INTRODUCTION

Pages:1-8

INTRODUCTION

Blunt thoraco-abdominal injuries are one of the major causes of unnatural deaths(1). These two body cavities contain most of the vital organs and therefore, injury to these organs even by blunt trauma usually leads to a fatal outcome. Blunt trauma to the chest and abdomen can be produced in various situations such as road traffic accidents, railway accidents, fall from height and blunt weapons. Maximum numbers of victims are generally from road traffic accidents. A significant number of these road traffic accident victims are likely to die of thoracoabdominal trauma. Data available suggests that a significant mortality due to road traffic accidents exists in north east Delhi. In India 1, 00,300 males and 17,939 females totaling 1, 18,239 persons were killed during the year 2008, while traveling by various modes of transport on roads. 25,135 persons (21.2%) of these were occupants of Truck/Lorry, 23,552 (19.9%) were riding on Two-wheelers, 12,551 (10.6%) were killed while traveling in buses and 10,324 (8.7%) were pedestrians. While in Delhi 1884 males and 214 females totaling 2098 persons were killed during the year 2008, while traveling by various modes of transport on roads. 173 persons of these were occupants of Truck/Lorry,69 were riding on Twowheelers,110 were tempo/van occupants,10 were jeep occupants,151 were car

occupants,554 were riding on three wheelers,589 were bicycle occupants ,133 were killed while traveling in buses,230 were others and 230 were pedestrians. 883 males and 96 females totaling 979 persons were killed during the year 2008 in rail accidents in Delhi (2). North east Delhi has two national highways and railway lines in its vicinity. As a result of this the pattern of road traffic in this region is quite distinct from that in other parts of Delhi. In 2006 total number of Cars and Jeeps plying on the roads of Delhi were 15,89,872, Motor cycles and Scooters were 32,99,838, Auto Rickshaws were 74,189, Taxis were 24,958, Buses were 46,581,and Goods Vehicles were 1,49,972.The total number of cases of road traffic accidents were 9699 and in these accidents 2167 persons died and 8769 persons were injured(3). Railway accidents are also not uncommon in this region. Homicides using blunt weapons are also quite common here. Physiologically based trauma scores available are: 1. 2. 3. 4. 5. The Revised Trauma Score (RTS) The Acute Physiology and Chronic Health Evaluation (APACHE) The sequential organ failure assessment (SOFA) score The systemic inflammatory response syndrome (SIRS) score Emergency trauma score (EMTRAS)

The Revised Trauma Score (RTS) is one of the more common physiologic scores. It uses 3 specific physiologic parameters, as follows: (1) Glasgow Coma Scale (GCS), (2) systolic blood pressure (SBP), and (3) respiratory rate (RR). The Acute Physiology and Chronic Health Evaluation (APACHE) has 2 components, as follows: (1) the chronic health evaluation, which incorporates the influence of comorbid conditions (eg, diabetes mellitus, cirrhosis, chronic renal failure, heart disease malignancy), and (2) the Acute Physiology Score (APS). The APS consists of weighted variables representing the major physiologic systems, including neurologic, cardiovascular, respiratory, renal, gastrointestinal, metabolic, and hematologic variables. In 1985, the APACHE system was revised (ie, APACHE II) by reducing the number of APS variables from 34 to 12, restricting the comorbid conditions, and deriving coefficients for specific diseases. The sequential organ failure assessment (SOFA) score is based on 6 different parameters, as follows: respiratory system (PaO2/FiO2, mm Hg), cardiovascular system (blood pressure/vasopressors), hepatic system (bilirubin,

mg/dL), coagulation system (plateletsX103/mm3), renal system (creatinine, mg/dL), and neurological system (Glasgow Coma Scale). The systemic inflammatory response syndrome (SIRS) score is a generalized response to nonspecific insults, including infections, pancreatitis, trauma, and burns.

Raum et al developed the emergency trauma score (EMTRAS) comprising of 4 parameters: patient age, Glasgow Coma Scale, base excess, and prothrombin time (PT). Physiologically based scores measure parameters such as blood pressure, respiratory rate, and level of consciousness and are useful for early evaluation of the injured person and not relevant in postmortem evaluation. Combined Anatomical and physiologically based trauma scores available are: 1. 2. Trauma and Injury Severity Score (TRISS) Severity Characterization of Trauma (ASCOT)

Trauma and Injury Severity Score (TRISS) combines anatomic and physiologic measures of injury severity (ISS and RTS, respectively) and patient age in order to predict survival from trauma. Champion et al introduced A Severity Characterization of Trauma (ASCOT) in 1990 as an improvement over TRISS. ASCOT uses the AP in place of the ISS.
(4)

Anatomical scores are based on the characterization of injuries anatomically, as outlined below.

Abbreviated Injury Score (AIS) Injury Severity Score (ISS) New Injury Severity Score (NISS) Penetrating Abdominal Trauma Index (PATI) ICD-based Injury Severity Score (ICISS)

Anatomic scales score each organ injury separately. The abbreviated injury scale (AIS) and the injury severity score (ISS), which is based on the AIS, are the most frequently used anatomical scales. The American Medical Association, for Automotive Medicine & the Society of Automotive Engineers established the AIS in 1973.It has been revised several times, and latest revision was in 2005. In its present form the AIS codes injuries based on their anatomic site, nature and severity. The ISS is also an anatomically based ordinal scale, with a range from 1 to 75. To compute the ISS the nine AIS body regions are grouped into six: head or neck, face, chest, abdominal or pelvic contents, extremities or pelvic girdle, and external. The ISS is then calculated as the sum of the squares of the highest AIS scores for the three most severely injured body regions. For example, if a person sustained multiple injuries to the head, thorax and extremities, and if the most severe injuries in each body region were a closed non-depressed vault skull fracture (AIS =2), one rib fracture (AIS = 1), and an open tibial fracture 6

(AIS = 3), the ISS would be calculated as the sum of squares of each of these values. An exception to this algorithm happens when any single body region has AIS of 6, when an ISS of 75 is then assigned. Recently, researchers have proposed a new injury severity score (NISS) which, unlike the ISS, considers the three most severe injuries, regardless of body region. The NISS is computed as the simple sum of squares of the three most severe AIS (1990 revision and 2005) injuries (5). The penetrating abdominal trauma index (PATI) score is used to calculate the risk of complications in patients undergoing celiotomy for penetrating abdominal trauma. Another, more recent approach to anatomic injury scoring is based on the International Classification of Disease, Ninth Edition (ICD-9) codes. This method is termed ICD-9 Injury Severity Score (ICISS) and uses survival risk ratios (SRRs) calculated for each ICD-9 discharge diagnosis. SRRs are derived by dividing the number of survivors in each ICD-9 code by the total number of patients with the same ICD-9 code. ICISS is calculated as the simple product of the SRRs for each of the patient's injuries. NISS being the latest and effective method for studying postmortem injuries, was used in my study. The regular use of trauma scores in Forensic Medicine may provide a standardized database of autopsy findings which would make a tremendous 7

contribution to the quality of trauma treatment and assessment of preventable death. This study will highlight the importance of ISS/NISS in trauma care and in assessing the prognosis of thoraco-abdominal trauma cases. In the recent past no study assessing the thoraco abdominal injuries using ISS/NISS has been done in this region. Hence the present study was undertaken.

REVIEW OF LITERATURE
Pages: 9-37

REVIEW OF LITERATURE
Cox (6) studied Blunt abdominal trauma in a 5-year analysis of 870 patients requiring celiotomy in the department of surgery, Maryland institute for emergency medical systems, Baltimore, Maryland. 870 patients with blunt abdominal trauma were reviewed, representing 12.89 % of the total admissions over a five year period. Motor vehicles continued to be the major cause(89.5%) of injury to these patients. Of the injuries incurred, spleen was involved in 42% of cases, the liver in 35.6% of cases, the serosa, and blood vessels diaphragm and bowel, were involved to a lesser extent (0.4%).

Bergqvist et al (7) studied patients with abdominal trauma and fatal outcome in an analysis of a 30-year series in rural Swedish area. They found that Patients with blunt abdominal trauma with fatal outcome comprised of 127 patients. Several facts indicate that more severe trauma has been appearing more often during this period The mortality rate has, however, been stable, but the patients have become older. More patients died from pulmonary complications than from the trauma itself. One very important development was the significant decrease in mortality among children.

Brainard et al (8) studied Injury profiles in pedestrian motor vehicle trauma in Tucson, USA. Hundred fifteen consecutive pedestrians who were struck by motor vehicles were studied to determine the magnitude and patterns of the injuries sustained. The mortality rate was 22%, and 17 of 25 patients who died 10

did so during the initial resuscitative efforts, primarily due to head, chest, and/or abdominal injury. The average Injury Severity Score (ISS) among all patients was 20; however, it was significantly higher (46) in nonsurvivors. The majority of the victims were men (72%), and the average age of all patients was 35 years. As the patient's age increased, so did the likelihood of mortality, fractures, and prolonged hospital stay. The most frequently injured organ system was musculoskeletal (77%), followed by head (34%), abdomen (21%), and chest (15%). The most common fractures seen were tibia-fibular (39), pelvis (35), and femur (31). Hospital stay averaged 11 days.

Arajarvi et al (9) studied Chest injuries sustained in severe traffic accidents by seatbelt wearers, in Finland during the period 1972-1985, there occurred 3,468 severe traffic accidents in which one or more of the drivers or passengers sustained an injury leading to a fatal outcome within 30 days. Of the victims who had been wearing seatbelts, 207 had fatal and 73 had severe chest injuries. The four leading causes of fatalities resulting from chest injuries were ruptures of the aorta (37%), ruptures of the heart (28.4%), and bilateral lung contusions (31.1%) or lacerations (15.5%). In addition to chest injuries, 87% of the victims had other concomitant injuries, the most common abdominal injuries being liver injuries (40.2%) and spleen ruptures (26.5%).

Kumar et al

(10)

studied ISS as a yard stick in assessing the severity and

mortality of various abdominopelvict trauma hospitalized victims a clinical vis a

11

vis autopsy study. They studied 51 cases of vehicular accident showing abdominopelvic trauma, along with associated injuries. A detailed ISS score was done in all the cases and it was seen that victims in their 30s and 40s died only if their severity score was above 50.It was also observed that when the score was less than 20, the mortality level was minimal, while above 20 there was linear increase. In two of the cases studied, the score was 75.When comparing the ISS obtained from postmortem examination with the score derived from the clinical assessment, there was a difference of 9 to 16 in 64.86% of victims.

