Federal Scientific Clinical Center of Miners’ Health Protection,

Kemerovo Regional Agency of Forensic Medicine, interdistrict department, 

Leninsk-Kuznetsky, Russia

 

In the beginning of 21^st century the injury rates are still high. Traumatism problem is associated with its frequency, medicosocial and economic significance (high costs of medical aid, high levels of mortality and disability, high direct and indirect losses because of lost labor potential in the society) [5].

In the mortality structure in population of the developed and developing countries traumatism takes 3d and 4^th places after cardiovascular diseases, malignant tumors, respiratory and infectious diseases [2]. In Russia mortality after injuries in employable age persons (according to years of possible life, summary economic and medicosocial harm to society) takes the first place in the general structure of mortality (52 %). It is higher compared to cardiovascular diseases and malignant tumors [3, 5].

It is associated with urbanization, increasing industrialization favoring increase in cases of severe industrial, home and road injury rates. During the last years one can observe persistent tendency to worsening traumatic injuries. Most of which are associated with multiple, concomitant or combined characteristics with inherent mutual burdening syndrome. Mostlethaloutcomesareobservedinpolytrauma. Despiteof some success in treatment of such patients, hospital mortality is high: from 15.9 to 49.5 % according to the data from different authors [4, 5, 9, 10].

Most clinicians believe that polytrauma treatment outcomes depend primarily on organization of specialized medical aid, and, as result, significant improvement of outcomes is anticipated only with improving the system of its rendering at different stages [2, 3, 10]. One of the actual issues is investigation of quality of rendering medical assistance. During estimation of quality of hospital activity the main clinical morphologic criteria of efficiency are hospital mortality rates. Analysis of hospital death causes demonstrates defects in diagnostics, treatment, correctness in making clinical and pathologic anatomic diagnosis and organization of medical assistance [1].

Objective ‒ to investigate the level and structure of hospital mortality in polytrauma, and thanatological profile in dependence on dominating injury and terms of hospital stay; to evaluate quality of clinical diagnostics in different periods of traumatic disease; to give expert estimation of identified defects in rendering medical assistance.

 

MATERIALS AND METHODS

The retrospective monitoring included 636 cases of polytrauma treated in the specialized traumatology center at the basis of Clinical Center of Miners’ Health Protection during 2008-2012. 102 patientsdied. Themortalitywas 16 %.

The clinical morphologic analysis of hospital mortality was carried out. Thequalityofclinicaldiagnosticswasestimated.

The term “polytrauma” means set of two or more injuries, one of which or their combination has direct threat for patient’s life and is an immediate cause of traumatic disease [2].

All died patients were distributed into the groups according to their age, gender, injury mechanism, location of main (dominating) injury, main causes and time of death.

The analysis of mortality causes was performed according to the data from forensic medical expertise using the techniques for postmortem clinical diagnosis by G.G. Avtandilov et al [1] and the recommendations from the International Classification of Diseases (ICD) 10 [7]. During investigation of the forensic medical conclusions about death the examiners studied frequency and characteristics of non-identified injuries and complications, conducted their systematization and defined causes and thanatological significance.

 

For identification of the structure of diagnostic defects the morphological standards of clinical diagnostics quality were used [6]:

-          Difference between clinical and forensic diagnoses;

-          One (or more) unrecognized injury;

-          Unrecognized lethal complication;

-          Late diagnostics of main disease;

-          Late diagnostics of lethal complication;

-          Unrecognized concomitant injuries.

 

The causes of errors were subdivided into:

1)      objective ones (short period of hospital stay, severity of state);

2)      subjective ones (insufficient examination, underestimation of anamnesis data, underestimation of incorrect interpretation of clinical data, underestimation or overestimation of laboratory data).

 

The statistical preparation of the data was performed with Statistica 6.1.

The comparison of analyzed values was performed with the parametric method. Student’s t-test was used for estimation of reliability of differences between the groups.Pearson criterion was used for evaluation of statistical significance. The correlation between signs was assessed with lineal relationship correlation. The critical level of significance of null statistic hypothesis was 0.05.

 

RESULTS AND DISCUSSION

During 2008-2012 636 patients with polytrauma were treated. 102 patents died during hospital treatment (16%, table 1).

Table 1
Distribution of patients with polytrauma according to age, gender, and mortality in hospital

Note:* p < 0.05 level of significance of difference in comparison of mortality level according to gender. 

There were 433 men (68.1 %), 203 women (31.9 %).  The mortality rate was 74 men (72.5 %) and 28 women (27.5 %). The hospital mortality was 17.1 % for men and 13.8 % in women. The differences were statistically significant (p < 0.05). The main proportion of the died patients consisted of working age persons: 88.2 % of the patients were of age < 60, the mean age was 43 ± 4.2. The hospital mortality increased with increasing age of the patients. The maximal mortality (40 %) was in the men of age > 61.

For estimation of relationship between age and mortality rate the correlation analysis and Pearson’s correlation coefficient were used (Fig. 1). There was a strong lineal relationship between age and mortality rate (r= 0.98734, p = 0.00001).

