

Urban

Urban

Urban
those studies that reported transfusing patients,
73% of polytrauma patients and 100% of burn
patients received blood. Wound care was found to
Administrative:
time, transport
description of care
Prehospital care:

Prehospital care:

Prehospital care:
definitions and

received care

received care
be inadequate in small hospitals with a reported
Consistency of
Consistency

Hospital care:
Prehospital

prehospital

wound infection rate between 45% and 75%. The

mortality,
training

quality of surgical management was described by

one study as partially adequate to inadequate. No
study described clinical capabilities with regard to
control of external hemorrhage control.
Administrative capabilities. Eight studies ad-
Study population

dressed one or more aspect of the capability of

patients with

trauma care administrative, including data collec-

Fall injuries

Physicians

tion (n = 1), trauma course certification (n = 8),

Injuries

trauma quality improvement (n = 1), and the pres-

RTIs

ence of a designated trauma team (n = 1; Tables IV

and V). Findings from one study showed how a
data collection form can be an effective means to
develop a trauma registry. Eight articles discussed
Single- center

Single- center

Single- center

Single- center
Study site

aspects of education and staff training in trauma,

revealing deficiencies in the training of medical
study

study

study

study

personnel managing traumas in both the prehospi-

tal and in-hospital settings. One study that dis-
ATLS, Advanced Trauma Life Support; ED, emergency department; MI, myocardial infarction.

cussed evaluation and research of trauma care in

Limitations

Facility based with

Facility based with

Facility based with

Facility based with

terms of quality improvement found an absence

representativeness
Study population

moderate bias

moderate bias

moderate bias
minimal bias

of trauma-related quality improvement programs

and development of trauma teams among facilities
of all sizes.

DISCUSSION
The exceptionally high rate of injury-related
12 mo
period
Study

7 mo

deaths and disabilities in India is a multifaceted

1y

2y

issue resulting from the lack of concerted efforts of

injury prevention and the absence of integrated
Cross sectional

and organized systems of trauma care.4-6 Our re-

Cross-sectional
study design
Retrospective

Retrospective
Prospective

Prospective

view focused on the state of prehospital and hospi-

tal trauma care in India. The review was limited in
that we used the published literature to describe
Table III. (continued)

trauma systems. As such, we captured only those

trauma systems whose outcomes were published.
Given the nature of the literature review, we could
Radijou, 201360
Jagnoor, 201258

Pathak, 201461

not describe a population-based approach to

Author, y

Bhoi, 201359

trauma care. Nevertheless, given that a

population-based system is not in place currently,
we can provide an initial description of trauma
care limited to the published literature.
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12 Wesson and Kwong Surgery
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Table IV. Summary of findings from studies included in the literature review (n = 38)
No. of studies that
Summary findings Median Range reported the finding
Age 25 y 5–55 y 30
Male 77% 22%–93% 28
Glasgow Coma Scale 9.7 n/a 1
BSA 44% 22–65 6
Mean Injury Severity Score 19 5–38 4
Mortality rate* 17% 0%–61% 18
Prehospital care (n = 26)
Received prehospital care 15% 1%–72% 9
Transported by ambulance 4% 0.3%–35% 6
Prehospital time 3h 0.5–12 h 15
Prehospital mortality 26% 5%–40% 5
Hospital care: clinical capabilities (n = 8)
Airway management 22% 4%–43% 6
Chest tubes 12% n/a 2
Oxygen Absent at small hospitals n/a 1
Hemorrhage control n/a n/a 0
Resuscitation 21% 8%–81% 4
Blood transfusion 87% 73%–100% 4
Wound care 58% wound infection 40%–75% wound 3
infection
Operative treatment 43% 9%–100% 9
Spinal immobilization 12% n/a 2
Hospital care: administrative capabilities (n = 8)
Data collection n/a n/a 1
Trauma training 81% pass rate 20%–90% pass rate 8
Trauma quality improvement n/a n/a 1
Designated trauma team n/a n/a 1
*Excluding 4 studies that only included patients who had died.
BSA, Burn surface area.

