Trauma Deaths Research Articles

A sudden death, an aortic rupture, and an unexpected cause: a report about suspected child abuse.

All unexpected deaths of children require an autopsy to determine the cause of death. In cases of aortic rupture, the immediate cause of death is easily identified at autopsy. Although the majority of aortic ruptures are caused by high-energy trauma, other causes should not be missed.We present and discuss the case of a 29-month-old child who died suddenly at home. Her recent medical history and the ecchymotic lesions observed on external examination of the body appeared potentially suspicious of physical abuse. The autopsy concluded that death was due to complete rupture of the abdominal aorta with associated vertebral disjunction. At first glance, the overall forensic picture could suggest a traumatic death. However, careful inspection of the retroperitoneum revealed a discrete atypical mass of infiltrative tissue within the hematoma. Histopathological examinations confirmed tumor proliferation of the soft tissues, triggering vascular and spinal injuries. Other paraneoplastic elements or metastases were ultimately revealed (orbital and subcutaneous). Overall, this was a rare and fatal case of abdominal aortic rupture induced by tumors. Due to the mechanisms and the forces needed to cause vertebral dislocations and aortic rupture, the combination of the two is highly suggestive of child abuse when an accidental traumatic history is absent or inconsistent with the injuries. Nevertheless, this case illustrates the importance of a systematic and rigorous forensic examination, rather than ignoring other possible diagnoses.

Can computed tomography replace or supplement autopsy?

Postmortem computed tomography (PMCT) has been integrated into the practice of many forensic pathologists. To evaluate the utility of PMCT in supplementing and/or supplanting medicolegal autopsy, we conducted a prospective double-blind comparison of abnormal findings reported by the autopsy pathologist with those reported by a radiologist reviewing the PMCT. We reviewed 890 cases: 167 with blunt force injury (BFI), 63 with pediatric trauma (under 5 years), 203 firearm injuries, and 457 drug poisoning deaths. Autopsy and radiology reports were coded using the Abbreviated Injury Scale and abnormal findings and cause of death (COD) were compared for congruence in consensus conferences with novel pathologists and radiologists. Overall sensitivity for recognizing abnormal findings was 71% for PMCT and 74.6% for autopsy. Sensitivities for PMCT/autopsy were 74%/73.1% for BFI, 61.5%/71.4% for pediatric trauma, 84.9%/83.7% for firearm injuries, and 56.5%/66.4% for drug poisoning deaths. COD assigned by reviewing PMCT/autopsy was correct in 88%/95.8% of BFI cases, 99%/99.5% of firearm fatalities, 82.5%/98.5% of pediatric trauma deaths, and 84%/100% of drug poisoning deaths of individuals younger than 50. Both autopsy and PMCT were imperfect in recognizing injuries. However, both methods identified the most important findings and are sufficient to establish COD in cases of BFI, pediatric trauma, firearm injuries and drug poisoning in individuals younger than 50. Ideally, all forensic pathologists would have access to a CT scanner and a consulting radiologist. This would allow a flexible approach that meets the diagnostic needs of each case and best serves decedents' families and other stakeholders.

COVID-19 in Vietnam and its impact on road trauma: A national data review.

