Average thickness of the bones of the human neurocranium: development of reference measurements to assist with blunt force trauma interpretations

The accurate interpretation of a blunt force head injury relies on an understanding of the case circumstances (extrinsic variables) and anatomical details of the individual (intrinsic variables). Whilst it is often possible to account for many of these variables, the intrinsic variable of neurocranial thickness is difficult to account for as data for what constitutes 'normal' thickness is limited. The aim of this study was to investigate the effects of age, sex and ancestry on neurocranial thickness, and develop reference ranges for average neurocranial thickness in the context of those biological variables. Thickness (mm) was measured at 20 points across the frontal, left and right parietals, left and right temporals and occipital bones. Measurements were taken from post-mortem computed tomography scans of 604 individuals. Inferential statistics assessed how age, sex and ancestry affected thickness and descriptive statistics established thickness means. Mean thickness ranged from 2.11 mm (temporal squama) to 19.19 mm (petrous portion). Significant differences were noted in thickness of the frontal and temporal bones when age was considered, all bones when sex was considered and the, right parietal, left and right temporal and occipital bones when ancestry was considered. Furthermore, significant interactions in thickness were seen between age and sex in the frontal bone, ancestry and age in the temporal bone, ancestry and sex in the temporal bone, and age, sex and ancestry in the occipital bone. Given the assorted influence of the biological variables, reference measurement ranges for average thickness incorporated these variables. Such reference measurements allow forensic practitioners to identify when a neurocranial bone is of normal, or abnormal, thickness.

Pan-cancer analysis of whole genomes

Cancer is driven by genetic change, and the advent of massively parallel sequencing has enabled systematic documentation of this variation at the whole-genome scale1-3. Here we report the integrative analysis of 2,658 whole-cancer genomes and their matching normal tissues across 38 tumour types from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). We describe the generation of the PCAWG resource, facilitated by international data sharing using compute clouds. On average, cancer genomes contained 4-5 driver mutations when combining coding and non-coding genomic elements; however, in around 5% of cases no drivers were identified, suggesting that cancer driver discovery is not yet complete. Chromothripsis, in which many clustered structural variants arise in a single catastrophic event, is frequently an early event in tumour evolution; in acral melanoma, for example, these events precede most somatic point mutations and affect several cancer-associated genes simultaneously. Cancers with abnormal telomere maintenance often originate from tissues with low replicative activity and show several mechanisms of preventing telomere attrition to critical levels. Common and rare germline variants affect patterns of somatic mutation, including point mutations, structural variants and somatic retrotransposition. A collection of papers from the PCAWG Consortium describes non-coding mutations that drive cancer beyond those in the TERT promoter4; identifies new signatures of mutational processes that cause base substitutions, small insertions and deletions and structural variation5,6; analyses timings and patterns of tumour evolution7; describes the diverse transcriptional consequences of somatic mutation on splicing, expression levels, fusion genes and promoter activity8,9; and evaluates a range of more-specialized features of cancer genomes8,10-18.

Mortuary operations following mass fatality natural disasters: a review

This is a critical review to discuss the best practice approaches to mortuary operations in preparation for and the response to natural, mass fatality, disaster events, as identified by a review of published articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) Statement guided the identification of potential articles to use in this critical review. Subsequent searches were also conducted to identify articles relating to heat wave, and flood mortality. All identified peer-reviewed studies published in English which discussed the preparation and response of mortuaries to mass fatality natural disasters occurring in developed countries were included. Using the PRISMA-P method of identifying articles, 18 articles were selected for inclusion in this review. Although there are numerous articles which describe the mortuary response to mass fatality incidents, few articles analyzed the response, or discussed the roles which supported and enabled the organization to undertake the task of identifying disaster victims. It is thus difficult to determine objectively if the actions and activities outlined in the articles represent best-practice.