Guirguis et al

(11)

studied Trauma Outcome Analysis of Two Canadian

Centers Using the TRISS Method .A total of 274 adult patients with multiplesystem injuries were studied; their demographic data, Trauma Scores (TS) on arrival to the Emergency Room, and Injury Severity Scores (ISS) were reviewed. The TRISS scores and Z and M statistics were then calculated. In the Hamilton group, 106 consecutive patients from April through July 1987 were studied. The majority of patients (72%) were male, and the median age was 26 years. The majority of patients (96.2%) sustained blunt trauma, with motor vehicle accidents (MVA) being the most common (76.4%) mechanisms of injury. In the Ottawa group, 168 consecutive patients from April 1987 through October 1988 were studied. The majority of patients (73%) were male, and the median age was 39 years. Blunt trauma accounted for the majority (91.7%) of injuries, with MVAs being responsible for 58% of injuries.

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Poole et al

(12)

studied Pelvic fracture from major blunt trauma. Outcome is

determined by associated injuries. The medical records of all patients admitted to the University of Mississippi Medical Center (UMC) from January 1986 through December 1989 with a diagnosis of pelvic fracture were reviewed. Pelvic hemorrhage has been implicated as the cause of death in 50% of patients who die following pelvic fractures. To establish correlates of morbidity and mortality from pelvic fractures due to blunt trauma, they reviewed 236 patients treated during 4 years. The average age of the 144 men and 92 women was 31.5 years, the average Injury Severity Score was 21.3, the average blood requirement was 5 units, and the average hospital stay was 16.8 days. One hundred fifty-two patients (64.4%) were injured in motor vehicle accidents, 33 (14%) had motor vehicle-pedestrian accidents, 16 (6.8%) had crush injuries, 12 (5.1%) each had either motorcycle accidents or falls, and 11 (4.6%) had miscellaneous accidents. Eighteen patients (7.6%) died, with seven (38.9%) deaths due to hemorrhage. Only one death was caused by pelvic hemorrhage. Other deaths were due to hemorrhage from other sites (6), head injury (5), sepsis or multiple-organ failure (4), pulmonary injury (1), and pulmonary embolus (1). None of the septic deaths was related to a pelvic hematoma. Multivariate multiple regression analysis showed that the severity of injury was correlated with indices of severity of pelvic fractures such as fracture site (p less than 0.0001), fracture displacement (p less than 0.005), pelvic stability (p less than 0.0001), and vector of injury (p less than 0.01). However death could not be predicted on the basis of these indices of severity (p greater than 0.28). Massive bleeding from pelvic fractures was

13

uncommon, and the major threat of hemorrhage was from nonpelvic sites. Furthermore, although injury severity was correlated with the severity of the pelvic fracture, hospital outcome was determined by associated injuries and not by the pelvic fracture.

Bishop et al (13) studied evaluation of a comprehensive algorithm for blunt and penetrating thoracic and abdominal trauma in the Department of Surgery, King-Drew Medical Center, Los Angeles. During a 4-month period, the management decisions and clinical course of 434 trauma patients were prospectively observed. Thirty-four patients had no signs of life on arrival to the emergency department (ED) and were excluded from the statistical evaluation; the remaining 400 patients constituted the study group. The mean Injury Severity Score (ISS), Penetrating Abdominal Trauma Index (PATI), and Trauma Score (TS) scores in the series were 21 +/- 10, 34 +/- 12, and 13 +/- 3 respectively. The overall patient mortality of the study group was 17 per cent; it was 61 per cent in those patients with major deviations from the algorithm and 6 per cent in patients who complied with the algorithm. There were 108 patients with ISS scores between 20 and 50.

Roux and Fisher

(14)

.Studied Chest injuries in children: an analysis of 100

cases of blunt chest trauma from motor vehicle accidents in Rondebosch, South Africa. One hundred twenty-eight cases of chest injury were seen in a Paediatric Trauma Unit over a 5 1/2-year period. One hundred patients sustained motor

14

vehicle accident (MVA)-related blunt chest injuries, 91 of them as pedestrians. Nine children had blunt chest injuries from falls, 10 had stab wounds (3 assault, 7 accidental), and 9 had gunshot injuries (6 from birdshot used by police during civil disturbance). MVA-related injuries were studied separately, as an etiologically homogeneous group. Sixty-five of these patients were under the age of 6. All but 3 also had serious extrathoracic injuries. The mean injury severity score (ISS) in MVA-related injuries was 25. Eight patients died, all with an ISS of 34 or more, 7 of whom had fatal head injuries. In MVA-related injuries, pulmonary contusion (n = 73) was the most frequent lesion seen, followed by rib fracture (n = 62), posttraumatic effusion (n = 58), pneumothorax (n = 38), and pneumatocele (n = 5). Analysis suggests that lung injury is a central event in MVA-related blunt chest trauma.

Daly and Thomas

(15)

studied trauma deaths in the South West Thames

Region. All traumatic deaths occurring in the South West Thames Region during 1988 were studied. They analyzed 434 of these deaths (mean age 52 years) in some detail. Of the deaths, 59 per cent occurred before arrival at hospital. Road traffic accidents are the commonest cause of death from trauma, being most prevalent in the areas containing major trunk roads. The majority of deaths due to chest injury (79 per cent) and multiple injuries (70 per cent) occurred before arrival at a hospital, whereas the majority of deaths due to head injury (63 per cent) occurred after admission.

15

King et al(16) studied correlation of trauma scoring and outcome in a Canadian trauma centre. Three hundred consecutive patients treated at a single trauma unit were studied. Two patients were excluded because of lack of physiologic data. Blunt injuries (94%) were most frequently from motor vehicle accidents (46%). The mean Injury Severity Score was 21.16.

Poole and Ward

(17)

studied causes of mortality in patients with pelvic

fractures in the University of Mississippi Medical Center, Jackson. Three hundred forty-eight patients were admitted directly to the hospital following blunt injuries; these patients formed the basis of this review. There were 220 men and 128 women with an average age of 31 years, a mean Injury Severity Score of 21.8, and an average hospital stay of 16.5 days. Almost two thirds of patients were injured in motor vehicle accidents, and about one eighth were pedestrians struck by a vehicle. Smaller numbers were injured in crushing accidents, motorcycle accidents, falls, and miscellaneous injuries. Only 32 patients (9%) had an isolated pelvic fracture. Associated injuries to the head, chest, abdomen, and upper and lower extremities were frequent, and these injuries often had a greater impact on outcome than the pelvic fracture. Twenty-eight patients died, an overall mortality rate of 8%. Only four deaths (14.3%) were a direct result of the pelvic fracture, and bleeding from a transected femoral artery contributed to one of these deaths. Most deaths were caused by severe head injury, nonpelvic hemorrhage, and multiple organ failure. Although the pelvic fracture may result in

16

prolonged hospitalization, and can be a cause of extended disability, it is an infrequent cause of mortality.

Craig et al (18) studied pancreatic injuries from blunt trauma in Hungary and found that during past 10 years they treated 13 patients with major pancreatic injuries from blunt trauma. Twelve had been involved in motor vehicle collisions, none of whom were wearing seat belts. One patient was injured in an assault. Only five patients had physical findings suggesting intra-abdominal injury. The five patients in whom peritoneal lavage was performed had free intraperitoneal blood from injuries to other abdominal viscera. One injury was diagnosed by ultrasound. Injuries were equally distributed throughout the pancreas, with two injuries in the head, three in the body, five in the tail, and three with injuries in both the head and the body. Five patients had ductal injuries. Injury Severity Score averaged 28.5 +/- 2.6 (mean +/- standard error), and mean hospital stay was 31 +/- 9.8 days.

Hill et al

(19)

studied the outcome after injury to car occupants and to

pedestrians in the Department of Surgery, Royal Prince Alfred Hospital, Sydney, Australia. The study group consisted of all adult car occupants and pedestrians sustaining major injury -- Injury Severity Score (ISS) of >15 -- in a defined area of central Sydney from mid-1991 to mid-1994. The study included 65 car occupants (median ISS, 32) and 101 pedestrians (median ISS,34). Major abdominal injury (p = 0.003) and thoracic aortic disruption (p = 0.06) were more common in car

17

occupants. The overall car occupant mortality was 38% compared with 46% in the pedestrians (p = 0.37). Seventy-two percent of car occupant fatalities occurred in the field, most commonly from ruptured thoracic aorta, whereas 63% of pedestrian deaths occurred in hospital (p = 0.005), most commonly from head injury.

Friedman et al(20) studied the AIS. They assessed the applicability of the AIS and the ISS systems for postmortem forensic documentation of trauma in the department of Anesthesiology, Sheba Medical Center, Jerusalem, Israel. In a prospective study, all trauma autopsies performed between January 1 and June 30, 1993, were coded according to the AIS and ISS method. All the cases were reviewed by a consultant in forensic medicine and a traumatologist. Cases were grouped in three categories according to ISS values: 0-14, 16-66, and 75. These categories represent minor, major, and incompatible with life injuries, respectively. All autopsy findings in which ISS was <14 were peer-reviewed to establish mechanism and cause of death. In the six month period, 279 trauma related autopsies were studied. Age at death averaged 37.1 .Eighty six percent of the victims were male. Penetrating trauma was the mechanism of injury in 67%.ISS was 0-14 in 19 cases, 16-66 in 150 cases, and 75 in 110 cases. In conclusion, AIS and ISS scoring systems are applicable to trauma forensic documentation. Using these methods for coding postmortem findings may help in establishing a database for trauma research, and this information could constitute a major part of continuous quality improvement of trauma

18

management. Low ISS values may serve as a warning, sometimes indicating preventable death.

