Fatal trauma: the modal distribution of time to death is a function of patient demographics and regional resources

Rural high north: a high rate of fatal injury and prehospital death

Background

Finnmark County is the northernmost county in Norway. For several decades, the rate of mortality after injury in this sparsely inhabited region has remained above the national average. Following documentation of this discrepancy for the period 1991–1995, improvements to the trauma system were implemented. The present study aims to assess whether trauma-related mortality rates have subsequently improved.

Methods

All injury-associated fatalities in Finnmark from 1995–2004 were identified retrospectively from the National Registry of Death and reviewed. Low-energy trauma in elderly individuals and poisonings were excluded.

Results

A total of 453 cases of trauma-related death occurred during the study period, and 327 of those met the inclusion criteria. Information was retrievable for 266 cases. The majority of deaths (86%) occurred in the prehospital phase. The main causes of death were suicide (33%) and road traffic accidents (21%). Drowning and snowmobile injuries accounted for an unexpectedly high proportion (12 and 8%, respectively). The time of death did not show trimodal distribution. Compared to the previous study period, there was a significant overall decline in injury-related mortality, yet there was no change in place of death, mechanism of injury, or time from injury until death.

Conclusions

Changes in injury-related mortality cannot be linked to improvements in the trauma system. There was no change in the epidemiological patterns of injury. The high rate of on-scene mortality indicates that any major improvement in the number of injury-related deaths lies in targeted prevention.

A profile of deaths among trauma patients in a university hospital: the Philippine experience

Background:

The Philippine General Hospital (PGH) is the pioneer in trauma care in the country, being the first to create a dedicated Trauma Service in 1989. The service has not conducted a review of its admissions and mortalities since 1992. The purpose of this study is to describe the mortality patterns of this service.

Methods:

A descriptive and retrospective 3-year review, covering January 2004 June 2007, was conducted using an electronic patient database. Review of patient records included: population demographics, mechanism of injury, length of stay prior to death, and the cause of death.

Results:

Of the 4947 patients admitted to the Division of Trauma during the study period, there were 231 (4.7%) deaths. The most common mechanisms of injuries were stab wounds (32.9 %), vehicular crashes (28.6 %), and gunshot wounds (25.5 %). Multiple organ failure/Sepsis (37.7 %) was the most frequent causes of death, followed by Exsanguinations (27.7 %), Central Nervous System failure (18.6 %) and other causes (10.8%). Forty four (66.7 %) of the 66 patients who died within the first 24 hours died from Exsanguinations, while 66 (61.1 %) of the 8 patients who died after 72 hours died from Multiple organ failure/Sepsis.

Conclusions:

Intentional causes of injury (i.e. penetrating interpersonal violence) caused the majority of trauma deaths in this series from the Philippine General Hospital. This highlights the need for prioritizing a public health approach to violence prevention in the Philippines. Further research must be conducted to identify risk factors for interpersonal violence. Early identification of lethal injuries that may cause exsanguinations and definitive control of hemorrhage should be the primary focus to prevent acute deaths, within 24 hours of admission. Further adjuncts to the definitive treatment of hemorrhage, the critical care of TBI and MOF/Sepsis are needed to reduce deaths occurring more than 72 hours after admission.

Changing epidemiology of trauma deaths leads to a bimodal distribution

Injury mortality was classically described with a trimodal distribution, with immediate deaths at the scene, early deaths due to hemorrhage, and late deaths from organ failure. We hypothesized that the development of trauma systems has improved prehospital care, early resuscitation, and critical care and altered this pattern. This population-based study of all trauma deaths in an urban county with a mature trauma system reviewed data for 678 patients (median age, 33 years; 81% male; 43% gunshot, 20% motor vehicle crashes). Deaths were classified as immediate (scene), early (in hospital, ≤4 hours from injury), or late (>4 hours after injury). Multinomial regression was used to identify independent predictors of immediate and early versus late deaths, adjusted for age, gender, race, intention, mechanism, toxicology, and cause of death. Results showed 416 (61%) immediate, 199 (29%) early, and 63 (10%) late deaths. Compared with the classical description, the percentage of immediate deaths remained unchanged, and early deaths occurred much earlier (median 52 vs 120 minutes). However, unlike the classic trimodal distribution, the late peak was greatly diminished. Intentional injuries, alcohol intoxication, asphyxia, and injuries to the head and chest were independent predictors of immediate death. Alcohol intoxication and injuries to the chest were predictors of early death, while pelvic fractures and blunt assaults were associated with late deaths. In conclusion, trauma deaths now have a predominantly bimodal distribution. Near elimination of the late peak likely represents advancements in resuscitation and critical care that have reduced organ failure. Further reductions in mortality will likely come from prevention of intentional injuries and injuries associated with alcohol intoxication.

Models of lower extremity damage in mice: time course of organ damage and immune response

BACKGROUND

Post-traumatic inflammatory changes have been identified as major causes of altered organ function and failure. Both hemorrhage and soft tissue damage induce these inflammatory changes. Exposure to heterologous bone in animal models has recently been shown to mimic this inflammatory response in a stable and reproducible fashion. This follow-up study tests the hypothesis that inflammatory responses are comparable between a novel trauma model ("pseudofracture", PFx) and a bilateral femur fracture (BFF) model.

MATERIALS AND METHODS

In C57BL/6 mice, markers for remote organ dysfunction and inflammatory responses were compared in four groups (control/sham/BFF/PFx) at the time points 2, 4, and 6 h.

RESULTS

Hepatocellular damage in BFF and PFx was highly comparable in extent and evolution, as shown by similar levels of NFkappaB activation and plasma ALT. Pulmonary inflammatory responses were also comparably elevated in both trauma models as early as 2 h after trauma as measured by myeloperoxidase activity (MPO). Muscle damage was provoked in both BFF and PFx mice over the time course, although BFF induced significantly higher AST and CK levels. IL-6 levels were also similar with early and sustained increases over time in both trauma models.

CONCLUSIONS

Both BFF and PFx create similar reproducible inflammatory and remote organ responses. PFx will be a useful model to study longer term inflammatory effects that cannot be studied using BFF.

