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Road traffic fatalities in Delhi: Causes, injury patterns, and incidence of preventable deaths
Accid. Anal. and Prev.. Vol. 26. No. 3, PD. 377-384. 1994 Copyright 0 1994 El&&r Science Ltd Printed in the USA. All rights reserved Oool-4575194 56.00 + .oo
Pergamon
ROAD TRAFFIC FATALITIES IN DELHI: CAUSES, INJURY PATTERNS, AND INCIDENCE OF PREVENTABLE PRADIP
SAHDEV,~
MICHAEL
DEATHS*
J. LACQUA,’
BIR SINGH,*
and T. D. DOGRA~
‘Division of Trauma Surgery, Nassau County Medical Center, East Meadow, NY 11554, U.S.A.; ?A11India Institute of Medical Sciences, New Delhi, India (Accepred
30 Jul?,
1993)
Abstract-India reported nearly 50,000 traffic accident deaths in 1989. Yet, literature addressing the causes, timing, and preventability of these deaths is sparse. We undertook an autopsy study of road traffic fatalities in South Delhi to determine the injury patterns and incidence of deaths that could be prevented by optimal utilization of available medical resources. Among the 177 autopsies reviewed, neurological injury caused death in 60% of patients and hemorrhagic shock in 2.5%. Twenty-three percent of the deaths were felt to be preventable, 41% possibly preventable, and the rest not preventable. The majority of preventable deaths resulted from a failure to diagnose or treat a treatable injury. Adherence to establish principles in the hospital management of intracavitory hemorrhage could have salvaged 70% of preventable deaths. Keywords-Traffic
fatalities,
Injury patterns,
Preventable
INTRODUCTION
deaths, India
MATERIALS
India, the former Soviet Union, and the United States have reported the largest number of traffic related fatalities among all nations. In 1989 Road traffic accidents in India resulted in 49,690 deaths despite the fact that the total number of motorized vehicles in India is a fraction of that reported from other countries (World Road Statistics 1991; Table 1). Delhi, the third most populous city in India, reported 1,276 fatalities from traffic accidents in 1986. In contrast, there were 410 fatalities in Calcutta, 555 in Bombay, and 432 in Madras in the same year. (Special Issue on Motor Vehicle Accidents Statistics in India 1986). The present study was undertaken to determine the demographics of persons dying on Delhi roads; to determine the time of death in relation to the time of accident; to review the severity of injuries sustained by the victims; and to determine the incidence and causes of deaths that could be prevented by the optimal utilization of available medical resources. These findings could have important implications in trauma systems research and development both in lndia and in other developing nations.
AND METHODS
Reports of all autopsies on road traffic fatalities performed by the Department of Forensic Medicine at All India Institute of Medical Sciences in New Delhi, India, between Ianuary 1 and May 31, 1991, were reviewed. Patient demographics and available details of the accident and subsequent death were recorded. Autopsy findings and final cause of death were noted. Prehospital care and acute hospital care given to patients arriving alive at the hospital were too inconsistently available in the autopsy records to be useful for analysis and are omitted from further discussion. The injuries reported at each autopsy were analysed to determine the Abbreviated Injury Scale (AIS) score of each injured body region, and the Injury Severity Score (ISS) was calculated (American Association for Automotive Medicine 198.5; Baker et al. 1974). The presence or absence of surgical diagnostic and therapeutic interventions was recorded from the history and autopsy findings. A determination as to the inevitability of the death was made for each of the reports analysed. Each death was placed into one of three categories: (1) not preventable, (2) possibly preventable, and (3) preventable. This determination was based on the time to death from the accident, injuries re-
*Presented at the Second World Conference on Injury Control, May 1993, Atlanta, Georgia, USA. 377
Brief Communications
378
I. Statistics
Table
Population (1000s)
India USSR (88) USA S. Korea (88) Japan South Africa France (87) Germany Spain ltaly (88)
811.253 284,500 248,491 41,975 123,340 30,193 23,010 62,679 39,159 57,504
49,690 47,197 45,555 I 1,563 I 1,227 10,887 10,289 7,995 7,186 6,939
buses, vans,
cars,
Motorized vehicles* (1000’S)
Deaths
goods
3,070 14,654 187,261 2,035 57,702 4,709 27,598 3 1,588 13,737 27.481
T
IMMEDIATE
Statistics
are for 1989,
Cars/ 1000 persons
Motorized two wheelers (1000s)
2.3 51 576 27 282 112 416 481 293 439
10,953 N/A 4,434 1,067 18,208 294 3.370 2,381 2,576 6,623
vehicles.
ported, patient age, and the presence or absence of surgical intervention. Deaths occuring one hour or more after the accident and resulting from hemorrhage into the thorax or abdomen were generally considered to be preventable unless an at-
45
Notes
for the 10 countries with the largest number of traffic-related deaths. unless otherwise indicated (World Road Statistics 1989)
Country
*Includes
and Research
tempt at surgical control was present. Deaths from intracranial hemorrhage were considered preventable if there was a definite epidural or subdural hematoma and no attempt at surgical evacuation of the clot was evident.