Chong et al

(21)

studied Pelvic fractures and mortality in the College of

Medicine and Asian Medical Center, Seoul, South Korea. A retrospective study of all patients (N = 343) with pelvic fractures admitted to the trauma service was conducted to evaluate the impact of pelvic fractures on mortality. All patients sustained additional injuries with an average Injury Severity Score (ISS) of twenty. Thirty-six patients died. Six patients died as a direct result of pelvic hemorrhage. In six other patients, pelvic fractures contributed to their demise. The other twenty-four patients died from brain injury, thoracic hemorrhage, or other non-pelvic causes. Overall mortality for patients with pelvic fractures was 10.5 percent. This was a 1.4 fold increase in mortality compared to other trauma patients during the same time period without pelvic fractures. Mortality was dramatically increased in patients over sixty years of age (37 percent mortality compared to 8 percent). This greater than four-fold increase in deaths in the elderly appears to be an age related effect because the elderly patients generally had a lower ISS and less severe pelvic trauma than younger patients. They conclude that sustaining a pelvic fracture places the patient at an increased risk of death. Pelvic fractures contributed directly to death in one-third of the mortalities, one-third died from complications associated with pelvic fractures, and one-third died from other causes.

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Velmahos et al (22) studied patterns of injury in victims of urban free falls in Los Angeles, California and found that 187 consecutive presented to their trauma centre during a 9 month period (September 1994 to June 1995) after a fall from a height of 5 to 70 feet. Only three falls were from heights of more than 40 feet. Of these patients, 116(65.1%) suffered significant trauma. Fractures were the most common injuries, accounting for 76.2% of all injuries. Spinal fractures were detected in 37 patients and were associated with neurologic deficit in 7.Intraabdominal injuries occurred in 11 patients, requiring operative intervention in 9 of them. Solid organ lacerations prevailed, but small bowel perforation and bladder rupture were present in one case each. Significant retroperitoneal hematoma was detected in only one case and a thoracic aortic rupture in one more. Intraabdominal organ injuries are much more common than retroperitoneal ones.

Adesunkanmi et al

(23)

studied road traffic accidents to African children:

assessment of severity using the ISS and found that 324 Children were injured in road traffic accidents in western Nigeria between January 1992 to December 1995. This represented 2% of all attendances at the emergency room. Pedestrians represented the largest group of patients. Head injuries were the most common injuries, followed closely by limb trauma. Chest and abdominal trauma accounted for only 2.5 and 1.5 % of patients, respectively. IN 306 children the ISS was 1-25 with no mortality but significant morbidity. Eighteen

20

patients had an ISS of 26-54 with a 61% mortality rate (11 patients). The highest ISS were found in the group of patients who were passengers in a motor vehicle.

Banerjee KK et al

(24)

studied thoracoabdominal injuries in fatal road traffic

accidents in northeast Delhi. Amongst all the victims of fatal road traffic accidents 47.4% of victims had thoracoabdominal injuries with an adult male

preponderance. Most of these cases (50.9%) died at the spot with very few (1.8%) surviving more than 12 hours. Majority of the victims (29%) had a combination of injuries to the chest, abdomen and fracture of pelvis. The lungs (52.7%) in the chest and Liver (56.3%) in the abdomen were the commonest solid organs involved besides perforation of intestines (10.9%) amongst hollow viscera. Pedestrians (54.5%) were the most vulnerable amongst the victims. Trucks (42.1%) and buses (34.2%) formed the majority of offending vehicle.

Allen et al

(25)

studied outcomes after severe trauma at a northern

Canadian regional trauma centre. All trauma patients admitted between 1991 and 1994 who had an Injury Severity Score (ISS) greater than 12 were studied. Of 526 patients with an ISS greater than 12, 416 (79%) were suitable for TRISS analysis. Of these 416 patients, 310 (74%) were men. The mean age was 39 years The leading causes of injury were motor vehicle-traffic accidents in 48%, motor vehicle-nontraffic in 21% and falls in 8%. Overall, there were more unexpected survivors than patients who died.

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Pape et al (26) studied appraisal of early evaluation of blunt chest trauma: development of a standardized scoring system for initial clinical decision making in the department of trauma surgery at Hannover medical school, Germany. A retrospective investigation was performed on the basis of 4,571 blunt polytrauma (Injury Severity Score [ISS] > or = 18) patients admitted to their unit. Inclusion criteria were treatment of thoracic injury that required intensive care therapy, initial Glasgow Coma Scale score greater than 8 points, and no local or systemic infection. Patients with thoracic trauma and multiple associated injuries (ISS > or = 18) were included. In all patients, the association between various parameters of the thoracic injuries and subsequent mortality and morbidity was investigated. The association between rib fractures and chest-related death was low (> three ribs unilateral, mortality 17.3%, odds ratio 1.01) unless bilateral involvement was present (> three ribs bilateral, mortality 40.9%, odds ratio 3.43).

Gustavo et al (27) studied the role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures in the emergency service, department of surgery and orthopaedic surgery, Santa casa school of Medicine, Sao Paulo, Brazil. Retrospective review of the medical records of patients admitted with a pelvic fracture during a 42-month period was carried out. One hundred and three patients were included in the study. Fifty-nine were male, and the mean age was 34. The mean Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.1 and 20, respectively. Pedestrian vs vehicle (59%), was the most frequent mechanism of injury. Twenty patients died (19%) most frequently due to

22

"shock". Complications developed in 37 patients (36%), pneumonia being the most frequent. Age greater than 40 years (p=0.02), "shock" upon admission (p=0.002), a Glasgow Coma Scale (GCS)<9, Head AIS>2 (p<0. 001), Chest AIS>2 (p=0.007), and abdominal AIS>2 (p=0.03) all correlated with increased mortality. The outcome of patients with pelvic fractures due to blunt trauma correlates with the severity of associated injuries and physiological derangement on admission rather than with characteristics of or the type of fracture

Segers et al

(28)

conducted the retrospective analysis of 187 cases of

thoracic trauma seen between January 1, 1994 and June 30, 1999 in Belgique. The majority of the patients were male (male-female ratio 2.9:1) and the average age at admission was 41.1 years. Blunt trauma, especially motor vehicle accidents (72.2%) and falls (17.1%), were the most frequent causes of chest injury (95.8%). The average ISS for the total group was 27.8 (ranges: 4-75). In only 17.6% of the patients an isolated thoracic trauma was present. Rib fractures (n = 133), pulmonary contusion (n = 110), pneumothorax (n = 78) and haemothorax (n = 65) were the most frequent lesions The overall mortality rate was 16.6%. Main causes of death were intracranial hypertension, sepsis combined with multiple organ failure, and hypovolaemic shock. For patients who did not survive the average ISS was 40.3. Mortality after thoracic trauma remains relatively high, especially in case of associated neurotrauma. The ISS is a valuable score for assessing the severity of trauma and predicting outcome.

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Nikoli et al

(29)

studied correlation between survival time and severity of

injuries in fatal injuries in traffic accidents in the Institute of Forensic Medicine, University school of medicine, Belgrade. The sample included 272 persons: 193 males and 79 females. The proportion of men was more significant (chi 2 = 4.76; 0.01 < p < 0.05). Average age was 51.08 years (SD = 18.08): males 49.84 +/17.41 and females 54.09 +/- 19.38. The most frequently injured persons in their sample were pedestrians (134). The sample distribution by ISS values showed three peaks: for ISS--75, 41-50 and 26-35. Peaks indicated the number of the injured body regions and trauma severity in these persons. In 87 persons who did not survive, the ISS value was 75. There were 73 persons without outliving period with ISS values less than 75: their mean ISS value was 31.87 (SD = 11.30). In 112 cases the mean outliving period was 4.79 days (SD = 3.77) and their mean ISS value was 18.05 (SD = 15.33), which was a statistically significant lower ISS value than in previous group (t = 7.015; p < 0.001). A weak negative correlation between outliving period and ISS values in their sample was noted (coefficient of linear correlation r = -0.452). Coefficient of a determination (r2 = 0.20), pointed to the fact that direct correlation outliving period-trauma severity was only about 20% and the rest of correlation i.e. 80% depended on other factors (e.g. effective emergency medical system and triage, prompt and correct diagnosis, adequate medical treatment and care, etc.). The calculated linear regression was as follows: outliving period approximately 52-3 ISS. This regression pointed out that critical and potentially fatal injury, in their sample, was injury with ISS of 17. There were 22 persons with ISS < or = 7. Six of them died

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on the spot as car passengers; they died due to mechanical asphyxia (thoracoabdominal pressure) or respiratory and/or circulation failure due to critical chest injury (flail chest, contusions and rupture of the lungs with consequent haemopneumothorax). The rest of 16 persons survived trauma in an average of 8.56 days (SD = 3.88), and the causes of death were pneumonia, thrombus and fat embolism, sepsis, etc.

Mili et al

(30)

studied causes of death in long-term survivors of injuries

sustained in traffic accidents at the Institute of Forensic Medicine, University school of medicine, Belgrade. 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 their 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 their 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 the 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

25

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 autopsy findings and were not crucial for case solution. It was alarming, that one third of cases in the 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, multiple organ failure) and systemic inflammatory response syndrome. The diagnosis of these syndromes is possible only clinically: the autopsy and histological findings are not specific.

Hughes et al

(31)

studied intraabdominal gastrointestinal tract injuries

following blunt trauma in Australia and found that motor vehicle accidents were responsible for 92% admissions. Injuries were gastric (1.1%), duodenal (8.4%), small bowel (67.3%), and rectal (1.1%).Thirty day mortality was 23%.Patients dying within 24 hour of injury were 9.5%, out of which 4.1% were directly related to the GIT. 13.5% patients died within two weeks of admission, 4.1% of which were attributable to the GIT.

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Jha et al (32) studied epidemiological study of road traffic accident cases at Jawaharlal Institute of Postgraduate medical education and research (JIPMER) Hospital, Pondicherry and found that there were 83% male and 17% female accident victims. Labourers were the highest (29.9%) among the victims. The highest number of accidents took place in the month of January (12.9%) and on Sundays (17.1%). The occupants of the various vehicles constituted the large (45%) group of the victims. Among the motorized vehicles, two wheeler drivers were more (31.1%) involved in accidents.