An implantable biochip to influence patient outcomes following trauma-induced hemorrhage

Following hemorrhage-causing injury, lactate levels rise and correlate with the severity of injury and are a surrogate of oxygen debt. Posttraumatic injury also includes hyperglycemia, with continuously elevated glucose levels leading to extensive tissue damage, septicemia, and multiple organ dysfunction syndrome. A temporary, implantable, integrated glucose and lactate biosensor and communications biochip for physiological status monitoring during hemorrhage and for intensive care unit stays has been developed. The dual responsive, amperometric biotransducer uses the microdisc electrode array format upon which were separately immobilized glucose oxidase and lactate oxidase within biorecognition layers, 1.0-5.0 μm thick, of 3 mol% tetraethyleneglycol diacrylate cross-linked p(HEMA-co-PEGMA-co-HMMA-co-SPA)-p(Py-co-PyBA) electroconductive hydrogels. The device was then coated with a bioactive hydrogel layer containing phosphoryl choline and polyethylene glycol pendant moieties [p(HEMA-co-PEGMA-co-HMMA-co-MPC)] for indwelling biocompatibility. In vitro cell proliferation and viability studies confirmed both polymers to be non-cytotoxic; however, PPy-based electroconductive hydrogels showed greater RMS 13 and PC12 proliferation compared to controls. The glucose and lactate biotransducers exhibited linear dynamic ranges of 0.10-13.0 mM glucose and 1.0-7.0 mM and response times (t(95)) of 50 and 35-40 s, respectively. Operational stability gave 80% of the initial biosensor response after 5 days of continuous operation at 37 °C. Preliminary in vivo studies in a Sprague-Dawley hemorrhage model showed tissue lactate levels to rise more rapidly than systematic lactate. The potential for an implantable biochip that supports telemetric reporting of intramuscular lactate and glucose levels allows the refinement of resuscitation approaches for civilian and combat trauma victims.

Contrast-enhanced US evaluation in patients with blunt abdominal trauma()

INTRODUCTION

To evaluate the use of contrast-enhanced ultrasonography (CEUS) in patients with blunt abdominal trauma.

MATERIALS AND METHODS

A total of 133 hemodynamically stable patients were evaluated using ultrasonography (US), CEUS and multislice Computer Tomography (CT) da eliminare.

RESULTS

In 133 patients, CT identified 84 lesions: 48 cases of splenic injury, 21 of liver injury, 13 of kidney or adrenal gland injury and 2 of pancreatic injury. US identified free fluid or parenchymal abnormalities in 59/84 patients positive at CT and free fluid in 20/49 patients negative at CT. CEUS revealed 81/84 traumatic injuries identified at CT and ruled out traumatic injuries in 48/49 negative at CT. Sensitivity, specificity, positive and negative predictive values for US were 70.2%, 59.2%, 74.7% and 53.7%, respectively; for CEUS the values were 96.4%, 98%, 98.8% and 94.1%, respectively.

CONCLUSIONS

The study showed that CEUS is more accurate than US and nearly as accurate as CT, and CEUS can therefore be proposed for the initial evaluation of patients with blunt abdominal trauma.

Epidemiology of traumatic deaths: comprehensive population-based assessment

BACKGROUND

The epidemiology of traumatic deaths was periodically described during the development of the American trauma system between 1977 and 1995. Recognizing the impact of aging populations and the potential changes in injury mechanisms, the purpose of this work was to provide a comprehensive, prospective, population-based study of Australian trauma-related deaths and compare the results with those of landmark studies.

METHODS

All prehospitalization and in-hospital trauma deaths occurring in an inclusive trauma system at a single Level 1 trauma center [400 patients with an injury severity score (ISS) >15/year] underwent autopsy and were prospectively evaluated during 2005. High-energy (HE) and low-energy (LE) deaths were categorized based on the mechanism of the injury, time frame (prehospitalization, <48 hours, 2-7 days, >7 days), and cause [which was determined by an expert panel and included central nervous system-related (CNS), exsanguination, CNS + exsanguination, airway, multiple organ failure (MOF)]. Data are presented as a percent or the mean +/- SEM.

RESULTS

There were 175 deaths during the 12-month period. For the 103 HE fatalities (age 43 +/- 2 years, ISS 49 +/- 2, male 63%), the predominant mechanisms were motor vehicle related (72%), falls (4%), gunshots (8%), stabs (6%), and burns (5%). In all, 66% of the patients died during the prehospital phase, 27% died after <48 hours in hospital, 5% died after 3 to 7 days in hospital, and 2% died after >7 days. CNS (33%) and exsanguination (33%) were the most common causes of deaths, followed by CNS + exsanguination (17%) and airway compromise 8%; MOF occurred in only 3%. Six percent of the deaths were undetermined. All LE deaths (n = 72, age 83 +/- 1 years, ISS 14 +/- 1, male 45%) were due to low falls. All LE patients died in hospital (20% <48 hours, 32% after 3-7 days, 48% after 7 days). The causes of deaths were head injury (26%) and complications of skeletal injuries (74%).

CONCLUSIONS

The HE injury mechanisms, time frames, and causes in our study are different from those in the earlier, seminal reports. The classic trimodal death distribution is much more skewed to early death. Exsanguination became as frequent as lethal head injuries, but the incidence of fatal MOF is lower than reported earlier. LE trauma is responsible for 41% of the postinjury mortality, with distinct epidemiology. The LE group deserves more attention and further investigation.

Disparities in injury death location for people with epilepsy/seizures

OBJECTIVE

Wide variation has been reported in the proportion of injury deaths occurring during the prehospital phase. Potential disparities in where injured people with epilepsy and seizure disorders die have not been examined. We compared location of death between injured patients with epilepsy and seizure disorders and similar patients without epilepsy/seizures and tested the hypothesis that injured people with epilepsy/seizures are more likely to die outside of a hospital or health care setting.

METHODS

U.S. vital statistics (mortality) data from the multiple cause of death files of the National Center for Health Statistics were analyzed. Patients less than 65 years of age at death who had injury as the underlying cause of death were included. Multinomial logistic regression was used to assess location of death, controlling for patient and injury characteristics.

RESULTS

Controlling for potential confounders, people with epilepsy/seizures were more likely to die at home from unintentional injuries (relative risk ratio [RRR]=1.51, P<0.001) and less likely to die in public places (RRR=0.27, P<0.001). People with epilepsy/seizures were less likely to die at home or in public places from suicide, but significantly more likely to die at home from homicide (RRR=2.29, P<0.001). By mechanism of injury, people with epilepsy/seizures were more likely to die at home from drowning (RRR=2.35, P<0.001).

DISCUSSION

Disparities in where injured people with epilepsy/seizures die deserve further attention. Identifying the underlying causes of these disparities will allow for the development of targeted prevention interventions.

Does intent matter? The medical and societal burden of self-inflicted injury

BACKGROUND

The objective of our study was to assess the impact of injury intentionality on the outcomes and healthcare resource utilization of severely injured patients in the United States.

METHODS

The National Trauma Data Bank for the years 2001 through 2006 was used for our analysis. Adult patients with an injury severity score >or=15 were divided into three groups based on injury intentionality: unintentional, assault, and self-inflicted. Demographic and injury characteristics, unadjusted and risk-adjusted mortality rates, and healthcare resource utilization variables were compared for these three groups using t tests, analysis of variance, and multivariable regression analyses where appropriate. Stata/SE version 9.2 was used for all statistical analyses. p values <0.05 were considered significant.