Regarding prehospital care, there was a lack of
documented, on-the-scene care and limited ambu-
lance transport. Long transport times to hospital
were reported even in urban settings. When
reported, prehospital mortality was high with a
median average of 26%. The general consensus
among prehospital studies was that there is an
urgent need to improve prehospital care and to
address the high prehospital death
rate.24,32,38,40,43,53,55,60
These studies do not discuss examples in which
improvements have been noted or initiatives are
underway to support appropriate responses to
these challenges. Instead, studies suggest that
prehospital care has been inadequate and inap-
propriate due to high costs of resuscitation and
lack of training in emergency medical service
(EMS).52 Recommendations from these studies
include improving transport systems, enhancing
first-aid training for community members, and
developing low-cost EMS systems and emergency
call centers.25,36,38 Developing a low-cost EMS
system should parallel the development of training
programs for community members, such as taxi
drivers and police, as community members are
often the first to arrive at the injury.52
To evaluate trauma care provided by hospitals,
we applied the 11 WHO essential care trauma care
capabilities to the literature to understand how
trauma care was described in the literature and the
extent to which these capabilities were adequate.
We found that the studies did not necessarily use
the capabilities to describe trauma care in a
consistent fashion, because many studies described
one or few of the capabilities. We did, however,
find that when studies did describe the capabilities,
tcapabilities were often inadequate or insufficient.
Similar to the prehospital studies, the hospital-
based studies described the urgent need for
improved clinical and administrative needs in
trauma care. Many studies described the need for
a dedicated trauma team approach.29,35,54 Other
studies described the need for hospital-based,
regional-based, and national trauma
Table V. Studies that describe the epidemiology of injury in terms of prehospital and hospital trauma care provided in India (n = 38)

Volume j, Number j
Surgery
Summary of findings
Hospital care:
Study Hospital care: clinical administrative
Author, y Study location population Demographics Patient outcome Prehospital care capabilities capabilities
Colohan, 198924 New Delhi 551 patients Mean age: Admitted: 100%* Received Operative
with head 25 ± 1.4 years Mortality rate: 7% prehospital care: management:
injury Male: 81% (n = 446) (n = 38) 3% 11%
Transported by
ambulance: 0.5%
Mean prehospital
time: <1 h for 7%
of patients
Maheshwari, New Delhi 807 RTIs Mean age: 21–40 y Admitted: 18% Received NA
198925

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Male: NS Mortality rate: NS prehospital care:
10%
Transported by
ambulance: 4%
Mean prehospital
time: <30 min
Sharma, 199326 Jaipur, 2,100 pediatric Mean age: 4.8 y Admitted: 100%* NA Airway
Rajasthani injuries Male: 67% Mortality rate: 8% management: 4%
(n = 1,411) (n = 161) intubated
Operative
management:
10%
Gupta, 199327 Jaipur, 629 burn Mean age: 21–30 y Admitted: 100%* Mean prehospital NA
Rajasthani patients Male: 54% (n = 339) Mortality rate: 48% time: 1–3 h
Mean BSA: 31%– (n = 304)
40%
Jayaraman, Madras, 1,368 burn Mean age: 21–30 y Admitted: 71% Mean prehospital Resuscitation: 81%
199328 Tamil Nadu patients Male: 48% (n = 663) Mortality rate: 37% time: 1–3 h Operative
Mean BSA: NS. 31% (n = 505) management: 9%

Wesson and Kwong 13

had >50% TBSA
Sarma, 199429 Digboi, Assam 348 burn Mean age: 21–30 y Admitted: 100%* NA Operative
patients Male: 54% (n = 348) Mortality rate: 18% management:
(n = 64) 75%
Wound care: 40%
wound infection
(continued)
Table V. (continued)

