Journal of Emergencies, Trauma, and Shock

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 14  |  Issue : 2  |  Page : 86--91

Cattle-related trauma: A 5-year retrospective review in a adult major trauma center


John-Henry Rhind1, Dominic Quinn2, Lucy Cosbey2, Douglas Mobley2, Ingrid Britton2, Justin Lim2,  
1 Robert Jones Agnes Hunt Hospital, Gobowen, England
2 Royal Stoke University Hospital, Stoke-on-Trent, England

Correspondence Address:
John-Henry Rhind
Robert Jones Agnes Hunt Hospital, Gobowen
England

Abstract

Introduction: Bovine injuries are a common and significant cause of trauma, often requiring admission and operative treatment. We review all bovine-related injuries over 5 years, both emergency and general practitioner (GP) referrals at an adult major trauma center in England. Methods: Retrospective evaluation was undertaken using the keywords through radiology referrals and hospital admissions speciality databases. By searching patient notes, demographics were collected as well as the mechanism and the situation of injury; trauma scores were calculated using: injury severity score (ISS) and probability of survival (Ps19). The results were divided into emergency patients and GP referrals. Results: Sixty-seven patients were identified retrospectively over 5 years, 44 emergency patients (including 23 major traumas), and 23 GP referrals. Combined (emergency and GP) mean age 52 years old; 67% male; and mean ISS 11. Most common combined mechanism of injury, kicked (n = 23). In emergency patients, trampling injuries were the most common. Eighty-six percent of the trampled patients were major traumas and associated with increased ISS (mean 13). Indirect injuries mainly involved farm gates (92%). Seventy-three percent of bull-related injuries were major traumas and had increased ISS scores (mean 17). Orthopaedics was the most common admitting speciality followed by cardiothoracic and neurosurgery. In emergency patients, fractures were the most common primary injury (n = 20), upper limb followed by spine. In GP, soft-tissue injuries were the most common primary injury. Seventy percent of the emergency referrals required admission and 50% operations. Fracture fixation was the most common operative procedure. Only, one GP referral required an operation. There were significant delays in GP patients presenting. Two patients had a Ps19 score <90. There were two mortalities. Conclusion: Cattle-related injuries are a significant cause of severe morbidity and mortality. They are under-reported. Patterns of injury are similar to high-velocity road traffic collisions and bull-related injuries or trampling in particular, should alert the clinician to more significant trauma. Farm gates are a frequent cause of trauma associated with cattle. GP referrals with ongoing symptoms for more than 2 weeks seeking medical advice should alert the clinician to a more serious diagnosis.



How to cite this article:
Rhind JH, Quinn D, Cosbey L, Mobley D, Britton I, Lim J. Cattle-related trauma: A 5-year retrospective review in a adult major trauma center.J Emerg Trauma Shock 2021;14:86-91


How to cite this URL:
Rhind JH, Quinn D, Cosbey L, Mobley D, Britton I, Lim J. Cattle-related trauma: A 5-year retrospective review in a adult major trauma center. J Emerg Trauma Shock [serial online] 2021 [cited 2021 Sep 17 ];14:86-91
Available from: https://www.onlinejets.org/text.asp?2021/14/2/86/314962


Full Text



 Introduction



Cattle-related injuries are serious, common, and often under-reported. On average, there are 4–5 cattle-related deaths per year throughout the UK, with around 90 cattle-related fatalities since 2000.[1]

The majority of these injuries are associated with farmers and farming communities, up to 24%.[2] However, nonfarming members of the general public are also at risk, particularly in England, where there is a considerable network of footpaths crossing through farms and fields with public access. In addition, the Countryside and Rights of Way Act 2000[3] gave the public the right to walk on mapped access land which includes mountain, moor, heath, down, and registered common land. Fifty-four cattle attacks were reported in the UK media to the members of the general public, walking, from January 1993 to May 2013.[4] However, the full extent is unknown.

Patients who present to the hospital following cattle-related accidents should be treated as high-velocity trauma victims as the pattern of injuries is similar to those seen in road traffic accidents.[5] This is an important issue for rural trauma teams to consider as, in 2018, approximately 309,000 people in England worked on commercial agricultural holdings looking after around 5.3 million cattle and calves.[6]

It is difficult to get an accurate figure for nonfatal cattle-related trauma as the majority go under-reported or are managed by the general practitioner (GP).[7] There have been no previous studies examining the impact of cattle-related trauma in the United Kingdom at a major trauma center in a rural location examining both general practice and emergency admissions. A retrospective study was performed over 5 years to determine the nature and severity of these injuries seen at a rural adult major Trauma center in England.