DEATHS
I
40
li
4
35
EARLY
DEATHS
;I
30
LATE DEATHS DELAYED I
NUMBER
25
;’
OF PATIENTS
I
i
2.
i
ACCIDENT
’
’
HO;R
3
3
4
5
0.5
TIME Fig.
1. Number
DEATHS
/
of deaths
as a function
of time to death
1
2
;AY
4
5
6
7
2
3 WEEK
4
OF DEATH
from the accident 13 fatalities.
in 164 fatalities.
Time
to death
was
not available
for
Brief Communications
and Research Notes
379
6%
n ’ g
I
CENTRAL
NERVOUS
SYSTEM
t
HEMORRHAGE
m COMBINATION
25%
n
SEPSIS
60%
Fig. 2. Causes of death in 177 fatalities.
RESULTS Records of 177 consecutive autopsies of road traffic victims between January 1 and May 3 1, 1991 were reviewed. There were 156 males and 21 females. Age ranged from 2 to 70 years, with a mean of 3.5 years. Seventy (40%) of the deaths were in the 26- to 40-year age group; 52 (30%) occurred in persons under 25 years old, and 54 (30%) in persons over 40 years old. The age of one fatality was not recorded. Patient demise occurred in eight hospitals. Twenty-seven patients were interhospital transfers. Of the 172 patients for whom the location of death was recorded, 40 were pronounced dead in the field, 23 were dead on arrival at the hospital, and 109 died following in-hospital treatment. Eighty percent of the victims pronounced dead in a hospital were direct transfers from the accident site. The time to death following the accident was available for 164 persons. When the number of deaths were plotted as a function of time to death from the accident, four peaks were noted. The greatest number of deaths, the first peak, occurred within one hour from the time of the accident. The second peak occurred at two to three hours after the accident, the third at 24 to 48 hours, and the fourth at two weeks (Fig. 1). The important implications of these peaks in the timing of deaths is discussed later.
The exact mechanism of injury was recorded for 69 fatalities. Among these fatalities, 28 were occupants of motorized two-wheelers, 23 pedestrians, 4 bicycle riders, 3 automobile occupants. The remaining 11 fatalities involved other mechanisms of injury. Further details of the accidents, including protective devices and alcohol intoxication, were too inconsistently documented to lend themselves to analysis and are therefore omitted. Of the 177 fatalities, the major cause of death was head injury in 60% of the cases. Twenty-five percent of deaths resulted from intrathoracic or intra-abdominal hemorrhage, 6% from sepsis, and 9% from a combination of factors (Fig. 2). When the cause of death was analysed by time to death following the accident, head injuries were noted to be the most common cause of demise at all time intervals. Deaths from intrathoracic and intra-abdominal hemorrhage were disconcertingly frequent at all time intervals up to 96 hours from the time of the accident (Fig. 3). Severity of injuries graded according to the AIS demonstrated that severe head injury (AIS of 5 or greater) was present in 120 (68%) of the deaths. This severity of abdominal injury was present in 35 (20%) deaths, and of thoracic injury in 33 (19%) deaths. An AIS of 4 or less in the various categories was present significantly less frequently (Fig. 4).
Brief Communications
380
and Research Notes
CAUSES OF DEATH BY TIME FROM ACCIDENT
N
N= 164
__-..._-.._._
30
.____~_~
25
U M B E
20
R
0 F
g
15
HEMORRAGE
IllI COMBINATION
P A T I
10
E N T s
5
0
4 ACCIDENT
<
1 HOUR
HOUR
1-4
HOUR
TIME
12-96
DAY4-7
> OAY
7
OF DEATH
Fig. 3. Causes of death by time from accident in 164 fatalities. Note the high incidence of neurological deaths at each time interval.