Evaluation of the Prehospital Management of Road Traffic Fatalities in Victoria, Australia

Introduction:

This study was undertaken to identify prehospital system and management deficiencies and preventable deaths between 01 January 1997 and 31 December 1998 in 243 consecutive Victorian road crash victims with fatal outcomes.

Methods:

The complete prehospital and hospital records, the deposition to the coroner, and autopsy findings were evaluated by computer analysis and peer group review with multidisciplinary discussion.

Results:

One-hundred eighty-seven (77%) patients had prehospital errors or inadequacies, of which 135 (67%) contributed to death. Three-hundred ninety-four (67%) related to management and 130 (22%) to system deficiencies. Technique errors, diagnosis delays, and errors relatively were infrequent. One of 24 deaths at the crash scene or en route to hospital was considered to be preventable and two potentially preventable.

Conclusion:

The high prevalence of prehospital deficiencies has been addressed by a Ministerial Task Force on Trauma and Emergency Services and followed by the introduction of a new trauma care system in Victoria.

Victoria's trauma care system: national implications for quality improvement

Progressive reduction in trauma mortality and morbidity demands both peer-group and state registry evaluations, with ensuing recommendations implemented by a responsive state government trauma committee.

Management deficiencies and death preventability of road traffic fatalities before and after a new trauma care system in Victoria, Australia

BACKGROUND

The Consultative Committee's findings that preventable or potentially preventable (P/PP) death rates (survival prospects > or =25%) of road crash fatalities who received treatment were unaltered between 1992 and 1998 led to a Ministerial Taskforce on Trauma and the gradual introduction of a new Victorian trauma care system. The present study compares outcomes before (1997-1998) and after (2002-2004) the new system.

METHODS

The emergency and clinical management and death preventability of 245 consecutive fatalities in the 'before' period and 193 in the 'after' period was assessed by the committee's multidisciplinary panels using the complete hospital, ambulance, and autopsy findings.

RESULTS

Emergency department admissions to expanded Major Trauma Services (MTS) increased from 34% to 62% (p < 0.05). More patients were attended by Advanced Trauma Life Support paramedics (p < 0.05) and scene times increased (p < 0.05). Patients admitted within 1 hour decreased from 70% to 45% (p < 0.05). The mean number of deficiencies per patient including those contributing to death was decreased (p < 0.05). The combined P/PP death rates decreased from 36% to 28% (22% relative risk reduction). The P/PP death rates for MTS, Metropolitan Trauma Services, Rural Trauma Services, and Urgent Care Centers for 2002 to 2004 were 25%, 33%, 50%, and 83%, respectively, and did not differ significantly from those of 1997 to 1998 (23%, 49%, 36%, 75%, respectively). The P/PP death rates in MTS were less than those of the other hospital groups.

CONCLUSIONS

The new Victorian trauma care system has resulted in a significant decrease in deficiencies including those contributing to death and a decrease in P/PP deaths rates. The improvement has been largely consequent to a marked increase in admissions to MTS.

Missing persons-missing data: the need to collect antemortem dental records of missing persons

The subject of missing persons is of great concern to the community with numerous associated emotional, financial, and health costs. This paper examines the forensic medical issues raised by the delayed identification of individuals classified as "missing" and highlights the importance of including dental data in the investigation of missing persons. Focusing on Australia, the current approaches employed in missing persons investigations are outlined. Of particular significance is the fact that each of the eight Australian states and territories has its own Missing Persons Unit that operates within distinct state and territory legislation. Consequently, there is a lack of uniformity within Australia about the legal and procedural framework within which investigations of missing persons are conducted, and the interaction of that framework with coronial law procedures. One of the main investigative problems in missing persons investigations is the lack of forensic medical, particularly, odontological input. Forensic odontology has been employed in numerous cases in Australia where identity is unknown or uncertain because of remains being skeletonized, incinerated, or partly burnt. The routine employment of the forensic odontologist to assist in missing person inquiries, has however, been ignored. The failure to routinely employ forensic odontology in missing persons inquiries has resulted in numerous delays in identification. Three Australian cases are presented where the investigation of individuals whose identity was uncertain or unknown was prolonged due to the failure to utilize the appropriate (and available) dental resources. In light of the outcomes of these cases, we suggest that a national missing persons dental records database be established for future missing persons investigations. Such a database could be easily managed between a coronial system and a forensic medical institute. In Australia, a national missing persons dental records database could be incorporated into the National Coroners Information System (NCIS) managed, on behalf of Australia's Coroners, by the Victorian Institute of Forensic Medicine. The existence of the NCIS would ensure operational collaboration in the implementation of the system and cost savings to Australian policing agencies involved in missing person inquiries. The implementation of such a database would facilitate timely and efficient reconciliation of clinical and postmortem dental records and have subsequent social and financial benefits.

