Jonathan P. Wyatt

The time of death after trauma

The pre-eminence of trauma as a cause of death in young adults in the United Kingdom is well established, but little is known about the temporal distribution of these deaths.1 The only complete data are from a frequently quoted paper, in which Trunkey described trauma deaths in San Francisco over two years.2 These data are nearly two decades old and come from a country where the causes of trauma and the system for dealing with it differ from those in the United Kingdom. All patients aged over 12 who died after trauma in the Lothian and Borders regions of Scotland between 1 February 1992 and 31 January 1994 were studied prospectively by the Scottish Trauma Audit Group and …

Fatal falls down stairs

Fatal falls down stairs in south-east Scotland were studied using prospectively collected data between 1992 and 1997. 51 individuals, comprising 27 men and 24 women with mean age 68.9 years, died following falls down stairs, 30 (59%) of which were unwitnessed. 43 (84%) individuals died following falls within their own homes. Overall, 27 (53%) fatal falls resulted in death at the scene of the accident. Analysis of injuries according to the Abbreviated Injury Scale yielded injury severity scores (ISS) of between 5 and 75, but only four individuals had injuries recognised to be unsurvivable (ISS = 75). Injury to the brain and/or spinal cord was responsible for the vast majority of most severe injuries. The results demonstrate that stairs represent a significant hazard for the elderly. Most of the deaths in the pre-hospital setting appeared to be more the result of the fact that the victim was alone and unable to summon assistance, rather than as a result of unsurvivable injuries. Consideration needs to be given to both how the safety of stairs can be improved and whether a particular elderly person can safely cope with stairs.

The association between seniority of Accident and Emergency doctor and outcome following trauma

The actual survival of patients treated following trauma in four Scottish Teaching hospitals during five years was compared with predicted survival according to TRISS analysis. The data were analysed according to the seniority of the Accident and Emergency (A&E) doctor treating each patient. The group of patients treated by a consultant had a significantly better outcome (p < 0.05) than the group of patients treated by junior doctors. Analysis of outcome according to the grade of junior A&E doctor suggested a step-wise improvement in outcome with seniority, thus supporting the concept that an improved outcome is associated with experience and seniority. These results support calls for A&E consultants to be increasingly involved in the management of patients with major trauma. Such increased involvement would require an increase in the number of A&E consultants.

Quantifying injury and predicting outcome after trauma

The Abbreviated Injury Scale (AIS), Injury Severity Scale and TRISS methodology comprise a mathematically sound system for the analysis of injuries and injured patients. This system is of value for research and audit and has potential applications in forensic medicine, such as its use as a tool to assist the classification and analysis of injuries sustained by those injured in mass disasters.

A comparison of fatal with non-fatal knife injuries in Edinburgh

Assault using a knife is a common problem in the United Kingdom. Between February 1992 and December 1996, 120 individuals died or received hospital treatment in Edinburgh after being assaulted with a knife. Twenty individuals (17%) died as a result of their injuries. Comparison of the survivors with non-survivors revealed both groups to have similar age and sex distributions, but those who died had significantly more severe injuries when scored according to the Abbreviated Injury Scale. Eight individuals died of unsurvivable chest injuries at the scene of the attack and of the remainder, only five reached hospital with signs of life. Analysis of hospital treatment using TRISS methodology revealed there to be two unexpected survivors and no unexpected deaths. The risk of death appears to depend mostly upon injuries sustained and also to a lesser extent upon other factors such as alcohol consumption and the presence of a bystander capable and willing to request emergency medical assistance. There does not appear to be much potential to save lives by improving hospital treatment for those assaulted with a knife in Edinburgh. Instead, greater focus needs to be placed upon rapid transfer to hospital and upon restricting the possession and use of knives.

HANGING DEATHS IN CHILDREN

Relatively little is known about death in children following hanging. This 12-year retrospective study in southeast Scotland revealed 12 such deaths among children <15 years of age, involving 10 boys and 2 girls. The rate of hanging deaths was 0.7 deaths/100,000 children/year and was equal to that from falls in children during this time period. The children who died following hanging were aged between 4 and 14 years. All 12 children were in cardiac arrest when found, and 11 were declared dead at the scene, demonstrating the limited potential to reduce the death rate through improved treatment. Scrutiny of the circumstances surrounding each death suggested that 6 of the deaths were accidents and 6 were suicides. There appears to be some, albeit limited, potential to prevent some hanging deaths in children through increased parental supervision, education, and restriction of access to ligatures.

Rate, causes and prevention of deaths from injuries in south-east Scotland

Data on all deaths after injuries in Lothian and Borders regions of south-east Scotland were collected prospectively over 2 years. Post-mortems were performed after all deaths and Injury Severity Scores (ISS) calculated. There were 331 deaths at a rate of 20 per 100,000 per year; of those who died 49 per cent were younger than 40 years and most were male; 37 per cent of deaths were caused by road traffic accidents, 16 per cent by falls and 15 per cent by hangings. Two hundred and forty-eight patients (75 per cent) were either dead when found or died instantly with unsurvivable injuries (ISS = 75). A further five patients died in the first hour after injury and before reaching hospital. Nineteen (7 per cent) died between 1 and 4 h after injury, 59 (17 per cent) died more than 4 h after. These results demonstrate the rate, causes and timing of deaths following injuries in one UK region. The pattern of these deaths differs markedly from that previously described in the US. There is no evidence to support the concept of a trimodal distribution of trauma deaths. The greatest potential to reduce the number of trauma deaths lies with prevention.

Timing of paediatric deaths after trauma

Trauma is the leading cause of death in children aged over 1 year.1 2 The government has identified this problem as worthy of special attention. The Health of the Nation sets a target of reducing the death rate for accidents in children by at least 33% by the year 2005, to no more than 4.5 per 100 000.2 The principal methods of reducing the death rate are either to improve treatment for those injured or to prevent the injuries. We examined the timing of death after injury for insight into the potential of each stratagem. The deaths of all children after injury in south east Scotland are investigated by the police and by postmortem examination under the direction of the procurator fiscal. We identified deaths following trauma in children aged less than 15 years in Lothian and …

Pedestrian deaths following collisions with heavy goods vehicles.

Pedestrian fatalities following collisions with heavy goods vehicles (‘lorries’) in south-east Scotland were studied between 1992 and 1998. Data sources included police and ambulance reports, forensic medicine records, hospital casenotes and the Scottish Trauma Audit Group database. All injuries were scored according to the Abbreviated Injury Scale, yielding Injury Severity Scores (ISS). Sixteen pedestrians (mean age 60.2 years) died after being hit by a lorry. Actions of pedestrians were implicated in causing all the collisions - four of which appeared to be suicides. Four of the apparently accidental deaths involved pedestrians with significant blood alcohol levels. Thirteen pedestrians were dead when found. Ten pedestrians had an ISS of 75, having a total of 13 injuries acknowledged to be unsurvivable (Abbreviated Injury Scale = 6), largely to the head and chest. The unsurvivable injuries reflect huge forces, explaining why only a small proportion of the pedestrians survived to hospital. There is little potential to reduce the number of deaths by improving hospital treatment, rather the focus needs to be directed towards injury prevention. Although pedestrians appeared to be responsible for the collisions, the results suggest it may be more feasible and effective to direct injury prevention measures towards lorry drivers.