Analysis of Injury and Mortality Patterns in Deceased Patients with Road Traffic Injuries: An Autopsy Study

Time and Risk Factors of Trauma-Related Mortality: A 5-Year Retrospective Analysis From a National Level I Trauma Center

Background: We aimed to analyze in-hospital timing and risk factors for mortality in a level 1 trauma center. Methods: This is a retrospective analysis of all trauma-related mortality between 2013 and 2018. Patients were divided and analyzed based on the time of mortality (early (≤48 h) vs late (>48 h)), and within different age groups. Multivariate regression analysis was performed to predict in-hospital mortality. Results: 8624 trauma admissions and 677 trauma-related deaths occurred (47.7% at the scene and 52.3% in-hospital). Among in-hospital mortality, the majority were males, with a mean age of 35.8 ± 17.2 years. Most deaths occurred within 3-7 days (35%), followed by 33% after 1 week, 20% on the first day, and 12% on the second day of admission. Patients with early mortality were more likely to have a lower Glasgow coma scale, a higher shock index, a higher chest and abdominal abbreviated injury score, and frequently required exploratory laparotomy and massive blood transfusion (P < .005). The injury severity scores and proportions of head injuries were higher in the late mortality group than in the early group. The severity of injuries, blood transfusion, in-hospital complications, and length of intensive care unit stay were comparable among the age groups, whereas mortality was higher in the age group of 19 to 44. The higher proportions of early and late in-hospital deaths were evident in the age group of 24 to 29. In multivariate analysis, the shock index (OR 2.26; 95%CI 1.04-4.925; P = .04) was an independent predictor of early death, whereas head injury was a predictor of late death (OR 4.54; 95%CI 1.92-11.11; P = .001). Conclusion: One-third of trauma-related mortalities occur early after injury. The initial shock index appears to be a reliable hemodynamic indicator for predicting early mortality. Therefore, timely hemostatic resuscitation and appropriate interventions for bleeding control may prevent early mortality.

Pathophysiology in patients with polytrauma

The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.

Causes of fatalities in motor vehicle occupants: an overview

Injuries from motor vehicle collisions are frequently encountered in routine forensic practice. While the most common lethal events involve blunt force trauma with injuries to the head and neck, chest, abdomen, pelvis and limbs, review of the literature and case files shows that a wide variety of other fatal situations can occur that may involve sharp force and penetrating trauma, incineration, drowning, asphyxia, organic diseases and combinations of these. The following overview details potential factors that may contribute to death following vehicle crashes.

Characteristics of Prehospital Death in Trauma Victims

Background: Using Injury Severity Score (ISS) data, this study aimed to give an overview of trauma mechanisms, causes of death, injury patterns, and potential survivability in prehospital trauma victims. Methods: Age, gender, trauma mechanism, cause of death, and ISS data were recorded regarding forensic autopsies and whole-body postmortem CT. Characteristics were analyzed for injuries considered potentially survivable at cutoffs of (I) ISS ≤ 75 vs. ISS = 75, (II) ISS ≤ 49 vs. ISS ≥ 50, and (III) ISS < lethal dose 50% (LD50) vs. ISS > LD50 according to Bull’s probit model. Results: In n = 130 prehospital trauma victims (45.3 ± 19.5 years), median ISS was 66. Severity of injuries to the head/neck and chest was greater compared to other regions (p < 0.001). 52% died from central nervous system (CNS) injury. Increasing injury severity in head/neck region was associated with CNS-injury related death (odds ratio (OR) 2.7, confidence interval (CI) 1.8–4.4). Potentially survivable trauma was identified in (I) 56%, (II) 22%, and (III) 9%. Victims with ISS ≤ 75, ISS ≤ 49, and ISS < LD50 had lower injury severity across most ISS body regions compared to their respective counterparts (p < 0.05). Conclusion: In prehospital trauma victims, injury severity is high. Lethal injuries predominate in the head/neck and chest regions and are associated with CNS-related death. The appreciable amount (9–56%) of victims dying at presumably survivable injury severity encourages perpetual efforts for improvement in the rescue of highly traumatized patients.

An Autopsy-Based Analysis of Fatal Road Traffic Collisions: How the Pattern of Injury Differs with the Type of Vehicle

In Italy, in only 2018, 3310 people died in road traffic accidents, more than in any other European country. Since the revelation of this occurrence, the authors carried out an analysis aimed at investigating if there was a difference in the injury patterns among different road users. A retrospective post-mortem study on road traffic fatalities was performed, which had been autopsied at the Institute of Forensic Medicine of Milan. First, the authors analyzed the epidemiological data of all the 1022 road traffic accidents subjected to an autopsy from 2007 to 2019. Secondly, further analysis of individual autopsy reports was carried out. For this purpose, 180 autopsies belonging to 5 different categories were analyzed: car, pedestrian, motorbike, bicycle, and truck. Seventy-six percent of road traffic fatalities were male, 54% were between 10 and 49 years of age, and 62% of the patients died before arriving at a hospital. “Multiple injuries” was the main cause of death. Traumatic brain injuries were particularly high in pedestrians and cyclists. In car, motorbike, and truck fatalities, thoracic and abdominal injuries were the most frequent. Therefore, pedestrians and cyclists had a higher prevalence for traumatic head injuries, while car, motorcycle, and truck occupants, on the other hand, had a higher prevalence for thoracic and abdominal injuries.