Evaluation of Management of Road Trauma Survivors with Brain Injury and Neurologic Disability in Victoria

BACKGROUND

Victoria recently established a new trauma care system following the Consultative Committee's findings on frequent preventable deaths after road crash injury. This study investigates the contribution to neurologic disability of preventable deficiencies in health care in survivors of road crashes occurring from 1998 to 1999.

METHODS

The emergency and clinical management of 60 road crash survivors with head Abbreviated Injury Scale score > or = 3 and residual neurologic disability were evaluated by analysis and multidisciplinary discussion of their complete prehospital, hospital, and rehabilitation records.

RESULTS

The mean number of potentially preventable errors or inadequacies per patient was 19.2 +/- 7.5, with 10.5 +/- 7.2 contributing to neurologic disability. The mean number contributing to neurologic disability was greatest in the emergency room (3.5 +/- 3.2), followed by the intensive care unit (2.2 +/- 2.7) and the prehospital setting (1.8 +/- 2.0). Eighty-four percent of the deficiencies were management errors/inadequacies and 7% were system inadequacies. Fifty-five percent of deficiencies contributed to neurologic disability. In patients with a systolic blood pressure less than 90 mm Hg with hypovolemia consequent to inadequate resuscitation, the frequency of severe neurologic disability was increased almost twofold (p < 0.05). Deficiencies contributing to neurologic disability were significantly less frequent in university teaching hospitals with neurosurgical units.

CONCLUSION

Improvement in neurologic outcomes can be achieved through appropriate triage and increased attention to basic principles of trauma and head injury care.

Choking deaths: the role of antipsychotic medication

BACKGROUND

An increased risk of choking associated with antipsychotic medication has been repeatedly postulated.

AIMS

To examine this association in a large number of cases of choking deaths.

METHOD

Cases of individuals who had died because of choking were linked with a case register recording contacts with public mental health services. The actual and expected rates of psychiatric disorder and the presence of psychotropic medication in post-mortem blood samples were compared.

RESULTS

The 70 people who had choked to death were over 20 times more likely to have been treated previously for schizophrenia. They were also more likely to have had a prior organic psychiatric syndrome. The risk for those receiving thioridazine or lithium was, respectively, 92 times and 30 times greater than expected. Other antipsychotic and psychotropic drugs were not over-represented.

CONCLUSIONS

The increased risk of death in people with schizophrenia may be a combination of inherent predispositions and the use of specific antipsychotic drugs. The increased risk of choking in those with organic psychiatric syndromes is consistent with the consequences of compromised neurological competence.

Road traffic fatalities in Victoria, Australia and changes to the trauma care system

BACKGROUND

The aim was to identify organizational and clinical errors in the management of road traffic fatalities and to use this information to improve Victoria's trauma care system.

METHODS

A multidisciplinary committee evaluated the complete ambulance, hospital and autopsy records of 559 consecutive road traffic fatalities, who were alive on arrival of ambulance services, in five substantial time periods between 1992 and 1998. Patients who survived more than 30 days were excluded. Errors or inadequacies in each phase of management, including those contributing to death, were identified and an assessment was made of the potential preventability of death.

