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The why and how our trauma patients die

A prospective Multicenter Western Trauma Association study

Callcut, Rachael A., MD; Kornblith, Lucy Z., MD; Conroy, Amanda S., BSN; Robles, Anamaria J., MD; Meizoso, Jonathan P., MD; Namias, Nicholas, MD; Meyer, David E., MD; Haymaker, Amanda, BS; Truitt, Michael S., MD; Agrawal, Vaidehi, PhD; Haan, James M., MD; Lightwine, Kelly L., MPH; Porter, John M., MD; San Roman, Janika L., MPH; Biffl, Walter L., MD; Hayashi, Michael S., MD; Sise, Michael J., MD; Badiee, Jayraan, MPH; Recinos, Gustavo, MD; Inaba, Kenji, MD; Schroeppel, Thomas J., MD; Callaghan, Emma, BS; Dunn, Julie A., MD; Godin, Samuel, BS; McIntyre, Robert C. Jr, MD; Peltz, Erik D., DO; O'Neill, Patrick J., MD, PhD; Diven, Conrad F., MD; Scifres, Aaron M., MD; Switzer, Emily E., MD; West, Michaela A., MD, PhD; Storrs, Sarah, MD; Cullinane, Daniel C., MD; Cordova, John F., MD; Moore, Ernest E., MD; Moore, Hunter B., MD, PhD; Privette, Alicia R., MD; Eriksson, Evert A., MD; Cohen, Mitchell Jay, MD Western Trauma Association Multicenter Study Group

Journal of Trauma and Acute Care Surgery: May 2019 - Volume 86 - Issue 5 - p 864–870
doi: 10.1097/TA.0000000000002205

BACKGROUND Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality.

METHODS Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed.

RESULTS One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32–75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care.

CONCLUSION Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research.

LEVEL OF EVIDENCE Epidemiologic, level II.

From the Department of Surgery (R.A.C., L.Z.K., A.S.C., A.J.R.), Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California; Department of Surgery (J.P.M., N.N.), University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida; Department of Surgery (D.E.M., A.H.), McGovern Medical School, University of Texas Health Science Center, Houston; Division of Trauma and Acute Care (M.S.T., V.A.), Methodist Dallas Medical Center, Dallas, Texas; Department of Trauma (J.M.H., K.L.L.), Via Christi Health, Kansas University School of Medicine Wichita Campus, Wichita, Kansas; Division of Trauma (J.M.P., J.L.S.R.), Cooper University Hospital, Camden, New Jersey; Department of Surgery (W.L.B.), Scripps Memorial Hospital La Jolla, La Jolla, California; Department of Surgery (M.S.H.), The Queen's Medical Center, The University of Hawaii, Honolulu, Hawaii; Trauma Service (M.J.S., J.B.), Scripps Mercy Hospital, San Diego; Division of Surgical Critical Care and Trauma (G.R., K.I.), Los Angeles County + University of Southern California Medical Center, Los Angeles, California; Department of Surgery (T.J.S., E.C.), University of Colorado Health, Memorial Hospital, Colorado Springs; Department of Surgery (J.A.D., S.G.), University of Colorado Health North, Medical Center of the Rockies, Loveland, Colorado; Department of Surgery (R.C.M.Jr., E.D.P.), University of Colorado School of Medicine, Aurora, Colorado; Department of Trauma and General Surgery (P.J.O., C.F.D.), Abrazo Medical Group, Abrazo West Campus, Goodyear, Arizona; Department of Surgery (A.M.S., E.E.S.), University of Oklahoma, Oklahoma City, Oklahoma; Division of Trauma and Emergency Acute Care Surgery (M.A.W., S.S.), North Memorial Health Hospital, Robbinsdale, Minnesota; Department of Surgery (D.C.C., J.F.C.), Marshfield Clinic, Marshfield, Wisconsin; Department of Surgery (E.E.M., H.B.M.), Denver Health Medical Center, University of Colorado Denver, Denver, Colorado; Department of Surgery (A.R.P., E.A.E.), Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.J.C.), Denver Health Medical Center, Denver; and University of Colorado Medical Center (M.J.C.), Aurora, Colorado.

Submitted: February 15, 2018, Revised: September 8, 2018, Accepted: October 25, 2018, January 10, 2019.

Meetings: 8th Annual Meeting of Western Trauma Association, March 2, 2018, Whistler, British Columbia, Canada.

Address for reprints: Rachael A Callcut, MD, Department of Surgery, Ward 3A, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110; email:

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