Pathology of fatal diffuse brain injury in severe non-penetrating head trauma

Traumatic brain injury (TBI) is recognised as a serious global public health problem that imposes a heavy socioeconomic burden on society. The vast majority of cases result from road traffic accidents and falls, and the injuries are mainly attributed to velocity-related mechanisms. Lethal cases are mostly found to suffer from severe diffuse brain injuries (DBI), comprising diffuse vascular injury, diffuse axonal injury (DAI), generalized cerebral edema and ischemic-hypoxic injury. Coup and contrecoup brain contusions may also occur. This study set out to describe the pathological findings of severe DBI in terms of survival times and Abbreviated Injury Scale (AIS) severity scores. The autopsy data from 2 recent years (2018 and 2019) were reviewed to recruit over 800 cases presenting with severe head injuries. Many demographic characteristics of TBI were identified (for example, causes, victim genders and victim ages). These were revealed to be like those previously reported in the literature, confirming that there are shared risk factors across the globe. The hallmarks of severe TBI-such as a unimodal survival distribution and a period for detecting DAI via conventional staining-were also evident, as per previous reports. However, it was noticed that the histopathological detection rates of DAI surged after 72 h, which might be because these injuries are mediated by secondary axotomy. This study also analysed real brain weights to identify the time period for the development of cerebral edema in humans; this period seems to have never been reported. The increment time of cerebral edema reached a peak in 12 h, after which the condition sustained for at least 72 h. This may be a golden period in clinical practice as well as a prognostic factor in forensic medicine.

Health Care Resources and 24,910 Deaths Due to Traffic Accidents: An Ecological Mortality Study in Poland

Background: Deaths due to traffic accidents are preventable and the access to health care is an important determinant of traffic accident case fatality. This study aimed to assess the relation between mortality due to traffic accidents and health care resources (HCR), at the population level, in 66 sub-regions of Poland. Methods: An area-based HCR index was delivered from the rates of physicians, nurses, and hospital beds. Associations between mortality from traffic accidents and the HCR index were tested using multivariate Poisson regression models. Results: In the sub-regions studied, the average mortality from traffic accidents was 11.7 in 2010 and 9.3/100.000 in 2015. After adjusting for sex, age and over time trends in mortality, out-of-hospital deaths were more frequently compared to hospitalized fatal cases (incidence rate ratio (IRR) = 1.68, 95% CI 1.45–1.93). Compared to sub-regions with high HCR, mortality from traffic accidents was higher in sub-regions with low and moderate HCR (IRR = 1.25, 95% CI 1.11–1.42 and IRR = 1.19, 95% CI 1.02–1.38, respectively), which reflected the differences in out-of-hospital mortality most pronounced in car accidents. Conclusions: Poor HCR is an important factor that explains the territorial differentiation of mortality due to traffic accidents in Poland. The high percentage of out-of-hospital deaths indicates the importance of preventive measures and the need for improvement in access to health care to reduce mortality due to traffic accidents.

Injury Pattern and Injury Severity of In-Hospital Deceased Road Traffic Accident Victims in The Netherlands: Dutch Road Traffic Accidents Fatalities

BACKGROUND

Further reduction in road traffic accident (RTA) fatalities is a key priority in the European Union. Since data on injury patterns related to mortality in RTAs are scarce, the aim of this study was to analyze injury patterns and injury severity of in-hospital RTA fatalities in the Netherlands.

METHODS

All in-hospital deceased RTA victims in the Netherlands during the period 2015-2016 were analyzed. Data were obtained from the National Trauma Registry. Injury patterns, injury severity, accident and patient characteristics of road user groups were compared.

RESULTS

A total of 497 deceased RTA victims were analyzed, of which most were bicyclists. All analyzed motorcyclists had an ISS ≥ 16. Head trauma was most frequent in pedestrians (73.7%) and bicyclists (71.3%). Thorax trauma was most frequent in motorcyclists and motorists (60.9% and 65.8%, respectively). RTA victims younger than 25 years were more severely injured (median ISS 38, interquartile range [IQR] 29-46) compared to RTA victims aged over 75 years (median ISS 25, IQR 13-30). More than 10% of the severely injured (ISS ≥ 16) RTA victims was not transported to a level I trauma center. The majority of this group was older than 75 years.

