ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10030-1428 |
Traumatic In-hospital Mortality: Where, How, and When Our Trauma Patients Die?
1,4Unidad de Trauma y Urgencias. Hospital Dr. Sótero del Río. Santiago de Chile; Departamento de Cirugía. Pontificia Universidad Católica de Chile. Santiago, Chile
2,3Unidad de Trauma y Urgencias. Hospital Dr. Sótero del Río. Santiago de Chile
Corresponding Author: Juan P Ramos, Unidad de Trauma y Urgencias. Hospital Dr. Sótero del Río. Santiago de Chile; Departamento de Cirugía. Pontificia Universidad Católica de Chile. Santiago, Chile, Phone: +5622354 6483, e-mail: jramos.med@gmail.com
Received: 22 April 2023; Accepted: 23 September 2023; Published on: 30 December 2023
ABSTRACT
Introduction: The analysis of traumatic mortality helps us evaluate critical points in the care of this type of patient, and its identification allows for changes and improvements in their treatment. This is of vital importance in places where there is no trauma system. This study aims to characterize the epidemiology of patients who died from trauma in a reference hospital for this type of patient.
Methodology: Retrospective and descriptive study that includes all patients who died from trauma over 15 admitted to the trauma registry between 2018 and 2021.
Results: A total of 174 patients who died from severe trauma and managed to receive hospital care were analyzed. The included patients represent an overall mortality of 3%. The primary mechanism of trauma was blunt 61 vs 39% penetrating. Around 44% of the total deaths were secondary to traffic accidents. The leading cause of death during the first hours of care was hemorrhage due to penetrating trauma. In addition, the sample highlights high mortality from traumatic brain injury (TBI) in the resuscitation area.
Conclusion: The epidemiological description of mortality due to severe trauma in a highly complex hospital allows the identification of critical points within care. In our cohort, the rapid mortality from penetrating trauma and the high mortality from TBI in the resuscitation area represent a lack of regionalization and a need to improve the prehospital system around a trauma system.
RESUMEN
Introducción: El análisis de la mortalidad traumática nos ayuda a evaluar puntos críticos dentro de la atención de este tipo de pacientes y su identificación posibilita cambios y mejoras en su tratamiento. Esto es de vital importancia en lugares en donde no se cuenta con un sistema de trauma. El presente estudio tiene por objetivo caracterizar la epidemiología de los pacientes fallecidos por trauma en un centro hospitalario de referencia para este tipo de pacientes.
Metodología: Estudio retrospectivo y descriptivo que incluye todos los pacientes fallecidos por trauma mayores de 15 años admitidos al registro de trauma entre 2018 y el 2021.
Resultados: Se analizaron 174 pacientes fallecidos por trauma grave, que alcanzaron a recibir atención hospitalaria. Los pacientes incluidos, representan una mortalidad global del 3%. El principal mecanismo del trauma fue contuso 61% versus un 39% penetrante. El 44% del total de muertes, fue secundario a accidentes de tránsito. La principal causa de muerte durante las primeras horas de atención fue por hemorragia y secundario a trauma penetrante. En la muestra destaca una alta mortalidad del trauma encéfalo-craneano (TEC) en el area de reanimación.
Conclusión: La descripción epidemiológica de la mortalidad secundaria a trauma grave en un centro hospitalario de alta complejidad, permite identificar puntos críticos dentro de la atención. En el centro analizado la rápida mortalidad por trauma penetrante y la alta mortalidad por TEC en el area de resucitación, representan una falta de regionalización y una necesidad de mejora del sistema prehospitalario en torno a un sistema de trauma.
How to cite this article: Ramos JP, Neumann M, Zinco A, et al. Traumatic In-hospital Mortality: Where, How, and When Our Trauma Patients Die? Panam J Trauma Crit Care Emerg Surg 2023;12(3):97–101.
Source of support: Nil
Conflict of interest: None
Keywords: Major trauma, Trauma death, Trauma registry, Trauma system
Palabras Clave: Trauma mayor, Mortalidad traumática, Registro de trauma, Sistema de trauma
INTRODUCTION
Trauma continues to be the leading cause of mortality and disability in people between 1 and 44 years old.1 The epidemiology of trauma deaths has been described since the 70s, mainly in Trunkey’s studies with the trimodal distribution of trauma death.2 Immediate or prehospital, early death within the first 4 hours of arrival at the hospital, late deaths when they occur days or weeks later. This leads to interventions to optimize the management of these patients, especially from the point of view of prevention, prehospital, and early intrahospital management, to reduce avoidable mortality.