Despite significant improvement in the last decade, road trauma remains a significant contributor to deaths in Vietnam. The COVID-19 pandemic necessitated public health measures which had an unforeseen benefit on road trauma in high income countries. We investigate if this reduction was also seen in a low to middle income country, Vietnam. Our aim was to investigate how the COVID-19 pandemic, and the government policies to address it, impacted on road trauma fatalities in Vietnam. We also compared this impact with other government policies intended to road trauma in the preceding 14 years (2007 to 2020). COVID-19 data was extracted from the Vietnamese Ministry of Health (MoH) database. Road traffic deaths from 2007 to 2021 were derived from the Vietnamese General Statistical Office (GSO). We used Stata software 17 for statistical analysis. Poisson regression modelling, with the logarithm of the national population of Vietnam of each year included as an offset, was used to estimate trends in rates of road fatalities from the annual national mortality data for the period 2007-2021. The actual change in road traffic mortality in 2021 was compared with calculated figures to demonstrate the effect of COVID-19 on road trauma fatalities. We also compared this impact with other government road toll reduction policies for 14 years (2007 to 2020). Between 2007 and 2020 the number of annual road traffic deaths had more than halved from 15.3 to 7.0 per 100,000, an average reduction of 5.4% per annum. We estimated that the road traffic mortality rate declined by 12.1% (95% CI 8.9 to 15.3%) in 2021 relative to trend. The actual number of road trauma deaths fell by 16.4%. This reduction was largely seen from August to October 2021 when lockdown and social distancing were in force. In 2021, the road traffic death reduction in Vietnam was 3 times greater than the trend over the preceding 14 years. The public heath response to the COVID-19 pandemic in Vietnam was associated with a third of this reduction. It can thus be reasonably concluded that government policies to address the COVID-19 pandemic resulted in a 4.3% decrease of road traffic deaths in 2021. This has been observed in High-Income Countries but was demonstrated by us for the first time in a Low- and Middle-Income Country.

Kidney Transplant Practice in Pandemic Times: Lessons Learned for the Future.

Kidney Transplant Practice in Pandemic Times: Lessons Learned for the Future.

Availability of bereavement support following traumatic pediatric death in a large metropolitan area

Following an unexpected pediatric death, survivors undergo unique trauma. Medical examiners (MEs) evaluate most of these deaths. We evaluated the bereavement support available to survivors in the Chicagoland area following a pediatric death. We had two goals: to characterize the available bereavement support options and compare the locations (by zip code) of support groups with the locations (by zip code) in which pediatric ME cases occurred. We identified 48 organizations that provided bereavement support services at 74 locations in the summer and fall of 2020. Locations by zip codes in which the largest number of ME cases occurred did not have support groups. Locations in which more ME cases occurred generally had lower-income populations and a greater proportion of Black or Hispanic residents. Bereavement support following pediatric death is inadequate and unevenly distributed across the Chicagoland area.

Comparing the Effects of Low-Dose Ketamine, Fentanyl, and Morphine on Hemorrhagic Tolerance and Analgesia in Humans

Hemorrhage is a leading cause of preventable battlefield and civilian trauma deaths. Ketamine, fentanyl, and morphine are recommended analgesics for use in the prehospital (i.e., field) setting to reduce pain. However, it is unknown whether any of these analgesics reduce hemorrhagic tolerance in humans. We tested the hypothesis that fentanyl (75 µg) and morphine (5 mg), but not ketamine (20 mg), would reduce tolerance to simulated hemorrhage in conscious humans. Each of the three analgesics was evaluated independently among different cohorts of healthy adults in a randomized, crossover (within drug/placebo comparison), placebo-controlled fashion using doses derived from the Tactical Combat Casualty Care Guidelines for Medical Personnel. One minute after an intravenous infusion of the analgesic or placebo (saline), we employed a pre-syncopal limited progressive lower-body negative pressure (LBNP) protocol to determine hemorrhagic tolerance. Hemorrhagic tolerance was quantified as a cumulative stress index (CSI), which is the sum of products of the LBNP and the duration (e.g., [40 mmHg x 3 min] + [50 mmHg x 3 min] …). Compared with ketamine (p = 0.002 post hoc result) and fentanyl (p = 0.02 post hoc result), morphine reduced the CSI (ketamine (n = 30): 99 [73–139], fentanyl (n = 28): 95 [68–130], morphine (n = 30): 62 [35–85]; values expressed as a % of the respective placebo trial’s CSI; median [IQR]; Kruskal-Wallis test p = 0.002). Morphine-induced reductions in tolerance to central hypovolemia were not well explained by a prediction model including biological sex, body mass, and age (R2=0.05, p = 0.74). These experimental data demonstrate that morphine reduces tolerance to simulated hemorrhage while fentanyl and ketamine do not affect tolerance. Thus, these laboratory-based data, captured via simulated hemorrhage, suggest that morphine should not be used for a hemorrhaging individual in the prehospital setting.