CONCLUSIONS

Further prevention of head trauma is needed to reduce RTA fatalities, especially in bicyclists. Also, undertriage of severe trauma in elderly RTA victims is obvious and should be addressed in the early phases of trauma care, especially during prehospital triage and initial care at admission.

Laparoscopic splenectomy after trauma: Who, when and how. A systematic review

Importance:

A deep knowledge of the indication for laparoscopic splenectomy (LS) in trauma case can lead trauma surgeon to offer in a wider number of situations a minimally invasive approach to a common injuries.

Objective:

To present and review the advantages and disadvantages of laparoscopic approach for spleen trauma and to identify patient whose can benefit from a minimally invasive approach versus patient that need open surgery to assess the whole severity of trauma.

Evidence Review:

A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. Studies conducted on animals were not considered. All other laparoscopic procedures for spleen trauma were excluded.

Results:

Nineteen articles were included in this study, reporting 212 LS after trauma. The most study includes blunt trauma patient. All LS were performed in haemodynamically stable patient. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%), including 16 (7.5%) post-operative deaths.

Conclusions and Relevance:

This article reports the feasibility and safety of a minimally invasive approach for common trauma injuries which can help non-advanced laparoscopic skill trauma surgeon to develop the best indication to when to adopt this kind of approach.

Are Pre-hospital Trauma Deaths Preventable? A Systematic Literature Review

BACKGROUND

The first and largest peak of trauma mortality is encountered on the trauma site. The aim of this study was to determine whether these trauma-related deaths are preventable. We performed a systematic literature review with a focus on pre-hospital preventable deaths in severely injured patients and their causes.

METHODS

Studies published in a peer-reviewed journal between January 1, 1990 and January 10, 2018 were included. Parameters of interest: country of publication, number of patients included, preventable death rate (PP = potentially preventable and DP = definitely preventable), inclusion criteria within studies (pre-hospital only, pre-hospital and hospital deaths), definition of preventability used in each study, type of trauma (blunt versus penetrating), study design (prospective versus retrospective) and causes for preventability mentioned within the study.

RESULTS

After a systematic literature search, 19 papers (total 7235 death) were included in this literature review. The majority (63.1%) of studies used autopsies combined with an expert panel to assess the preventability of death in the patients. Pre-hospital death rates range from 14.6 to 47.6%, in which 4.9-11.3% were definitely preventable and 25.8-42.7% were potentially preventable. The most common (27-58%) reason was a delayed treatment of the trauma victims, followed by management (40-60%) and treatment errors (50-76.6%).

CONCLUSION

According to our systematic review, a relevant amount of the observed mortality was described as preventable due to delays in treatment and management/treatment errors. Standards in the pre-hospital trauma system and management should be discussed in order to find strategies to reduce mortality.

Trauma demography and clinical epidemiology of motorcycle crash-related head injury in a neurosurgery practice in an African developing country

OBJECTIVE

Though motor vehicle crashes (MVCs) were the main cause of head trauma from road traffic injuries (RTIs), motorcycle crashes (MCCs) are now a major cause of RTI-related head injury (HI) in many developing countries.

METHODS

Using a prospective database of HIs from a neurosurgical practice in a sub-Saharan African developing country, a cross-sectional survey was conducted for the trauma demography and clinical epidemiology of this MCC-related HI.

RESULTS

Motorcycle crashes accounted for 57% (473/833) of all RTI-related HIs in this registry. The victims, with a mean age of 33.1 years (SD = 18.3), consisted mainly of males (83.1%), those of low socioeconomic status (>90%), and those aged between 20 and 40 years old (56%). MCCs involved only riders in 114 cases (114/473, 32.1%), of which 69% were motorcycle-motorcycle crashes. The HI was moderate-severe in 50.8%; clinical symptomatology of significant HI included loss of consciousness (92%), anisocoria (35%), Abbreviated Injury Scale head (AIS-head) score > 3 (28%), and CT-Rotterdam score > 3 (30%). Extracranial systemic injury involved the limbs most frequently, with an Injury Severity Score (ISS) >25 in 49%. The fatality rate was 24%. MCC-related HI among pedestrian victims involved more vulnerable age groups (the young and elderly) but have lower mean ISS compared to motorcycle passengers (mean ISS = 23.5 [11.6] vs. 27.4 [13.0]; 95% confidence interval [CI], 1.27-6.49; P = .004). In addition, compared to a contemporary cohort of MVC-related HIs in our registry, MCC victims were older (mean age 34.8 years [18.0] vs. 30.8 [18.4]; P = .002); had higher proportions of certain extracranial trauma like long bone fractures (71 vs. 29%; P = .02); and suffered fewer surgical brain lesions (25.5 vs. 17.2%; P = .004).

CONCLUSIONS

Motorcycle crashes are now a significant threat to the heads, limbs, and lives of vulnerable road users in developing countries.