The average ISS for the mortalities reviewed was 37.8 (range 8 to 75). In Fig. 5, the ISS of each accident victim is plotted as a function of his or her age. The isobar LDSO line defines patients who have a 50% chance of survival following injury. Patients falling below the line have a greater than 50% chance of surviving while those above the line have a greater than 50% chance of dying (Bull 1975). In this study, of the 176 patients plotted, 131 (74%) fall below the isobar LD50 line. This cohort of patients should have had a greater than 50% statistical likelihood of survival. Consequently, the management of these patients should be scrutinized to determine whether their deaths were preventable. Overall, 46 deaths were judged to be preventable, 73 possibly preventable, and 58 not preventable. The average AIS scores for each body region and the average ISS scores for each category are given in Table 2. Further analysis of the deaths felt to be preventable or possibly preventable showed that 69 (58%) of these were due to a failure to diagnose a treatable injury, 19 (16%) due to a delay in transport, 21 (18%) due to failure of treatment, and
the rest due to a combination of factors. A graphic illustration of the causes of preventable and possibly preventable deaths is shown in Fig. 6. DISCUSSION All traffic accident deaths in Delhi are subjected to a medico-legal autopsy. The purpose of this is to satisfy legal requirements for establishment of the cause and circumstances of death. Prior studies from India have reviewed the incidence of injuries sustained by patients attending hospital emergency rooms (Maheshwari and Mohan 1989; Sathiyasekaran 1991). Kumar (1989) reviewed 51 autopsies of traffic fatalities and attempted to relate the patients’ ISS to outcome. No attempt to define specific injuries and determine the incidence of preventable deaths was, however, made by this author. In the present study, the autopsy findings have been reviewed to obtain a better understanding of the nature of injuries and circumstances leading up to the fatalities in Delhi. The age and sex distribution of deaths was simi-
Brief Communications
0
and Research
Notes
381
I____ 1
2
ABBREVIATED Fig. 4. The number
of patients
assigned
4
3
INJURY
SCALE
each abbreviated
lar to that reported in other studies (Maheshwari and Mohan 1989; Kumar 1989), with the maximum number of deaths occurring in the 26- to 40-year age group. Interestingly, in this study, although the number of male deaths varied widely in different age groups, the 21 female deaths were not significantly different among the age groups. In addition, male deaths outnumbered female deaths in all age groups, except that among children under 10 years old, female deaths outnumbered male deaths. The significance of these findings is uncertain. In this study, the majority of patients dying following traffic accidents and brought to a hospital alive were transferred from the site of the accident. A prior study based in Delhi reported by Maheshwari and Mohan (1989) showed that of 807 accident victims studied, 4% were brought to the hospital by ambulance, 19% by police vehicles, 51% by taxis, 12% by personal vehicles, and the remainder by unspecified modes of transportation. Forty-six percent arrived at the hospital more than 30 minutes after the accident, and 90% of all victims received no prehospital care.
Injury
5
SCORE Scale score,
by category
(N = 177).
The four peaks in the number of deaths (Fig. 1) are significant. The time sequence of these deaths resembles that reported by Trunkey (1983). This author described three peaks in traumatic deaths and classified them as immediate (deaths within one hour of the accident), early (deaths within one to four hours), and late (deaths at one to five weeks following injury). In this study, we noted not only the three peaks in deaths reported by Trunkey, but a fourth peak at 24 to 48 hours after the accident. This suggests that a significant number of deaths occurred in a delayed fashion that did not occur in Trunkey’s study. The large numbers of patients who expired from intra-abdominal and intrathoracic hemorrhage between one hour to four days from the time of the injury (Fig. 2) suggests that measures could be undertaken to improve survival among this group of patients. It is notable that neurological injury accounted for 60% of all deaths and was the most frequent cause of death at each time interval from accident to death. This, in addition to the occurance of severe head injuries (AIS of 5 or above) in 120 (68%) deaths,
Brief Communications
382
80
T
mm
a.
.
and Research
Notes
a.
I 70
1
a
a 60
/
50
j-
a .
INJURY SEVERITY
n
40
SCORE
30
.
j
a 20
10
I
.
i
0
a
.
.
.=
.
.
.
10
1
20
40
30 AGE
of all hospital
deaths
in terms
of Injury
2. Cateeories
Severity
Score
and age (N = 176). Curve
indicates
LD SO.
[41%]) is notable. A landmark publication in 1979 (West, Trunkey, and Robert 1979) addressed preventable deaths in San Francisco county, which had an established trauma system, and Orange county, which lacked such a system. These authors reported a preventable-death rate of 1% in San Francisco county compared to 73% of non-central nervous system (CNS) related deaths and 28% of CNS-related deaths in Orange county. Numerous other studies have also addressed preventable deaths as a means of assessing trauma care (Cales and Trunkey 1985). The fact that a failure to diagnose or manage a treatable injury caused death in more instances than delay in transport to the hospital and unsuccessful treatment combined, is significant. The 27 preventable deaths among patients dying between one hour and four days after the accident and resulting from undiagnosed intra-abdominal or intrathoracic bleed-
deaths
and Abbreviated AIS
Iniurv
Scale
AIS abdomen
scores AIS extremity
Mean ISS
AIS head & neck
AIS face
thorax
58 73 46
5.0 4.6 I.9
1.3 0.2 0.2
I.9 1.7 2.3
1.9 0.3 2.7
1.1 0.7 1.6
50 30 35
177
4.0
0.5
I.9
I.2
1.1
38
Deaths
Overall
of oreventable
70
50
IN YEARS
underscores the importance of introducing measures to limit the incidence and severity of head injury and the need to readdress present practices in the diagnosis and management of multiply injured patients. In reviewing the deaths with respect to the age and ISS of the fatalities, it is striking that 13 I deaths (74%) fall below the isobar LDSO line. As stated earlier, this suggests that these patients should have a less than 50% chance of dying from the injuries described and that some of these deaths may be preventable. It must be borne in mind, however, that the high incidence of head injury may have resulted in a low ISS in spite of a lethal injury. This may be responsible for some unpreventable deaths falling below the LD50 line. The number of preventable deaths (46 [20% of all deaths]) and possibly preventable deaths (73
Table
:
:
-W-l
_-
0
Not preventable Possibly preventable Preventable
.