14 Wesson and Kwong

Summary of findings
Hospital care:
Study Hospital care: clinical administrative
Author, y Study location population Demographics Patient outcome Prehospital care capabilities capabilities
Subrahmanyam, Maharashtra 175 burn Mean age: 21–30 y Admitted: 100%* Mean prehospital NA
199630 patients Male: 36% (n = 99) Died within 24 h: time: <4 h
Mean BSA: 51%– 8% (n = 14)
80%
Ahuja, 200231 New Delhi 11,196 burn Mean age: 16–35 y Admitted: 100%* Mean prehospital NA
patients Male: 44% Mortality rate: 52% time: <6 h
(n = 4,958) (n = 5,799)
Mean BSA: 50%
Goel, 200432 Uttar Pradesh 180 injured Mean age: 24.7 y Admitted: 100%* Mean prehospital NA

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patients Male: 70% (n = 123) Mortality rate: 31% time: 1–6 h
(n = 55/175)
Murlidhar, Mumbai, 1,074 severely Mean age: 31 years Admitted: 100%* Received Operative
200433 Maharashtra injured Male: 84% (n = 902) Mortality rate: 21% prehospital care: management:
patients Mean ISS: 16.7 18% 16%
Mean prehospital
time: 6 h
Mohta, 200635 New Delhi 105 patients Mean age: 21–40 y Admitted: 100%* Prehospital time: 1 Airway
with chest (50%) Mortality rate: 7% to >24 h management: 5%
trauma Male: 90% (n = 95) intubated
ISS: 1–41 (range) Resuscitation: 8%
Mock, 200634 Gujarat 43 facilities NA NA NA Airway Training: All
management: ET facilities did not
intubation have a trauma
capabilities education course
inadequate or
absent at small
clinic level;
mechanical
ventilation absent
at small hospital
level and
inadequate at
large hospital
level

j 2017
Surgery
(continued)
Table V. (continued)

Volume j, Number j
Surgery
Summary of findings
Hospital care:
Study Hospital care: clinical administrative
Author, y Study location population Demographics Patient outcome Prehospital care capabilities capabilities
Chest tubes: Absent
at small hospital
level; partially
adequate at large
hospital level
Oxygen: Partially
adequate at small
clinic level
Blood transfusion

ARTICLE IN PRESS
capabilities:
Partially adequate
at large hospital
level; absent at
small hospital
level
Wound care:
Antibiotic
dressing
inadequate at
small clinic level
Operative
management:
neurosurgical.
spine, and
thoracotomy
capabilities
inadequate or
partially adequate

Wesson and Kwong 15

at large hospital
level; laparotomy
capabilities
adequate at large
hospital. Traction
and internal/
(continued)
Table V. (continued)

16 Wesson and Kwong

Summary of findings
Hospital care:
Study Hospital care: clinical administrative
Author, y Study location population Demographics Patient outcome Prehospital care capabilities capabilities
external fixation
absent at small
hospital level and
adequate at large
hospital level.
Rautji, 200636 South Delhi, 400 RTI Mean age: 21–30 y Admitted: 100%* Received NA
New Delhi fatalities Male: 90% Mortality rate: prehospital care:
(n = 360/400) 100%y 6%
Mean ISS: 37.8 Transported by

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ambulance: 4%
Mean prehospital
time: <1 h (92%
of patients)
Prehospital deaths:
26%
Pandey, 200737 New Delhi 60 patients Mean age: 34 years Admitted: 100%* Mean time to NA
with spinal Male: 85% (n = 51) Mortality rate: NS rehabilitation:
cord injuries 45 days to arrive
at spinal care
rehab
Transported by
ambulance: 25%
(from referral
center to rehab)
Ramanujam, Chennai, Injured Mean age: 16–45 y Admitted: NS Received Airway
200738 Tamil Nadu patients Mortality rate: 20% prehospital care: management:
(n = NS) 15% ;1/3 of hospitals
had bag valve
masks and RSI
paralytics
Resuscitation: ;1/3
of hospitals had
central line
equipment

j 2017
Surgery
(continued)
Table V. (continued)

Volume j, Number j
Surgery
Summary of findings
Hospital care:
Study Hospital care: clinical administrative
Author, y Study location population Demographics Patient outcome Prehospital care capabilities capabilities
Spinal
immobilization:
;1/3 of hospitals
had cervical
collars
Tchorz, 200739 Bangalore 44 providers Training: 87.5%
pass rate
following training
Kumar, 200840 New Delhi 2,472 injured Mean age: 21–30 y Admitted: 100%* Prehospital deaths: NA

