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

doi:10.1016/j.injury.2007.05.022

Injury

Volume 39, Issue 1, January 2008, Pages 102-106

https://doi.org/10.1016/j.injury.2007.05.022 Get rights and content

Summary

Objective

To determine whether the classical trimodal distribution of trauma deaths is still applicable in a contemporary urban New Zealand trauma system.

Methods

All trauma deaths in the greater Auckland region between 1 January 2004 and 31 December 2004 were identified and reviewed. Data was obtained from hospital trauma registries, coroner autopsy reports and police reports.

Results

There were 186 trauma deaths. The median age was 28.5 years and the median Injury Severity Score was 25.

The predominant mechanisms of injury were hanging (36%), motor vehicle crashes (31.7%), falls (9.7%), pedestrian–vehicle injury (5.4%), stabbing (4.3%), motorcycle crashes (3.2%), and pedestrian–train injury (2.2%).

Most deaths were from central nervous system injury (71.5%), haemorrhage (15.6%), and airway/ventilation compromise (3.8%). Multi-organ failure accounted for 1.6% of deaths.

Most deaths occurred in the pre-hospital setting (80.6%) with a gradual decrease thereafter.

Conclusion

There was a skew towards early deaths. The trimodal distribution of trauma deaths was not demonstrated in this group of patients.

Introduction

Studies into the epidemiology of trauma in the 1970s proposed a trimodal distribution of trauma deaths—immediate (within 1–2 h of injury), early (up to 4 h after injury), and late deaths (days to weeks after injury).1, 9 Of these three groups, early and late deaths could potentially be prevented by optimising post-injury management.

With improvements in trauma care in the last two decades, the trimodal distribution of trauma may no longer be applicable and several recent studies have failed to demonstrate such a trimodal distribution.3, 6

The aim of this population-based study is to identify the causes and timing of deaths in the Auckland region in 2004 and determine whether the trimodal distribution of deaths is still applicable in the modern urban New Zealand trauma setting.

Section snippets

Materials and methods

The greater Auckland region (population 1.15 million) is served by three major trauma hospitals—Auckland City Hospital, Starship Childrens Hospital and Middlemore Hospital. Pre-hospital care is initiated by a 111 call to a centralised ambulance despatch centre which sends the closest available ambulance with an appropriately skilled crew (based on information obtained from the 111 call) to the scene. The skill level of the ambulance crew may range from officers with first aid certification to

Results

There were a total of 186 deaths from trauma in the Auckland region in 2004. One hundred and thirty-nine (74.7%) were males. The median age of patients was 28.5 years (4 months to 94 years) with a mean age of 36.5 years. The median ISS was 25 (1–75).

Blunt trauma predominated. The most common mechanism of injury in our group of patients was hanging (36.0%)—all self-inflicted, followed by motor vehicle crashes (31.7%). Falls accounted for 18 deaths (9.7%), and pedestrian–vehicle injury for a

Discussion

The trimodal distribution of trauma deaths was first described by Trunkey in 1983 based on epidemiological studies on trauma in the 1970s.⁹

Since then, trauma systems have been improved and advances made in the inpatient management of trauma patients. Sauaia et al. reviewed trauma deaths in the Denver region in 1992 and did not demonstrate the classical trimodal pattern of trauma deaths from their data.⁶

In our group of patients, most died before arrival at hospital (80.6%), with a gradual

Conclusions

Deaths resulting from trauma in our study were predominantly in the pre-hospital phase. The trimodal distribution of deaths was not demonstrated in this group of patients. This may reflect improved post-injury care and is influenced by our inclusion criteria, but also emphasises the importance of injury prevention in reducing trauma related deaths.

Conflicts of interest statement

Nil.

Acknowledgement

The authors thank Mr. Rangi Dansey for assistance with collection of data.

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

Summary

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusions

Conflicts of interest statement

Acknowledgement

Am J Surg

J Am Coll Surg

Fatal trauma: the modal distribution of time to death is a function of patient demographics and regional resources

J Trauma