Multiple studies suggest that over time and with changes in the management strategies of these patients, such as resuscitative damage control, strengthening of the prehospital system, and the development of trauma systems, the distribution of this mortality has changed.3–6 For this reason, the analysis of intrahospital mortality makes it possible to distinguish the areas and the moment of patient care where it is necessary to optimize the management strategy and implement necessary measures, such as training, redistribution or request of resources, and establishment of protocols, among others. However, the different variables involved in traumatic mortality are unknown in countries without trauma systems or registries.
In Latin America, there are no trauma systems; in particular, in Chile, there are no specialized trauma centers for the optimal management of this type of patient. In 2017, in Santiago de Chile, at Dr Sótero del Río Hospital, a trauma registry was created, which demonstrated the importance of concentrating human and material resources on traumatic pathology and later allowed the organization of the first trauma and emergency teams in the country.
The objective of this study was to analyze the time, place, and primary cause of mortality of multiple trauma patients admitted to Dr Sótero del Río Hospital in Santiago de Chile from 2018 to 2021.
PATIENTS AND METHODS
Study Site
Although we do not have trauma systems or trauma centers in Chile, Dr Sotero del Rio Hospital, since 2017, has functioned as a trauma reference center for a population of 2 million inhabitants within Santiago. This center has 900 beds and all the resources to care for a trauma patient, including surgical specialties, protocols, a trauma committee, and a trauma team exclusively dedicated to these patients and 24/7 availability of tomography, angiography, and endovascular treatment. However, there is no regionalization for these types of patients, being referred to the nearest hospital to provide primary care.
Data Collection
A retrospective review of the patients who died due to trauma included in the trauma registry of the Southeast Metropolitan Health Service from 2018 to 2021 was carried out. Causes such as burns, hanging, electrocution, and patients under 18 or with death criteria on arrival were excluded. In addition, the following variables were included in the patient analysis: age, sex, comorbidities, mechanism of injury, injury severity score (ISS), vital signs and admission Glasgow Coma Scale, need for intubation of admission, computer tomography or focus assessment sonography for trauma of admission, the requirement for surgery, need for transfusions, days of hospitalization, and place of death. The time of death is determined from the time the patient arrives at the trauma box, which is considered time zero, and the place of death within the intrahospital system (trauma bay, operating room, and critical patient unit) is recorded when the team of trauma determines an order not to resuscitate or to stop resuscitation maneuvers. Each mortality within the hospital system was attributed to a primary cause immediately after death by the trauma team and was classified into hemorrhagic shock, traumatic brain injury (TBI), multiple organ failure, cardiac tamponade, and unexpected causes.
Statistical Analysis
The data were analyzed in a grouped manner according to the mechanism of trauma, place, and time of intrahospital death. We chose the North American trauma system as a benchmark, and the results found by Callcut et al.7 in their 2019 report were used to compare the data in graphical form. Continuous variables were reported as medians and interquartile ranges. Categorical variables were compared as Chi-squared and t-test. A Kaplan–Meier curve based on the time of death was created using the GraphPad program (GraphPad Software, Inc., La Jolla, California, United States of America). A significance level of p < 0.05 was used.
RESULTS
Demographic Characteristics
During the study period, 5,800 patients were entered into the trauma registry. Of these, 58.6% correspond to blunt trauma and 27.3% to penetrating trauma. The patients who died due to trauma who met the inclusion criteria were 174, which gives an overall mortality of 3%. A total of 107 patients died from blunt trauma (61.5%) and 67 from penetrating trauma (38.5%). Among the demographic characteristics, it is worth noting that the group that died from blunt trauma has an average age of 53, and the penetrating trauma group is 33 (Table 1).