ARTICLE IN PRESS
fatalities Male: 88% Mortality rate: 40%
(n = 2,181) 100%y
Singh, 200841 Manipal, 470 RTI Mean age: 21–30 y Admitted: 100%* Prehospital deaths: NA
Karnataka fatalities Males: 71% Mortality rate: 24% (n = 90)
(n = 334) 100%y
Fitzharris, 200942 Hyderabad, 378 MTV Mean age: 31.3 y Admitted: 100%* Prehospital deaths: NA
Andhra users Male: 88% (n = 333) Mortality rate: 7% 5% (2% at the
Pradeah Mean ISS: 5.2 ± 7.5 scene; 3% en
route)
Kumar, 200943 Lucknow, 4 trauma NA NA NA Airway Training: 25% of
New Delhi, centers management: 4/4 hospitals had
Mumbai hospitals had trauma-trained
inadequate physicians
ventilators
Operative
management: 2/4
hospitals had
adequate
operating rooms

Wesson and Kwong 17

Saini, 200944 Punjab 50 providers Training: 87% pass
rate following
training
Verma, 200945 New Delhi 225 pediatric Mean age: 6.1 y Admitted: 21% Mean prehospital
injuries Male: 70% (n = 158) Mortality rate: NS time: 2.8 h
Mean AIS: 31%
(continued)
Table V. (continued)

18 Wesson and Kwong

Summary of findings
Hospital care:
Study Hospital care: clinical administrative
Author, y Study location population Demographics Patient outcome Prehospital care capabilities capabilities
minor; 57%
moderate; 12%
severe
Dandona, 201046 Andhra 129 patients Mean age: 50–59 y Admitted: 8% Mean prehospital NA
Pradesh with fall Male: 22% (n = 29) (n = 10) time: <3 h
injuries Mean ISS: NS Mortality rate: 0%
Douglas, 201049 Tamil Nadu 56 providers Training: 20% pass
rate following
training

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Charkraborty, Kalkatoa, 83 burn Mean age: 20–39 y Admitted: 100%* NA Blood transfusion
201048 West Bangal patients Male: 39% (n = 32) Mortality rate: 16% capabilities: 100%
Mean BSA: NS;
>80% BSA: 22%
Ganesamoni, Puducherry 222 burn Mean age: Admitted: 100%* Prehospital time: NA Training: 90% pass
201047 patients 24.6 ± 1 years Mortality rate: 61% 4 ± .1 h rate following
Male: 37% (n = 82) FAST training
Mean BSA: 23% for
survivors; 65% for
deaths
Gupta, 201050 New Delhi 42 providers
Menon, 201051 Karnataka, 32,188 injured Mean age: 20–29 y Admitted: 100%* Received NA
Maharashtra patients Male: 77% Mortality rate: 2.3% prehospital care:
(n = 24,370) of RTIs (n = 140/ 41% of RTIs
6,004) Transported by
ambulance: 14%
Roy, 201052 Mumbai, 161 injured Mean age: 29.9 y Admitted: 100%* Received NA
Maharashtra patients Male: 84% (n = 136) prehospital care:
19% (by police)
Transported by
ambulance: 35%
Bajwa, 201153 Punjab 531 Mean age: 15–35 y Admitted: 100%* Mean prehospital Airway
poly-trauma Male: 93% (n = 493) time: 32 ± 8 min management:
patients Mean GCS: 9.7 Intubated: 43%
Chest tube: 12%

j 2017
Surgery
(continued)
Table V. (continued)

Volume j, Number j
Surgery
Summary of findings
Hospital care:
Study Hospital care: clinical administrative
Author, y Study location population Demographics Patient outcome Prehospital care capabilities capabilities
Operative
management:
82%
Resuscitation: 46%
Blood transfusion
capabilities: 73%
Gupta, 201154 Punjab 892 burn Mean age: 35 ± 19.6 y Admitted: 100%* NA Operative
patients Male: 54% (n = 485) Mortality rate: 40% management:
Mean BSA: 48 ± 18% (n = 357) 100%