RESULTS

A total of 138,589 patients were included for analysis. After adjustment for potentially confounding variables, self-inflicted injury remained a significant predictor of increased mortality (mortality 42.3%, adjusted odds ratio for death = 2.31, 95% confidence interval 1.97-2.71), and injury by assault a significant predictor of decreased mortality (mortality 18.3%, adjusted odds ratio for death = 0.83, 95% confidence interval 0.74-0.92), when compared with unintentional injury (mortality 15.1%). Patients surviving self-inflicted injury required longer intensive care unit stays and overall hospital stays than survivors of unintentional injury.

CONCLUSIONS

Patients who are treated for self-inflicted injury have higher risk-adjusted mortality and utilize comparatively higher levels of healthcare resources than victims of assault or patients sustaining unintentional injury. The findings of our study emphasize the need for trauma center participation in the development and maintenance of aggressive primary and secondary suicide prevention programs.

Contrast-enhanced ultrasonography in blunt abdominal trauma: considerations after 5 years of experience

PURPOSE

The aim of the study was to evaluate the diagnostic capability of contrast-enhanced ultrasonography (CEUS) in a large series of patients with blunt abdominal trauma.

MATERIALS AND METHODS

We studied 133 haemodynamically stable patients with blunt abdominal trauma. Patients were assessed by ultrasonography (US), CEUS and multislice computed tomography (MSCT) with and without administration of a contrast agent. The study was approved by our hospital ethics committee (clinical study no. 1/2004/O).

RESULTS

In the 133 selected patients, CT identified 84 lesions; namely, 48 splenic, 21 hepatic, 13 renal or adrenal and two pancreatic. US identified free fluid or parenchymal alterations in 59/84 patients with positive CT and free fluid in 20/49 patients with negative CT. CEUS detected 81/84 traumatic lesions identified on CT and ruled out traumatic lesions in 48/49 patients with negative CT. The sensitivity, specificity and positive and negative predictive values of US were 70.2%, 59.2%, 74.7% and 53.7%, respectively, whereas those of CEUS were 96.4%, 98%, 98.8% and 94.1%, respectively.

CONCLUSIONS

Our study showed that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. The technique is able to detect active bleeding and vascular lesions, avoids exposure to ionising radiation and is useful for monitoring patients undergoing conservative treatment.

Epidemiology of Fatal Trauma in Italy in 2002 Using Population-Based Registries

BACKGROUND

Population-based registries have been proposed for epidemiologic studies and quality assessment in trauma care because they consider the entire population of a given geographic area.

PATIENTS AND METHODS

Trauma mortality in pre-hospital and in-hospital settings and death time from injury have been calculated for Italy during 2002 by cross-analyzing two national databases: the death certificates register (DCD) and the hospital discharge register (HDR). All diagnosis codes from 800.0 to 939.9 and from 950.0 to 959.9 in both the DCD and the HDR, with the exclusion of femur fractures (820.0 and 821.9) if older than 65, have been included.

RESULTS

The total number of people who died during 2002 as a consequence of trauma in Italy was 15,456; of these, 43.5% were older than age 64, and 35.9% belonged to the 15-44 age group. The overall incidence rate of trauma death was 27.23 per 100,000 inhabitants/ year, with a relative risk to men vs. women of 2.3. An analysis of the time distribution of the trauma deaths showed that 46.8% were pre-hospital mortalities, 18% of the deaths occurred within 48 h after hospital admission (acute mortality), 11.2% of the deaths occurred between three and seven days after admission (early mortality), and 24.0% of the patients died more than seven days after admission (late mortality). Patients who died before they arrived at hospital were younger and the proportion of men was higher than for the deaths that occurred after hospital arrival.

CONCLUSION

The use of population-based registries proved to be effective in our study because it allowed us to use currently available data to obtain information useful for trauma system planning and design.

Patterns of mortality and causes of death in polytrauma patients--has anything changed?

INTRODUCTION

Numerous articles have examined the pattern of traumatic deaths. Most of these studies have aimed to improve trauma care and raise awareness of avoidable complications. The aim of the present review is to evaluate whether the distribution of complications and mortality has changed.

MATERIALS AND METHODS

A review of the published literature to identify studies examining patterns and causes of death following trauma treated in level 1 hospitals published between 1980 and 2008. PubMed was searched using the following terms: Trauma Epidemiology, Injury Pattern, Trauma Deaths, and Causes of Death. Three time periods were differentiated: (n=6, 1980-1989), (n=6, 1990-1999), and (n=10, 2000-2008). The results were limited to the English and/or German language. Manuscripts were analysed to identify the age, injury severity score (ISS), patterns and causes of death mentioned in studies.

RESULTS

Twenty-two publications fulfilled the inclusion criteria for the review. A decrease of haemorrhage-induced deaths (25-15%) has occurred within the last decade. No considerable changes in the incidence and pattern of death were found. The predominant cause of death after trauma continues to be central nervous system (CNS) injury (21.6-71.5%), followed by exsanguination (12.5-26.6%), while sepsis (3.1-17%) and multi-organ failure (MOF) (1.6-9%) continue to be predominant causes of late death.

DISCUSSION

Comparing manuscripts from the last three decades revealed a reduction in the mortality rate from exsanguination. Rates of the other causes of death appear to be unchanged. These improvements might be explained by developments in the availability of multislice CT, implementation of ATLS concepts and logistics of emergency rescue.

Reassessment of the tri-modal mortality distribution in the presence of a regional trauma system

BACKGROUND

The temporal distribution of trauma-related deaths has been described as tri-modal with immediate, early, and late peaks. With the development of trauma centers and systems, it has been suggested that this distribution might be altered.

METHODS

Information regarding all trauma-related deaths occurring from 1990 through 2003 in Jefferson County, AL, was obtained and the elapsed time from injury to death was calculated and categorized as <1 hour, 1 to 6 hours, 7 to 24 hours, 1 to 3 days, 4 to 7 days, and >1 week. The distribution of the time from injury to death was compared before and after the implementation (November 1, 1996) of a regional trauma system.

RESULTS

Of the 5,240 deaths included in the analysis, 2,830 occurred between January 1, 1990 and October 31, 1996, before trauma system implementation, and 2,410 occurred afterward (i.e. November 1, 1996 to December 31, 2003). The temporal distribution of trauma death was significantly different (p < 0.0001) after trauma system development with a higher percentage of immediate deaths (56.3% compared with 51.4%) and a lower percentage that occurred 1 week after injury (4.8% compared with 8.1%).

CONCLUSION

The development of a regional trauma system had a significant impact on the temporal distribution of trauma deaths. An increase in the proportion of immediate deaths and a decrease in the proportion of deaths that occurred >1 week after injury was observed, suggesting a shift toward a bimodal distribution.