The utility of histology in assessing the cause of death in medico-legal autopsies in selected trauma deaths: Suspension-, immersion-, fire-, and traffic-related.

The goal of a medico-legal autopsy is primarily to determine the cause and manner of death. To this end, the pathologist often uses auxiliary analyses, including histology. However, the utility of routine histology in all medico-legal autopsies is unknown. Earlier studies on the utility of routine histology have shown inconsistent effects, with some studies recommending it and others rejecting it. To study the degree to which histology informs on the underlying cause of death, we sent autopsy reports from suspension-, immersion-, fire-, and traffic-related deaths to senior board-certified forensic pathologists and had them assess the cause of death, first without knowledge of the histological findings and then with knowledge thereof. Fifty cases were identified in each of four subgroups: fire-, immersion-, suspension-, and traffic-related deaths. The autopsy reports were anonymized, and the histological findings and conclusions were removed. Two board-certified forensic pathologists independently reviewed the reports in each subgroup and assessed the manner and underlying cause of death (including their certainty of this assessment on a five-level scale) with and without access to histological findings. The probability of changing the underlying cause of death posthistology was low in all study groups. There was a slight increase in the degree of certainty posthistology in cases where the underlying cause of death was not changed, but only when the antehistology certainty was low. Our results suggest that histology does not meaningfully inform on the underlying cause of death in suspension-, immersion-, fire-, and traffic-related deaths except when antehistology certainty is low.

Determining the Association Between Emergency Department Crowding and Debriefing After Pediatric Trauma Resuscitations.

Debriefing in the pediatric emergency department (PED) is an invaluable tool to improve team well-being, communication, and performance. Despite evidence, surveys have reported heavy workload as a barrier to debriefing leading to missed opportunities for improvement in an already busy ED. The study aims to determine the association between the incidence of debriefing after pediatric trauma resuscitations and PED crowding. A total of 491 Trauma One activations in Riley Children's Hospital Pediatric Emergency Department that presented between April 2018 to December 2019 were included in the study. Debriefing documentations, patient demographics, time and date of presentation, mechanism of injury, injury severity score, disposition from PED, and length of stay (LOS) were collected and analyzed. The National Emergency Department Overcrowding Scale score at arrival, Average LOS, total PED census, total PED waiting room census, and rates of left without being seen were compared between groups. Of 491 Trauma One activations presented to our PED, 50 (10%) trauma evaluations had documented debriefing. The National Emergency Department Overcrowding Scale score at presentation was significantly lower in those with debriefing versus without debriefing. In addition, the PED hourly census, waiting room census, average LOS, and left without being seen were also significantly lower in the group with debriefing. In addition, trauma cases with debriefing had a higher proportion of patients with profound injuries and discharges to the morgue. Pediatric emergency department crowding is a significant barrier to debriefing after trauma resuscitations. However, profound injuries and traumatic pediatric deaths remain the strongest predictors in conducting debriefing regardless of PED crowding status.

Tourniquets, types and techniques in emergency prehospital care: A narrative review.

Massive uncontrolled hemorrhage is an important cause of preventable death in trauma. Therefore, applying an arterial tourniquet (TQ) is recommended as a pre-hospital measure to control bleeding after severe traumatic bleeding. Limb TQ applies circumferential compression proximally to the injury site to compress the arteries, resulting in blood flow and consequently hemorrhage interruption. The use of commercial tourniquets (C-TQ), which are designed, tested, and registered to control hemorrhages in pre-hospital care, is a consensus. However, they are still uncommon in many prehospital emergency services and the overall level of evidence in most studies is low. This narrative review aimed to characterize the importance of tourniquets use in prehospital emergency care and its application techniques. Furthermore, it proposes to stimulate the development of new devices, more accessible and easier to use, to suggest new directions of studies and medical education demands, with manikin and simulation development.