ARTICLE IN PRESS
Blood transfusion
capabilities: 100%
Wound care: 75%
had wound
infections
Kavita, 201155 Bengaluru, 13,231 injured Mean age: 15–29 y Admitted: 52% Received NA
Karnataka patients Male: 77% Mortality rate: 6% prehospital care:
(n = 10,162) 1%
ISS: 36% mild; 44%
moderate; 20%
severe
O’Reilly, 201156 Pubjab 22 providers Training: 75% pass
rate following
trauma
Tandle, 201157 Maharashtra 138 RTI Mean age: 21–30 y Admitted: 100%* Prehospital deaths: NA
fatalities Male: 87% (n = 120) Mortality rate: 66% (26% at the
100%y scene; 40% en
route)
Jagnoor, 201258 Chandigar, 1,407 patients Mean age: 15–34 y Admitted: 21%* Mean prehospital NA

Wesson and Kwong 19

Punjab with fall Male: 76% Mortality rate: 10% time: 7.9 h
injuries (n = 1,074) (n = 143) Transported by
Mean GCS: #8 ambulance: .3%
Bhoi, 201359 New Delhi 5 providers Training: Improved
skills following
FAST training
(continued)
 ARTICLE IN PRESS
20 Wesson and Kwong Surgery
j 2017

registries.33,40,51,58 Other studies focused on the

AIS, Abbreviated Injury Score; BSA, burn surface area; FAST, Focused Assessment with Sonography in Trauma; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; NS, not stated; SCI, spinal cord injury; STSG, split
need for targeted trauma training, including mo-
administrative
Hospital care:

capabilities
dalities such as the Focused Assessment with So-
nography in Trauma exam.27,39,43,44,49,50,56,59,62
Given these findings, we propose essential
research and development goals. For prehospital
care, a multisector approach must be implemented
to address training of EMS providers and commu-
Hospital care: clinical

nity members. Prehospital transport time needs to

be decreased through improved communication
capabilities

and transport modalities. Recommendations to

implement a national emergency response number
have been detailed in a recently published white
paper.63 These efforts could be implemented under
NA

NA

the leadership of existing organizations, such as the

Indian Association of Traumatology and Critical
Summary of findings

prehospital care:
Mean prehospital

Care, the Apex Trauma Center in New Delhi, and

Prehospital care

the Indian Academy of Traumatology.

time: 4.5 h

Regarding hospital care, an important first step

Received

is to inventory the available equipment and services

72%

at each hospital. As outlined by the WHO, the 11

essential core trauma care services and 260 essential
or desirable individual human or physical resource
items designated by the Essential Trauma Care
Mortality rate: NS
Admitted: 100%*

Admitted: 100%*
Patient outcome

Project may serve as good starting points to evaluate

Mortality rate:

the adequacy of available resources at each dedi-

cated trauma hospital in India.62 After this initial in-
100%y

ventory, emphasis must be placed on developing

systems for collecting data on trauma. National or-
ganizations, such as the Non-Communicable Dis-
Male: 88% (n = 211)

ease Division of the Indian Council for Medical

Mean age: 25–65 y

Mean age: 20–30 y

Research, could lead the effort to establish a univer-

Demographics

sal trauma registry.64 This approach could lead to

Male: 84.6%

the development of hospital-based training pro-

grams in trauma care, quality improvement, and
dedicated trauma response teams.62
This review identifies the gaps in prehospital
and hospital-based trauma care in India and
7,241 injured

suggests evidence-based interventions. Such inter-

population

*All study patients were admitted, per study inclusion criteria.

fatalities

ventions require commitments from the Indian

Study

182 RTIs

government, local hospitals, and individual com-

munity members. Through these efforts, we may
yAll study patients died, per study inclusion criteria.

be able to better confront and ultimately overcome

the burden of injury that continues to affect
Study location

thickness skin graft; VP, ventral-peritoneal.

millions of lives.
Puducherry

Pune
Table V. (continued)

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