| Penetrating (n = 67) | Blunt (n = 107) | p-value | ||
|---|---|---|---|---|
| Age (median, interquartile range) | 33 (16–73) | 53 (15–94) | <0.0001 | |
| Male (n) | 59 | 77 | 0.0029 | |
| Mechanism (n) | ||||
| Gunshot wound | 48 | |||
| Stab wound | 19 | |||
| MVC-MCC | 78 | |||
| Fall | 18 | |||
| Others | 11 | |||
| TBI (n) | 15 | 72 | <0.0001 | |
| Median day of death | 3 | 12 | 0.0009 | |
| ED thoracotomy (n) | 10 | 10 | 0.261 | |
| ISS | 25,7 | 25 | 0.751 | |
| Surgery | 45 | 64 | 0.329 | |
| Massive transfusion | 27 (40.2%) | 30 (28%) | 0.093 | |
TBI, traumatic brain injury; ISS, injury severity score; MVC-MCC, motor vehicle collision-motorcycle collision
Patients who die from penetrating trauma have an average hospital stay of 3 days (1–58), and those who die from blunt trauma have 12 days (1–154). The ISS was similar for both the penetrating and blunt trauma groups, and the same number of resuscitation thoracotomies were performed. In the group of patients who died due to blunt trauma, 64 surgeries were performed, while in the penetrating trauma group, 45 were performed. Around 32.7% of the patients received a massive transfusion, with a higher proportion in the penetrating mechanism (40.2%) than in the blunt trauma mechanism (28%). This difference not being significant.
Causes of Mortality
Within the series (Table 2), TBI stands out as the leading cause of mortality (44.8%), with blunt trauma as the primary mechanism (80 vs 19.2%). Hemorrhagic shock is the second cause of mortality (39.6%) and occurs more frequently in penetrating trauma (68 vs 22%). Other causes of mortality were cardiac tamponade, septic shock, and pulmonary embolism, representing the third cause of mortality. A minimum of patients account for mortality from hemorrhagic shock in addition to TBI (1.7%).
| Cause of death | Penetrating | Blunt | Total | |
|---|---|---|---|---|
| n = 67 | n = 107 | (n = 174) | p-value | |
| TBI | 15 (19.2%) | 63 (80%) | 78 (44.8%) | <0.0001 |
| HS | 47 (68%) | 22 (22%) | 69 (39.6%%) | <0.0001 |
| TBI HS | 1 (33%) | 2 (66%) | 3 (1.7%) | 0.852 |
| Other | 4 (17%) | 20 (83%) | 24 (13.7%) | 0.017 |
HS, hemorrhagic shock; TBI, traumatic brain injury
Mortality Time
In this series, TBI is the main cause of death (51.4%) in patients who presented cardiac arrest in the Emergency Department (ED), and the second cause in this group is hemorrhagic shock (27%). Regarding the patients who died during the first 24 hours of hospitalization, we found hemorrhagic shock as the primary cause at 73% and TBI at 20.6%. Patients who died after 24 hours of hospitalization are mainly due to TBI in 61.2% and hemorrhagic shock in 17.6% (Fig. 1).
Fig. 1: Cause of death according to time
In Figure 2, we can see that patients with penetrating trauma died earlier during their hospitalization than patients with blunt trauma (79.1 vs 54% on day 1 and a p-value of <0.0001).
Fig. 2: Kaplan–Meier survival time for penetrating and blunt trauma
Place of Death
Within the series, 22.4% of blunt trauma died in the ED, and 19.4% of penetrating trauma died without significant difference. In the operating room, we observed higher mortality in the penetrating trauma group (41.8%, p < 0.0001) and in the critical care unit in the blunt trauma group with 67.3% (p = 0.0002) (Table 3).
