The time of death after traumaBMJ 1995; 310 doi: http://dx.doi.org/10.1136/bmj.310.6993.1502 (Published 10 June 1995) Cite this as: BMJ 1995;310:1502
- Jonathan Wyatt, senior registrara,
- Diana Beard, central coordinator, Scottish Trauma Audit Groupa,
- Alasdair Gray, senior house officera,
- Anthony Busuttil, regius professora,
- Colin Robertson, consultantb
- a Directorate of Accident and Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW
- b Forensic Medicine Unit, University of Edinburgh, Edinburgh EH8 9AG
- Correspondence to: Mr Robertson.
- Accepted 21 March 1995
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.
Patients, methods, and results
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 the university department of forensic medicine. The time and mechanism of injury and the time of death were recorded. Postmortem examinations were performed in every case, and injury severity scores calculated, using the abbreviated injury scale, 1990 revision. The definition of trauma used was that previously used by Trunkey, allowing direct comparison.
There were 331 deaths following trauma, including 26 murders and 98 suicides. Of the victims, 253 (76%) died within one hour of injury; 248 of these died instantaneously and had unsurvivable injuries (abbreviated injury scale 6, injury severity score 75) or were found dead. The remaining five patients died at the scene or in transit to hospital. Seventy eight patients survived more than one hour after injury; 59 surviving for more than four hours. The table compares the timing of deaths after trauma in this study with the United States data.
In his analysis Trunkey suggested that deaths after trauma follow a trimodal distribution.2 The first and largest peak, comprising 50% of the total, is seen immediately, or within seconds of injury. The second peak, 30% of deaths, occurs up to four hours later, while the third comprises those 20% of patients who die after four hours.
Much significance has been placed on this temporal relation, particularly to the second peak.2 3 Many commentators believe that appropriate intervention for patients in this group offers the greatest potential for preventing unnecessary deaths.2 3 As a result, the provision and nature of prehospital and hospital trauma services have been profoundly affected, both in the United States and the United Kingdom. In particular, ambulance service paramedic training and the concept of trauma centres have received considerable attention.4 5
It is therefore relevant that three quarters of the patients in this study died immediately or were found dead at the scene. Furthermore, the subsequent deaths do not cluster together into the peaks previously described in north America. The accepted concept of a trimodal distribution of death after trauma does not apply in our area. This may be partly due to improvements in trauma care, resulting in fewer unnecessary deaths. Data from the Scottish trauma audit group for our region confirm that there are significantly more survivors after trauma than predicted from the United Kingdom dataset, but the numbers in this category are small and insufficient to affect the overall conclusions. A more important factor is likely to be the type of trauma seen.
If our results are mirrored throughout the United Kingdom, they necessitate a re-evaluation of pre-hospital and trauma care systems. Attempts to improve care for those who initially survive major trauma must continue, but our study emphasises that prevention offers the most cost effective and rational approach.
We thank Mr David Steedman and the Scottish Trauma Audit Group for advice and help with this study.