Risk of Harm in Needle Decompression for Tension Pneumothorax.

Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site. Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of =30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests. The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79). The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.

Usefulness of virtual autopsy in diagnosing pathologies in the paediatric population: A systematic review.

Virtual autopsy is a non-invasive/minimally invasive method for conducting an autopsy, with the assistance of imaging techniques. We aim to review the benefits of virtual autopsy in detecting pathologies in the paediatric population. The procedure adhered to Institute of Medicine and Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Seven databases including MEDLINE and SCOPUS were searched for articles published 2010-2020 worldwide in English. A narrative synthesis of the findings of included studies was carried out to discuss and summarize the results of the review. From 686 studies on paediatric deaths, 23 met selection/quality criteria. Virtual autopsy was better than conventional autopsy in detecting skeletal lesions and bullet trajectory, thus a crucial tool in the investigation of traumatic and firearm deaths. Virtual autopsy was superior to conventional autopsy in identifying the point of bleeding in postoperative deaths and objectively quantifying air/fluid in body cavities. Virtual autopsy was a useful adjunct for detecting pulmonary thrombo-embolism, foreign body aspiration, drowning and metastatic malignancies. The use of non-contrast imaging in investigating natural paediatric deaths did not offer more information than conventional autopsy. Misinterpretation of normal post-mortem changes as pathological findings was another disadvantage of virtual autopsy leading to erroneous conclusions. But accuracy may be improved with contrast enhancement and post-mortem magnetic resonance imaging. Virtual autopsy is a crucial tool in the investigation of traumatic and firearm deaths in the paediatric population. Virtual autopsy will be useful as an adjunct to conventional autopsy in asphyxial deaths, stillbirths and decomposed bodies. Virtual autopsy has limited value in differentiating antemortem and post-mortem changes with the added risk of misinterpretations, therefore should be used with caution in natural deaths.

Relation of the Lunar Cycle and Trauma Deaths in Tehran over 10 Years.

Relation of the Lunar Cycle and Trauma Deaths in Tehran over 10 Years.

Post-mortem Imaging of Brain/Spine Injuries: The Importance of a Comprehensive Forensic Approach.

In forensic investigations, the limitations of the traditional purely autoptic approach can be overcome through post-mortem imaging (virtopsy). Virtospy has several applications to the investigation of brain and spinal injuries, whose analysis can be of forensic interest, especially in cases of suspected malpractice. In this scoping review, we briefly describe the main applications of the two most common post-mortem radiological techniques (computed tomography (CT) and magnetic resonance imaging (MRI)) to the forensic investigation of brain and spinal injuries in cases of medical malpractice or traumatic (accidental/homicidal/suicidal) deaths. Although CT represents the traditional approach to post-mortem imaging, MRI is proving to be a valuable tool to investigate brain and spinal injuries and lesions. These post-mortem radiological techniques can also be used to guide the surgeons in simulated surgical procedures on corpses in the context of training programs, thus helping operators to improve technical and non-technical skills and to reduce the risk of avoidable errors.

Study of Epidemiological Characteristics of Fatal Injuries Using Death Registry Data in Georgia.

This study aimed to evaluate epidemiological aspects of fatal injuries in Georgia. This was a retrospective, descriptive study that included all traumatic injury deaths in Georgia from January 1 to December 31, 2018. The National Center for Disease Control and Public Health of Georgia's Electronic Death Register database was utilized in this research. Of the study fatal injuries, 74% (n=1489) were males. 74% (n=1480) of all fatal injuries were caused by unintentional injuries. Road traffic accidents (25%, n=511) and falls (16%, n=322) were the primary causes of mortality. During the research year, the number of Years of life lost (YLL) was associated with injuries and was increased to 58172 for both sexes (rate per 1000 population: 15.6). Most of the years were lost in the age group of 25-29 years (7515.37). Road traffic deaths accounted for 30% (17613.50) of YLL. Injuries are still a major public health problem in Georgia. In 2018, 2012 individuals died from injuries across the country. However, mortality and YLL rates of injury varied by age and cause of injury. To prevent injury-related mortality, it is crucial to conduct ongoing research on high-risk populations.