RESULTS

Findings between 1992 and 1998 were similar. In 1998, 1672 problems were identified in 110 deaths with 1024 (61 per cent) contributing to death. Eight hundred and forty-two (50 per cent) of the total problems occurred in the emergency department. There were frequent problems in initial patient reception and medical consultation, resuscitation, investigation and assessment (especially of the abdomen and head), and in transfer to the operating theatre or to a higher-level hospital. Victoria's combined preventable and potentially preventable death rate has been unchanged between 1992 and 1998 (34-38 per cent).

CONCLUSION

The problems identified led to a Ministerial Taskforce on Trauma and Emergency Services in Victoria as a consequence of which a new trauma system is now being implemented.

Issues in child homicides: 11 cases

For a variety of reasons, child homicides are the most difficult cases for forensic pathologists. For example, the events are usually not witnessed, accidental explanations are offered, often there is more than one carer spanning the period over which the injuries might have occurred and there can be conflicting opinions between the various medical specialities. Eleven cases of fatal child abuse are presented to illustrate and briefly discuss particular difficulties. Reference is also made to interaction with the legal process and parallel difficulties the law has with fatal child abuse.

The preventability of death in road traffic fatalities with head injury in Victoria, Australia. The Consultative Committee on Road Traffic Fatalities

Since 1992 the Consultative Committee on Road Traffic Fatalities in Victoria (CCRTF) has examined the medical management of patients who died following motor vehicle accidents. Three hundred and fifty-five fatalities with head injury occurring between 1 July, 1992 and 31 December 1997 were assessed by the CCRTF. They represented 79% of the total 449 fatalities examined by the Committee. Following examination of the complete medical records and multidisciplinary discussion, the Committee considered 237 (67%) of the 355 neurotrauma deaths to be non-preventable, 105 (30%) potentially preventable and 13 (4%) preventable. The present analysis excludes the non-preventable deaths in order to focus on preventable factors. Problems identified in the 118 patients pre-hospital included: no intubation; prolonged scene time; and no intravenous access; in 139 emergency room attendances: inappropriate reception including delay in arrival of a consultant, no neurosurgical consultation, no CT scan of the head, inadequate blood gases and oxygen monitoring, inadequate fluid resuscitation, delayed respiratory resuscitation and delayed dispatch to the operating room; in 111 operating room visits: no ICP monitoring, inadequate fluid administration and inappropriate anaesthetic technique; and in 90 intensive care unit admissions: no ICP monitoring. Overall, 1745 individual problems in the various areas of care were identified, of which 1104 (63%) were judged to have contributed to death. Improved delivery and quality of trauma care could reduce the identified problems in emergency services and clinical management. Basic principles of trauma management remain the most important means of reducing morbidity and death following road trauma. The leadership role of the neurosurgeon in neurotrauma care is emphasised.

Consultative Committee on Road Traffic Fatalities: trauma audit methodology

BACKGROUND

Since 1992 the Consultative Committee on Road Traffic Fatalities in Victoria has identified deficiencies and errors in the management of 559 road traffic fatalities in which the patients were alive on arrival of ambulance services. The Committee also assessed the preventability of deaths. Reproducibility of results using its methodology has been shown to be statistically significant. The Committee's findings and recommendations, the latter made in association with the learned Colleges and specialist Societies, led to the establishment of a Ministerial Taskforce on Trauma and Emergency Services. As a consequence, in 2000, a new trauma care system will be implemented in Victoria. This paper presents a case example demonstrating the Committee's methodology.

METHODS

The Committee has two 12 member multidisciplinary evaluative panels. A retrospective evaluation was made of the complete ambulance, hospital and autopsy records of eligible fatalities. The clinical and pathological findings were analysed using a comprehensive data proforma, a narrative summary and the complete records. Resulting multidisciplinary discussion problems were identified and the potential preventability of death was assessed.