Goel et al

(33)

studied epidemiological and Trauma Injury and Severity

Score (TRISS) analysis of trauma patients at a tertiary care centre in Lucknow, Uttar Pradesh, India. Of the 180 trauma patients studied, 123 were men (70.3%) with a mean age of 24.7 years; 143 patients had blunt injuries while 32 patients had penetrating injuries. A nearly equal percentage of men were injured on the road (39.8%) as at home (39.0%), while most women (65.4%) were injured at home. The mortality rate was 31.4%. TRISS methodology was applied to 88.6% of patients. All the 113 survivors had a probability of survival > or = 0.5 and were considered expected survivors. Among the 42 deaths, 32 had a probability of survival > or = 0.5 and were considered unexpected deaths, while 10 of the deaths had a probability of survival <0.5 and were expected deaths.

27

Singh and Dhattarwal (34) studied pattern and distribution of injuries in fatal road traffic accidents in Rohtak and found that 450 fatal road accidents which occurred during one year period, constituted 29.8% of total medicolegal deaths autopsied (1510) during same period. Pedestrians were the commonest group of victims involved, comprising 28.7% cases, followed by occupants of cabs and jeeps (25.8%) and motorcyclists (23%). The commonest age group involved was 21-30 years (27.3%) followed by 31-40 years (20.6%) and 11-20 years (17.3%) males out- numbered females in ratio 9: 1. Two third of cases were in age group of 11-- 40 years. 31.6% cases occurred on National Highways and 27.1% cases occurred on State Highways. Heavy vehicles were commonest offenders, responsible for 38.9% fatalities followed by cars and jeeps (30.4%) cases. Counted together extremity injuries outnumbered others (78.5%). Next were head and face 77.6%, chest 44%, abdomen 31.8% and neck 12.9% of all cases. Chest injuries were present in 44% cases and included fracture of ribs 36.9% cases, rupture of diaphragm 2% cases only and contusions and laceration of lungs in 29.8% cases. Abdominal injuries were seen in 31.8% cases and included laceration of liver (26.9%), spleen 12.7%, gut 4.7%, kidneys 3.8%, and bladder 2.9%.Fractures, dislocation and lacerations were commonest seen in 89.1 % and 88.8% cases followed by abrasions (84.4%). In 450 subjects, 664 injuries or group of injuries were believed to be fatal or contributing to death. Fatal injury per case being 1.4. Head injury was dominant in all road users (50.4%) followed by multiple injuries (15.8%) and thoraco-abdominal injuries (7.6%). 4.2% cases reached hospital within first 15 minutes, 15.4% died on the

28

spot and were not brought to hospital 24% reached within half an hour and 57% reached in next one hour and remaining 19% were rushed to hospital in more than one and half hours. Altogether, 39.5% victims had succumbed within 1 hour, 2/3rd (67.8%) by 12 hours, 3/4th (77.1%) by 48 hours and 90% by one week and 97.7% within two weeks. The longest survival period was 30 days and 15 hours.

Cooper et al (35) studied the incidence of abdominal injury in patients with thoracic and/or pelvic trauma. The Scottish Trauma Audit Group (STAG) collected the data on trauma patients reaching to the hospital in Scotland who were hospitalised for at least three days or who die as a result of their injuries and found that 507/3644(14%) patients with significant chest trauma but no pelvic trauma had concomitant abdominal injuries, compared to 111/1397(8%) patients with pelvic Trauma but no chest trauma. The likelihood of concomitant abdominal injury increased significantly if both chest and pelvis injuries were present (239/507, 47%; p< 0.001).Amongst patients with combined chest and pelvic trauma, the incidence of abdominal injury increased with severity of pelvic and chest injury (pelvis and chest both AIS=2:5/45,11%;either pelvis or chest AIS=3+:81/198,41%;both pelvis and chest AIS=3+:153/264,58%;p< 0.001).

Murlidhar and Roy

(36)

studied trauma outcomes in India: an analysis

based on TRISS methodology in a Mumbai university hospital. They studied 1074 severely injured patients. Survival analysis was completed for 98.3% of the patients. The majority of the patients were men (84%) and the average age was

29

31 years. 90.4% were blunt injuries, with road traffic crashes (39.2%) being the most common cause. The predicted mortality was 10.89% and the observed mortality was 21.26%. The mean Revised Trauma Score (RTS) was 6.61 +/- 1.65 and the mean Injury Severity Score (ISS) was 16.7 +/- 10.67. The average probability of survival (Ps) was 89.14. The M and Z statistics were 0.84 and -14.1593, respectively.

Meera and Nabachandra

(37)

studied pattern and ISS in blunt thoraco-

abdominal trauma cases in Manipal and found that males out numbered females in the ratio of 3.8: 1. The commonest age group of the victims was 21-30 years (20.80%). Vehicular accident was the leading cause of blunt thoraco abdominal trauma (86.40%) followed by assault by blunt weapon (8%). 12.80% of the victims had no associated external injuries to the thoraco abdominal region. 59 victims (47.2%) died at the spot. 15 cases (12.0%) died within1hour and 13 victims (10.04%) survived less than 2 hours. Only 2 victims (1.60%) survived up to more than 1 week. The commonest cause of death was haemorrhagic shock (as a result of intra thoracic and abdominal bleeding) combined with head injury in 61(48.80%) cases followed by haemorrhagic shock alone in (44%) of the cases. Peritonitis was the cause of death in 2 (1.60%) cases. It was found that in victims with low ISS (21-30 and 31-40 ISS score ranges) survival was more as compared to the victims with high ISS (51-60, 61-70 and 71-75 ISS score ranges). The spot-death victims had a mean ISS of 61.73 and cases who died

30

within 1 hour showed 48.33 as the mean ISS. Mean ISS was low in those victims who survived more than 1 week i.e. 27.50.

Chaudhary et al

(38)

studied profile of Road Traffic Accident cases in

Kasturba Hospital of M.G.I.M.S., Sevagram, Wardha, Maharashtra and found that a total 125 road traffic accident cases were admitted from July 1999 to June 2000. Out of them 32 cases died and were autopsied, 15 patients were brought dead from the spot and directly sent for autopsy examination. Maximum cases of road traffic accident were among males (83.20%), male to female ratio was 4.9%. Maximum incidence of RTA was in the age group of 20 to 39 years comprising 51.20%. Most common victim was pedestrian 44% followed by drivers 32.87%, and occupant 23.20%.Incidence was more common among the two wheeler vehicle driver. Head was the commonest site to be injured in road traffic accident. Liver and lung involvement was highest among internal organ injuries. Overall fatality was 27.11% and it was more in female cases. Head injury was commonest cause of death in road traffic accident.

Flagel BT et al (39) studied rib fractures. The National Trauma Data Bank (NTDB, v. 3.0 American College of Surgeons, Chicago, IL) was queried for patients sustaining 1 or more rib fracturesThe NTDB included 731,823 patients. Of these, 64,750 (9%) had a diagnosis of 1 or more fractured ribs. Thirteen percent (n = 8,473) of those with rib fractures developed 13,086 complications, of which 6,292 (48%) were related to a chest-wall injury. The overall mortality rate 31

for patients with rib fractures was 10%. The mortality rate increased (P < .02) for each additional rib fracture. Increasing the number of rib fractures correlated directly with increasing pulmonary morbidity and mortality. Patients sustaining fractures of 6 or more ribs are at significant risk for death from causes unrelated to the rib fractures.

Sharma et al (40) studied trauma score as a valuable tool for documentation of autopsy reports of trauma victims and found that out of a total 14390 victims of Road Traffic Accidents reporting to the Emergency Wing at Government Medical College Hospital,Chandigarh, 552 (4%) had a fatal outcome; whereas 304 (2%) sustained permanent disability of variable extent. Over all, 282 (51%) victims died within 6 hours of the accident, of which 149 (27%) died either on the spot or were declared brought dead to the hospital. Among the offending vehicles, motorcycles outnumbered all other categories of vehicles claiming 25% victims of fatal accidents whereas pedestrians (41%) constituted the majority among the victims.

Rautji et al (41) studied the AIS and its correlation with traumatic accidental deaths in South Delhi in 400 autopsies of road traffic accident victims. They classified these cases into different injury groups according to the ISS. Fifty eight cases (14.5%) were assigned an ISS value of <25; 244(61%) cases were valued between 25-49, 38 cases(9.5%) were valued between 50-74 and 60 cases (15%) had a value of 75.The age group between 21-30 years was most vulnerable,

32

comprising 38% of the cases. Males comprised 90% of the total cases. Pedestrians were involved in 44% of cases. Buses/minibuses were the most common offending vehicles. Head and neck were the most vulnerable body regions being involved in 75% cases. Sixty six percent of the patients suffered multiple traumas. In cases with ISS less than 50; about 96% of the victims did not receive optimal care quickly enough with lack of prehospital resuscitation measures and lengthy transportation time to Hospital being of major importance.

Pathak et al

(42)

studied fatality due to chest injury in road traffic accident

victims of Varanasi and adjoining districts, U.P. and found that chest injuries in combination with other regional injuries (61.76%) were the second commonest cause of fatal road traffic accident cases, commonest being head injuries . The greater frequency of fatality in the regional injury, i.e. chest injuries was due to involvement of two vital organs, viz. heart and lungs. In chest injury, the majorities of cases had lung injuries (81.30%) and were followed by injuries to the heart (43.08%). Major great vessels were injured in (21.95%) of deceased. The abdominal injuries were mostly found associated with chest injuries. Liver was injured in 12.19% victims. Syncopal death (haemorrhagic shock) along with asphyxia was the commonest mode of death (30.08%) followed by asphyxia (27.64%) alone. More than two third (69.91%) victims died at the place. of incidence.

33

Nikoli et al

(43)

studied forensic expertise of the injury severity in fatally

injured car-occupants. A total of 500 cases were analyzed: 282 car-drivers and 218 front car-passengers, average age of 41.48 +/- 15.31 and 39.78 +/- 16.93. There were 401 males and 99 females. The most injured body region was head with neck: AIS = 3.50 +/- 2.48, for car-drivers, and AIS = 3.54 +/- 2.50, for front car-passengers, as well as thorax: AIS = 3.63 +/- 2.16 car-drivers, and AIS = 3.37 +/- 2.14, for front car-passengers. More severe injuries of head (AIS > or =4) suggested that deceased was a front car-passenger (Wald = 13.27; p = 0.04). More severe injuries of thorax and abdomen (AIS > or =5) indicated that deceased was a car-driver (Wald = 5.72; p = 0.02, and Wald = 8.23; p = 0.01, respectively). The injury severity of the face and limbs were useless in such expertise (Wald = 1.72; p = 0.19, and Wald =0.89; p = 0.34, respectively). An average ISS was 57.31 +/- 20.16 for car-drivers, and 54.54 +/- 21.01 for front car-passengers.

