Deaths from blunt trauma: a review of 105 cases

Blunt abdominal trauma: back to clinical judgement in the era of modern technology

BACKGROUND AND METHODS

Abdominal trauma poses a diagnostic challenge to most trauma surgeons. This study evaluates a clinical scoring system in 476 blunt abdominal trauma patients treated by the author over a period of 92 months. Patients were sorted into three groups according to the score results. Priority I group (160 patients) was subjected to an immediate laparotomy. Priority II group (200 patients) was treated according to the results of auxiliary investigations. Priority III group (116 patients) was kept under observation. The treatment outcome was used as a gold standard for the evaluation of the results.

RESULTS

In priority I and III groups (276 cases) the management was only dependent on the proposed clinical score with a 100% specificity, 88% sensitivity, 90% positive predictive value, 100% negative predictive value and an overall accuracy of 94%.

CONCLUSIONS

This scoring system (CASS) is helpful in ensuring rapid diagnosis and treatment, reduces time, costs and mortality that may result from improper and/or delayed diagnosis.

Deaths from blunt trauma, after arrival at hospital: plus ça change, plus c'est la même chose

In this retrospective review of 94 deaths from blunt trauma occurring after admission to the hospital, in the region of Northern Ireland, for the year of 2001, data is presented with reference to preventable deaths (10%). Comparison is made with previous audit from the year of 1981 (preventable death rate 16%). Adverse events continue to occur in relation to abdominal haemorrhage, and issues pertaining to multidisciplinary care.

Initial assessment and outcome of head injured patients transferred to a regional neurosurgical service: what do we miss?

OBJECTIVE

To assess the level of missed extracranial injuries in patients transferred to a regional neurosurgical service for ongoing head injury management.

METHODS

A three year prospective study conducted under the auspices of the Scottish Trauma Audit Group. All patients were followed during their hospital stay by independent audit staff, their injuries being recorded and scored using established criteria.

RESULTS

115 head trauma patients were transferred during the study period. 15 patients died (13% mortality). Eight of a total of 87 separate, scorable extracranial injuries were missed (error rate 9%), none of which was serious. There were no missed injuries in patients who died. 77% of patients were managed by an accident and emergency doctor of at least registrar grade.

CONCLUSIONS

In contrast to other published series, this study has shown a low rate of missed extracranial injuries in a group of patients whose initial assessment is notoriously difficult. Early involvement by an experienced accident and emergency doctor may play an important part in the overall management of such patients.

Evaluation of the medical management and preventability of death in 137 road traffic fatalities in Victoria, Australia: an overview. Consultative Committee on Road Traffic Fatalities in Victoria

OBJECTIVES

In 1992 a multidisciplinary committee was established to identify problems in the management of road fatalities in Victoria, Australia, to assess their contribution to death, and to identify preventable deaths (preventable: survival probability more than 75%; potentially preventable: 25 to 75%).

METHODS

For 1992 and 1993 all 137 fatality cases surviving until arrival of ambulance services were evaluated by analysis and discussion of their complete prehospital, hospital, and autopsy records.

RESULTS

1,012 problems were identified in 509 admissions to the various areas of care. Six hundred eighty-five (68%) were management errors and 217 (21%) were system inadequacies. Technique errors (45 (4%)), diagnosis delays (25 (2%)), and diagnosis errors (40 (4%)) were less frequent. The emergency department (ED) accounted for 537 (53%) problems, followed by prehospital (200 (20%)) and intensive care unit (118 (12%)). Four hundred seventy (46%) problems were assessed as contributing to death. Two hundred twenty-eight (49%) occurred in the ED, 90 (19%) were prehospital problems, and 63 (13%) occurred in the intensive care unit. Management errors comprised 326 (69%) problems contributing to death, and system inadequacies 88 (19%). Resuscitation problems accounted for 82 (49%) of the 167 ED management errors contributing to death. Eighty-five (62%) deaths were assessed as nonpreventable, 7 (5%) as preventable, and 45 (33%) as potentially preventable.

CONCLUSION

Organizational and educational counter measures are required to reduce the high frequency of problems in emergency services and clinical management.

Trauma outcomes: a death analysis study

Survival and mortality outcomes for trauma patients admitted to Liverpool Hospital, Sydney were analysed to determine the adequacy of trauma care. TRISS and ASCOT survival probabilities and peer review were utilised to determine if deaths were avoidable. Evaluation methods were compared for assessment of care. During the study period 2205 trauma patients were admitted, 518 of which fulfilled the study entry criteria. There were 38 deaths. The age and Injury Severity Score (ISS) of survivors was 34 +/- 18 years, 9.8 +/- 9 (mean +/- sd) compared to age and ISS for nonsurvivors 37 +/- 22 years and 45 +/- 22*, *p < 0.001. Peer review suggested that 32 deaths were non avoidable, 4 potentially avoidable and 2 were probably avoidable. TRISS and ASCOT survival probabilities were > 0.5 in 16 and 18 patients respectively. TRISS and ASCOT had low positive predictive value (25%) in identifying avoidable deaths. The Z Score was 1.79. The standardised mortality ratio (SMR) was 1.16. The Effectiveness (E) value for outcome was 0.91. Poor communication within the Area Trauma System was the greatest contributor to avoidable deaths. All trauma deaths need peer review rather than solely relying upon ASCOT and TRISS probabilities to identify "unexpected" deaths for detailed review.