RESULTS

In the present case example the Committee identified 16 management deficiencies of which 11 were assessed as having contributed to the patient's death; the death, however, was judged to be non-preventable.

CONCLUSION

The presentation of this example demonstrating the Committee's methodology may be of assistance to hospital medical staff undertaking their own major trauma audit.

Deaths due to brain injury among footballers in Victoria, 1968-1999

OBJECTIVES

To determine the frequency and nature of fatal brain injuries occurring in Australian football.

SETTING

State of Victoria, January to July 1999.

DESIGN

Retrospective case series of football-related deaths identified from the coronial autopsy records of the Victorian Institute of Forensic Medicine (1990-1999) and newspaper reports (1968-1989).

MAIN OUTCOME MEASURES

Coronial autopsy findings and circumstances of injury.

RESULTS

25 deaths associated with Australian football were identified, nine due to brain injury. Coronial findings in the brain-injury deaths were intracranial haemorrhage in eight patients and infarct in the territory of the middle cerebral artery in one. In three of four cases of subarachnoid haemorrhage, vertebral artery trauma was noted. In all but one case, injury occurred as an accidental part of play.

CONCLUSIONS

The most common findings in deaths due to brain injury in Australian football were intracranial haemorrhage, including subarachnoid haemorrhage from vertebral artery injury.

Sudden unexpected death in epilepsy in Victoria

Sudden unexpected death in epilepsy (SUDEP) refers to sudden unexpected death in patients with epilepsy in whom autopsy fails to reveal an anatomic or toxicological cause of death. The purpose of this study was to examine associated factors and mechanisms relating to SUDEP in Victoria. The study was a retrospective study based on data from questionnaires completed by treating doctors and coronial files including police reports of death, autopsy and toxicology reports. The deaths were of people with epilepsy in Victoria that were referred to the coroner between 1991 and 1997. There were 15,751 coronial autopsies of which 357 had epilepsy and 50 (14%) were SUDEPs. The SUDEP rate was approximately 1 per 3000 epileptics per year. This study suggested the following associations: young age, tonic-clonic seizures, seizure frequency greater than 10/year, duration of epilepsy greater than 10 years, mental retardation, psychiatric disease and alcohol abuse. Antiepileptic drug (AED) compliance was rated by treating doctors as good in 24 cases. One or more postmortem AED drug levels was subtherapeutic in 30 of 50 cases. Only 5 were receiving psychotropic drugs; only 1 of these was receiving more than one of these drugs. A history of recent unusually stressful life event was present in only 4 cases. At least 11 showed evidence of terminal seizure, and the majority of events occurred in sleep. These observations support the hypothesis that seizures are the mechanism of many cases of SUDEP. The associations observed were largely in agreement with previous studies. However, seizure frequency was greater and duration of epilepsy greater than most previous studies. The role of factors such as AED compliance, psychotropic drug prescription and recent unusually stressful life event is less clear. This highlights the need for case-control studies of risk factors for SUDEP.

Comparison of antiepileptic drug levels in sudden unexpected deaths in epilepsy with deaths from other causes

PURPOSE

(a) To compare postmortem antiepileptic drug (AED) levels in patients with sudden unexpected death in epilepsy (SUDEP) with those in a control group of subjects with epilepsy. If SUDEP patients more frequently had undetectable or subtherapeutic AED levels, this would suggest that compliance with AED treatment is poorer in this group and that poor compliance is a risk factor for SUDEP. (b) To determine whether a particular AED was detected more commonly in the SUDEP group, suggesting that this AED is associated with a higher risk of SUDEP.

