Clinical surgery–American
Trauma deaths in the first hour: are they all unsalvageable injuries?

https://doi.org/10.1016/j.amjsurg.2006.09.010Get rights and content

Abstract

Background

With the advent of trauma systems, time to definitive care has been decreased. We hypothesized that a subset of patients who are in extremis from the time of prehospital transport to arrival at the trauma center, and who ultimately die early after arrival, may in fact have a potentially salvageable single-organ injury.

Methods

We reviewed all deaths that occurred in the first hour after hospital admission. Trauma registry, medical records, and autopsy reports for 556 patients were evaluated.

Results

The median time to arrival was 39 minutes, and the median Injury Severity Score was 29. Blunt injuries (53%) were most commonly auto-accident injuries (134 of 285 patients; 47%). Penetrating wounds (42%) were mostly gunshot wounds to the chest (73 of 233 patients; 31%). For patients with initial vital signs, the most common cause of death was isolated brain injury (26 patients; 28%). Possibly survivable injuries (single organ or vessel) occurred in 35 (38%) patients, of which 4 were isolated spleen injuries (4%).

Conclusions

Some patients with potentially survivable single organ injuries did not have associated head injuries. An aggressive approach is warranted on patients with detectable vital signs on at least one occasion in the field but who arrive at the trauma center in extremis.

Section snippets

Study design, setting, and inclusion criteria

After receiving Institutional Review Board approval, we reviewed our trauma registry for all deaths that occurred within the first hour after admission at Ryder Trauma Center during the 5-year period from January 1, 1995, to February 28, 2000. Ryder Trauma Center is part of a statewide trauma system and was already well developed by 1995, including helicopter services from 1986. Only Advanced Life Support–trained EMS paramedics and flight crew flew the helicopters and drove the ambulances for

Characteristics of the study cohort

There were 556 deaths during the study period, and 65 of these patients did not have a full autopsy report for data retrieval. In Fig. 1, the analysis of the 556 study patients by completeness of data and presence or absence of vital signs is shown.

Mean age was 39 years, and there were 49% white, 39% black, and 12% Hispanic patients. Men accounted for 78% of the population, and the mean length of resuscitation efforts from the time of hospital admission was 10.3 minutes (SD [mean] = .5

Limitations

Because our study was retrospective in design it has a number of inherent weaknesses. First, any investigation of time to death is biased by the health personnel’s intrinsic definition of declaration of death. For example, patients with similar injuries or conditions at time of arrival at the trauma center may or may not be pronounced dead at the same time or in the same fashion by different health care providers. Second, the autopsy information is retrieved by a medically trained health care

Comments

Early death is caused by a broad spectrum of injuries, with head injury being the main cause of early death for patients with and without vital signs at the scene. Vessel disruption was also a major cause for both groups of patients. Previously published literature on the epidemiology of trauma death also reported head injury, followed by vascular injury, as the main causes of death [1], [8], [9], [12], [13], [14], [15].

Many investigators have shown that most deaths occur within the first 24

References (25)

  • D.D. Trunkey

    Trauma

    Sci Am

    (1983)
  • J. Wyatt et al.

    The time of death after trauma

    Br Med J

    (1995)
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