Retrospective autopsy-based survey of fatal traumatic brain injuries in Benin City, Nigeria

Background: Traumatic brain injury (TBI) is major cause of death in young adults. It results from external force to the head causing injury to the contents of the skull with or without damage to the skull itself.
 Aims and objectives: To describe the autopsy findings in patients with Traumatic brain injuries.Materials and Methods: A Retrospective Study of findings in patients who suffered Traumatic Brain Injuries as seen at autopsy. The historical and autopsy data of all Traumatic brain injury patients whose bodies were received between 2011 and 2021 were analyzed.
 Results: TBIs account for 66.7% of traumatic deaths in our institution. Male to female ratio was 1:0.22, and mean age was 39.30±16.65 years. The most common cause of TBI was road traffic accidents (90.9%), with gunshots (5.6%) as a distant second. Intracranial hemorrhages were present in 99.6% of cases and almost all (98.8%) died as a result of Raised Intracranial pressure associated with intracranial hemorrhage. The most common pattern was Subdural hemorrhage (62.65%); followed by Subarachnoid hemorrhage (52.35%); Intraparenchymal hemorrhage (40.88%), Epidural hemorrhage (18.24%); and intraventricular hemorrhage (9.71%). Skull fractures were present in 41.6% of cases. 
 Conclusion: RTA is the most common cause of traumatic brain injury in our study and the leading cause of traumatic deaths. Multiple injuries appears to contribute less to mortality amongst our TBI patients but this may be due to under reporting of injuries found in polytraumatized patients. Morbidity and mortality due to TBI, and trauma in general, will be reduced by improving road safety, and functional protocols for emergency and prehospital care of trauma patients.

Understanding Regional Trauma Centers and managing a trauma care system in South Korea: a systematic review.

The Korean government initiated a plan to designate and establish Regional Trauma Centers to reduce the preventable trauma death rate to <20% so as to be on par with advanced countries by 2020. This initiative was undertaken because the reported preventable trauma death rate was close to 40% in South Korea from 1997 to 2009. This review aimed to provide an overview of these Regional Trauma Centers and discuss further development of the trauma care system to assess its performance. As of September 2021, 15 Regional Trauma Centers had been established through a metropolitan-based designation process. Each center has been equipped with Level-I facilities. These Regional Trauma Centers have had 2 positive effects; namely, an increase in the number of severely injured patients attending these centers and a decrease in the national preventable trauma death rate from 30.5% in 2015 to 19.9% in 2017. The establishment of Regional Trauma Centers can lead to improved performance, maximal efficiency, and reduction of preventable deaths in trauma patients. They can also play a key role in prehospital triage and transportation in the trauma care system.

Comparison of Preventable Trauma Death Rates in Patients With Traumatic Brain Injury Before and After the Establishment of Regional Trauma Center: A Single Center Experience.