METHODS

A retrospective study of coronial cases was performed. Postmortem AED levels in 44 SUDEP cases and 44 control cases were compared. The control group consisted of epileptics who died of causes other than epilepsy, including natural disease (e.g., ischemic heart disease, accidents, and suicide). The AEDs measured included carbamazepine (CBZ), phenytoin, (PHT), valproate (VPA), phenobarbitone (PB), lamotrigine (LTG), clonazepam (CZP), and clobazam (CLB). The number of SUDEP and control cases in which CBZ only was detected were compared, as were the number in which PHT only was detected.

RESULTS

Compared with the controls, the SUDEP group showed no difference in the number with no detectable AEDs (13 vs. 11), the number with subtherapeutic AEDs (10 vs. 13), and the number with therapeutic levels (21 in both groups). CBZ only was detected in 11 SUDEPs and 11 controls, and PHT only in five SUDEPs and 10 controls.

CONCLUSIONS

Our study suggests the SUDEP group were no less compliant with AED treatment than the control group. This study does not support the hypothesis that poor compliance with AED treatment is a risk factor for SUDEP. There was no evidence that PHT or CBZ is associated with a higher risk of SUDEP.

Management of severe trauma in intensive care units and surgical wards

OBJECTIVE

To evaluate the management of severe trauma in intensive care, high dependency and general surgical wards of Victorian hospitals.

DESIGN

Retrospective case review by multidisciplinary committees.

SUBJECTS

The first 256 people who died from road traffic accidents who were alive on the arrival of emergency services between 1 July 1992 and 30 June 1994.

MAIN OUTCOME MEASURES

(1) Severity of injury according to clinical diagnosis, autopsy findings and recognised trauma-scoring methods; (2) errors in management, identified as contributing or not contributing to the cause of death, and categorised as "management", "system", "diagnostic" or "technique" errors.

RESULTS

Most patients (61%) were admitted to an intensive care unit (ICU), and 19.5% were admitted to high dependency or general surgical wards. Of 2187 errors of care identified, 11.8% occurred in ICU and 6.7% in wards, with the remainder occurring during the earlier phases of care. Most errors were classified as management errors (82% of ICU errors and 88% of ward errors). Fifty-two per cent of ICU errors and 71% of ward errors were judged to contribute to the patient's death.

CONCLUSIONS

A significant number of errors of trauma management occur in the intensive care and general surgical ward. Improvement in late trauma care may reduce the number of preventable trauma deaths.

Quality assessment of the management of road traffic fatalities at a level I trauma center compared with other hospitals in Victoria, Australia. Consultative Committee on Road Traffic Fatalities in Victoria

OBJECTIVES

Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria, Australia, has identified problems including those contributing to death and the potential preventability of deaths in road fatalities who survived until at least the arrival of ambulance services. The present analysis examines the outcomes at a Level I trauma center compared with other hospital groups in Victoria.

METHODS

Between 1992 and 1994, 257 consecutive eligible fatalities were evaluated. Problems in management and preventable deaths were identified at the trauma center (TC) and in pooled data from other hospital groups, i.e., specialist teaching (Level II), other metropolitan (Level III), large regional (Level III), and small regional hospitals.

RESULTS

Mean problems identified and those contributing to death (controlled for the number of areas of care), were less frequent at TC (1.7 and 0.6) than at other hospital groups (specialist teaching, 1.9 and 1.1*; metropolitan, 3.1* and 1.6*; large regional, 3.8* and 1.8*; small regional, 5.1* and 2.6*) (*p < 0.05 compared with TC). Preventable and potentially preventable deaths were also less common at TC (20%) than at the other hospital groups (specialist teaching, 40%*; metropolitan, 41%*; large regional, 53%*; small regional, 62%*) (*p < 0.05 compared with TC). When a Trauma and Injury Severity Score of 75% or more was used to define preventable death, a similar trend was identified.

CONCLUSION

Management of patients with major trauma at a Level I trauma center was associated with fewer problems contributing to death and fewer preventable and potentially preventable deaths than at the different hospital groups. A trauma system in Victoria, including bypass of major trauma patients to designated hospitals with 24-hour trauma services, is likely to decrease the frequency of problems, including the preventable death rates.