A genomic score prognostic of outcome in trauma patients

Traumatic injuries frequently lead to infection, organ failure, and death. Health care providers rely on several injury scoring systems to quantify the extent of injury and to help predict clinical outcome. Physiological, anatomical, and clinical laboratory analytic scoring systems (Acute Physiology and Chronic Health Evaluation [APACHE], Injury Severity Score [ISS]) are utilized, with limited success, to predict outcome following injury. The recent development of techniques for measuring the expression level of all of a person's genes simultaneously may make it possible to develop an injury scoring system based on the degree of gene activation. We hypothesized that a peripheral blood leukocyte gene expression score could predict outcome, including multiple organ failure, following severe blunt trauma. To test such a scoring system, we measured gene expression of peripheral blood leukocytes from patients within 12 h of traumatic injury. cRNA derived from whole blood leukocytes obtained within 12 h of injury provided gene expression data for the entire genome that were used to create a composite gene expression score for each patient. Total blood leukocytes were chosen because they are active during inflammation, which is reflective of poor outcome. The gene expression score combines the activation levels of all the genes into a single number which compares the patient's gene expression to the average gene expression in uninjured volunteers. Expression profiles from healthy volunteers were averaged to create a reference gene expression profile which was used to compute a difference from reference (DFR) score for each patient. This score described the overall genomic response of patients within the first 12 h following severe blunt trauma. Regression models were used to compare the association of the DFR, APACHE, and ISS scores with outcome. We hypothesized that patients with a total gene response more different from uninjured volunteers would tend to have poorer outcome than those more similar. Our data show that for measures of poor outcome, such as infections, organ failures, and length of hospital stay, this is correct. DFR scores were associated significantly with adverse outcome, including multiple organ failure, duration of ventilation, length of hospital stay, and infection rate. The association remained significant after adjustment for injury severity as measured by APACHE or ISS. A single score representing changes in gene expression in peripheral blood leukocytes within hours of severe blunt injury is associated with adverse clinical outcomes that develop later in the hospital course. Assessment of genome-wide gene expression provides useful clinical information that is different from that provided by currently utilized anatomic or physiologic scores.

Hemorrhage is More Prevalent than Brain Injury in Early Trauma Deaths: The Golden Six Hours

INTRODUCTION

Under the trimodal distribution, most trauma deaths occur within the first hour. Determination of cause of death without autopsy review is inaccurate. The goal of this study is to determine cause of death, in hourly intervals, in trauma patients who died in the first 24 h, as determined by autopsy.

MATERIALS AND METHODS

Trauma deaths that occurred within 24 h at a Level I trauma center were reviewed over a six-year period ending December 2005. Timing of death was separated into 0-1, 1-3, 3-6, 6-12 and 12-24 h intervals. Cause of death was determined by clinical course and AIS scores, and was confirmed by autopsy results.

RESULTS

Overall, 9,388 trauma patients were admitted, of which 185 deaths occurred within 24 h, with 167 available autopsies. Blunt and penetrating were the injury mechanisms in 122 (73%) and 45 (27%) patients, respectively. Of 167 deaths, 73 (43.7%) occurred within the first hour. Brain injury, when compared to other body areas, was the most likely cause of death in all hourly intervals, but hemorrhage was as or more important than brain injury as the cause of death during the first 3 h and up to 6 h. No deaths were attributable to hemorrhage after 12 h.

CONCLUSIONS

The temporal distribution of the cause of death varies in the first 24 h after admission. Hemorrhage should not be overlooked as the cause of death, even after survival beyond 1 h. Understanding the temporal relationship of causes of early death can aid in the targeting of management and surgical training to optimize patient outcome.

Applicability of the trimodal distribution of trauma deaths in a Level I trauma centre in the Netherlands with a population of mainly blunt trauma

BACKGROUND

Death due to trauma is assumed to follow a trimodal distribution. Since 1995 measures have been taken to regulate organisations involved in trauma care systems in the Netherlands. In estimating the effect of this system we have evaluated the time of death distribution in the University Medical Centre Utrecht (UMCU).

STUDY DESIGN

Prospectively collected databases of all trauma victims between January 1996 and December 2005 were retrospectively reviewed. All traumatic deaths were included. Cause of death was divided into exsanguination, thorax, CNS, organ failure, pneumonia, other and unknown.

RESULTS

Nine thousand eight hundred and five patients were admitted after trauma; of these patients 659 (6.7%) died. Blunt trauma occurred in 615/659 (93.3%) patients. The temporal distribution did not show a trimodal distribution. One predominant peak was observed, <or=1h after arrival at the emergency unit. Within the first day 310/659 (47%) deaths occurred, of which 76/310 (11.5%) <or=1h. CNS injuries were significantly the main cause of death; 334/659 (50.7%, p<0.05). Exsanguination was the main cause of death <or=1h; 31/76 (40.8%, p<0.05). Both CNS injuries and organ failure were the main causes of late death; >or=14 days, 28% and 29%, respectively.

CONCLUSION

No trimodal distribution was confirmed. Only one predominant peak, with a rapid decline, was observed within the first hour after trauma. Even analysed for different causes of death, the trimodal distribution could not be demonstrated. In particular death due to CNS injury showed a complete absence of any peaks.

[Epidemiological analysis of demographic characteristics and type of injuries in patients with multiple trauma with respect to conclusive treatment outcome]

INTRODUCTION

Multiple trauma is one of the leading causes of mortality and morbidity in the population of people under 45 years of age. The consequences of multiple trauma have huge epidemiological, social and economic significance.

OBJECTIVE

The aim of the paper was to analyse the conclusive treatment outcome of multiply traumatized patients with respect to their sex, age, injury mechanism and type.

METHOD

This retrospective study included 100 patients with multiple injuries (ISS > 16) treated in the Emergency Room of the Clinical Centre of Serbia in the course of 2004. Clinical, X-ray, laboratory and numerical presentation methods--scores (ISS and GCS) were used to show the injury severity.

RESULTS

Most of the injured were males (80%), and the average age was 40 +/- 20 (5-83). Out of the total number of patients who died, 23 (82%) were males, and 5 (18%) were females. The average age of the patients with fatal outcomes was 48 +/- 21 (8-86). Traffic accidents were the leading cause of injury (59%). The median GCS was 10 +/- 3 (3-15). The average ISS was 30 (20-66) in the surviving patients, and 53 (27-77) in those who died.

CONCLUSION

With respect to sex, in most cases multiple trauma affects males (p < 0.01), with the average age of about 40. With respect to injury mechanism, the main cause of the occurrence of multiple trauma is traffic accidents (p < 0.01). There is a statistically significant difference in the values of GCS and ISS relative to the definitive outcome (p < 0.01). Statistical data processing indicated that there was a statistically significant correlation between mortality and type of injury in a given organic system (p < 0.01), but that there was no statistically significant correlation between mortality and age.

Mortality Distribution in a Trauma System: From Data to Health Policy Recommendations

INTRODUCTION

Trimodal distribution of deaths and the golden hour concepts are in part responsible for the genesis of all modern trauma systems but these concepts have been challenged recently. Our aim was to describe distribution of death in trauma using data from a trauma system and discuss what could be done from the organizational point of view to improve outcome.