 Methods



Data collection

We conducted the study in the Royal Stoke University Hospital, an Adult Major Trauma Centre in the county of Staffordshire, England. It serves a population of 3 million, including North Wales.[8]

Only patients directly injured by cattle were included in the results over 5 years (March 10, 2014–March 10, 2019). Indirect injuries, such as road traffic accidents, were excluded.

We conducted the search, 3 October 2019. Two independent authors searched our trauma admissions database retrospectively using the following keywords, namely “cattle,” “cow,” “bull,” “bullock,” “ox,” “oxen,” “farm,” and “farmer.” Similarly, the orthopaedic, cardiothoracic, neurosurgery, maxillofacial, ENT, general surgery, urology, and medical admission databases were also searched with the keywords. Individual referrals or admissions matching the keywords were checked to ensure the trauma was bovine related.

Electronic imaging requests stored on the hospital data system were also searched using the same keywords retrospectively. Each matching patients' imaging and records were checked to ensure the trauma was bovine related.

All relevant referral types seen in our hospital within the specified data range were included: Major trauma referrals, emergency department referrals, and GP direct access patients. Major trauma referrals were defined by the Trauma Audit and Research Network-TARN Criteria – England and Wales Nov 2019.[9]

Mechanism of injury was ascertained from the clinical notes and classified into broad groups: Unknown, kicked, charge/headbutt, body contact, indirect, and trampled. Indirect referred to those, for example, injured indirectly between a gate a and a cow. The situation of the injury was recorded where the information was declared in the patient notes; this fell into distinct categories: Unknown, herding, slaughtering, vaccinating, milking, manual labor, and walking by. The term walking by was used when there was no specific task or event recorded at the time they were injured. Demographics were recorded, and occupation was recorded from the terms the patient used on admission or from the admitting doctor's notes.

Injuries were grouped according to the major primary injury. The injury severity score (ISS) was calculated for all patients from the patient notes. In the major trauma patients, the probability of survival (Ps19) was calculated using the Ps19 method, using available data from patient records.[9]

Data analysis

The ISS was one of the first trauma scores established.[10] Based on the abbreviated injury system, it produces a single value which correlates with the description of injury and outcome. It is one of the most common trauma scoring systems worldwide, and a score of 16 represents the cutoff for approximate predictive mortality of 10%.[11] ISS was calculated for all patients. The Ps19 method is an updated value of the TRISS method of Ps19 that incorporates The Glasgow Coma Scale (GCS), comorbidities and outcomes at 30 days[9],[12] Ps19 was calculated in the major trauma patients using the patient records.

Microsoft Excel (Microsoft corp., WA, USA) was used to record the data anonymously. ISS and Ps19 scores were calculated by the trauma directorate data analyst team local to our hospital. Prism v. 8.4 (GraphPad, CA, USA) was used for graphs.

 Results



Emergency referrals

Forty-four patients were referred from the emergency department within the 5-year data range (March 10, 2019–March 10, 2014), including 23 major traumas and two mortalities.

Seventy percent of the patients were male.

Age (mean 42 years old), majority of patients >50 years old (n = 24) [Figure 1].{Figure 1}

Farming was the most common occupation (n = 20). Three others were identified as living on a farm, and there were two vets. The occupation was unknown for the remaining patients (n = 19).

Eleven of the episodes were bull-related, 73% of these were major traumas.

Trampling was the most common mechanism in emergency referrals (n = 14); 86% of these were major traumas.

Indirect trauma was the second most mechanism of injury (n = 12). Indirect trauma consisted of 11 episodes of trauma sustained whilst leading a cow through a gate and being injured indirectly by the gate (such as being crushed between the gate and the wall or beneath the gate as the cow passed through) and one episode of indirect trauma from the chain a cow was being led on. Kicked was the third most common (n = 11). Body contact consisted of events where the cow fell or stumbled on to the patient (n = 2) [Figure 2].{Figure 2}

The situation of injury was unknown in 39% of the patients. In those recorded: Walking by (36%) was the most common situation of injury, within that category three were walking with dogs [Table 1].{Table 1}

Overall, fractures were the most common primary injury sustained (n = 20). Within that category, upper limb fractures were the most common (n = 9), spine fractures (n = 5) were the next most common type of fracture followed by lower limb (n = 4). Blunt chest injury (n = 8) was the second most common primary injury followed by soft-tissue injuries (n = 7). Both long bone fractures were tibial, one was an open fracture requiring multiple washouts and external fixation, the other intramedullary nailing [Figure 3].{Figure 3}

Seventy percent required admission into hospital. Fifty percent underwent an operation.