.
+_-+___-
Fig. 5. Distribution
...
.
Brief Communications
and Research
383
Notes
30 N U M B E
25
i-i 0 F
n
PREVENTABLE
7
POSSIBLY
20 PREVENTABLE
P A T ’ E
15
N T s 10
5
0 DELAY IN TRANSPORT
FAILURE
TO
DIAGNOSE
Fig. 6. Reasons
FAILED
OPERATION
SEPSIS
COMBINATION
OR TREATMENT
why preventable
and possibly
ing is especially regrettable, as diagnosis of these conditions requires procedures (diagnostic peritoneal lavage, tube thoracostomy, chest X-ray) that could have been made readily available at all the hospitals where the deaths occurred. The validity of the autopsy method used in this study receives support from the work of West (1981; 1982). This author used the patient’s age, interval from injury to death, cause of death, and surgical treatment provided to decide whether or not the death was preventable. This determination was compared to an independent determination of preventable deaths as made by an evaluation of the patient’s clinical records. In this review, all deaths judged to be preventable by the autopsy method, were also deemed preventable by the method of reviewing the clinical records (West 1982). Other authors have also used the autopsy method to evaluate preventable deaths (Cales 1985). It is suggested that measures should be instituted to increase physician awareness of concealed intracavitory hemorrhage. Early diagnosis and treatment of this eminently treatable cause might have salvaged up to 70% of preventable deaths and 18%
preventable
deaths
occurred.
of all fatalities studied. Improvement in transport and treatment could have salvaged the remaining 30% of preventable deaths. Furthermore, improved management of the head-injured patient could have helped in the survival of many of the possibly preventable deaths. Introduction of preventive measures to limit the incidence and severity of traumatic injuries is essential to decrease the costs involved in the acute and long-term care of injured patients. Such interventions in relation to underdeveloped countries have been suggested in other publications (Mohan 1992; Saunders 1990; World Health Organization Technical Report Series 1984). Meanwhile, the unnecessary deaths from trauma, even when available resources are accounted for, need to be recognised. Further research utilizing clinical and autopsy data should be undertaken urgently to guide trauma systems development. Trauma management needs to be introduced as a recognized field in third-world countries. Trauma systems appropriate to the practices and resources available, and based on outcome studies undertaken in these countries, need to be developed (Bangdiwala and Elias 1985; Maheshwari
Brief Communications
384
and Mohan 1989). Low-cost alternatives and less capital-intensive approaches to trauma management must be considered. Undue reliance on methodologies that have proved successful in industrialized yet prohibitively expensive, must be nations, avoided. Acknow,i~d~etnent-The authors thank Dr. Peter his assistance with the graphic illustrations.
Schaefer
for
REFERENCES American Association
for Automotive Medicine. The Abbreviated Injury Scale (AIS)-l985 revision. Des Plaines, IL: AAAM; 1985. Baker, S. P.; O’Neill, B.; Haddon, W., Jr.; Long, W. B. The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J. Trauma, 14:187-196; 1974. Bangdiwala, S. I.; Elias, A. Statistical considerations for the interpretation of commonly utilized road traffic indicators: Implications for developing countries. Accid. Anal. Prev. 17:419-427; 1985. Bull, J. P. The injury severity score of road traffic casualties in realation to mortality, time to death, and disability. Accid. Anal. Prev. 7:249; 1975. Gales, R. H.; Trunkey, D. D. Preventable trauma deaths: A review of trauma care systems development. JAMA 254:1059-1063; 1985.
and Research
Notes
Kumar, B. Injury Severity Score (ISS) as a yardstick in assessing the severity and mortality of various abdomino-pelvic trauma hospitalized victims-a clinical visa-vis autopsy study. Med. Sci. Law 29:333-336; 1989. Maheshwari, J.; Mohan, D. Road traffic fatalities in Delhi: A hospital based study. Journal Traffic Medicine 17:23-27; 1989. Mohan, D. Safety of the vulnerable road users. Indian Highways 29-35; April 1992. Sathiyasekaran, B. W. C. Accident trauma-A descriptive hospital study. J. R. Sot. Health 111: 10-I I ; 1991. Saunders, R. A. Road safety management in developing countries. J. R. Sot. Health 110:23-28; 1990. Special Issue on Motor Vehicle Accident Statistics in India, 1986. New Delhi: Transport Research Division, Ministry of Surface Transport, Government of India; 1986. Trunkey, D. D. Trauma. Scientific American. 249:28-36; August 1983. West, J. G. An autopsy method for evaluating trauma care. J. Trauma 21:32-34, 1981. West, J. G. Validation of autopsy method for evaluating trauma care. Arch. Surg. 117:1033-1035; 1982. West, J. G., Trunkey, D. D., Robert, C. L. Systems of trauma care; a study of two countries. Arch. Surg. 114:455-460; 1979. World Health Organization Technical Report Series. Road traffic accidents in developing countries 1984. 703: l-29; 1984. World Road Statistics, 1986-1990. Geneva: International Road Federation; 1991.