METHODS

We included all traumatic deaths occurring between 2001 and 2005 in a trauma system. Data on age, gender, time and place of injury, time of first and second hospital arrival, cause of trauma and type of accident, hospital characteristics, dominant injury and time of death were collected for this study. Formortality distribution the variable time was transformed applying a natural logarithm.

RESULTS

A total of 1,436 deaths occurred over a period of 53 months; 52% at the scene, 18% in the level I trauma center, 21% in level III trauma center and the remaining in level IV/V trauma center. Death distribution using a logarithmic scale in minutes showed four peaks: deaths at the scene, deaths in the first hours, deaths in the first 2 days and finally, deaths in the second week that we referred as 2 min, 2 h, 2 days and 2 weeks peak. We found statistically significant differences in age and dominant injury concerning timing of death.

CONCLUSIONS

A tetramodal pattern of death distribution could be described. Our data support the need to focus on the treatment of severe head injuries namely in the intensive care environment.

Is the trimodal pattern of death after trauma a dated concept in the 21st century? Trauma deaths in Auckland 2004

OBJECTIVE

To determine whether the classical trimodal distribution of trauma deaths is still applicable in a contemporary urban New Zealand trauma system.

METHODS

All trauma deaths in the greater Auckland region between 1 January 2004 and 31 December 2004 were identified and reviewed. Data was obtained from hospital trauma registries, coroner autopsy reports and police reports.

RESULTS

There were 186 trauma deaths. The median age was 28.5 years and the median Injury Severity Score was 25. The predominant mechanisms of injury were hanging (36%), motor vehicle crashes (31.7%), falls (9.7%), pedestrian-vehicle injury (5.4%), stabbing (4.3%), motorcycle crashes (3.2%), and pedestrian-train injury (2.2%). Most deaths were from central nervous system injury (71.5%), haemorrhage (15.6%), and airway/ventilation compromise (3.8%). Multi-organ failure accounted for 1.6% of deaths. Most deaths occurred in the pre-hospital setting (80.6%) with a gradual decrease thereafter.

CONCLUSION

There was a skew towards early deaths. The trimodal distribution of trauma deaths was not demonstrated in this group of patients.

Abdominal insufflation for control of bleeding after severe splenic injury

BACKGROUND

To date, there is no rapid method to control intracavitary bleeding without an operation. Over 70% of trauma deaths from uncontrollable internal bleeding occur early after injury before an operation is feasible. Abdominal insufflation (AI) by carbon dioxide has been shown to reduce the rate of bleeding after intra-abdominal injury in pigs. The concept was proven in highly lethal models of severe vascular and liver injuries. Similar injuries in humans would result in immediate exsanguination and low likelihood for any intervention. We hypothesized that AI would similarly reduce bleeding in a model of moderate but persistent bleeding from a splenic injury. This model represents a clinically relevant scenario of continuous bleeding, which does not kill the patient immediately but may ultimately result in death if not managed early.

METHODS

A new model of splenic injury was applied on 19 pigs, randomized to standard resuscitation (SR, N = 10) or standard resuscitation with AI to 20 cm H2O (SRAI, N = 9). For 30 minutes, the pigs were bled and the hemodynamics recorded. At 30 minutes, the abdomen was opened and free blood was collected and measured. Outcomes were blood loss, mean arterial pressure, hemoglobin, lactate levels, and arterial blood gases at the end of the experiment.

RESULTS

All pigs survived to the end of the experiment. Blood loss was lower (1,114 +/- 486 mL vs. 666 +/- 323 mL, p = 0.03) and final mean arterial pressure higher (64 +/- 12 mm Hg vs. 54 +/- 8 mm Hg, p = 0.04) in SRAI when compared with those in SR animals. Heart rate, arterial blood gases, oxygen saturation, hemoglobin, and lactate levels were similar in the two groups, except there was a more acidotic pH among SRAI animals (7.27 +/- 0.06 vs. 7.47 +/- 0.21, p = 0.02).

CONCLUSIONS

AI is a novel method to control intra-abdominal bleeding temporarily. With proper portable instruments and first-responder training, this is a technique that can potentially be used in the field to save lives from intra-abdominal exsanguination.

The impact of premorbid conditions on temporal pattern and location of adult blunt trauma hospital deaths

BACKGROUND

This study was designed to show the importance of age, presence of premorbid conditions, and the type of injury on time and location of adult inhospital trauma mortality.

METHODS

All acute blunt trauma deaths at a Level I urban trauma center between April 1, 1993 and March 31, 2003 were individually reviewed to collect data on the following variables: age, gender, presence and number of premorbid conditions, mechanisms of trauma, location of death, acute transfer from another hospital, delay to death, initial Glasgow Coma Score (GCS), Abbreviated Injury Score (AIS), Injury Severity Score (ISS), and revised trauma score (RTS). Bivariate analysis using simple logistic regression was used to show the association between each variable and delay to death. Variables significantly associated with death underwent multivariate analysis to yield adjusted odds ratios (aORs) with 95% confidence interval (CI).

RESULTS

During the study period there were 463 blunt trauma deaths (6.8%). Their mean age was 67.5 years, mean ISS was 22.6, mean GCS was 11.0, and 55.3% were male. Most deaths occurred in either the intensive care unit (45.8%) or the ward (46.4%); there were few deaths in the emergency department (6.8%) or the operating room (0.4%). The following were significant bivariate predictors for death: presence of premorbid conditions, number of premorbid conditions, age >60, pulmonary diseases, cardiac diseases, diabetes mellitus, neurologic diseases, GCS, AIS > or =4, and ISS. Multivariate analysis demonstrated the following significant findings: patients with severe thoracic injuries were significantly more likely to die in the first 6 hours (aOR = 1.37; CI = 1.12-1.68; p = 0.002); and patients with severe head injuries were more likely to die after 48 hours (aOR = 1.275; CI = 1.158-1.405; p = 0.0001). Older patients and those with neurologic diseases were more likely to die later and in a hospital ward (aOR = 2.18; CI = 1.25-3.81; p = 0.006). Men and women differed as to age, ISS, mechanism of injury, and type of injury, but not as to delay to death.

CONCLUSIONS

Age, body area injured, and presence and type of premorbid conditions are significant predictors of location of and delay to death after blunt trauma. We think that incorporating information on premorbid conditions is essential for mortality analysis in an aging population.