| Penetrating | Blunt | Total | p-value | |
|---|---|---|---|---|
| n = 67 | n = 107 | n = 174 | ||
| ED | 13 (19.4%) | 24 (22.4%) | 37 (21.2%) | 0.634 |
| Operating room | 28 (41.8%) | 11 (10.3%) | 39 (22.4%) | <0.0001 |
| Intensive care unit | 26 (39%) | 72 (67.3%) | 98 (56.3%) | 0.0002 |
DISCUSSION
Trauma continues to be a public health problem, and in most Latin American countries, its specific results in terms of mortality are unknown due to the lack of a trauma system, centers, and registries. This study represents the most extensive analysis of hospital trauma deaths in Chile, based on a center with all the resources to care for a trauma patient. There are multiple reports on the epidemiology of patients who die from trauma in their care.8–10 However, this information is scarce in places without an established trauma system.11
When analyzing the causes of mortality in our series, we found TBI in the first place, determined mainly by a blunt trauma mechanism secondary to a traffic accident. Hemorrhagic shock is our second cause of mortality, with 39.6% mainly due to penetrating causes and in young individuals. These results are similar to those found in the literature.4,7,12–15
When analyzing the in-hospital death time, according to etiology, we found TBI determined mainly by blunt trauma as the leading cause of death in the ED, with 51.4%. It is essential to highlight that this result differs from the one presented by Callcutt et al.,7 where the main cause of mortality in this place is hemorrhagic shock with 44.7% (Fig. 1). This can be explained by the large volume of patients that our hospital receives, as it is a reference center for TBI for a population of 1.5 million inhabitants. Because there is no regionalization for this type of patient, a patient with severe blunt trauma can receive the first attention in a hospital without all the resources, which results in a late referral to our center.
Also, the underdevelopment of a prehospital system around a robust trauma system may affect these results. When we analyze mortality during the first 24 hours of admittance, we find bleeding as the primary cause, 73% of which occurs in the operating room or the immediate postoperative period. This result is inconsistent with other series, where the same cause determines a mortality of 39.1% in this same period, as shown in Figure 1.
There may be many factors that explain this difference in mortality between our series and North American patients; among them may be the protocolization of each center, the shorter transfer time to a level 1 trauma center, greater availability of resources, etc., which allows for lower mortality due to hemorrhagic shock within the first 24 hours. When analyzing late mortality, after 24 hours, we found TBI as the primary etiology and predominantly in the critical care unit, a result similar to that found in other series.7
By analyzing the type of trauma and its in-hospital survival time, we could see that mortality determined by the penetrating mechanism is very early within health care, compared to blunt trauma. This determines that 79.1% of the patients who died from penetrating trauma did so during the first day of hospitalization. This result differs from that found in the literature, where mortality due to this mechanism in the first days is not as marked and is similar to blunt trauma.7,12 Although multiple determinants may be involved, we believe that one of the main factors that may explain these results is the difference between the prompt and timely treatment required for penetrating trauma and that which can be provided in a mature trauma system, compared to the sample analyzed where there is no established trauma system, and the prehospital transfer system is deficient, determining extremely early mortality from penetrating trauma.
The analysis and evaluation of trauma deaths, in terms of their etiology, place, and time, can identify critical areas within the care system that provide opportunities for changes, such as implementing training, creating research, and distributing resources.15 For example, in our series, given the early mortality from penetrating trauma, it is necessary to implement a prehospital system with early transport and training for staff to apply “stop the bleed” strategies. This would impact the 27% who present cardiorespiratory arrest in the resuscitation area due to hemorrhagic shock and would eventually decrease mortality within the first 24 hours of care. Regarding the high mortality due to TBI found in the first hours of care (resuscitation area), it is central to implement a regionalization of this type of patient, so any patient who suffers trauma with a high-energy mechanism should be transferred to the center that has all the resources for their care, which is not necessarily the closest one.
Some limitations in our work need to be mentioned. First, there is no record of prehospital time, so the implication of this factor in the early mortality observed in the series can only be deduced. However, this is validated in the clinical experience of the study participants. Second, there is no final autopsy to determine the cause of death with certainty; instead, it was deduced by the treating team at the time of the patient’s death, taking into account the clinical variables. Third, there is no information on the patients who died at the event’s site and were not transferred to the hospital; therefore, overall mortality is not known.
CONCLUSION
Although the causes of mortality are similar to those found in the literature, hemorrhagic shock due to penetrating trauma presents extremely early mortality within hospital care, and TBI, due to blunt trauma, has high mortality in the resuscitation area. Therefore, it is necessary to implement a trauma system that optimizes transfer times and regionalizes this type of patient to transfer a patient with severe trauma to the most appropriate center that offers the best survival options.
ORCID
Juan P Ramos https://orcid.org/0000-0001-9698-7572
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