Sudden death in psychiatric patients

BACKGROUND

The present study investigated histories of prior psychiatric treatment in cases of sudden death reported to the coroner.

METHODS

A matching survey linked the register of deaths reported to the coroner with a comprehensive statewide psychiatric case register covering both in-patient and community-based services.

RESULTS

Sudden death was five times higher in people with histories of psychiatric contact. Suicide accounted for part of this excess mortality but deaths from natural causes and accidents were also elevated. Schizophrenic and affective disorders had similar suicide rates. Comorbid substance misuse doubled the risk of sudden death in affective and schizophrenic disorders.

CONCLUSIONS

The rates of sudden death are sufficiently elevated to raise questions about current priorities in mental health care. There is a need both for greater attention to suicide risk, most notably among young people with schizophrenia, to the early detection of cardiovascular disorders and to the vigorous management of comorbid substance misuse.

Reproducibility of preventable death judgments and problem identification in 60 consecutive road trauma fatalities in Victoria, Australia. Consultative Committee on Road Traffic Fatalities in Victoria

BACKGROUND

Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria has identified problems in the management of traffic fatalities. Its two evaluative committees have additionally assessed the potential preventability of death. Previous studies have shown only poor to fair reproducibility of death judgments.

METHODS

Problems in the management of 60 consecutive road traffic fatalities and the potential preventability of death were independently evaluated by the two committees. Inter-rater and inter-committee concordance were analyzed using the kappa statistic.

RESULTS

Reproducibility was high. Inter-committee agreement on nonpreventable, potentially preventable, and preventable death judgments was high (kappa = 0.73, 95% confidence interval = 0.57-0.89). Agreement within the two evaluative committees was also high (average weighted kappa = 0.73 and 0.74). There was good agreement between committees on problems identified, including those contributing to death.

CONCLUSION

The high kappa concordance on preventable death judgments and the agreement on problem identification supports the reproducibility of the methodology used.

Management deficiencies and death preventability in 120 Victorian road fatalities (1993-1994). The Consultative Committee on Road Traffic Fatalities in Victoria

BACKGROUND

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: survival probability between 25 and 75%).

METHODS

For 1993-94, 120 consecutive fatality cases surviving until arrival of ambulance services were evaluated by analysis and discussion of their complete pre-hospital, hospital and autopsy records.

RESULTS

A total of 1175 problems were identified in 455 admission to the various areas of care. A total of 949 problems (81%) were found to be management errors and 123 (11%) were found to be system inadequacies. Technique errors (35 (3%)), diagnosis delays (27 (2%)) and diagnosis errors (41 (4%)) were less frequent. The emergency department (ED) accounted for 662 (56%) problems, followed by 191 (16%) pre-hospital problems and 140 (12%) intensive care unit (ICU) problems. There were 598 (51%) problems that were assessed as contributing to death. A total of 308 (52%) problems occurred in the ED, 106 (18%) were pre-hospital problems and 71 (12%) occurred in ICU. Management errors comprised 465 (78%) problems contributing to death, and system inadequacies comprised 76 (13%) problems. Resuscitation problems accounted for 101 (40%) of the 254 ED management errors contributing to death. A total of 79 (66%) deaths were assessed as non-preventable, five (4%) were assessed as preventable and 36 (30%) were assessed as potentially preventable.

CONCLUSIONS

Organization and educational countermeasures are required to reduce the high frequency of problems in emergency services and clinical management.

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.