Giannoudis et al

(44)

studied prevalence of pelvic fractures, associated

injuries, and mortality in the United Kingdom. Prospective data from 106 trauma receiving hospitals forming the Trauma Audit and Research Network were studied. Between January 1989 and December 2001 data of 159,746 trauma patients were collected in the Trauma Audit and Research Network database. Because of incomplete data, 1,610 pelvic fracture patients and 13,499 patients without pelvic fracture were excluded from detailed analysis. In total, 11,149 patients in the pelvic ring fractures (PG) and the remaining 133,486 patients in

34

the NPG (control) group were included in the final analysis.There were statistically significantly more patients with an Injury Severity Score >15 in the PG group (n = 3,576; 32.1%) than in NPG group (n = 19,238; 14.4%) (p < 0.001), indicating that pelvic injuries were more often associated with other injuries. The majority of patients sustained Abbreviated Injury Score (AIS) 2 pelvic injuries (65.0%), whereas AIS 4 and 5 injuries were found in less than 10% of patients. Pelvic ring injuries were most commonly associated with chest trauma with >AIS 2 severity in 21.2% of the patients, head injuries (>AIS 2) in 16.9%, liver or spleen injuries in 8.0%, and two or more long bone fractures in 7.8%. The 3month cumulative mortality rate of the patients with pelvic injuries was 14.2% (1,586 patients) versus 5.6% (7,465 patients) of the NPG group.Age, early physiologic derangement, and presences of other injuries (head or trunk) were associated with reduced survival rates.

Zargar et al

(45)

studied a total of 276 consecutive trauma patients in 6

general hospitals for thoracic injury at Sina trauma and surgery research center, Sina general hospital, medical sciences, University of Tehran. There were 246 males (89.1%) and 30 females (10.9%) ranging from 3 to 80 years with a mean age of (34+/-17) years. Road traffic accident was the main cause of injury, especially for pedestrians, followed by stab wound (89 cases, 32.1%) and falling injuries (32 cases, 11.6%), respectively. Haemothorax or pneumothorax (50.4%) and rib fracture (38.6%) were the most common types of chest injury. Extremity fracture was the most common associated injury with the rate of 37% ( 85/230),

35

followed by head injury (25.2%) and abdominal trauma (19.6%). The presence of blunt trauma, head injury and abdominal injury independently adversely affect mortality after chest trauma.

Michiue et al

(46)

evaluated 5 cases of clinically unexpected delayed

collapse followed by death using the abbreviated injury scale (AIS), injury severity score (ISS), and a clinical trauma care method (trauma and injury severity score, TRISS). In these cases, major injury (AIS = 3-5) was found in the head, chest and/or abdomen at autopsy, and ISS was estimated to be 11-45 (serious to critical but not incompatible with life). By the TRISS method, the probability of survival (P (s)) was estimated to be >0.5 for all cases (0.60-0.99), suggesting that these were preventable deaths.

Ndiaye et al (47) studied the fatal injuries of car drivers in France. Mean annual mortality at the wheel of a car was computed by dividing the total number of drivers killed (n=383) by the population of the Rhne Department (1.6 million) during the period 1996-2004 it was 5.41 males per 100,000 and 1.41 females per 100,000, with 78% of the casualties residing in the Department. Three-quarters of the casualties died at the scene of the crash. The injuries were analyzed for the 287 killed drivers whose deaths could be explained by the described injuries (at least one AIS 4+ injury). Of these, 41% had an ISS of 75 (at least one AIS 6 injury), 21% had an ISS of between 40 and 74, 33% an ISS of between 25 and 40, and 6% an ISS of between 16 and 24. In the case of all the AIS 4+ injuries,

36

the three most frequent locations for injuries were the thorax only (30% of casualties), the head only (23%) and a combination of the two (18%). Abdominal injuries occurred in only 10% of casualties and spinal injuries in 9% of casualties. In the thorax, the most common injury was flail chest with haemothorax or pneumothorax. In the case of the head, the most frequent injuries were to the brain (haemorrhage, haematoma and axonal injuries). In spite of the use of restraint devices, the thorax and head are still the priority vital areas for protection in the case of car drivers. For one in four of the fatalities, death cannot be explained by any of the injuries we know about.

Koo et al (48) studied mortality in patients with multiple injuries in a referral hospital. They studied the cases of 198 patients with a mean (SD) age of 43.9 (19) years. Ninety-three percent had suffered blunt trauma. The mean ISS, the prehospital RTS, and the TRISS were 16.9 (11.2), 10.8 (2.5), and 0.95 (0.2), respectively. Twenty-five patients died. Fifteen deaths were classified as preventable or potentially preventable.

Palmer

(49)

studied AIS 2005 versus AIS 1998A double-coding exercise

to identify issues for trauma data .602 injuries sustained by 109 patients were compared Discrepancies in data consistency were more common in head and chest injuries. Data mapped to a different codeset performed better in comparisons than raw AIS98 and AIS05 code sets.

37

OBJECTIVES OF RESEARCH
Page s: 38-39

38

OBJECTIVES OF RESEARCH
1. To study the pattern of fatal blunt thoraco-abdominal trauma. 2. To correlate the relationship between survival time and injury severity score.

39

MATERIAL AND METHODS

Pages: 40-43

40

MATERIAL AND METHODS

1. Material for the present study was collected from the cases of blunt thoracoabdominal trauma brought for medico legal autopsy to the Mortuary of the Department of Forensic Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi.

2. Cases brought during the period November 2008 to February 2010 were taken up for the study. A total of 95 cases were studied irrespective of age and sex of victims.

3.

a. All the cases showing fatal blunt thoracic and/ or abdominal injuries with or without external injuries were included in the study.

b. Dead bodies showing severe degree of decomposition particularly of the internal organs were excluded from this study to avoid false interpretation of findings.

4. The severity of the injuries was established using the NISS. NISS of each injured body region was calculated using the Association for Advancement of Automotive Medicine, 1990(50) (Appendix 1) and Association for Advancement of Automotive Medicine, 2005(51) (Appendix 2) protocol.

41

5. In cases of road traffic accidents detailed information regarding type of vehicle involved and category of victims was obtained from inquest papers, police and relatives of the deceased. The types of vehicles were categorized into bus/minibus, truck, car, two wheelers, others (three wheelers etc.) and unknown. Victims were categorized into pedestrians, two wheelers occupants, cyclist, car occupants, bus/truck passenger and others.

6. The following instruments and documents were used for the study : a. Autopsy table and instruments. b. Inquest papers and other related documents. c. Measuring tape / Scale d. Gloves e. Standard Autopsy suit f. Computer

7. Universal precautions were taken while performing autopsies. They were a. Appropriate proper clothing i.e. gloves, masks, eyewear, headwear, shoe covers, an impervious or full-covered gown were worn while conducting postmortem examination. b. Hand washing was done after contamination with blood or other body fluids and immediately after the gloves were removed.

42

c. After using scalpels, disposable syringes, needles and other sharps they were placed in puncture resistant containers for disposal. These containers were placed as close as practical to the area where sharps were being used.(52)

8. A predesigned Case Record Form (Appendix 3) was used to enter the various data for: a. Parameters being studied. b. New Injury Severity Score(NISS)

9. Relationship between NISS and survival time was established using regression analysis and obtaining coefficient of correlation.

43

OBSERVATIONS AND RESULTS

Pages : 44-59

44

OBSERVATIONS AND RESULTS

Detailed observations for 93 autopsies with evidence of fatal thoracoabdominal trauma during the period 1st November 2008 to 30th March, 2010 were carried out and various statistical results were drawn from them. These are described as follows:

AGE INCIDENCE
The most common age group involved was between 21-30 years of age comprising 29% of total 93 cases followed by the age group of 11-20 years comprising 20.4% of total cases. Children below 10 years constituted only 7.5% of total cases. Persons above 60 years constituted only five cases, i.e., 5.4% of total cases. (Table 1) The most vulnerable age group involved among males was between 21-30 years of age comprising 30.4% of total 79 cases followed by the age group of 1120 years comprising 22.8% of total cases. The most vulnerable age group involved among females between 21-30 and 31-40 years of age each comprised of 21.4% of the 14 cases. (Table2).

SEX INCIDENCE
Among those 93 cases studied, males comprised 79 cases, i.e., 84.9% of cases, while females were only 14 in number, i.e., 15.1% of cases. 45

Table 1: Age wise distribution of males and females.

AGE GROUP IN YEARS 0-10 11-20 21-30 31-40 41-50 51-60 >60 Total

MALES 5 18 24 13 12 4 3 79

FEMALES 2 1 3 3 1 2 2 14

Total 7 19 27 16 13 6 5 93

Percentage 7.5 20.4 29 17.2 14 6.5 5.4 100

Table 2: Age and sex wise distribution of cases.

Age Group in Years 0-10 11-20 21-30 31-40 41-50 51-60 >60 Total

Males

Percentage

Females

Percentage

5 18 24 13 12 4 3 79

6.3 22.8 30.4 16.5 15.2 5.1 3.8 100

2 1 3 3 1 2 2 14

14.3 7.1 21.4 21.4 7.1 14.3 14.3 100

46

CAUSE OF TRAUMA
The most common cause of blunt fatal thoracoabdominal trauma was vehicular accident seen in 79.57% of cases. (Table 3)

Table 3: Distribution of cases according to cause of trauma Number of cases Vehicular accident Train accident Fall from height Others Total 74 14 3 2 93 Percentage 79.57 15.05 3.23 2.15 100

REGIONS OF BODY INVOLVED IN VICTIMS HAVING FATAL THORACOABDOMINAL INJURIES

Pelvic injuries alone constituted the maximum number of cases (22.58%). Whereas chest and pelvis combined were injured only in a solitary case (1.08%). Abdomen alone or in combination with other regions were involved in the maximum number of cases (63.44%) (Table 4).