Figure 1

The correlation dependence between the age of the patients with polytrauma and mortality level

The analysis of distribution according to injury mechanism showed that 79.4 % of cases were associated with road traffic accidents, 11.8 % – with falling from height, 3.9 % – with industrial injuries, 4.9 % – with other causes.

Depending on localization of main injury the main amount of patients were with dominating traumatic brain injury (38 patients or 37.3 % from the total number of diseased patients), the least amount was with dominating abdominal injury (6 patients or 5.9 %, table 2). 

Table 2
Distribution of died patients with polytrauma depending on a dominating injury

27 patients (26.5 %) had concurrent dominating injuries with life threat. Among 27 cases, 23 cases were with combinations of thoracic injuries with other dominating injury (26.5 %, table 3).

Table 3
Structure of mortality in patients with concurrent dominating injuries

Thiscategoryofpatientsincludes 70.4 % of cases with combinations of injuries to 3 or more anatomic injuries, 77.5 % of cases shock of degree 3 (hemorrhagic shock was in most cases) and multiple organ failure.

For mortality analysis in terms of hospital stay duration the patients were distributed into 3 groups: acute (1-3 days), early (4-10 days) and late period (> 10 days) of traumatic disease (table 4).

Table 4
Mortality structure depending on length of hospital stay

              Note: * – mortality during 24 hours.

Such distribution of mortality as result of polytrauma with dependence on hospital stay distribution corresponds to the literature data: 60-70 % in acute and early periods, 30-40 % in late period of traumatic disease [4, 10, 11].24 patientsdiedduring 3 days. Itis 23.5 % of the total amount of mortality as result of polytrauma. Onedaymortalitywas 9.8 % (10 patients). Ondays 4-10 themortalitywas 38 patients (37.3 %).40 patientsdiedduringlateperiodoftraumaticdisease. Itis 39.2 % of total amount of died patients with polytrauma.

Our data demonstrates changes in death time in the last years. One can observe decrease in mortality in acute period of traumatic disease, including the first day, and relative increase after 10 days.

Decreasing 1-3 day mortality was achieved with modern transportation of patients to a specialized center, improvement in medical diagnostic measures during transportation, decreasing time of presurgical examination with highly informative diagnostic techniques (ultrasound, MSCT, laparoscopy et al.), active implementation of modern high-tech techniques for intensive care (infusion-transfusion, vascular therapy, respiratory support). The great importance is related to use of 24 hour technique of autoblood reinfusion with cell-celver device [10]. Increased number of resuscitation long-livers is a result of improvement in intensive care techniques, using modern effective antibiotics (carbapenems), immunocorrection, nutrition etc.

According to forensic examination, in acute period of traumatic disease the leading causes of lethal outcomes were acute blood loss and shock because of extremely severe injuries to parenchymal organs, the brain (14), brain edema with stem dislocation (8), ascendant spinal cord edema (1), heart contusion (1).

In early period the mortality index has no tendency to significant decrease yet. The immediate causes of death in early period of traumatic disease were severe reperfusion complications with development of different types of organ failure, infectious complications: multiple organ failure (14), ARDS III-IV – pneumonia (12), brain edema with stem dislocation (8), peritonitis (2), sepsis (1), ascendant spinal cord edema (1).

In late period of traumatic disease the causes of death were multiple organ failure (18), pneumonia (1), sepsis (4), meningitis (3), peritonitis (2), pulmonary embolism (1) (table 5).

Table 5
Causes of lethal outcomes in different terms of traumatic disease

During the study the structure of direct causes of death from different dominating injuries was analyzed (table 5). It was demonstrated that in case of dominating traumatic brain injury the main causes of death were brain edema with stem dislocation (39.5 %),  multiple organ failure (31.6 %) and purulent septic complications (pneumonia, meningitis, sepsis).

In case of dominating skeletal injury the causes of death were related to pneumonia in 62.5 %, multiple organ failure in 37.5 %.

In case of dominating thoracic injury the direct causes of death were acute respiratory distress syndrome (ARDS) III-IV (53.3 %), multiple organ dysfunction syndrome (MODS) (20 %), sepsis (13.3 %). Some observations showed such causes as traumatic shock and embolism of the pulmonary artery or its branches.

In dominating abdominal injury the causes of lethal outcome were peritonitis (50 %), MODS (33.3 %) and hemorrhagic shock (16.7 %).

In case of dominating spinal cord injury patients died from ascendant spinal cord edema (28 %) and MODS (75 %).

As for concurrent dominating injuries, the causes of lethal outcomes were severe traumatic and hemorrhagic shock because injury to parenchymal organs, the brain (44.4 %), MODS (22.2 %), purulent septic complications, pneumonia, peritonitis, sepsis (22. %). In some cases the causes of death were heart contusion and brain edema (table 6).

Table 6
Structure of immediate cause of death in different dominating injuries

In our study the causes of death after polytrauma, with dependence on dominating injuries, were similar to the data from different literature [8, 11].