Pergamon
ROAD TRAFFIC FATALITIES IN DELHI: CAUSES, INJURY PATTERNS, AND INCIDENCE OF PREVENTABLE PRADIP
SAHDEV,~
MICHAEL
DEATHS*
J. LACQUA,’
BIR SINGH,*
and T. D. DOGRA~
‘Division of Trauma Surgery, Nassau County Medical Center, East Meadow, NY 11554, U.S.A.; ?A11India Institute of Medical Sciences, New Delhi, India (Accepred
30 Jul?,
1993)
Abstract-India reported nearly 50,000 traffic accident deaths in 1989. Yet, literature addressing the causes, timing, and preventability of these deaths is sparse. We undertook an autopsy study of road traffic fatalities in South Delhi to determine the injury patterns and incidence of deaths that could be prevented by optimal utilization of available medical resources. Among the 177 autopsies reviewed, neurological injury caused death in 60% of patients and hemorrhagic shock in 2.5%. Twenty-three percent of the deaths were felt to be preventable, 41% possibly preventable, and the rest not preventable. The majority of preventable deaths resulted from a failure to diagnose or treat a treatable injury. Adherence to establish principles in the hospital management of intracavitory hemorrhage could have salvaged 70% of preventable deaths. Keywords-Traffic
fatalities,
Injury patterns,
Preventable
INTRODUCTION
deaths, India
MATERIALS
India, the former Soviet Union, and the United States have reported the largest number of traffic related fatalities among all nations. In 1989 Road traffic accidents in India resulted in 49,690 deaths despite the fact that the total number of motorized vehicles in India is a fraction of that reported from other countries (World Road Statistics 1991; Table 1). Delhi, the third most populous city in India, reported 1,276 fatalities from traffic accidents in 1986. In contrast, there were 410 fatalities in Calcutta, 555 in Bombay, and 432 in Madras in the same year. (Special Issue on Motor Vehicle Accidents Statistics in India 1986). The present study was undertaken to determine the demographics of persons dying on Delhi roads; to determine the time of death in relation to the time of accident; to review the severity of injuries sustained by the victims; and to determine the incidence and causes of deaths that could be prevented by the optimal utilization of available medical resources. These findings could have important implications in trauma systems research and development both in lndia and in other developing nations.
AND METHODS
Reports of all autopsies on road traffic fatalities performed by the Department of Forensic Medicine at All India Institute of Medical Sciences in New Delhi, India, between Ianuary 1 and May 31, 1991, were reviewed. Patient demographics and available details of the accident and subsequent death were recorded. Autopsy findings and final cause of death were noted. Prehospital care and acute hospital care given to patients arriving alive at the hospital were too inconsistently available in the autopsy records to be useful for analysis and are omitted from further discussion. The injuries reported at each autopsy were analysed to determine the Abbreviated Injury Scale (AIS) score of each injured body region, and the Injury Severity Score (ISS) was calculated (American Association for Automotive Medicine 198.5; Baker et al. 1974). The presence or absence of surgical diagnostic and therapeutic interventions was recorded from the history and autopsy findings. A determination as to the inevitability of the death was made for each of the reports analysed. Each death was placed into one of three categories: (1) not preventable, (2) possibly preventable, and (3) preventable. This determination was based on the time to death from the accident, injuries re-
*Presented at the Second World Conference on Injury Control, May 1993, Atlanta, Georgia, USA. 377
Brief Communications
378
I. Statistics
Table
Population (1000s)
India USSR (88) USA S. Korea (88) Japan South Africa France (87) Germany Spain ltaly (88)
811.253 284,500 248,491 41,975 123,340 30,193 23,010 62,679 39,159 57,504
49,690 47,197 45,555 I 1,563 I 1,227 10,887 10,289 7,995 7,186 6,939
buses, vans,
cars,
Motorized vehicles* (1000’S)
Deaths
goods
3,070 14,654 187,261 2,035 57,702 4,709 27,598 3 1,588 13,737 27.481
T
IMMEDIATE
Statistics
are for 1989,
Cars/ 1000 persons
Motorized two wheelers (1000s)
2.3 51 576 27 282 112 416 481 293 439
10,953 N/A 4,434 1,067 18,208 294 3.370 2,381 2,576 6,623
vehicles.
ported, patient age, and the presence or absence of surgical intervention. Deaths occuring one hour or more after the accident and resulting from hemorrhage into the thorax or abdomen were generally considered to be preventable unless an at-
45
Notes
for the 10 countries with the largest number of traffic-related deaths. unless otherwise indicated (World Road Statistics 1989)
Country
*Includes
and Research
tempt at surgical control was present. Deaths from intracranial hemorrhage were considered preventable if there was a definite epidural or subdural hematoma and no attempt at surgical evacuation of the clot was evident.