Table 4: Distribution of cases according to regions of the body involved Region of the body No. of cases Percentage

47

involved Chest alone Abdomen alone Pelvis alone Chest and abdomen Chest and Pelvis Abdomen and Pelvis Abdomen, Chest and Pelvis Total 12 19 21 15 1 7 18 93 12.90 20.43 22.58 16.13 1.08 7.53 19.35 100

PERIOD OF SURVIVAL
In 93 cases, it was found that 60cases (64.5%) (Were dead on arrival i.e., died at the scene/spot or were brought dead to the casualty (Table 5).Those surviving for more than a day constituted only 8.6% of the cases.

48

Table 5: Distribution of cases in relation to period of survival. Period of survival Number of cases Percentage of cases

Dead on arrival

60

64.5

<2 HRS. 2-6 HRS 6-12 HRS

9 7 5

9.7 7.5 5.4

12-24 HRS 1-7 DAYS 1-4 Weeks Total

4 7 1 93

4.3 7.5 1.1 100

VICTIMS
A total of 37 pedestrians (39.78%) were killed in 93 fatal blunt thoracoabdominal trauma cases. The next common category was two wheeler occupants which accounted for 24 cases (25.81%). Car occupants were not involved in any case. (Table 6).

49

Table 6: Thoracoabdominal trauma victims

Type of Victim Pedestrian Two wheelers occupants Cyclist Car occupants Bus/Truck passenger Fall from height Train accidents Others Total

Number of victims 37 24 7 0 2 3 14 6 93

Percentage 39.78 25.81 7.53 0 2.15 3.23 15.05 6.45 100

OFFENDING VEHICLES
In the pesent study Bus/Minibus and Unknown caused maximum, blunt fatal thoracoabdominal trauma i.e., 15 cases which amount to 16.13% of the total cases. (Table 7).Two wheelers like motorcycle/scooter caused the least number of fatalities (5.38%).

Table 7: Victims in relation to offending vehicles

50

Offending vehicle Bus/Minibus Truck Car Two wheelers (Motorcycle, scooter ) Train Three wheelers (Auto, rickshaw etc) Others* Unknown

Number of victims 15 11 13 5 14 10 10 15

Percentage 16.13 11.83 13.98 5.38 15.05 10.75 10.75 16.13

Total 93 100 *Wall collapse, fall of copper bundle on body, fall from bullock cart etc.

ASSOCIATED EXTERNAL INJURIES

In the present study, 88.20% of the cases showed associated external injuries on the thoracoabdominal region while the remaining 11.80% did not show any external injuries.

ORGANS INJURED
Rib fracture is seen in majority of cases (55). Liver and lungs were the

commonest injured visceral organs. (Table 8).Pancreas was the least injured organ. In the 0-20 years age group Liver was most commonly injured whereas after 20 years of age the Lungs were the most commonly injured organ.

Table 8: Number of victims in relation to different organs injured

51

Age group

Liver Spleen Bowel 5 10 14 7 8 3 3 50 2 5 11 4 6 0 2 28 2 7 3 2 2 0 0 16

Pancreas Kidney

Urete Bladd r er

Rib # 0 6 19 11 9 5 5 55

Lung Heart Pelvis 2 9 16 9 6 5 3 50 0 3 5 4 3 0 0 15 3 9 14 6 7 3 1 43

0-10 11-20 21-30 31-40 41-50 51-60 >60 total

0 1 1 1 1 0 0 4

2 7 9 5 2 1 2 28

0 0 0 1 0 0 0 1

1 4 2 3 2 1 0 13

INJURY SEVERITY SCORE

NEW INJURY SEVERITY SCORE (1990)

Mean NISS was 42.89. Maximum cases belong to high (50-75) NISS group i.e. 43%. (Table 9)

Table 9: Distribution of cases according to new injury severity score (1990)

NISS Score (1990)

Number of cases

Percentage

52

0-25 25-50 50-75 Total

21 32 40 93

22.6 34.4 43.0 100

NEW INJURY SEVERITY SCORE (2005)

Mean ISS was 46.59.Maximum cases belong to high (50-75) ISS group i.e. 51.6% (Table 10)

Table 10: Distribution of cases according to new injury severity score (2005)

NISS Score (2005) 0-25 25-50 50-75 Total

Number of cases 21 24 48 93

Percentage 22.6 25.8 51.6 100

AGE GROUPS IN RELATION TO NEW INJURY SEVERITY SCORE (2005)

The maximum numbers of victims (48) were having NISS of 50-75 (Table 11). Amongst these the largest number (16) belonged to the 21-30 year age group. 53

Table 11: Age groups in relation to new injury severity score (2005) Age group 0-10 11-20 21-30 31-40 41-50 51-60 >60 TOTAL NISS 0-25 3 5 7 2 3 1 0 21 NISS 25-50 2 5 4 5 3 4 1 24 NISS 50-75 2 9 16 9 7 1 4 48 Total 7 19 27 16 13 6 5 93

Survival period in relation to new injury severity score

In the present study maximum, blunt fatal thoracoabdominal trauma i.e., 35 cases belong to NISS 50-75 among dead on arrival group, and as survival period increases, NISS 0-25 and NISS 25-50 contain more number of cases (Table 12 and Table13).

Table 12: Survival period in relation to new injury severity score (1990) NISS Score (1990) 0-25 Dead on arrival 7

<2 HRS

2-6 HRS 2

6-12 HRS 2 54

12-24 HRS 3

1-7 DAYS 3

1-4 Weeks 0

25-50 50-75 Total

18 35 60

3 2 9

5 0 7

2 1 5

1 0 4

3 1 7

0 1 1

Table 13: Survival period in relation to new injury severity score (2005) NISS Score (2005) 0-25 25-50 50-75 Total

Dead on arrival 6 15 39 60

<2 HRS 4 1 4 9

2-6 HRS 3 2 2 7

6-12 HRS 2 2 1 5

12-24 HRS 3 1 0 4

1-7 DAYS 3 3 1 7

1-4 Weeks 0 0 1 1

55

MANNER OF DEATH
In all the cases studied manner of death was accidental.

CAUSE OF DEATH
Haemorrhagic shock accounted for the largest number of cases (70.97%). followed by Asphyxia (20.43%) (Table 14).Asphyxia was as a result of bilateral rib fractures (flail chest).

Table 14: Showing cause of death in relation to sex Cause of death Asphyxia Neurogenic shock Haemorrhagic shock Septicaemic shock Total Number of cases 19 4 66 4 93 Percentage 20.43 4.30 70.97 4.30 100

CORRELATIONS
Correlation between NISS 1990 /NISS 2005 and period of survival (Ps) Correlation or co-relation can refer to any departure of two or more random variables from independence, but most commonly refers to a more specialized type of relationship between mean values. There are several correlation

56

coefficients, often denoted or r, measuring the degree of correlation. The most common of these is the Pearson correlation coefficient, which is mainly sensitive to a linear relationship between two variables.

The most familiar measure of dependence between two quantities is the Pearson product-moment correlation coefficient, or "Pearson's correlation." It is obtained by dividing the covariance of the two variables by the product of their standard deviations. Karl Pearson developed the coefficient from a similar but slightly different idea by Francis Galton.

The population correlation coefficient X, Y between two random variables X and Y with expected values X and Y and standard deviations X and Y is defined as:

where E is the expected value operator, cov means covariance, and, corr a widely used alternative notation for Pearson's correlation.

The Pearson correlation is defined only if both of the standard deviations are finite and both of them are nonzero. It is a corollary of the CauchySchwarz inequality that the correlation cannot exceed 1 in absolute value. The correlation coefficient is symmetric: corr(X,Y) = corr(Y,X).

The Pearson correlation is +1 in the case of a perfect positive (increasing) linear relationship, 1 in the case of a perfect decreasing (negative) linear relationship 57

[5]

, and some value between 1 and 1 in all other cases, indicating the degree of

linear dependence between the variables. As it approaches zero there is less of a relationship. The closer the coefficient is to either 1 or 1, the stronger the correlation between the variables.

If the variables are independent, Pearson's correlation coefficient is 0, but the converse is not true because the correlation coefficient detects only linear dependencies between two variables. For example, suppose the random variable X is symmetrically distributed about zero, and Y = X2. Then Y is completely determined by X, so that X and Y are perfectly dependent, but their correlation is zero; they are uncorrelated. However, in the special case when X and Y are jointly normal, uncorrelatedness is equivalent to independence (55).

The results showed a negative correlation between NISS 1990 and Ps (period of survival) with an r-value of 0.438 (p < 0.005). (Table15) and Coefficient of a determination r2 = 0.19. The results also showed a negative correlation between NISS 2005 and Ps (period of survival) with an r-value of 0.472 (p < 0.005)(Table 16) and Coefficient of a determination r2 = 0.19. This means that as NISS increases period of survival decreases.NISS 1990 had a mean of 42.89 and the NISS 2005 had a mean of 46.59 in our trauma patient population The strength of the relationship between NISS 2005 and Ps was greater than that between NISS 1990 and Ps.

58

Table 15: Correlation between NISS 1990 and Period of survival.

Period of survival(Ps) Ps Pearson Correlation Significance (2-tailed) N Pearson Correlation Significance (2-tailed) N 1.000

NISS 90 -0.438 0.000 93

NISS 90

-0.438 0.000 93

1.000

Correlation is significant at the 0.01 level (2-tailed).

Table 16: Correlation between NISS 2005 and period of survival Period of survival(Ps) Ps Pearson Correlation Significance (2-tailed) N Pearson Correlation Significance (2-tailed) N 1.000 NISS 90 -0.472 0.000 93

NISS 90

-0.472 0.000 93

1.000

Correlation is significant at the 0.01 level (2-tailed).