The thanatological profile (structure of immediate causes of death) was as shown below (Fig. 2): shock and blood loss – (13.7 %), brain dislocation and edema – 16 (15.7 %), MODS – 32 (31.4 %), infectious complications – 36 (35.3 %), other causes – 4 (3.9 %).

Figure 2

The thanatological profile in polytrauma

 

It is necessary to note that in early and late periods of traumatic disease the main direct causes of death were mostly infectious complications of traumatic disease at the background of secondary immune deficiency and MODS.

During diagnostics the complex expert estimation of quality of clinical diagnostics was performed.

After comparison of postmortem clinical and forensic diagnoses the differences in main diseases were not found.

The study showed the following defects in quality of clinical diagnostics (table 7).

Table 7
Structure and  causes of defects in quality of clinical diagnostics

One of the concomitant injuries was not diagnosed clinically –2 cases (acute period of traumatic disease). Diagnostic errors were conditioned by objective factors: extremely severe state of patients with concurrent injuries (with thanatological significance) and short period of hospital stay.

Late diagnostics was in 2 observations in acute and early periods of traumatic disease. The diagnostic errors were conditioned by subjective causes:

1.                            Insufficient examination: no diagnostic laparoscopy after admission of a patient with intestinal injury; surgical treatment was performed only after clinical signs of peritonitis.

2.                            UnderestimationofTBIseverity: late MSCT of severe brain contusion with formation of strained hydrome in the frontal lobes, late surgical treatment, development of uncontrolled brain edema and lethal outcome.

In these cases the incorrect diagnostic algorithm for polytrauma took place: necessary realization of all available diagnostic techniques and involvement of other specialists. In conditions of specialized traumatology center these possibilities were provided on 24 hour basis.

Late diagnosis of one of the concomitant injuries was in one case (early period of traumatic disease) in a patient with dominating TBI: during diagnostic laparoscopy the injury to the mesentery was not diagnosed. It was the subjective cause: insufficient experience of a specialist. However, this defect did not have significant influence on dynamics of traumatic disease and lethal outcome.

 Among the died patients, in 49 (48 %) 91 concurrent injuries were found after death, not diagnosed clinically, including 68 patients (85.7 %) – in acute period of traumatic disease.

As for autopsy results, the rib fractures took the first place – 21 autopsy procedures (23 %). The additional fractures of the ribs were found despite of X-ray diagnostics before death. Facial skeleton fractures took the second place: nose, eye socket, lower jawbone (20 cases, 22 %). Lessfrequentlythefracturesof spinous processes of vertebrae were found which were mostly invisible in plain anterior-posterior X-ray images. The same fact is related to fractures of pubic andischial bones. There were no lethal non-diagnosed injuries to the internal organs. In 10 cases (11 %) autopsy found subcapsular disruptions and hemorrhage to the spleen and the liver. Alsosmallintracraniallamellarhematomaswerefound (upto 20 ml).

The identified defects in diagnostics of concurrent injuries had no thanatological significance and were conditioned by objective facts (severity of patients’ state, difficulties in diagnostics). The rare defects were conditioned by subjective causes (non-qualitative formation of a conclusive diagnosis, insufficient experience of specialists).  

 

CONCLUSION

1.      The activity of “Polytrauma” center isassociated with decreasing hospital mortality (including 24 hours) and high level of quality of clinical diagnostics – the most important indicators of efficiency of medical diagnostic measures at hospital stage. Inpolytraumahospitalmortalityisabout16 %. This value increases with age of patients. The overwhelming majority of patients (88.2 %) are persons of working age, men mostly (72.5 %). The maximal number of lethal outcomes is related to road traffic accidents (79.4 %). In polytrauma the leading dominating injuries are TBI (37.3 %) and concurrent dominating injuries (26.5 %).

2.      During the last years one can observe decrease in mortality in acute period of traumatic disease (including 24 hour) with relative increasing after 10 days. In acute period of traumatic disease the main causes of mortality are shock and blood loss because of extremely severe injury to parenchymal organs, the brain and brain edema with stem dislocation. In early period of traumatic disease death is associated with severe reperfusion complications with development of different types of organ insufficiency. After 10 days the main causes are multiple organ failure and infectious complications.

3.      Thegreatestamount ofdiagnosticmeasures (80.2 %) is noted in acute period of traumatic disease because of objective causes: extremely severe state of patients on admission, necessity of emergent and sometimes simultaneous conduction of resuscitation measures and surgeries, and short period of hospital stay. It is necessary to give attention to all defects: insufficient examination, low professional level, non-qualitative execution of medical documentation.

4.      The results of the retrospective analysis of hospital mortality and quality of clinical diagnostics of polytrauma can be used for development of measuresfor improving medical assistance with aim of improving outcomes of diagnostics and treatment. It is necessary to continue investigation of hospital mortality in polytrauma, its structure, causes and cases with defects. It will allow to give scientific explanation for organizational measures for improvement of medical assistance in severe injuries with aim of improving outcomes of diagnostics and treatment.