DEATHS
I
40
li
4
35
EARLY
DEATHS
;I
30
LATE DEATHS DELAYED I
NUMBER
25
;’
OF PATIENTS
I
i
2.
i
ACCIDENT
’
’
HO;R
3
3
4
5
0.5
TIME Fig.
1. Number
DEATHS
/
of deaths
as a function
of time to death
1
2
;AY
4
5
6
7
2
3 WEEK
4
OF DEATH
from the accident 13 fatalities.
in 164 fatalities.
Time
to death
was
not available
for
Brief Communications
and Research Notes
379
6%
n ’ g
I
CENTRAL
NERVOUS
SYSTEM
t
HEMORRHAGE
m COMBINATION
25%
n
SEPSIS
60%
Fig. 2. Causes of death in 177 fatalities.
RESULTS Records of 177 consecutive autopsies of road traffic victims between January 1 and May 3 1, 1991 were reviewed. There were 156 males and 21 females. Age ranged from 2 to 70 years, with a mean of 3.5 years. Seventy (40%) of the deaths were in the 26- to 40-year age group; 52 (30%) occurred in persons under 25 years old, and 54 (30%) in persons over 40 years old. The age of one fatality was not recorded. Patient demise occurred in eight hospitals. Twenty-seven patients were interhospital transfers. Of the 172 patients for whom the location of death was recorded, 40 were pronounced dead in the field, 23 were dead on arrival at the hospital, and 109 died following in-hospital treatment. Eighty percent of the victims pronounced dead in a hospital were direct transfers from the accident site. The time to death following the accident was available for 164 persons. When the number of deaths were plotted as a function of time to death from the accident, four peaks were noted. The greatest number of deaths, the first peak, occurred within one hour from the time of the accident. The second peak occurred at two to three hours after the accident, the third at 24 to 48 hours, and the fourth at two weeks (Fig. 1). The important implications of these peaks in the timing of deaths is discussed later.
The exact mechanism of injury was recorded for 69 fatalities. Among these fatalities, 28 were occupants of motorized two-wheelers, 23 pedestrians, 4 bicycle riders, 3 automobile occupants. The remaining 11 fatalities involved other mechanisms of injury. Further details of the accidents, including protective devices and alcohol intoxication, were too inconsistently documented to lend themselves to analysis and are therefore omitted. Of the 177 fatalities, the major cause of death was head injury in 60% of the cases. Twenty-five percent of deaths resulted from intrathoracic or intra-abdominal hemorrhage, 6% from sepsis, and 9% from a combination of factors (Fig. 2). When the cause of death was analysed by time to death following the accident, head injuries were noted to be the most common cause of demise at all time intervals. Deaths from intrathoracic and intra-abdominal hemorrhage were disconcertingly frequent at all time intervals up to 96 hours from the time of the accident (Fig. 3). Severity of injuries graded according to the AIS demonstrated that severe head injury (AIS of 5 or greater) was present in 120 (68%) of the deaths. This severity of abdominal injury was present in 35 (20%) deaths, and of thoracic injury in 33 (19%) deaths. An AIS of 4 or less in the various categories was present significantly less frequently (Fig. 4).
Brief Communications
380
and Research Notes
CAUSES OF DEATH BY TIME FROM ACCIDENT
N
N= 164
__-..._-.._._
30
.____~_~
25
U M B E
20
R
0 F
g
15
HEMORRAGE
IllI COMBINATION
P A T I
10
E N T s
5
0
4 ACCIDENT
<
1 HOUR
HOUR
1-4
HOUR
TIME
12-96
DAY4-7
> OAY
7
OF DEATH
Fig. 3. Causes of death by time from accident in 164 fatalities. Note the high incidence of neurological deaths at each time interval.