Fatal trauma: a five year review in a Dublin hospital

The autopsy reports and clinical data of 96 patients presenting to St. James's Hospital with trauma of fatal outcome, between January 1, 1986 and December 31, 1990, were analysed. Eighty-one (84%) deaths were due to road traffic accidents and all were the result of blunt trauma. Ninety-five (99%) had an Abbreviated Injury Scale (AIS) score > or = 3 in at least one anatomical category. Cerebral trauma (41%) and shock and haemorrhage secondary to multiple injuries (40%) were the commonest causes of death. Sixty-eight (71%) patients were dead on arrival at the hospital. Of the twenty-eight deaths occurring after admission to hospital nine (32%) were potentially preventable. The mean (sem) Injury Severity Score (ISS) for those with preventable deaths was 24.1 (3.8). These data have implications for the development of trauma care facilities in Ireland.

Emergency laparotomy for abdominal trauma

We have retrospectively reviewed our experience of 153 consecutive patients who underwent emergency laparotomy for suspected intraabdominal injury over a 10-year period. The commonest cause of injury was road traffic accidents (61 per cent), and the commonest indication for operation was signs of peritoneal irritation (35 per cent). Peritoneal lavage was performed in 62 patients (41 per cent). The liver was the organ most frequently injured (52 patients, 34 per cent) and 52 per cent of these patients died. Splenic injuries occurred in 46 patients (30 per cent). The negative laparotomy rate was 16 per cent. Forty-five patients died (29 per cent) and five of these had negative laparotomies. The Injury Severity Score (ISS) of all patients who died was > 16.

Trauma audit: experience in north-east Scotland

The management of 125 patients with trauma treated at Aberdeen Royal Infirmary from 1 January 1988 has been analysed using a microcomputer-based hospital trauma registry incorporating trauma and injury severity scores (TRISS) methodology. These patients fulfilled the North American Major Trauma Outcome Study (MTOS) inclusion criteria and were the first for whom data were available. Sixty-six patients had multiple injuries, of whom 52 were suffering from major trauma (defined as an injury severity score of 16 or greater). There were 14 deaths in the series, three (21 per cent) of which were considered to be preventable. Surgery was required in 84 (67.2 per cent) patients, of whom 59 (70 per cent) were operated on by a consultant or senior registrar. Five of six critically injured patients who died from their injuries were operated on by a consultant.

Retrospective study of 1000 deaths from injury in England and Wales

One thousand consecutive deaths from injury in 11 coroner's districts in England and Wales were reviewed by four independent assessors, who studied necropsy reports to identify deaths in hospital that might have been preventable. Of 514 patients admitted to hospital alive, 102 deaths (20%) were judged by all four assessors to have been potentially preventable. When those cases in which three out of four assessors considered that the death was preventable were added the total rose to 170 (33%). Nearly two thirds of all non-central nervous system deaths were judged to have been preventable. The median age of the 170 patients whose deaths were preventable was 41, and the mean Injury Severity Score was 29. Further analysis suggested that the preventable deaths were principally the result of failure to stop bleeding and prevent hypoxia and the absence of, or delay in, surgical treatment. The results closely parallel those from similar studies from the United States and suggest that there are serious deficiencies in the services for managing severe injury in England and Wales. Debate is needed now on how to correct these deficiencies. In particular, the place of trauma centres must be considered.

Progress in surgical emergency care: improvement in accuracy of diagnosis in a university hospital in France

The accuracy of diagnosis in multiple trauma can be greatly improved by the use of standardized assessment routines and uniform documentation. In the three groups of patients reviewed, the diagnostic error rate decreased from 23 percent in 1979 to 1980 to 8 percent in 1981 to 1982, and decreased further to 7.6 percent in 1983 to 1984. Our latest results show that a margin of error still persists. We believe that standardization of assessment routines in the difficult area of emergency medical practice is in the patient's best interest.

The use of standardized assessment procedures in the evaluation of patients with multiple injuries

The accuracy of diagnosis in multiple trauma can be greatly improved by the use of standardized assessment routines and standard documentation. In the two groups of patients reviewed the diagnostic error rate fell from 23% in the period 1979-1980 to 8% for the period 1981-1982.