Timing of paediatric deaths after traumaBMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7084.868 (Published 22 March 1997) Cite this as: BMJ 1997;314:868
- Jonathan Wyatt, senior registrara,
- Lorna McLeod, senior house officera,
- Thomas Beattie, consultanta,
- Diana Beard, national co-ordinatorb,
- Anthony Busuttil, regius professor of forensic medicinec,
- Colin Robertson, consultantd
- a Department of Accident and Emergency Medicine Royal Hospital for Sick Children Edinburgh EH9 1LF
- b Scottish Trauma Audit Group Royal Infirmary of Edinburgh Edinburgh EH3 9YW
- c Forensic Medicine Unit Medical School University of Edinburgh Edinburgh EH8 9AG
- d Department of Accident and Emergency Royal Infirmary Edinburgh EH3 9YW
- Correspondence to: Mr Wyatt
- Accepted 15 November 1996
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.
Subjects, methods, and results
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 Borders regions of south east Scotland during the 11 years 1985-95 from forensic medicine records and the records of the procurator fiscal. A cross check was performed against data from the registrar for deaths to confirm that the dataset was complete. The mechanism of injury and times of trauma and death were obtained from forensic medicine and the procurator fiscal's records and from police, ambulance, and hospital records. Injury severity scores were calculated for each child, using the 1990 revision of the abbreviated injury scale.3
A total of 138 children (84 boys, 54 girls) died after injury during the 11 years. The 1991 census showed 146 826 children aged less than 15 years for the region; hence the overall death rate was 8.5 per 100 000 children per year. The rate varied from year to year (9.5 (14 deaths) in 1985; 8.9 (13) in 1986; 6.1 (9) in 1987; 10.9 (16) in 1988; 7.5 (11) in 1989; 4.8 (7) in 1990; 18.4 (27) in 1991; 4.1 (6) in 1992; 7.5 (11) in 1993; 8.2 (12) in both 1994 and 1995), with no discernible trend.
The mechanisms of injury responsible, and time of death, are shown in table 1). Fifty seven of the 138 deaths (41%) occurred in preschool children (aged less than 5 years). Twenty of these had been left unsupervised in the presence of an obvious danger (access to matches, deep water, an open road, or an unguarded drop). Ninety nine children (72%) died within one hour of injury or were dead when found; 92 of these children showed no signs of life when the ambulance crew arrived at the scene. These included 40 children who had injuries considered to be unsurvivable (injury severity score=75) and 36 other children who were found dead after an unwitnessed incident.
Children continue to die after accidents with relatively predictable causes.2 In south east Scotland the death rate after trauma in children fluctuates somewhat from year to year, but the overall rate remains unacceptably high. To achieve the government target for 2005, the death rate in the region needs to be reduced by 47%.
Improving hospital treatment offers only limited potential for preventing some deaths of children in hospital after injury.4 Most children in this study, however, were either dead when found or died at the scene of the accident before receiving medical attention. The potential for improving survival by providing seriously injured children with earlier medical attention at the scene is difficult to quantify but seems to be limited, as most children either had unsurvivable injuries or were found dead after an unwitnessed incident. These results are in keeping with those relating to adults.5
As with adults, the greatest potential for reducing the number of children dying after trauma lies with introducing and implementing effective accident prevention measures. The high proportion of deaths related to road traffic accidents shows the need to concentrate efforts in this area. Research designed to identify appropriate accident prevention measures should be strongly encouraged and supported. The number of deaths from injury in children will not be reduced unless this is borne in mind and resources allocated appropriately.
We thank the Scottish Trauma Audit Group for help with this study.
Conflict of interest None.