The average ISS for the mortalities reviewed was 37.8 (range 8 to 75). In Fig. 5, the ISS of each accident victim is plotted as a function of his or her age. The isobar LDSO line defines patients who have a 50% chance of survival following injury. Patients falling below the line have a greater than 50% chance of surviving while those above the line have a greater than 50% chance of dying (Bull 1975). In this study, of the 176 patients plotted, 131 (74%) fall below the isobar LD50 line. This cohort of patients should have had a greater than 50% statistical likelihood of survival. Consequently, the management of these patients should be scrutinized to determine whether their deaths were preventable. Overall, 46 deaths were judged to be preventable, 73 possibly preventable, and 58 not preventable. The average AIS scores for each body region and the average ISS scores for each category are given in Table 2. Further analysis of the deaths felt to be preventable or possibly preventable showed that 69 (58%) of these were due to a failure to diagnose a treatable injury, 19 (16%) due to a delay in transport, 21 (18%) due to failure of treatment, and
the rest due to a combination of factors. A graphic illustration of the causes of preventable and possibly preventable deaths is shown in Fig. 6. DISCUSSION All traffic accident deaths in Delhi are subjected to a medico-legal autopsy. The purpose of this is to satisfy legal requirements for establishment of the cause and circumstances of death. Prior studies from India have reviewed the incidence of injuries sustained by patients attending hospital emergency rooms (Maheshwari and Mohan 1989; Sathiyasekaran 1991). Kumar (1989) reviewed 51 autopsies of traffic fatalities and attempted to relate the patients’ ISS to outcome. No attempt to define specific injuries and determine the incidence of preventable deaths was, however, made by this author. In the present study, the autopsy findings have been reviewed to obtain a better understanding of the nature of injuries and circumstances leading up to the fatalities in Delhi. The age and sex distribution of deaths was simi-
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Notes
381
I____ 1
2
ABBREVIATED Fig. 4. The number
of patients
assigned
4
3
INJURY
SCALE
each abbreviated
lar to that reported in other studies (Maheshwari and Mohan 1989; Kumar 1989), with the maximum number of deaths occurring in the 26- to 40-year age group. Interestingly, in this study, although the number of male deaths varied widely in different age groups, the 21 female deaths were not significantly different among the age groups. In addition, male deaths outnumbered female deaths in all age groups, except that among children under 10 years old, female deaths outnumbered male deaths. The significance of these findings is uncertain. In this study, the majority of patients dying following traffic accidents and brought to a hospital alive were transferred from the site of the accident. A prior study based in Delhi reported by Maheshwari and Mohan (1989) showed that of 807 accident victims studied, 4% were brought to the hospital by ambulance, 19% by police vehicles, 51% by taxis, 12% by personal vehicles, and the remainder by unspecified modes of transportation. Forty-six percent arrived at the hospital more than 30 minutes after the accident, and 90% of all victims received no prehospital care.
Injury
5
SCORE Scale score,
by category
(N = 177).
The four peaks in the number of deaths (Fig. 1) are significant. The time sequence of these deaths resembles that reported by Trunkey (1983). This author described three peaks in traumatic deaths and classified them as immediate (deaths within one hour of the accident), early (deaths within one to four hours), and late (deaths at one to five weeks following injury). In this study, we noted not only the three peaks in deaths reported by Trunkey, but a fourth peak at 24 to 48 hours after the accident. This suggests that a significant number of deaths occurred in a delayed fashion that did not occur in Trunkey’s study. The large numbers of patients who expired from intra-abdominal and intrathoracic hemorrhage between one hour to four days from the time of the injury (Fig. 2) suggests that measures could be undertaken to improve survival among this group of patients. It is notable that neurological injury accounted for 60% of all deaths and was the most frequent cause of death at each time interval from accident to death. This, in addition to the occurance of severe head injuries (AIS of 5 or above) in 120 (68%) deaths,
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80
T
mm
a.
.
and Research
Notes
a.
I 70
1
a
a 60
/
50
j-
a .
INJURY SEVERITY
n
40
SCORE
30
.
j
a 20
10
I
.
i
0
a
.
.
.=
.
.
.
10
1
20
40
30 AGE
of all hospital
deaths
in terms
of Injury
2. Cateeories
Severity
Score
and age (N = 176). Curve
indicates
LD SO.
[41%]) is notable. A landmark publication in 1979 (West, Trunkey, and Robert 1979) addressed preventable deaths in San Francisco county, which had an established trauma system, and Orange county, which lacked such a system. These authors reported a preventable-death rate of 1% in San Francisco county compared to 73% of non-central nervous system (CNS) related deaths and 28% of CNS-related deaths in Orange county. Numerous other studies have also addressed preventable deaths as a means of assessing trauma care (Cales and Trunkey 1985). The fact that a failure to diagnose or manage a treatable injury caused death in more instances than delay in transport to the hospital and unsuccessful treatment combined, is significant. The 27 preventable deaths among patients dying between one hour and four days after the accident and resulting from undiagnosed intra-abdominal or intrathoracic bleed-
deaths
and Abbreviated AIS
Iniurv
Scale
AIS abdomen
scores AIS extremity
Mean ISS
AIS head & neck
AIS face
thorax
58 73 46
5.0 4.6 I.9
1.3 0.2 0.2
I.9 1.7 2.3
1.9 0.3 2.7
1.1 0.7 1.6
50 30 35
177
4.0
0.5
I.9
I.2
1.1
38
Deaths
Overall
of oreventable
70
50
IN YEARS
underscores the importance of introducing measures to limit the incidence and severity of head injury and the need to readdress present practices in the diagnosis and management of multiply injured patients. In reviewing the deaths with respect to the age and ISS of the fatalities, it is striking that 13 I deaths (74%) fall below the isobar LDSO line. As stated earlier, this suggests that these patients should have a less than 50% chance of dying from the injuries described and that some of these deaths may be preventable. It must be borne in mind, however, that the high incidence of head injury may have resulted in a low ISS in spite of a lethal injury. This may be responsible for some unpreventable deaths falling below the LD50 line. The number of preventable deaths (46 [20% of all deaths]) and possibly preventable deaths (73
Table
:
:
-W-l
_-
0
Not preventable Possibly preventable Preventable
.
