Deaths at a Level 1 Trauma Unit: a clinical finding and post-mortem correlation study

David Steinwall, Fabian Befrits, Steve R Naidoo, Timothy Hardcastle, Anders Eriksson, David J J Muckart
Injury 2012, 43 (1): 91-5

BACKGROUND: Missed injuries continue to cause deaths amongst trauma patients. Regardless of the definition of missed injuries, it is important to identify all injuries at any stage in the care of trauma patients in order to improve patient outcome. This study was performed to evaluate to what extent missed injuries contribute to a fatal outcome at a new Level 1 Trauma Unit.

METHODS: The medical records and autopsy reports of all trauma patients who died at the IALCH trauma unit from March 2007 through August 2009 were reviewed. The mortality rate and incidence of missed injuries were determined. A missed injury was defined as one that was found at autopsy but was not mentioned in the medical records or in any ante mortem radiological report. This excluded minor injuries such as superficial contusions and minor lacerations, which are sometimes not included in the case notes during resuscitation. Deaths due to trauma are considered unnatural and legal provisions require that all unnatural deaths undergo medico-legal postmortem examination. The study was approved by the UKZN Biomedical Research Ethics Committee.

RESULTS: Five hundred and forty-seven patients were admitted to the trauma unit of which 135 (24.7%) demised. Three patients were excluded, due to inability to retrieve their autopsy reports, leaving a study group of 132 patients in which there were 100 males and 32 females. The mean age was 33.2 years, mean ISS was 34.0. A total of 26 missed injuries were found in 14 patients, giving a total incidence of 10.6%. Three percent had missed injuries that were variously deemed to be possibly related, probably related, or related to the fatal outcome, whether the deaths were deemed preventable or not. Severe physiological derangement which precluded any imaging before death may have caused the injury to be overlooked. The thorax was the anatomical region where most injuries were missed.

CONCLUSIONS: A number of injuries remain undetected in trauma care and are found only at autopsy, emphasizing that the autopsy remains an important tool in evaluating trauma care. However, in only a few patients did the missed injuries have a detrimental effect on outcome.

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