[Analysis of causes of death in long-term survivors of injuries sustained in traffic accidents].

INTRODUCTION: The manner of death, i.e. if death is moros or violent, is the most important fact for the court and therefore, the most important part of the finding of autopsy reports [1]. To recognize the manner of death in cases with long outliving period after injury could be difficult for forensic pathologists. In such cases, the dissector should be able to point out the direct relationship between initial injury and death by using his (her) own experience and medical knowledge. Could the deaths provoked by low injuries be prevented? These injuries have score of 3 by Abbreviated Injury Scale (AIS) i.e. 12-20 by injury Severity Score (ISS) [3-5].

PURPOSE: The purpose of this paper is to suggest the measures for improvement of postmortem autopsy diagnosis of causes of death in cases with long outliving period (more than 15 days) after initial traffic injury.

MATERIAL AND METHOD: A retrospective autopsy study was performed. It included the material of the Institute of Forensic Medicine in Belgrade for 1998. The autopsy report and accessible clinical medical data were analyzed for persons fatally injured in traffic accidents who outlived trauma more than 15 days. The sample was statistically prepared (chi 2 test, correlation coefficient).

RESULTS AND DISCUSSION: The sample included 31 persons injured in traffic accidents with outliving period longer than 15 days: 21 males and 10 females (chi 2 = 0.047; p > 0.1). Average age was 49.90 years (SD = 18.28). All persons in our sample were over the age of 19. The most commonly injured persons were pedestrians (16). The mean outliving period was 41.19 days (SD = 12.60). There was a weak positive correlation between outliving period and age in our sample (coefficient of linear correlation r = 0.35). The authors combined the autopsy and available clinical data in order to get the ISS value for each case. The mean ISS value was 36.18 (SD = 8.70). There was no correlation between outliving period and severity of trauma (coefficient of linear correlation r < 0.14). All deaths in our sample were violent according to autopsy reports. In autopsy reports, dissectors always noted only one injured body region: head and neck injuries in 21 cases, chest injuries in 3, trauma of locomotor system in 5 and in 2 cases abdominal injuries. However, by analyzing these reports, the authors emphasized that in 22 cases one body region was severely injured, in 7 cases two body regions and three regions in 2 cases. According to the authors severe injury has score 3 or more by 3. In four cases the dissectors pointed no complication of initial injuries as a competitive cause of death. In 15 cases they mentioned it as general, and in the rest of cases as decided (e.g. pneumonia, sepsis, thromboembolism, etc.). In five cases, the complications of initial injury were the precipitated and immediate cause of death (the initial injury in all these cases was less than 16 by ISS i.e. severe but not critical). The seven cases were treated microscopically. These microscopical findings only proved the already established microscopical autopsy findings and were not crucial for case solution. It was alarming, that one third of cases in our sample were completed without considering the clinical medical data. This is forensic vitium artis. Nowadays, there are a few syndromes which could be the cause of death i.e. fat embolism syndrome [7], multiple organ failure) [8, 9] and systemic inflammatory response syndrome [9, 10]. The diagnosis of these syndromes is possible only clinically: the autopsy and histological findings are not specific.

CONCLUSION: As long as a direct chain of events can be traced from the injury to the death, then the initial injury must be considered to be the basic cause of death, and this fact may have profound legal implications for both civil compensation and criminal responsibility. Some of the most difficult problems in forensic pathology concern deaths from which posttraumatic complications are disputed as being fatal causative factors. The agony and dying are irreversible dynamic pathophysiological processes. By autopsy only the morphological consequences of these processes could be noted by dissector. The dynamics of dying, direct correlation between initial injury and death, as well as appearance and development of complications provoked by trauma could be established only by clinical medical data. Therefore, medical clinical data are crucial for forensic pathologists and for solving the problems about the mode and manner of death in cases with long outliving period. Microscopical findings have only academic and scientific importance and are less useful in daily practice. The authors suggest that all complications of injury must be generally involved in autopsy reports, and all severe injuries should separately be registered both in medical data and autopsy reports. The finding of cause of death must include all observed severe injuries and not only one of the most severe injuries and its complications.