.
+_-+___-
Fig. 5. Distribution
...
.
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383
Notes
30 N U M B E
25
i-i 0 F
n
PREVENTABLE
7
POSSIBLY
20 PREVENTABLE
P A T ’ E
15
N T s 10
5
0 DELAY IN TRANSPORT
FAILURE
TO
DIAGNOSE
Fig. 6. Reasons
FAILED
OPERATION
SEPSIS
COMBINATION
OR TREATMENT
why preventable
and possibly
ing is especially regrettable, as diagnosis of these conditions requires procedures (diagnostic peritoneal lavage, tube thoracostomy, chest X-ray) that could have been made readily available at all the hospitals where the deaths occurred. The validity of the autopsy method used in this study receives support from the work of West (1981; 1982). This author used the patient’s age, interval from injury to death, cause of death, and surgical treatment provided to decide whether or not the death was preventable. This determination was compared to an independent determination of preventable deaths as made by an evaluation of the patient’s clinical records. In this review, all deaths judged to be preventable by the autopsy method, were also deemed preventable by the method of reviewing the clinical records (West 1982). Other authors have also used the autopsy method to evaluate preventable deaths (Cales 1985). It is suggested that measures should be instituted to increase physician awareness of concealed intracavitory hemorrhage. Early diagnosis and treatment of this eminently treatable cause might have salvaged up to 70% of preventable deaths and 18%
preventable
deaths
occurred.
of all fatalities studied. Improvement in transport and treatment could have salvaged the remaining 30% of preventable deaths. Furthermore, improved management of the head-injured patient could have helped in the survival of many of the possibly preventable deaths. Introduction of preventive measures to limit the incidence and severity of traumatic injuries is essential to decrease the costs involved in the acute and long-term care of injured patients. Such interventions in relation to underdeveloped countries have been suggested in other publications (Mohan 1992; Saunders 1990; World Health Organization Technical Report Series 1984). Meanwhile, the unnecessary deaths from trauma, even when available resources are accounted for, need to be recognised. Further research utilizing clinical and autopsy data should be undertaken urgently to guide trauma systems development. Trauma management needs to be introduced as a recognized field in third-world countries. Trauma systems appropriate to the practices and resources available, and based on outcome studies undertaken in these countries, need to be developed (Bangdiwala and Elias 1985; Maheshwari
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and Mohan 1989). Low-cost alternatives and less capital-intensive approaches to trauma management must be considered. Undue reliance on methodologies that have proved successful in industrialized yet prohibitively expensive, must be nations, avoided. Acknow,i~d~etnent-The authors thank Dr. Peter his assistance with the graphic illustrations.
Schaefer
for
REFERENCES American Association
for Automotive Medicine. The Abbreviated Injury Scale (AIS)-l985 revision. Des Plaines, IL: AAAM; 1985. Baker, S. P.; O’Neill, B.; Haddon, W., Jr.; Long, W. B. The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J. Trauma, 14:187-196; 1974. Bangdiwala, S. I.; Elias, A. Statistical considerations for the interpretation of commonly utilized road traffic indicators: Implications for developing countries. Accid. Anal. Prev. 17:419-427; 1985. Bull, J. P. The injury severity score of road traffic casualties in realation to mortality, time to death, and disability. Accid. Anal. Prev. 7:249; 1975. Gales, R. H.; Trunkey, D. D. Preventable trauma deaths: A review of trauma care systems development. JAMA 254:1059-1063; 1985.
and Research
Notes
Kumar, B. Injury Severity Score (ISS) as a yardstick in assessing the severity and mortality of various abdomino-pelvic trauma hospitalized victims-a clinical visa-vis autopsy study. Med. Sci. Law 29:333-336; 1989. Maheshwari, J.; Mohan, D. Road traffic fatalities in Delhi: A hospital based study. Journal Traffic Medicine 17:23-27; 1989. Mohan, D. Safety of the vulnerable road users. Indian Highways 29-35; April 1992. Sathiyasekaran, B. W. C. Accident trauma-A descriptive hospital study. J. R. Sot. Health 111: 10-I I ; 1991. Saunders, R. A. Road safety management in developing countries. J. R. Sot. Health 110:23-28; 1990. Special Issue on Motor Vehicle Accident Statistics in India, 1986. New Delhi: Transport Research Division, Ministry of Surface Transport, Government of India; 1986. Trunkey, D. D. Trauma. Scientific American. 249:28-36; August 1983. West, J. G. An autopsy method for evaluating trauma care. J. Trauma 21:32-34, 1981. West, J. G. Validation of autopsy method for evaluating trauma care. Arch. Surg. 117:1033-1035; 1982. West, J. G., Trunkey, D. D., Robert, C. L. Systems of trauma care; a study of two countries. Arch. Surg. 114:455-460; 1979. World Health Organization Technical Report Series. Road traffic accidents in developing countries 1984. 703: l-29; 1984. World Road Statistics, 1986-1990. Geneva: International Road Federation; 1991.