Elsevier

Injury

Volume 40, Issue 9, September 2009, Pages 907-911
Injury

Review
Patterns of mortality and causes of death in polytrauma patients—Has anything changed?

https://doi.org/10.1016/j.injury.2009.05.006Get rights and content

Abstract

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.

Introduction

Trunkey's63 hallmark publication on the causes of mortality after trauma differentiates between immediate deaths (on scene/within 60 min), early deaths (emergency department (ED) or operating room (OR)/within 1–4 h), and late deaths that occur more than 1 week after trauma. In Trunkey's review of 425 trauma fatalities the primary cause of death (blunt trauma deaths = 56%) was brain injury (44.9%) following by haemorrhage causing injuries (35.2%).64 Since this description many cofactors have changed, such as injury prevention advancements, the implementation of advanced-trauma-life-support (ATLS®) concept in rescue systems, improvements in hospital diagnostics and surgical techniques (minimally invasive surgery), and the development of treatment strategies (implementation of damage control (DC) and damage control orthopaedics (DCO)). To date it is unclear whether these changes have simply been associated with improvements in mortality or whether they have themselves affected the distribution of peaks of mortality. Regel et al.48 have found a decrease in the mortality rate (37–22%) of multiple trauma patients over the past two decades (1972–1991), but do not mention potential causes. However, recent reports (2000–2005) appear to confirm these improved mortality rates (18–23%) as well.4, 33, 40, 43, 51

This review investigates whether the distribution of complications and mortality has changed. We have reviewed the published literature examing the causes, locations and timing of trauma death after traumatic injury and focused on one question: is there a change in pattern of trauma deaths over the last 3 decades?

Section snippets

Search strategy

This review focused on literature examing patterns and causes of death following trauma treated in level 1 hospitals. The PubMed database was searched for relevant medical literature in English and/or German language published within the last three decades (1980–2008). This time period was chosen due to relevant improvements in trauma management made in the last 30 years (e.g. introduction of ATLS® in 197816) that possibly had affected the patterns of trauma mortality. The following search

Results

A total of 22 articles satisfied the inclusion and exclusion criteria for this analysis: 6 reports between 1980 and 1989, 6 between 1990 and 1999, and 10 between 2000 and 2008 (Table 1).2, 3, 13, 14, 17, 19, 20, 23, 27, 36, 37, 38, 42, 46, 52, 54, 55, 56, 57, 58, 60, 61 The overall median age of patients in all publications was 40.6 years [range, 34.5–67.5], and the median injury severity score was 38 points [range, 22.6–49.5]. Furthermore, the median percentage for patients sustained a blunt

Discussion

Identification of the epidemiology, patterns, and causes of death following trauma may provide useful information for improving treatment strategies and enhancing the quality of the trauma care system. Our comparison of the three time periods reveals the following main results: firstly, the pattern of trauma deaths as described in 1980s does not appear to have changed. Secondly, the incidence of haemorrhage as cause of death has decreased during the last decade. Thirdly, no considerable

Conclusion

We conclude: (1) pre-admission mortality continues to be the most important reason for clinical trauma deaths among level 1 trauma patients. This fact persists despite well-described improvements in passive car safety. (2) Brain injury and haemorrhage remain the leading most important causes of post-injury death, whereas the mortality of polytrauma patients from exsanguination has been reduced. This improvement in survival for acute haemorrhage patients is likely to be multifactorial. The

Conflict of interest statement

I declare that the authors do not have financial and non-financial competing interests.

Acknowledgements

Authors contributions: All authors were involved in the research project and preparation of the manuscript. HCP, IST, BR: They made a substantial contribution to conception, performed an analysis and interpretation of these data and design, and gave a critical and final approval. RP: He has collected the data and made an analysis and interpretation of these data. All authors worked on the manuscript and revisions. All authors read and approved the final version of the manuscript.

References (67)

  • J.G. Muscedere et al.

    The impact of ventilator-associated pneumonia on the Canadian health care system

    J Critical Care

    (2008)
  • C.J. Olson et al.

    Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers

    Surgery

    (2001)
  • J.M. Pang et al.

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

    Injury

    (2008)
  • S.J. Pereira et al.

    Dynamic helical computed tomography scan accurately detects hemorrhage in patients with pelvic fracture

    Surgery

    (2000)
  • M. Richter et al.

    Improvements in passive car safety led to decreased injury severity—a comparison between the 1970s and 1990s

    Injury

    (2005)
  • P. Sahdev et al.

    Road traffic fatalities in Delhi: causes, injury patterns, and incidence of preventable deaths

    Accid Anal Prev

    (1994)
  • M.A. Sampson et al.

    Computed tomography whole body imaging in multi-trauma: 7 years experience

    Clin Radiol

    (2006)
  • D.D. Trunkey et al.

    Analysis of 425 Consecutive Trauma Fatalities

    J Am Coll Emerg Phys

    (1974)
  • G.D.J. Van Olden et al.

    Clinical impact of advanced trauma life support

    J Emerg Med

    (2004)
  • J. Ali et al.

    Trauma outcome improves following the advanced trauma life support program in a developing country

    J Trauma

    (1993)
  • C.C. Baker et al.

    Epidemiology of trauma deaths

    Am J Surg

    (1980)
  • J.M. Bamvita et al.

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

    J Trauma

    (2007)
  • M. Bardenheuer et al.

    Epidemiology of severe multiple trauma—a prospective registration of preclinical and clinical supply

    Unfallchirurg

    (2000)
  • A.E. Baue et al.

    Systematic inflammatory response syndrom (SIRS), multiple organ dysfunction syndrom (MODS), multiple organ failure (MOF): are we winning the battle?

    Shock

    (1998)
  • J. Browne et al.

    High quality acute care for the severely injured is not consistently available in England, Wales and Northern Ireland: report of a survey by the Trauma Committee. The royal college of surgeons of England

    Ann R Coll Surg Engl

    (2006)
  • C. Brun-Buisson

    The epidemiology of the systemic inflammatory response

    Intensive Care Med

    (2000)
  • C. Brun-Buisson et al.

    Bacteremia and severe sepsis in adults: a multicenter prospective survey in ICUs and wards of 24 hospitals. French Bacteremia-Sepsis Study Group

    Am J Respir Crit Care Med

    (1996)
  • A.R. Burgess et al.

    Lower extremity injuries in drivers of airbag-equipped automobiles: clinical and crash reconstruction correlations

    J Trauma

    (1995)
  • B.J. Campbell

    Safety belt injury reduction related to crash severity and front seated position

    J Trauma

    (1987)
  • G.P. Castelli et al.

    Procalcitonin and C-reactive protein during systemic inflammatory response syndrome, sepsis and organ dysfunction

    Crit Care

    (2004)
  • T.F. Certo et al.

    Review of care of fatally injured patients in rural state: 5-year follow up

    J Trauma

    (1983)
  • Y.-E. Claessens et al.

    Diagnosis and treatment of severe sepsis

    Crit Care

    (2007)
  • P.E. Collicott

    Advanced trauma life support course, an improvement in rural trauma care

    Nebr Med J

    (1979)

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