Orthopaedics was the most common admitting speciality, followed by cardiothoracic and neurosurgery.

Overall, fracture fixation procedures were the most common (n = 12). Of these, spinal fixation was the most common type of fracture fixation carried out (n = 5) followed by chest wall reconstruction (n = 3) [Table 2].{Table 2}

There were 23 major trauma patients, within the emergency referrals, as defined by the TARN criteria for major trauma.[9]

All the major traumas were admitted, 70% underwent operations.

Fifty-two percent of these patients had an ISS >16.

Two patients had a Ps19 score <90%.

There were two mortalities (n = 2) within the major trauma referrals.

Ninety-one percent of the major trauma patients had a complete data set (physiological parameters, observations charts, comorbidities, and 30-day outcomes) to calculate Ps19 [Figure 4].{Figure 4}

GP referrals

There were 23 GP direct access patients referred within the date range.

Seventy percent were male.

The mean age was 53 years old [Figure 1].

The situation of injury was unknown in GP patients due to less detail in patient records.

The most common mechanism was kicked (n = 12).

The majority of GP referrals were soft-tissue injuries (n = 16). There were three rotator cuff injuries with delayed presentations [Figure 3]. None of the patients required admission; however, one of the hand fractures was a scaphoid fracture requiring operative fixation at a later date after a failed trial of conservative management due to delayed presentation.

The GP referrals had a varied time to presentation ranging from 2 days to 3 months, mean (n = 25 days).

Three patients have an ISS >5 [Figure 5].{Figure 5}

Combined Results (Emergency and GP)

Sixty-seven patients overall.

Combined mean age was 52 years old [Figure 1].

Most common mechanism kicked (n = 23) [Figure 2].

Overall, the most common primary injury was soft-tissue injury (n = 23) followed by fractures (n = 22) [Figure 3]. Twenty-seven percent of patients had an ISS >16 [Figure 5]. The overall mean ISS was 11.

 Discussion



In this retrospective study, 67 patients were identified over 5 years. Double the incidence reported in a similiar retrospective study by Murphy et al. in Ireland, where 47 patients were identified over 10 years.[13] This may be due to more comprehensive retrospective search techniques using radiology search records in addition to searching patient databases. It may also reflect how under reported these injuries are, particularly in the British Isles. However, in another prospective study in New Zealand, the incidence was higher.[14]

Male working farmers more than 50 years old were the most common demographic in our study. Not only was this demographic more common, but their injuries were more severe and consisted of more polytraumas, supporting other literature.[13],[15],[16] Patterns of injury in bovine-related trauma are described as similar to road traffic collisions,[5] whereas road traffic collisions typically occur in young male patients bovine trauma is more frequent in older patients.

Walking by was the most common situation of injury in emergency patients. In three of these situations, they had dogs, which are a recognized risk factor for trauma with cows.[4] Milking was the next most common situation in this study. Dairy farming is common in the local county, Staffordshire, making this unsurprising and is a risk.[17] There were two injuries from injections while vaccinating, sustained by vets; Lucas et al. recognized this risk with veterinarians.[18] Slaughtering was another situation identified; tagging new-born calves and clipping cattle before slaughter has been identified as a risk factor for injury in previous literature.[2] Thirty-nine percent of the situations in the emergency patients and all the situations in GP patients were unknown, highlighting the limits of this retrospective study.

Another established risk factor is maternal behavior in cows with calves;[19] no calves were identified in this study. It is unclear if this was due to the limitations of this study, or there were none present.

In terms of mechanism, kicking was the most common when all emergency and GP referrals were combined. However, trampling was more common in emergency referrals and associated with more major traumas (86%) and higher ISS scores – mean 13 (overall mean 11).

Indirect injuries were the second most common mechanism in emergency referrals (third overall), 92% of these involved moving cattle through farm gates and crush injuries. Fifty-eight percent of these episodes were major traumas and were associated with higher ISS scores – mean 14 (overall mean 11). It is unclear if current gates being used are inadequate or are incorrectly used, in which case, further education is required. The Health and Safety Executive offers safety advice on cattle for farmers and landowners and recommends that gates are regularly checked and maintained.[20] There is no mention of what constitutes an adequate safe gate. Watts et al. also found being crushed by the gate, a common mechanism.[14] Browning et al. identified that limiting the size of cattle herds reduced injury, mainly through gates, as well as the use of all-terrain vehicles (ATV).[21] Introducing minimum safety standards for gates and maximal herd sizes in the UK may be a useful addition.