Contrast-Enhanced Ultrasound for Blunt Abdominal Trauma

Sonography is widely used in the initial diagnostic assessment of blunt abdominal trauma in adults and children. It has been formally incorporated worldwide into the routine armamentarium available for emergency diagnosis and treatment as a means of rapid detection of free abdominal fluid, normally referred to as FAST (Focused Assessment with Sonography in Trauma). However, there is some controversy regarding its value because free abdominal fluid may be lacking in patients with abdominal organ injuries from blunt trauma. More recently, a new ultrasound technique has been developed using contrast agents. Contrast-enhanced ultrasound performs better than the non-contrast-enhanced technique for the detection of abdominal solid organ injuries and can play an important role in the prompt evaluation of patients with blunt trauma. Furthermore, contrast-enhanced ultrasound can be used in the follow-up of patients who have solid organ lesions and are managed with nonoperative treatment, avoiding radiation and iodinated contrast medium exposure.

Head-Injured Patients Who “Talk and Die”: The San Diego Perspective

BACKGROUND

Head-injured patients who "talk and die" are potentially salvageable, making their early identification important. This study uses a large, comprehensive database to explore risk factors for head-injured patients who deteriorate after their initial presentation.

METHODS

Patients with a head Abbreviated Injury Score (AIS) score of 3+ and a preadmission verbal Glasgow Coma Scale (GCS) score of 3+ were identified from our county trauma registry during a 16-year period. Survivors and nonsurvivors were compared with regard to demographics, initial clinical presentation, and various risk factors. Logistic regression was used to explore the impact of multiple factors on outcome, including the significance of a change in GCS score from field to arrival. In addition, patients were stratified by injury severity and hospital day of death to further define the relationship between outcome and multiple clinical variables.

RESULTS

A total of 7,443 patients were identified with head AIS 3+ and verbal GCS score 3+. Overall mortality was 6.1%. About one-third of deaths occurred on the first hospital day, with more than one-third occurring after hospital day 5. Logistic regression revealed an association between mortality and older age, more violent mechanisms of injury (fall, gunshot wound, pedestrian versus automobile), greater injury severity (higher head AIS and Injury Severity Score), lower GCS score, and hypotension. In addition, mortality was associated with a decrease in GCS score from field to arrival, the use of anticoagulants, and a diagnosis of pulmonary embolus. Two important groups of "talk-and-die" patients were identified. Early deaths occurred in younger patients with more critical extracranial injuries. Anticoagulant use was also an independent risk factor in these early deaths. Later deaths occurred in older patients with less significant extracranial injuries. Pulmonary embolus also appeared to be an important contributor to late mortality.

CONCLUSIONS

More severe injuries and use of anticoagulants are independent risk factors for early death in potentially salvageable traumatic brain injury patients, whereas older age and pulmonary embolus are associated with later deaths.

Spiral Computed Tomography for the Initial Evaluation of Spine Trauma: A New Standard of Care?

BACKGROUND

Although spiral computed tomographic scanning (SCT) is frequently used for spinal imaging in injured patients, many trauma centers continue to rely on plain film radiography (PFR). The purpose of this study was to determine the effects of a trauma center's transition from PFR to SCT for initial spine evaluation in trauma patients by comparing diagnostic sensitivity, time required for radiographic imaging, costs, charges, and radiation exposure.

METHODS

Registry-based review of all trauma patients evaluated for spinal trauma during two three-month intervals, one before (1999, "X-ray Group"), and one after (2002, "CT Group") adopting SCT as the initial spinal imaging method. Demographic data, mechanism of injury, Injury Severity Score (ISS), the presence and location of spine fractures, and the results of all spine imaging were recorded. The dates and diagnostic sensitivity for spine fractures, time for initial imaging, costs, and charges were compared between groups. Radiation exposure associated with both SCT and PFR of the spine was measured.

RESULTS

There were 254 patients in the X-ray Group and 319 in the CT Group, with similar demographic data, ISS, mechanism of injury, and incidence of spine fractures. Sensitivity in the detection of spine fractures was 70% (14 out of 20) in the X-ray Group compared with 100% (34 out of 34) for the CT Group (p < 0.001). Mean time in the radiology department during initial evaluation decreased significantly in the CT Group compared with the X-ray Group (1.0 hours vs. 1.9 hours; p < 0.001). SCT of the spine was associated with higher mean overall spinal imaging charges than PFR (4,386 dollars vs. 513 dollars, p < 0.001), but a similar mean overall spinal imaging cost per patient (172 dollars vs. 164 dollars). Radiation exposure was higher with SCT versus PFR for cervical spine imaging (26 mSv vs. 4 mSv) but SCT involved lower levels of exposure than PFR for thoracolumbar imaging (13 mSv vs. 26 mSv).

CONCLUSIONS

SCT is a more rapid and sensitive modality for evaluating the spine compared with PFR and is obtained at a similar cost. The advantages of SCT suggest that this readily available diagnostic modality may replace PFR as the standard of care for the initial evaluation of the spine in trauma patients.

Trauma Deaths in a Mature Urban Trauma System: Is “Trimodal” Distribution a Valid Concept?

BACKGROUND

Trimodal distribution of trauma deaths, described more than 20 years ago, is still widely taught in the design of trauma systems. The purpose of this study was to examine the applicability of this trimodal distribution in a modern trauma system.

STUDY DESIGN

A study of trauma registry and emergency medical services records of trauma deaths in the County of Los Angeles was conducted over a 3-year period. The times from injury to death were analyzed according to mechanism of injury and body area (head, chest, abdomen, extremities) with severe trauma (abbreviated injury score [AIS] >/= 4).

RESULTS

During the study period there were 4,151 trauma deaths. Penetrating trauma accounted for 50.0% of these deaths. The most commonly injured body area with critical trauma (AIS >/= 4) was the head (32.0%), followed by chest (20.8%), abdomen (11.5%), and extremities (1.8%). Time from injury to death was available in 2,944 of these trauma deaths. Overall, there were two distinct peaks of deaths: the first peak (50.2% of deaths) occurred within the first hour of injury. The second peak occurred 1 to 6 hours after admission (18.3% of deaths). Only 7.6% of deaths were late (>1 week), during the third peak of the classic trimodal distribution. Temporal distribution of deaths in penetrating trauma was very different from blunt trauma and did not follow the classic trimodal distribution. Other significant independent factors associated with time of death were chest AIS and head AIS. Temporal distribution of deaths as a result of severe head trauma did not follow any pattern and did not resemble classic trimodal distribution at all.

CONCLUSIONS

The classic "trimodal" distribution of deaths does not apply in our trauma system. Temporal distribution of deaths is influenced by the mechanism of injury, age of the patient, and body area with severe trauma. Knowledge of the time of distribution of deaths might help in allocating trauma resources and focusing research effort.

Auto launch/early activation: a survey of AAMS members and literature review

BACKGROUND

Rapid access to definitive care is a fundamental tenet of trauma care and forms the basis for current emergency medical and trauma systems. Helicopters offer expedited transport to trauma centers and can deliver advanced practice personnel to the scene of injury, but many systems do not dispatch air medical crews until after assessment by ground providers.

OBJECTIVES

Here we report data from the AAMS Auto Launch Survey and perform a literature review.

