The why and how our trauma patients die: A prospective Multicenter Western Trauma Association study

Abstract

Introduction: Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality. Methods: 18 trauma centers prospectively enrolled all adult trauma patients at the time of death during 12/2015-8/2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed. Results: 1536 patients were enrolled with a median age of 55 (IQR 32-75). 74.5% were male. Penetrating mechanism (n=412) patients were younger (32 vs 64, p<0.0001) and more likely male (86.7% vs. 69.9%, p<0.0001). Falls were the most common mechanism of injury (26.6%), with GSWs second (24.3%). The most common overall primary COD was TBI (45%), followed by exsanguination (23%). TBI was non-survivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p<0.0001) and penetrating patients exsanguination (51.7% vs 12.5%, p<0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p<0.0001). Most deaths were deemed disease related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care. Conclusions: Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research.

WSES consensus conference guidelines: monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours

“…Life-threatening hemorrhage is one of the major preventable causes of early death after trauma [3–5]. Therefore, precise and early control of hemorrhage, with associated restoration of circulating blood volume, remains a priority [9, 19, 20].…”

“…Traumatic brain injury (TBI), both isolated and in combination with extra-cranial lesions, is a global health problem associated with high mortality and disability [1, 2]. In addition, post-traumatic bleeding is a leading cause of preventable death among injured patients [3–5]. A multicenter observational study, involving 1536 trauma patients, identified exsanguination as the most frequent cause of early death [5].…”

“…In addition, post-traumatic bleeding is a leading cause of preventable death among injured patients [3–5]. A multicenter observational study, involving 1536 trauma patients, identified exsanguination as the most frequent cause of early death [5]. The same study, however, found TBI as the most common cause of delayed mortality and disability [5].…”

“…A multicenter observational study, involving 1536 trauma patients, identified exsanguination as the most frequent cause of early death [5]. The same study, however, found TBI as the most common cause of delayed mortality and disability [5]. Therefore, the combination of brain damage and extra-cranial injuries, causing bleeding, shock, and arterial hypotension, is especially challenging.…”

Injury-related deaths in the Ontario provincial trauma system: a retrospective population-based cohort analysis

“…Previous studies from the United States have generally been small or regional, with limited generalizability to the Canadian context because of differing patterns of injury (e.g., higher rates of penetrating injuries in the US), variations in health care system design and socioeconomic factors. 11 – 14 …”