59

DISCUSSION
Pages: 60-75

60

DISCUSSION
Age and sex distribution of victims
In the present study it was observed that majority of cases were males in the age group of 21-30 years. The large number of cases in this age group can be attributed to the fact that this period of life is the most vulnerable to trauma because of a very high level of outdoor activities. Male dominance in this type of injury could likely be due to the fact the males are more exposed to trauma as they constitute working and earning member in majority of families and so move out of the house more often than females, Similar findings were also observed by Jha et al (32), Meera and Nabachandra Mansar et al (53)
(37)

, Rautji et al (41), Sharma et al (40), and

Associated External injuries

In this study, 88.20% of the cases showed associated external injuries on the thoracoabdominal region while the remaining 11.80% did not show any external injuries. Similar findings were also observed by Meera and Nabachandra(37). In their study, 87.20% of the cases showed associated external injuries on the thoracoabdominal region while the remaining 12.80% did not show any external Injuries. The reason for absence of associated external injuries in 12.80% of cases may be that most part of the thoracoabdominal region is covered with clothes and so abrasions and bruises are less likely. 61

Cause of blunt thoracoabdominal trauma

In the present study, majority of blunt thoracoabdominal injuries were due to vehicular accidents (79.57%), followed by train accident, fall from height, hit by fall of heavy objects etc. There was no case of assault by blunt weapon. This finding is also in agreement with the work of Meera and Nabachandra
(37)

who

also observed that the commonest cause of blunt thoracoabdominal trauma was vehicular accidents (86.40%).(Table 17)

Table 17 comparison of causes of fatal blunt thoracoabdominal trauma with the study done at Imphal. Present study (North east Delhi) Vehicular Accident Assault by blunt weapon Hit by fall of heavy objects Fall from height Kick by horse Train accidents Others 79.57% 0% 1.08% 3.23% 0% 15.05% 1.07% Meera and Nabachandra (37) (Imphal) 86.40% 8.00% 2.40% 2.40% 0.80% 0% 0%

Regions of body involved in victims having fatal Thoracoabdominal injuries 62

Pelvis was injured in maximum number of cases. (22.58%).This may be due to the fact that in maximum cases offending vehicle were bus/minibus and trucks (heavy vehicles) and accident with these vehicles causes primary impact injuries over the pelvic region. Another reason for the greater involvement of the pelvis could be due to fall on the ground after impact with offending vehicle leading to pelvic trauma. Abdomen alone was involved in 20.43% of cases.Abdomen alone or in combination with other regions was involved in the maximum number of cases (63.44%). This is because cases of fatal blunt thoracoabdominal trauma were taken and so due to lack of any protective bony cage unlike the chest there was a far greater fatality when the abdomen was involved in comparison to the chest.

These findings are also in agreement with the findings of Bergqvist et al

(7)

who

studied patients with abdominal trauma and fatal outcome in an analysis of a 30year series in a rural Swedish area. They found that Patients with blunt abdominal trauma with fatal outcome comprised of 127 patients and found that one fourth of these patients died from an abdominal inury alone.

In the present study chest and abdomen involvement without pelvic trauma comprised 16.13% of cases, abdomen and pelvis involvement without chest trauma in 7.53% of cases. These findings are also in agreement with the findings of Cooper et al (35). who studied the incidence of abdominal injury in patients with

63

thoracic and/or pelvic trauma. The Scottish Trauma Audit Group (STAG) collected the data on trauma patients reaching to the hospital in Scotland who were hospitalised for at least three days or who die as a result of their injuries and found that 507/3644(14%) patients with significant chest trauma but no pelvic trauma had concomitant abdominal injuries, compared to 111/1397(8%) patients with pelvic Trauma but no chest trauma. The likelihood of concomitant abdominal injury increased significantly if both chest and pelvis injuries were present (239/507, 47%; p< 0.001).Amongst patients with combined chest and pelvic trauma, the incidence of abdominal injury increased with severity of pelvic and chest injury (pelvis and chest both AIS=2:5/45,11%;either pelvis or chest AIS=3+:81/198,41%;both pelvis and chest AIS=3+:153/264,58%;p< 0.001).

Accident victims
A total of 37 (39.78%) pedestrians were killed in 93 fatal blunt thoracoabdominal trauma cases. Similar increased numbers of thoracoabdominal trauma among pedestrians have also been reported by Jha et al
(37) (32)

, Meera and Nabachandra

, and Sharma et al (40) (Table 18).The next common category was two wheeler

occupants which accounted for 24 (25.81%) cases. Two victims were Bus/Truck passengers. Cyclists were killed in 7(7.5%) cases. Others (occupants of TSR, tractors etc.) accounted for 6 (6.45%) cases. Car occupants were not involved in any case. This may be because cars plying with high speed on the roads in this region are less as compared with other parts of Delhi due to heavy traffic congestion in this area of Delhi making speeding difficult. The pedestrians in 64

most of the instances were knocked down by heavy vehicles leading to fatal thoracoabdominal injuries. Encroachment of pavements making people walk on roads, little segregation between vehicular and pedestrian traffic, lack of awareness among pedestrian of road rules and lack of pedestrian crossings are some of the reasons for increased involvement of pedestrians. Poor maintenance of roads and lack of observance of traffic rules by vehicular traffic are some other reasons.

Table 18: Comparison of victims of blunt fatal thoracoabdominal trauma with those at Jammu, Delhi and Chandigarh

Victim

Present study North east Delhi Jammu 46.17% 30.38% 1.92% 12.6% 0% N.I* N.I 8.94%

Sharma et al (40) Delhi 47.03% 22.17% 10.85% 8.11% 0% N.I N.I 12.98% Chandigarh 42.07% 24.97% 13.24% 8.28% 0% N.I N.I 11.45%

Pedestrian Two wheelers occupants Cyclist Bus/Truck passenger Car Fall from height Train accident Others *N.I = Not included in the study

39.78% 25.81% 7.53% 2.15% 0% 3.23% 15.05% 6.45%

OFFENDING VEHICLE

65

Amongst the offending vehicles Bus/Minibus were responsible for blunt fatal thoracoabdominal deaths in 15 cases which amount to 16.13% of the total cases. The trucks and cars were also responsible for large number of deaths (11.83% and 13.98% respectively). A large number of buses are plying on the roads in this region as people of low socioeconomic group live here and so it is a common mode of transport. Hence a large number of fatalities are caused by these vehicles. Three wheelers (auto rickshaws) were responsible for 10.75% of fatal blunt thoracoabdominal trauma cases. Low income/middle income group people use more auto rickshaws and so there is increased use of auto rickshaws in this part of Delhi leading to an increased percentage of auto rickshaws as offending vehicle in our study. Another major killer was Trains which caused fatal thoracoabdominal trauma in 15.05% of cases. These findings are also in

agreement with the findings of Sharma et al (40) who however had a large number of Bus/Minibus being the offending vehicles as compared to the present study. (Table19) Two wheelers caused only 5.38% of deaths whereas in study of Sharma et al (40) it was the offending vehicle in 12.59% cases in Jammu, 10.53% cases in Delhi and 12.41% cases in Chandigarh respectively. The reason for this could be that two wheelers move with slow speed on the roads because of heavy traffic congestion in this part of Delhi as compared to other parts of Delhi and other cities like Jammu and Chandigarh.

66

Table 19: Comparison of Offending vehicle in blunt fatal thoracoabdominal trauma with those at Jammu, Delhi and Chandigarh

Present study North east Delhi Bus/Minibus 16.13% Truck 11.83% Car 13.98% Two wheelers 5.38% Train 15.05% Three wheelers 10.75% Unknown 16.13% Others 10.75% *N.I = Not included in the study

Offending vehicle

Jammu 26.09% 17.79% 15.32% 12.59% N.I* 0% 16.88% 10.49%

Sharma et al (40) Delhi Chandigarh 29.68% 26.21% 14.5% 13.52% 10.41% 18.06% 10.53% 12.41% N.I N.I 0% 0% 18.92% 14.48% 16.02% 15.31%

PERIOD OF SURVIVAL
In the present study majority of cases were dead on arrival. Similar findings have also been reported by Meera and Nabachandra
(37)

and Sharma et al

(40)

. This

emphasizes the fact that most of our vital organs are present in the chest and abdominal cavity and further the abdominal cavity lacks any protective bony cover. So trauma quickly leads to injuries to the vital organs and major blood vessels present in the thoracic and abdominal cavities. Inadequate infrastructure for early transport of victims and lack of proper management of trauma patients on the way to hospital because of traffic congestion on the highway leads to early deaths. These victims need onspot emergency, medical care and rapid transportation from the incident site to the hospital which is lacking in this part of Delhi. Further there is involvement of heavy vehicles in 27.96% of cases and

67

trains in 15.05% of cases which leads to severe trauma to vital organs leading to early deaths

INJURY SEVERITY SCORE

The strength of the relationship between NISS 2005 and Ps was greater than that between NISS 1990 and Ps in the present study as the results showed a negative correlation between NISS 1990 and Ps (period of survival) with an rvalue of 0.438 (p < 0.005) and Coefficient of a determination r2 = 0.19. The results also showed a negative correlation between NISS 2005 and Ps (period of survival) with an r-value of 0.472 (p < 0.005) and Coefficient of a determination r2 = 0.19.

The reason could be that in AIS 2005 the pelvis is divided into the pelvic ring and the acetabulum.The pelvic ring is a single anatomical structure for AIS coding no matter the number of fractures to specific aspects. In AIS 2005 displaced as a fracture descriptor has been deleted. In AIS 2005 coding for rib fractures has been simplified with the most significant discrimination being between flail and no flail. In AIS 2005 code is one level higher for the bilateral situation (56).

In the present study maximum cases belong to high (50-75) NISS group. (Table 20)

Table 20: Comparison of NISS 1990 and NISS 2005 68

NISS 1990 NISS 0-25 NISS 25-50 NISS 50-75 22.6% 34.4% 43.0%

NISS 2005 22.6% 25.8% 51.6%

NISS of trauma victims had a mean of 42.89. The results showed a negative correlation between NISS 90 and Ps (period of survival) with an r-value of 0.438 (p < 0.005). The results also showed a negative correlation between NISS 05 and Ps (period of survival) with an r-value of 0.472 p < 0.005). NISS 90 had a mean of 42.89 and the NISS 05 had a mean of 46.59 in our trauma patient population. This means that as NISS increases period of survival decreases.

A weak negative correlation between period of survival and NISS values [coefficient of linear correlation r = -0.438 (1990) and -0.472 (2005) respectively] and Coefficient of a determination [r2 = 0.19 (1990) and 0.22 (2005) respectively], pointed to the fact that direct correlation between period of survival and NISS was only about 19% and 22% respectively and the rest of correlation i.e. 81% and 78% depended on other factors (e.g. effective emergency medical system and triage, prompt and correct diagnosis, adequate medical treatment and care, etc.).