METHODS

A 7-question survey was developed by the AAMS Research Committee and approved by the board. An invitation to participate in the survey was sent by electronic mail to all current members. A link to an online survey was included. Results were presented descriptively. Some respondents were willing to share auto launch protocols, which were categorized into patient-related factors, event-related factors, and geographic considerations.

RESULTS

A total of 86 usable responses were recorded, which represented about a third of the 240 total AAMS members. Of these, 38 respondents (44.2%) routinely use auto launch. Just over half of those using early activation reported using a combination of event- and patient-related considerations; most also incorporating geographic criteria. About one-third of respondents auto launch only at the request of ground personnel, and about one-quarter use geographic criteria alone. Threshold distances ranged from 20 to 25 miles or 20 to 30 minutes by ground.

CONCLUSIONS

About half of respondents routinely use auto launch, although protocols are not consistent. Auto launch appears to offer a mechanism for decreasing EMS response times, but additional research is needed to help define optimal dispatch criteria.

Epidemiology of major injury in the population of Friuli Venezia Giulia-Italy

OBJECTIVE

To provide reliable and comparable information on major injury (MIJ) (Injury Severity Score (ISS) > 15) by establishing a comprehensive and Utstein-style compliant registry of all occurrences in a defined geographical area.

METHODS

Prospective, population-based, 12-month study targeting the 1,200,000 inhabitants of the Italian region Friuli Venezia Giulia (FVG). Deliberate self-harm was excluded.

RESULTS

The total number of MIJ cases was 627, the resulting incidence 522 per million per year. Trauma was mostly blunt (98.4%). Young (15-44 years) adults (54.8%) and males (78.6%) were most affected. Leading mechanisms of injury were traffic accidents (81%) and falls (9.1%). Most events occurred in rural (80.9%) areas despite one third of the regional population living in major urban centres. Summer and weekends carried the highest frequency. The mean ISS ( n = 455 ) was 30.0, median 25. On-scene vital parameters were often subnormal, e.g. 53.9%, GCS < 14. The Emergency Medical System was nearly always activated (98.4%). The time intervals were within standards although in part susceptible of improvement. The percentage of direct triage to the definitive hospital was 79.8%. Overall mortality was 45.6% or 238 per million per year. Most fatalities were found already dead (171/300) and no trimodal distribution was verified. Only 1.5% of the patients found alive died outside hospital. Mean GOS was 4.4 +/- 1 (S.D.), median 5.

CONCLUSION

A considerable amount of information on MIJ in FVG has been gathered, of both local and general interest because it can help to assess the local trauma system and also, given the relative scarcity of prospective, population-based information on MIJ, contribute to scientific research.

Trauma fatalities: time and location of hospital deaths

BACKGROUND

Analysis of the epidemiology, temporal distribution, and place of traumatic hospital deaths can be a useful tool in identifying areas for research, education, and allocation of resources.

STUDY DESIGN

Trauma registry-based study of all traumatic hospital deaths at a Level I urban trauma center during the period 1993 to 2002. The time and hospital location where deaths occurred were analyzed according to mechanism of injury, age, Glasgow Coma Score, and body areas with severe injury (Abbreviated Injury Scale [AIS] >/= 4). Logistic regression analysis was used to identify risk factors associated with death at various times after admission.

RESULTS

During the study period there were 2,648 hospital trauma deaths. The most common body area with critical injuries (AIS >/= 4) was the head (43%), followed by the chest (28%) and the abdomen (19%). Overall, 37% of victims had no vital signs present on admission. Chest AIS >/= 4, penetrating trauma, and age greater than 60 years were significant risk factors associated with no vital signs on admission. Patients with severe chest trauma (AIS >/= 4) reaching the hospital alive were significantly more likely to die within the first 60 minutes than were patients with severe abdominal or head injuries (17% versus 11% versus 7%). In patients reaching the hospital alive, the time and place of death varied according to mechanism of injury and injured body area. Deaths caused by severe head trauma peaked at 6 to 24 hours, and deaths caused by severe chest or abdominal trauma peaked at 1 to 6 hours after admission.

CONCLUSIONS

The temporal distribution and location of trauma deaths are influenced by the mechanism of injury, age, and the injured body area. These findings may help in focusing research, education, and resource allocation in a more targeted manner to reduce trauma deaths.

Death after injury in rural Norway: high rate of mortality and prehospital death

BACKGROUND

Finnmark is a rural and remote area in Norway with a sparse population and long distances. Trauma-related mortality has been consistently above the Norwegian national average for the last 20 years. Although the causes of death are well established, very little is known about the time and place of death. This information has implications for the organization of emergency services in rural areas. We examined all trauma deaths over a five-year period in order to inform the debate on how best to reduce our above-average mortality rate.

METHODS

A retrospective study of all deaths after trauma (ICD-9 E800-E999) during the years 1991-95 using data obtained from the National Registry of Death.

RESULTS

Of the 183 cases found, 130 deaths were due to trauma using definitions comparable to similar studies. The mortality rate was 77 per 100,000 inhabitants per year. Death occurred in the prehospital phase in 85% of cases. Seventy-two per cent of all deaths (regardless of location) occurred within the first h after injury, eight per cent from 1 to 4 h and the remaining 20% occurred after 4 h.

CONCLUSION

When planning interventions to reduce the mortality rate from trauma in rural areas, a high proportion of prehospital deaths should be expected. The high number of patients who are found dead (which can only be reduced by injury prevention) must be taken into account. Measures to reduce 'preventable' causes of death by bystanders should be evaluated. Further knowledge of exact mechanisms of death in the prehospital phase is required.

Trauma deaths in an Italian urban area: an audit of pre-hospital and in-hospital trauma care

In Italy, a comprehensive regional study of trauma deaths has never been performed. We examined the organization and delivery of trauma care in the city area of Milan, using panel review of trauma deaths. Two panels evaluated the appropriateness of care of all trauma victims occurred during 1 year, applying predefined criteria and judging deaths as not preventable (NP), possible preventable (PP), and definitely preventable (DP). Two hundred and fifty-five deaths were reviewed. Blunt trauma were 78.04% and motor vehicle crashes accounted for over 50%. Most victims (73.72%) died during pre-hospital settings and 91.1% died within the first 6h, principally because of central nervous system injuries in blunt and hemorrhage in penetrating trauma. Panels judged 57% of deaths NP, 32% PP, 11% DP (inter-panel K-test 0.88). Preventable deaths were higher after in-hospital admission. Main failures of treatment were lack in airway control or intravenous infusions in pre-hospital and mismanagement with missed injuries in emergency department. The high rate of avoidable deaths in Milan supports the need of trained pre-hospital personnel and of well equipped referring hospitals for trauma.

Predicted effect of automatic crash notification on traffic mortality

OBJECTIVE

To estimate the reduction in traffic mortality in the United States that would result from an automatic crash notification (ACN) system.