To compare preventable trauma death rates (PTDRs) in patients with traumatic brain injury before and after the establishment of a regional trauma center (RTC) at a single center. Our institution established an RTC in 2014. A total of 709 patients were enrolled from January 2011 to December 2013 (before RTC) and 672 from January 2019 to December 2021 (after RTC). The revised trauma score, injury severity score, and trauma and injury severity score (TRISS) were evaluated. Definitive preventable (DP), possibly preventable (PP), and non-preventable deaths were defined as TRISS >0.5, TRISS 0.25-0.5, and TRISS <0.25, respectively. PTDR was the proportion of deaths from DP+PP out of all deaths, and the preventable major trauma death rate (PMTDR) was the proportion of deaths from DP+PP out of all DP+PP. The overall mortality rates before and after the establishment of RTC were 20.3 and 13.1%, respectively. PTDR was lower after the establishment of RTC than before (90.3% vs. 79.5%). The PMTDR was also lower after the establishment of RTC than before (18.8% vs. 9.7%). The ratio of direct hospital visits was higher in patients before the establishment of RTC than in those after (74.9% vs. 61.3%, p<0.001). Establishing the RTC reduced PTDRs. Additional studies on factors associated with PTDR reduction are required.

Recommendations for Placement of Bleeding Control Kits in Public Spaces - a Simulation Study.

Bleeding control measures performed by members of the public can prevent trauma deaths. Equipping public spaces with bleeding control kits facilitate these actions. We modeled a mass casualty incident to investigate the effects of public bleeding control kit location strategies. We developed a computer simulation of a bomb exploding in a shopping mall. We used evidence and expert opinion to populate the model with parameters such as the number of casualties, the public's willingness to aid, and injury characteristics. Four alternative placement strategies of public bleeding control kits in the shopping mall were tested: co-located with automated external defibrillators (AEDs) separated by 90-second walking intervals, dispersed throughout the mall at 10 locations, located adjacent to one exit, located adjacent to two exits. Placing bleeding control kits at two locations co-located with AEDs resulted in the most victims surviving (18.2), followed by ten kits dispersed evenly throughout the mall (18.0). One or two kit locations placed at the mall's main exits resulted in the fewest surviving victims (15.9 and 16.1 respectively). Co-locating bleeding control kits with AEDs at 90-seconds walking intervals, results in the best casualty outcomes in a modeled mass casualty incident in a shopping mall.

EPIDEMIOLOGICAL ASPECTS OF POLYTRAUMATISM IN THE PEDIATRIC POPULATION

"Polytrauma" is a term frequently used in the practice and literature of trauma specialties. This term refers to a series of multiple injuries at the level of several organs or systems, in contrast to isolated traumatic injuries, where a single injury is encountered [Marsden NJ, 2022].Millions of patients with polytrauma require medical care, some of them suffering injuries that will lead to lifestyle changes with the limitation of multiple activities. Globally, road collision is the leading cause of traumatic death, followed by suicide and homicide [Marsden NJ, 2022]."Golden hour" expression coined by Professor Richard Cowley, concludes that most deaths due to polytrauma occur in the first 60 minutes after injury [Marsden NJ, 2022].Following the research carried out on deaths from traumatic causes, a trimodal distribution was highlighted from them: immediately, early and late. The first 2 represent 80% of all traumatic deaths, occurring in the first hours after the injury, either due to brain injuries or major exsanguination. On the other hand, late deaths occur within days to weeks of trauma, secondary to sepsis or multiple organ failure [Marsden NJ, 2022].

Implicit organisational trauma and a dis-membered congregation: a psychoanalytic exploration

This article will explore the phenomenon of implicit organisational trauma through a case study example of a religious congregation that was closed following cumulative experiences of enduring collective trauma over the course of several decades. These included the traumatic death of a beloved member, repeated violations of relational trust, and betrayal by congregational leaders, as well as intergenerational child sexual abuse perpetrated by various clergy members. Psychoanalytic and systems psychodynamics views of traumatogenic processes within an organisational level of experience will be explored and applied. Particular attention will be given to discussing the phenomenon of splitting and affective dissociation within the psychological, relational, and organisational experiences of a traumatised congregation. In addition, the process of organisational healing will be explored through the perspective of reintegrating implicit emotional memories of trauma within the collective consciousness of its members, through which the community's sense of agency was rediscovered. In the case study reviewed throughout this article, we highlight the organisational decision that promoted healing from the history of shared trauma, which was the community's collective choice to close their congregation.