A study of deaths involving oxycodone

Nine deaths involving oxycodone were investigated to assess the contribution of this opiate to these fatalities. All except one of the bodies were subjected to a full autopsy by specialist pathologists with a subsequent thorough toxicological examination. No significant anatomical pathology was found at autopsy. All deaths gave concentrations of oxycodone in femoral blood higher than expected following normal therapeutic use. In three cases no other drug in toxic concentrations was detected. Two cases involved the presence of a high concentration of a benzodiazepine and in a further two cases a high concentration of alcohol in addition to other drugs in therapeutic concentrations were present. One case involved methamphetamine in significant concentrations and another involved high concentrations of oxazepam in combination with pethidine. In all cases the presence of oxycodone was given as a factor contributing to the death. In only one case were there circumstances clearly indicating suicide. Our observations suggest that oxycodone is at least as toxic as other opiates and will cause deaths if misused.

Postmortem clomipramine: therapeutic or toxic concentrations?

Postmortem blood and liver concentrations of clomipramine were determined in ten cases by high performance liquid chromatography (HPLC). Blood concentrations ranged from 0.21 to 4.9 mg/L, and liver concentrations from 7.0 to 320 mg/kg. Two cases associated with clomipramine toxicity were clearly differentiated from other cases by the analysis of liver. The concentrations of clomipramine in these two cases were 3.3 and 1.8 mg/L in blood, and 280 and 320 mg/kg in liver. The liver concentrations were 10 to 30 fold greater in the deaths associated with drug toxicity compared with the other cases. One case, where cardiac blood was collected in place of femoral blood, showed a high blood concentration (4.9 mg/L), but an arguably therapeutic liver concentration (13 mg/kg). The analysis of femoral blood together with liver provides the best guide as to the significance of post-mortem clomipramine concentrations.

Deaths involving the benzodiazepine flunitrazepam

A study of eight deaths involving the benzodiazepine flunitrazepam was performed to assess the contribution of this drug to the fatalities. Coronial deaths in Victoria in the 2-year period to mid-1991 were selected in which either flunitrazepam or flunitrazepam and ethanol were the principal toxicological findings. All bodies were subject to a full autopsy by forensic pathologists, and a full toxicological examination. No significant pathology was found at autopsy in any case. Very high concentrations of 7-aminoflunitrazepam, a metabolite of flunitrazepam, were present in all cases. In four cases no other significant drug was detected, whereas in the other four cases there were significant concentrations of ethanol (mean 1.6 g/L). In these two groups of cases the concentrations of 7-aminoflunitrazepam were 0.45 mg/L and 0.16 mg/L, respectively. Only moderate levels of flunitrazepam were detected, suggesting that 7-aminoflunitrazepam is produced postmortem and may be an important marker of flunitrazepam usage. The causes of death in these eight cases were probably either flunitrazepam toxicity or a combination of flunitrazepam and ethanol toxicity. Only one case appeared likely to have been a suicide. Our observations in these cases suggest that flunitrazepam may cause death in the absence of other drugs or significant disease. The presence of ethanol reduces the amount of flunitrazepam needed to cause death.

Methadone toxicity causing death in ten subjects starting on a methadone maintenance program

Methadone maintenance therapy is designed to reduce the need for addicts to use heroin or other illegal opiates. Death in patients starting on such a program has not previously been documented. We report the death of 10 persons who died within days of starting a methadone maintenance program administered by general practitioners. Their bodies were subject to a full autopsy by forensic pathologists, with a full toxicological examination. The mean starting dose had been 53 mg, which had been increased to a mean of 57 mg by the final dose. Death occurred after a mean of 3 days. The mean blood methadone concentration at death was 2.1 mumol/L. Complete toxicological analysis showed that six subjects had additional drugs present including two with alcohol, two with benzodiazepines and morphine, and one with benzodiazepines alone. Pathological examination revealed the presence of chronic persistent hepatitis in all subjects and bronchopneumonia in five. The causes of death were given as methadone toxicity or methadone toxicity in combination with bronchopneumonia. Our observations highlight the dangers of methadone in the first days of starting on a maintenance program, particularly when the starting doses are relatively high and subjects have no demonstrated tolerance to opiates.