The present study is in agreement with the study of Kumar et al (10) who studied 51 cases of vehicular accident showing abdominopelvic trauma, along with associated injuries. A detailed ISS score was done in all the cases and it was 69

seen that victims in their 30s and 40s died only if their severity score was above 50.It was also observed that when the score was less than 20, the mortality level was minimal, while above 20 there was linear increase. In two of the cases studied, the score was 75.

The present study is also in agreement with the study of Nikoli et al

(29)

who

studied correlation between survival time and severity of injuries in fatal traffic accidents in the Institute of Forensic Medicine, University school of medicine, Belgrade. The sample included 272 persons: 193 males and 79 females. They also found a weak negative correlation between outliving period and ISS values in his sample (coefficient of linear correlation r = -0.452) and Coefficient of a determination (r2 = 0.20).

The present study is also in agreement with the study of N. Yousaf et al (54) who correlated different parameters and scoring systems with the probability of survival in trauma patients in Pilgrim Hospital, UK and found that ISS of trauma victims had a mean of 10.22. The results showed a strong negative correlation between ISS and Ps with an r-value of 0.633 (p < 0.005). GCS correlated strongly with Ps, with an r-value of 0.733 (p < 0.005). In the regression analysis; ISS showed a strong correlation with Ps.

The present study is also in agreement with the study of Verma and Biswas

(57)

who studied all cases of accidental deaths at Department of Forensic Medicine, 70

University College of Medical Sciences & GTB Hospital Delhi. One hundred and ten victims of road traffic accidents were studied consecutively whose detailed history and case records were available. The multiple regressions establish that NISS correlate significantly with survival period (Sing F=0.0486) in their study.

The present study differs from the study done by Rautji et al (41) (Table 21).This is because their study was on traumatic deaths involving any region of the body where as the present study was confined to fatal thoracoabdominal injuries. Head injury contributed to a large number of deaths in their study. Most of the victims of head injury had only minor injuries present over other parts of the body leading to a lower injury severity score. In the present study 2-3 major organs had significant trauma leading to higher injury severity score.

Table 21: Comparison of NISS in blunt fatal thoracoabdominal trauma in our study with those at south Delhi.

Present study (North East Delhi) NISS 1990 NISS 0-25 NISS 25-50 NISS 50-75 22.6% 34.4% 43.0% NISS2005 22.6% 25.8% 51.6%

Rautji et al (41) (South Delhi) 14.5% 61% 24.5%

71

The present study is also in agreement with the study of Friedman et al

(20)

who

studied all trauma autopsies performed between January 1 and June 30, 1993, were coded according to the AIS and ISS method in Sheba Medical Center, Jerusalem, Israel.. All cases were reviewed by a consultant in forensic medicine and a traumatologist. Cases were grouped in three categories according to ISS values: 0-14, 16-66, and 75. These categories represent minor, major, and incompatible-with-life injuries, respectively. All autopsy findings in which ISS was < or = 14 were peer-reviewed to establish mechanism and cause of death. In the 6-month period, 279 trauma-related autopsies were studied. Age at death averaged 37.1 +/- 18.7 (mean +/- SD). Eighty-six percent of the victims were male. ISS was 0-14 in 19 cases, 16-66 in 150 cases, and 75 in 110 cases. This meant that ISS 0-14 comprised of 6.81% of cases and ISS 16-66 comprised of 53.76% of cases. As their ISS range is different from the present study an exact comparison cannot be made. However their findings in general are in agreement with the present study.

The present study also differ from the study done by Mili J et al (30) who studied causes of death in long-term survivors of injuries sustained in traffic accidents at the Institute of Forensic Medicine, University school of medicine, Belgrade. 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). There was a weak positive correlation between outliving period and age in their sample (coefficient of linear correlation r = 0.35). The authors combined the autopsy and

72

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).

It was observed that in our study victims with low NISS (0-25 and 25-50 NISS score ranges) survival was more as compared to the victims with high NISS (5075 NISS score ranges). These findings are in agreement with the findings of Meera and Nabachandra (37), who studied 125 cases of blunt thoracoabdominal trauma which were brought for medicolegal autopsy at the mortuary of Forensic Medicine Department of Regional Institute of Medical Sciences, Imphal during the period from October 2001 to July 2003 and it was found that in victims with low ISS (21-30 and 31- 40 ISS score ranges) survival was more as compared to the victims with high ISS (51-60, 61-70 and 71-75 ISS score ranges). The spotdeath victims had a mean ISS score of 61.73 and cases who died within 1 hour showed 48.33 as the mean ISS. Mean ISS was low in those victims who survived more than 1 week i.e.27.50.

The present study findings are also in agreement with the findings of Sharma et al
(40)

who found that out of a total 14390 victims of Road Traffic Accidents

reporting to the Emergency Wing at Government Medical College Hospital, Chandigarh, 552 (4%) had a fatal outcome. Out of these 124 cases had an ISS 36-75 and they survived for 1-6 hours. Twenty eight cases had an ISS 16-65 with

73

the survival of 6-12 hours. Thirty nine cases had an ISS <16 with the survival of 12-24 hours and Fortythree cases an ISS <16 with the survival of 1-3 days.

The present study findings are also in agreement with the findings of Bergqvist et al (7) who studied patients with abdominal trauma and fatal outcome in an analysis of a 30-year series in rural Swedish area. They found that Patients with blunt abdominal trauma with fatal outcome comprised of 127 patients and when ISS is below 25 the mortality risk is minimal and above 25 it is an almost linear increase. When ISS is 50 the mortality is 50% and when above 70 it is close to 100%.

These findings are also in agreement with the findings of Ndiaye et al

(47)

studied

the fatal injuries of car drivers in France. Three-quarters of the casualties died at the scene of the crash. The injuries were analyzed for the 287 killed drivers whose deaths could be explained by the described injuries (at least one AIS 4+ injury). Of these, 41% had an ISS of 75 (at least one AIS 6 injury), 21% had an ISS of between 40 and 74, 33% an ISS of between 25 and 40, and 6% an ISS of between 16 and 24.

74

CONCLUSION AND RECOMMENDATIONS

Pages : 76-79

75

CONCLUSION AND RECOMMENDATIONS

In the present study majority of the victims were male (84.9%).Youngsters in the age group of 21-30 years (29%) were most commonly involved in trauma cases. 64.5% of cases of fatal thoracoabdominal trauma were dead on arrival. Vehicular accident was the most common cause of fatal thoracoabdominal trauma (79.57%). Buses were found to be the main offending vehicles.(16.13% of the cases). Most common category of victims involved in vehicular accidents was pedestrians (39.78%).

Among 0-10 and 11-20 years age groups most frequently injured organ was Liver. Rib fracture is seen in majority of cases (55). commonest injured visceral organs. Liver and lungs were the

Maximum number of victims had pelvic

injuries alone. (22.58%) Maximum cases died of haemorrhagic shock. (70.97%). Maximum cases are in NISS (50-75) group.i.e. in 43% of cases.NISS 1990 had a mean of 42.89 and the NISS 2005 had a mean of 46.59.There is a negative correlation between NISS 1990 and Ps with an r-value of 0.438 (p < 0.005) and between NISS 2005 and Ps with an r-value of 0.472 (p < 0.005).NISS 2005 is better than NISS 1990. There is a weak negative correlation between ISS and period of survival.

Further studies are needed on this topic where physiological parameters should also be included along with anatomical parameters for trauma scoring. 76

The following preventive measures are suggested 1. 2. 3. 4. Encroachments on roads should be dealt with strictly. There should not be any stray animals walking on the roads. Trauma centers should be established in this part of Delhi. Separate tracks should be made alongside the main roads for cyclists and pedestrians. 5. Strategies that increase the use of seat belts or child restraints will result in fewer injuries. 6. Stricter enforcement of speed limits will result in fewer injuries. The overall contribution of speed to accidents is not known but is widely quoted to be one third of all fatalities. 7. Safer design of roads and roadside environments will result in fewer injuries as a result of trauma. 8. Roadside guardrails (crash barriers) and crash cushions will reduce injury severity. 9. Area wise traffic management schemes should be targeted at areas with high injury rates which will reduce pedestrian injury rates. The provision of crossing patrollers, measures to redistribute traffic, and the design of roads to reduce speeds are effective in reducing pedestrian injuries. 10. Permanently switched on lights on cars can reduce daytime road traffic accidents. 11. Road safety education for children will reduce road traffic accidents .

77

12.

People should be encouraged to use railway over bridge rather than directly crossing the railway tracks.

The police, the fire brigade, individual initiatives, private ambulances and non government organizations provide some prehospital care to the injured in this part of Delhi and there is no central coordination for trauma patients. Most of the ambulances operating in this part of Delhi are just transport vehicles that only have an oxygen cylinder and the ambulance staff is generally not trained in prehospital care. Patients are transported to the hospital by personal or commercial vehicle in most of the cases. These are some of the factors apart from injury severity scoring which affect the period of survival.NISS will give knowledge about the prognosis of trauma victim. It will guide on the urgency of treatment i.e. people with greater injury severity score have to be given priority or energetic treatment.

So therefore it is recommended that injury severity scoring be done immediately as soon as the patient arrives to the casualty so that some of the deaths can be prevented.

78

SUMMARY
Pages: 80-81

79

SUMMARY

The present study was undertaken to focus light upon the pattern and injury severity score of fatal thoracoabdominal injuries in relation to various factors in the Northeast Delhi. A total number of 93 cases were studied from 1st November 2008 to 30th March, 2010. The results of the present study are summarized as follows:

1. 84.9% of the victims were male and 64.5% of cases of fatal thoracoabdominal trauma were dead on arrival. 2. Vehicular accident was the most common cause of fatal thoracoabdominal trauma (79.57%). 3. Buses were found to be the main offending vehicles and pedestrians were the most common category of victims. 4. Ribs, lungs and Liver were the organs most commonly affected. 5. Maximum number of victims had pelvic injuries alone. (22.58%) 6. Maximum cases died of haemorrhagic shock. (70.97%) 7. Maximum cases are in ISS (50-75) group.i.e. in 43% of cases. 8. NISS 90 had a mean of 42.89 and the NISS 05 had a mean of 46.59. 9. There is a negative correlation between NISS 90 and Ps with an r-value of 0.438 (p < 0.005) and between NISS 05 and Ps with an r-value of 0.472 (p < 0.005).

80

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81

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