METHODS

1997 Fatality Analysis Reporting System (FARS) data from 30,875 cases of incapacitating or fatal injury with complete information on emergency medical services (EMS) notification and arrival times were analyzed considering cases at any time to be in one of four states: (1) alive prior to notification; (2) alive after notification; (3) alive after EMS arrival; and (4) dead. For each minute after the crash, transition probabilities were calculated for each possible change of state. These data were used to construct models with (1) number of incapacitating injuries ranging from FARS cases up to an estimated total for the US in 1997; (2) deaths equal to FARS total; (3) transitions to death from other states proportional to FARS totals and rates and (4) other state transitions equal to FARS rates. The outcomes from these models were compared to outcomes from otherwise identical models in which all notification times were set to 1 min.

RESULTS

FARS data estimated 12,823 deaths prior to notification, 1800 after notification, and 14,015 between EMS arrival and 6 h. If notification times were all set to 1 min, a model using FARS data only predicted 10,703 deaths prior to notification, 2,306 after notification, and 15,208 after EMS arrival, while a model using an estimated total number of incapacitating injuries for the US predicted 9,569 deaths prior to notification, 2,261 after notification, and 15,134 after arrival. In the first model, overall mortality was reduced from 28,638 to 28,217 (421 per year. or 1.5%), while in the second model mortality was reduced to 26,964 (1,674 per year, or 6%).

CONCLUSIONS

Modest but important reduction in traffic mortality should be expected from a fully functional ACN system. Imperfect systems would be less effective.

Low-volume fluid resuscitation for presumed hemorrhagic shock: helpful or harmful?

For the past 4 decades, the standard approach to the trauma victim who is hypotensive from presumed hemorrhage has been to infuse large volumes of fluids as early and as rapidly as possible. The goals of this treatment strategy are rapid restoration of intravascular volume and vital signs towards normal, and maintenance of vital organ perfusion. The most recent laboratory studies and the only clinical trial evaluating the efficacy of these guidelines however, suggest that in the setting of uncontrolled hemorrhage, today's practice of aggressive fluid resuscitation may be harmful, resulting in increased hemorrhage volume and subsequently greater mortality. This has been demonstrated in animal models representative of penetrating trauma as well as those representative of blunt trauma. The data strongly suggest that limited or hypotensive resuscitation may be preferable for the trauma victim with the potential for ongoing uncontrolled hemorrhage. Limited resuscitation provides a mechanism of avoiding the detrimental effects associated with early aggressive resuscitation, while maintaining a level of tissue perfusion that although decreased from the normal physiologic range is adequate for short periods. Large randomized clinical trials are necessary to confirm this new laboratory data. Future research should focus on developing resuscitation methods that may actually enhance tissue perfusion during limited resuscitation and therefore offset its potential detrimental effects.

The influence of prehospital trauma care on motor vehicle crash mortality

BACKGROUND

This study evaluated the impact of the prehospital trauma care system on the mortality from motor vehicle crashes and on the temporal distribution between the crash and related death.

METHODS

Autopsies performed by the Forensic Medical Institute on all deaths caused by motor vehicle crashes 1 year before and 1 year after the beginning of the prehospital trauma care system were evaluated.

RESULTS

In the first period, 128 deaths occurred, 53.9% of them in the first hour after the crash, 36.7% between the first hour and the seventh day, and 9.4% after 1 week. In the second period, 115 deaths occurred, 40.8% of them in the first hour, 52.2% between the first hour and the seventh day, and 7% after 1 week. Central nervous system injury was the most frequent cause of death in both periods. Mortality was greatest among young people as well as male victims in both periods.

CONCLUSION

After starting the prehospital trauma care system in our city, there was a decrease in the deaths occurring before hospital admission, a change in temporal distribution of deaths, and a reduction in the motor vehicle crash mortality rate.

Lethality of firearm-related injuries in the United States population

STUDY OBJECTIVE

To characterize differences in the lethality of firearm-related injuries in selected demographic subgroups using national representative data on fatal and nonfatal firearm-related injuries. We also characterize the lethality of firearm-related injuries by intent of injury and anatomic location of the gunshot wound.

METHODS

We analyzed case-fatality rates (CFRs) of firearm-related injuries in the United States by using death data from the National Vital Statistics System and data on nonfatal injuries treated in US hospital emergency departments from the National Electronic Injury Surveillance System. National estimates of crude and age-adjusted CFRs are presented by sex, race/ethnicity, age, intent, and primary body part affected.

RESULTS

Each year during the study period (July 1992 through December 1995), an estimated 132,687 persons sustained gunshot wounds that resulted in death or treatment in an ED. The overall age-adjusted CFR among persons who sustained firearm-related injuries was 31.7% (95% confidence interval [CI] 27.7 to 35.6). The age-adjusted CFR for persons who were alive when they arrived for treatment in an ED (11. 3%; 95% CI 9.4 to 13.2) was about one third as large as the overall CFR. The age-adjusted CFR varied by sex, race/ethnicity, and age, but these differences depended on intent of injury. For assaultive injuries, the age-adjusted CFR was 1.4 times higher for females (28. 7%) than males (20.6%). For intentionally self-inflicted injuries, the age-adjusted CFR was 1.1 higher for males (77.7%) than females (69.1%). For assaults, the age-adjusted CFR was 1.5 times higher for whites (29.5%) than blacks (19.2%). For assaultive and intentionally self-inflicted injuries among persons 15 years and older, the age-specific CFR increased with age. Persons shot in the head (age-adjusted CFR, 61.0%) were 3.3 times as likely to die as those shot in other body parts (age-adjusted CFR, 18.7%).

CONCLUSION

The lethality of firearm-related injuries was influenced strongly by the intent of injury and body part affected. The high lethality of firearm-related injuries relative to other major causes of injury emphasizes the need to continue prevention efforts and efforts to improve access to care and treatment (including emergency medical and acute care services) to reduce the number and increase survivability of firearm-related injuries.

Fatal injury: characteristics and prevention of deaths at the scene

BACKGROUND

Almost half of all trauma deaths occur at the scene. It is important to determine if these deaths can be prevented.

METHODS

Penetrating or blunt force trauma deaths were identified through the Office of the Medical Examiner during a 2-year period. Data were also obtained through review of these records.

RESULTS

There were 312 deaths at the scene that received no medical care. Almost 60% were firearm-related. About 80% of the victims were men, and 55% of these deaths occurred in people between 20 and 49 years old. Suicide accounted for nearly half of these deaths. Eighty percent of these injured people had Abbreviated Injury Scale scores of 5 or 6.

CONCLUSION

Almost 60% of deaths at the scene occurred at the same time as injury and reflect severe injury to vital regions of the body. These findings suggest that primary prevention of the initial event causing injury may be more important than definitive prehospital emergency medical care to prevent these deaths.