Bull injuries, although less frequent, were also associated with more major traumas (73%) and higher ISS scores-mean 17 (overall mean 13). One of the two mortalities was bull related[15],[16],[22]

Overall, blunt over penetrative trauma was more common and associated with more severe trauma in this study, supporting the literature.[13],[23]

The most common primary injury in emergency patients was fractures, supporting other literature[13],[15] Overall, upper limb fractures were the most common category of fracture, similar to other studies[14],[18] followed by the spine. Eighty percent of the spine fractures were in male farmers more than 70 years old, and all involved thoracic fractures. This may highlight an additional injury pattern seen in the elderly male working farmers. When the primary injury was combined with GP patients, the most common injury was soft-tissue injuries.

Elderly male farmers sustaining blunt head and chest injuries have been identified as the most at risk group for mortalities associated with cattle.[24] Both mortalities in this study were male farmers over 50 years old, sustaining blunt trauma, one a head injury while the other suffered multiple abdominal injuries and spinal fractures. This demographic may need to consider extra precautions such as body armour or alternative working practices.

The GP patients had significantly delayed presentations. It is likely that there are even more injuries that go unrecorded as patients, particularly with soft-tissue injuries, will have an improvement in their symptoms before presenting and no longer seek medical advice. This is particularly prevalent in the farming community who are often self-employed.

Although most of the GP injuries were soft tissue, there were some important diagnoses initially missed such as scaphoid fractures and rotator cuff tears. This highlights the importance of investigating these injuries fully in patients with ongoing symptoms that have not improved over a significant amount of time. There are no previous studies we could find that have have been set in a major trauma center and included general practice injuries, in the United Kingdom. Doyle et al. described farming-related injuries in general practice in Ireland.[7]

The most common operative procedures were upper limb fracture fixation and spine fracture stabilisation; all these patients had unstable thoracic spine fractures or combined thoracolumbar, thoracic-cervical injuries. Chest wall reconstruction was the third most common operation type. The majority of these operations were associated with blunt trauma.

Orthopaedics was the most common admitting speciality confirming that fractures were the most common overall injury associated with bovine trauma. This was followed by cardiothoracic and neurosurgery. This highlights the significant chest and head injuries found in this study which are most associated with mortality.[24]

Out of all animal-related injuries, cattle injuries cause the most hospital admissions[22],[25] In addition, previous studies have indicated that bovine injuries are more expensive to treat than other animal-related injuries.[26] We were unable to calculate the cost of each admission in this study. Watts et al. calculated the total hospital cost for 78 patients in New Zealand with bovine-related injuries as $32,884 and total loss of income as $86,178.[14]

The chief limiting factor in this study is its retrospective design. The data systems in the hospital rely on user input to collect the information such as the mechanism of the injury, which may not always be accurate. There is also no specific coding system for bovine-only related injuries in either the ICD 9 or ICD 10 classification manuals if the patient is admitted to the hospital. In addition, many people do not seek primary or secondary care when they are injured. Only the injuries in which the doctors document the causative animal were picked up through our methods. Some of the identified patient's notes were also incomplete or lacked key details to allow more detailed analysis of injury patterns or calculation of trauma scores.

Introducing specific hospital coding (ICD classification) for bovine injuries would allow further research in this area to be carried out more easily.

Future research would also benefit from more prospective level one and two studies dedicated to collecting all the available patient information and negating the limits of this study. We identified only one prospective study, carried out in New Zealand.[14]

In Sweden, animal registries are kept in some rural communities to monitor the nature of these animal injuries, which may be a useful addition in this setting.[26]

 Conclusion



Cattle-related injuries are a significant cause of severe morbidity and mortality. They are under-reported and more awareness should be raised, as a public health risk. Patterns of injury are similar to high velocity road traffic collisions and bull-related injuries or trampling in particular, should alert the clinician to more significant trauma. Farm gates are a frequent cause of trauma associated with cattle. GP referrals with ongoing symptoms for more than 2 weeks seeking medical advice should alert the clinician to a more serious diagnosis. Clinicians should maintain a high suspicion for upper limb and spinal fractures. Further prospective research is required on this important topic.

Research quality and ethics statement

This study was determined to not require the Institutional Review Board / Ethics Committee review, and the corresponding protocol/approval number is not applicable. The authors followed applicable EQUATOR Network (http:// www.equator-network.org/) guidelines during the conduct of this research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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